General Posters
General Posters
Poster Session B
Monday, June 26 • 5:30 pm – 7:00 pm
●Impact of Prescription Drug Benefit Plan on Medication
Adherence
Berhanu Alemayehu, Dr.P.H., Rich Feifer, M.D., Allen
Schwartz, PharmD, Shamus Mcguire, M.B.A., Ronald Aubert,
Ph.D.
Presented By: Berhanu Alemayehu, Dr.P.H., Director, Medical
Affairs, F2-4, Medco Health Solutions, Inc., 100 Parsons Pond
Drive, Franklin Lakes, NJ 07417; Tel: (201)269-6338; Fax:
(201)269-1025; Email: berhanu_alemayehu@medco.com
Research Objective: To determine the association between
prescription drug plan design features and patient adherence
(compliance and persistency); identify disease conditions
most affected by plan designs; and determine if demographic
variables or other covariates of interest are confounding
factors.
Study Design: A cross-sectional study using prescription
claims data. Medication adherence, measured by drop-off
rates and medication possession ratio (MPR), was calculated
for selected medication classes (statins, antidepressants,
antihypertensives and oral diabetes drugs). Chi-square and ttests were used to determine the overall association between
adherence (drop-off and MPR) and plan design variables.
Logistic regression was used to determine plan design
characteristics associated with whether or not patients
continue to use medication during the study period (i.e. dropoff), controlling for a set of covariates. Generalized Linear
Model was used to identify plan design variables and patient
characteristics associated with medication compliance (MPR).
Population Studied: Patients in 28 employer groups enrolled
in pharmacy benefits through Medco in 2004; patients had
two-year continuous eligibility.
Principal Findings: New patients had a lower MPR and are
more likely to drop off therapy than existing users (odds ratio
ranged from 1.8, 95% CI: 1.7-2.0 for antihypertensive drugs, to
2.5, 95% CI: 2.2-2.8 for oral diabetic drugs). Lower adherence
rate was observed for predominantly - retail users vs. mailorder users (OR ranged from 1.3, 95% CI 1.2-1.4, to 2.3, 95% CI
2.1-2.6), low generic users (OR ranged from 1.4, 95% CI: 1.11.5, to 1.6, 95% CI: 1.5-1.8) and patients with higher out-ofpocket cost-share and with no out-of-pocket maximum. Older
and sicker patients had a higher MPR and were more likely to
stay on therapy than younger and healthier patients. Average
MPR for oral diabetic drugs was 0.80 (95% CI: 0.78-0.81), 0.83
(95% CI: 0.82-0.84) for antihypertensive drugs, 0.81 (95% CI:
0.80-82) for cholesterol-lowering drugs, and 0.71 (95% CI:
0.70-0.72) for antidepressants.
Conclusions: Compliance and persistency are influenced by
most plan design attributes. Patients most vulnerable to
worsening compliance and drop-off include those that were
new to therapy, predominantly retail, had low generic use, low
disease severity, were younger, paid higher total cost-share,
covered by plans with coinsurance and plans without an outof-pocket maximum.
Implications for Policy, Delivery, or Practice: Prescription
drug plan design features have a significant impact on
utilization and patient adherence. With the new Medicare
prescription drug benefit plan in 2006 the findings of this
study may help employers and health plans identify cost
control measures that may be useful for designing retiree
benefit plans that do not adversely affect utilization of chronic
maintenance medications.
Primary Funding Source: No Funding
●National Estimated of Excess Healthcare Expenditures
Due to Arthritis
Orit Almagor, MA, Larry M. Manheim, Ph.D., Rowland W.
Chang, M.D.; M.P.H., Christina J. Yang, BA, Dorothy D.
Dunlo, Ph.D.
Presented By: Orit Almagor, MA, Research Associate,
Institute for Healthcare Studies, Northwestern University, 339
East Chicago Avenue, Room 717, Chicago, IL 60611;
Tel: (312)503-4466; Fax: (312)503-2936;
Email: o-almagor@northwestern.edu
Research Objective: Compare health care expenditures for
persons with and without arthritis at low (10th percentile),
median, and high (75th and 90th percentiles) expenditure
levels using a nationally representative sample, to examine
whether higher costs due to arthritis are consistent across the
expenditure distribution.
Study Design: The 2002-2003 Medical Expenditure Panel
Survey (MEPS) is used to obtain a nationally representative
sample. MEPS survey followed individuals for two years.
Baseline (2002) self-reported information includes
demographics, function limitations, and chronic diseases
including arthritis, as defined by the National Arthritis Data
Workgroup. Total health care expenditures (sum of office and
hospital-based care, home health care, dental services, vision
aids, other medical equipment and services, and prescribed
medicines) and concurrent insurance status were obtained
from the second year (2003). We examined three questions at
each expenditure percentile studied: 1) Do persons with
arthritis have higher expenditures than those without? 2) Does
arthritis cost more after controlling for differences in
demographics, economics and comorbid chronic conditions?
3) What baseline factors contribute to high arthritis
expenditures? Quantile regression at each percentile
compared health care expenditures between persons with and
without arthritis. Logistic regression examined what factors
predict high expenditures among persons with arthritis.
Population Studied: The MEPS is used to obtain a nationally
representative sample of 4,788 individuals age forty-five years
and older.
Principal Findings: Total health care expenditures for persons
with arthritis are at least doubled compared to persons
without for all percentiles of expenditures examined.
Expenditures for persons with arthritis remain higher after
adjusting for demographics, health conditions, and
economics status compared to their counterparts without
arthritis. A substantial portion of excess costs were explained
by functional limitations. Furthermore, among persons with
arthritis, the presence of functional limitations strongly
predicted high (90th percentile) expenditures.
Conclusions: Total expenditures among persons with arthritis
are greater compared to counterparts without arthritis
controlling for risk factors across a spectrum of low to high
expenditures. Excess expenditures due to arthritis are largely
explained by accounting for the presence of functional
limitations.
Implications for Policy, Delivery, or Practice: Prevention
and intervention programs targeted at reducing functional
limitations are central to reducing high health care expenses
among persons with arthritis.
Primary Funding Source: NICHD; NIAMS
●Patient Access to US Physicians who Conduct Email
Consults
Kristy Alvarez, B.S., Christopher Sciamanna, M.D., M.P.H.,
Michelle L. Rogers, Ph.D., Edmond D. Shenassa, Sc.D.,
Thomas K. Houston, M.D., M.P.H.
Presented By: Kristy Alvarez, B.S., Research Study
Coordinator, Health Policy, Thomas Jefferson University, 1015
Walnut Street, Suite 115, Philadelphia, PA 19107; Tel: (215) 9555733; Fax: (215) 923-7583; Email: kristy.alvarez@jefferson.edu
Research Objective: To describe the patients’ access to
physicians who conduct email consults using both physicianand patient-level data, to better understand the association of
other, potentially important variables.
Study Design: Data from the National Ambulatory Medical
Care Survey, an annual nationally representative crosssectional survey conducted by the National Center for Health
Statistics, in 2001, 2002, and 2003 were analyzed.
Population Studied: Approximately 3000 physicians and
25,000 outpatient visits from the in United States.
Principal Findings: Overall, 6.8% of visits were with a
provider who conducted email consultations (9.2% in 2001,
5.8% in 2002, and 5.5% in 2003). After adjusting for physicianand patient-level variables, there was a trend toward a
decrease between 2002 and 2003, compared to 2001.
Multivariate analyses indicated that the likelihood of seeing a
provider who conducted email consults was greater for visits
to primary care providers (v. specialty providers), among visits
of male patients (v. female) and for visits coded by providers
as not being for preventive care.
Conclusions: The two most striking findings were the low
overall rate in the proportion of visits in which patients saw a
provider who reported doing email consults, and the trend
toward a decline in the rate between 2001 and 2003. Though
the decline was not statistically significant, it amounted to a
40% decrease between 2001 and 2003, at a time when nearly
all other Internet-related activities, such as health information
seeking, enjoyed brisk growth. This represents one of the
largest published studies of patient access to US physicians
who conduct email consults to date. Similarly large studies
have been conducted, but no previous published study had
access to both physician- and patient-level data, to better
understand the association of other, potentially important
variables with this trend.
Implications for Policy, Delivery, or Practice: This study
suggests that without significant positive incentives,
physicians will be extremely slow to adopt doctor-patient
email.
Primary Funding Source: No Funding
●A Novel Website to Improve Asthma Care: Qualitative
Analysis of End-User Experiences
Kristy Alvarez, B.S., Christine Hartmann, Ph.D., Christopher N.
Sciamanna, M.D., M.P.H., Sarah Mui, Danielle C. Blanch
Presented By: Kristy Alvarez, B.S., Research Study
Coordinator, Health Policy, Thomas Jefferson University, 1015
Walnut Street, Suite 115, Philadelphia, PA 19107; Tel: (215) 9555733; Fax: (215) 923-7583; Email: kristy.alvarez@jefferson.edu
Research Objective: To explore patients’ reactions to and use
of an interactive website designed, using current evidencebased guidelines, to provide patients with tailored feedback
and help them understand what questions they should ask
during doctor visits to improve the quality of care they receive.
Study Design: Website feedback consisted of three elements:
(1) a list of suggested questions for patients to ask their
physician, (e.g., “would I benefit from a daily inhaled
corticosteroid?” and “would I benefit from using a long-acting
bronchodilator like salmeterol?”) (2) a lay explanation of why
patients should ask each question, and (3) links to other
websites for further reading and explanations of the suggested
topics. Semi-structured phone interviews were conducted with
36 subjects that had used the website and subsequently
visited a physician. Interview questions addressed issues
including 1) use of the website before the visit; 2) utilization of
information generated from the website during the
subsequent physician’s visit; and 3) how use of the website
changed communication with their physician, if at all.
Interviews were audio-recorded, transcribed, entered into QSR
NVivo® qualitative software and coded based on the
grounded theory technique.
Population Studied: 36 individuals responded to a study
advertisement on www.google.com or a letter to asthma
patients of a large health insurance company in Rhode Island.
All patients were over age 21, had a self reported history of
asthma, a visit with an asthma care provider in the next 2
months, internet access at home or work, and received
asthma care from a primary care provider, rather than a
specialist (e.g., pulmonologist).
Principal Findings: Analysis revealed two main themes. The
first was a shift in attitudes regarding interactions with
physicians: “I’ve been going to this doctor for about 17 years,
[but this was] the first time that I’ve actually gotten anywhere
with him as far as changing what he was doing for me… [The
website gave me] the questions to ask him that seemed to
push him in the right direction as far as giving me something
on a daily basis instead of the inhaler that I was becoming
reliant on.” The second theme revealed a change in how
patients perceived their role in managing their asthma:
“[Asking questions from the feedback sheet] creates a
relationship where you’re working together to create a plan,
and it’s not just the doctor creating the plan…I have more
knowledge now to be able to go to him and have him work on
me.” “[This time] I was able to speak about the fact that I
probably should — or she probably should — look at other
means of treatment, and that’s different than my usual office
visit where I don’t make any suggestive contribution to what
part of treatment is. I just take it all in.”
Conclusions: Overall, the website and its feedback positively
influenced patients’ experiences, prompted physician-patient
communication, and encouraged patients to ask providers for
changes to their plan of care.
Implications for Policy, Delivery, or Practice: Interactive
websites providing patients with tailored messages based on
evidence-based guidelines have the potential to improve
physician-patient communication and the management of
chronic diseases.
Primary Funding Source: National Heart, Lung, and Blood
Institute
●Attitudes Toward Nurse Practitioner-led Management of
Chronic Diseases in Primary Care Settings
Kristy Alvarez, B.S., Christopher Sciamanna, M.D., M.P.H.,
Judy Miller, Kristy L. Alvarez, BS, Tiffany L. Gary, M.H.S.,
Ph.D., Mary Bowen, CRNP, DNS, CNAA, JD
Presented By: Kristy Alvarez, B.S., Research Study
Coordinator, Health Policy, Thomas Jefferson University, 1015
Walnut Street, Suite 115, Philadelphia, PA 19107; Tel: (215) 9555733; Fax: (215) 923-7583; Email: kristy.alvarez@jefferson.edu
Research Objective: To gain an understanding of physician
and nurse-practitioners’ attitudes towards a model of nurse
practitioner-led chronic disease management in primary care
settings.
Study Design: A cross sectional, two page survey was
designed with the goal of introducing the proposed model of
outpatient chronic disease management, and evaluating the
level of support for it in a sample of primary care providers
and nurse practitioners. Questions were designed to assess
aspects of support for the model as well as characteristics of
the provider and professional practice. All questions were
asked on a four point Likert-type scale, with anchors at each
point, from “disagree strongly,” “disagree,” “agree,” to “agree
strongly.” A draft of our one-page hypertension care
encounter form, based on clinical treatment algorithms, which
is proposed for use at the point of care, accompanied the
survey. A two-page self-report survey was mailed to each
provider, along with a $20 gift card to Amazon.com, and the
sample encounter form.
Population Studied: Individuals responding from a randomly
generated list of 200 primary care physicians (Family Practice,
Internal Medicine, General Practice) and 200 nurse
practitioners in the Philadelphia, Pennsylvania area, purchased
from SK&A Information Services, Inc from their database of
over 600,000 providers nationwide. All providers had an
active license, and were located in a 5 mile radius of Thomas
Jefferson University Hospital.
Principal Findings: A total of 212 subjects completed the
survey for a total response rate of 53% (physicians, 44%:
nurse practitioners: 61%). The majority of physicians (79.5%)
reported that nurse practitioners were seeing patients in their
practice. Many respondents reported working in academic
health centers (48.4%) and most seeing outpatients for at
least four days per week (59.4%). Both Physicians and Nurse
practitioners strongly agreed that the proposed model would
make a positive impact on the control of chronic disease
(80.0%, 95.7 respectively. p=<0.001). Both physicians and
nurse practitioner believed the model would be of interest to
similar providers (73.8% 87.6 respectively, p=0.013) though
fewer agreed that the model would have a positive financial
impact on their practice (46.3%, 64.3% respectively, p=0.016).
In general, support for the model was greater among nurse
practitioners, and those who believed that future pay will be
related, at least in part, to patient satisfaction.
Conclusions: The main findings suggest that physicians and
nurse practitioners believe that a nurse practitioner led model
of care can improve the control of chronic illness. Also, it
appears that providers believe that patients will be more
satisfied with this model of care.
Implications for Policy, Delivery, or Practice: Overall, the
high level of support for the model and the presence of nurse
practitioners in a high percentage of physician offices
suggests that such a model of care has the potential to diffuse
naturally if the model is proven in to be effective in the
management of multiple chronic diseases.
Primary Funding Source: National Heart, Lung, and Blood
Institute
●Primary Care Leaders' Responses to Analytic Mapping
Andrew Bazemore, M.D., M.P.H., Robert L. Phillips, Jr., M.D.,
MSPH, Thomas Miyoshi, M.S.W.
Presented By: Andrew Bazemore, M.D., M.P.H., Assistant
Director, Robert Graham Center, 1350 Connecticut Avenue,
N.W., Suite 201, Washington, DC 20036; Tel: (202) 331-3360;
Email: abazemore@aafp.org
Research Objective: The ability to combine outpatient clinical
and population data through analytic mapping has been
demonstrated, but its utility to clinicians and administrators
has not. We evaluated the responses of primary care clinic
leaders, administrators, and community board members to
analytic mapping of their clinic and regional population data.
Study Design: Using a geographic information system, maps
were generated from clinic billing records and census data
identifying each clinical service areas and penetration rates in
an urban primary care network. Focus groups and key
informant interviews were conducted with a selective sample
of community health center staff and members of the
community, exploring their impressions of the utility, risks and
relevance of analytic mapping to their clinical operations and
planning. Subsequently, thematic analysis was performed on
interview notes and transcripts by the investigators.
Population Studied: A selective sample of community health
center administrators, clinicians, and community advisory
board members from a single community health center
network.
Principal Findings: Administrators and clinicians readily
grasped the implications of mapping for targeting outreach
efforts, planning expansion, defining their communities and
populations served, and improving the financial stability of
their clinics. Accurate interpretation of analytic maps required
collaboration between researchers and clinic leaders, which
led to an active and ongoing inquiry. Among limitations to
broader implementation of our methods cited were its cost
and the technological expertise required.
Conclusions: Analytic mapping is enthusiastically received
and practically applied in the primary care setting, and is
readily comprehended and adopted by clinicians and clinic
leaders for innovative purposes.
Implications for Policy, Delivery, or Practice: This is a tool
of potential relevance to all primary care clinics, particularly if
the hurdles of cost and technological expertise can be
overcome through the use of secure, internet-based mapping
technology.
Primary Funding Source: No Funding
●Nesiritide Utilization in the CHF Population - Analysis of
In-Hospital Outcomes
Adam Beck, M.H.S.
●Patient Distribution Among Hospitals Treating Acute
Myocardial Infarction
Kevin Bennett, BS, MS, Ph.D.
Presented By: Adam Beck, M.H.S.,Outcomes Manager,
Outcomes Measurment, Medstar Research Institute, 6495
New Hampshire Avenue, Suite 201, Hyattsville, MD 20783;
Tel: (301) 560-2925; Fax: (301) 560-2974; Email:
adam.beck@medstar.net
Research Objective: Determine the impact of nesiritide
utilization within the congestive heart failure population
Study Design: This was a retrospective, case-control study
utilizing information input into a commercial risk-adjusted
software (Quovadx's CareScience Quality Manager software.)
The study analyzed risk-adjusted mortality, length of stay, and
cost including a comparison of performance of the subset
who received nesiritide to the remainder who did not receive
nesiritide. Also analyzed was performance based on the
timing of the first dose of nesiritide (day 1 vs. day 2 vs. day3,
etc.)
Population Studied: The congestive heart failure population
for all 6 inpatient hospitals of an integrated health system for
a 1 year time period between July 1, 2004 and June 30, 2005.
Congestive heart failure was defined by the patient's principal
diagnosis code. The principal diagnosis codes used were
identical to those used by JCAHO's Core Measure project and
Medicare's Hospital Quality Alliance's Hospital Compare
effort. No other inclusion or exclusion criteria was used.
Principal Findings: The findings anticipated were better than
expected performance for the population that received
nesiritide and similar or better performance than the
population that did not receive nesiritide. The analysis
revealed that the population that received nesiritide did not
perform better than expected and its mortality performance
was similar and length of stay and cost performance was
worse than the performance of the population that did not
receive nesiritide. However one hospital's experience revealed
improved mortality performance and similar length of stay
performance in comparison to the population that did not
receive nesiritide. Differences in length of stay and mortality
performance were observed when the nesiritide was
administered sooner in the patient's stay.
Conclusions: The in-hospital benefit of nesiritide is still in
question. There seems to be no impact to "high level"
outcomes such as length of stay and mortality. Nesiritide is a
costly drug and the population that received the drug was
costly to care for. If nesiritide is used; outcomes are better the
earlier the drug is used in the patient's stay.
Implications for Policy, Delivery, or Practice: In times of
thin margins and tight budgets it is critical that the benefitis
for new, costly drugs targeted at large volume populations are
well defined and carefully analyzed before added to
formularies and "given the green light."
Primary Funding Source: No Funding
Presented By: Kevin Bennett, BS, MS, Ph.D., Assistant
Professor, Family & Preventive Medicine, University of South
Carolina School of Medicine, 3209 Colonial Drive, Columbia,
SC 29203; Tel: (803) 434-3611; Email: kevin.bennett@sc.edu
Research Objective: To determine the extent to which
hospitals treating patients with AMI have unequal
distributions of racial groups and to determine if these
distributions play a significant role in the measurement of
treatment provision.
Study Design: We utilized hospital admissions data from
three states (Florida, Maryland, New York) from the 2000
State Inpatient Database (SID). These data were then linked
to the 2003 Area Resource File and the 2000 American
Hospital Association Survey of Hospitals. Simple bivariate
analysis displayed the characteristics of the hospital visits
(including gender, race, age, and payment method of the
patient). To assess the distribution of race for each hospital,
Lorenz curves and Gini Coefficients were calculated. The
distribution of non-white patients was then included in
hierarchical logistic regression models to assess the impact
on the odds of receiving treatment for AMI. The results
emphasized the impact on the odds ratio for African American
patients.
Population Studied: Patients who had a diagnosis of acute
myocardial infarction (AMI) between the ages of 30 and 75.
The population was further delimited to those who did not die
during the episode of care, and those who were transferred to
another hospital. Those who had missing data were also
excluded.
Principal Findings: The three states had the following Gini
Coefficients: Florida – 0.56 , Maryland – 0.49, and New York
– 0.66. These coefficients indicated a significant level of
maldistribution of race across treatment hospitals. For
Florida and Maryland, the inclusion of the percentage of nonwhite patients at the hospital level in hierarchical logistic
regression models indicated a significant contribution to odds
of receiving treatment by minorities (Odds ratios: 0.96 –
0.99, P < 0.05). The inclusion of the percentage variable
improved the odds of African Americans of receiving
treatment significantly (OR: 0.64 – 0.78, p < 0.05).
Conclusions: The distribution of racial groups within
treatment hospitals may be an important factor to consider
when measuring treatment disparities. It remains to be seen
whether or these distributions play a primary role in treatment
provision.
Implications for Policy, Delivery, or Practice: Targeting
disparity reduction interventions in areas and facilities with
high proportions of minority populations may be more
effective in improving overall disparity measures than more
comprehensive approaches.
Primary Funding Source: No Funding
●Palliative Care Transitions: Factors in Patient Experience
Kate Bent, R.N., Ph.D.
Presented By: Kate Bent, R.N., Ph.D., Associate Chief,
Nursing, VA Eastern Colorado Health Care System, 1055
Clermont Street, Denver, CO 80220; Tel: (303) 399-8020
x2145; Fax: (303) 393-4687;
Email: Katherine.Bent@med.va.gov
Research Objective: The purpose of this three-year study is to
describe the experience of transition to palliative care and
factors associated with successful transitions, as well as
suggest interventions to improve the experience. Specific aims
of the study include: Aim 1: Identify and define key elements of
palliative care transitions including structures, processes, and
outcomes. Aim 2: Identify factors of satisfaction and variability
in patient and family experiences during transitions to
palliative care.
Study Design: The primary source of data for this Grounded
Theory study is in-depth interviews with patients, families, and
health care providers. In addition, the study includes medical
record review and observations of clinical encounters. The
researcher will also maintain research logbooks and field
notes describing ongoing decisions, methods, and logistics of
the study and the interpretive processes that will be subject to
analysis and audit. Grounded theory requires simultaneous
data generation and analysis. This study employs the following
strategies cyclically: coding, memoing, sorting to restore order
in data by grouping codes together to create categories; and
selective coding to generate the grounded theory that relates
different categories and their properties.
Population Studied: Veteran patients with advanced illness
who have recently been referred for palliative care services will
represent the largest target group within the sample.
Principal Findings: Interviews and chart audits continue.
Conclusions: Little is known about how patients and families
manage transitions to end of life care or what services are
needed to improve the quality of care during transitional
periods.
