Student Posters
Student Posters
Poster Session A
Sunday, June 26 • 2:00 pm – 3:15 pm
●Characteristics Associated With Home- and CommunityBased Service Utilization For Medicare Managed Care
Consumers
Gretchen Alkema, MSW, Judy Y. Yip, Ph.D., Kathleen H.
Wilber, Ph.D.
Presented By: Gretchen Alkema, MSW, Doctoral Candidate,
Leonard Davis School of Gerontology, University of Southern
California, 3715 McClintock Avenue, Los Angeles, CA 900890191; Tel: 213-740-9685; Email: alkema@usc.edu
Research Objective: This study identified characteristics of
those most likely to use home- and community-based services
(HCBS) in a sample of high-risk older adults from a southern
California-based Medicare managed care provider.
Study Design: As part of a California HealthCare Foundation
initiative that sought to integrate medical care and social
service delivery for Medicare managed care members, the
Care Advocate Demonstration Program linked chronically ill
older adults to HCBS via a community-based personal
advocate. Two hundred thirty-nine frail older adults received a
care management assessment, service referrals, and 12
months of telephone follow-up by master’s level social service
professionals.
Population Studied: Frail older adults in a Medicare
managed care plan who scored high on a health service
utilization algorithm.
Principal Findings: Logistic regression models indicated that
age, gender, social support, living situation, education, and
high health service utilization at baseline significantly
predicted utilization in six different HCBS categories.
Conclusions: Demographic and social characteristics are
more important than health or functional status in
determining home and community-based service utilization
for Medicare managed care consumers.
Implications for Policy, Delivery, or Practice: Policy
implications include the benefit of integrating social care
management into medical settings and understanding
consumer choice in a consumer directed intervention.
Primary Funding Source: California HealthCare Foundation
●Testing for Statistical Discrimination in Health Care
Danielle Ash, MPH,
Presented By: Danielle Ash, MPH, Doctoral candidate, Health
Services, UCLA School of Public Health, 3232 Sawtelle
Boulevard, #301, Los Angeles, CA 90066; Tel: (310) 397-1214;
Email: droseash@ucla.edu
Research Objective Balsa and McGuire (2001) adapted the
theory of statistical discrimination to health care markets.
Statistical discrimination implies that the physician, in
interacting with the patient, does so in a much less efficient
manner with the minority patient. This may result in minority
patients having poorer matches to treatment compared to
white patients. Using NHANES III data, we explore if minority
patients are less likely to receive medication or lifestyle advice
associated with management of hypertension.
Study Design: We use data from NHANES III, conducted
from 1988 through 1994. The NHANES III was designed to
provide national estimates of the health and nutritional status
of the United States' civilian, non-institutionalized population
Population Studied: The NHANES III data was subset into a
group who indicated that a doctor told them they had
hypertension or high blood pressure at least two times. The
group (N=4,193) included Non-Hispanic Whites (51.0
percent), Non-Hispanic Blacks (31.6 percent), and MexicanAmericans (17.4 percent). Using Stata Version 7.0, we
estimate the likelihood of Non-Hispanic Blacks or Mexican
Americans reporting receiving medical care or lifestyle advice.
Standard errors were computed using the first-order Taylor
series linear approximation. The models presented controlled
for age, gender, marital status, education, poverty status,
health status (self-report of fair or poor health) and usual
source of care. The analyses with Mexican-Americans also
controlled for language of interview (English or Spanish). We
also report the relative risks, highlighting those with
statistically significant results.
Principal Findings: Non-Hispanic Blacks were more likely
than Non-Hispanic Whites to have been told by a doctor or
other health professional to take a prescribed medicine (13%),
or reduce salt intake (12%). Mexican Americans were 20%
more likely to being told to lose weight. However, NonHispanic Blacks and Mexican Americans were less likely to be
told to stop smoking (47% and 31%, respectively) or reduce
tension (44% and 47%, respectively). There were no
statistically significant differences on topics such as being told
to exercise, reduce alcohol intake or cut fat in their diet
Conclusions: There were positive findings about the care for
Non-Hispanic Blacks and Mexican-Americans with
hypertension. In a number of instances, there were either no
statistically significant differences, or minority patients were
more likely to receive care to control their hypertension.
Nonetheless, Non-Hispanic Blacks were only half as likely to
report being advised to stop smoking or reduce tension.
Implications for Policy, Delivery, or Practice: If physicians
assume that Non-Hispanic Blacks are less likely to quit
smoking or work on reducing tension, they may be less likely
to offer this advice to minority patients compared to White
patients. If these differences exist, this may be an example of
statistical discrimination, because the physicians base their
lifestyle advice on some sort of rationale (correct or incorrect)
about minority patients. Relying on this rationale may result in
poorer quality of care for minorities.
Primary Funding Source: AHRQ
●Depressive Symptoms and Common Health Problems
among Latinos
Jennifer Bellamy, MSSW
Presented By: Jennifer Bellamy, MSSW, Columbia University
School of Social Work, 130 Morningside Drive, New York, NY
10027; Tel: (512)653-4525; Email: jlb2109@columbia.edu
Research Objective: To examine the relationship between
common depressive symptoms and three major health
problems: hypertension, diabetes and asthma among Latinos.
Study Design: This study is a secondary data analysis using
the National Health Interview Survey 2000. This survey was
chosen becaus of its detailed demographic and
socioeconomic variables, large sample of Latinos, and
variables related to the language preference of participants.
More recent versions of the NHIS do not include assimilation
or immigration variables. Descriptive statistics are used to
describe patterns of health and depressive symptoms in this
population. Multivariate analyses describe the association
between common depressive symptoms and major health
problems.
Population Studied: Adult Latino respondents are included in
the study. The total Latino population is examined, along with
specific analyses for Mexican, Mexican American, Puerto
Rican, and Other Latino groups.
Principal Findings: As in prior research depressive symtpoms
are related to each of the three health problems, however
distinct patterns of depressive symptomology and their
association to hypertension, diabetes, and asthma are
identified for each ethnic group. Puerto Ricans appear to
suffer disproportionately from both depressive symtpoms and
health problems. Perceived hopelessness and worthlessness
played a strong role in Puerto Rican health whereas perceived
effort played a more important role for Mexicans and Mexican
Americans and feelings of sadness were more strongly
associated with health problems for other Latinos.
Conclusions: Patterns of depressive symtpoms and health
are different for individual Latino ethnic groups but may often
be overshadowed by relatively large Mexican American group
when this panethnicity is lumped together in analyses.
Implications for Policy, Delivery, or Practice: Increasing
specificity in research in ethno-cultural groups is essential to
targetting efficient and culturally appropriate interventions.
Intervention programs aimed at reducing health and mental
health problems should be tailored to the population of
interest. One-size-fits-all approaches, too often based on
research with White or pan-ethnic Latino populations, may be
rendered ineffective when misapplied to minority ethnic
groups.
Primary Funding Source: No Funding
●Enabling Access to Medical Technologies in Developing
Countries: The Aurolab Model
Aman Bhandari, MPH, Mahad Ibrahim, MIMS, Jaspal S.
Sandhu, MS,
Presented By: Aman Bhandari, MPH, doctoral student,
Health Policy & Management, UC Berkeley, 2006 Cedar
Street, Berkeley, CA 94709; Tel: (510)849-1632; Email:
aman1@berkeley.edu
Research Objective: The goal of our research was to
understand how Aurolab, one of the only non-profit medical
manufacturing entities in the world, has created a sustainable
organization that has addressed the barriers to producing
medical technologies in developing countries. In this case
study, we: (1) examine the barriers in accessing specific
medical technologies, (2) analyze the key factors that enabled
Aurolab and Aravind Eye Care System to address those
barriers, and (3) discuss how Aurolab’s success might be
replicated for medical technologies other than eye care
consumables.
Study Design: This research employed a case study
methodology utilizing both qualitative and quantitative
research techniques. Such a mixed technique has been
advocated by leading health services researchers and has been
well documented. Primary data sources consisted of over 50
in-depth interviews and site visits, while secondary data
collection involved analysis of epidemiological data, financial
records, literature reviews, and regulatory issues. Onsite work
was conducted during June 2004 in Tamil Nadu, India at
Aurolab and the Aravind Eye Care System. Additionally, onsite
work in the United States was conducted in early 2004 with
Seva Foundation (Berkeley, California) and Project Impact
(Berkeley).
Population Studied: N/A
Principal Findings: Aurolab is one of the only non-profit
organizations in the world that produces medical devices or
pharmaceuticals. They have managed to help bring down the
cost of cataract surgery to roughly $20 in India compared with
an average cost of $2000 in the US. This socially-driven
organization produces ophthalmic technologies more cost
effectively than any other comparable manufacturer, delivering
their products to over 120 countries and owning 10% of the
global market for intraocular lenses (IOLs, the synthetic lens
implanted during cataract surgery). The factors of success
span organizational, financial, and technical aspects of
Aurolab. The organizational structure is characterized by
strong leadership and a unified vision; partnerships with key
NGOs have aided in technology transfer; and a close working
relationship with the Aravind Eye Care System has provided a
critical resource for product development. Also critical are
disease prevalence, disease characteristics, and importance of
technology to the cost of surgery.
Conclusions: Aurolab’s success in developing low cost
medical technologies has played a significantly role in helping
cure millions of people of blindness due to cataract in
developing countries. However, the elements of their success
are not necessarily transferable to other disease categories,
technologies, and contexts. The issue of increasing access to
medical technology is broader than cost, and includes factors
such as research and development, health care infrastructure,
medical cost burden, and intellectual property protections.
Implications for Policy, Delivery, or Practice: Access to
medical technologies across the developing world is extremely
limited and the development of such technologies is virtually
non-existent and faces significant barriers. Aurolab’s
phenomenal success should serve as an example to
institutional donor organizations, policymakers and
researchers as a best practices model for building health care
infrastructure and delivering medical technologies in
developing countries.
Primary Funding Source: UC Berkeley and the United
Nations Industrial Development Organization (UNIDO)
●Consumer Perspectives Regarding Use of Generic
Equivalents for Medications with Narrow Therapeutic
Index
Monali Bhosle, MS, Sujit S Sansgiry, Ph.D., Rajesh
Balkrishnan, Ph.D.
Presented By: Monali Bhosle, MS, Doctoral Student,
Pharmacy Practice and Administration, Ohio State University,
500 West 12th Avenue, Columbus, OH 43210; Tel: (614)2978910; Fax: (614)292-0815; Email: bhosle.1@osu.edu
Research Objective: Narrow therapeutic index (NTI) drugs
are those for which a very small change in the dosage level
could result in toxic reactions in patients. These drugs are
generally associated with high-risk diseases such as epilepsy
and asthma. Patients’ attitude towards generic drugs is highly
influenced by the nature of disease and the risk involved in the
treatment. The perceived difference between generic and
brand drugs may restrict use of generic NTI medications. The
objective of this study was to understand consumer
awareness, attitude, and intention to use generic NTI
medications.
Study Design: Data were collected by administering a survey.
A standardized questionnaire was used to evaluate consumer
awareness regarding availability of generic narrow therapeutic
index drugs. Consumers’ attitude towards generic drugs and
generic substitution practices with respect to NTI drugs was
assessed using a 5-point Likert scale (1= strongly disagree 5=
strongly agree). Consumers’ intention to use generic NTI
drugs was measured both, pre and post intervention that
consisted of information on safety, efficacy, quality, costs and
therapeutic equivalency of generic NTI drugs using a scale
where 1=Yes, 2=No and 3=Not Sure. Demographic data such
as age, gender, income, education were collected and
analyzed using SAS statistical package to conduct descriptive
and regression analyses.
Population Studied: Consumers filling a prescription at 100
participating community pharmacies in the Houston area.
Principal Findings: A total of 154 surveys were obtained with
a response rate of 77.77%. The mean age of respondents was
52 years with 55.03%. Approximately 57.14% participants
taking NTI drugs were not aware of the term ‘Narrow
Therapeutic Index’. Patients had neutral attitude towards
generic NTI drugs after getting familiarized with the nature of
these drugs (3.02 ? 0.98). Patients intention to use these
drugs was slightly higher after knowing about FDA’s
assurance about safety and efficacy (3.50 ? 0.95). More
participants (81.70%) indicated that they would purchase
generic NTI drugs after physician’s assurance than
pharmacist’s assurance (54.90%). Multinomial logistic
regression indicated that patients with positive attitude
towards generic NTI drugs were 1.60 times more likely to use
generic NTI drugs than those with negative attitude while
controlling for other predictor variables (p<0.05).
Conclusions: Most patients were not aware of the term
‘Narrow Therapeutic Index’ drugs. Participants’ neutral
attitude towards generic NTI drugs changed positively after
getting information on FDA’s assurance regarding safety of
generic NTI equivalents. Participants’ intention to use generic
drugs was largely depend on the assurance of safety given by
the physicians.
Implications for Policy, Delivery, or Practice: Increased use
of generic NTI drugs could help control escalating health care
costs. Although, health care professionals are major players in
generic drug selection, consumers’ opinions is also a critical
factor influencing medication use. Since, consumers’ approval
is necessary for generic drug use, it is essential to know their
awareness, attitude, and intention to use these medications.
The results of this study were important to understand
consumers’ knowledge regarding NTI drugs and necessity to
organize educational campaigns to educate consumers if
required.
Primary Funding Source: No Funding Source
●Treating Depression During Pregnancy and in the
Postpartum: A Meta-Analysis
Sarah Bledsoe, MSW
Presented By: Sarah Bledsoe, MSW, NIMH Pre-Doctoral
Trainee in Mental Health Services Research, School of Social
Work, Columbia University, 530 Riverside Drive, E6, New York,
NY 10027; Tel: (212)866-2887; Email: seb2108@columbia.edu
Research Objective: Non-psychotic major depression is
common during pregnancy and in the postpartum, affecting
from 10-25% of pregnant and postpartum women, and has
harmful effects across the family unit. Various
pharmacological, therapeutic, group, and educational
interventions exist for the treatment of major depression
during pregnancy and in the postpartum. Meta-analysis is
used to examine the various treatments currently available to
combat the harmful effects of depression during pregnancy
and in the postpartum in an effort to suggest best practices
based on evidence. The main objective of this meta-analysis
was to evaluate the efficacy of current treatments for nonpsychotic major depression during pregnancy and in the
postpartum and to compare the interventions based on the
type of treatment used.
Study Design: Database searches of the Cochrane Central
Register for Controlled Trials, MEDLINE, PSYLIT, and Social
Work Abstracts were conducted. Citation list searches and
personal approaches were also used. All studies that have
tested an intervention directed at decreasing depressive
symptomatology in women during pregnancy and in the
postpartum that have applied a treatment trial using
standardized outcome measures were sought for the purpose
of this review. Data were analyzed using the Comprehensive
Meta-Analysis software package (Bornstein & Rothstein,
1999). Standardized mean differences were calculated for
continuous variable outcome data. Quality of studies was
assessed using a relatively simplistic model due to the time
limitations of this analysis.
Population Studied: Women who are diagnosed with nonpsychotic major depression during pregnancy or in the
postpartum period.
Principal Findings: The review reported the efficacy of current
treatment interventions for non-psychotic depression during
pregnancy and in the postpartum. Of the 16 treatment
interventions analyzed 13 reported positive effect sizes. 1
treatment intervention reported a marginally positive effect
size, one intervention reported no effect, and the remaining
intervention reported a marginally negative effect size.
When grouped by category of treatment intervention and
ranked by combined effect size, medication in combination
with cognitive behavioral therapy and medication alone
reported the largest effect sizes (3.871, P < .001 and 3.048, P <
.001 respectively) and counseling and educational
interventions reported the lowest effect sizes ( .418, P = .014
and .100, P = .457).
Conclusions: Finding suggest that medication, alone and in
combination with CBT, produces the largest effect size in this
population. However, doctors may be reluctant to prescribe
and women may be unwilling to take medication during
pregnancy and while breastfeeding (Wisner, et al, 1999; Oren,
et al, 2002). This creates an urgent need to utilize and develop
efficacious treatment alternatives to medication. This review
has begun the process of identifying viable alternatives with
findings supporting group therapy, interpersonal
psychotherapy, and cognitive behavioral therapy, respectively.
Implications for Policy, Delivery, or Practice: While further
research and analyses are needed to validate the findings of
this review, preliminary finding suggest that medication, alone
and in combination with cognitive behavioral therapy, group
therapy, interpersonal therapy and cognitive behavioral
therapy produce the largest effect sizes in this population
among the interventions tested in this review. Future research
should focus on further testing and developing these
interventions as well as culturally competent interventions and
engagement strategies targeting women diagnosed with major
depression during pregnancy and in the postpartum.
Primary Funding Source: NIMH
●Managed Care Controls and Physicians’ Perception of
the Delivery of Quality Health Care
Betsy Brigantti, MS, MPH
Presented By: Betsy Brigantti, MS, MPH, Health Policy and
Management, Johns Hopkins University, Bloomberg School of
Public Healh, 624 North Broadway, Hampton House, Room
508, Baltimore, MD 21205; Tel: (410)245-7867; Email:
bbrigant@jhsph.edu
Research Objective: Despite distant memories of the
backlash, concerns regarding cost overruns and over
utilization of services, has led the managed care industry to
revisit the use of cost control measures that may affect patient
safety. The onus of insuring that prudent financially based
health care decisions continues to be in the hands of primary
care physicians. This study assesses whether three managed
care cost and utilization control measures (a) control over
physicians’professional autonomy,(b) the amount of time that
a physician has for the patient visit and (c) being in a
gatekeeper role, are associated with physicians’ perceived
ability to deliver quality health care and ability to maintain a
continuing relationship with patients.
Study Design: Cross sectional analysis of the 1998-1999
Community Tracking Study (CTS) Physician Survey.
Population Studied: This analysis uses survey data collected
from a nationally representative sample of physicians. The
population of interest is restricted to 6,220 primary care
physicians who indicated that their practice was addressing
the health care needs of managed care patients. Multivariate
logistic regression is being used to estimate associations
between the three cost and utilization control measures and
physicians’ perceived ability to deliver quality health care and
ability to maintain a continuing relationship with patients.
Principal Findings: Preliminary results reveal that after
controlling for physician and practice setting characteristics
those physicians that agreed strongly with the statement “I
have the freedom to make patient care decisions” were nine
times more likely to agree with the statement “It’s possible to
provide high quality care to all my patients” and eight times
more likely to agree with the statement “I have the ability to
maintain a continuing relationship with patients” than
physicians who disagree strongly with the freedom statement.
In addition, physicians that agreed strongly with the statement
“I have adequate time to spend with my patients during a
patient visit were four times as likely to agree with both the
quality statement and the continuing relationship statement
than physicians who disagree strongly with the adequate
amount of time statement (P <0.001 for all comparisons).
Conclusions: The study suggests that physicians perceive
that their ability to adequately care for patients could be
compromised by managed care’s control over their
professional autonomy and the lack of time available to see
patients.
Implications for Policy, Delivery, or Practice: Obtaining
information about a physician’s work experience and how this
experience contributes to his/her perceived ability to treat
patients is critical. Managed care systems must develop
mutual partnerships with physicians to insure that the health
care needs of patients are comprehensively met. One method
to improve quality and ultimately contain cost might be to
track the use of cost and utilization control measures with
patient health outcomes.