Implications for Policy, Delivery, or Practice: It is
increasingly apparent that our health care delivery system is
less than successful in providing desired and appropriate
supportive care to patients seeking palliative care rather than
curative care. Better support for patients and families during
the end-of-life trajectory will depend on developing a better
understanding of the personal and affective dimensions of
symptoms, attitudes, behaviors, and decision making they
experience. As a key, cross-cutting experience in end of life
care, the transition experience is likely to influence other
important domains such as functional status, emotional
symptoms, or caregiver well-being, among others. This study
will extend current and recent research by providing
theoretical insight and understanding of the patient and family
experience of palliative care transitions, an area that has
remained problematic despite other improvements in
palliative care.
Primary Funding Source: VA
●A Study of the Proportions of Women Overdue for Breast
Cancer Screening Served by the National Breast and
Cervical Cancer Early Detection Program
Donald Blackman, Ph.D., Janet Royalty, M.S., Christie
Eheman, Ph.D.
Presented By: Donald Blackman, Ph.D., Epidemiologist,
Division of Cancer Prevention and Control, Centers for
Disease Control and Prevention, MS K55, 4770 Buford
Highway, N.E., Atlanta, GA 30341; Tel: (770) 488-3023; Fax:
(770) 488-4639; Email: dblackman@cdc.gov
Research Objective: The National Breast and Cervical Cancer
Early Detection Program (NBCCEDP), sponsored by the
Centers for Disease Control and Prevention (CDC), is
designed to provide breast and cervical cancer screening for
low-income, uninsured and underinsured women. CDC
provides funding through cooperative agreements to state and
territorial health departments, tribes, and tribal organizations
to implement and administer the program. This study
examines one aspect of the natural history of program
maturation: After 5 years of operation, did programs continue
to enroll new clients who had never been screened or who had
delayed screening beyond recommended intervals in
proportions similar to the enrollment during the first year?
Study Design: The NBCCEDP collects information about each
woman served and services provided, including clients’
demographic characteristics, self-reported screening history,
screening results, diagnostic procedures, final diagnosis, and
initiation of treatment information. This study compared the
screening histories of women receiving their first programsponsored mammogram from selected programs’ first
(N=68542 women) and fifth (N=62678) year of operation.
Thirty-five programs in operation for at least 5 years and for
which at least 80% of first breast cancer screening records
had sufficient prior screening history information were
included.
Population Studied: The study population included lowincome, uninsured or underinsured women aged 40—64
years receiving their first NBCCEDP-sponsored mammogram.
Based on self-reported prior screening, women were classified
as never having a previous mammogram, having their last
mammogram over 5 years ago (delayed), or having a previous
mammogram within five years (recent).
Principal Findings: Overall, 42% of women receiving initial
program mammograms in year 1 had not had a recent
mammogram, compared with 40% in year 5. Differences
among the 35 programs ranged from a decrease of 11
percentage points from year 1 to year 5 (58.8% to. 47.7%) to
an increase of 45.7 percentage points (43.1% to 88.8%)
Twenty programs reported higher percentages in year 5
compared to year 1; fifteen programs reported lower
percentages. The median difference was 0.9 percentage
points and 50% of differences between year 1 and year 5 were
within a range of -2.5 percentage points to 10.3 percentage
points.
Conclusions: After 5 years of operation, NBCCEDP continued
to enroll not-recently-screened women at a level similar to
enrollment during the first year of operation. Wide variation in
differences between years 1 and 5 among individual programs
may be due to changing program policies, different client
characteristics, and differences in program operations.
Implications for Policy, Delivery, or Practice: A public
health goal is to attract women to regular breast cancer
screening. There are women in the U.S. population for whom
screening is recommended but who have never been screened
or who have long delayed screening. As programs for
underserved groups mature, they will have the dual challenge
of serving the new clients and providing service to returning
clients. NBCCEPD programs continued to enroll women who
had not received recent breast cancer screening, even as they
faced increasing demands for re-screening among previous
enrolled clients. Ongoing surveillance can evaluate how well
programs meet this complex challenge.
Primary Funding Source: CDC
●Estimated Prevalence of Children With Special Health
Care Needs in 74 Metropolitan and Micropolitan
Statistical Areas
Stephen Blumberg, Ph.D., Matthew Bramlett, Ph.D.
Presented By: Stephen Blumberg, Ph.D., Senior Scientist,
National Center for Health Statistics, Centers for Disease
Control and Prevention, 3311 Toledo Road, Room 2112,
Hyattsville, MD 20782; Tel: (301) 458-4107; Fax: (301) 4584035; Email: sblumberg@cdc.gov
Research Objective: This poster presents estimates of the
prevalence of children with special health care needs
(CSHCN) in 70 metropolitan and 4 micropolitan statistical
areas across the United States.
Study Design: Prevalence estimates of CSHCN were
generated for all metropolitan and micropolitan statistical
areas that were represented by at least 1,000 children in the
sample. Seventy metropolitan and 4 micropolitan statistical
areas met this criterion. Within those
metropolitan/micropolitan statistical areas, prevalence
estimates were also generated for 44 individual counties. To
generate the prevalence estimates, the original child-level
sample weights (which permit representative statistical
estimates at the national and state level) were recalibrated
within each MSA, micropolitan statistical area, and county to
match the U.S. 2000 census counts of the child population by
age, sex, and race/ethnicity.
Population Studied: Estimates are based on data from the
National Survey of CSHCN. The National Survey of CSHCN
was funded by the Maternal and Child Health Bureau, Health
Resources and Services Administration, and was conducted by
the National Center for Health Statistics, Centers for Disease
Control and Prevention. In 2001, this random-digit-dial
telephone survey screened between 5,000 and 9,000 children
from each state and the District of Columbia for special health
care needs.
Principal Findings: The prevalence of CSHCN was highest in
the New Orleans/Metairie/Kenner MSA of Louisiana (18.2%)
and lowest in the Los Angeles/Long Beach/Santa Ana and the
San Francisco/Oakland/Fremont MSAs of California (both
8.7%).
Conclusions: The prevalence estimate for a metropolitan or
micropolitan statistical area often differed from the prevalence
estimate for the state.
Implications for Policy, Delivery, or Practice: Metropolitan
health departments and MCH agencies that serve the urban
areas may find these new small area estimates useful for
program planning purposes.
Primary Funding Source: HRSA
●Expert Consensus for Chronic Illness Care Informatics
Priorities: The CHIACC Expert Panel
Laura Bonner, Ph.D., Edmund Chaney, Ph.D., Alexander
Young, M.D., MSHS, David Dorr, M.D., Amy Cohen, Ph.D.,
Eve Kerr, M.D.
Presented By: Laura Bonner, Ph.D., Project Director, Health
Services Research & Development, VA, 1100 Olive Way, Suite
1400, Seattle, WA 98101; Tel: (206) 277-1780; Fax: (206) 7642935; Email: Laura.bonner@va.gov
Research Objective: Effective care for chronic illness requires
coordination and communication among all members of the
care team, including the patient, primary care and specialty
provider, care manager, and others (e.g., pharmacists, social
workers, family members). The Institute of Medicine (IOM)
has defined 8 aspects of chronic care that require informatics
support. The goal of the VA CHIACC (Creating HealtheVet
Informatics Applications for Collaborative Care) project is to
develop software to facilitate chronic illness care, informed by
the IOM domains, with emphasis on the specific needs
agreed upon by national clinical and informatics experts. The
software module developed will be implemented and assessed
in VA practice settings.
Study Design: Expert consensus identified priorities for
software development to support chronic illness care. We
employed use-case methodology to guide expert panel
discussion. One use case was developed for each of three
chronic disorders (depression, schizophrenia and diabetes);
an additional use case was developed for the common
situation of comorbid disorders. Experts included specialists
in primary care, specialty mental health care, diabetes,
comorbidity, recovery and policy as well as informatics
development and implementation, with VA and non-VA
representatives.
Population Studied: The software currently under
development will support care for chronic illness among VA
patients. Initial development focuses on the needs of veterans
with mental illness (depression and schizophrenia) but later
stages will address the software functions needed in other
conditions, including diabetes and co-occurring diseases.
Principal Findings: The expert panel agreed that informatics
support would improve quality of care for chronic illness.
Experts identified the following as high priorities for software
development: 1) routine standardized assessment of critical
outcomes (e.g., PHQ-9 scores for depression) with automatic
scoring algorithms that facilitate interpretation and treatment
recommendations; 2) availability of outcome measures to all
members of the treatment team; 3) performance measures for
providers based on appropriate response to patient outcomes;
4) an interactive and sequential treatment plan that is
accessible to all team members and includes contact
information for all clinicians; and 5) software for managing
and tracking a panel of patients at various stages of care.
Additional informatics needs with lower priority were
suggested. Informatics needs were similar across mental and
physical disorders.
Conclusions: Software to support chronic illness care must
enhance communication and tracking at the patient and panel
level. Use-case methodology provides an efficient guide to
expert discussion about the desired attributes of informatics
support for chronic illness care.
Implications for Policy, Delivery, or Practice: Currently,
many applications in IT do not meet the needs of patients
with chronic illness. The CHIACC software will be useful as a
prototype for informatics support of chronic illness care. The
knowledge gained from implementation and testing of this
software within the VA electronic medical record environment
will increase our understanding of how IT support can
improve the quality of care in the VA and in other systems.
Primary Funding Source: VA
●Racial and Ethnic Differences in Hospital Outcomes for
Persons with Moderate to Severe Traumatic Brain Injury
Steve Bowman, M.H.A., Ph.C., Diane Martin, Ph.D., Sam
Sharar, M.D., Frederick Zimmerman, Ph.D.,
Presented By: Steve Bowman, M.H.A., Ph.C., Epidemiologist,
Office of EMS and Trauma System, Washington State
Department of Health, PO Box 47853, Olympia, WA 985047853; Tel: (360) 236-2873; Fax: (360) 236-2829; Email:
smbowman@u.washington.edu
Research Objective: To investigate racial and ethnic
disparities in the care and outcomes of patients with
moderate to severe traumatic brain injury and to identify
hospital characteristics associated with differences in care and
outcome.
Study Design: Retrospective cohort study using data from the
National Trauma Data Bank (NTDB) for the years 2000-2003.
Multivariate logistic regression was used to control for patient,
injury and hospital characteristics, with clustering on hospital
to account for correlation of outcomes within individual
hospitals. Main dependent variables included in-hospital
mortality for admitted patients and discharge to rehabilitation
for survivors of severe traumatic brain injury. Access to
rehabilitation is an important measure of quality. The primary
independent variable was race, with indicator variables for
White, Black, Hispanic, Asian/Pacific Islander, and other race.
Population Studied: We identified 71,673 major trauma
patients with a moderate to severe traumatic brain injury who
were hospitalized in any of the 271 level I or II trauma
designated hospitals participating in the NTDB. These data
include submissions from 33 states. Moderate to severe
traumatic brain injury (TBI) was defined by the presence of an
Abbreviated Injury Scale (AIS) code of 3, 4 or 5 to the head.
For the discharge to rehabilitation analysis, we defined severe
TBI by the presence of an AIS 5 injury to the head. We
excluded patients with unsurvivable injuries (AIS=6), with
major burns or who were transferred from other acute care
facilities.
Principal Findings: After adjusting for patient, injury and
hospital characteristics, we observed an increased risk of
death for Blacks compared to Whites in level II hospitals (OR
1.32, p=.012), but not in level I hospitals (OR 1.14, p=.173).
Asians were at increased risk of death in both level I and II
hospitals (OR 1.41, p=.053 and OR 1.47, p=.008 respectively).
Hispanics appeared more likely to die in both level I and II
hospitals, although these findings were of borderline
significance (OR 1.37, p=.064 and OR 1.24, p=.068
respectively). For survivors in both level I and II hospitals,
Blacks were less likely to be discharged to a rehabilitation
service (OR 0.66, p=.002 and OR 0.60, p=.015). Hispanics
were also less likely to be discharged to rehabilitation,
although these findings were significant in level II hospitals
only (OR 0.73, p=.091 for Level I and OR 0.63, p=.020).
Conclusions: After adjusting for potential confounders, racial
and ethnicity disparities exist in the outcomes of persons with
moderate to severe traumatic brain injury. In-hospital survival
tended to be worse for Blacks, Asians and Hispanics. In
addition, Black and Hispanic survivors of severe traumatic
brain injuries also appeared less likely to receive post-acute
inpatient rehabilitation. These disparities appeared greatest in
level II trauma centers.
Implications for Policy, Delivery, or Practice: By identifying
racial and ethnic disparities, policymakers can develop
targeted initiatives aimed at improving outcomes in people of
color who experience traumatic brain injuries. Additional
research is needed to identify the underlying causes of
disparities and why outcomes at level II hospitals appear to be
worse for people of color.
Primary Funding Source: No Funding
●Employment and Cancer: Findings from a longitudinal
study of breast and prostate cancer survivors
Cathy Bradley, Ph.D., M.P.A., David Neumark, Ph.D., Zhehui
Luo, Ph.D., Maryjean Schenk, M.D.
Presented By: Cathy Bradley, Ph.D., M.P.A., Professor, Health
Administration, Virginia Commonwealth University, 1008 East
Clay Street, Richmond, VA 23298-0203; Tel: (804) 828-5217;
Fax: (804) 828-1894; Email: cjbradley@vcu.edu
Research Objective: In this paper, we discuss ways in which
cancer affected the employment situations of nearly 800
employed cancer patients. Hopefully, this information will
stimulate discussion and ideas that will minimize the
employment losses associated with cancer and its treatment.
Study Design: We present findings from a longitudinal study
aimed at understanding how cancer affected employed
patients’, newly diagnosed with either breast or prostate
cancer, ability to work. The design criteria were: 1)
population-based enrollment of newly diagnosed patients with
breast or prostate cancer, 2) longitudinal data collection that
spanned a period of 18 months, 3) enrollment of employed
adults, 4) inclusion of a non-cancer control group, and 5)
sufficient sample size to statistically distinguish between
employment changes in the cancer and control groups.
Population Studied: We enrolled 496 women with breast
cancer and 294 men with prostate cancer. This sample size
was adequate to detect statistical differences in employment
and weekly hours worked between the cancer and control
groups.
Principal Findings: Patients were less likely to be employed
relative to the non-cancer control group at 6 months following
diagnosis. Among those who remained employed, they
worked fewer hours per week relative to the control group. At
12 and 18 months, the labor supply effect of cancer lessened.
However, patients reported considerable disability with regard
to performing physical tasks.
Conclusions: The study supports the relatively clear finding
that women with breast cancer and men with prostate cancer
have a difficult time working at 6 months following diagnosis.
Although the negative employment effects diminish over time,
some women and men never return to work. This negative
employment effect may be stronger for women from racial
and ethnic minorities. Married women who depended on
their jobs for health insurance were more likely to return to
relative to women who depended on their husband’s for
health insurance, suggesting that health insurance may
influence patients to make trade-offs between recovery and
work.
Implications for Policy, Delivery, or Practice: We suggested
4 priority areas for future research: collect additional data on
employment outcomes, initiate studies comparing
employment outcomes among white patients and
racial/ethnic minority patients, engage in research to
minimize the effect of cancer on employment, and explore the
relationship between health insurance and employment
outcomes for cancer patients.
Primary Funding Source: NCI
●The Effects of a Coordinated Asthma Population Disease
Management Model and Individual Asthma Care
Management Program on Prescribing Patterns,
Medication Management, and Healthcare Utilization
Joan Branin, Ph.D.
Presented By: Joan Branin, Ph.D., Director, Center for Health
& Aging, Health Services Management, University of La Verne,
1950 3rd Street, La Verne, CA 91750; Tel: (909)593-3511 x4247;
Fax: (909) 392-2702; Email: braninj@ulv.edu
Research Objective: The purpose of this research was to
investigate the effects of a coordinated asthma disease
management model and individual asthma care management
program on prescribing patterns, medication management,
and healthcare utilization.
Study Design: An asthma population disease management
model coordinated with individual asthma care management
program was initiated a major health maintenance
organization to monitor and facilitate treatment of adult
asthma patients. Patients were enrolled in an asthma care
management program that emphasized the use of
preventative asthma control measures including increased use
of anti-inflammatory medications and non-pharmaceutical
methods such as dust control and peak flow meter usage;
better recognition of asthma triggers; and one-on-one asthma
self care management training, patient education materials,
and an individualized follow up program involving an
interdisciplinary asthma team approach. A retrospective
review of medical records and data sources was made before
and after the implementation of the individual asthma care
management program for adult and pediatric asthma
patients.
Population Studied: A total of 2,600 asthmatic pediatric and
adult patients up to 56 years of age who were identified as
having moderate and severe asthma and a history of
hospitalizations and emergency room visits for asthma and
were continuously enrolled in the asthma population disease
management program from 2002-03.
Principal Findings: There was a statistically significant
reduction in uncontrolled acute asthma episodes,
hospitalizations, and emergency room visits after the
implementation of the asthma population disease
management model coordinated with individual asthma care
management. There was a significant reduction in the
number of oral corticosteriod courses, the number of
prescribers, and the ratio of inhaled anti-inflammatory
medications to beta-agonist usage (p< 05). Total number of
asthma hospitalizations decreased by 18.5%. Similarly,
emergency room decreased 24.3%. There was a positive
correlation between the number and type of prescribers and
the rate of emergency room visits and hospitalizations. There
was a positive correlation between the number and type of
prescribers and the rate of emergency room visits (r = .73) and
hospitalizations (r = 68). Within one year of implementation
of the asthma care management program, the number of
asthma patients identified with moderate and severe high-risk
characteristics was reduced by 26%. These findings support
the findings of an earlier similar study.
Conclusions: A coordinated asthma disease management
model and individual asthma care management can reduce
the number of prescribers and result in better medication
management and fewer emergency visits and hospitalizations
for asthma.
Implications for Policy, Delivery, or Practice: These findings
suggest that coordinated interdisciplinary population and
individual asthma care management can lead to (1) better self
care medication and symptom management, and (2) reduced
healthcare utilization.
Primary Funding Source: ULV Faculty Research Grant
●Pilot Study of The Relationship Among Depression and
Visual Impairment in Older Adults
Robert Bremer, M.A., Ph.D., Michael B Gorin, M.D., Ph.D.,
Thomas R. Friberg, M.D., Andrew W. Eller, M.D., Joel S.
Schuman, M.D., Harold Alan Pincus, M.D.
Presented By: Robert Bremer, M.A., Ph.D., Post Doctoral
Scholar, Psychiatry, University of Pittsburgh, 1118 Lancaster
Avenue, Pittsburgh, PA 15218; Tel: (412) 708-2260; Email:
rob_bremer@comcast.net
Research Objective: A small number of recent studies have
demonstrated high rates of depression in patients with agerelated vision impairment. However, the relative contribution
of self reported vision-specific functioning measures and
objective visual acuity has not been well examined. This pilot
study investigates the relation between depression and a selfreport vision functioning measure versus objective visual
functioning in patients with age-related visual impairment.
Study Design: Visual acuity data was obtained from the
patient’s medical record. The 25-item National Eye Institute
Visual Functioning Questionnaire (NEI-VFQ) was used to
assess self-report vision functioning. Depression was
categorized as positive if the subjects reported a Center for
Epidemiologic Studies Depression Scale (CESD) score >= 16.
Population Studied: Subjects were recruited from the
University of Pittsburgh Medical Center (UPMC) Eye Center if
they had moderate to severe vision impairment and a
diagnosis of age-related macular degeneration or glaucoma.
Principal Findings: Thirty-seven subjects to date have
completed the assessment battery. Overall, 35% (N=13) of the
sample had a CESD>16. There was a significant relationship
between the NEI-VFQ and the CESD after controlling for
significant covariates, including visual acuity (F=13.08,
p=0.0011). Depression severity scores were not associated
with best eye visual acuity (r=-.06, p=.71). Stratifying between
better vision (better than 20/200) versus worse vision
(20/200 or worse), NEI-VFQ scores were moderately
correlated with worse vision (r=.49, p=.05), but highly
correlated with better vision (r=.81, p<.001).
Conclusions: Depressive symptoms are common in patients
with vision loss. However, depressive symptoms are not
related to visual acuity, but rather the patient’s evaluation of
their daily vision functioning.
Implications for Policy, Delivery, or Practice: This study
shows the high prevalence of depressive symptoms in an
academic medical center ophthalmology clinic. It also
suggests the importance of obtaining low vision rehabilitation
before vision loss is severe. Future studies need to examine
the direction of this relationship and if depression treatment
can impact self-report vision functioning.
Primary Funding Source: NIMH
●Effect of WIC and Public Insurance on the Dental Health
of Children
Tegwyn Brickhouse, D.D.S., Ph.D., Dahlia Naqib, M.P.H., Saba
W. Masho, M.D., M.P.H.
Presented By: Tegwyn Brickhouse, D.D.S., Ph.D., Assistant
Professor, Pediatric Dentistry, Virginia Commonwealth
University School of Dentistry, 521 North 11th Street, Woods
Building 317, Richmond, VA 23298-0566; Tel: (804) 827-2699;
Fax: (804) 827-0163; Email: thbrickhouse@vcu.edu
Research Objective: To examine the impact of the Special
Supplemental Nutrition Program for Women, Infants, and
Children (WIC) and public insurance on the dental health
status of young children. Dental Caries is the most prevalent
chronic disease among US children. It disproportionately
affects children from low-income and minority families. These
families are often enrolled in both WIC and Medicaid/S-CHIP.
Previous studies have shown improved access to dental
services with WIC enrollment.
Study Design: This was a cross-sectional study. Multivariate
logistic regression techniques were used to study the
relationship between program participation and the dental
health status of children. The independent variable was
participation in Medicaid/SCHIP, WIC, or both and the
primary dependent variable the presence of dental caries.
Population Studied: The study used data from the 1999-2002
National Health and Nutrition Examination Survey
(NHANES). Children 2-4 years of age who participated in
Medicaid, S-CHIP, and/or WIC for whom both interview and
oral health examination data were available were included in
the study.
Principal Findings: There was no statistically significant
association between dental caries and participation in public
assistance programs. Although insignificant, when compared
to children who participated in Medicaid/S-CHIP only,
children were less likely to have dental caries if they
participated in both WIC and Medicaid/S-CHIP (OR=0.97,
95% CI 0.6-1.6), or in WIC only (OR=0.65, 95% CI 0.4-1.2).
Conclusions: Participation in WIC and Medicaid/S-CHIP
together or in WIC only does not reduce the risk of dental
caries compared to children enrolled only in Medicaid/SCHIP.
Implications for Policy, Delivery, or Practice: While
participation in WIC has been show to improve access to
dental services, this national survey did not find
improvements in dental health status associated with WIC.
Because low-income children and minorities constitute a high-
risk group requiring more intensive preventive efforts,
partnerships between programs such as WIC and Medicaid/SCHIP must provide targeted preventive interventions in
addition to improving access to dental services.
Primary Funding Source: No Funding
●The Association Between Chronic Psychosocial Stress
and Adverse Pregnancy Outcome in a Low-Income
Population of Women.
Ann Bryant, M.D., M.Sc., Laura Amsden, M.S.W., M.P.H.,
William Grobman, M.D., M.B.A., Jane Holl, M.D., M.P.H.
Presented By: Ann Bryant, M.D., M.Sc., Maternal Fetal
Medicine Fellow, Obstetrics and Gynecology, Institute for
Healthcare Studies, Northwestern University, Feinberg School
of Medicine, 333 East Superior, Suite 110, Chicago, IL 60611;
Tel: (312) 926-7518; Fax: (312) 926-0367; Email:
abryant@md.northwestern.edu
Research Objective: To determine if there is an association
between chronic psychosocial stress and low birth weight
neonates in low-income women.
Study Design: Between 1999 and 2004, randomly selected
women from the 1998 welfare rolls in 9 Illinois counties were
interviewed yearly to evaluate their psychosocial,
socioeconomic and health characteristics. Women who
delivered during this period were identified. Using a nested
case-control design, responses of those who delivered low
birth weight neonates were compared with responses of those
who did not. Self-reported stress was assessed as the: (1)
external stressors (e.g. life events, hardships in the home
environment, hardships obtaining food, hardship obtaining
medical care, child with chronic illness in the home, and home
crowdedness); (2) enhancers of stress (e.g. depression,
mental health, drug or alcohol use); (3) buffers against stress
(e.g. social support, community group involvement, church
attendance, coping skills); and (4) perceived stress (e.g.
perceived economic hardship, self-rated health, perceived
neighborhood safety) that occurred in temporal proximity to
the delivery.
Population Studied: Low-income reproductive age women.
Principal Findings: Of the 1363 women who were
interviewed, 294 women (21.6%) became pregnant and
delivered during the study period. Of the 294 infants born, 39
(13.3%) were low birth-weight. Bivariate analysis showed that
having poor coping skills (p=.001), hardship obtaining
appropriate amounts of food (p=.003), a child in the home
with a chronic illness (p=.003), and increased crowding in the
home (p= .005) were all significantly associated with low birth
weight. History of depression in the last year (p=.05), high
levels of perceived economic hardship (p=.05) and poor social
supports (p=.05) were reported more often by women with
low birth weight infants, however, did not reach statistical
significance. Conversely, demographics such as: race,
education level, age, marital status, parity and health
insurance status were not associated with low birth weight.
Conclusions: This study provides evidence that chronic
psychosocial stress may be associated with low birth weight
neonates in a low-income population of women. Future
research should focus on the role of biomarker measurement
of chronic psychosocial stress and its relationship to and
predictive role of low birth weight.
Implications for Policy, Delivery, or Practice: Interventions
in pregnant women that identify psychosocial stress, address
stressors and coping strategies, and monitor stress response,
may improve perinatal outcomes.
Primary Funding Source: AHRQ, The National Institute of
Child Health and Human Development (R01HD39148), the
John D. and Catherine T. MacArthur Foundation, and the
Joyce Foundation
effectively measured by biomarkers; it may be possible to
more easily identify patients at risk, link these patients to
effective interventions to decrease stress and improve coping
strategies and improve health outcomes.
Primary Funding Source: AHRQ, The National Institute of
Child Health and Human Development (R01HD39148), the
John D. and Catherine T. MacArthur Foundation, and the
Joyce Foundation
●Are Stress Biomarkers Elevated in Low-Income Women
with Increased Self-Reported Stress?
Ann Bryant, M.D., M.Sc., William Grobman, M.D., M.B.A.,
Laura Amsden, M.S.W., M.P.H., Jane Holl, M.D., M.P.H.
●Pilot Evaluation of a Regional Program to Improve HIV
Screening and Testing in the VHA
Bowman Candice, Ph.D., RN, Matthew B. Goetz, M.D.,
Barbara Rossman, Ph.D., Tuyen Hoang, Ph.D., Allen Gifford,
M.D., Steven Asch, M.D., M.P.H.
Presented By: Ann Bryant, M.D., M.Sc., Maternal Fetal
Medicine Fellow, Obstetrics and Gynecology, Institute for
Heathcare Studies, Northwestern University, Feinberg School
of Medicine, 333 East Superior, Suite 410, Chicago, IL 60611;
Tel: (312) 926-7518; Fax: (312) 926-0367; Email:
abryant@md.northwestern.edu
Research Objective: To determine if there is an association
between self-reported and biologic measures of stress in lowincome, reproductive age women.
Study Design: Between 1999 and 2005, randomly selected
reproductive age women from the 1998 welfare rolls in 9
Illinois counties were interviewed yearly to assess their
psychosocial, socioeconomic, and health characteristics. Selfreported stress was assessed as the: (1) external stressors
(e.g. life events, hardships in the home environment,
hardships obtaining food, hardship obtaining medical care,
child with chronic illness in the home, and home
crowdedness); (2) enhancers of stress (e.g. depression,
mental health, drug or alcohol use); (3) buffers against stress
(e.g. social support, community group involvement, church
attendance, coping skills); and (4) perceived stress (e.g.
perceived economic hardship, self-rated health, perceived
neighborhood safety) that occurred in temporal proximity to
the delivery. In the final year, in addition to the interview, a
dried blood spot sample was requested from all women
interviewed in Chicago. The blood spots were analyzed for
two proposed biomarkers of chronic stress: Epstein-Barr virus
antibody (EBV) and C-reactive protein (CRP) levels.
Population Studied: Low-income, reproductive age women.
Principal Findings: Of the 206 women interviewed in
Chicago during 2005, 205 women (99%) agreed to provide a
blood sample during the interview. 196 of these samples
(96%) met technical standards for analysis. There was no
difference in mean EBV or CRP levels based on age, race,
parity, employment, marital status or education. However,
women who had the greatest degree of perceived
discrimination had significantly elevated levels of EBV, (mean
175.6 + 71.5 vs. mean 132.5 + 71.7 ELISA units, p=.038). In
addition, higher levels of CRP were seen in women with the
fewest buffers against stress (mean 6.7 + 7.2 vs. mean 3.7 + 5.1
mg/L, p=.037). EBV and CRP levels were found to be highly
correlated (p<.001).
Conclusions: Some measures of self-reported psychosocial
stress may be associated with elevated levels of stress
biomarkers in a low-income population of reproductive age
women.
Implications for Policy, Delivery, or Practice: If stress,
which has been linked to poor health outcomes, can be
Presented By: Bowman Candice, Ph.D., RN, QUERI-HIV
Implementation Research Coordinator, Health Services
Research & Development, VA San Diego Healthcare System,
3350 La Jolla Village Drive (111N-1), San Diego, CA 92161; Tel:
(858) 552-8585 x5967; Fax: (858) 552-4321;
Email: candice.bowman@va.gov
Research Objective: HIV testing is done in less than 40% of
at-risk Veterans Health Administration (VHA) patients. We
conducted a pilot test of an integrated quality improvement
(QI) project, the goals of which were to determine whether
rates of HIV testing in primary care clinics increase after
implementation; to determine the barriers to increased HIV
testing within the VHA; and to develop an exportable model
for increasing VHA HIV testing rates nationally.
Study Design: We implemented this QI project at two west
coast-based VA medical centers (VAMCs); 3 other VAMCs
within the region served as controls. This project relied on 1.)
a computerized clinical reminder for HIV testing to prompt
testing of at-risk patients and to generate hospital and cliniclevel HIV testing performance reports fed back to individual
providers; 2.) provider activation, via academic detailing and
social marketing strategies; and 3.) systematic removal of
identified organizational barriers to HIV testing. The
outcomes of these interventions were evaluated qualitatively
via provider surveys and quantitatively by assessing HIV
testing rates.
Population Studied: Patients with documentation of HIV risk
factors in the electronic medical record who were seen in
primary care clinics at two VAMCs during 2005.
Principal Findings: Analysis of the reminder reports indicated
that after three months, the rate of HIV screening (or rates of
reminder resolution) in previously untested, at-risk individuals
increased from 22% to 47% and 31% to 52% at the two
intervention hospitals although there was wide variation
between clinics at both hospitals. No change in test rates was
seen in the three control facilities. We have confirmed that the
increase in the reminder resolution rate reflects an increase in
actual HIV testing (because there are several ways to resolve a
reminder). During the year prior to the intervention, an
average of 162 HIV tests were done per month at one
intervention hospital and 180 at the other. In contrast, after
implementation of the reminder, 330 and 270 tests per month
were done.
Conclusions: Pilot implementation of a clinical reminder
combined with audit/feedback, provider activation and
removal of systemic barriers to improve HIV testing
performance increased the rates of testing at-risk patients in
two VAMCs over a 3-month period.
Implications for Policy, Delivery, or Practice: These quality
improvement interventions have the potential to significantly
increase the rates of testing at-risk patients in the VHA and
thus allow early diagnosis and treatment for these vulnerable
patients. These results warrant continued implementation of
such strategies.
Primary Funding Source: VA
●Health Care that Works for All Americans: Preliminary
Survey Results from the Citizens' Health Care Working
Group
Craig Caplan, MA, Jill Bernstein, Ph.D.
Presented By: Craig Caplan, MA, Senior Program Analyst,
Citizens' Health Care Working Group, 7201 Wisconsin
Avenue, Suite 575, Bethesda, MD 20814; Tel: (301) 443-1587;
Fax: (301) 480-3095; Email: ccaplan@ahrq.gov
Research Objective: The Citizens' Health Care Working
Group was established by the Congress "to provide for a
nationwide public debate about improving the health care
system to provide every American with the ability to obtain
quality, affordable health care coverage." Through nationwide
surveys and local meetings throughout the country, Americans
are asked: (1)what health care benefits and services should be
provided?; (2) How does the American public want health
care delivered?; (3) How should health care coverage be
financed?; and (4) What tradeoffs are the American public
willing to make in either benefits or financing to ensure access
to affordable, high quality health care coverage and services?
This study sees how responses differ across the country, and
by age, gender, and race.
Study Design: Preliminary data will be available from a
nationwide, random telephone survey of adults age 18 and
older, conducted in early 2006. Other data collected from
over 20 community meetings held between late January and
mid-May, 2006, will also be available.
Population Studied: Two large professionally facilitated
meetings in Los Angeles and Chicago include audiences up to
1000 persons, with segments of the audience selected to be
representative of the area. Also, ten professionally facilitated
meetings each include up to 250 individuals, at least 100 of
whom are selected for attendance to reflect the demographics
of the area in which the meetings are being held. There are 30
additional meetings in cities throughout the country. Data
from the meeting will be compared to those from the
nationwide random survey.
Principal Findings: Survey and community meeting data are
being collected between late January and mid-May, 2006, and
will be available for presentation at the meeting.
Conclusions: To be determined following the community
meetings and the survey.
Implications for Policy, Delivery, or Practice: To be
determined following the community meetings and the
survey.
Primary Funding Source: Other Government
●Land Use Pattern and Hospitalization for Chronic
Conditions: A Spatial Study on Modifiable Health Risks in
San Francisco
Arpita Chattopadhyay, Ph.D., XiaHang Liu X., Ph.D., Sudip
Chattopadhyay, Ph.D.
Presented By: Arpita Chattopadhyay, Ph.D., Senior
Statistician, Division of General Internal Medicine, University
of California at San Francisco, Box 1364, Parnasus Avenue,
San Francisco, CA 94143; Tel: (415) 206-6188; Fax: (415) 206
5586; Email: achat@medsfgh.ucsf.edu
Research Objective: Hospitalization for diabetes,
hypertension and congestive heart failure reflect a decline in
disease management in which active mlifestyle plays an
important role. However, the opportunities to adopt and
maintain an active lifestyle depend on the environmental
infrastructure of the community. The objective of this
research is to examine the spatial association between
hospitalization rates for diabetes, hypertension and congestive
heart failure.
Study Design: This is a retrospective cross-sectional study.
We use GIS methods to examine the locational distribution of
environmental amenity for physical activity at the and
hospitalization rates for the three study conditions at the zipcode level. We use a multivariate Poisson model to estimate
the hospitalization rates. We adjust for demographic
composition of the zip-code population. We then examine the
spatial association between access to three physical activity
amenities --fitness centers, bikepath and open spaces-- and
hospitalization rates.
Population Studied: All residents of the San Francisco Bay
Area aged 40 and above
Principal Findings: All communities in the bay area have easy
access to fitness centers. However, there is variation in
access to bikepath and and open space. Communities in
north bay have less bikepath and access to open space is less
in north and south bay. The associations of Physical Activity
amenities and hospitalization rates were not significant
Conclusions: Although there is some variation in access to
physical activity amenity in the San Francisco Bay Area, there
is little evidence that these amenities have a role in the
management and control of diabetes, hypertension and heart
failure.
Implications for Policy, Delivery, or Practice: Public
spending on provision of fitness centers, bikepath and
conserving open spaces may have little impact in reducing
hospitalization rates for diabetes, hypertension and congestive
heart failure
Primary Funding Source: No Funding
●Provider Availabiltiy and Racial Ethnic Disparity among
Medicaid Population
Huey Chen, Ph.D.
Presented By: Huey Chen, Ph.D., Assistant Research Faculty,
MHLP, USF-FMHI, 13301 Bruce B. Downs Bouleveard, Tampa,
FL 33612; Tel: (813) 974-7409; Fax: (813) 974-0327; Email:
chen@fmhi.usf.edu
Research Objective: Purposes of this study will examine the
Medicaid provider distribution, which can be used as a proxy
to assess service availability for the Medicaid population, and
explore issues related to race/ethnic disparity in Medicaid
health services.
National studies report that minorities experience more
barriers to care, a greater incidence of chronic disease, lower
quality of care, and higher mortality than other groups. They
are also less likely to use mental health services (Padgett,
Patrick, Burns, 1994; Matsuoka, Breaux, & Ryujin, 1997;
Snowden, 1999). Similar findings in Florida Medicaid
population have been observed (Chen, Chen, & Mehra, 2005).
Simply having insurance coverage is not sufficient for
ensuring access to needed health services for individuals,
especially for disadvantaged minorities. Other factors, such as
provider availability, reliable transportation, provider’s
communication with minorities, as well as culturally
competent practice are important factors related to health
disparity (van Ryn, 2002). “Doctors wanted do not take
Medicaid” and “lack of transportation” are two of the more
frequently identified barriers by Florida Medicaid recipients,
especially among non-Hispanic Black adults and caregivers of
both black and Hispanic Medicaid children. These findings
prompt us to further investigate answers for “Why do
Medicaid beneficiaries seek health services from providers
outside the Medicaid health services network?” and “How are
the geographical location of Medicaid providers compatible to
geographical distribution of Medicaid beneficiaries?”
Study Design: All Medicaid providers data will be used
examined in terms of their professional type (such as medical
professionals, psychologist, nurse, counselor, or social
worker), professional specialty (such as internal medicine,
family practice, psychiatrist, neurologist, and etc.), as well as
location of their practice. Meanwhile, geographical distribution
of Medicaid beneficiary distribution will be used to calculate
the Medicaid beneficiaries and provider ratios.
Population Studied: Subjects include Medicaid providers and
Medicaid population in Florida.
Implications for Policy, Delivery, or Practice: Results from
the study will inform Florida Agency for Health Care
Administration (AHCA) the geographical availabilities of
Medicaid providers comparing to geographical distribution of
Medicaid beneficiaries for developing appropriate strategies
for recruiting Medicaid providers or reallocating health care
resources.
Primary Funding Source: Florida Agency for Health Care
Adminstration
●Suboptimal Control of Atherosclerotic Disease Risk
Factors after Cardiac or Cerebrovascular Procedures
Eric Cheng, M.D., MS, Asch, SM, M.D., M.P.H., Vassar, SB,
BS, Jacob, EL, BS, Lee, ML, Ph.D., Vickrey, BG, M.D., M.P.H.
Presented By: Eric Cheng, M.D., MS, Asstant Professor,
Neurology, VA GLA Healthcare System, 11301 Wilshire
Boulevard, Los Angeles, CA 90073; Tel: (310) 478-3711 x48100;
Email: eric.cheng@med.va.gov
Research Objective: Patients who undergo a vascular
procedure such as a carotid endarterectomy, a coronary artery
bypass graft, or a percutaneous coronary intervention remain
at risk for atherosclerotic events after the procedure. Little is
known about post-procedure control of risk factors such as
blood pressure and low-density lipoprotein after these
procedures.
Study Design: Observational study, comparison of blood
pressure and low-density lipoprotein in 12-month periods
before and after a vascular procedure.
Population Studied: In five Veterans Health Administration
Healthcare Systems in the southwestern United States, 252
patients underwent a carotid endarterectomy, 486 underwent
a coronary artery bypass graft, and 720 underwent a
percutaneous coronary intervention.
Principal Findings: The proportions of carotid endarteretomy
patients who had optimal control of both blood pressure and
low-density lipoprotein increased from 23% before the
procedure to 33% after the procedure, compared to increases
from 32% to 43% for coronary artery bypass graft patients, and
from 29% to 45% for percutaneous coronary intervention, all
p<0.05 by chi-squared testing. In logistic modelling, the
percutenous coronary intervenion group was more likely than
the carotid endarterectomy group to achieve optimal control
of blood pressure and low-density liporprotein. The coronary
artery bypass graft group was more likely than the carotid
endarterectomy group to achieve optimal control of blood
pressure. Further modeling showed that pre-procedure
control of risk factor and post-procedure cardiology visits
seemed to account for differences in post-procedure control
across vascular procedures.
Conclusions: Though patients who underwent a vascular
procedure had modest improvements in risk factor control, a
majority of patients in each vascular procedure group did not
attain optimal risk factor control.
Implications for Policy, Delivery, or Practice: More effective
risk factor control programs are needed among most vascular
procedure patients, especially carotid endarterectomy patients.
Primary Funding Source: VA
●The Cost of Working Together in Hospitals
Irene Christodoulou, M.D., Msc HPB Surgery, Chris
Pogonidis, M.Sc., Eygenia Xenodoxidou, M.Sc., Miltiadis
Handolias, M.D., Dimitrios Babalis, M.Sc., Dimitrios Rizos,
M.D.
Presented By: Irene Christodoulou, M.D., Msc HPB Surgery,
Surgeon, 2nd Surgical Department, Papanikolaou Hospital,
Heronias 8, Thessaloniki, 56625; Tel: 00302310613736; Fax:
00302310350150; Email: irenesurgeon@yahoo.gr
Research Objective: Team work is essential in cases of
emergencies, cancer, geriatrics and systemic diseases. Our
study writes down problems of team work among health
professionals in Greek Hospitals.
Study Design: We used questionnaires and interviewed
health professionals of different specialties. We focused on
problematic areas of team work such as Emergencies
Departments, Intensive Care Units and Surgical Departments.
Population Studied: We asked surgeons, pathologists,
anesthesiologists, cardiologists, doctors working in ICU units
and nurses of the relative departments. In total, 145 health
professionals were asked.
Principal Findings: Team work is thought to be problematic
or adequately held, causing limited team effectiveness
according to the 66%. The co-ordinator of the medical team
does not always have the approval of the team according to
the 79% of asked physicians. In a case of sudden death or
severe complication the team members often do not have a
common strategy (53%) and often have limited knowledge of
medical legislation (72%), while only 21% feel secure and safe
inside the Hospital. The establishment of teamwork seminars
and active psycho modulating exercises are approved by all
asked physicians and nurses.
Conclusions: Problems in teamwork belong to the routine of
Greek Hospitals according to the health professionals asked.
Implications for Policy, Delivery, or Practice: Stress of
health professionals could be eliminated by seminars teaching
behaviour of working in a team and practicing based in
simulation models, especially for emergencies.
Primary Funding Source: No Funding
●Gender, Age, and Income Difference in Loss of Quality of
Life due to Injury
Phaedra S. Corso, Ph.D.
Presented By: Phaedra S. Corso, Ph.D., (acting) Chief,
National Center for Injury Prevention and Control, Centers for
Disease Control and Prevention, 4770 Buford Highway, MSK63, Atlanta, GA 30341; Tel: (770) 488-1734; Fax: (770) 4881317; Email: pcorso@cdc.gov
Research Objective: To estimate the health utility score
(preference-based quality of life index) associated with an
injury condition for non-institutionalized adults and health
utility losses due to injury in subgroups stratified by age,
gender, and income.
Study Design: This study used nationally representative data
from the 2000 Medical Expenditure Panel Survey (MEPS) and
the newly available preference-based utility weights derived
from the US population to estimate a health utility index (on a
scale from 0 to 1, where 0 represents death and 1 represents
perfect health) for persons experiencing at least one injury
condition. Univariate and multivariate analyses were used to
examine how age, gender, education, and income affect health
utility loss.
Population Studied: All respondents to the self-administered
questionnaire of the 2000 MEPS who were not
institutionalized were included. These respondents represent
the non-institutionalized U.S. population (age18+).
Respondents were identified as injured if they had reported at
least one injury related medical condition coded with ICD-9CM classifications 800-957 or 959-994.
Principal Findings: The difference in utility scores between
the injury and no injury groups was significant at the one
percent level across all stratifications. On average, a person
with an injury-related condition had a utility score of 0.8260,
which was 0.045 lower than that of a person who did not have
injury (p<0.001). This difference was 0.035 for males and
0.055 for females (p<0.001). Among all age groups, persons
aged 18-25 years experienced the highest utility loss due to
injury (0.056), while persons aged 56-65 years experienced the
least utility loss (0.033). The loss of utility due to injury
decreased as income increased. A person with an annual
income more than $150,000 lost 0.0036 in utility score when
injured compared to a loss of 0.0069 for a person with an
annual income less than $10,000. After controlling for injury
mechanisms and number of injury conditions, we still found
that age, gender, and income were significant factors that
affected a person’s utility score (p<0.05).
Conclusions: Injury significantly reduces quality of life.
Groups defined by gender, age, and income show substantial
variation in health utility loss due to injury. When injured,
females experience greater loss in quality of life compared to
males, so do the young compared to the old, and persons
with low income compared to persons with high income.
Implications for Policy, Delivery, or Practice: Our findings
suggest that quality of life losses due to injury are significant
and vary among gender, age, and income groups. Identifying
vulnerable populations can assist policy makers in designing
injury prevention interventions to ameliorate these disparities
in health.
Primary Funding Source: No Funding
●Comparing Outreach Activities and Investment with
Need
Michael R Cousineau, Dr.P.H., Erin Cox, M.P.H., Eriko Wada,
M.P.P., Gregory Stevens, Ph.D.
Presented By: Michael R Cousineau, Dr.P.H., Director, Keck
School of Medicine, Division of Community Health, 1000
Fremont Drive, Alhambra, CA 91803; Tel: (626) 457-4010; Fax:
(626) 457-5858; Email: cousinea@usc.edu
Research Objective: To understand how the deployment of
resources for outreach and enrollment (applications
submitted) compares to need (the number of uninsured
children) across 26 health districts in Los Angeles County
Study Design: We compared the number of outreach
contacts, applications submitted and total outreach dollars
invested per 1000 uninsured children in each of the county's
26 health districts, and 8 Service Planning Areas (SPAs). Two
data sourcs were used: The LA Health Survey, for assessing
the number of uninsured children in each sub area of the
county, and the CHOI data base, for assessing outreach
contacts and applicaitons and dollars spent in each health
District.
Population Studied: Uninsured children ages 0-18 by SPA
and health district
Principal Findings: Some significant differences are observed
in the rate of outreach contacts, applications submitted and
outreach funding per 1000 uninsured children are observed
across health districts in the county. Outreach contact rates
ranged from 62 to over 1400 contacts per 1000 uninsured
children. Applications also varied, ranging from a low of 53 to
a high of 280 applications per 1000 uninsured. Finally, dollars
invested also varied from a low of $10,000 to over $188,000
per 1000 uninsured.