Primary Funding Source: WKK
●Ready of Not - Intrapartum Prevention of Perinatal HIV
Transmission in Illinois
Ann Bryant, M.D., MSc, Rebecca Eary, BS, Yolanda Olszewski,
MS, MPH, Anne Statton, BA, Mardge Cohen, M.D., Patricia
Garcia, M.D., MPH
Presented By: Ann Bryant, M.D., MSc, Maternal-Fetal
Medicine Fellow, NRSA Post-Doctoral Fellow, Department of
OB/GYN, Division of Maternal-Fetal Medicine, Institute of
Health Services Research and Policy Studies, Northwestern
University, Feinberg School of Medicine, 333 East Superior
Street, Suite 410, Chicago, IL 60611; Tel: (312)926-7518; Fax:
(312)926-0367; Email: abryant@md.northwestern.edu
Research Objective: In 2003 Illinois mandated that
institutions providing labor and delivery (L&D) care ascertain
HIV status and provide interventions to reduce perinatal
transmission. The purpose of this study is to determine the
overall readiness of Illinois birthing hospitals to identify HIV
positive women in L&D and prevent perinatal transmission to
newborns. This study identifies hospital characteristics that
predict specific components of readiness to prevent perinatal
transmission and comply with the Illinois HIV Perinatal
Prevention Act. In addition, barriers to readiness are
evaluated.
Study Design: A written survey was faxed and mailed to L&D
nurse managers of all birthing hospitals in Illinois in March
2004. The survey reported hospital characteristics and
current hospital practice around perinatal HIV status
identification, documentation, testing and treatment.
Additional data on hospital characteristics were collected from
the Illinois Department of Public Health HIV/AIDS
Surveillance Report, Illinois Department of Public Health
Hospital Profile and The Illinois Hospital Association.
Bivariate analysis was conducted to determine the association
between hospital characteristics and specific components of
hospital readiness. Multiple logistic regression was
performed to identify hospital characteristics that were
independently and significantly associated with overall
hospital readiness.
Population Studied: Birthing hospitals in Illinois.
Principal Findings: Surveys were sent to 137 birthing
hospitals and 137 (100%) were returned. Overall readiness
was defined by 4 components: 1) >75% documentation of
maternal HIV status available on L&D, 2) documentation of
prenatal HIV results in the maternal L&D chart and in the
newborn chart, 3) HIV test ordered on L&D if prenatal HIV
status not available, and 4) availability of AZT IV and syrup
formulation. Only 18 out of 137 (13.1%) birthing hospitals met
this definition of readiness. In terms of specific components
of readiness: 64/137 hospitals (46.7%) had > 75%
documentation of maternal HIV status available on L&D,
99/137 hospitals (72.3%) routinely document prenatal HIV
results in the L&D chart, 90/137 hospitals (65.7%) routinely
document prenatal HIV in the newborn chart, 53/137 hospitals
(38.7%) order HIV tests on L&D if no prenatal HIV is available
and 84/137 hospitals (61.3%) had AZT available. In multiple
regression analysis important predictors of hospital readiness
included: serving a higher percentage of black patients,
identification as a teaching hospital and classification as a
level III perinatal center. Teaching hospital
status(p=.03)appeared to be the only significant independent
predictor of overall hospital readiness.
Conclusions: Many of the birthing hospitals in Illinois do not
have in place key components of readiness to prevent
perinatal HIV transmission to newborns. Readiness levels in
Illinois hospitals are likely similar to current hospital practices
in other states.
Implications for Policy, Delivery, or Practice: This research
supports the importance of state policies and public health
guidelines for perinatal HIV transmission prevention that
address hospital protocols around prenatal testing, rapid
testing on L&D, documentation of HIV status and
antiretroviral treatment availability. Resources must be
provided to improve hospital readiness if the safety net of HIV
prevention is to be extended to the perinatal setting.
Primary Funding Source: Pediatric AIDS Chicago Prevention
Initiative
●Are In-Home Blood Samples Feasible in an Inner-City
Sample of Mothers?
Ann Bryant, M.D., MSc, William Grobman, M.D., MPH, Laura
Amsden, MSW, MPH, Emily Collins, BS, Whitney Witt, Ph.D.,
MPH, Jane Holl, M.D., MPH
Presented By: Ann Bryant, M.D., MSc, Maternal-Fetal
Medicine Fellow, NRSA Post-Doctoral Fellow, Department of
OB/GYN, Division of Maternal-Fetal Medicine, Institute of
Health Services Research and Policy Studies, Northwestern
University, Feinberg School of Medicine, 333 East Superior
Street, Suite 410, Chicago, IL 60657; Tel: (312)926-7518; Fax:
(312)926-0367; Email: abryant@md.northwestern.edu
Research Objective: To examine the feasibility of obtaining
blood samples from an inner-city welfare population during inhome interviews. Feasibility of blood sample collection was
assessed for both the respondent and interviewer groups.
Study Design: Ten non-medical interviewers and eight
respondents participated in separate two hour focus groups
led by a trained facilitator. Both interviewers and respondents
have been involved in the Illinois Family Study-Child Well
Being, a longitudinal study of the effect of welfare reform upon
maternal and child health outcomes. Focus groups were
designed primarily to assess the acceptability of collecting
respondents’ blood for research purposes in general and
secondarily to assess receptivity of respondents to research
addressing chronic stress and health outcomes. The focus
groups were taped and transcribed. Transcriptions were
coded for themes by individuals on the research team and
then reconciled as a group based on a predetermined
protocol. Prominent themes and representative quotes were
identified for each focus group.
Population Studied: Two focus groups: Illinois Family StudyChild Well Being interviewers and study respondents.
Principal Findings: Overall, both respondents and
interviewers made clear that they were comfortable with finger
stick blood samples being added to the in-home interview
process. The interviewers felt that adequate training was
critical to ensure their own comfort and made multiple
suggestions regarding operational procedures that could be
followed to maximize professional appearance and safe
handling of blood products. Respondents identified issues
about which they needed to be reassured, including that blood
would not be used for purposes other than the reason stated
and that interviewers would be properly trained to secure and
dispose of blood safely. Both respondents and interviewers
felt that in order to maximize acceptance it was crucial to
communicate with respondents prior to the interview the
rationale and process used for the blood sample. Both groups
also felt it was important to communicate the results of the
laboratory results to the individual participants.
Recommendations from the focus groups were implemented
and the respondent acceptance rate for blood sampling during
the interview process was 99.5% (205/206).
Conclusions: Proper training of interviewers, organization of
supplies and adequate communication with respondents can
be combined to maximize acceptance of blood collection for
research purposes among an inner-city indigent population.
Implications for Policy, Delivery, or Practice: These results
support the feasibility of using non-medical interviewers to
collect blood samples in respondents' homes and expands the
available methods to collect data in this important population.
Primary Funding Source: National Institute of Child Health
and Development
●Relationships among Selected Nursing Unit
Characteristics and Medication Errors Requiring Increased
Observation or Treatment
Yunkyung Chang, MPH, Barbara Mark, Ph.D.
Presented By: Yunkyung Chang, MPH, student, School of
Nursing, University of North Carolina at Chapel Hill,
Carrington Hall Room 217 CB #7460, Chapel Hill, NC 27599;
Tel: (919)843-3156; Fax: (919)843-3168; Email:
ykchang@email.unc.edu
Research Objective: Few studies have examined
characteristics of nursing units that are associated with the
incidence of medication errors. Previous research suggests
that healthcare providers’ inadequate knowledge about a drug
and inadequate patient information are common factors
contributing to medication errors. This study was based on
Reason’s human error model, which suggests that many
errors originate from skill-based or knowledge-based deficits.
Using the nursing unit as the unit of analysis, this study
examined relationships among educational level and selfreported expertise of the registered nurse staff, nurse-reported
quality of communication with physicians, and medication
errors requiring increased observation or treatment.
Study Design: This study is a secondary analysis of data from
a multi-site organizational study testing a model of the effects
of nursing unit characteristics and professional nursing
practice variables on administrative and patient outcomes. For
this study, data on nurses’ education level, expertise, and selfreported relational coordination with physicians were used. All
data were aggregated to the nursing unit level. Medication
errors were defined as number of medication errors reported
over three consecutive months that required increased
nursing observation or treatment. Educational level was
defined as proportion of nurses on the unit with a bachelor’s
degree or higher. Nurses’ expertise was measured by an eightitem measure of nurses’ ability to identify clinical problems
and exercise clinical expertise properly. Quality of
communication with physicians was measured using sevenitems from the Relational Coordination Scale.
Population Studied: The sample was 267 medical/surgical
nursing units in 145 randomly selected hospitals across the
United States. The average number of nurses responding on
each unit was 17.
Principal Findings: Number of unit level medication errors
ranged from 0 to 27 (mean=2). Analysis, using a negative
binomial model indicated that nursing units having a higher
proportion of registered nurses with a bachelor’s degree or
higher had a lower incidence of medication errors than did
their counterparts (p < .05). If a nursing unit increased its
proportion of baccalaureate-prepared nurses by 10%, it could
decrease the number of medication errors by four over a
three-month time interval. Nurses’ expertise did not
significantly predict medication errors at the nursing unit level.
Nursing units where nurses reported quality relationships with
physicians in terms of frequent communication had fewer
medication errors than did those where nurses reported poor
quality relationships (p < .05).
Conclusions: At the unit level, nurses’ education and selfreported frequency of communication with physicians were
significantly associated with fewer medication errors that
required increased observation or treatment.
Implications for Policy, Delivery, or Practice: The findings
suggest that nurses’ education level and frequency of
communication with physicians play an influential role in the
incidence of medication errors. Future research should explore
the proportion of baccalaureate-prepared nurses on a unit that
provides the best mix of personnel in terms of cost to the
organization and benefits in terms of patient safety.
Primary Funding Source: Large study funded by NINR,
Barbara Mark, Ph.D., RN, FAAN, Principal Investigator
●The Impact of Race and Nativity on Child Health Care
Utilization
Jamie Chatman, BS, Katherine Donato, Ph.D. in Sociology,
Bridget Gorman, Ph.D. in Sociology
Presented By: Jamie Chatman, BS, Graduate Student,
Department of Statistics, Rice University, 1515 Bissonnet
Street, Unit 4, Houston, TX 77005; Tel: (713)256-5857; Email:
jchatman@rice.edu
Research Objective: Recent studies have shown that
immigration status affects child health and preventative care.
This study will examine the determinants of children's health
service use. Analysis was conducted to examine the
differences across race and ethnic groups and immigrant
generations (first, second, and third or higher) in the
propensities of children to visit a doctor and dentist for
preventive care and when sick.
Study Design: Data from the 1999-2003 National Health
Interview Survey was used. Logistic regression was used to
estimate the adjusted odds of these forms of health service
use, and examine the extent to which immigration status
explains race and ethnic differences in children's use of health
services.
Population Studied: The population studied include children
under the age of 18 from across the United States. This study
compares four racial and ethnic groups (Whites, Blacks,
Mexicans and Puerto Ricans) and three immigrant
generations (first, second, and third or higher).
Principal Findings: Results from preliminary analysis indicate
that 1st generation Mexicans have lower rates of visiting the
dentist and doctor for preventative care and when sick.
Continued analysis will explore specific factors around this
issue, such as the duration in the US and health insurance
status.
Implications for Policy, Delivery, or Practice: More
attention should be given to determine the specific barriers
that reduce utilization rates for 1st generation Mexican
American children. Identification of these specific barriers will
assist in developing strategies for eliminating the disparities
that contribute to this phenomenon.
Primary Funding Source: No Funding Source
●The Effect of Health Information Technology on
Efficiency and Quality: A Systematic Review
Basit Chaudhry, M.D., MSHS, Jerome Wang, M.D., Sally
Morton, Ph.D., Emmett Keeler, Ph.D., Shin-Yi WU, Ph.D., Paul
Shekelle, M.D., Ph.D.
Presented By: Basit Chaudhry, M.D., MSHS, Robert Wood
Johnson Clinical Scholar, Medicine, Southern California
Evidence-Based Practice Center/ Greater Los Angles VA, 911
Broxton Avenue, 3rd Floor, Los Angeles, CA 90034; Tel:
(310)794-2268; Fax: (310)794-3288; Email:
BChaudhry@mednet.ucla.edu
Research Objective: 1) To review the evidence on the effects
of HIT utilization on health care efficiency and quality. 2) To
review the evidence for what the major barriers to HIT
adoption are.
Study Design: Systematic Review
Population Studied: A multilayered search strategy was
utilized to identify articles related to HIT. We performed
searches of MEDLINE, Cumulative Index to Nursing and
Allied Health (CINAHL), Periodical Abstracts, and the
Cochrane Database. All references cited in the systematic
reviews and meta-analyses identified were reviewed
individually. A grey literature search of conference
presentations was performed. Hand searches of key
references maintained by the project’s content experts were
performed. The initial inclusion criteria utilized to screen
identified papers was use of an IT system to provide clinical
care or to provide health services. Secondary inclusion criteria
included reporting of quantitative findings and/or reporting of
qualitative barriers to adoption. Exclusion criteria included
studies limited to technological issues with no clinical
application tested, purely financial and administrative
systems, and qualitative analyses not related to barriers to
adoption. All final data extraction was performed by two
independent reviewers with differences resolved by
consensus.
Principal Findings: To date approximately 792 articles have
been screened. Of these, 676 (86%) met initial screening
criteria. Of these, 483 met all inclusion criteria. The most
common reasons for exclusion was absence of quantitative
findings (25% of total screened). 55% of articles examined
electronic health records (EHR), 45% decision support
systems, 11% computerized provider order entry (CPOE), 8%
data summary/ population health functions, 7%
administrative support, 6% consumer health/ patient decision
support, and 4% electronic prescribing (note--numbers don’t
add to 100% because papers could involve systems with
multiple HIT functionalities). 45% of studies tested a
hypothesis and used some type of comparison group, 41%
reported quantitative findings but did not utilize a comparison
group, 7% were systematic reviews/ meta-analysis, 5% were
non systematic reviews, and 3% were formal costeffectiveness/cost-benefit or predictive analyses. 41%
reported findings related health care effectiveness, 36% on
efficiency, 16% on safety, 19% on timeliness, 8% on patient
centeredness, and 5% on administration. Financial costs are
most frequently cited as the major barrier to adoption. We are
currently in the process of synthesizing our findings within
topic, which will be presented at the meeting.
Conclusions: Considerable heterogeneity exists in the HIT
literature with respect to content and methodological quality.
With respect to content, the majority of studies involve
electronic health records and decision support systems. Most
research focuses on the effects of isolated HIT component
functionalities with little assessment or evaluation of
interoperability. Few studies have examined the effect of
comprehensive, interoperable health information technology
systems on quality or efficiency. With respect to methodology,
the highest quality evidence available is in the domain of
computerized clinical reminders. Despite, financial cost being
frequently cited as a major barrier to adoption, very few formal
cost benefit or cost effectiveness studies are available.
Implications for Policy, Delivery, or Practice: HIT holds
great promise to improve health care quality and efficiency.
However, sound empirical evidence supporting this is limited.
As initiatives are developed to promote HIT adoption,
additional methodologically rigorous research is needed in
order for policy makers, business leaders, health care
professionals and consumers to make informed decisions. In
particular, high quality cost-effectiveness and cost-benefit
analyses of interoperable HIT systems are needed to address
prevalent barriers to implementation.
Primary Funding Source: AHRQ
●Reliability of Self-reported Behavioral Health Services
Utilization and its Implications for Economic Evaluations
Sukyung Chung, MPH, Elizabeth Jackson, Ph.D., Marisa
Domino, Ph.D., Joseph Morrissey, Ph.D.
Presented By: Sukyung Chung, MPH, Graduate Student,
Department of Health Policy and Administration, University of
North Carolina at Chapel Hill, 1103B McGavran-Greenberg
Hall, CB#7411, Chapel Hill, NC 27599-7411; Tel: (408)7460916; Email: sukyungc@email.unc.edu
Research Objective: Self-reported services utilization data
capture information on a broader range of services than
administrative records kept by health care payers or service
providers. In behavioral health services research where
patients use a variety of service domains outside of usual
medical care, self-reporting may provide more accurate and
complete information on overall service utilization. The
objectives of our study are: 1) to examine test-retest reliability
of self-reported service use received by women with behavioral
health problems; 2) to identify factors affecting reliability of
reported service types and intensities; and 3) to assess
impacts of inconsistency in reporting on economic
evaluations.
Study Design: The test-retest data examined in this study
come from the Women, Co-occurring Disorders, and Violence
Study. We first analyzed test-retest reliability of self-reported
service use: any service use, service-type specific and facility
specific intensity of service use, and contents of service
(mental health, substance abuse, and trauma) for each service
type. Kappa coefficients and intraclass-correlation coefficients
(ICC) were used for dichotomous and continuous measures,
respectively. Measures were considered as reliable when
coefficients were above 0.4. Second, we estimated a logit
model of any service use and an OLS model of intensity of
services to identify determinants of consistent responses with
repeated measures. Factors examined were service type,
psychiatric symptom severity, intervention status (intervention
vs. control), and relevant demographic characteristics. Finally,
we compared the overall services costs and the incremental
cost of intervention estimated using the test data and retest
data to assess robustness of economic evaluation with
repeated measures.
Population Studied: The Women, Co-occurring Disorders,
and Violence Study is a quasi-experimental study conducted in
9 sites nationwide during 2001 and 2002. Study subjects were
women aged 19-59 with either a psychiatric or substance
abuse diagnosis and a trauma history. A retest interview was
given within 12 days from the baseline assessment to 186
participants from intervention and comparison group across 9
sites.
Principal Findings: Test-retest reliability of service use was
high (kappa=0.68 – 0.94) for any use and generally good
(ICC=0.46 – 0.99) for intensity of services. However, reliability
of patients’ perceptions on contents of services received
during individual and group counseling were fairly low
(kappa=-0.04 – 0.66). Second, consistency of reports varied
across service types. Patients reported hospital use more
consistently than outpatient-based services (odds ratio=0.28 –
0.32). Psychiatric symptoms severity, intervention, and
demographic factors did not affect consistency in reporting.
Finally, overall costs and incremental costs of intervention did
not differ across test and retest data.
Conclusions: Self-reports of health services utilization are
generally reliable and can be a useful data source for
economic evaluations. Considering the severity of mental
conditions among study participants, the result should be
interpreted as a conservative boundary. Future research
should explore the reliability of self-reported service use
among the general population.
Implications for Policy, Delivery, or Practice: Self-reported
services use data is not only comprehensive in scope but also
reliable, and can be recommended as a primary data source in
behavioral health services research.
Primary Funding Source: Substance Abuse and Mental
Health Services Administration (SAMHSA)
●Effect of Retirement on Body Mass Index (BMI) among
the Near Elderly
Sukyung Chung, MPH
Presented By: Sukyung Chung, MPH, Graduate Student,
Department of Health Policy and Administration, University of
North Carolina at Chapel Hill, 1103B McGavran-Greenberg
Hall, CB#7411, Chapel Hill, NC 27599-7411; Tel: (408)7460916; Email: sukyungc@email.unc.edu
Research Objective: Retirement changes the availability of
financial resources and leisure time, and could act as either an
opportunity or a barrier to the maintenance of healthy body
weight. This study investigates the causal effect of retirement
on BMI to help determine the population of priority for
interventions to halt the growth of obesity and related health
care costs. The role of wealth and the relative importance of
quantity and content of leisure time in the BMI response to
retirement are also explored.
Study Design: Retirement in this study is defined as currently
not working and self-considered as retired. To get consistent
estimate of retirement, not induced by health conditions, the
fixed effects with instrumental variable method is employed.
Eligibilities for defined-benefit pension and Social Security
benefit were used as instruments for retirement. Subsamples
based on total household wealth were compared to examine
the role of wealth in the BMI response to retirement. The
relative importance of retirement-related changes in quantity
and content of leisure time is examined by estimating the
effect of reduced working hour on BMI among workers, and
the effects of retirement on BMI as compared to working in
physical jobs and sedentary jobs.
Population Studied: This study uses six panels of the Health
and Retirement Study conducted every two years from 1992 to
2002 with age ranged from 50 to 71. The HRS is a national
survey including all genders and racial groups.
Principal Findings: The mean BMI of the sample was 28.5
and retirement increases BMI by 0.4 points on average
compared to currently working status either full time or part
time. The BMI response to retirement was greater, 1.0 in BMI,
among those with lower wealth, but disappeared among the
wealthier group. Retirement significantly increased BMI as
compared to working in sedentary jobs or physical jobs.
However, reduced working hour or increasing leisure time did
not change BMI for current workers. The weight gain effect
was persistent in the model using a broader definition of
retirement.
Conclusions: Retirement causes the greatest gain in BMI for
those with less wealth. Two pieces of evidence – gain in BMI
with retirement compared with working, regardless of job
types, and no effect on BMI from reduced working-hours
among workers – suggest that change in content of leisure
time with retirement lead to BMI gain. Changing leisure time
health behavior, such as physical activity and diet, with
retirement, and differences in these responses between people
with different socioeconomic status should be further
explored.
Implications for Policy, Delivery, or Practice: The modest
marginal weight change with retirement has a sizable impact
on the population obesity rate because the majority of people
in their fifties and sixties are overweight prior to retirement.
The impact of BMI gain with retirement on public health and
Medicare costs will accelerate with the expanding retired
population. Interventions to improve leisure time health
productivity of retired people in low wealth status should be
among the highest priorities in public health policy.
Primary Funding Source: No Funding Source
●A Longitudinal Analysis of Postpartum Depression
among Employed Women
Rada Dagher, MPH, Ph.D. student in Health Services
Research and Policy, Pat McGovern, Ph.D., Bryan Dowd,
Ph.D., Laurie Ukestad, MS, David McCaffrey, BA
Presented By: Rada Dagher, MPH, Ph.D. student in Health
Services Research and Policy, Graduate Instructor, School of
Nursing, University of Minnesota, 425 13th Avenue SE,
Minneapolis, MN 55414; Tel: 612-379-0562; Email:
dagh0004@umn.edu
Research Objective: To investigate changes in the prevalence
and predictors of postpartum depression among employed
women during the first six months after childbirth.
Study Design: This study utilizes secondary data from three
Twin Cities hospitals in 2001. Data on maternal and infant
health, demographics, maternal employment characteristics,
and health services use were collected using structured
questionnaires and medical records. Eligible subjects were
interviewed in-person while hospitalized for childbirth and bytelephone at 6 weeks, 3 months, and 6 months after delivery.
The response rate was 88% (n=716), 81% (n=661), and 76%
(n=625), respectively. Group comparisons showed no
differences between initial participants and non-participants in
regards to selected demographics and birth characteristics.
Postpartum depression was measured using the Edinburgh
Postnatal Depression Scale (EPDS). The independent
variables included (1) baseline covariates measured only once,
including demographics, pregnancy and delivery
characteristics, and (2) repeated measures covariates
evaluated at every time point including job characteristics
(perceived job stress, job satisfaction, supervisor and
coworker support, and job flexibility), perceived control, social
support, health services used, and infant sleep problems. Data
were analyzed using General Linear Models for repeated
measures, with the total EPDS score as a continuous
outcome.
Population Studied: The study population consisted of all
women delivering a live, singleton infant at selected hospitals
and who were 18 years or older. Vital statistics data revealed
that the study population was representative of all birth
mothers, age 18 years and older, residing in the Twin Cities
metropolitan community and delivering at non-study sites on
key demographic and birth factors.
Principal Findings: The women were 18 to 45 years old
(mean = 30), 78% were married, 50.6% had a Bachelor’s
degree or above, 88% were white, 46% were primiparas, and
44% reported prenatal mood problems of anxiety and
depression. The prevalence of depression was 4.2% (N=24) at
6 weeks, 4.9% (N=28) at 12 weeks, and 3.9% (N=22) at 3
months postpartum. Variables found to significantly predict a
higher postpartum depression score at every period were:
Being non-white, experiencing prenatal moods, higher
perceived job stress in the previous period, less job flexibility,
less available social support, and baby sleep problems during
the preceding 4 weeks. As time elapsed after childbirth,
depression scores decreased.
Conclusions: An increased postpartum depression score was
associated with poorer prenatal mental health, increased job
stress, less job flexibility, less available social support, and
baby sleep problems. Findings are relevant to health
professionals and employers, and consistent with the
literature.
Implications for Policy, Delivery, or Practice: There is an
important role for health care providers assessing and
educating women about risk factors for depression and
exploring the need for resources (e.g., counseling, parenting
support groups, and primary health services). Women
perceived as vulnerable should undergo formal screening for
depression and appropriate referrals. Employers can support
postpartum women by implementing flexible work schedules.
Given the positive association between increased job stress
and the likelihood of depression, future research should
investigate what factors contribute to women’s job stress.
Primary Funding Source: NIOSH
●The Relationship Between Financial Barriers to Health
Care Utilization and Disease Control in Type 1 Diabetes
Rashida Dorsey, MPH, Thomas J Songer, Ph.D.
Presented By: Rashida Dorsey, MPH, Graduate Student,
Epidemiology, University of Pittsburgh, 200 Lothrop Street,
Suite B-400, UPMC Presby, Pittsburgh, PA 15232; Tel:
(412)624-6820; Fax: (412)648-8924; Email: rrd3@pitt.edu
Research Objective: Adequate disease management is
necessary to protect against diabetes complications and other
adverse disease outcomes. The majority of diabetes care is
performed by the patient; however financial constraints may
limit the level of attainable self-care. This study will examine
the correlation between financial barriers to health care
utilization and disease control.
Study Design: Between 1997-1998, subjects completed a selfreport survey that addressed health insurance, employment
status and disease management. Financial barriers included
lack of insurance, and income decrease over the past year.
Insurance items of interest included general insurance
coverage and insurance coverage of the following health
services: prescription medications, blood testing strips,
insulin, syringes. Participants were also asked to indicate if
they paid higher rates for insurance because they had
diabetes. In this analysis, we examined health care utilization
according to recommended diabetes management practices.
Diabetes management practices of interest were daily blood
glucose monitoring, four physician visits per year, and three
daily insulin injections. Individuals who satisfied at least 2
conditions were considered to have recommended diabetes
management (RDM). Individuals were asked to rate their
attempts to control their diabetes as either very poor, poor,
fair, good, or excellent. Those with fair or poor rating were
grouped into one category termed low and those with good or
excellent were grouped into another termed high. Data were
analyzed cross-sectionally to examine associations between
barriers and RDM as well as associations between barriers
and self-rating of diabetes control using chi-squared tests and
logistic regression.
Population Studied: Participants consisted of 399 persons
with type 1 diabetes from the Pittsburgh Epidemiology of
Diabetes Complications study, diagnosed between 1950-1980.
Principal Findings: Individuals in the RDM group were more
likely to have insurance (p=.042) and insurance coverage of
prescription medications (p=.018), insulin (p=.039), syringes
(p=.05), blood testing strips (p<.001) than those without
RDM. Subjects in the RDM group were less likely to report a
decrease in income (p=.05). In logistic regression,
participants with insurance coverage for blood testing strips
were 2.6 times as likely to be in the RDM group (p<.001)
compared to those without RDM. Respondents in the high
self-rating group were more likely to have insurance coverage
for prescription medications (p=.036) and blood testing strips
(p=.048), compared to the low self-rating group. Subjects
with a high self-rating were also less likely to report a decrease
in income compared to the low self-rating group (p=.003). In
logistic regression, individuals with prescription medical
coverage were 1.9 times as likely to be in the high self-rating
group (p=.038).
Conclusions: Barriers were associated with reduced health
care utilization and poorer diabetes control.
Implications for Policy, Delivery, or Practice: These data
suggest that addressing the financial aspects of disease
management may improve health care utilization and disease
control.
Primary Funding Source: National Institutes of Health
●Are There Differences in Online Resources for Answering
Primary Care Proctitioner Questions?
Susan Fenton, MBA, BS
Presented By: Susan Fenton, MBA, BS, Ph.D. Student, Texas
A&M School of Rural Public Health, 21 Inwood Manor, San
Antonio, TX 78248; Tel: (210)332-3525; Fax: (210)479-1043;
Email: shfenton@srph.tamhsc.edu
Research Objective: 1. There are significant differences
among seemingly comparable online resources in the ability
to easily find answers to questions from primary care
practitioners. 2. There is a significant difference in the degree
of evidence-based information found in two online resources,
by patient gender, patient age or disease category.
Study Design: This study randomly selected 752 questions
from the NLM's Clinical Questions Collection and searched
two different online knowledge sources using the question's
keywords. One knowledge source was subscription-based,
UpToDate, and one was publicly available, National Guideline
Clearinghouse.
Population Studied: Primary care practitioner clinical
questions
Principal Findings: 1. The subscription-based knowledge
source had a greater breadth of coverage for the clinical
questions, 75% vs. 65%. 2. The publicly available knowledge
source had a greater depth of coverage, 16.27 vs. 8.62 results.
3. Disease category was the only variable with a significant
impact upon the presence or absence of knowledge source
content.
Conclusions: A subscription-based knowledge source has
more content than a publicly available knowledge source,
most likely related to editorial control and content creation.
Even subscription sources did not have complete content
coverage.
Implications for Policy, Delivery, or Practice: 1. Access to
subscription knowledge sources may need to be provided for
disadvantaged areas. 2. Creators of knowledge sources, both
subscription and public, may want to develop content for
uncovered disease categories.
Primary Funding Source: No Funding Source
students was $3,093.80 annually and 29.4% indicated they
were very satisfied with their coverage.
Conclusions: These findings show that gender, annual cost of
coverage, payroll deduction, and co-pay for medications
significantly affected the reported level of satisfaction. As the
overall costs decreased, students indicated higher levels of
satisfaction. The examination of overall cost of coverage also
found co-pay of medications and level of satisfaction
decreased as the cost of insurance increased.
Implications for Policy, Delivery, or Practice: This study has
potential implications for managed care organizations, health
care administrators, planners, and marketing strategists.
Overall cost of coverage, payroll deductions, and co-pay for
medications suggest increased levels of overall satisfaction of
insurance.
Primary Funding Source: Student-Faculty Research Grant
●An Examination of Health Insurance Coverage of Collegeaged Students
Amber Frame, BS, MPH, Tanya Morgan, Ph.D.
Presented By: Amanda Gilmore, MPH, Doctoral Candidate,
Health Services, University of California, Los Angeles, Box
951772, Los Angeles, CA 90095; Tel: (818)676-2820; Fax:
(818)715-9934; Email: aschofie@ucla.edu
Research Objective: Among patients with arthritis, to assess
differences in medication adherence between new users of
two different classes of analgesic: 1) cyclooxygenase-2
inhibitors (coxibs) and 2) certain non-selective nonsteroidal
antiinflammatories (NSAIDs) We will use this information in
future studies designed to address the associations between
these therapies and various health outcomes.
Study Design: This retrospective cohort analysis employed
2001-2003 administrative claims data from two private health
plans on the East and West coasts covering more than 6
million patient lives. Patients with arthritis were identified
using International Classification of Diseases—9th Edition
codes 711–719. Medication adherence was defined as the
total number of therapy days supplied, which involved
summing contiguous prescription refills for the index drug
and their days supply, allowing for gaps in coverage no greater
than 15 days and for overlap in days supply to carry over.
Population Studied: All patients included in the study had at
least one index prescription claim for either a coxib including
rofecoxib, valdecoxib and celecoxib, or NSAID including
ibuprofen, naproxen, diclofenac, and nabumetone. Patients
with a prescription claim for any study drug during the twelve
months prior to index date or patients with prescription
claims for both study therapies were excluded. Patients were
followed up to one year post index date.
Principal Findings: A total of 28,339 patients were identified,
28% which were in the coxib group (N=7,808) and 72% in the
NSAIDs group (N=20,531). Mean adherence was significantly
higher for patients taking coxibs (1.64 months) compared to
patients in the NSAIDs group (0.73 months) (p<0.0001) and
ranged from 1.87 months for celecoxib to 0.53 months for
ibuprofen. Only nine percent and 1% of the coxib and
NSAIDS groups respectively, were adherent for 3 months or
more.
Conclusions: Although patients initiating coxib therapy were
significantly more adherent than patients initiating NSAIDs,
overall levels of adherence for the entire study population were
Presented By: Amber Frame, B.S., MPH, Graduate Assistant,
West Chester University, P.O. Box 2425 W.C.U., West Chester,
PA 19383; Tel: (610)436-3041; Email: AF575191@wcupa.edu
Research Objective: The purpose of this study is to examine
medical insurance coverage of West Chester University
students who are enrolled in a Dimensions of Wellness course
at West Chester University. Many students take this course as
an elective and come from a variety of disciplines across
campus. The topics related to insurance coverage that were
assessed in relation to overall satisfaction and cost are age,
gender, type of coverage (such as HMO, PPO, POS,
Indemnity, and Government coverage), amount of payroll
deduction, co-pay for general practitioner visits and
medications, type of plan (independent, family, school plan,
etc.), and utilization of health care.
Study Design: SPSS was used to analyze the data for this
study. An initial examination of the descriptive statistics was
reported. The Pearson product-moment Correlation Text was
used to determine the existence of correlations within the data
set. Additionally, linear regressions were used to examine the
effect of the dependent variables on cost and satisfaction.
Population Studied: This study examined one hundred and
one students who were enrolled in several sections of a
general wellness course at West Chester University in West
Chester, Pennsylvania during the Spring and Fall semesters of
2004.
Principal Findings: The average of the student population in
this study was 19.6 years. Forty-two percent of the students
were covered by HMOs, 35.3% were covered by PPOs, 10.8%
were covered by POSs, with the remainder of the students
with insurance covered through Indemnity and Government
plans. Of the students with a co-pay for general practitioner
visits, 55.9% had a co-pay between $5.00 - $10.00.
Approximately 65% of the students paid between $5.00 $10.00 for prescription medications. Seventy-six percent had
between 1 – 5 general practitioner visits during the course of
the year. The average cost of health insurance for these
●Medication Adherence in Cox-2 Inhibitors and
Nonsteroidal Antiinflammatory Drugs
Amanda Gilmore, MPH, Michelle D. Seelig, M.D., MSHS
somewhat low. Therefore, studies addressing associations
between these therapies and health outcomes should consider
levels of adherence over time, as well as differences in dose
and other characteristics of the medication regimen. Future
work should examine these factors as well as patient
characteristics in relation to adverse gastrointestinal and
cardiovascular events.
Implications for Policy, Delivery, or Practice: Differences in
medication adherence impact the effectiveness of the
therapies and influence health plan decisionmakers who must
balance health benefits and costs when developing formulary
guidelines.
Primary Funding Source: Health Benchmarks, Inc.
●Past Violence, Future Violence: The Effect of History of
Violence on Nurses’ Risk of Work-Related Physical Assault
Mira Grice, MS, Terry Gromala, D.C., Susan Goodwin
Gerberich, Ph.D., Bruce H. Alexander, Ph.D., James G. Gurney,
Ph.D., Patricia M. McGovern, Ph.D.
Presented By: Mira Grice, M.S., Doctoral Student,
Environmental Health Sciences, University of Minnesota, 420
Delaware Street SE, MMC 807, Minneapolis, MN 55455; Tel:
(612)626-4824; Fax: (612)626-0650; Email:
gric0001@umn.edu
Research Objective: The majority of healthcare workers
experience one or more violent events in the workplace during
their career. A recent survey of registered nurses conducted
by the American Nurses Association revealed that issues
surrounding health and safety played a major role in nurses’
decisions about leaving the profession. Prior research also
reveals a significant cost burden associated with physical
assault (PA) in healthcare settings, with average costs totaling
$13,197 per case and $10 per employee. In addition, studies
on revictimization show that persons with a prior history of
violence are at increased risk of experiencing future PA.
However, few studies address the relation between a history of
workplace violence and subsequent risk of PA among those
who work in healthcare settings. The primary research
objective was to investigate the extent to which a reported
history of work-related and non work-related PA and nonphysical violence (NPV) was associated with the risk of current
work-related PA among nurses.
Study Design: A nested case-control study was conducted
from a comprehensive survey of 6300 randomly selected
Minnesota licensed registered (RNs) and practical (LPNs)
nurses. Cases (n=310) were identified as respondents who
reported being a victim of physical assault while at work in the
twelve months prior to the survey date. Controls (n=946)
were randomly selected from those who reported no physical
assaults at work. Self-administered questionnaires were
mailed to collect exposure information for one-month before
the PA events for cases, and for a random month during the
study period for controls. Multivariate logistic regression was
used to estimate odds ratios (OR) and 95% confidence
intervals (CI). Directed acyclic graphs, based on the
hypothesized causal model, guided selection of variables for
logistic regression. Horvitz-Thomspon reweighting was used
to adjust for potential biases associated with unknown
eligibility and non-response.
Population Studied: The target population included all
licensed registered (RN) and practical (LPN) nurses (79,128)
who worked in Minnesota as of October 1, 1998.
Principal Findings: Of the cases and controls, 90% and 35%,
respectively, reported a history of work-related violence, which
was strongly associated with the risk of current work-related
PA (OR = 13.4; CI = 2.1, 85.2). Previous history of a workrelated threat was also associated with increased risk of
current work-related PA (OR = 4.6; CI = 1.01, 20.9). Risks were
also elevated for histories of work-related sexual harassment
(OR = 2.5; CI = 0.8, 27.3), verbal abuse (OR = 4.7; CI = 0.8,
27.3), non work-related PA (OR = 1.9; CI = 0.4, 8.7), non workrelated threat (OR = 1.8; CI = 0.5, 6.5), sexual harassment (OR
=1.6; CI = 0.4, 6.2) and verbal assault (OR = 1.9; CI = 0.6, 6.2).
Conclusions: The results from this study revealed an
association between histories of work-related and non workrelated violence with an increased risk of current work-related
PA among nurses.
Implications for Policy, Delivery, or Practice: Given nurses’
concerns and the significant cost burden associated with PA, a
need exists to identify effective ways to reduce work-related
violence. These findings serve as a basis for further research
that can ultimately address relevant prevention and control
measures.
Primary Funding Source: CDC
●Hospice Care in the Nursing Home: Is Diagnosis
Associated with Configuration of Care?