Conclusions: The depolyment of outreach and enrollment
activities are not consistent with need in Los Angeles with
some health districts receiving more and others less than is
warranted based ont the number of uninsured children in the
area.
Implications for Policy, Delivery, or Practice: Good data
systems for tracking outreach and enrollment linked to subcounty population data bases provides an evidence-based
approach to funding and allocation decisions. Such analyses
are important for effectively tartgeting investments to
maximize enrollment.
Primary Funding Source: The California Healthcare
Foundation
●Community-level Economic Resources and Adolescents’
use of Counseling Services: A Multi-level Analysis
Janet Cummings, B.A., Richard Wight, Ph.D., Carol
Aneshensel, Ph.D.
Presented By: Janet Cummings, B.A., Ph.D. Student, Health
Services, University of California at Los Angeles; Tel: (310)
267-2490; Fax: (310) 267-0153; Email: jrc12@ucla.edu
Research Objective: The majority of adolescents in need of
mental health care do not receive any services. A large body
of literature has examined individual-level factors associated
with adolescent mental health service use, but there is a
paucity of information concerning the role of contextual- or
community-level factors. Using data from the National
Longitudinal Study of Adolescent Health (Add Health), we
apply the Andersen model of health services utilization to an
examination of the associations between community-level
socio-economic resources and mental health service use
among adolescents, controlling for individual-level
characteristics.
Study Design: We estimate hierarchical logistic regression
models to examine the relationship between community-level
income and adolescents’ self-reported use of counseling
services, operationalized as: 1) any counseling services; 2)
counseling services in a private doctor’s office or community
health clinic (clinical setting); 3) counseling services in a
school setting; and 4) counseling services in other setting(s).
At the individual-level, we control for predisposing, enabling,
and need-related characteristics. The contextual-level measure
of community income (logged) is derived from the 1990 U.S.
Census.
Population Studied: Add Health is a nationally representative
school-based sample of 20,745 adolescents in grades 7-12.
Our analytic sample consists of 16,792 adolescents, after
dropping individuals with missing data (N=2,158), and after
sampling one child per household to avoid clustering
problems at the family-level (N=1,795). The primary sampling
unit is the high school, and Census tract data are aggregated
for all sampled adolescents within a particular community in
which schools are located (N = 80) by averaging tract
variables within communities.
Principal Findings: There is statistically significant variation
in the use of all counseling services across communities. Net
of individual-level factors, community-level income is
positively associated with the use of “any” counseling services
(ß=0.59, p=0.001) and accounts for 24% of the contextuallevel variation in the use of any counseling services.
Community-level income is also positively associated with the
use of counseling services in a clinical setting (ß=0.71,
p<0.001) and accounts for 32% of the contextual-level
variation in the use of clinical counseling services.
Community-level income is not significantly associated with
the use of school-based services or “other” counseling
services.
Conclusions: Contextual-level economic resources are
associated with the use of mental health services among
adolescents, net of predisposing, enabling, and need-related
factors at the individual-level. However, our results suggest
that while community-level income is positively associated
with the use of counseling services in clinical settings, it is not
significantly associated with the use of counseling services in
school or “other” settings.
Implications for Policy, Delivery, or Practice: These findings
highlight how efforts to influence adolescents’ mental health
service use in a clinical setting may be of limited success if the
impact of the larger social context is not addressed.
Moreover, when investing in mental health care resources for
adolescents, policy makers may wish to invest more heavily in
school-based counseling services because in this setting, the
negative effect of community-level economic disadvantage is
somewhat attenuated.
Primary Funding Source: NIMH
●Lower Rates of Emergency Room Visits among Patients
with Diabetes, Coronary Artery Disease, and Congestive
Heart Failure who have a High Continuity of Care
James Davis, Ph.D., Kelley Withy, M.D., Deborah Taira, Sc.D.
Presented By: James Davis, Ph.D., Research Analyst, Care
Management, Hawaii Medical Service Association, 818
Keeaumoku Street, P.O. Box 860, 96808; Tel: (808) 948-5086;
Fax: (808) 948-5680; Email: james_davis@hmsa.com
Research Objective: To examine the extent that maintaining
continuity of care (COC) with the same physician may reduce
the frequency of emergency room visits among patients with
diabetes, coronary artery disease, and congestive heart failure.
Study Design: The study employed a longitudinal design
measuring continuity of care by yearly intervals and emergency
department (ED) visits in the subsequent quarters. Four
yearly intervals were used, intervals that overlapped and
spanned the years 2003 and 2004. Continuity of care was
assessed using an index ranging from zero to one. A zero
meant that all physician visits were with different physicians
whereas a one meant that all physician visits were with the
same physician. Having an ED visit (yes or no) was analyzed
by logistic regression using generalized estimating equations
to account for the clustering of repeated intervals within
patients.
Population Studied: The patients were members of a large
health insurer in Hawaii identified as having diabetes,
coronary artery disease (CAD), or congestive heart failure
(CHF) by the insurer’s disease management programs. The
study included 34,072 patients aged 18 to 64 with four or
more physician visits (26,478 patients with diabetes, 10,575
patients with CAD, and 3,759 patients with CHF).
Principal Findings: The mean COC was 0.50 ± 0.29 (SD)
ranging from 0.42 ± .46 (SD) for patients with CHF to 0.43 ±
0.26 (SD) for patients with CAD to 0.52 ± 0.29 (SD) for
patients with diabetes. COC was entered as a continuous
measure in the logistic regression models adjusted for age,
gender, morbidity, the number of office visits, the island of
residence in Hawaii, the number of ED visits in the past year,
having asthma, a stroke, an acute myocardial infarction, and
acute coronary syndrome. Regression models were also
adjusted for diabetes, CAD, and CHF (excluding adjustment
for the disease being analyzed). Per unit increase in COC the
odds ratios for having an ED visit were 0.81 for patients with
diabetes (95% CI=0.73, 0.92, p=0.03), 0.62 for patients with
CAD (95% CI=0.50, 0.79, p=0.02), 0.41 for patients with CHF
(95% CI=0.31, 55, p < 0.001). Other regression models
examined COC categorized into thirds. The increased
percentages in risks comparing the middle and lowest thirds
to the highest were 5.9% and 7.5% for diabetes, 8.4% and
22.3% for CAD, and 32.3% and 47.1% for CHF. Patients with
CHF, for example, in the lower third for COC were 47.1% more
likely to incur an ED visit than patients in the upper third.
Conclusions: Patients with diabetes, CAD, and CHF who had
a higher COC in the past 12 months were less likely to have
ED visits during the subsequent quarter. The relation
appeared stronger for patients with cardiovascular disease
than for patients with diabetes.
Implications for Policy, Delivery, or Practice: The findings
are preliminary, but if substantiated in more detailed studies,
then disease management programs might focus greater
attention on patients with diabetes, CAD, or CHF who have a
low COC in their physician visits.
Primary Funding Source: No Funding
●Costing Shifting from a Private HMO to Public Agencies
for Substance Abuse Treatment Services.
John Dickerson, MS, Frances L. Lynch, Ph.D., Bentson H.
McFarland, M.D., Ph.D.
Presented By: John Dickerson, MS, Research Analyst,
Research, Center for Health Research, Kaiser Permanente
Northwest, 3800 North Interstate Avenue, Portland, OR
97227-1098; Tel: (503) 335-2412; Fax: (503) 335-2424; Email:
john.f.dickerson@kpchr.org
Research Objective: To examine the magnitude and type of
out-of-plan cost shifting between a private health maintenance
organization (“HMO”) and state-funded substance abuse
(“SA”) treatment services for a sample of commercial and
Medicaid HMO members. This study has the unique ability to
measure SA treatment utilization within the HMO and across
all state-funded SA agencies. Examining the magnitude and
type of out-of-plan cost shifting is important because much of
the literature focuses on within-plan cost shifting. In addition,
examining differences between Medicaid and commercial
members in the context of out-of-plan cost shifting further
differentiates this analysis.
Study Design: This study was conducted at Kaiser
Permanente Northwest (“KPNW”), an HMO centered in
Portland, Oregon. This study was a secondary analysis of
information from HMO and state agency databases. The
HMO databases provided information on use and costs of
HMO SA treatment, claims submitted to the HMO for out-ofplan SA treatment, and the duration of enrollment in the
HMO. HMO Addiction Medicine assessment interviews
strengthened the study by yielding extensive social and
demographic information (e.g., prior arrests, suicide
attempts). The Oregon addiction treatment agency provided
information about use of all state-funded (including Medicaidfunded) SA treatment.
Population Studied: Includes 1,303 adult Medicaid clients
who contacted the HMO’s addiction medicine department in
1996 or 1997 and a comparison group of 1,294 commercial
HMO addiction medicine patients matched to the Medicaid
members on age and gender.
Principal Findings: Twenty-nine percent of the study
population had at least one state-sponsored SA encounter
while they were eligible KPNW members. There were 586
state SA episodes not paid for by the HMO (excluding
services outside of contractual agreements). Medicaid
members accounted for 437 (75%) and non-Medicaid
members accounted for the remaining 149 (25%). The HMO
denied payment for only 15 of the state SA episodes, mostly
because of administrative reasons (e.g., insufficient
coinsurance information). The remaining 571 state episodes
were not submitted to the HMO for payment. The HMO did
not seem to be substituting state-funded SA services for
internal SA services. State-funded services appeared to
complement the treatment received within the HMO.
Conclusions: The study population received a substantial
proportion of SA services from state-funded agencies. There
was little evidence of reduced services within the HMO for
persons using state-funded services nor of the HMO denying
payment for outside services, which would be expected if the
HMO intentionally shifted costs to state-funded programs.
Implications for Policy, Delivery, or Practice: Publiclyfunded SA treatment agencies could improve their billing
practices - especially for Medicaid clients enrolled in private
sector HMOs.
Primary Funding Source: NIDA
●Disability Prevention Programs for Elders with Chronic
Disease: Organizational and Provider Perspectives on
Elder Participation
Almas Dossa, M.P.H., MS PT
Presented By: Almas Dossa, M.P.H., MS PT, Ph.D.
Candidate, The Heller School for Social Policy and
Management, Brandeis University, MS035, 415 South Street,
Waltham, MA 02454; Tel: (617) 566 1861; Email:
adossa@brandeis.edu
Research Objective: Health and social care services required
by disabled elders is a growing economic burden and a major
societal concern for the U.S. due to the increasing number of
elders. Since significant association exists between chronic
disease and disability in elders with chronic disease, strategies
to effectively manage chronic illness and prevent physical
disability are essential to reduce long-term care costs and
improve quality of life for elders. The Senior Wellness Project
consists of four evidence-based components shown to
prevent and decrease elder disability. This study explored
organizational (contextual, structural, and coordination)
features, and provider perspectives on getting elders to
participate in the Health Enhancement Program and Health
Mentor component of the Senior Wellness Project.
Study Design: This qualitative study was conducted via semistructured telephone interviews with administrators and
providers in 22 senior center sites located in the U.S.
Population Studied: 20 senior center administrators and 20
program providers (12 nurses, 8 social workers) were
interviewed on: contextual features (site size, site location,
elder racial/ethnic mix); structural features (funding source,
leadership, site stability, program components, client
networks, provider experience and training, provider hours,
etc.); coordination features (percentage of PCP referrals,
collaborations, internal and external communication, etc.);
and provider perspectives on program belief, provider-client
relationships, and elder participation.
Principal Findings: Findings include: descriptive information
on the variation of contextual, structural, and coordination
features across the 22 sites; how nurses and social workers
vary in their perspectives on provider role and provider-client
relationships on getting elders to participate; how
administrators, nurses, and social workers vary in their
perspectives on the importance of elder health mentors in
getting elders to participate (mentors are other elders paired
with elder clients, and who help with program goals, etc);
structural and coordination barriers in getting elders to
participate, including racial/ethnic issues and difficulty in
getting elder health mentors; exploration of trends and
patterns a) within the organizational variables b) between the
organizational and provider variables, and program
participation
Conclusions: Organizational and provider features, and elder
program participation vary in senior center sites that provide
the Health Enhancement Program/Health Mentor program.
Program providers and administrators vary in the perspectives
on how to get elders to participate and why elder participate in
programs
Implications for Policy, Delivery, or Practice: A prime object
of the Healthy People 2010, the Nation’s health promotion
and disease prevention agenda is to improve quality of life and
longevity of adults with chronic disease - one objective is to
increase the proportion of elders who participate in an
organized health promotion program, to 90%. Since elder
health promotion is of such importance, it is imperative for
health services researchers and policy makers to identify
organizational and provider efforts more likely to recruit and
engage elders in programs.
This knowledge is of critical importance in improving the
organizational and provider features within an organization, to
enhance participation rates. We also need to explore efficient
use of senior centers in the continuum of care so that policy
makers recognize them as essential community long-term
care components.
Primary Funding Source: Other Foundation Support
●Adoption of Evidence-Based Practices in Addiction
Treatment: The Impact of Funding Streams
Lori Ducharme, Ph.D., Hannah K. Knudsen, Ph.D., Paul M.
Roman, Ph.D.
Presented By: Lori Ducharme, Ph.D., Assistant Research
Scientist, Institute for Behavioral Research, University of
Georgia, 101 Barrow Hall, Athens, GA 30602-2401; Tel: (706)
542-6090; Fax: (706) 542-6436; Email: lorid@uga.edu
Research Objective: Substantial attention has been paid to
bridging the research to practice gap in addiction treatment,
with increasing emphasis on the diffusion of evidence-based
practices, or EBPs. Recent research has begun to examine the
organizational correlates of innovative behavior within
treatment programs. However, the role of program funding
streams has received less attention. This poster examines the
impact of treatment program funding – net of other
organizational, staffing, and client variables – on the adoption
of EBPs.
Study Design: Face-to-face interviews conducted in 2003-’04
with program administrators of 766 community-based
treatment programs in the U.S.
Population Studied: Addiction treatment programs, divided
into four groups for analysis: government-operated programs
- GOV, n=100; privately owned for-profit programs - FP, n=118;
and two groups of nonprofits: those relying predominantly on
SAPT block grant and other government grant funds - PBNP,
n=254; and those relying predominantly on revenues from
commercial insurance and client fees - PRNP, n=277.
Principal Findings: Findings reveal consistent and significant
differences in EBP adoption along funding lines. Private-sector
programs were significantly more likely to have adopted
pharmacotherapies, including naltrexone, buprenorphine, and
acamprosate; e.g., naltrexone adoption rates were:
GOV=13.1%, PBNP=7.5%, PRNP=32.5%, and FP=32.8%.
Meanwhile, government-operated programs and nonprofits
relying predominantly on public revenues were more likely to
have adopted one or more evidence-based psychosocial
therapies; e.g., adoption rates for contingency
management/motivational incentives were: GOV=30.6%,
PBNP=34.8%, PRNP=19.6%, and FP=12.2%. Publicly-funded
programs were also significantly more likely to have adopted a
variety of evidence-based wraparound services; e.g., adoption
rates for formal HIV/AIDS programming were: GOV=21.0%,
PBNP=20.7%, PRNP=9.8%, FP=7.6%. Particularly notable are
differences within the nonprofit sector when funding is
considered, with privately-funded nonprofits behaving much
like for-profit facilities in their adoption of EBPs. These
differences hold even after controlling for a variety of programlevel structural, staffing, and caseload characteristics.
Conclusions: Treatment programs’ funding streams play a
significant role in the diffusion and adoption of EBPs. Of
particular importance are distinct differences in adoption
behavior within the non-profit sector. Assuming homogeneity
within the broad category of privately owned non-profits may
mislead researchers as well as technology transfer agents by
underestimating the impact of divergent funding streams on
organizational behavior.
Implications for Policy, Delivery, or Practice: Patterns of
adoption of EBPs vary across service sectors and revenue
streams. Certain funding sources may directly facilitate or
impede adoption of EBPs. Agencies responsible for
disseminating research and for engaging in technology
transfer efforts must attend to the impact of funding sources
on adoption decisions. Dissemination methods need to be
tailored to different sectors, and expectations for diffusion of
EBPs should be aligned with the practical constraints imposed
by payors and funding agencies.
Primary Funding Source: NIDA
●Quality of Mental Health Care for Children and
Adolescents: Access to Psychotherapy
Farifteh Duffy, Ph.D., Joyce C West, Ph.D., M.P.P., Ilze Ruditis,
LCSW, Gary Blau, Ph.D., William E Narrow, M.D., M.P.H.,
Darrel A Regier, M.D., M.P.H.
Presented By: Farifteh Duffy, Ph.D., Research Scientist,
American Psychiatric Institute for Research & Education, 1000
Wilson Boulevard; Suite 1825, Arlington, VA 22209; Tel: (703)
907-8620; Fax: (703) 907-1087; Email: fduffy@psych.org
Research Objective: Access to mental health services has
been shown to be limited for children and adolescents with
mental disorders where only about 20 to 30% of the children
who require mental health and substance abuse treatment
services appear to receive any care (Surgeon General Report,
1999). Even lesser is known about the quality of treatment
provided to youth who access mental health services. As an
important evidence-based indicator of quality care, this study
will examine rates and patterns of psychotherapy across a
broad range of clinical settings among children and
adolescents treated by psychiatrists.
Study Design: In this study, cross-sectional data from the
1997 and 1999 American Psychiatric Practice Research
Network (PRN) Study of Psychiatric Patients and Treatments
(SPPT) was used. A total of 189 PRN-member psychiatrists
provided clinically detailed data on a national sample of 393
children and adolescents under 18 years of age. Analyses were
performed using SAS and SUDAAN software to adjust for the
weights and the nested sampling design.
Population Studied: Approximately 42.0% of psychiatrists
were specialized in Child and Adolescent Psychiatry. Sampled
youth were between 2 and 17 years old (mean 12.5); 70% male;
predominantly white (75%) with 12% African-American, and
6% Hispanic.
Principal Findings: Findings indicate that nearly 40% of
children and adolescents were not provided evidence-based
guideline recommended psychotherapeutic care from any
provider within 30 days of the index visit to the treating
psychiatrist. Highest rates of psychotherapy were observed
among those diagnosed with schizophrenia (67%). Factors
associated with not receiving guideline-concordant
psychotherapeutic care include: having a managed care health
plan, no reported psychosocial problems, and being treated in
1997.
Conclusions: This study provides a snapshot of “real world”
psychiatric treatment for children and adolescents. Despite
evidence-based and expert-consensus-based support for
provision of psychotherapy as a component of treatment for
children and adolescents, 2 out of every 5 youth in psychiatric
care did not receive psychotherapy within 30 day period.
Healthcare financing and management policies need to
facilitate greater access for this treatment modality.
Implications for Policy, Delivery, or Practice: The current
findings give needed direction for payers, health plans,
practitioners, parents and other constituents who seek to
improve access and quality, and promote wider use of
evidence-based practices in mental health services systems for
children and adolescents.
Primary Funding Source: Center for Mental Health Services
●Changes in Organ Donation Attitudes, Perceptions, and
Behavior among African Americans in the U.S.
Roger Durand, Ph.D., Kimberly Davis, RN, CPTC, Samuel
Holtzman, B.A., Phillip J. Decker, Ph.D., Lamon Atkins, B.S.
Presented By: Roger Durand, Ph.D., Professor of Healthcare
Administration, Healthcare Administration, University of
Houston-Clear Lake, 2700 Bay Area Boulevard, Houston, TX
77058; Tel: (281) 283-3141; Fax: (281) 283-3136; Email:
Durand@uhcl.edu
Research Objective: Among African Americans in the United
States, the number of organ donors continues to lag
considerably behind the demand for transplantable human
organs. The reasons for these continuing lower donation rates
among African Americans have been studied in a number of
previous investigations. Yet, there remain few studies of
changes in organ donation attitudes and behavior among this
racial minority, especially changes in response to public
educational and outreach efforts by Organ Procurement
Organizations (OPOs). In this research, changes in attitudes,
perceptions, and organ donation behavior among African
Americans were studied over a period immediately preceding
to immediately following Federally funded and regional OPO
administered programs aimed at this racial minority.
Study Design: In the year 2000 interviews were conducted by
telephone, utilizing a standardized questionnaire, with a crosssection of 375 African American adults residing in Harris
County (Houston), Texas. Subjects were selected by random
digit dialing techniques. In early 2003 a second cross-section
survey was completed utilizing identical methods. In the
second survey 386 randomly selected African American adults
residing in Harris County were interviewed. The size of each
sample yielded a margin of error of +/- 5% at the 95 percent
confidence level. This survey evidence was supplemented with
data derived from a true experiment (n=101 subjects) over the
same time period as well as with data on actual numbers of
African American organ donors. The two surveys, the
experiment, and the donation data bracketed in time Federally
funded programs administered by the regional OPO intended
to enhance donation among African Americans.
Population Studied: Adult, African American residents of
greater Houston, Texas.
Principal Findings: Preliminary findings show evidence of an
increase in knowledge about donating organs and, especially,
in hearing or reading a lot about such topics as costs to the
donor and donor funeral arrangements. They also show that
organ donation was increasingly a comfortable topic for
discussion. On the other hand, no evidence was found of
enhanced acceptance of, or support for, donation. Similarly,
there was no evidence of changes in perceived problems (e.g.,
it is against one’s religion) with organ donation, in the
amount of family discussion regarding donation, in intention
to donate upon death, or in actual donation.
Conclusions: These findings taken together are quite in
keeping with considerable previous social science research.
Knowledge and information levels regarding organ donation
are relatively easy to change through public education
campaigns. Moreover, increased knowledge and information
do appear to make the topic of donation a more comfortable
one for discussion. On the other hand, more fundamental
acceptance of, support for, and even perceived problems with,
donation are not easy to modify.
Implications for Policy, Delivery, or Practice: OPOs should
consider concentrating more of their efforts among African
Americans at enhancing knowledge about organ donation
itself and about “how” to donate rather than at the more
difficult task of altering attitudes or fundamental perceptions.
In doing so, they are likely to promote donation as a topic that
is at least easier for individuals to discuss.
Primary Funding Source: HRSA
●Lack of Correlation Between Proportion of Inpatient
Cases Involving Severe Sepsis And Composite Quality
Scores For US Hospitals
Frank Ernst, Pharm.D., M.S., William Saunders, Ph.D., M.P.H.,
Chris Craver, MA
Presented By: Frank Ernst, Pharm.D., M.S., Senior Outcomes
Research Associate, US Outcomes Research, Eli Lilly and
Company, Lilly Corporate Center DC 6835, Indianapolis, IN
46285; Tel: (317) 655-9227; Fax: (317) 277-8291; Email:
f_ernst@lilly.com
Research Objective: Hospital composite quality scores in US
hospitals are available as metrics to assess care for emergent
illnesses including acute myocardial infarction (AMI), heart
failure (HF), and pneumonia (PN), but not for severe sepsis
(SS). This study was designed to determine whether any
relationship exists between hospital rates of SS and currently
available hospital quality scores.