Andrea Gruneir, MS, Ph.D. candidate, Kate Lapane, Ph.D.,
Susan Miller, Ph.D.
Presented By: Andrea Gruneir, MS, Ph.D. candidate,
Graduate Student, Community Health, Brown Medical School,
Box G- Hemisphere, Providence, RI 02912; Tel: (401) 8639260; Fax: (401) 863-3713; Email: Andrea_Gruneir@brown.edu
Research Objective: Although initially designed for people
with terminal cancer, the increased availability of covered
hospice services along with mainstream recognition of its
benefits, have lead to efforts to improve the provision of such
services to patients with other types of end-stage illnesses. In
the nursing home setting, access to and provision of end-oflife care services to patients with Alzheimer’s disease and
other dementias is of particular interest. We sought to
quantify the effect of a dementia diagnosis on the
configuration of hospice services provided in the nursing
home.
Study Design: We used a cross-sectional study design. All
data were obtained from an administrative database
maintained by a single large hospice provider. Four diagnostic
groups were created based on the primary diagnosis at the
time of hospice enrolment: cancer, dementia, debility, and all
others. Configuration of care was measured as the percent of
patients who received visits, the median total number of
minutes spent with patients, and the median visit length. The
configuration of care of several types of providers (physicians,
RNs, LPNs, aides, social workers, and chaplains) was
examined. We focussed on the first 2 days of care.
Population Studied: We included 8,718 residents of US
nursing homes who received hospice services from a for-profit
hospice provider between January 1, 1998 and September 1,
2000.
Principal Findings: Twenty-seven % had a diagnosis of
cancer, 23.5% had dementia, 14.9% had a diagnosis of
debility, and 34.5% had other diagnoses. Missing information
regarding pain assessment was common in all patients:
cancer patients (33%), patients with dementia (67%), patients
with debility (51%). Fewer than 20% of all patients were seen
at least once by an aide, social worker, or chaplain in the initial
2 day period of hospice care and this did not differ by
diagnosis group. Patients with dementia and debility were
visited by RNs and LPNs but had less overall care time than
patients with cancer. Physicians appeared to be the least
involved with direct patient care, yet visited patients with
dementia and debility less often than those with cancer.
Conclusions: Major differences in the configuration of
hospice care in the first two days of care were not observed
across diagnosis groups. The extent to which this reflects that
hospice care is not directly responsive to the varying needs of
different groups needs to be explored. Missing information
regarding pain assessment in patients with dementia and
debility was highly prevalent. These data may reflect the
challenges of pain assessment and control, which are
mainstays in hospice care, in patients with communication
difficulties.
Implications for Policy, Delivery, or Practice: The needs of
patients with dementia are likely to be vastly different than
those with cancer, and further knowledge is needed to
determine whether current conceptualizations of hospice
appropriately meet these needs. End-of-life care for patients
with dementia may require a very different approach than that
taken in the same care of patients with other diagnoses,
especially cancer.
Primary Funding Source: No Funding Source
●Four High Risk Groups of SED Youth in Transition to
Adult Service Systems
Cheri Hoffman, MMFT, Craig Anne Heflinger, Ph.D., Robert
Saunders, MPP
Presented By: Cheri Hoffman, MMFT, Pre-doctoral Fellow,
Community Research and Action, Vanderbilt University,
Peabody #151, 230 Appleton Place, Nashville, TN 37203; Tel:
(615)343-1652; Fax: (615)322-7049; Email:
cheri.hoffman@vanderbilt.edu
Research Objective: There are concerns that the link between
adolescent and adult mental health services is not smooth
and that many youth with serious emotional disorders (SED)
get “lost.” However, detailed information about the highest
risks groups is needed for policy and program planning, as
well as advancing research in this area. This study examines
characteristics of four high risk groups of youth with SED in
Tennessee’s Medicaid system as the first step in a program of
research to examine their transition to the adult service
system.
Study Design: This study uses Tennessee Medicaid
(TennCare) enrollment and claims/encounter data to identify
the highest risk groups and their patterns of service utilization
before and after their 18th birthdays. The data set includes all
TennCare enrollees ages 12-17, with the sample ranging from
130,000 in Fiscal Year 1993 to 190,000+ in FY 2000 and
beyond. Data are available for all enrolled youth who were
born after 1980 with services data from FY 1993 through FY
2003. A large number will have reached their 18th birthday
during this time period. Descriptive statistics will be used to
present information by group membership on demographic,
eligibility, and service use characteristics. In addition, overlap
among group membership will be presented.
Population Studied: In this study, four groups of high risk
youth are identified. The first group are youth who have
received a rating of SED in the enrollment data at some point
since age 10. This rating is made by mental health providers
based on the presence of a mental health diagnosis and an
impaired global level of functioning score. The second group
is comprised of youth who have been diagnosed with serious
mental disorders after their 12th birthday, including
schizophrenia, bipolar disorder, major depression, and
borderline personality disorder. The third group are youth who
have utilized high levels of mental health services between
their 14th and 18th birthdays, including hospitals, residential
treatment centers, day treatment, and frequent outpatient
services. Finally, the fourth group are youth in the custody of
the state of Tennessee who as a result qualified for Medicaid
during the time period between their 14th and 18th birthdays.
Principal Findings: This study is not yet complete; data is
expected by Feb. 11th.
Conclusions: This study is not yet complete; data is expected
by Feb. 11th.
Implications for Policy, Delivery, or Practice: These findings
will be the first step in a larger program of research that will
lead to a better understanding of the high risk youth and
inform next steps in this program of research, which will be to
detail their service use before and after their 18th birthdays. It
is anticipated that we will find that the transition from youth to
adult service systems is more problematic for some groups
(and sub-groups) than others, indicating those who will need
most attention from policy makers, program administrators,
advocates, and researchers. The goal of this study, and this
program of research, is to provide the information needed for
policy and program improvement such that the transition
from child to adult mental health care systems can be as
seamless as possible.
Primary Funding Source: No Funding Source
●Factors Affecting Access to Mental Health Services
among HIV Patients with Mental Health and/or Substance
Abuse Problems
Yunho Jeon, MS, Jong-Deuk Baek, Ph.D., Carleen Stoskopf,
Sc.D.
Presented By: Yunho Jeon, MS, Research Assistant, Health
Services Policy and Management, University of South
Carolina, 6 Doral Court, Columbia, SC 29229; Tel: (803)7772772; Email: jeon@sc.edu
Research Objective: To determine use of mental health
services, such as individual or family basis mental health
provider, psychotherapy groups, and substance abuse
treatment, and to investigate factors affecting access to
mental health services among HIV patients with mental health
and/or substance abuse problems
Study Design: Crosssectional Study
Population Studied: A national probability sample of 2,466
adults receiving HIV care who completed first follow-up
interviews from December, 1996 to July, 1997
Principal Findings: The proportions of visits to mental health
provider on an individual or family basis were 55% of anxiety
disorder, 48% of panic disorder, 50% of depression, 48% of
dysthymia, and 33% of substance abuse among HIV patients,
and the visit to mental health provider were significantly
different among subgroups (no mental health/substance
abuse problems, mental health problems only, substance
abuse problems only, and both mental health and substance
abuse problems). After controlling for mental health and
substance abuse status and other variables, age, gender, race,
mode of exposure, employment, and education attainment
were significant factors to access to mental health services.
Factors affecting access to those mental health services were
various along with the subgroups.
Conclusions: The magnitude of metal health services
provided to HIV patients with mental health and/or substance
abuse problems is suboptimal, and inequalities in access to
care are challenging to general medical, especially mental
health treatment sectors.
Implications for Policy, Delivery, or Practice: Incidence of
HIV infection is still growing regardless of development of
antiretroviral therapy, and enhancing access to mental health
care among such a vulnerable group might be not only
beneficial to HIV patient themselves but also reducing HIV
dissemination.
Primary Funding Source: No Funding Source
●Effects of Physical Activity on Medical Expenditures of
US Adults
Eric Keuffel, MPH
Presented By: Eric Keuffel, MPH, Graduate Student (PhD),
Health Care Systems Department, University of Pennsylvania - Wharton, 6 Reaney Court, Philadelphia, PA 19103; Tel: (215)
546-9286; Email: ekeuffel@wharton.upenn.edu
Research Objective: Regular physical activity improves
clinical outcomes in coronary heart disease, hypertension,
diabetes, stroke, obesity, osteoporosis, mental health
disorders and other chronic conditions. While the
epidemiological implications of regular physical activity
(frequently defined as rigorously activity sustained for at least
30 minutes three times per week) are well-established,
particularly in adults with chronic disease; the association
between activity level and medical costs, even short-run
medical costs, is poorly understood. Public and private health
insurers may reevaluate or reconsider disease management
exercise and physical activity programs on the basis of the
treatment effect associated with physical activity programs.
This study extends upon prior economic estimates by using
cross-sectional data to quantify the effect of regular physical
activity (defined as rigorously activity sustained for at least 30
minutes three times per week) on direct medical costs after
adjusting for underlying health status, income, demographic
characteristics and other relevant covariates.
Study Design: The primary dependent variable in this analysis
is log of total medical expenditures in year 2000 (excluding
dental costs). Both unadjusted and adjusted regressions were
conducted on cross sectional data. Independent variables in
various OLS regressions generally include demographic
characteristics, income, education, insurance coverage,
behavioral covariates, health status measures and a dummy
variable for physical activity. Health status was measured with
19 dummy variables that either reflect distinct diagnoses or
conditions, summaries of domains of health and disability
levels.
Population Studied: The sample is comprised of Medical
Expenditure Panel Survey (MEPS-Year 2000) respondents
over age 17 who answered the question about whether or not
they were physically active (n=17,423). The mean (median)
total medical expenditure is $2,266 ($433). Unadjusted
annual mean (median) medical expenditures are $2,914
($565) for inactive adults (n=8,095) and $1,715 ($350) for
active adults (n=9,328). Assuming no selection bias, initial
examination of basic means and correlations are suggestive of
a negative association between log medical cost and physical
activity (Coeff= -.52, p<.01). The coefficient value translates
into 40% lower medical costs for those who are physically
active.
Principal Findings: Controlling for health status and other
patient characteristics eliminates the medical cost discount
associated with physical activity. The association between
participation in physical activity and log medical costs reverses
sign and loses statistical significance (Coeff=+.07, p=.09).
This effect is robust across subgroups as the same
specification for those with particular types of insurance
(public, private, uninsured) exhibit the same coefficient values
and significance levels for the adjusted and unadjusted
analyses. The effect also occurs when the dependent variable
is redefined as the log of medical costs covered by insurance.
Conclusions: This cross-sectional analysis suggests that
short-run cost savings attributed to physical activity may be
overstated in unadjusted analyses which do not account for
health status of individuals.
Implications for Policy, Delivery, or Practice: Public and
private insurers seeking short-run returns may not benefit
from cost reductions within the first year of disease
management programs even if uptake is effective. Panel data
over an extended time period is needed to more carefully
identify the effect of physical activity on short and long run
medical costs in US adults.
Primary Funding Source: AHRQ, NRSA
●The Effect of Medicaid Transportation Brokerage Services
on Expenditures and use of Medicaid Services
Jinkyung Kim, MPH, Edward C. Norton, Ph.D., Sally C.
Stearns, Ph.D.
Presented By: Jinkyung Kim, MPH, Ph.D. student, Health
Policy and Administration, University of North Carolina at
Chapel Hill, McGavran Greenberg Hall, CB #7411, Chapel Hill,
NC 27599-7411; Tel: (919)622-9109; Fax: (919)966-6961;
Email: jinkyung@email.unc.edu
Research Objective: Given rising Medicaid costs, states strive
to provide mandatory non-emergency medical transportation
(NEMT) efficiently. For people for whom lack of
transportation is a barrier to receiving necessary medical
services, inefficient provision of transportation services could
lessen the use of timely medical interventions and, in turn,
increase Medicaid expenditures via delayed and expensive
care. The tension between the states’ goals of access to care
and Medicaid cost containment produces innovative
approaches in managing NEMT. Twenty one states have
taken the innovative approach of providing transportation
brokerage services. Thus, the study analyzes how
transportation brokerage services affect Medicaid
beneficiaries’ use of services and Medicaid expenditures.
Study Design: The study uses retrospective data analysis with
a quasi-experimental design. Georgia implemented statewide
transportation brokerage services in October 1997. We
specified a 21-month pre and a 21-month post period using
four calendar years of Georgia Medicaid Claims Data, 19961999. We use two-part models to predict the effect of
transportation brokerage services on Medicaid expenditures,
controlling for personal characteristics and month. The
dependent variables of interest are total and inpatient
Medicaid expenditures. We created monthly observations for
each individual.
Population Studied: The study sample includes children with
asthma in Georgia. Using ICD-9 diagnosis codes and national
drug codes, we identified children with asthma. We randomly
chose 53,427 asthma children, which is about 20% of
Medicaid asthma children in Georgia. The final study sample
had 1,790,718 observations at the person-month level. Total
and inpatient expenditures are analyzed for babies age 0-2, for
children age 3-18, and for all children, because effects may
differ by age of children.
Principal Findings: The probability of any health care use in a
month decreased by 7.4 percentage points after the start of
transportation brokerage services from a mean of 40 percent.
The shift to transportation brokerage services has led to a
decrease in total Medicaid expenditures of $41.72 per person
per month. The probability of any inpatient expenditures also
decreased by 1.5 percentage points from a mean of 2 percent
and by $77.17 per person per month inpatient expenditures.
Different effects were found by children’s age: babies have
larger effects than older kids on total health care expenditures
while older kids have larger effects than babies on inpatient
expenditures.
Conclusions: Transportation brokerage services are
associated with an overall decrease in total and inpatient
Medicaid expenditures and the probability of using Medicaid
services. However, our results did not control for health
outcomes. Decreased Medicaid expenditures are positive if
beneficiaries’ health is not compromised. Further research is
needed to address this issue.
Implications for Policy, Delivery, or Practice: Currently, 21
states have implemented transportation brokerage services to
reduce expenditures and improve the quality of NEMT. Our
results would help other state policymakers decide whether to
implement transportation brokerage services.
Primary Funding Source: Other Foundation
●Impact of Health Benefit Limits on Treatment of
Psoriasis and Dermatological Conditions
Amit Kulkarni, MS, Arun P. Venkat, M.D., MBA, Noah S.
Schienfield, M.D., JD, Rajesh Balkrishnan, Ph.D., Steven R.
Feldman, M.D., Ph.D.
Presented By: Amit Kulkarni, MS, Doctoral Student,
Department of Pharmacy Practice and Administration, Ohio
State University, 500 12th Avenue, Columbus, Ohio, 43210,
OH 43210; Tel: (614)292-0136; Fax: (614)292-0815; Email:
kulkarni.40@osu.edu
Research Objective: Health benefit limits or ‘‘caps’’, a
measure of cost containment, is the amount insurance
companies pay for drugs during a certain period of time. Caps
can be effective on an annual or lifetime policy basis
depending on plans chosen and state in which policy is
obtained. Caps previously were important in inpatient settings
using expensive medications. Health insurance caps have now
become an issue in outpatient specialties such as
dermatology with the use of high priced targeted immune
response modifiers or ‘biologicals’. This study hence looked at
the impact of health benefit limits on treatment of psoriasis
and other dermatological conditions.
Study Design: Information regarding health benefit limits was
acquired from five major health insurance providers in the
United States, Kaiser, Foundation Health Plan, United Health
Group, CIGNA Corp, Aetna Inc, and AFLAC Inc. Potential
effects of caps on treatment of psoriasis and other
dermatological conditions were estimated using annual costs
of drugs obtained from the Drug Topics Red Book 2003 for a
70-kg participant. Age at which insurance benefits would
exhaust was calculated based on different onset ages for
treatment costing $30,000/year and different lifetime benefit
limit amounts.
Population Studied: N/A
Principal Findings: Health benefit limits were enforced in
more forms than one. In some cases, annual caps ranged
from $1000 to $20,000, limiting the amount companies paid
for drugs in a given year. Annual benefits were divided into
two parts, one for brand-name drugs and another for generic
drugs. The second cap encountered was the lifetime benefit
maximum. This maximum applied to physician office and
hospital visit expenses. The drugs were restricted to those
given in hospitals and paid by major medical components of
health plans. For the treatment of psoriasis, a lifetime benefit
cap of $500,000 for treatment starting at age 20 years would
exhaust around the age of 40 years, assuming no other claims
applied. Furthermore, an annual cap of $1000 allowed for full
coverage of only methotrexate while, annual caps of $15,000
or less affected coverage for etanercept and efalizumab. For
patients requiring multiple drug treatments, even higher
annual caps limited drug coverage.
Conclusions: Different plans have different methods of
capping pharmaceutical use, yet annual and lifetime limits
were most common. Insurance limits affect coverage of
treatments for psoriasis and potentially other conditions, thus
limiting patient access to health care. Moreover, currently
there is no standardized method to investigate drug coverage.
Implications for Policy, Delivery, or Practice: As health
insurance companies shift more costs to consumers, patient
access to care may be at greater risk. It is important for
physicians to be aware of the variations in insurance coverage,
especially before a new treatment option is explored. If
insurance coverage was a standard question in the doctorpatient encounter, it could arguably improve patient
compliance and outcomes. It is also very important that the
patients be aware of the caps in their drug benefits. Insurance
companies in turn should also shoulder some responsibility in
making their members aware of these caps.
Primary Funding Source: No Funding Source
●Galveston County’s Progress in Meeting Healthy People
2010 Objectives: A Health Services Research
Methodology
Frank C. Lemus, MA, Patricia A. Blair, Ph.D., LLM, JD, MSN,
Daniel H. Freeman, Ph.D., Jean L. Freeman, Ph.D.
Presented By: Frank C. Lemus, MA, Graduate Research
Assistant, Preventive Medicine and Community Health,
University of Texas Medical Branch, 700 Harborside Drive,
Route 1153, Galveston, TX 77555-1153; Tel: (409) 762-5140; Fax:
(409) 772-2573; Email: fclemus@utmb.edu
Research Objective: According to Healthy People 2010 and a
study by the Institute of Medicine, hospitalization admission
rates for certain diseases serve as a marker to identify access
to high-quality primary care services. Knowing hospitalization
rates for these disease markers, or ambulatory care sensitive
conditions or ACSCs, is essential for communities to establish
health care priorities. We assessed progress of Galveston
County and the cities of Galveston, League City, Texas City
toward achieving Healthy People 2010 Objective 1.9: Reduce
hospitalization rates for the following 3 ACSCs: pediatric
asthma - under age 18; uncontrolled diabetes - aged 18 – 64;
and immunization-preventable pneumonia or influenza - age
65 and older. For Galveston County and these 3 cities, we
estimated baseline hospitalization rates for 3 ACSCs in 3
major racial/ethnic groups: non-Hispanic White, Black, and
Latino. Hospitalization rates were based on Texas Health
Care Information Council’s hospital discharge data for years
1999 - 2001, and population counts from the 2000 U.S.
Census.
Study Design: In this descriptive study we followed precisely
the methodology of Healthy People 2010. We developed a
subset of data from the hospital discharge records for
Galveston County for years 1999 – 2001: 40,093 records in
1999; 42,555 records in 2000; and 43,202 records in 2001; for
a total of 125,850 hospital discharges. We further refined our
database using a data subset for targeted cities of Galveston,
Texas City, and League City. The numerator for our rate
calculation was the number of hospital discharges for each
ACSC in the target community multiplied by 10,000. We
derived our denominator from the 2000 U.S. Census: number
of persons within the specified ACSC age category multiplied
by 3. We used this multiplier because the 2000 U.S. Census
served as a mid-point in our rate determination, and
represented one year, while the numerator consisted of 3 years
of data.
Population Studied: We used ICD-9-CM codes specified by
Healthy People 2010 to identify the number of hospitalizations
for each ACSC where the code was the first listed or principal
diagnosis. For pediatric asthma under age 18: ICD-9-CM code
493; for uncontrolled diabetes age 18-64: ICD-9-CM codes
250.02-250.03, 250.10-250.13, 250.20-250.23, 250.30-250.33;
and for immunization preventable pneumonia or influenza
age 65 and older: ICD-9-CM codes 481 or 487.
Principal Findings: Disparity exists between Blacks and nonHispanic Whites for pediatric asthma and uncontrolled
diabetes in each community studied. Results show lower than
anticipated rates of uncontrolled diabetes among Latinos in
each community studied. Income gradients highly correlated
with rates of ACSCs in the targeted communities.
Conclusions: Some Healthy People 2010 goals have been
reached. Our estimate of baseline rates for 3 ambulatory care
sensitive conditions in targeted communities in Galveston
County sets the basis for future rate estimates.
Implications for Policy, Delivery, or Practice: With these
study results Galveston County stakeholders can assess
population health status to guide and target funding priorities.
This study provides basis to extend analysis to other Texas
counties and targeted cities and demonstrates use of hospital
discharge data for community based health services research.
Primary Funding Source: NIH
●Impact of a Change in Prescription Drug Benefit on
Utilization and Expenditures among Patients Receiving
Cardiovascular Medications
Musetta Leung, MS
Presented By: Musetta Leung, MS, 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: To investigate how a change in
prescription drug benefits affects drug utilization and
expenditures among enrollees treated with cardiovascular
(CV) agents, and whether this differs by recent event status,
which may alert patients to the severity of their condition.
Study Design: This study uses administrative claims data
from a health maintenance organization, and includes
enrollment and prescription drug claims from 1999 to 2001.
The plan implemented a change in outpatient prescription
drug benefits on a rolling basis, beginning in January 2000,
when enrollees went from a 2-tier (generic/brand) to a 3-tier
(generic/preferred brand/non-preferred brand) formulary
structure with increases in copayments. Late- and nonadopters served as the ‘control’ group. Prescription drug
utilization and expenditures were evaluated. A difference-indifference technique, using t-tests for comparison of means,
was used to ascertain changes between the pre- and postimplementation periods. Multivariate ordinary least squares
and fixed-effects models controlled for potential biases.
Population Studied: Continuously-enrolled patients under 65
years old who had 2 or more prescriptions for an ACEinhibitor, angiotensin receptor blocker, beta-blocker, calcium
channel blocker or statin in the 6 months pre-implementation
were included. Individuals who had a recent health shock
(e.g., MI, angina) were included in the ‘event’ cohort, while
others on medications only were considered ‘no-event’
patients.
Principal Findings: The study included 18,029 patients, of
whom 1,548 had a recent CV event. The rolling 3-tier adoption
resulted in a 3:1 ratio of number of patients in the intervention
vs. control groups for both event cohorts. Gender and age
were similar in the comparison groups. Difference-indifference results found no significant changes in drug
utilization within the ‘event’ cohort. Results for the ‘no-event’
intervention group found significantly larger reductions in
non-preferred CV drug use per enrollee (0.16 Rx vs. 0.04 Rx;
p<0.0001), and larger increases in the number of generic drug
used per enrollee (0.12 Rx vs. 0.05 Rx; p=0.0269) compared to
controls. Patient copayments increased for all tiers of CV
drugs in the intervention groups. However, plan payments per
enrollee for non-preferred drugs dropped significantly more
for people who experienced the benefit change (by $9.74 vs.
$2.28 for no-event, p<0.0001; and by $17.09 vs. $4.86 for
event, p=0.0021). As a result, intervention groups had higher
overall patient copayments compared to controls (by $4.96 for
no-event and by $8.65 for event; p<0.001), and more
reduction in overall plan payment (by $7.18 for no-event;
p=0.0008). Multivariate analyses controlling for age, gender,
proxy for income and time confirmed these findings.
Conclusions: Implementation of a three-tier formulary
resulted in increased use of preferred drugs among the noevent group, but had little influence over the drug utilization of
people with symptomatic cardiovascular disease. Out-ofpocket costs were higher for all enrollees who experienced the
tier-change, but plan spending was significantly less for these
individuals than for the control group.
Implications for Policy, Delivery, or Practice: The average
effect of a drug benefit change may mask important
differences in impact between subgroups with different
awareness of their medical condition. Plans should consider
this in redesigning benefits.
Primary Funding Source: AHRQ
●Nursing Home Chains: Structure and Strategy
Michael Lin, BA, MSPH
Presented By: Michael Lin, BA, MSPH, Graduate Student
Researcher, Health Services and Policy Analysis, University of
California at Berkeley, 140 Warren Hall, Berkeley, CA 94720;
Tel: (510)528-3069; Fax: (510)643-8613; Email:
lin_mike@berkeley.edu
Research Objective: The primary research objective is to
describe and analyze all nursing home chains operating in the
United States during 2003 and 2004. Specific attention on the
nursing home chain's components will provide insights
regarding organizational structure and operating strategies.
Study Design: This study will analyze the most recently
available (as of 12/2004) Online Survey and Certification
Reporting System (OSCAR) data that has chain linked
information. The study will include descriptive analyses at
both the chain and individual facility level. In addition, the
study uses cross tabulations to describe where these chains
operate, how many homes they operate, the type and amount
of staff they employ, and the characteristics of the residents
that live in these homes.
Population Studied: This population-level study examines all
free standing nursing homes that are certified to receive
Medicare and/or Medicaid funds during 2003 and 2004. This
sample includes 15,006 nursing homes. Facilities from all 50
states are included, and includes non-profit (24%), for-profit
(71%), and publicly-owned nursing homes (5%). Fifty-two
percent of this sample of nursing homes are chain-affiliated.
Principal Findings: Using the chain-linkage information, 37%
of the chain-affiliated homes are operated by a parent
company that has only one other certified facility. Ninety
percent of the chains operate 15 homes or fewer, and only two
percent of the chains operate 50 or more homes. Nearly twothirds (66.3%) of the chains operate in only one state.
Meanwhile, 19% of the chains operate in two states, and 5%
of the chains have components in more than five states
(maximum is 30 states).
Conclusions: Chain-affiliation in the field of nursing homes is
commonplace-- over fifty-percent, and residents living in
chain-owned nursing homes may be receiving below average
levels of care. The for-profit status of the majority of these
chains suggests the possibility that profit motives may affect
the quality of care delivered in these nursing homes.
Implications for Policy, Delivery, or Practice: Greater
attention is needed from survey agencies and researchers to
the chains to which nursing homes belong. Certain nursing
homes chains may be able to standardize high quality care,
while the major concern is that other nursing home chains
standardize low quality care.
Primary Funding Source: No Funding Source
●The Role of Drug Characteristics in the Diffusion of
Prescription Drugs
Melissa Morley, MA
Presented By: Melissa Morley, MA, Ph.D. student, The Heller
School, Brandeis University, 415 South Street Mail Stop 035,
Waltham, MA 02493; Tel: (781)736-3954; Fax: (781)736-3928;
Email: mmorley@brandeis.edu
Research Objective: The purpose of this study is to examine
the relationship between the adoption and diffusion of
prescription drugs and drug characteristics, including directto-consumer advertising, publications in medical journals,
safety alerts and labeling changes, and price.
Study Design: Times series cross-section regression analyses
were performed to analyze the relationship between drug
characteristics and the use of prescription drugs over the
period 1996-2000. The models focused on the utilization of
four drugs approved by the Food and Drug Administration in
1995, alendronate sodium (osteoporosis), glimepiride (type II
diabetes), nisoldipine (hypertension), and cetirizine hcl
(allergies). Data on level of direct-to-consumer advertising,
number of publications in medical journals, number of safety
alerts and labeling changes, and average wholesale price were
collected for each of these four drugs, and for each of their
therapeutic alternatives, for each of the five years 1996-2000,
for use in regression models.
Population Studied: Beneficiaries filling a prescription for
alendronate sodium, glimepiride, nisoldipine, and cetirizine
hcl, and each of their therapeutic alternatives, were identified
using survey responses from the 1996-2000 Medicare Current
Beneficiary Survey (MCBS). The study population was
restricted to non-HMO, non-institutionalized Medicare
beneficiaries.
Principal Findings: The results of the times series crosssection regressions yielded different results for each of
therapeutic areas in the study. In the model for osteoporosis
drugs, variables significantly related to utilization included
direct-to-consumer advertising (p = 0.0206), publications in
medical journals (p = 0.0003), and safety alerts and labeling
changes (p = 0.0046; R-square = 0.90). The results of the
allergy drug model showed that direct-to-consumer
advertising was significant and positively related to the
utilization of allergy drugs (p < 0.0001) and that safety alerts
and labeling changes were significant and negatively related to
utilization of allergy drugs (p = 0.0228; R-square = 0.63). The
results of the regression model including drugs from all four
therapeutic areas (osteoporosis, type II diabetes,
hypertension, and allergies) indicated that levels of direct-toconsumer advertising (p < 0.0001) and number of published
clinical studies (p < 0.0001) were highly significant predictors
of the utilization of prescription drugs for the treatment of
these conditions.
Conclusions: The results of the analyses reveal that there is a
relationship between drug characteristics and the utilization of
prescription drugs. Direct-to-consumer advertising, targeting
patients, and publications in medical journals, targeting
physicians and patients, have a significant and positive impact
on the utilization of prescription drugs.
Implications for Policy, Delivery, or Practice: The patterns
of adoption and diffusion of new prescription drugs are
important to understand given the impact that prescription
drugs have both on the total cost of treating illness, and in
improving health status and quality of life.
Primary Funding Source: AHRQ
●Modeling Quality Improvement for Depression
Rachel Mosher, BA, Ph.D. Candidate, Thomas McGuire, Ph.D.
Presented By: Rachel Mosher, BA, Ph.D. Candidate,
Department of Health Care Policy, Harvard Medical School,
180 Longwood Avenue, Boston, MA 02115; Tel: (617)432-5303;
Fax: (617)432-2905; Email: mosher@fas.harvard.edu
Research Objective: Depression quality improvement (QI)
interventions based on the collaborative care model have been
found to significantly improve depression care and outcomes
in controlled trials. Despite proven efficacy, efforts by health
care organizations to integrate the collaborative care model
into practice are often unsuccessful. In order to make
progress in improving the quality of care for depression and
other conditions, therefore, it is critical to understand the
factors preventing the adoption of evidence-based practices.
However, conventional empirical approaches to assessing the
importance of organizational and provider characteristics
associated with change are limited because they rely on singleequation models that may fail to account for the decision
structure in organizations where doctors practice. In this
paper, we develop and assess a structural model for
measuring implementation of depression quality
improvement interventions to address this issue and to
improve the design of future studies in this area.
Study Design: This paper consists of two parts. First, a
structural model of the implementation of the collaborative
care model for depression is developed based on the
literature. Second, patient and provider data from a grouplevel randomized controlled trial of quality improvement
programs for depression are used to test the predictions of
the model.
Population Studied: Data from 265 primary care providers
and 1498 adult primary care patients with major depression
receiving care in 108 primary care clinics that participated in a
randomized controlled trial to improve depression care are
used in this analysis.
Principal Findings: A two-stage model of the implementation
of the collaborative care model for depression was developed
based on the QI literature which highlights the importance of
systems change for successful QI adoption. The first stage of
the model specifies the factors associated with clinic-level QI.
In depression interventions, clinic-level QI includes change to
the structure and financing of care to enable clinicians to
improve depression care for their patients. The second stage
of the model specifies factors associated with provider-level
QI. Provider-level QI in depression interventions entails
change in the delivery of depression care to patients including
improved diagnosis, symptoms assessment, treatment
options, and follow-up. As predicted, preliminary findings
suggest that the structural model held for the implementation
of depression QI components hypothesized to be contingent
on clinic-level systems change.
Conclusions: The two-stage model of implementation
appears to be an appropriate model for the adoption of
intervention components which are contingent on clinic-level
change. The improvement in fit and explanatory power of the
structural model over the conventional model will be assessed
in future research on the factors associated with depression
QI adoption.
Implications for Policy, Delivery, or Practice: Findings from
this paper advance a new methodological approach for
modeling QI implementation and lay the groundwork for
future analyses of the organizational and provider
characteristics associated with successful implementation of
QI interventions.
Primary Funding Source: NIMH, Sloan Foundation
●Predictors of Utilization of Colorectal Cancer Screening
Tests (CRC) and Adherence to the Screening Guidelines
among Low-Income Populations
Mika Nagamine, Ph.D., Kathryn Phillips, Ph.D., Jennifer Haas,
M.D., Su-Ying Liang, Ph.D.
Presented By: Mika Nagamine, Ph.D., Post-doctoral fellow,
University of California, San Francisco, 3333 California Street,
San Francisco, CA 94118; Tel: (415)514-1471; Email:
mikan@itsa.ucsf.edu
Research Objective: The purpose of this study is to find
socio-demographic factors that predict 1) CRC screening
utilization and 2) adherence to CRC screening guidelines
among the low-income population in the US. Many
researchers have noted low levels of colorectal cancer (CRC)
screening utilization and adherence to CRC screening
guidelines among low-income individuals. However, a
surprisingly small number of studies used a nationally
representative sample and have examined what factors could
be associated with the utilization and adherence of these
individuals. This study is intended to fill this gap of
knowledge.
Study Design: The utilization of and adherence to FOBT,
sigmoidoscopy and colonoscopy were examined. Individual
level analysis was conducted on the NHIS2000. “Lowincome” was defined as family income <200% poverty
threshold. This criterion was selected because this income
level is often used by states to determine welfare eligibility.
“Utilization” means in the current study that individuals had
ever been screened. This was the first dependent variable.
“Adherence” means that individuals receive a specific CRC
screening test within the recommended time frame. In this
study, this second dependent variable was specified as
“among those who had ever had any CRC screening,
individuals who either 1) had a Fecal Occult Blood Test
(FOBT) in the last year, 2) had a sigmoidoscopy in the last 5
years, or 3) had a colonoscopy in the past 10 years”. Various
socio-demographic variables were identified as “potential
predictors of CRC screening utilization or adherence to CRC
screening guidelines” based on review of the literature. These
variables include age, gender, health insurance types,
physician recommendation for CRC screening, having a usual
source of care, health conditions and risk factors associated
with CRC such as processed meat consumption. Preliminary
associations between dependent variables and independent
variables were examined using a Chi-Square test. Further
analysis with the Chi-square test and logistic regression will be
conducted to find the differences in predictors of the
utilization and adherence between low-income populations
and middle to high-income populations.
Population Studied: Participants of NHIS2000 who had the
family income <200% poverty threshold, were at least 50 years
of age, and had no personal history of colorectal cancer were
selected (N=3321).
Principal Findings: The results of the preliminary analysis
showed that, first, 43% of low-income individuals had ever
been screened and 64% of these screened individuals were
adherent to the CRC screening recommendation. These
proportions were smaller than the rates of utilization, 54%,
and adherence, 69%, of the representative sample of the US
general population (including all income groups) based on the
NHIS2000. Second, some individual characteristics seemed
to be associated with lower utilization rates and/or adherence
rates than the overall utilization rate (43%) and adherence rate
(64%) of low-income individuals. They were not, however,
statistically significant. These individual characteristics and
their rates of utilization and adherence were “Hispanic” (31%,
57%), “Asian”(32%, 53%), “Never married”(40%, 52%), “living
with partner”(29%, 42%), “uninsured”(23%, 54%), and “have
Medicaid”(41%, 59%). Third, only 7% of low-income
individuals reported that they had a physician
recommendation for CRC screening. This proportion was
smaller than the US general population with physician
recommendation (9%). Forth and finally, the proportion of
Medicaid beneficiaries, including those with private insurance
but not Medicare, who had ever had CRC screening (41%) was
the same with those with both Medicaid and Medicare (41%).
The number was smaller than those with private health
insurance (56%), and larger than the uninsured (23%). The
differences in these proportions were marginally significant
(p=0.06). Likewise, the proportion of Medicaid beneficiaries
who were adherent to the CRC screening guideline (57%) was
smaller than those with both Medicaid and Medicare (59%) or
private health insurance (68%), but larger than the uninsured
(54%). The differences among these proportions were not
statistically significant, however. Statistically significant or
marginally significant predictors of utilization and adherence
seemed to be consistent with the ones that were found in the
literature. The variables in the current study associated with
the utilization include age over 75 (p=0.08), high school
education or greater (p=0.02), US born (p=0.09), insured
(p=0.03), having health insurance requiring referral for
specialist care (p=0.05), former smoker (p=0.05), having
family history of cancer (p=0.07), and vitamin supplement use
(p<.001). Marginally significant predictors of adherence were
high school education or greater (p=0.09), managed care
participation (p=0.08), having a health insurance requiring
referral for specialist care (p=0.07), and physically active
(p=0.06).
Conclusions: Low-income individuals are generally thought to
be less adherent to treatment and less likely to use cancer
screening compared to other income groups. However, this
study showed the possibility that low-income individuals can
be adherent to the CRC screening guideline once they have
gone through CRC screening. Among the low-income
individuals, those who were Hispanic or Asian, never married
or living with a partner, uninsured, and Medicaid beneficiaries
could be particularly disadvantaged in terms of receiving CRC
screening. Though some of these variables were not
statistically significant in the current study, it could be still
important to note these variables since they overlap with the
variables associated with low rates of the utilization and
adherence among the US general population including lowincome individuals. Finally, to have Medicaid may not be as
helpful as having private insurance, though it seems that
Medicaid beneficiaries were better off than those without
insurance in terms of receiving CRC screening or adhering to
the CRC screening guideline.
Implications for Policy, Delivery, or Practice: The Medicaid
income cutoff point is family income below 133% of poverty
line. For these very low-income individuals, Medicaid is often
the only health insurance that they can afford to have.
Unfortunately, the results of the current study indicated that
Medicaid might not have as much positive effect as private
insurance has on these individuals to increase their utilization
of or adherence to CRC screening. One of the potential
reasons is that Medicaid coverage of CRC screening varies
depending on states, and there is no federal assurance for
each state Medicaid program to cover CRC screening in
people without symptoms (American Cancer Society, n.d.).
The other reason could be that Medicaid participants have a
larger number of barriers to access the screening compared to
others. Health care professionals and policy makers may need
to be mindful about the issues that the Medicaid population
faces in order to increase their utilization of and adherence to
CRC screening. In addition, health care professionals need to
actively encourage low-income individuals (particularly those
who are Hispanic, Asian, never married or living with a
partner, and uninsured) to participate in CRC screening and
also provide recommendations for this participation. Studies
in the past repeatedly showed the importance of physician
recommendation, but the current study showed only a few %
of low-income individuals received it. This proportion needs
to be improved. Reference: American Cancer Society (n.d.).