Study Design: Quality of care at the facility level was defined
using the Composite Quality Score (CQS) methodology
outlined in the Centers for Medicare and Medicaid Services
(CMS)/Premier Hospital Quality Incentive Demonstration
(HQID) Project, a program designed to assess the
effectiveness of financial incentives toward improving the
quality of inpatient care. Quality scores for the three acute
care project areas were calculated using data submitted by
participating hospitals to the Premier Perspective™
Comparative Database for CY2004 for Joint Commission on
Accreditation of Healthcare Organizations (JCAHO) Core
Measures and CMS 7th Scope of Work (not HQID data). AMI
included patients with ICD-9-CM primary diagnosis codes for
AMI. HF included patients with primary diagnosis codes for
HF. PN included patients with primary diagnosis codes for
PN, in addition to patients with primary codes for septicemia
or respiratory failure plus secondary codes for PN. SS was
defined using the 2001 methodology of Angus and colleagues,
updated with coding changes since their publication. For
hospitals in which patients with CQS scores for AMI, HF, or
PN, were treated, we calculated hospital-wide inpatient rates
of SS. We assessed correlations between the CQS for each
focus area and individual hospital-wide SS rates.
Population Studied: We studied patients with AMI
(N=69,755), HF (N=115,822), and PN (N=131546), as defined
by JCAHO Core Measures and the CMS 7th Scope of Work,
from approximately 290 hospitals.
Principal Findings: Institutional SS rates ranged from <1%8% for the hospitals with AMI, HF, and PN patients. CQS
scores ranged from 25%-100% for AMI, from 18%-100% for
HF, and from 58%-98% for PN. Little or no correlations were
found between CQS and SS rates for AMI (r=0.057) and HF
(r=0.048). Similarly, little or no correlations were found for PN
cases overall (r=-0.075) and PN cases involving septicemia
(r=0.113). The CQS for AMI, HF, and PN combined was also
not well correlated with SS rates (r=-0.035).
Conclusions: Hospital composite quality scores in US
hospitals are not well correlated with the proportion of
inpatient cases involving SS. Thus, assessing how SS may
affect the quality of hospital care is difficult using measures for
AMI, HF, or PN, including PN cases involving septicemia.
This may be due to the low SS rates among hospitalized
patients overall as compared to ICU patients alone, or due to
poor relationships between SS and other illnesses.
Implications for Policy, Delivery, or Practice: Currently
available metrics for AMI, HF, and PN are inadequate to
identify healthcare quality problems in SS. Existing metrics
could be improved by incorporating adjustments for factors
known to be associated with SS incidence (age, ICU status).
Using metrics developed specifically to assess ICU and SS
quality may hold the greatest potential.
Primary Funding Source: Eli Lilly and Company
●Teens, Technology and Transforming Healthcare
Donna Ettel, Ph.D., George Leonard Ettel III, Student, Lisa
Simpson, MB, BCh, M.B.A., Michael Anthony Cerio, M.Ed.,
John Charles Briggs, Jennifer Nichole Travis, Maura Michelle
Thoenes
Presented By: Donna Ettel, Ph.D., Pediatrics, University of
South Florida College of Medicine, 601 4th Street South, CRI
1008, Saint Petersburg, FL 33701; Tel: (727) 553-3673; Fax: (727)
553-3666; Email: dettel@hsc.usf.edu
Research Objective: Recent national and state attention has
centered on the need to accelerate the utilization of health
information technology applications. Despite a national push
toward the use of health information technology (HIT), not
much is known about the knowledge and use of these
applications among high school students. The main objective
of this project is to assess the knowledge and extent to which
students at Saint Petersburg Catholic High School are utilizing
various HIT applications. A secondary purpose is to build
upon and complement other HIT related research by
providing the kids’ voice to the national agenda.
Study Design: Initially, a comprehensive literature review was
conducted in order to identify gaps in HIT knowledge. Second,
the survey instrument was developed which comprised of
questions relating to HIT applications such as: teenager’s
access to computers and internet connectivity, types of health
information sought, and the knowledge and use of personal
health records. Individuals with expertise in medical
informatics and/or health policy reviewed the content, offered
recommendations for revision, which were integrated in the
document which simultaneously supported a claim for
content validity. After developing the cover letter the
document was submitted to the IRB for an expedited review
process. Analysis includes descriptive statistics, visual displays
and summaries statistics. The statistical procedure will be a
multi-variate analysis of variance MANOVA. The independent
variables include student characteristics (grade level, age, and
race/ethnicity). The HIT dependent variables were the student
utilization of personal health records, email communication
and internet applications.
Population Studied: The questionnaire, cover letter (which
described the purpose of the study and encouraged
participation) was hand delivered to students at Saint
Petersburg Catholic High School by their home room teachers
to each member of the student body. Specifically this study
examined all high school seniors, juniors, sophomores and
freshman in the school. Students who did not complete the
survey in its entirety or chose not to participate were excluded
from the study. All questionnaires were tracked by a six digit
identifying code.
Principal Findings: Forthcoming. However, findings are
anticipated to show an overall lack of knowledge on HIT
applications, but a willingness to learn and use this advancing
technology.
Conclusions: Although additional research is needed, current
and emerging technologies provide potential opportunities to
improve the quality and safety of adolescent healthcare. It is
expected that over the next several years we will see pervasive
adoption of these applications due to federally mandated
changes in healthcare. Existing understanding regarding the
adoption of these technologies has been limited in this
population, due to a lack of compelling studies that
demonstrate the impact on adolescent healthcare.
Implications for Policy, Delivery, or Practice: This
information is the first of its kind in the adolescent arena and
may assist physicians, policymakers and other key stakeholder
in Florida—and nationally—in identifying, designing and
implementing strategies to promote the use health
information technology applications among teens to support
HIT utilization.
Primary Funding Source: No Funding
●Electronic Office Based Applications Supporting Quality
of Care
Donna Lee Ettel, Ph.D., Lisa Simpson, MB, BCh, M.P.H.,
FAAP, Nir Menachemi, Ph.D.
Presented By: Donna Lee Ettel, Ph.D., Director National Child
Health Data Standards Project, Pediatrics, University of South
Florida, College of Medicine, 601 4th Street South, CRI-1008,
Saint Petersburg, FL 33701; Tel: (727) 553-3673; Fax: (727) 5533666; Email: dettel@hsc.usf.edu
Research Objective: The literature provides numerous
studies that have identified that office based capabilities may
lead to improved quality. However, the extent these
applications exist in a sample of community based physicians
serving children remains unclear. The purpose of this study is
to assess the extent to which physicians serving children have
electronic and other capabilities known or believed to improve
quality of care.
Study Design: The current study is limited to Child Health
Providers (CHPs) who responded to a larger survey of all
ambulatory physicians in Florida. The independent variables
include physician and practice characteristics (i.e. age,
race/ethnicity, specialty, practice size/type and Medicaid
volume). Quality related variables include physician ability to
perform certain quality functions (e.g. sending reminder
notices), experience with process failures (e.g. missing patient
information), and beliefs about the effectiveness of various
strategies to improve quality (e.g. involvement in
collaboratives). Initial analyses included descriptive statistics
and univariate analyses. An index was constructed to
characterize a quality enabled practice which then served as a
continuous dependent variable in the multivariate analysis of
independent factors associated with higher scores on this
quality enabled practice index. The index is an un-weighted
sum of single points credited for each of several office
functions judged to be associated with higher quality such as
having an EHR, clinical decision support, weight based dosing
or growth charting, and being able to create lists of patients
by diagnosis or lab result.
Population Studied: Pediatricians, family practitioners and
pediatric sub-specialists received an instrument that included
additional questions on quality of care. Specifically, this study
analyzed results from all pediatricians, family practitioners
serving greater than 20% children, and pediatric subspecialists (n=1,014).
Principal Findings: Less than half of CHPs report being able
to perform certain quality related functions (e.g. 44.5% send
reminder notices for preventive care, 26.5% receive prompts
for special follow up care). CHPs have the ability to create
patient lists by diagnosis somewhat or very easily (44.1%)
more often than patient lists by medications (15.5%) or
laboratory results (17.1%). CHPs report rarely or never
observing the following process failures: repeated tests
because findings were unavailable (62.2%); or medication
errors (82.7%). The logistic regression findings suggest that
42% of African American physicians in the higher category for
(quality index points, 7+) were twice as likely to utilize
electronic office functions (p=.017) than White, Hispanic, or
Asian child health providers. Additionally, CHPs who are less
than 40 or more than 60 years of age are credited with higher
scores.
Conclusions: Office based capabilities felt to be associated
with higher quality have not been widely adopted by child
health providers. This suggests that improvements in the
quality and safety of care for children and adolescents may
continue to lag behind adult populations unless specific
attention is paid to the needs of child health providers.
Implications for Policy, Delivery, or Practice: This
information is the first of its kind in the pediatric arena and
may assist policymakers and other key stakeholder in
Florida—and nationally—in identifying, designing and
implementing strategies to promote the use of electronic
applications to support quality improvement.
Primary Funding Source: No Funding
●The Relationship Between Change in SF8 Physical Scores
and a Self-Reported Health Question for Participants in a
Medication Access Program
Robert Federici, MSPH, Gary Harmon, M.P.H., Wendy Roy,
M.H.A., Danny Jackson, R.Ph., Larry Webber, Ph.D., John
Lefante Jr., Ph.D.
Presented By: Robert Federici, MSPH, Biostatician,
Biostatistics, Tulane University School of Public Health and
Tropical Medicine, 1440 Canal Street, Suite 2001, New
Orleans, LA 70112; Tel: (504) 988-7874; Fax: (504) 988-1706;
Email: rfederic@tulane.edu
Research Objective: SF-8 scores have been used to gain a
relative understanding of an individual’s health related quality
of life. Composed of eight questions, the SF-8 gives separate
physical-PCS and mental-MCS scores which can be used in
comparisons both within and with other populations. The
goal of this study is to examine the change in participant’s SF8 physical score from their first to second visits and relate that
to change in a single self reported health question.
Study Design: Through a partnership between The Rapides
Foundation and the outpatient clinics at a regional state
hospital in Central Louisiana, the Cenla Medication Access
Program-CMAP provides prescription medications to
residents who cannot afford them. This analysis examines
CMAP participants SF-8 PCS score and self reported health
responses at baseline enrollment and at follow-up. Selfreported health is measured in terms of the participants rating
their health as poor, fair, or good-excellent.
Population Studied: The population consists of participants
in rural central Louisiana who are participating in the Central
Louisiana Medication Access Program. Participants who meet
certain eligibility requirements are provided prescription
medications at a substantially reduced cost. The study
sample includes 1090 participants who were tracked for an
average time of 10.8 months in order to examine the
relationship between their self reported health and their SF8
PCS score. The sample has an average age of 50.7 years, is
73.6 percent female, and 43.7 percent African American.
Principal Findings: The participants self reported health
status was tracked in terms of movement from one group to
another, i.e. poor to good, or lack of movement, i.e. poor to
poor, between their first and second visits. Of the 1090, 23.9
percent of the participants indicated a poor self status at
baseline compared to 47.0 percent who stated fair and 29.1
percent who indicated good-excellent. Overall, 58.3 percent of
all participants remained in the same self health category at
their second visit, 28.1 percent reported an increase, and 13.6
percent reported a decrease. When examining participants’
movement from one self health category to another, a trend in
their physical SF-8 scores was seen. For those individuals
reporting improvement in their self –reported health, i.e. poor
to fair, an increase in their SF8 PCS scores was seen.
Inversely, when an individual reported a decline in selfreported health, i.e. fair to poor, there was a decrease in their
SF8 PCS score. For example, participants who reported poor
health for both their first and second visit had a 0.8 unit
change in their physical score. Those who changed from poor
to fair had a 6.7 unit increase and those from poor to good
had a 12.9 unit increase.
Conclusions: In this study population, there is a direct
association between change in categories of self reported
health and change in SF8 physical scores. Therefore, a single
self health question may be satisfactory in determining the
relative physical health of participants.
Implications for Policy, Delivery, or Practice: One question
may be an adequate measure of participants overall physical
status as opposed to the eight questions needed for the SF8.
Primary Funding Source: The Rapides Foundation
●The Effect of Medicaid Eligibility Policies on Medicaid
Enrollment by Low-Income Seniors
Alex Federman, M.D., M.P.H., Ryan Ungaro, BA
Presented By: Alex Federman, M.D., M.P.H., Assistant
Professor of Medicine, Medicine, Mount Sinai School of
Medicine, 1470 Madison Avenue, Box 1087, New York, NY
10029; Tel: (212) 241-8605; Fax: (212) 831-8116; Email:
alex.federman@mssm.edu
Research Objective: To determine the effect of states’
applications of the Omnibus Budget Reconciliation Act
(OBRA) of 1986 and section 209(b) of the Social Security Act
Amendment of 1972 on Medicaid enrollment by elderly
Medicare beneficiaries. OBRA permits states to liberalize
Medicaid income and asset eligibility criteria, potentially
increasing Medicaid enrollment, whereas 209(b) allows states
to establish more restrictive income and asset eligibility
criteria, potentially reducing enrollment.
Study Design: Cross-sectional analysis. We modeled
Medicaid enrollment as a function of residence in states
applying OBRA or 209(b) policies, controlling for
demographic and health status characteristics.
Population Studied: Data were from the 2001 Medicare
Current Beneficiary Survey. Subjects were communitydwelling Medicare beneficiaries ages 65 or older with
household incomes less than 100% of poverty.
Principal Findings: Of the 1,404 low-income seniors included
in the analysis, mean age was 76.8, 72% were female, 89%
had no post-high school education and 74% had one or more
chronic diseases. 40% of study subjects were not enrolled in
Medicaid. Restrictiveness of state Medicaid eligibility criteria
did not affect Medicaid enrollment for low-income seniors.
The adjusted relative risk ratio (RR) of Medicaid enrollment
was 1.22 (95% CI 0.90, 1.62) for seniors from OBRA states
and 1.37 (95% CI 0.75, 2.30) for those from 209(b) states.
Conclusions: The restrictive and liberalizing effects of 209(b)
and OBRA policies, respectively, on Medicaid eligibility criteria
appear to be too modest to significantly affect Medicaid
enrollment by low-income seniors.
Implications for Policy, Delivery, or Practice: Factors other
than state eligibility criteria are serving as barriers to Medicaid
enrollment by low-income seniors.
Primary Funding Source: American Federation for Aging
Research
●Childbirth and Ethnicity: Cultural Comparisons of Health
Service Experiences of Primiparous Women During Labor
and Delivery
Veronica D. Feeg, Ph.D., RN, FAAN, Marie P. Kodadek, Ph.D.,
RN, Azza F. El-Adham, Ph.D., RN
Presented By: Veronica D. Feeg, Ph.D., RN, FAAN, Professor
& Chair, Women's Children's and Family Nursing, College of
Nursing, University of Florida, HPNPC PO Box 100187,
Gainesville, FL 32610-0187; Tel: (352) 273-6366; Fax: (352) 2736568; Email: rfeeg@nursing.ufl.edu
Research Objective: In a recent study using a secondary
analysis of the MEPS national data set on pregnant women,
we found significant differences in Hispanic women’s lack of
epidural use for mediating pain in childbirth. In fact, they were
twice as likely not to have had an epidural during childbirth
when controlling for marital status, parity, singleton births,
and uncomplicated deliveries. To explore other characteristics
around the childbirth labor and delivery experience of women,
this prospective study examined women’s childbirth pain
recall experiences immediately following delivery to determine
whether race and/or culture influences the likelihood of having
had a variety of common maternity interventions.
Study Design: As part of a larger study on the childbirth
experience of women from several racial and ethnic groups of
patients delivering normal, singleton babies in a large
metropolitan Mid-Atlantic hospital, this study focused on 3
specific groups for analysis: Whites, Blacks and Hispanics. A
convenience sample of women was recruited by nurse
partners on the postpartum units within 24 hours following
delivery and the women were invited to complete a
questionnaire prior to discharge in English or Spanish,
assisted by a hospital translator as necessary. The Childbirth
Pain Experience Recall Inventory (CPERI) was developed for
the study and was translated and back translated prior to use.
It included questions on the conditions of the woman’s labor
and delivery, demographics, pain recall, and satisfaction with
pain management during childbirth.
Population Studied: All patients who agreed to participate
were included in the sample. To acquire an adequate total
sample (n=247) that was adequately representative of the
racial and ethnic distributions of the geographic region,
oversampling of Hispanic women was done to yield the final 3
groups for comparison: Whites (n=156); Blacks (n= 38); and
Hispanics (n=53). The women were all married, first-time
mothers.
Principal Findings: Hispanic women significantly differed in
several aspects of the labor and delivery health services they
received. They were almost twice as likely to arrive at the
hospital in labor (Chi sq = 18.90, p<.001) and more likely not
to have epidurals (Chi sq = 17.37, p<.001) or episiotomies (Chi
sq = 6.33, p<.05). They reported their labor lengths of times
more often to be less than 6 hours from onset to delivery than
Blacks or Whites (Chi sq = 30.40, p<.001). They reported
similar use of pain medication, but almost twice as much use
of sedatives or tranquilizers (Chi sq = 8.37, p<.05). Ultimately,
they rated the childbirth pain management they received
during labor and delivery significantly poorer than Blacks or
Whites (p<.05).
Conclusions: Although “medicalizing” childbirth in the U.S. is
not a completely desirable approach to the delivery of quality
maternity services, the findings of this study suggest that for
possibly complex reason, Hispanic women are being treated
differently in the labor and delivery systems of our major
metropolitan health care institutions. They recall a delivery
experience that is quicker, less satisfying, and often without
the common interventions that are given to comparable
pregnant women in the same geographic region of health
service centers. Whether or not socioeconomic characteristics
play a role in the patterns of labor and delivery services offered
to women who arrive at hospitals today, it cannot be
overlooked that some cultural characteristics or conditions
exist which influence the likelihood of certain treatments.
Implications for Policy, Delivery, or Practice: It is important
to be cognizant of the differences that may play out in caring
for women during childbirth as they result in the services that
are provided during labor and delivery. Whatever prompts
women to seek hospital care when signals indicate that labor
has begun, there may be inherent differences based on
cultural teachings reinforced during prenatal visits that delay
earlier arrival. If their labors are faster, it may become less
opportune to provide the comfort and pain management
normally available to other women, thus yielding a less
satisfying childbirth experience. If epidural anesthesia is not
being made available to minimize the pain during labor, then
it needs to be determined whether it is a matter of the cost of
this intervention over the equity of delivering quality care.
Primary Funding Source: Epsilon Zeta Chapter, Sigma Theta
Tau International
●A System Perspective: Organizational Levels in
Evaluating an Implementation Initiative
Jacqueline Fickel, Ph.D., Parker, Louise E., Ph.D., Yano,
Elizabeth M., Ph.D., Ritchie, Mona, M.S.W., Kirchner, JoAnn
E., M.D.
Presented By: Jacqueline Fickel, Ph.D., Associate Investigator,
Center for the Study of Healthcare Provider Behavior, 16111
Plummer Street(152), North Hills, CA 91343-2036; Tel:
(818)891-7711 x5482; Email: jacqueline.fickel2@med.va.gov
Research Objective: Recent literature indicates the
importance of accounting for organizational structure and
complexity in planning and studying quality improvement
interventions. Interventions, however, are often initiated from
the top level of an organization. The object of the present
work is to identify the relational aspects within a complex,
multi-level health care system. The nature of associations and
interactions between top and lower levels is expected to be key
for implementation of research into practice and for
improving the effectiveness of evaluation efforts. We use
stakeholder interview findings from an evaluation of the initial
implementation of Translating Initiatives for Depression into
Effective Solutions (TIDES), a model for collaborative care of
depression in primary care, to explore the role of multiple
organization levels, and to help inform strategies and tools for
future implementations.
Study Design: This work examines three different Veterans’
Health Administration integrated networks of medical centers
and outpatient clinics. It is part of the qualitative component
of a post-intervention evaluation. Semi-structured interview
topics included associations and interactions among the
entities at all four levels of the networks: network
administration, medical center administration, clinic
administration, and primary care and mental health practice
groups. Responses were analyzed for themes within each
network, providing a picture of the patterns of relations within
the system structure of each network.
Population Studied: We interviewed 106 stakeholders from
three networks, including five Medical Centers, and six
outpatient clinics. Interview informants included network
directors, medical center directors, clinic administrators,
clinicians, non-clinical staff, consumers, and consumer
representatives. Individuals from both primary care and
mental health care service lines were represented at all levels.
Principal Findings: Stakeholders described distinct patterns
of relationships among the facilities within each network.
They highlighted various connections among organizational
units and levels, and between the primary care and mental
health services. Two network systems were described as more
rigidly hierarchical than the third, yet there were descriptions
of varying clinic autonomy and locally-initiated projects from
each. Informants reported that these relational aspects were
important to initiatives, and that active involvement at each
organizational level was crucial. The patterns for each network
are diagrammed and compared in light of the widely varied
extent of TIDES implementation among the sites.
Conclusions: Implementation of the TIDES model was
initiated by the network, but occurred within local primary care
clinics with medical center support. The interconnections
between the organization levels were important as a context
for implementation activities. The relations among the
entities in the system differed among, and within, networks.
Implications for Policy, Delivery, or Practice:
Implementation design and evaluation strategies must take
layered organizational context into account. Top-level support
is needed, plus latitude for adaptation at the local level. We
provide examples of a set of tools, using information from this
system-based evaluation, that will build upon the connections
between organizational levels in further stages of TIDES
implementation.
Primary Funding Source: No Funding
●Identifying and Addressing Significant Challenges in
Creating a Community-wide Health Information Exchange
Diane Fields, M.S.W., Margaret J. Gunter, Ph.D., Diane Fields,
MSW, Bob White, M.D., Shelley Carter, RN, M.P.H.
●Using Patient-Focused Research to Design Effective
Messages and Delivery Channels for Adherence
Interventions
Kathleen Foley, Ph.D., Leigh G. Hansen, MS, M.B.A.
Presented By: Diane Fields, M.S.W., Senior Clinical Research
Associate, Lovelace Clinic Foundation, 2309 Renard Place,
S.E., Suite 103, Albuquerque, NM 87106; Tel: 505-262-3361;
Fax: 505-262-7598; Email: Diane.Fields@LCFresearch.org
Research Objective: The exchange of health information
across organizational boundaries has recently gained
increased attention as a means of improving health care
quality and efficiency. However, this exchange does not occur
without challenges, e.g., legal/privacy, business competition,
resource constraints, selecting a focus valued by stakeholders.
Identifying and developing strategies to address these
challenges is critical to a health information exchange’s
success so has been an early objective of this study.
Study Design: In October, 2004, Lovelace Clinic Foundation
initiated the New Mexico Health Information Collaborative, a
3-year project to establish a health information exchange in
New Mexico, with support from the Agency for Healthcare
Research and Quality and community partners. Qualitative
methods employed, or planned, to identify and address
barriers include: review of publications and materials
concerning other health information exchange, HIE, projects;
conducting community assessments, including key
stakeholder interviews; soliciting regular written meeting
evaluations from stakeholders; and mid-project formative
evaluation using stakeholder surveys by an independent entity.
Population Studied: Key community stakeholders and data
providers, including healthcare organizations, health plans,
employers, public schools; other health information
technology initiatives in the state and nation.