Colorectal cancer: Early detection. Retrieved January 13, 2005,
from
http://www.cancer.org/docroot/CRI/content/CRI_2_6X_Color
ectal_Cancer_Early_Detection_10.asp?sitearea=
Primary Funding Source: NCI
●Nursing Home Staffing and Quality of Care: Is More
Staffing Always Better?
Jeongyoung Park, MPH
Presented By: Jeongyoung Park, MPH, Doctoral Candidate,
Department of Health Policy and Administration, University of
North Carolina at Chapel Hill, 1103F McGavran-Greenberg
Hall, CB#7411, Chapel Hill, NC 27599-7411; Tel: (919)8241696; Fax: (919)966-6961; Email: jypark@email.unc.edu
Research Objective: Nursing home staffing can be a main
determinant of quality of care measured by processes and
outcomes, and a proxy for quality of care as well. However, the
level and mix of nursing staff may be chosen by facilities in
response to the residents’ health needs as well as facilities’
internal resource allocation criteria. Such selection in staffing
decisions may lead to bias in estimates of the relationship
between staffing and patient outcomes or quality of care. The
purpose of this study is to determine the effect of staffing level
and mix with respect to health outcomes while controlling for
choices made by the facilities.
Study Design: To identify the relationship between staffing
and quality of care at the facility level, multivariate regression
analysis with instrumental variables is used with resident,
facility, and market-level covariates. The IVs are Medicaid
payment rates, state minimum staffing standards, and market
factors. These IVs help to identify how nursing homes
respond to exogenous state policy shocks and the relative
competitiveness of the market and local resource constraints,
and to investigate how these changes interact with staffing to
yield changes in quality of care. With adjusting for the
endogeneity of staffing decision, the empirical model
introduces both continuous and categorical measures of
staffing level into the models based on possible nonlinear
relationship between staffing and quality of care. The unit of
analysis in this study is the facility and specific quality
measures represent facility rates regarding use of physical
restraints, functional changes, pressure sore, and
incontinence. The facility staffing level variables are hours per
resident day for nurse aides, LPNs, and RNs, and the facility
staffing mix variables are the proportion of RNs, and
RNs+LPNs hours compared to total staff hours.
Population Studied: The data on staffing and quality come
from Online Survey Certification and Reporting System from
1998 through 2002. The OSCAR system is from state surveys
of all federally certified Medicare skilled nursing facilities and
Medicaid nursing facilities including about 96% of nation’s
nursing homes. OSCAR data are being linked to data on
specific market conditions, Medicaid payment rates, and state
staffing regulations.
Principal Findings: Currently in progress
Conclusions: Currently in progress
Implications for Policy, Delivery, or Practice: The cost to
increasing the staffing level and mix can be a substantial
burden for both nursing facilities and the government.
Therefore, identification of the true relationship between
staffing and quality of care in order to determine specific
staffing standards to achieve the optimal quality of care is an
important public policy issue. The results from the study will
be useful for understanding the contributions of staffing level
and mix to the quality of nursing home care. The results will
also enable a broader understanding of the effects and costs
of policies such as minimum staffing ratios.
Primary Funding Source: No Funding Source
●Evaluation of Community-Based Participatory Research
Program: The Witness for Wellness Experience
Kavita Patel, M.D., Ricky Bluthenthal, Ph.D., Loretta Jones,
MA, Kenneth Wells, M.D., MPH
Presented By: Kavita Patel, M.D., Robert Wood Johnson
Clinical Scholar, Division of General Internal Medicine, UCLA,
911 Broxton Avenue, 3rd Floor, Los Angeles, CA 90402; Tel:
(310)794-2257; Fax: (310)794-2268; Email:
kavitapatel@mednet.ucla.edu
Research Objective: National research recommendations call
for new models of community participation as an integral part
of mental health services research. Mobilization of
communities is required to identify barriers to care, to
implement efficient and efficacious interventions, and support
availability of mental health services. The Witness for
Wellness project is an ongoing community partnered project
between community based organizations, academic centers of
excellence, community members and local governments. The
purpose of the collaborative effort is to improve access to
depression care, to promote the implementation of evidencebased mental health services by providers, increase
community interest and commitment to identifying and caring
for those with depression and advocate for policy changes in
support of mental health services. The overall project is
monitored by a Support Council which is composed of
representatives from each of the aforementioned constituents.
The approach to evaluation of the numerous aspects of this
collaboration is critical to the success of community-based
research, but traditional methods of evaluation are not wellsuited for academic-community partnerships. The Witness for
Wellness Project has begun to implement various evaluation
techniques tailored for community based research.
Study Design: This study is a pre- and post- design of the all
the attendees of the Witness for Wellness Community
Conference. Our evaluation approach incorporated both
qualitative and quantitative techniques to capture the process
and outcome of activities at a community-wide conference
held in the city of Los Angeles in July 2003. The purpose of
the conference was to give feedback on the progress of the
research collaboration back to the relevant community. The
qualitative data include observations and field notes along
with semi-structured open-ended interviews. Quantitative
data consisted of self-administered surveys. The evaluation
domains included knowledge, attitudes, and beliefs about
depression and depression care.
Population Studied: The conference had 370 participants
(n=370) and each conference participant was asked to
complete surveys at the beginning and end of the conference.
264 participants (71.4%) completed pre-conference
assessments and 274 participants (74.1%) completed postconference assessments. 168 participants (45.1%) completed
both pre- and post- conference assessments. Over 50% of the
conference participants were from community based
organizations, with the remainder of participants from
academics, government agencies, providers and community
members.
Principal Findings: Quantitative Results: The pre- and postconference survey revealed that the conference itself increased
the information that community members had about where to
seek treatment for depression. The conference participants
also expressed an increased feeling that they could respond to
depression as a community. Additionally, over 80% of the
respondents of the post-conference survey felt that the
community and medical professionals could actually help
make a difference with regard to depression recognition and
treatment.
Qualitative Results: Responses to the question "What does
depression look like?", participants stated that it is a "quiet
monster" and can afflict anyone and its signs and symptoms
can be masked by a lack of knowledge about mental illness
and the stigma associated with mental illness.
Conclusions: Evaluation in a community-academic
partnership must bring a community's voice to the analysis
and be a collaborative process in which quantitative and
qualitative data are shared in an equal fashion. Our findings
indicate an important role for a feedback process with
opportunities to measure the impact of a community based
conference on depression and depression care. Future
research should be directed at refining evaluation
methodology in community based projects.
Implications for Policy, Delivery, or Practice: Policymakers
may want to understand the unique aspects of community
based participatory research with regards to national research
agendas and funding of agencies who perform communitybased research.
Primary Funding Source: NIMH
●Effect of Influenza Vaccination on Acute Myocardial
Infarction in Diabetic Fee-for-Service Medicare
Beneficiaries
Mark Patterson, MPH, Sally C. Stearns, Ph.D.
Presented By: Mark Patterson, MPH, Ph.D. Student, Division
of Pharmaceutical Policy and Evaluative Sciences, University of
North Carolina-Chapel Hill School of Pharmacy, CB #7360
Beard Hall, Chapel Hill, NC 27599-7360; Tel: (919) 966-6722;
Fax: (919) 966-8486; Email: pattersm@email.unc.edu
Research Objective: The influenza vaccine has been shown to
be protective against acute myocardial infarction (AMI),
possibly by decreasing plaque rupture in the arteries. No
currently known study has examined this association in
diabetic Medicare beneficiaries, who are at higher risk for
experiencing myocardial infarction compared to the general
population. This study examines the association between selfreported receipt of influenza vaccination and the incidence of
acute myocardial infarction in diabetic Medicare FFS
beneficiaries
Study Design: This retrospective longitudinal cohort analysis
uses 1992-1998 Medicare Current Beneficiary Survey (MCBS)
Cost and Utilization data to examine whether Medicare feefor-service (FFS) diabetics vaccinated for influenza are less
likely to have an AMI or die within one year of receiving the
vaccine, compared to non-vaccinated diabetics. AMI was
defined using diagnosis-related group codes from claims data.
Vaccination status was assessed using self-reports and claims
indicators of vaccine receipt. As claims data yielded low
vaccination rates, the analysis relied primarily on self-reported
vaccination during the past 12 months. The analysis file has
8,002 person-year observations, representing 3,819 unique
individuals with an average follow-up time of 4.7 years.
Random effects logistic regression is used to model the
probability of AMI as a function of influenza vaccination status
within the prior year.
Population Studied: The MCBS survey sample consists of a
stratified random sample of 12,000 Medicare beneficiaries,
sampled from enrollment lists of persons entitled to
Medicare. The analysis was restricted to FFS diabetics aged 65
or older who were followed for at least 13 months. Diabetics
were identified using either self-reports of the disease or
indications of a diabetes diagnosis from 2 or more claims.
Principal Findings: Approximately 61% of the sample
reported being vaccinated within the previous year at baseline.
Unadjusted differences in the rates of myocardial infarction in
the previous year between vaccinated and non-vaccinated
individuals were not statistically significant.
After controlling for age, gender, smoking, BMI, co
morbidities in the previous year, medication utilization,
education level, income, marital status, and census region,
reported influenza vaccination was not significantly associated
with a reduction in the odds of acute myocardial infarction
[OR=0.80, 95% CI (0.59 – 1.08)(p=0.15]. On average,
vaccination decreased the probability of AMI by 0.04
percentage points.
Conclusions: Based on observational data, influenza
vaccinations do not appear to be protective against AMI in
diabetic Medicare FFS beneficiaries. Conversely, point
estimates do suggest a potential association which may be
masked by measurement error.
Implications for Policy, Delivery, or Practice: Despite the
null findings, influenza vaccinations are still clinically
recommended for the elderly, especially those with chronic
conditions such as diabetes.
Primary Funding Source: No Funding Source, Access to data
enabled through NIA grant
●Pediatricians' Perspectives on Access to Mental Health
Services and Coordination of Mental Health Care
Susan Pfefferle, MEd
Presented By: Susan Pfefferle, MEd, doctoral candidate,
Heller School for Social Policy and Mangement, Brandeis
University, 415 South Street, Waltham, MA 02454; Tel:
(781)646-2791; Email: pfefferle@comcast.net
Research Objective: Determine pediatricians' perceptions of
access to mental health services and mental health care
coordination.
Study Design: Qualitative descriptive study using comments
from a survey of pediatricians in six states. The survey covered
issues regarding pediatrician mental health screening and care
coordination children. Out of 584 survey responses (60%
response rate) 187 pediatricians (32%) answered the question,
“Is there anything else that you feel would be helpful in
understanding factors that help or hinder you from
coordinating care for children with mental illness.” Line by
line coding was done using Atlas-TI qualitative software.
Codes were then sorted into categories and themes
developed.
Population Studied: Pediatricians were randomly selected
from a mailing list of pediatricians. Comments were obtained
from all states, distributed as 31 from Connecticut, 29 from
Kansas, 34 for New Hampshire, 30 South Carolina, 26 from
Utah, 37 from Washington.
Principal Findings: Themes broke into two major categories:
access and coordination. For access pediatricians identified
not only the lack of mental health providers, but especially
psychiatrists. Limited provider panels further complicated
access, both for patients with Medicaid and private managed
care, although Medicaid was more problematic. Wait times for
mental health care ranged from weeks to almost a year. Also,
pediatricians in several states identified that they were unable
to bill for providing mental health treatment when there was
no psychiatrist nearby. Several wrote that in order to obtain
reimbursement for treating these children they needed to
game the diagnoses. Pediatricians also expressed frustration
that psychiatrists “dumped” children back to them for
“medication management” after exhaustion of mental health
benefits. Some felt comfortable treating mental illnesses while
others felt unprepared by their residency programs to treat
these disorders. Many identified that they are unable to make
direct referrals for treatment because Medicaid and private
plans require that parents self-refer. This complicates
pediatricians’ abilities to follow-up on referrals, establish
relationships with mental health specialists, and reassure
parents that their child will receive quality care. Regarding
coordination pediatricians expressed frustration at the lack of
communication from mental health specialists regarding
children they referred for treatment. Several noted that they
always receive feedback from other specialists. They expressed
the desire to develop relationships with mental health
providers for consultation and referrals. Lack of time, and
reimbursement for time spent in coordination were also
identified as obstacles.
Conclusions: Pediatricians are frustrated in finding
appropriate treatment for children with mental illness. They
see themselves as providers of last resort, often treating these
children themselves. Otherwise, the children often go
untreated. Pediatricians are left without consultation and
mental health training. Mental health professionals rarely
coordinate care with pediatricians who have referred patients.
Implications for Policy, Delivery, or Practice: These findings
highlight the need for: A. Increased mental health training in
pediatric residency programs. B. Pediatrician involvement in
problem solving access to services. C. Reimbursement
increases for mental health services and reimbursement of
pediatricians for treatment and coordination activities. D.
Dialogue between mental health providers and pediatricians
regarding coordination and mental health consultation.
Primary Funding Source: Fahs Beck Fund for Research and
Experimentation
●Influential Determinants of Chain Acquisition Among
Renal Dialysis Facilities
Alyssa Pozniak, M.A.E., Ph.D. candidate
Presented By: Alyssa Pozniak, M.A.E., Ph.D. candidate,
School of Public Health - Health Mgmt & Policy, University of
Michigan, 109 Observatory Street., Ann Arbor, MI 48109; Tel:
(734)994-0041; Email: apozniak@umich.edu
Research Objective: To better understand acquisition
decisions by renal dialysis chains. There is rationale to
support two conflicting theories regarding dialysis chains’
acquisition motives. A dialysis chain may target a high
performance facility (i.e., high quality/low cost), enabling the
chain to benefit financially from the unit’s efficiency.
Alternatively, a dialysis chain might target an underperforming
facility, theorizing that the chain’s better management will
reduce the unit’s inefficiency and eventually yield higher
profits. This study attempts to answer which acquisition
strategy, if either, dominates the renal dialysis industry.
Study Design: Although there are hundreds of distinct entities
providing dialysis-related services to nearly 300,000 End Stage
Renal Disease (ESRD) patients, the size of the companies vary
widely. In particular, over half of all ESRD patients in 2002
were treated by the four largest chains. Therefore, a logistic
regression that accounts for chain size (rather than a simple
binary variable for acquired vs. not acquired) is used to
investigate the probability that an independent dialysis facility
is acquired by differently-sized chains. In addition to
economic and financial factors (i.e., cost per dialysis
treatment, local market presence, regional vs. national
presence, competition, ownership), covariates include facility
practice patterns (i.e., different dialysis modalities offered,
staffing), quality-related outcomes (i.e., mortality rates,
anemia management), and chain, facility, and patient specific
characteristics. Although new chain affiliations (independentto-chain) is the main focus, chain conversion (chain-to-newchain) is also considered to determine differences between the
two methods of chain growth.
Population Studied: All freestanding dialysis facilities with
Cost Reports (CMS-265-94) from 1993 through 2003.
Hospital-based dialysis units (approximately 17% of ESRD
facilities) are excluded because of dissimilar reporting
methodology.
Principal Findings: Preliminary results suggest that dialysis
chains are more likely to acquire independent facilities with
low costs per treatment than those with high costs per
treatment. This relationship is especially strong for the largest
dialysis chains. The larger chains also are more likely to target
independent facilities where the chain already has a market
presence. Further research is also underway to more fully
understand the effect of facilities’ quality-related outcomes
and practice patterns on chains’ acquisition decisions.
Conclusions: These initial findings suggest that dialysis
chains engage in a “cream skimming” rather than a “turn
around” strategy when acquiring units. Facility-level
characteristics, quality-related outcomes, and practice patterns
also influence a chain’s acquisition decision, and the
importance of these factors appear to vary by the acquiring
chain’s dominance and size.
Implications for Policy, Delivery, or Practice: Like many
other healthcare sectors, chains have been commonplace in
the ESRD industry for many years. The benefits associated
with chain affiliation include economies of scale, lower
transaction costs, and other cost-reducing factors. However,
the recent merger between two of the largest dialysis chains
and the dramatic increase in chain acquisitions raise anti-trust
issues as well as concerns over what effect such large chains
will have on costs and quality of dialysis-related care. Because
the bulk of ESRD-related costs are paid by Medicare,
policymakers are particularly concerned that the potential
benefits associated with dialysis chain affiliation may be
outweighed by the threat of monopolistic pricing practices and
decreased consumer choice.
Primary Funding Source: No Funding Source
●Decreasing Gap in Life Expectancy Between Males and
Females: Effect on Long-Term Care Use Near Death
France M. Priez, MS
Presented By: France M. Priez, MS, Ph.D. candidate, Health
Policy and Administration, The University of North Carolina at
Chapel Hill, 7400 McGravan-Greenberg Hall, Chapel Hill, NC
27599-7400; Tel: (919)966-6445; Fax: (919)966-6961; Email:
priez@email.unc.edu
Research Objective: The differential in life expectancy
between males and females has been decreasing over the last
decades. As a result, elderly females are becoming more likely
to have a spouse/partner who is a potential source of informal
care. Increasing availability of spousal care may modify the
future use of LTC. Specifically, this study examines the role of
cohabiting status (being married or living with a peer adult)
and gender on the use of LTC when approaching death.
Special attention is paid to changes in use during the two
years before death, as prior studies have shown substantial
increases in LTC use during this period.
Study Design: Longitudinal Probit models are used to
estimate differences in the cohabitation- and gender-specific
probabilities of nursing home, formal and informal home care
use by proximity to death, i.e. being or not within two years of
death. The potential endogeneity of proximity to death is
addressed using an instrumental variable approach. The
instruments are characteristics of the interviewee’s parents
(age at death, education level, and socioeconomic status). The
control variables are age, health measures, socioeconomic
characteristics, living arrangement and area of residence.
Population Studied: The analysis uses a nationally
representative sample of the elderly aged 70+ in 1993,
obtained from the Health and Retirement Survey (1993 to
2002). In 1993, the target population contains 7,433
participants, 45.3% being married and 0.5% living with a peer
adult. Half of the baseline sample dies by 2002.
Principal Findings: Cohabitating status plays a significantly
different role by proximity to death. The effect of cohabitating
status is concentrated in the two last years of life, with the
largest variation in nursing home use. The likelihood of
institutionalization within two years of death is 20 times
higher for non-cohabiting women (19.73%) than cohabiting
women (0.96%). When not close to death, non-cohabiting
women (5.6%) are only 1.6 times more likely than cohabiting
ones (3.6%) to be institutionalized. The probability of formal
home care use within two years of death is 1.6 times higher for
non-cohabiting (13.7%) than cohabiting women (8.2%), and
for informal home care it is 0.7 times lower (25.2% versus
34.1%). Men display comparable results. Initial analysis
suggests, however, that the endogeneity of proximity to death
biases results upward.
Conclusions: Increases in LTC use prior death are
substantially smaller when the elderly are cohabiting. The
decreasing gender gap in life expectancy will reduce the future
use of nursing home because more women will be cohabiting
prior to death. Formal home care use may diminish as well,
but to a lesser extent. The results also confirm the
substitutability of market-based LTC with informal home care:
this latter will increase as women are cohabiting longer.