Principal Findings: Our qualitative research identified key
methods to reduce barriers, including: leadership by a
neutral, trusted entity; an inclusive governance structure that
facilitates broad community input; selection of an early
feasible focus valued by key stakeholders; development of
timely, short-term products/services to build credibility; use of
varied communication and marketing mechanisms tailored to
specific audiences; nurturing of strategic project champions
and early adopters; demonstration of the value
proposition/business case for stakeholders; plan for a
sustainable business model from the outset; and hiring of an
attorney with relevant privacy expertise. Our implementation
of these approaches is still a work in progress. The
stakeholder survey is in process; results will be presented.
Conclusions: Although a community may agree conceptually
on the importance of an HIE, the development and
implementation of an operational exchange requires
identification and adroit navigation of many community
minefields.
Implications for Policy, Delivery, or Practice: The promise
of health information exchange to improve health care and
efficiency will only be realized if leaders are skilled in the
identification and management of general and communityspecific barriers.
Primary Funding Source: AHRQ
Presented By: Kathleen Foley, Ph.D., Lead Researcher,
Pharmaceutical Outcomes Research, Thomson Medstat, 118
Lakeview Drive, New Hope, PA 18938; Tel: (215) 862-1323; Fax:
(215) 862-1323; Email: kathleen.foley@thomson.com
Research Objective: To identify patient segments based on
beliefs about medications, reasons for non-adherence,
demographics and psychographics to inform actionable
messaging for medication adherence improvement.
Study Design: Patients self-identifying as having high
cholesterol responded to a consumer health behavior survey
in October - November 2005. These respondents received
cholesterol-specific questions about their adherence, beliefs
and reasons for non-adherence. Beliefs about the necessity of
and concerns about taking cholesterol-lowering medications
were assessed via five likert-scale questions, each with
summed scores ranging between 5 and 25. A cut-point of 15
was used to identify high versus low necessity or concern
creating four patient segments: high necessity/high concern HNHC, low necessity/high concern - LNHC, low necessity/low
concern - LNLC, high necessity/low concern - HNLC. Nonadherence was measured as skipping, taking smaller doses,
delaying, and/or stopping medication fills in the past 30 days.
Reasons for non-adherence included: cost, forgetting,
experience with the medication, self-assessed need, and
convenience. Patients were assigned to one of 66 PRIZM
lifestyle segmentation clusters to determine psychographic
characteristics and preferred message delivery vehicles.
Population Studied: 5,630 U.S. patients self-identified as
having high cholesterol when responding to the Thomson
Medstat PULSE consumer health behavior survey.
Principal Findings: 4,737 respondents reported taking
prescription cholesterol-lowering medications with 28.1%
reporting non-adherence. Non-adherence rates varied
significantly among patient segments: 51.6% of LNHC
respondents, 36.1% of HNHC, 29.1% of LNLC and 20.8% of
HNLC were non-adherent - chi-square p<0.0001. Type of and
reasons for non-adherence also varied. Patients with high
concerns were more likely to report taking smaller doses 33.5% of HNHC and 36.5% of LNHC versus 22.4% of LNLC
and 20.6% of HNLC - than those with low concerns and they
were more likely to be non-adherent due to experiences with
medications - 26.6% of HNHC and 30.2% of LNHC versus
12.2% LNLC and 8.7% of HNLC. Patient segments also
differed by income - chi-square p<0.0001, education - chisquare p<0.0001, and health status - chi-square p<0.0001.
Preliminary analysis of PRIZM clusters illustrates differences
in non-adherent patients between the four segments.
Conclusions: Medication adherence behavior is influenced by
many factors, complicating broad scale implementation of
effective adherence improvement programs. Previous research
has shown that patients’ beliefs about their medications play a
key role in adherence behaviors. Our study suggests that
information about patient beliefs on the necessity of
medications versus concerns about them can be used to
identify patient segments requiring distinct messages to
improve medication adherence. Linking patient segments with
demographic and lifestyle factors via PRIZM clusters helps to
identify appropriate message delivery channels to reach target
patients.
Implications for Policy, Delivery, or Practice: Effective
adherence intervention programs are complicated by the
matrix of factors affecting non-adherence. This research was
designed to identify opportunities for targeted messaging
based on beliefs and reasons for non-adherence to prescribed
cholesterol medications. Linking this information with
appropriate delivery channels to reach target populations in
specific geographies can create more effective interventions.
Primary Funding Source: Thomson Medstat
●Outcomes of Physician Residency/Fellowship Training in
New York, 1998-2005
Gaetano Forte, BA, David Armstrong, BA, Gaetano Forte, BA,
Jean Moore, MS
Presented By: Gaetano Forte, BA, Director of Information
Management, Center for Health Workforce Studies, 7
University Place, Room 334, Rensselaer, NY 12144; Tel: (518)
402-0250; Fax: (518)402-0252; Email: gjf01@health.state.ny.us
Research Objective: To summarize the outcomes of graduate
medical training in New York; to describe and analyze
changes, trends, and correlates of the education debt-load of
new physicians; to describe and analyze changes, trends, and
correlates of starting income among new physicians; to
describe and analyze changes and trends in the demand for
physicians across specialties.
Study Design: The data analyzed for this examination were
collected via an annual survey of physicians completing
residency or fellowship programs in New York between 1998
and 2005. The survey was conducted in collaboration with
teaching hospitals in New York from 1998 through 2003 and
again in 2005. The survey instrument, completed by each
individual resident/fellow, collected extensive information on
their demographic and educational backgrounds, their posttraining plans and their perceptions of the job market for new
physicians. Between 1998 and 2005, more than 20,000
physicians completing training in New York responded to the
survey (approximate response rate of 65%).
Two general linear models were specified to estimate a) the
level of educational debt among graduates of medical schools
in the US (USMGs) controlling for a number of variables,
including age, gender, race/ethnicity, type of medical
education, and specialty; and b) the starting incomes of new
physicians beginning practice controlling for a host of
variables significantly associated with starting incomes.
Finally, an index of relative demand for rank-ordering
specialties was constructed using a battery of items describing
the perceptions and experiences of new physicians in the job
market. Comparisons of changes and trends in income, debt,
and relative demand were made when possible and
appropriate.
Population Studied: Residents and fellows completing
graduate medical training programs in New York between
1998 and 2005.
Principal Findings: Average levels of educational debt
increased over time. Levels of educational debt varied
significantly across a number of variables, including: specialty,
type of medical education (allopathic and osteopathic), and
race/ethnicity. Educational debt varied by as much as 2:1
across specialties.
Among all physicians completing graduate medical training in
New York who had confirmed post-training plans to enter
clinical practice total starting incomes varied greatly,
approaching a 2:1 ratio across specialties. Starting incomes
for new physicians in primary care specialties (Family
Medicine, General Internal Medicine, and General Pediatrics)
were significantly less than the starting incomes for physicians
in non-primary care specialties. Starting incomes were
particularly high for new Anesthesiologists, Radiologists, and
Orthopedic Surgeons. Total starting income varied
significantly by a number of variables, including: specialty,
citizenship status, gender, and expected practice hours.
Despite the rich supply of physicians in New York (320 patient
care physicians per 100,000 population), respondents
continue to report high levels of success finding satisfactory
practice positions. Demand for primary care physicians was
lower relative to non-primary care physicians. Primary care
specialties consistently ranked among the lowest specialties
on the constructed demand index. Demand was particularly
high in the following specialties: Anesthesiology,
Gastroenterology, Dermatology, Cardiology, and Radiology.
Conclusions: Educational debt among new physicians
continues to increase for new physicians. There are a number
of important factors that affect the educational debt of new
physicians. The findings of this examination suggest that
specialty, type of medical education, and race/ethnicity are
among the influential factors affecting education debt levels.
At the same time, new physicians, especially those in nonprimary care specialties, continue to experience a relatively
easy time in the job market. Specialty is also one of the most
influential factors affecting the incomes of new physicians.
Implications for Policy, Delivery, or Practice: The findings
of this examination substantiate recent work suggesting that
the physician supply is not expanding quickly enough to keep
up with demand for physician services. With a growing
consensus of impending physician shortages and a renewed
discussion of bolstering the national physician supply through
the expansion of medical education capacity in the US,
determining how to finance this endeavor will have to
consider the role educational debt plays in the career
decisions of physicians. Because levels of debt vary
significantly, certain groups are saddled with high and
increasing levels of debt upon completion of their graduate
medical training. Policy makers would do well to consider
educational debt as they move to develop policies to ensure
that appropriate care is available to those who need it.
Primary Funding Source: HRSA
●Disaster Preparedness and Response for Persons with
Mobility Impairments
Michael Fox, Sc.D., Glen White, Ph.D., Catherine Rooney,
M.S., Jennifer Rowland, Ph.D., M.P.H., P.T.
Presented By: Michael Fox, Sc.D., Associate Professor and
Interim Chair, Health Policy & Management, University of
Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City,
KS 66160; Tel: (913)588-2687; Fax: (913)588-3762; Email:
mfox2@kumc.edu
Research Objective: To assess the impact of a major disaster
on county level preparedness for persons with mobility
limitations
Study Design: Thirty randomly-selected Federal Emergency
Management Agency (FEMA) disaster sites between 1998 and
2003 were surveyed about disability surveillance capacity; the
extent to which the disaster experience influenced changes in
policies and practices; whether persons with disabilities were
involved in the planning process; what factors appeared to
drive the planning process, and whether best practices appear
to exist.
Population Studied: FEMA declared disaster counties or
similar jurisdictions for disasters occuring between 1998 2003
Principal Findings: : People with disabilities were poorly
represented in emergency planning; federal training on the
needs of people with disabilities appears useful, even though
only 27% of emergency managers reported completing it;
20% of emergency managers reported having disability
guidelines in place; while county level surveillance systems
were very weak. Two/thirds of counties had no intention of
modifying their guidelines to accommodate the needs of
persons with mobility impairments. Reasons cited included
cost, limited staffing, lack of awareness, other security
demands, and broader responsiveness to all “special needs
individuals.
Conclusions: Findings and recommendations point to the
need for improved surveillance so that communities have a
better understanding of how many people with mobility
impairments are at risk in disasters. Also identified was the
need to develop improved technology assistance,
environmental changes to address persons with disabilities
needs during disasters and far greater participation of persons
with disabilities into all phases of the disaster planning and
response process.
Implications for Policy, Delivery, or Practice: Counties must
do more to accomodate the needs of persons with disabilities
in their disaster planning and management. These include
improved training and resource allocation geared more
towards natural disasters and less towards bioterrorism.
Primary Funding Source: CDC
●Health Care Spending and the Use of Information
Technology: An International Perspective
Bianca Frogner, BA, Gerard F. Anderson, Ph.D.
Presented By: Bianca Frogner, BA, Student, Health Policy and
Management, Johns Hopkins Bloomberg School of Public
Health, 371 Homeland Southway, Apt 1A, Baltimore, MD
21212; Tel: (410) 323-3904; Email: bfrogner@jhsph.edu
Research Objective: To present health care spending data
from thirty countries in the Organzation for Economic Cooperation and Development (OECD) and then propose one
method of controlling health care spending – the adoption of
health information technology (IT).
Study Design: Perpsective paper.
Population Studied: Thirty countries in the Organization for
Economic Co-operation and Development (OECD) with a
focus on health IT use in the United States, Australia, Canada,
Germany, Norway and the United Kingdom.
Principal Findings: In 2003, the U.S. had fewer practicing
physicians, practicing nurses, and acute care bed days than
the median country in the Organization for Economic Cooperation and Development. Nevertheless, U.S. spending per
capita was almost two and one half times the per capita
spending of the OECD country. One proposal for both
lowering health spending and improving quality is the
adoption of health information technology.
Conclusions: This paper shows that the U.S. is 4 to 13 years
behind several other industrialized countries in the diffusion
of health information technology. In these other countries,
the federal government played the major role in establishing
the rules and the health insurers have paid most of the costs
because the insurers are the entity most likely to benefit
financially from health information technology.
Implications for Policy, Delivery, or Practice: A significant
advantage other nations have in this regard is that their
simpler, more uniform and more universal health insurance
systems furnish better platforms for the use of IT than does
the highly pluralistic U.S. health care and health insurance
system.
Primary Funding Source: CWF
●External Evaluation of the Quality of Care of Mental
Health Services rendered to the Puerto Rico (State
Medicaid) Health Insurance Beneficiaries
Hector I. Garcia, M.P.H., Migdalia Lugo
Presented By: Hector I. Garcia, M.P.H., Director, Evaluation
and Technical Analysis, Puerto Rico Health Insurance
Administration, PO Box 195661, San Juan, PR 00919-5661; Tel:
(787) 474-3336; Fax: (787) 474-3346; Email:
hgarcia@ases.gobierno.pr
Research Objective: To evaluate the appropriateness or
quality of care of the mental health services, access and
promptness to services, and outcomes of care provided by the
Managed Behavioral Healthcare Organizations (MBHO) to
the Puerto Rico Government Health Insurance Plan (GHIP)
population during the fiscal year period of July 1, 2003 to June
30th, 2004
Study Design: The external evaluation was performed by a
contracted EQRO for mental health services according to
Medicaid regulations 42 CFR 438 Subpart E. The evaluation
was implemented through a combination of methods in two
phases: (1) analysis of data using a claims dataset, and (2) a
review of medical records. The first phase consisted on
determining quality of care performance measures for
inpatient, outpatient and partial hospitalization. Descriptive
statistics were used. For phase two, a review of medical
records (n = 3,200) addressing clinical evaluation and
documentation in the patient’s medical record was conducted.
Population Studied: The claims dataset consisted of 840,287
claims and 146,188 GHIP enrollees that had mental health
services and a review of 3,200 medical records.
Principal Findings: Most common mental disorders were
depression (47%), schizophrenia (15%), anxiety (14%) and
ADHD (9%). Outpatient services accounted for 89% of
claims, emergency 6%, hospitalization, 4% and partial
hospitalization 4%. Seventy percent outpatient claims were
medication treatment. Seventy-five percent of all patients had
less than 6 visits on an annual basis. Furthermore, 25% had
one visit. Among all patients with more than one visit the
average number of days between visits was 67 days. In phase
two, 75% of the medical records reviewed were found. From
those not found (25%) 65% were not at the clinic’s
information systems and 22% were not in the medical record
file room. Seventy-two percent of the patients had
documented clinical evaluation on the record, 4% did not
have it, and 24% did not have a medical record. Thirty-five
percent of the clinical evaluations were done by a Psychiatrist.
Most common diagnosis in the evaluation was depression
(29%). Fifty-eight percent had a treatment plan in the medical
record. All patients had an average of 4 follow-up visits during
the year of study, with 54% of them receiving psychiatric
treatment. Sixty-five percent of all records had a patient’s
consent form, and 35% did not. Sixteen percent of all records
had a signed informed consent that had not expired.
Conclusions: The claims dataset fields presented
irregularities in the use of fields and codes. Outcomes
indicators showed high utilization of outpatient services (87
per 1000) for which medication treatment (70%) was the
most. MBHOs had inadequate control and management of
the medical records of patients that received services at the
clinical setting, specifically for treatment plans and
documented clinical evaluation.
Implications for Policy, Delivery, or Practice: Periodic
monitoring of the quality of care is essential for improvement
of mental healthcare services. Informed consent forms must
be signed by the GHIP enrollees before services are rendered.
Government must provide training for completion and well
documentation of medical records to healthcare professionals.
Primary Funding Source: CWF
●Quality Intervention Toward Improving Communication
between the Inpatient Psychiatrist and the Outpatient
Physician.
Kalyani Gopalan, MS, M.H.A., Frank A. Ghinassi, Ph.D., Ken
Nash, M.D., Kim Owens, M.S.N., B.S.N., Eleanor Medved,
RN-C, M.S.N., David White, M.H.A.
Presented By: Kalyani Gopalan, MS, M.H.A., Analyst, Clinical
Outcomes, UPMC-Western Psychiatric Institute and Clinic,
3811 O'Hara Street, Room 558, Pittsburgh, PA 15213; Tel: (412)
246-5198; Fax: (412) 586-9057; Email: gopalank@upmc.edu
Research Objective: Findings by Institute of Medicine in
“Crossing the quality Chasm” indicate a severe lack of
communication and co-ordination of care resulting in
redundancies, gaps in care and miscommunication (IOM,
2001: 83). Research also shows that communication between
inpatient and outpatient psychiatrists significantly improve the
rate of follow up of inpatients. (Boyer CA, McAlpine DD,
Pottick KJ, et al, 2000)
As a preliminary step in ensuring this connection, UPMCWestern Psychiatric Institute and Clinic has initiated the
implementation of a quality project to measure and improve
the degree of communication between the inpatient
psychiatrist, the outpatient psychiatrist and the primary care
provider for patients admitted to its inpatient service.
Study Design: One component of the intervention involves
documentation of the specific communication efforts made by
the inpatient psychiatrist, nurse and social worker. This will be
accomplished through the use of form in the inpatient
medical record detailing the communication type and result.
The study also involves a systematic method of tracking and
reporting on the outcomes of the efforts.
Population Studied: Patients admitted at the inpatient
Psychiatric wing after January 2006
Principal Findings: A review of literature reveals continuity
and communication as primary elements that ought to be the
focus of intervention. Results and outcomes from the
aforementioned and proposed intervention are pending and
will be disclosed upon completion
Conclusions: The expected conclusion is that the results of
the study and intervention will show and underscore the need
for coordination of care through increased communication
between levels of care, both Behavioral and physical, in order
to attain an optimal outcome for the patient.
Implications for Policy, Delivery, or Practice: Improving
continuity of care through improved communication is a goal
which is both supportive and consistent when viewed within
the context of the IOM's 10 rules for redesigning systems
Primary Funding Source: UPMC – Western Psychiatric
Institute and Clinic
●Medical Professionalism: Volunteerism and Voter
Participation of Physicians
David Grande, M.D., M.P.A., Katrina Armstrong, M.D., MSCE
Presented By: David Grande, M.D., M.P.A., Robert Wood
Johnson Health and Society Scholar, Robert Wood Johnson
Health and Society Scholars Program, University of
Pennsylvania, 3641 Locust Walk, Colonial Penn Center 308,
Philadelphia, PA 19104; Tel: (215) 898-5456; Fax: (215) 7460397; Email: davidgrande@yahoo.com
Research Objective: Amid evidence of eroding trust and
reduced political legitimacy of the medical profession, many
organizational leaders and academic scholars have issued
calls for the profession to refocus its efforts on fulfilling the
core tenets of medical professionalism. Most agree that a key
element of professionalism is participation in community and
public affairs to provide civic leadership and contribute direct
service to the disadvantaged. This study aims to measure
physician voter participation rates and volunteerism as an
important dimension of medical professionalism.
Study Design: This is a secondary data analysis of a
nationally-representative, cross-sectional, telephone,
household survey. The Current Population Survey (CPS) is
administered monthly with supplements assessing voter
participation in November in even-numbered years and a
special volunteerism supplement in September 2003.
Physician voter participation was studied in the years 1996 to
2002 and physician volunteerism in 2003. The study includes
three measures of civic engagement: voting in the most recent
election, any volunteering in the previous year, and the
number of hours volunteered in the previous year. The odds
of physicians voting in the most recent election and
volunteering in the previous year were estimated with
multivariate logistic regression models controlling for
socioeconomic characteristics (race, ethnicity, income,
geography, marital status, gender, age, education,
employment, child in household). The number of hours
physicians volunteered in the previous year was estimated
with a linear regression model including the same covariates
in addition to hours worked per week. The comparison
groups were the general population and lawyers, representing
another major profession.
Population Studied: Population-based survey of
approximately 48,000 households per survey year which
included 1,274 physicians in the four voting supplements and
382 physicians in the volunteerism supplement. Non-citizens
were excluded from the voting analysis and children were
excluded from both the volunteer and voting analysis.
Principal Findings: After multivariate adjustment, physicians
were less likely to have volunteered in the previous year than
the general population (OR=0.53, CI=0.41,0.69) and less likely
to have voted in 3 of the 4 years studied (1996: OR=0.83,
CI=0.59.1.17; 1998: OR=0.76, CI=0.59,0.99; 2000: OR=0.64,
CI=0.44,0.93; and 2002: OR=0.62, CI=0.48,0.80). As a
comparative profession, lawyers were equally likely to have
volunteered as the general population (OR=1.04,
CI=0.84,1.30) and more likely to have voted (1996: OR=1.51,
CI=1.08-2.11; 1998: OR=2.17 CI=1.63-2.90; 2000: OR=1.55
CI=1.10-2.18; 2002: OR=1.61, CI=1.23-2.12). Physicians
volunteered on average 37.1 hours less per year (CI=-48.1,26.1) than the general population while lawyers total
volunteerism was no different than the general population
(OR=8.13, CI=-26.7, 43.0).
Conclusions: This study indicates that physicians vote and
volunteer less than the general population when controlling
for socioeconomic characteristics. These findings suggest
that physicians generally are not participating in community
and public affairs at levels expected of a profession.
Implications for Policy, Delivery, or Practice: Low voter
participation and volunteer effort of physicians may indicate
low levels of overall civic engagement in community and
public affairs and a lack of physician community leadership in
health and social policy. Physicians and organized medicine
should explore ways to reengage doctors in their local
communities to fulfill professional obligations and reestablish
public trust.
Primary Funding Source: RWJF
●Do Medicaid Obstetrical Physician Fees Affect Access to
Care and Birth Outcomes Among Eligible Populations?
Bradley Gray, Ph.D., MS, Kosali Ilayperuma Simon, Ph.D.,
Jonathan Gruber, Ph.D.
Presented By: Bradley Gray, Ph.D., MS, Research Analyst,
CNA Corporation, 4825 Mark Center Drive, Alexandria, VA
22311; Tel: (703) 824 2696; Email: grayb@cna.org
Research Objective: This study aims to inform policy by
examining the link between Medicaid physician fees for
obstetrical services, use of early prenatal care, and risk of low
birth weight (LBW) among Medicaid eligible women.
Study Design: We examine the impact of changes in
Medicaid physician fees on obstetrical outcomes by using
individual-level data describing access to prenatal services and
birth outcomes for the period 1985-1992. Our main analytical
data comes from the Natality Detail Data (NDD) files. During
the period of our analysis, the NDD constitute a census of all
births in most states and describe use of prenatal services and
birth outcomes, as well as maternal education, race, marital
status and age. Because our data spans years before and after
large expansions in the Medicaid program (around 1986),
these data allow us to examine the differential impact of fee
changes on outcomes as cohorts of pregnant women became
newly eligible for Medicaid insurance. Furthermore, our study
improves on past research by concurrently accounting for i)
unobservable factors that are constant over time within a
specific state among cohorts of women residing in that state,
ii) national secular trends common to all states, and iii) timevarying state-level factors affecting all pregnant women in a
given state that are contemporaneous with but unrelated to
Medicaid policy changes. Focusing our empirical analysis on
unmarried mothers with less then 12 years of education both
improves the validity of our difference-in-differences
methodology (Medicaid eligible versus ineligible) and adds to
the policy relevance of our study since these women are at
very high risk for poor newborn health.