Implications for Policy, Delivery, or Practice: The increase
in the future use of LTC may not be as high as anticipated by
some researchers and policy makers. Consideration of the
impact of the reduction in the gender gap in life expectancy
will improve forecasts of the evolution of programs covering
long-term care, such as Medicaid or Medicare.
Primary Funding Source: Swiss Science Foundation
●Home Healthcare Nurses' Perceived Level of Job-Related
Stress: Do Work Environments Make a Difference?
Linda Samia, RN, MS, CNAA
Presented By: Linda Samia, RN, MS, CNAA, Project Director
and Doctoral Student, College of Nursing and Health
Sciences, University of Massachusetts Boston, 100 Morrissey
Boulevard, Boston, MA 02125; Tel: (617)287-7523; Email:
linda.samia@umb.edu
Research Objective: Home healthcare nurses have
experienced unprecedented change since the enactment of the
Balanced Budget Act of 1997. New regulations, and evolving
interpretation in regulations, have contributed to nurses’
perceived level of job-related stress. Job related stress is a key
predictor of nurse satisfaction. The purpose of this study is to
examine the relationship between the Home Healthcare
agency environment and nurses’ perceived level of job related
stress. Specifically the dimensions of the professional practice
model will be explored in examining differences among
organizational structures and support for professional nursing
practice and their relationship to levels of perceived job-related
stress.
Study Design: This is a correlational study using secondary
data analysis of primary data collected during the Home
Healthcare Nurse Job Retention Study*. Data was collected by
self-report using the Home Healthcare Nurse Job Satisfaction
(HHNJS) scale. *The Home Healthcare Nurse Job Retention
Study is funded by the Agency for Healthcare Research and
Quality. Carol Hall Ellenbecker, Ph.D., RN, Associate
Professor at the University of Massachusetts Boston is
Principal Investigator for this study.
Population Studied: The population studied is home
healthcare nurses employed in Medicare Certified Home
Healthcare agencies located in one of six New England States.
There are approximately 6000 nurses employed in the 293
Medicare certified agencies in New England. The random
sample of over 2400 nurse participants represents nurses
employed in a proportionate to size random sample of 125
New England Home Healthcare agencies.
Principal Findings: Nurses working in home care are
experiencing high levels of stress in their job however there is
some variability in the level of stress related to agency
characteristics and type of nursing position. Nurses working
in agencies that support professional nursing practice report
lower levels of perceived job-related stress. Nurses working in
direct care positions report greater job-related stress than
nurse managers. Nurses working in part-time positions
perceive lower levels of stress.
Conclusions: Job–related stress experienced by nurses is
related to characteristics of the organization in which they
work. Agencies have opportunity to create environments that
support professional nursing practice.
Implications for Policy, Delivery, or Practice: The findings
from this study can be used by agencies to create more
effective organizational structures. They may also inform
policy makers considering regulatory revision necessary for
efficient and effective use of home healthcare nursing
resources when faced with a scarce resource pool
Primary Funding Source: AHRQ
●Beyond Access: Considering the Role of Health
Behaviors in Nonadherence to Mammography Guidelines
Karen Schneider, BA, Ph.D. candidate, Kate Lapane, Ph.D.
Presented By: Karen Schneider, BA, Ph.D. candidate,
Graduate Student, Community Health, Brown University, 167
Angell Street, Box G-H1, Providence, RI 02912; Tel: (917)6707837; Email: Karen_Schneider@brown.edu
Research Objective: Although progress has been made with
regard to mammography adoption, research differentiating
women who have never had a mammogram from intermittent
users in reference to routine screeners is still needed. While
healthy lifestyle choices are associated with regular screening,
health care access barriers are consistently associated with
never having mammography. We sought to evaluate the
extent to which behavioral factors explain the relationship
between access factors and nonadherence to guidelines.
Study Design: The 2001 California Health Interview Survey is
a large, cross-sectional survey. Women aged 55-79 years,
n=7,379, were categorized as: never had mammography,
n=455; had mammography but off-schedule, n=1,235; and
those adhering to biennial screening guidelines, n=5,689.
Using SUDAAN to develop polytomous multiple logistic
regression models, we evaluated access barriers: usual source
of care, insurance status, rural vs. urban area and English
proficiency. We then controlled for health behaviors, including
alcohol intake, exercise, BMI, and smoking status, in an
attempt to understand the influence of these variables on the
measured effect of access barriers.
Population Studied: The specified age range included women
for whom there are consistent guidelines and who had
adequate time to adhere to repeat screening
recommendations. We excluded women with history of breast
cancer, with missing information on mammography variables,
with an excessive number of mammograms in the asked time
frame, and women whose most recent mammogram was for
diagnostic purposes.
Principal Findings: Six percent of women never had a
mammogram and 17 percent were off-schedule. Adjusting for
sociodemographic variables and all access barriers, we found
that never users of mammography, compared to regular
screeners, were more likely to have no usual provider,
adjusted ROR = 4.73, 95 percent CI, 2.54-8.83; be uninsured,
AROR = 3.08, 1.89-5.02; and live in a rural area, AROR = 1.28,
0.92-1.76. Further adjustment for health behavior variables
did not appreciably alter these estimates - 0-1% change in
measures of association. Intermittent users, compared to
regular screeners, were more likely to have no usual provider,
AROR = 3.07, 1.91-4.95; be uninsured, AROR = 2.35, 1.61-3.43;
and live in a rural area, AROR = 1.23, 0.98-1.55. Once again,
differences in health behaviors did not explain the findings
between mammography and access barriers - 0-3.5% change
in estimates. English proficiency showed no association with
screening for either group and did not change with
adjustment.
Conclusions: Controlling for health behaviors did little in
altering the effect of health care access barriers on
mammography. Women with healthy lifestyles – low BMI,
daily exercise, low alcohol intake and nonsmoking status – are
just as likely to lack screening due to access barriers as
women who do not partake in other health behaviors.
Implications for Policy, Delivery, or Practice: We cannot rely
on individuals to seek out cancer preventive strategies if there
are significant access barriers. Those without insurance and
no usual provider should be targeted for free cancer screening
services before public health officials focus on the behavioral
and psychosocial issues of adopting routine practices.
Primary Funding Source: No Funding Source
●The Impact of VA Priority Score on Use of Fecal Occult
Blood Test in VA and Medicare Systems
Tamara Schult, MPH, Beth Virnig, Ph.D., Laura Kochevar,
Ph.D., Dave Nelson, Ph.D., Boris Bershadsky, Ph.D.
Presented By: Tamara Schult, M.P.H., Doctoral Trainee/Data
Manager, Occupational Health Services Research and
Policy/VA Colorectal Cancer QUERI, University of
Minnesota/Mpls VA Medical Center, One Veterans Drive
(152/2E), Minneapolis, MN 55417; Tel: (612)467-4650; Fax:
(612)727-5699; Email: tamara.schult@med.va.gov
Research Objective: To describe patterns of VA and non-VA
use of the fecal occult blood test, FOBT, for veterans enrolled
in both VA and Medicare.
Study Design: This analysis utilized data from the VA
Colorectal Cancer QUERI’s Colorectal Cancer Screening and
Follow-up Event surveillance system - CRC-SAFE. CRC-SAFE is
designed to collect data needed to estimate: variation in
screening and follow-up rates by patient characteristics;
reliability and validity of combined VA and Medicare
administrative databases for assessing and tracking
recommended colorectal cancer screening and follow-up
practices; and impact of Medicare service coverage on the
screening and follow-up rates of VA users. When veterans
enroll in VA, they are assigned into one of seven priority
groups based on service-connected and other disability,
income, and special considerations. Patterns of use were
compared for the following two groups: Group 1 - VA enrollees
who are catastrophically disabled, with low-income, or with
service-connected disability 50 percent or more and Group 2 enrollees in the other four priority groups including POWs and
veterans with service-connection less than 50 percent.
Enrollees in Group 1 are more likely to have no private
insurance or only basic Medicare coverage.
Population Studied: The population was comprised of 73,145
veterans with dual enrollment in VA and Medicare aged 65
years and older in 2001 and 2002 that had used services at
one of four VA facilities, including Durham, Minneapolis,
Portland or West L.A, and were not enrolled in a Medicare
HMO during this time.
Principal Findings: Overall, 55.2 percent of dual users were in
Group 1 and 44.8 percent were in Group 2. Use of FOBTs did
not vary considerably between priority groups. For Group 1,
32.2 percent had a FOBT in the 12 months preceding their
most recent visit to a VA or non-VA provider. The majority,
87.3 percent obtained the FOBT in a VA facility, 10.4 percent in
a non-VA facility, and 2.3 percent in both. For Group 2, 32.5
percent had a FOBT in the previous 12 months. However, a
smaller percentage, 66.1 percent obtained the FOBT in a VA
facility, while 26.1 percent obtained the FOBT in a non-VA
facility, and 4.0 percent obtained FOBTs in both types of
facilities.
Conclusions: The overall FOBT utilization for Group 1 was
very similar to that of Group 2. In addition, the findings
regarding location of FOBT utilization by priority group are
consistent with more general results from the 1999 Large
Health Survey of VA Enrollees, which found that dual enrollees
without supplemental Medicare coverage, including Medigap
or other private insurance, relied more on the VA for most of
their care, while VA enrollees with supplemental coverage
used primarily non-VA providers.
Implications for Policy, Delivery, or Practice: The major
concern with dual utilization is communication between VA
and non-VA providers. Although a high percentage of
veterans are being screened for colorectal cancer, the dual-use
and the size of the unscreened populations illustrate the need
for increased communication between VA and non-VA
providers. Results indicate the need for interventions
designed to increase compliance with screening guidelines
while taking the dual-use into account.
Primary Funding Source: VA
●The Effects of State Mandated Coverage of
Mammography
Rebecca Shackelton, ScM, Vincent Mor, Ph.D.
Presented By: Rebecca Shackelton, ScM, Ph.D. student,
Community Health, Brown University, 167 Angell Street,
Providence, RI 02912; Tel: (401)863-3172; Email:
Rebecca_Shackelton@brown.edu
Research Objective: Numerous regulations for the content of
private health insurance in the United States have emerged at
both the state and federal levels. Many state-mandated benefit
laws require coverage of particular types of providers or
services, such as screening mammography. However, little is
known about the effects or consequences state mandates
have on health behaviors or outcomes. We used Poisson
regression techniques as well as Geographic Information
Systems (GIS) techniques to examine the effects of state
mandates regarding coverage of mammography on recent
mammography screening rates.
Study Design: Data regarding mandated coverage of
mammography services are available from state insurance
departments. Mammography coverage mandates were
classified as none, general, other or specific based on the
description of mammography services in the mandate. We
calculated mammography rates on the county level using the
2002 Behavioral Risk Factor Surveillance System (BRFSS).
Specifically we were interested in whether a woman had a
recent mammogram, defined as having a mammogram in the
past one year. Data were spatially joined to geo-coding of U.S.
counties from the U.S. Census Bureau’s Topically Integrated
Geographic Encoding Reference (TIGER) data system.
Population Studied: The sample was 66,377 women aged 4079, living in the continental United States.
Principal Findings: Overall, 41,867 (63.1%) of women
reported they had a mammogram in the past year. Data on
mammography rates was available from 955 in the United
States. A significant association (Rate Ratio=1.08, p=0.0002)
was found between specific state mandates, those that
specifically reference a guideline group, and recent
mammography screening rates. All regression coefficients
were positive, with no mandate as the referent, indicating that
any state mandate regarding mammography is associated
with a higher mammography screening rate than no state
mandate. There was also a notable spatial dependency among
mammography rates (Moran’s I = 0.32, z = 4.84), indicating
that further analyses should incorporate a spatial design.
Conclusions: These analyses indicate a strong relationship
between state mandated coverage of mammography and the
rate of mammography. For example, states with specific
mandates are associated with an 8% higher screening rate
than states with no mandate regarding mammography.
Implications for Policy, Delivery, or Practice: To date, very
few studies have examined the effects of state mandates on
health behavior endpoints. This study indicates that state
mandates may have large impacts on health behaviors and
health outcomes.
Primary Funding Source: No Funding Source
●Examination of the Outpatient U.S. National Practice
Data to Estimate the Need for Prior Authorization of
Topical Retinoids.
Rahul Shenolikar, MS, Rajesh Balkrishnan, Ph.D., Steven R.
Feldman, M.D., Ph.D.
Presented By: Rahul Shenolikar, MS, Doctoral Student,
Pharmacy Practice and Administration, Ohio State University,
500 West 12th Avenue, Columbus, OH 43210; Tel: (614)2920136; Fax: (614)292-0815; Email: shenolikar.1@osu.edu
Research Objective: Topical retinoids that are prescribed in
acne vulgaris and psoriasis are now being used to treat
photodamaged skin. Insurance companies generally
reimburse for some of the costs associated with medications
to treat acne vulgaris and psoriasis, but not for medications
used to treat photodamaged skin. Fears of potentially costly
use of topical retinoids for cosmetic treatment of
photodamaged skin has resulted in many managed care
organizations placing prior authorization requirements on this
class of medications. The purpose of this investigation was to
examine whether prescribing patterns of a nationally
representative sample of US physicians shed light on potential
inappropriate use of topical retinoids.
Study Design: A retrospective, cross-sectional study of data
from the National Ambulatory Medical Care Survey (19962000) was used. The topical retinoids that were included were
tretinoin, adapalene, tazarotene, and all of the brand names
associated with these medications The impact of patient
diagnosis of acne on the probability of retinoid prescription
was determined by using weighted multivariate logistic
regression models. We examined predictors of both receipt of
any topical retinoid prescription as well as specific topical
retinoid in separate multivariate logistic regression models. All
analyses were adjusted using the NAMCS sampling weights.
Population Studied: Cross sectional analysis of national
survery data
Principal Findings: Topical retinoids were prescribed in 0.4%
of the 3.67 billion visits for any diagnosis from 1996-2000, and
in nearly 31% of the visits for 38.7 million visits for acne. Of
patients receiving a prescription for adapalene, 91% had a
diagnosis of acne vulgaris whereas only 45% of patients
receiving tazarotene had a diagnosis of acne vulgaris. Nearly
74% of patients receiving a prescription for tretinoin had an
acne vulgaris diagnosis. The study found that there was
negligible prescription of topical retinoids for non-acne related
conditions. Risk Ratio [RR] for topical retinoid prescription
with acne diagnosis: 58.8, 95% CI: 33.4, 103.7). This
association was the strongest for adapalene (RR: 99.2, 95%
CI: 34.0, 289.4) versus tretinoin (RR: 67.2, 95% CI: 301, 150.0)
versus tazarotene (RR: 2.8, 95% CI: 1.33, 5.91). Patients aged
18 years and under were 1.3 times more likely to be prescribed
a topical retinoid than patients aged 19-65 years (RR: 1.26,
95% CI: 0.98-1.62). Patients aged 65 years and over were less
likely to be prescribed a topical retinoid (RR: 0.37, 95%CI: 0.230.58). Clear age-related prescription trends were observed,
with significant decrease in prescriptions beyond the teen
years.
Conclusions: The data do not support a need for general
prior authorization of topical retinoids. There was negligible
prescription of topical retinoids for non-acne related
conditions and this finding held when individual topical
retinoids were examined separately. Prior authorization
requirements for topical retinoids may not be necessary in
young patients, given the very small probability of non-acne
related use. In older patients, prior authorization, if needed at
all, should focus only on those topical retinoids for which
there is evidence of efficacy in treatment of cosmetic
photoaging.
Implications for Policy, Delivery, or Practice: The findings
will aid formulary decision making
Primary Funding Source: No Funding Source
●Market Characteristics and Selection in Medicare
Managed Care
Stephanie Shimada, AB, Alan M. Zaslavsky, Ph.D., A. James
O'Malley, Ph.D., Amy Heller, Ph.D., Paul D. Cleary, Ph.D.
Presented By: Stephanie Shimada, AB, Ph.D. Candidate,
Department of Health Care Policy, Harvard Medical School,
180 Longwood Avenue, Suite 111A, Boston, MA 02115; Fax:
(617)432-3696; Email: shimada@hcp.med.harvard.edu
Research Objective: To document the degree of selection
between Medicare managed care (MMC) and fee-for-service
(FFS) based on health status, education, and race and the
extent to which selection is related to market characteristics
such as managed care penetration and market
competitiveness.
Study Design: Cross-sectional analysis of data from CAHPS
surveys administered to a probability sample of Medicare
beneficiaries in managed care plans and those with traditional
Medicare in 2000. The surveys asked respondents for global
ratings of care, reports about specific experiences with care,
personal characteristics and health status.
Population Studied: In 2000, CAHPS surveys were
completed by 173,395 MMC enrollees and 83,645 traditional
Medicare beneficiaries (response rate = 83%). Data were
included in the analyses if beneficiaries lived in a county in
which there were at least 10 managed care and 10 fee-forservice respondents, yielding a sample of 179,838 Medicare
beneficiaries from 595 counties.
Principal Findings: Healthy beneficiaries were significantly
more likely to be enrolled in MMC than sick ones (OR=1.22).
However, the degree of adverse selection was higher in
counties with low MMC penetration. The predicted odds ratio
for healthy relative to sick beneficiaries choosing managed
care was 1.22 at minimum (0.2%) penetration, falling to 1.14
at median (23.1%) penetration and 1.04 at maximum (55.0%)
penetration. Similar effects were found with the number of
plans in the market and the Herfindahl Index. Compared with
beneficiaries with an 8th grade education or less, beneficiaries
with higher levels of education were less likely to be in
Medicare managed care. Beneficiaries with more than a 4year college degree were significantly less likely to be enrolled
in a MMC plan than those with an 8th grade education or less
(OR=0.39). The effect of education was even more
pronounced among the healthy (OR=0.28). Compared with
white beneficiaries, all minorities, with the exception of Pacific
Islanders, were more likely to be enrolled in a MMC plan.
Conclusions: MMC plans experience favorable selection on
health. However, this effect was less pronounced in areas
with higher penetration of MMC, more MMC options, and
more competition among plans. Ethnic minorities and
beneficiaries with low educational attainment were more likely
to be enrolled in managed care. Those with the lowest levels
of education were even more likely to be enrolled in managed
care if they were healthy.
Implications for Policy, Delivery, or Practice: Results
suggest that if Medicare Advantage succeeds in expanding
enrollment in managed care, there would be less favorable
selection into MMC plans. The quality of the care received by
vulnerable subgroups should be monitored to ensure that they
do not receive inferior care or choose to remain in Medicare
managed care solely because it is more affordable than
traditional Medicare.
Primary Funding Source: CMS
●Price Elasticities for Three Types of Complementary and
Alternative Health Care Services
Elizabeth Sommers, MPH, Lic.Ac.
Presented By: Elizabeth Sommers, MPH, Lic.Ac., Research
Director, Research, Pathways to Wellness, 142 Berkeley Street 2nd floor, Boston, MA 02116; Tel: (617)859-3036 x24; Fax:
(617)859-0965; Email: esommers@bu.edu
Research Objective: The health economics literature of
complementary and altenative medicine (CAM) include
surveys on out-of-pocket expenditures and descriptions of
third party payers who reimburse for CAM services.