Population Studied: The focuse of our empirical analysis is
unmarried mothers with less then 12 years of education. We
choose this group because doing so both improves the
validity of our difference-in-differences approach and adds to
the policy relevance of our study since these women are at
very high risk for poor newborn health.
Principal Findings: Overall, the result of our estimation
supports the view that raising Medicaid fees improves access
to care as measured by use of a first trimester prenatal visit,
and newborn health as measured by risk of LBW (<2.5 kgs)
among women who are both likely to be Medicaid eligible and
at high risk for poor birth outcomes. For example, our results
imply that just a 20% increase in relative Medicaid fee is
associated with about a 4% decrease in the relative risk of
LBW among unmarried women with 12 years or less education
(statistically significant at the 1% level). We also find that this
20% increase in fees is associated with about a 1% increase in
the likelihood of having a first trimester prenatal visit for this
group (statistically significant at the 5% level). Women in this
group represent about 20% of all birth and nearly 60% of
births from Medicaid eligible women during our study period
(1985-1992).
Conclusions: Overall our results support the findings of Gray
(2001) who reports that differences in the risk of LBW between
Medicaid and non-Medicaid insured women are negatively
associated with fee differences across states, and the finding
of Currie et al. (1995) that differences across time within states
are negatively associated with the risk of infant death.
Implications for Policy, Delivery, or Practice: One of the
motivations for examining the relationship between Medicaid
fees and newborn health is to further explore the reasons why
extensions in eligibility in the late 1980s seemed to yield at
most modest impacts on newborn health. Presumably the
answer may lie in the fact that Medicaid fees are set too low to
support access to high quality care. To examine this
possibility, we derived the minimum relative fee necessary to
yield a positive association between our eligibility measure
and risk of low birth weight. This minimum fee ratio ranged
from just under 50% when applying estimates drawn from the
whole sample of women to about 60% applying estimates
drawn from our primary sample of low educated unmarried
women. This range in our Medicaid fee ratio is fairly close to
fees in place during large expansions in the Medicaid program
in the late 1980s and early 1990s. Thus, our research suggests
that one reason why Medicaid expansions yielded few
improvements in newborn health maybe that Medicaid
payment to physicians were too low to support access to high
quality prenatal services among Medicaid eligible populations.
Considering the high cost to the Medicaid program associated
with low birth weight, our research also suggests that
proposed reductions in Medicaid payments to physicians may
not yield the budgetary saving hoped for by government
officials.
Primary Funding Source: No Funding
estimated overall mortality on predicted patient
complications, nursing unit and facility-level predictors. All
analyses were conducted using the generalized linear latent
and mixed models procedure in STATA v9.0 with two levels of
clustering (unit and facility).
Population Studied: The analyses included VA 29,689
patients from 156 ICU units in 106 VA medical centers.
Principal Findings: Three factors appear associated with
increased mortality: predicted risk of complication (O.R. 1.16
(95% C.I. 1.14 to 1.17)), being a medical vs. surgical patient
(O.R. 1.72 (1.53 to 1.93)), and the ratio of average daily census
(ADC) to operational ICU beds (O.R. 2.19 (1.26 to 3.82) ). A
decrease in mortality appears to be associated with having an
ICU electronic interface that links the peripheral monitors with
the VA computer system and electronic medical record (O.R.
0.66 (0.50 to 0.88)).
Conclusions: Patient risk is the dominant factor associated
with mortality, highlighting the need for adequate risk
adjustment. Nurse staffing in VA ICUs is generally high at a
ratio of two patients per nurse. with little variation. As a
result, we see little effect of staffing on mortality. The
importance of an integrated monitoring system is unexpected,
and suggests that information technology may play an
important role in protecting patients.
Implications for Policy, Delivery, or Practice: More analysis
will focus on the possible mechanisms of action. Integrated
monitoring systems are not widespread, but appear to be
beneficial.
Primary Funding Source: VA
● The Association Between Nursing and other Inpatient
Organizational Factors and Inpatient Mortality for Patients
Experiencing an ICU Stay During their Hospitalization in a
Veterans Affairs (VA)
Gwen Greiner, Nancy Sharp, Elliott Lowy, Peter Almenoff,
Anne Sales
●Use of Information Technology to Measure and Improve
Quality of A Disease Management Intervention In Italy
Antonio Grieco, Ph.D., Rodolfo Rollo, M.D., Marina Panfilo, ,
Luca Castelluzzo, B.A., Diane Ito, M.A., Maryam NavaieWaliser, Dr.P.H.
Presented By: Gwen Greiner, 1100 Olive Way, Suite 1400,
Seattle, WA 98101; Tel: (206) 277-4583; Email:
gwendolyn.greiner@va.gov
Research Objective: We report on the association between
nursing and other inpatient organizational factors and
inpatient mortality for patients experiencing an ICU stay
during their hospitalization in a Veterans Affairs (VA) medical
center. Few large scale studies have explored these
relationships for patients experiencing an ICU stay.
Study Design: Data came from several sources: VHA nursing
labor files; data from VHA national databases for data on all
patients admitted to VHA inpatient acute care nursing units
between 2/03-6/03; and data from the VHA 2004 Survey of
Intensive Care Units, an organizational inventory of intensive
care within the VHA. We used facility level ICU
categorizations developed within the 2004 Survey of ICUs.
These categorizations are based on specified ICU complexity
criteria, such as type of services provided and availability of
subspecialty services and range from 1 to 5, with 1
representing the most complex ICU and 5 representing no
ICU. For the analyses, we developed a 2-step multilevel
regression model with patient, nursing unit and hospital level
data corrected for clustering at the unit and facility levels. The
first step predicted patient probability of developing a serious
complication using patient-level predictors. The second step
Presented By: Antonio Grieco, Ph.D., Professor, Facoltà di
Ingegneria, Università degli studi di Lecce, University of Lecce,
Viale Gallipoli 49, Lecce, 73100; Tel: +39 (0833) 29111; Email:
maryam.navaie-waliser@pfizer.com
Research Objective: Adoption of advanced information
technology to monitor quality of care processes offers a
unique approach to improving operational efficiencies in
health practice settings. Simulation techniques allow
forecasting of resources and have utility in identifying optimal
workflow scenarios for service delivery models. The purpose
of this study was to examine the use of an innovative software
simulation tool to predict nurse care managers (CM) workflow
processes to optimize care efficiencies in a disease
management (DM) intervention in Italy.
Study Design: Practitioner workflow scenarios were modeled
in a simulated environment for the DM intervention (e.g., care
coordination, patient education, coaching/motivation). Key
dependent variables included: percent of CM time spent on
program activities, time to enrollment, time between
enrollment and completion of initial assessments, and time to
complete follow-up assessments.
Population Studied: Simulations were conducted on an
artificial sample of patients (N=577) who met the following
intervention criteria: (a) age 18 years or older, and either (b)
had a primary diagnosis of diabetes (n=179) or heart failure
(n=47), or (c) a clinical history of cardiovascular disease
(CVD) event or a CVD algorithm score (based on age, blood
pressure, total cholesterol level, presence of diabetes, and
smoking) of 20% or greater (n=351).
Principal Findings: Simulations revealed 3 critical quality
improvement pathways. In the CM workload pathway, the
simulation indicated current processes would result in CM
overburden by 103% to 133%. The second pathway, which
focused on simulations of time efficiencies between patient
enrollment and completion of initial assessment by CM,
revealed significant delays with considerable variations in
observed versus expected (target completion was within 30
days) timeframes. The third pathway simulations examined
patient follow-up assessments. The 12-month follow-up
assessment was predicted to extend up to 45 months versus a
program goal of 15 months. Specific modifications were made
to intervention care processes to reduce inefficiencies
identified through the simulation exercises. First, the original
process called for the CM to accompany the patient to the
specialty clinic for consultations for an acute episode. The
simulator indicated this contributed to CM overextension,
thus the process was modified to a telephonic case
conference with the specialist. Similarly, CM home visits were
contributing significantly to CM overload which led to revised,
more stringent intervention criteria for home visits.
Conclusions: As a result of employing innovative information
technology to quality improvement, intervention processes
were modified, resulting in enhanced workflow efficiencies.
Implications for Policy, Delivery, or Practice: Use of
simulation information technology to measure and improve
quality is a promising strategy to reducing operational
inefficiencies in health care settings without disruption of
operations.
Primary Funding Source: University of Lecce, Pfizer Italia,
Pfizer Health Solutions
●Pay for Performance: Measuring clinical efficiency with
RVUs
Krista Gronley, M.P.H., M.B.A., James Cooper, MA, Andrew
White, Ph.D., Krista Gronley, M.B.A., M.P.H.
Presented By: Krista Gronley, M.P.H., M.B.A., Project
Manager, Research, Care Management, Hawaii Medical
Service Association, 818 Keeaumoku Street, Honolulu, HI
96814; Tel: (808) 948-6979; Fax: (808) 948-6043; Email:
krista_gronley@hmsa.com
Research Objective: To demonstrate the value of using
Relative Value Units (RVUs) over reimbursement as an
objective measure of resource utilization in comparing health
services utilization. Especially as it is used to compare
utilization across payment methodologies as well as in
measuring efficiency as part of a pay for performance
program.
Study Design: Administrative claims data for calendar years
2002, 2003 and 2004 were grouped using Symmetry’s ETGs
and RVUs were applied at the service line detail level of the
episode grouper. Responsible providers are identified for each
cluster within an episode of care with direct and indirect
resource utilization attributed to the responsible provider.
The definition of indirect resource utilization as those services
that the responsible provider ordered, referred or prescribed
but did not administer, perform or provide. Direct resource
utilization are those services performed or provided by the
cluster level responsible provide. Metrics include
practitioners’ cost relative to output or resource efficiency,
attributable resource utilization, and direct versus indirect
resource utilization.
Population Studied: The complete population of a large
health insurer in Hawaii, except the Medicaid or Medicare
population, for 2002, 2003 and 2004.
Principal Findings: Indirect resource utilization must be
considered in the evaluation of efficiency of care provision as
our analysis show that indirect resource utilization makes up
more than half of the reimbursement for some specialties.
For example, in Orthopedics, indirect costs comprised 58.7%
of all reimbursement costs. RVUs also provide a means of
measuring resource utilization in instances where costs are
unavailable or incomplete due to differences in fee schedules,
coordination of benefits with secondary payers, etc.
Conclusions: Relative Value Units are preferable to cost in
analyzing efficiency due to variations in reimbursement
methods, bias due to other payers, fee schedule adjustments,
and inflation over time.
Implications for Policy, Delivery, or Practice: Using Relative
Value Units will assist the development and regulating of
effective medical policies, appropriate practitioner network
development, identification of utilization management issues,
Primary Funding Source: No Funding
●Where People Die: A Multi-Level Analysis of Predictors of
Site of Death in America
Andrea Gruneir, M.Sc., Vincent Mor, Ph.D., Sherry Weitzen,
Ph.D., Jason Roy, Ph.D., Rachael Truchil, M.P.H., Joan Teno,
M.D., M.S.
Presented By: Andrea Gruneir, M.Sc., Graduate Student,
Department of Community Health, Brown University, Brown
University Box G-H1, Providence, RI 02912; Tel: (401)863-1275;
Email: Andrea_Gruneir@brown.edu
Research Objective: The objective of this study is to identify
predictors of where people die. We add to the current
literature by recognizing the nursing home as a distinct site
and by using multi-level methods that allow for simultaneous
consideration of individual, regional and state factors.
Study Design: This is a cross-sectional study in which we
used data from multiple national sources. Data on individual
characteristics, including site of death, were taken from the
National Vital Statistics System and data on county
characteristics were taken from the Area Resource File. We
included state data on Medicaid funding for nursing homes
and derived state-level proxies for income distribution and
social capital. We estimated the probability of each hospital
and nursing home death against that of home death. To
account for the hierarchical structure of the data, we used
generalized estimating equations with state-level indicator
variables.
Population Studied: The population of interest was
individuals who died in the U.S. during 1997 and whose
deaths were attributed to a chronic condition. A total of
1,368,263 deaths were available for analysis.
Principal Findings: The profile of decedents at each site
(hospital, nursing home or home) varied substantially and
showed little symmetry. Being female, being older, and having
Alzheimer’s disease were each associated with an increased
probability of nursing home death. Being non-White and
younger were each associated with an increased probability of
hospital death. Higher education and a diagnosis of cancer
were each associated with home death. Even controlling for
individual level characteristics, regional and state level
variables strongly influenced site of death. Decedents in
counties with higher percentages of African American
residents were more likely to die in hospital regardless of
individual race. Measures of health care access and availability
were associated with site of death. Residents of poorer
counties had a decreased probability of hospital or nursing
home death while the population-adjusted number of nursing
home beds resulted in increased nursing home death.
Increased average state Medicaid reimbursement rate for
nursing home care was also associated with increased nursing
home death.
Conclusions: The inclusion of county and state level variables
provided a great deal of context within which to interpret
regional preferences and culture. County composition, as
described by racial status, educational attainment, and
poverty, was associated with site of death regardless of an
individual’s own profile. As well, funding and availability were
each associated with nursing home death and have likely
contributed to the nursing home’s emergence as an important
site of death.
Implications for Policy, Delivery, or Practice: Our research
reveals that individual characteristics are strong predictors of
where people die but that the local environment plays an
equally important role. Features of the local environment are
amenable to change and can be shaped to better meet the
preferences of the local population. This can be observed in a
community’s investment in various forms of health care
infrastructure and reflected in regional policies, both local and
state, which influence outcomes by affecting access to health
services.
Primary Funding Source: NIA, AARP
●Factors Affecting the Duration of Return to Work of
Occupational Injured Workers after Medical Treatment:
The Population-Based Study in Korea
Whiejong Han, Ph.D., Won Mee Jeong, Ph.D., Tae Yong Sohn,
Ph.D.,
Presented By: Whiejong Han, Ph.D., Research Assistant
Professor, Health Services Policy and Management, University
of South Carolina, 800 Sumter Street, Columbia, SC 29208;
Tel: (803) 777-3460; Fax: (803) 777-1836; Email:
hanwj@gwm.sc.edu
Research Objective: The disabled workers by occupational
accident who cannot return to their work even after their
compensations are completed will be isolated from their
society relations, creating serious problems in their society.
Occupational Injured Workers’ early return to work is very
important to minimize economic losses of the workers in their
society. The objective of this study was to investigate factors
affecting the duration of return to work of OIWs.
Study Design: To examine the association of Duration of
Return to Work to workers’ socioeconomic status, workplace,
and disability variables, the Pearson chi-square test was used
in this study. As multivariate analysis the stepwise multiple
logistic regression analysis was also applied to find out the
likelihood of having longer DRW. DRW, in this study, was
classified into two categories of ‘short-term-within 30 days’
and ‘long-term-more than 30days’.
Population Studied: Twenty-six thousand three hundred sixtyseven cases of occupational injured workers who were
determined to be the beneficiaries of the disability
compensation in 1998 were initially reviewed. This encounterlevel data was linked with workforce data in National Health
Insurance Corporation in Korea, to identify characteristics of
workplace, accident type, and nature of injury. Of those 26,367
occupational injured workers, 3,658 workers who submitted
Disability Compensation Claims between January and March
2001 were randomly selected for this study. The data was
obtained from 36 branches of Korea Labor Welfare
Corporation and was divided by region and by the date of DCC
submission.
Principal Findings: Of those 3,658 workers, 1,378-37.7%
workers returned to their work after completion of
compensation. Among them, 1,223 workers have returned to
their work within 30days. One hundred fifty-five workers,
however, have returned to their work more than 30 days after
their compensation completed. After adjusting severity of
injury and age of workers, the logistic regression analysis
found that workers, who do not return to work within 30 days
after completion of compensation, prominently have a short
duration of employment, work in a small business, serve for a
construction industry, have their spine disabled, have relatively
lower income and have been medically treated for a long time.
Conclusions: According to the industrial accident analysis in
2003, reported by the Ministry of Labor in Korea, industrial
accidents has been increased by 15.9% in number of
Occupational Injured Workers, by 22.8% in the number of
days of economic loss, and by 9.5% in days of labor loss, in
comparison with the previous year. In the sample drawn for
this study most workers returned to workplace in short-term.
The focus of this study, however, was the remainder who
didn’t return to workplace within 30 days. Interestingly, the
workers whose salary is scanty had longer DRW than others.
Implications for Policy, Delivery, or Practice: The relatively
long DRW in Korea is mainly due to lack of proper evaluation
in occupational characteristics and in management of the
medical treatment period. It calls for the development of
comprehensive rehabilitation programs including medical,
vocational, and social rehab after controlling all the factors
affecting DRW. It is expected the programs to shorten DRW.
Primary Funding Source: No Funding
●Direct Cost Burden of Migraine Among Members of US
Employer Groups
Kevin Hawkins, Ph.D., Marcia Rupnow, Ph.D., Sara Wang,
Ph.D.
Presented By: Kevin Hawkins, Ph.D., Senior Economist,
Thomson-Medstat, 777 East Eisenhower Parkway, Ann Arbor,
MI 48108; Tel: (734) 913-3145; Fax: (734) 913-3200; Email:
kevin.hawkins@thomson.com
Research Objective: To estimate the direct healthcare cost
burden of migraine in a large commercially insured United
States (US) population.
Study Design: The data source for this study was the
MEDSTAT MarketScan database, comprised of medical,
pharmaceutical, and enrollment information on employees for
52 employer groups for the calendar year 2004. Subjects with
a diagnosis of migraine or use of a migraine-specific abortive
drug were identified as the migraine cohort. A random
sample of patients without migraine was propensity score
matched, based on demographic characteristics and
comorbidity index, to the migraine cohort to yield a matched
control group. Expenditures between migraine and matched
control cohorts were compared to derive the burden of illness
attributable to migraine.
Population Studied: The analyses included 215,209 subjects
in the migraine cohort, and equal number of subjects in the
control group. The mean age was 41 ( SD=13.3), and 82%
were female.
Principal Findings: After matching, the cohorts were similar
with respect to age, gender, geographic region, urban
residence, insurance type, the number of psychiatric
diagnostic groups and Charlson comorbidity index. The
migraine cohort incurred significantly higher expenditure than
the control cohort in all categories (prescriptions, outpatient,
ER, and inpatient). Total healthcare expenditures were $2,571
per patient per year (PPPY) higher in the migraine group
($7,007 versus $4,436 PPPY in the control group; p<.001).
Conclusions: The migraine cohort was associated with
significantly higher total healthcare expenditures compared to
a matched control, based on recent data from a large sample
of commercially insured individuals.
Implications for Policy, Delivery, or Practice: Since migraine
primarily affect women, some have argued that this diseases
burden on employers has not been studied as thoroughly as
others. This data suggest that US employers are bearing a
considerable direct cost burden as a consequence of migraine
and further research in this area is warranted.
Primary Funding Source: Ortho-McNeil Janssen Scientific
Affairs, LLC, Titusville, NJ
●The Indirect Cost Burden of Migraine Among Several
Large U.S. Employers
Kevin Hawkins, Ph.D., Marcia Rupnow, Ph.D., Sara Wang,
Ph.D.
Presented By: Kevin Hawkins, Ph.D., Senior Economist,
Thomson-Medstat, 777 E Eisenhower Parkway, Ann Arbor, MI
48108; Tel: (734) 913-3145; Fax: (734) 913-3200; Email:
kevin.hawkins@thomson.com
Research Objective: To estimate the indirect cost burden of
migraine on U.S. employers, in terms of workplace absence,
short-term disability (STD) and workers compensation (WC)
payments.
Study Design: The data source for this study was the
MEDSTAT Health and Productivity Management database,
composed of medical, pharmaceutical, enrollment, workplace
absence, STD, and WC information on employees for 10 large
employers in the U.S. for the calendar years 2002 and 2003.
Subjects with a diagnosis for migraine or use of a migrainespecific abortive drug were identified as the migraine cohort.
A random sample of patients without migraine was propensity
score matched, based on demographic characteristics and
comorbidity index, to the migraine cohort to yield a matched
control group. Indirect costs between migraine and matched
control cohorts were compared to derive the indirect burden
of illness attributable to migraine.
Population Studied: The analyses included 5,037 subjects in
the migraine cohort, and equal number of subjects in the
control group. The mean age was 39 (SD=9.3), and 71% were
female.
Principal Findings: After matching, the cohorts were similar
with respect to age, gender, geographic region, urban
residence, insurance type, the number of psychiatric
diagnostic groups and Charlson comorbidity index. The
migraine cohort incurred significantly higher indirect costs
than the control cohort in all categories (absence, STD, and
WC). Total indirect costs were $2,834 per patient per year
(PPPY) higher in the migraine group ($4,453 versus $1,619
PPPY in the control group; p<.001). Absence costs made up
the largest component of this difference at 75%, with STD and
WC making up 21% and 4%, respectively.
Conclusions: The migraine cohort was associated with
significantly higher indirect costs compared to a matched
control based on recent data from a sample of commercially
insured individuals.
Implications for Policy, Delivery, or Practice: Since migraine
primarily affect women, some have argued that this diseases
burden on employers has not been studied as thoroughly as
others. This data suggest that US employers are bearing a
considerable indirect cost burden as a consequence of
migraine and further research in this area is warranted.
Primary Funding Source: Ortho-McNeil Janssen Scientific
Affairs, LLC, Titusville, NJ
●Testing Three Theories of Community: Associations with
Insurance Coverage and Mortality
Michael Hendryx, Ph.D., Melissa M. Ahern, M.B.A., Ph.D.,
Nicholas Lovrich, Ph.D.
Presented By: Michael Hendryx, Ph.D., Director, Washington
Institute for Mental Illness Research and Training,
Washington State University Spokane, PO Box 1495, Spokane,
WA 99210; Tel: (509) 358-7624; Fax: (509) 358-7619; Email:
hendryx@wsu.edu
Research Objective: To test three competing theories of
successful community to determine whether they are
differentially related to important health care variables:
insurance coverage for children, insurance coverage for the
whole population, and age-adjusted mortality. The three
theories tested are social capital (Putnam), the creative class
(Florida), and political culture (Elazar).
Study Design: Non-experimental, retrospective correlational
design. The level of analysis is the US county, which included
28 primarily urban counties for which data were available on
all measures. We used data from Stowell surveys to measure
Trust as a central tenet of social capital; creative class scores
provided by Florida’s research, and political culture scored on
a discrete scale from “traditional” to “moralistic” based on
Elazar. We also added a fourth index, an indicator of the
community’s public health infrastructure. Insurance coverage
and mortality were taken from Census data. The first
dependent variable was the ratio: (% of children 0-17 in
poverty) / (% of children 0-17 without health insurance.) A
larger number indicates that a community is better able to
provide coverage, given the extent of childhood poverty. The
second dependent variable was the ratio: (% of total
population below poverty) / (% of total population without
insurance.) The third dependent variable was age-adjusted
mortality rates from all causes.
Population Studied: Residents of the selected counties in
2000.
Principal Findings: One of the 4 indicators, political culture
from the Elazar theory, was significantly correlated with better
child insurance ratios: r=.43, p<.03. Trust, creative class, and
public health infrastructure were not correlated significantly.
None of the 4 indicators correlated to overall uninsurance
rates, or to poverty rates. A lower age-adjusted mortality rate
was associated with both progressive political culture (r=-.47,
p<.02), and creative class (r=-.59, p<.01).