Investigators have not yet tackled issues such as price
elasticity of demand in CAM care. Using data from a large
public health CAM clinic in Boston, price elasticities of
demand will be determined for acupuncture, Chinese herbal
consultations, and shiatsu treatment.
Study Design: Using data collected on utilization and client
demographics, the study will evaluate the effects of a $5
increase in price of treatment for each of the three services. In
July, 2004 the price of all treatment went from $30 to $35.
Population Studied: Clinical services are used primarily by
low-income residents of metropolitan Boston. Individuals are
from a variety of ethnic backgrounds, including primarily
African-American, Asian-American, white, and Latino. The data
come from adults ranging in age from 19 to 84 years of age.
Principal Findings: Raising the price 17% had definite impact
on demand of care. Values of price elasticities were -0.35 for
acupuncture services, -1.31 for Chinese herbal consultation,
and -2.34 for shiatsu treatment.
Conclusions: The value of the price elasticity associated with
acupuncture treatment was the smallest of the 3 services,
indicating relatively less responsiveness of demand to price.
Clients may perceive that acupuncture treatment is more
relevant for their care, or acupuncture clients may have more
serious health conditions. Although this assessment cannot
address the question of why different magnitudes of
responsiveness occur, the evaluation can begin to quantify
relevant issues in health economics of CAM care.
Implications for Policy, Delivery, or Practice: Although the
sample is small and self-selected, the evaluation begins to
address the importance of understanding the economics of
CAM care. Consumers are choosing and paying millions of
dollars annually for CAM services throughout the U.S.,
offering health services researchers the opportunity to analyze
associated economic trends, preferences, and perceptions.
Primary Funding Source: No Funding Source
●Caregiver Strain: Experiences of Different Caregivers of
Children with Serious Emotional Disturbance
Kelly Taylor-Richardson, MSW, MS
Presented By: Kelly Taylor-Richardson, MSW, MS, Predoctoral Fellow, Center for Evaluation and Program
Improvement, Peabody #151, Vanderbilt University, 230
Appleton Place, Nashville, TN 37203; Tel: (615)322-8343; Fax:
(615)322-7049; Email: kelly.d.richardson@vanderbilt.edu
Research Objective: This study attempts to fill a knowledge
gap by analyzing how parents and other relative caregivers
that are dissimilar on several demographic variables
experience strain from caring for a child diagnosed with a
serious emotional disturbance (SED). The purpose of this
study is to improve the understanding of the differences in
strain experienced by different caregiver groups of these
children in an effort to better meet needs of the caregivers.
This will be done by exploring differential relationships
between dimensions of strain and demographic
characteristics common to many caregiving studies. This
study also attempts to examine whether caregiver strain, as
measured by the Caregiver Strain Questionnaire (CGSQ)
(Brannan, Heflinger, & Bickman, 1997), is generalizable to
groups other than the sample for which it was developed.
This study seeks to answer three questions regarding these
caregivers: 1) Within the Medicaid sample, parents vs. other
relative caregiver comparisons; 2) comparisons between total
Medicaid caregivers vs. military caregivers from the FBEP
study and; 3) factor analyses to determine if the CGSQ is
generalizable to groups other than the sample for which it was
developed.
Study Design: Between and within group differences were
examined in two samples using the 21-item, Likert scaled,
Caregiver Strain Questionnaire (CGSQ). Using descriptive
statistics and exploratory factor analysis (EFA), comparisons
were made of: 1) caregiver responses within a Medicaid
sample of parents (n= 539) and other relative caregivers
(n=109) and 2) the total Medicaid sample (n= 648) to a
military sample (n= 978) from the Fort Bragg Evaluation
Project, with which the CGSQ was developed.
Population Studied: This secondary analysis used data from
two studies of children with serious emotional disturbances
(SED). The first study focused on children who had Medicaid
in Mississippi and Tennessee; and the second focused on
children of military parents taken from the Fort Bragg
Evaluation Demonstration Project.
Principal Findings: Overall, parents reported higher levels of
strain than other relatives and Medicaid and military samples
had differential reports on the subscales. The EFA showed that
the CGSQ did an adequate job of capturing strain for all
caregivers, however, other relatives, in comparison to parents
caring for a child diagnosed with an SED: a) reported two
types of Objective Strain, and b) did not endorse as many of
the emotionally-based items (i.e., social isolation, sadness,
and embarrassment).
Conclusions: This study demonstrates that relative caregivers
in poverty report different levels of strain than those in the
military, but the CGSQ showed very similar factor structures
across all groups. These findings suggest the need to develop
tailored approaches to assisting different groups of caregivers
in coping with their strain.
Implications for Policy, Delivery, or Practice:
Understanding contributions to and protective factors of
caregiver strain is a relevant policy issue. Increased strain has
been shown to predict more expensive treatment, more days
of care, higher levels of care (Brannan, Heflinger, & Foster,
2003). Additionally, there is growing support for a system of
care that has a family-focused, community-based approach to
service delivery (Macro International, 1998).
Primary Funding Source: NIMH
●Relationship of Patient Safety to Patient Outcomes:
Analysis of HCUPnet Patient Safety Indicators
Deirdre Thornlow, MN, RN
Presented By: Deirdre Thornlow, MN, RN, Director,
Gerontology Programs, , American Association of Colleges of
Nursing, 9309 Boothe Street, Alexandria, VA 22309; Tel: (202)
463-6930; Fax: (202) 785-8320; Email: dkt4u@virginia.edu
Research Objective: Determining organizational factors that
are associated with patient safety is crucial for today’s
healthcare environment. This study is an examination of the
relationship between hospital organizational characteristics -size, ownership, location, teaching status, and region -- and
six indicators of potentially preventable complications using
the publicly available Healthcare Cost and Utilization Project
database.
Study Design: Rates of occurrence for six potentially
preventable complications and adverse events were measured
using the Agency for Healthcare Research and Quality
HCUPnet. The following six indicators were evaluated: 1)
death in low mortality DRGs, 2) failure to rescue; 3)
postoperative hemorrhage or hematoma; 4) postoperative
physiologic and metabolic derangement; 5) postoperative
respiratory failure; and 6) post-operative sepsis. These
indicators were selected as measures of hospital quality that
prior research suggests are potentially attributable to
organizational characteristics. Patient characteristics such as
age, gender, geographic residence, insurance status, and
income level were also evaluated within HCUPnet.
Population Studied: The study population was derived from
the 2000 HCUPnet Patient Safety Indicator database, an
interactive, publicly available database that contains dischargelevel information compiled in a uniform format with privacy
protections in place. HCUPnet generates statistics using data
from the Nationwide Inpatient Sample, which includes
inpatient data from a national sample of over 1,000 hospitals,
and the State Inpatient Databases, which covers inpatient care
in hospitals in twenty-eight participating States.
Principal Findings: HCUPnet descriptive statistics indicate
that males, adults older than 65 years of age, and patients with
Medicare and Medicaid insurance experience higher rates of
complications for select patient safety indicators.
Furthermore, descriptive statistics indicate that patients from
urban metropolitan service areas and those cared for in urban
hospitals also experience higher rates of complications for the
patient safety indicators analyzed in this review. Structural
characteristics such as ownership, teaching status, and bed
size demonstrate inconsistent findings, yet patients treated in
hospitals with less than 100 beds experienced lower rates of
complications for the majority of the patient safety indicators.
Conclusions: Our findings support earlier studies which
found that elderly patients are at particular risk for patient
safety incidents. Due to the inability to control for staffing and
skill mix, and without the ability to risk adjust for patient
characteristics, it is difficult to make assumptions regarding
the finding that smaller hospitals and hospitals in rural areas
had lower rates of patient safety incidents. Additional research
related to these organizational variables is warranted.
Implications for Policy, Delivery, or Practice: Although
inability to risk-adjust is a limitation of this study, the findings
support evidence within the literature that incidents
associated with hospitalization are more common in older
adults. Given that the older population is growing rapidly,
prompt attention to patient safety in this population is
warranted. Additionally, given today’s complex healthcare
environment, it is crucial to explore the extent to which
differences in mortality, complications, and other adverse
events are reflective of differences in organizational
characteristics. At present, elucidating this relationship among
the many variables is imprecise. Further research is warranted
to build a stronger evidence base to determine which
organizational factors are the best determinants of patient
outcomes.
Primary Funding Source: NINR
●Internet-Based Information and Quality of Care: The
Physician Perspective
Virginia Wang, MSPH, Shoou-Yih Daniel Lee, Ph.D.
Presented By: Virginia Wang, MSPH, Doctoral Student,
Health Policy and Administration, University of North Carolina
at Chapel Hill School of Public Health, CB #7411, Chapel Hill,
NC 27514; Tel: (919)593-2832; Fax: (919)966-6961; Email:
vwang@email.unc.edu
Research Objective: The increasing popularity of the Internet
as a source of information on medicine and health is
presumed to have a profound effect on the way health care
services are delivered. Users (both patients and physicians)
are equipped with information about their health and health
care options, which have the potential to alter
communications between patients and providers and to affect
patients’ compliance with treatment regimens and health
outcomes. However, the effect of this new media is unclear.
This study examines physicians’ use of the Internet as
resource in clinical practice and their perceptions of how
Internet use affects the physician-patient relationship and
quality of care.
Study Design: Secondary analysis of data from a physician
survey, conducted in 2000. Ordered probit estimation was
used to examine two dependent variables of interest, both
conditional on the physician-respondent having patients bring
information gathered from the Internet to their doctor visit.
The first assessed physicians’ perception of improvement in
the patient-physician relationship. The second dependent
variable assessed physicians’ perceived change in patients’
quality of care. Four variables of interest related to the
frequency of physicians' Internet use and the degree of
physicians’ interactions with patients who use Internet-based
information were tested. Characteristics of individual
physicians and their practices were also controlled for in the
model estimates.
Population Studied: A stratified random sample of 2,000
physicians, who spent at least 20 hours a week on direct
patient care, was selected from a national list of the American
Medical Association member and non-member physicians.
Principal Findings: Some of physicians’ use of Internet is
associated with improvement in quality of care. Physicians
who are active users of the Internet tend to view favorably
patients’ use of the same media. Specifically, physicians who
actively use the Internet as a professional reference for
information about medical conditions and treatments are less
likely to consider patients’ use of the Internet as harmful to
the patient-physician relationship. However, physicians who
use the Internet to communicate with patients are more likely
to report poor patient-physician relationships and poor quality
of care. The proportion of patients who discuss information
they found on the Internet during a doctor’s visit is unrelated
to improvements in patient care.
Conclusions: Physicians’ perceptions of the Internet’s impact
on patient care seems to be conditioned upon physicians’
personal use of the Internet; the perceptions are more positive
when physicians themselves use the Internet to gather
information on medical conditions and treatments. Findings
also suggest that physicians may feel the time constraint in
reading and responding to patients’ inquiries about Internetbased health information.
Implications for Policy, Delivery, or Practice: Recent
recommendations to increase patient-doctor communication
via electronic mail may unintentionally increase the workload
and time constraint in physician practice and therefore strain
the relationship between physicians and patients. Physicians
may need to adjust their practices to accommodate patients’
who have better access to Internet-based health information
and who are more inquisitive about treatment options.
Primary Funding Source: No Funding Source
●The Use of Spanish by Medical Students and Residents
at a University Hospital
Daniel Yawman, M.D., Scott McIntosh, Ph.D., Diana
Fernandez, Ph.D., Marjoree Allan, BS, Peggy Auinger, MS,
Michael Weitzman, M.D.
Presented By: Daniel Yawman, M.D., Fellow, Pediatrics,
University of Rochester, 1351 Mt. Hope Avenue, Suite 130,
Rochester, NY 14620-3917; Tel: (585)-275-1833; Fax: (585)-2760150; Email: daniel_yawman@urmc.rochester.edu
Research Objective: Background: US census data show that
the number of people who speak Spanish at home increased
from 17.3 to 28.1 million from 1990 to 2000. There is a
shortage of Spanish-speaking physicians to care for this
expanding population. Objective: To describe how medical
trainees self-report communication with Spanish-speaking
patients at one university hospital in a community where the
Hispanic population increased by 50% from 1990 to 2000.
Also, to assess the willingness of trainees to improve their
Spanish language skills.
Study Design: A survey was mailed to subjects at three-week
intervals for a total of three mailings. Each subject was
assigned a code number at the initiation of the study.
Analysis was performed with SPSS.
Population Studied: The survey was mailed to all 4th year
medical students and non-first year residents in: Family
Practice, Pediatrics, Medicine, Medicine-Pediatrics,
Emergency, and OB/GYN (N=263). Each respondent had at
least one year of clinical experience at the university.
Principal Findings: The response rate was 241/263 (92%).
Respondents categorized their Spanish skills as: none (32%),
rudimentary (51%), conversational (13%), or fluent (5%). More
than 99% have seen Spanish-only speaking patients and 165
(68%) see such patients at least monthly. Of the 199 (83%)
who had no or rudimentary Spanish language skills, 105 (53%)
had taken a history and/or provided medical advice directly to
these patients without using any form of translation. If a
translator was utilized, family/staff were utilized more
frequently than professional translators (58% vs. 42%, p<.05).
Of the 164 (68%) who report having at least rudimentary
Spanish skills: 139 (85%) would probably or definitely
participate in further individual language training, 120 (73%)
expressed at least possible willingness to have their Spanish
formally evaluated, and 132 (80%) predict that it is at least
possible that they will use their Spanish as an attending.
These percentages did not differ between medical students
and residents (p>.05).
Conclusions: These data show that medical students and
residents from multiple specialties use inadequate Spanish
language skills to provide direct medical care. This adds to
published data that found similar findings in one pediatric
residency program. In addition, a subset of trainees (1) wants
to improve, (2) welcomes evaluation, and (3) plans to use
their Spanish.
Implications for Policy, Delivery, or Practice: Incorporating
language training and evaluation into the curriculum of
motivated medical trainees may benefit trainees and patients.
Primary Funding Source: HRSA
●Effects of Health on Changing Labor Force Participation
in Transition China
Deokhee Yi, MPH
Presented By: Deokhee Yi, MPH, Ph.D. candidate, Health
Policy and Administration, School of Public Health, 1103B
McGavran-Greenberg Hall, CB#7411, Chapel Hill, NC 275997411; Tel: (919)968-3624; Email: dhyi@email.unc.edu
Research Objective: The proposed study investigates the
effect of health on labor force participation of aged 40-70
during the economic transition in China, which experienced
huge social and economic transition in the late 20th century.
An extensive literature demonstrates that there are substantial
returns in labor markets to investments in education, but
comparatively few studies have examined the returns to other
dimensions of human capital, such as health, particularly for
developing countries. This study seeks to answer the following
questions: 1) Did individuals with lower stocks of baseline
health contribute less to economic growth, as measured by
labor force participation? 2) Did negative health shocks cause
substantial near-term changes in labor force participation? 3)
Were any negative effects of poor health buffered by factors
such as education levels, marital status, urbanization, age?
Study Design: A wide array of health indicators include selfreported general health status, anthropometric measure such
as height and body mass index (BMI), a clinical measure of
blood pressure and one of the activities of daily living,
mobility. Dependent variable is labor force participation
defined by working status at the point of survey. The rich
panel design of CHNS allows lagged effects model, growth
model, fixed effects and instrumental variables estimators to
better identify the causal effects of interest.
Population Studied: This study uses the China Health and
Nutrition Survey (CHNS) panel household data set collected
by the Carolina Population Center in 1989, 1991, 1993, and
1997. The overall age range during four waves is 21 to 84
because adults aged 30 and above in any survey year are
included in the analytic file.
Principal Findings: BMI and blood pressure have statistically
significant effects on LFP and the magnitude of coefficient
shows dose-response relationship. Lighter persons are more
likely to work than heavier ones and people with hypertension
or those who are taking anti-hypertensive drug are less likely to
work. General health status and mobility also show significant
effects. But height does not have strong effect on LFP, which
might be due to uncontrolled heterogeneity.
Conclusions: Health, in general, has strong effects on labor
force participation among Chinese adults when per capita
asset, education, marital status, region, and so forth are
controlled. BMI shows an opposite results to the usual
prediction, which may be due to characteristics of Chinese
situation and agricultural labor. Hypertension is a clinical
measurement with a significant effect on LFP. Further studies
with longer follow-ups and more reasonable instrumental
variables are strongly required.
Implications for Policy, Delivery, or Practice: Social and
economic changes stirred in a transition economy may render
many people without health stock less likely to participate in
the labor force. The differential investment in human capital
like health may be one of the reasons for the increasing gaps
among different social groups and different regions. Long
term investment in health is needed to be taken into account
for policy decision making.
Primary Funding Source: No Funding Source
●Association of Hospital Ownership and Resource
Availability with Implementation of Computerized
Physician Order Entry (CPOE)
Feliciano Yu, M.D., MSHI, Jeroan J. Allison, M.D., MS, Eta S.
Berner, EdD, Thomas K. Houston, M.D., MPH
Presented By: Feliciano Yu, M.D., MSHI, Postdoctoral Fellow
UAB Outcomes Research Training Program, UAB Center for
Outcomes and Effectiveness Research and Education, 5428
Sunrise Drive, Birmingham, AL 35242; Tel: (205) 910-2467;
Email: fyu@peds.uab.edu
Research Objective: To assess the association of hospital
ownership, location and resource availability with
implementation of computerized provider order entry (CPOE).
Study Design: Retrospective cohort study of hospitals. CPOE
implementers were defined as hospitals that reported they had
or were in the process of implementing CPOE. Hospital
location, teaching status, ownership, and three resource
availability markers (nurse-staffing, total beds, and a “Saidin”
technology index) were linked from the 2001 American
Hospital Association survey.
Population Studied: 650 hospitals participating in a Leapfrog
Group CPOE survey (July 2004)
Principal Findings: Sixteen percent (104/650) of the hospitals
had implemented or were implementing CPOE. Of the 104
implementors, only 25 had fully implemented CPOE. For-profit
hospitals were less frequently CPOE implementers than notfor-profit hospitals (2% vs. 24%; p < 0.001). Because only 5 of
the for-profit hospitals were implementing CPOE, we
performed further analysis within the not-for-profit hospitals.
Univariate analysis among not-for-profit hospitals showed that
CPOE was more frequently implemented in hospitals located
in larger metropolitan areas and those that were teaching
hospitals, had higher nurse staffing ratios, more hospital
beds, and higher medical technology adoption. After
adjustment, two of the three resource markers, nurse-to-bed
ratio [OR = 1.79 (95% CI = 1.17 – 2.74)] and total hospital beds
[OR = 1.18 (95% CI = 1.04 – 1.35)] were independently
associated with CPOE implementation.
Conclusions: Large implementation differences were seen
between not-for-profit and for-profit hospitals. Resource-poor
hospitals have limited CPOE implementation.
Implications for Policy, Delivery, or Practice: The Institute
of Medicine and the Leapfrog Group have advocated
implementation of Computerized Physician Order entry
(CPOE) because of its potential impact on patient safety.
However, diffusion of CPOE has been limited. Policy makers
should be aware that there are significant differences in CPOE
implementation by hospital ownership and resource
availability. If CPOE is to become a standard, we need to
consider how best to support hospitals that may not have
financial incentives or resources to afford implementing
CPOE.
Primary Funding Source: AHRQ