Conclusions: There are many ways to measure community
success. The presence of a creative class may be important
for some economic indicators but is not the whole story of
community success. Social capital may carry certain benefits
but is also incomplete. Communities with progressive political
cultures characterized by greater concern for others are better
able to provide poverty-adjusted insurance coverage for
children, although this benefit does not extend to insurance
coverage for everyone. Limitations of the study should be
acknowledged. The small sample precluded multivariate
statistics. (However, a paper by Koven showed that income
was a predictor of insurance coverage, but urbanicity or %
democrats was not, so a major confound has been accounted
for in the analysis.) In addition, we can't say if anything
inherent to political culture causes better coverage, or whether
there are unmeasured variables driving both. The observed
effect is probably to some degree a state, not a county,
phenomenon.
Implications for Policy, Delivery, or Practice: Theories of
community such as social capital and creative class have
generated recent heuristic appeal and research effort, but
applications to health care services must be made cautiously.
A benefit of social capital, for example, in one context may not
generalize to other indicators. Likewise, coverage for children
is only one indicator and perhaps different political cultures
benefit health care access in other ways. The results suggest
the possibility that the culture of county government can make
a difference in how well children are provided for in the health
insurance arena; whether or not one finds comfort in this may
depend on the degree to which political culture is malleable or
fixed.
Primary Funding Source: No Funding
●The Use of Discrete Simulation to Evaluate Waiting Time
of an Experimental ‘Fast Track’ Process in an Emergency
Department in Singapore
Bee Hoon Heng, MBBS,MSc(PH),FAMS, Kiok Liang Teow,
B.Eng(EE), MSc(ISE), Bee Hoon Heng,
MBBS,MSc(PH),FAMS, Ayliana Phe, BSc(OR),MSc(Statistics),
James P. Travers, BSc(Hons), MB.ChB.FRCS.Ph.D..FAMS,
Jason Cheah, MBBS,MMed(PH),FAMS
Presented By: Bee Hoon Heng, MBBS,MSc(PH),FAMS,
Director(HSOR), Health Services & Outcomes Research,
National Healthcare Group, 6 Commonwealth Lane #06-02
GMTI Building, Singapore, 145947; Tel: (65) 64718966; Fax:
(65) 64711767; Email: bee_hoon_heng@nhg.com.sg
Research Objective: An experimental ‘fast track’ workflow
was piloted in an emergency department (ED) in Singapore
where patients attending for simple ailments were seen and
discharged without requiring them to enter the physician’s
consultation room. The objective is to study the impact on
waiting time of this pilot (experiment) compared to the
standard ED process (control), using a computer simulation
approach.
Study Design: Two different workflows were studied; i.e. the
experiment and control. In the experiment arm, all patients
were triaged by the physician, and suitable cases were treated
and discharged (see and treat, or SAT), while the rest who
could not be discharged would be referred to physicians in the
consultation rooms (consult physicians). Two waiting times
were measured using simulation, from registration to triage
and registration to first contact with consult physicians. For
the control arm, all cases were triaged by the nurse and seen
by consult physicians. Waiting time from registration to
seeing the consult physician was measured. Discrete event
simulation models to simulate the experiment and control
processes were built using SIMUL8 (version 2005). A total of
nine scenarios were created to simulate different workloads,
heavy, moderate and light, measured by expected utilization
rate of physician.
Population Studied: All ambulatory patients belonging to
patient acuity categories (PAC) scales of P2 and P3 attending
ED.
Principal Findings: The various scenarios showed that
regardless of workload: (a) overall waiting time of patients to
see a consult physician in experiment arm was not better off
than that in control arm; and (b) SAT patients could be seen,
treated and discharged earlier. Under moderate workload
conditions (60%-85% physician utilization rate, PUR), SAT
patients get to see the doctor earlier. In light workload
conditions (<60% PUR), there would be no difference in the
waiting time to first contact with physician in both arms. In
heavy workload conditions (>85% PUR), the experimental
process would not work. This is because waiting time for both
arms would increase exponentially, and even worst off in
experiment arm. Splitting demand (patients) and supply
(physicians) into more than one process invariably leads to a
more adverse (longer) waiting time; more so if the number of
resources is small. The effect is less significant if resources
are increased.
Conclusions: The simulation models allow us to compare the
performance of this experiment under various scenarios. With
the same number of physicians in experiment and control
processes, the average waiting time to see a consult physician
would always be longer in experiment process, while SAT
could offer a shorter waiting time in terms of patients’ first
contact with physicians under moderate workload conditions.
Implications for Policy, Delivery, or Practice: Hospitals
seeking to implement SAT should understand the trade-offs.
The benefits from SAT will vary according to hospitals’
workload and resources. In general, unless other significant
time savings could be achieved (e.g. process streaming),
splitting the physicians to two locations as in SAT would
reduce the overall throughput rate.
Primary Funding Source: No Funding
●Use of the Geographical Information System to
Determine the Potential Impact of a New Hospital on an
Existing Hospital in Singapore
Bee Hoon Heng, MBBS, MSc(PH), FAMS, Bee Hoon Heng,
MBBS, MSc(PH), FAMS, Wong Lai Yin, BASc (Econs and
Stats), Cheah Tiang Seng Jason, MBBS, MMED(PH),MSc
Presented By: Bee Hoon Heng, MBBS, MSc(PH), FAMS,
Director(HSOR), Health Services and Outcomes Research,
National Healthcare Group, 6 Commonwealth Lane #06-02
GMTI Building, Singapore, 149547; Tel: (65)64718966; Fax:
(65)64711767; Email: bee_hoon_heng@nhg.com.sg
Research Objective: Research objective is to determine the
potential impact of a new public sector acute care general
hospital on an existing public sector acute care general
hospital in Singapore.
Study Design: The decision to locate a new hospital in the
northern part of Singapore, to fill a health service gap in the
area, to be operational in 2010, was made by policy makers.
Its location fell within the population catchment of an existing
and bigger hospital (Hospital T) located in the central part of
the island, which had faced a problem of high utilization over
several years. The geographical information system (GIS) was
used to determine the potential catchment of the new hospital
using information on population from census, age-specific
health care utilization rate and market share by geographical
zones. As patients in Singapore are free to choose their
healthcare providers, responses of a random sample of a
population-based survey on people’s preference for the
various hospitals was used to determine the share of patients
from Hospital T that would ‘migrate’ to the new hospital.
Population Studied: The study involved (a) the population of
Singapore from Census 2000; (b) every episode of inpatient
admission and ambulatory procedure in Singapore in 2002
(henceforth referred to as episodes), available from a national
database for claims; and (c) a random sample of a populationbased survey on the population’s preferences for hospitals.
Principal Findings: The new hospital was estimated to have a
total of 33,000 episodes per year in its steady state (2015). Of
these, an overall 35% would be derived from Hospital T.
However, assuming the current rate of high growth in
utilization of Hospital T, there would not be a net reduction
from its current volume, after this loss to the new hospital.
The population catchment of the new hospital was relatively
younger (<5% aged 65+) compared with that of Hospital T
(>11% aged 65+), which also reported the oldest patient
profile among all five public sector acute general hospitals in
Singapore. With a significant proportion of younger patients
lost to the new hospital, the ‘ageing’ of Hospital T would
accelerate. The population-based survey also found that those
who preferred to remain in Hospital T after opening of the
new hospital were mainly the older population with chronic
medical conditions; i.e. physician loyalty.
Conclusions: After an expected loss of 35% of its volume to a
new hospital within its geographical catchment, total net
episodes in Hospital T would not be reduced from its current.
With an anticipated shift in its demographics, it would need to
develop specialties to deal with a significantly higher
proportion of elderly patients.
Implications for Policy, Delivery, or Practice: Findings of
the research would be useful for planners and policy makers of
hospitals. The potential impact of a new hospital on an
existing hospital would guide them in their planning of its
services and resources in the medium and long term to meet
the expected demand.
Primary Funding Source: No Funding
●Research@Work: An Innovative Public-Private
Occupational Health Partnership
Cara Hirsch, M.H.A., M.B.A., Andrea R. De Vries, Ph.D.,
Gerald O'Donnell, MS
Presented By: Cara Hirsch, M.H.A., M.B.A., Health Care
Informatics, Research and Analysis, Highmark, 120 5th
Avenue, Suite P7205, Pittsburgh, PA 15222; Tel: (412) 544-3885;
Fax: (412) 544-0700; Email: cara.hirsch@highmark.com
Research Objective: A mid-Atlantic health insurer and the
Centers for Disease Control and Prevention have partnered to
identify opportunities for employer-level health promotion.
The initiative focuses on chronic illnesses and conditions that
may relate to workplace exposure.
Study Design: Eleven diseases with known or suspected
connections to occupational exposures were selected in
collaboration with occupational health experts at the Centers
for Disease Control and Prevention. The conditions and
illnesses include: Asthma, bladder cancer, carpal tunnel
syndrome, chronic obstructive pulmonary disease, depression,
dermatitis, hearing loss, hypertension, low back pain,
Parkinson’s disease, and pneumoconiosis. Using health
insurance claims data, prevalence rates for selected diseases
were calculated by industry for the population of workers
between 18 and 65 years of age for workers who remained
insured within the same industry code during 2004 and
during 2002-2004. Age and sex adjusted prevalence rates will
also be calculated. Results will be used to identify employers
with above average prevalence rates and to share
opportunities for interventions with selected employers.
Population Studied: The population is drawn from a large
mid-Atlantic health insurer with more than 3 million members
enrolled in a range of insurance products. The study identified
1,526,619 insured workers (i.e. contract-holders) between the
ages of 18-65 within 841 industries. Additionally, 1,094,486
cases meeting the diagnosis criteria for one or more of the 11
conditions were identified.
Principal Findings: Preliminary 2004 prevalence rates for the
population were asthma (34.32 per 1,000), bladder cancer
(1.19 per 1,000), carpal tunnel syndrome (19.33 per 1,000),
chronic obstructive pulmonary disease (16.80 per 1,000),
depression (68.56 per 1,000), dermatitis (37.42 per 1,000),
hearing loss (6.94 per 1,000), hypertension (190.09 per
1,000), low back pain (147.16 per 1,000), Parkinson’s disease
(0.50 per 1,000), and coal workers’ pneumoconiosis (0.10 per
1,000). Comparisons of employer rates within high risk
industries will be discussed.
Conclusions: Previous research performed by the authors has
demonstrated that health insurance claims data can identify
employers with opportunities for health risk reduction. Using
the most current health insurance claims data to identify
health improvement opportunities can lead to employer
collaboration in a voluntary, proactive manner.
Implications for Policy, Delivery, or Practice: The health
insurer will utilize its existing relationship with employers,
worksite based preventive health services department and
case management department to pursue active partnerships
with employers in 2006. This private-public partnership has
created a model for insurers and employers to improve health
and working conditions for employees and to lower healthcare
costs for employers.
Primary Funding Source: CDC
●Care and Outcomes of Patients Discharged to LongTerm Care after ACS in the VHA
P. Michael Ho, M.D., Ph.D., Haili Sun, Ph.D., Evelyn Hutt,
M.D., Anne E. Sales, Ph.D., John S. Rumsfeld, M.D., Ph.D.
Presented By: P. Michael Ho, M.D., Ph.D., Staff Cardiologist,
Medicine, Denver VA Medical Center, 1055 Clermont Street
(111B), Denver, CO 80220; Tel: (303) 370-7579; Fax: (303) 3707580; Email: michael.ho@uchsc.edu
Research Objective: Little is known about the incidence, care
and outcomes of patients discharged to long-term care (LTC)
following hospital admission for acute coronary syndrome
(ACS).
Study Design: This was a retrospective cohort study of 6,526
ACS patients enrolled in the Cardiac Care Follow-up Clinical
Study (CCFCS).
Population Studied: Patients were categorized as discharged
to long-term care if they were discharged to a skilled nursing
facility, intermediate care facility, inpatient rehabilitation
facility, or to long-term hospital care following ACS admission.
Patients discharged to hospice care were excluded. The
primary outcome of interest was 6-month mortality.
Multivariable regression analyses assessed the independent
association between discharge to long-term care and 6-month
mortality, adjusting for patient demographics, co-morbidities,
ACS treatment factors, and cardiac discharge medications.
Principal Findings: Patients discharged to long–term care
after ACS (n=497; 7.6%) were older and had more comorbidities compared to patients with a routine discharge.
They were more likely to present with a non-ST elevation
myocardial infarction (87.1% vs. 65.8%; p<0.01). Patients
discharged to LTC were less likely to receive thrombolytics
(1.3% vs. 4.8%) or percutaneous coronary intervention (23.1%
vs. 31.4%), however, they were more likely to undergo bypass
surgery (7.5% vs. 4.5%) during ACS admission. Patients
discharged to LTC were more likely to have reduced left
ventricular systolic function. At hospital discharge, there were
no differences in rates of discharge medications for aspirin, ßblockers, and clopidogrel, however patients discharged to LTC
were less likely to receive ACE-inhibitors (74.9% vs. 83.5%;
p<0.01). At 6-months, the mortality rate was significantly
higher among patients discharged to LTC (30.2% vs. 7.2%;
p<0.01). In multivariable analysis, discharged to LTC remained
significantly associated with 6-month mortality (OR 2.27; 95%
CI 1.64-3.31).
Conclusions: Approximately 1 in 13 patients with ACS in the
VHA are discharged to long-term care facilities. These patients
have increased 6-month mortality compared to those with a
routine discharge.
Implications for Policy, Delivery, or Practice: Studies are
needed to assess whether there are gaps in the transition of
care from the hospital to the LTC setting and whether
interventions, such as increasing rates of ACE-inhibitor
prescription can improve outcomes for patients discharged to
LTC after ACS hospitalization.
Primary Funding Source: VA
●Medication Use Following Bariatric Surgery in a
Managed Care Cohort
Denise M. Hodo, BA, Jennifer L. Waller, Ph.D., Robert G.
Martindale, M.D., Ph.D., Donna M. Fick, Ph.D., RN
Presented By: Denise M. Hodo, BA, Research Associate,
Medicine, Medical College of Georgia, 1120 15th Street, BI
5072, Augusta, GA 30912; Tel: (706) 721-6924; Fax: (706) 7218631; Email: dhodo@mail.mcg.edu
Research Objective: Obesity is a growing public health
concern, and conventional medical treatments have not
proven to be a successful form of treatment for long-term
weight loss. Individuals who suffer with obesity are at risk for
many adverse outcomes including increased comorbidities
and the associated increased medication costs, as well as a
negative self-image and decreased quality of life. Bariatric
surgery has been shown to provide long-term weight loss, in
addition to significant reduction of obesity related
comorbidities. The primary aim of this study was to describe
medication utilization and costs within a large, managed care
cohort following bariatric surgery. A secondary aim was to
describe utilization rates for other health services following
bariatric surgery.
Study Design: This retrospective cohort study used data from
an administrative database from a large managed care
organization (MCO) located in the southeast United States to
examine medication utilization and health outcomes in
persons six months before and six months after bariatric
surgery.
Population Studied: We used Current Procedural
Terminology, 4th Edition (CPT-4) codes for bariatric surgery to
identify patients who had undergone bariatric surgery between
January 1, 2001 to December 31, 2003, and who had 12
consecutive months of enrollment.
Principal Findings: A total of 605 individuals had bariatric
surgery within our specified time frame. Of the 605, 86.6%
were female, and the average age was 40. The average
Charlson Comorbidity Index score before surgery was 0.28.
We found that claims for prescriptions, office visits, and
outpatient visits decreased significantly in the post-surgery
time period, while claims for inpatient visits increased in the
post-surgery time period. Utilization of anti-asthmatic
medications, cardiac medications, diuretics and diabetes
medications also decreased significantly post-surgery. Paid
costs for prescriptions decreased in the post-surgery time
period. Additionally, patients were less likely to have sleep
apnea, gastroesophageal reflux disease and hypertension
post-surgery, but were more likely to report nausea and
vomiting.
Conclusions: Claims for multiple medications and other
health services decreased following bariatric surgery. This
study is not without limitations, such as the retrospective
nature of the analysis and the lack of direct clinical data, such
as body mass index. Yet the inclusion of data from multiple
centers and providers within this MCO strengthens the
validity of the findings.
Implications for Policy, Delivery, or Practice: These data
suggest that medication utilization and costs do decrease
following bariatric surgery, even within a short follow-up
period. However, this must be weighed against the costs
associated with the surgery itself and the potential
complications that may arise during the peri-operative period,
which could have been responsible for the increase in claims
for inpatient stays in the post-surgery time period that was
observed in this study. Future prospective studies should
include a longer follow up period to determine if the quickly
achieved reduction in medication use offsets the cost of
surgery and complications over time, as well as both the
biomedical and psychosocial outcomes of bariatric surgery.
Primary Funding Source: The Center for Health Care
Improvement
●A Survey of Connecticut Nurse-Midwives on Practice
Patterns
Margaret Holland, MS, Eliza Holland, CNM, MSN
Presented By: Margaret Holland, MS, graduate student,
Community and Preventive Medicine, University of Rochester,
601 Elmwood Avenue, Box 644, Rochester, NY 14618; Tel:
(585) 271-2745; Fax: (585) 461-4532; Email:
margaret_holland@urmc.rochester.edu
Research Objective: The objective of this study was to gain
an understanding of the current styles of certified nursemidwife practice in Connecticut. Little information is available
on the variations in midwife practice. Understanding these
variations may improve training of midwives, identify
treatments that lack consensus, and inform the community.
Study Design: This study was part of a larger survey
sponsored by the Connecticut chapter of the American College
of Nurse-Midwives. All licensed midwives in Connecticut were
invited to participate in the survey, either online or through the
mail with a hardcopy of the survey. The full survey included 66
questions, 16 of which focused on practices such as the use of
Complementary and Alternative Medicine, scope of practice,
techniques used, and precepting students. Of 214 potential
participants, 129 returned the survey and 97 were currently
practicing in Connecticut and completed the survey.
Population Studied: Certified nurse-midwives practicing in
Connecticut.
Principal Findings: Most respondents attend births and
provide care during and after pregnancy, as well as offer
general gynecologic care. More than half provide primary care,
although few provide newborn care. Most respondents
precept students, although many are not required to do so by
their practice. The respondents use a variety of advanced
techniques. Most perform IUD insertion and endometrial
biopsy, but another nine advanced techniques are performed
by 14 to 44 percent of respondents, including ultrasounds,
water birth, and repair of third and fourth degree lacerations.
There is significant variation between practices about when a
physician is called in and on restrictions for vaginal-birth-aftercesarean patients. Several techniques emerged as the most
common for repositioning breech or posterior babies,
although no single method was used by all respondents. Most
respondents refer patients to other resources for CAM and
some also practice CAM techniques themselves. The use of
herbs was the most common, with 39 percent of respondents
reporting use.
Conclusions: Significant variations in practices were reported
by nurse-midwives in Connecticut. Some of these variations
are directed by the practice in which they work, while others
are the result of the midwife’s own choice and experience. The
variations in advanced techniques may indicate different levels
of training, both formal and informal. Widespread use of, and
referral to, CAM may represent the first time many patients
have discussed these treatments with a medical professional.
Implications for Policy, Delivery, or Practice: The variations
in practices between midwives in a single, small state illustrate
a range of personal practice styles, but may also indicate a lack
of consensus regarding the best approaches. Given the variety
of allopathic and alternative methods used, it is important to
ensure that midwives are sufficiently trained in the techniques
they perform.
Primary Funding Source: AHRQ, Connecticut Chapter of the
American College of Nurse-Midwives
●No-Show Rates and Time to Appointment at a Pediatric
and Adolescent Mental Health Clinic
Jennifer Humensky, M.P.P., SooMi Lee, M.D., M.P.P., Tanya
Anderson, M.D., Bernard Leventhal, M.D.
Presented By: Jennifer Humensky, M.P.P., Ph.D. Student,
Harris School of Public Policy, University of Chicago, 5242
South Hyde Park Boulevard, Apt 811, Chicago, IL 60615; Tel:
773-456-3480; Email: jhumensk@uchicago.edu
Research Objective: To examine no-show rates and time
from initial contact to appointment in a large child and
adolescent psychiatric specialty clinic, and to determine
patient and institutional factors that may affect time to
appointment and probability of showing for the appointment.
Study Design: Intake records were analyzed and linked to
billing records for demographic data and show status.
Population Studied: 513 intake records for patients seeking an
initial appointment at the clinic from 2001-2003.
Principal Findings: One third of patients seeking initial
appointments at this clinic did not show for their scheduled
appointments. Patients with private health insurance, patients
living further from the clinic, who were adopted, or who had
ADHD symptoms were more likely to show. Patients who
waited four months or more for an appointment were
significantly less likely to show, as were patients with public
aid insurance. Males waited an average of 9 days longer for
an appointment at this clinic than females, and patients
presenting with developmental symptoms waited an average
of 10 days longer. Children ages 6-17 waited an average of 17
days less for an appointment than children under age 6, and
previous or current substance abuse treatment decreased
waiting time by about 15 days at this clinic.
Conclusions: There are many patient and institutional factors
which affected show status and time to appointment for
patients seeking initial appointments at this clinic.
Implications for Policy, Delivery, or Practice: High no-show
rates place a strain on an already scarce resource, mental
health treatment for children and adolescents. Reducing
patient no-shows can lead to more efficient distribution of
appointments. Note: These two papers are currently under
submission with Psychiatric Services, poster submitted with
journal's permission.
Primary Funding Source: RWJF, National Research Service
Award T-32
●Prevalence of Hepatitis B s-Antigen and Hepatitis B eAntigen in pregnant women born in Taiwan and other
South East Asia countries
Hsin-Chia Hung, Dr.PH, Chin-Chiang Lin, MS, Hsiu-Shu
Hsieh, MS, Min-Tzu Chen, Ph.D., Mei-Ching Chiu, MS
Presented By: Hsin-Chia Hung, Dr.PH, Assistant Professor,
Institute of Health Care Management, National Sun Yat-sen
University, 70 Lien-Hai Road, Kaohsiung, Tel: (011886)
75252000-4877; Fax: (011-886) 75251511; Email:
hhung@mail.nsysu.edu.tw
Research Objective: In recent years, more and more
Taiwanese men got married with women from South East
Asia, who gave birth to almost 13% of newborn babies in
2004. Hence,we would like to investigate the prevalence of
HBsAg and HBeAg between pregnant women from Taiwan
and other Asian countries and further evaluate the effect of
natioanl hepatitis B vaccination initiated in July, 1984 and
explore the potential impact of increasing international
marriages on the Hepatitis B public health policy in Taiwan.
Study Design: This study is a secondary data analysis. We
retrospectively collected the data on serum hepatitis B surface
(HBsAg) and hepatitis e surface antigen (HBeAg) and other
variables from pregnant women, who received prenatal
exmainations at Fooyin University Hospital during 1996 to
2004 through medical chart review.
Population Studied: From 1996 to 2004, there were 10,607
women received routine prenatal examinations in this reginal
hospital. 9,436 (89%) of them were born in Taiwan and 1171
(11%) women were from other 5 South East Asia countries
(Philippine, Cambodia, Indonesia, Thailand, and Vietnam).
Principal Findings: In our study, pregnant women from
Taiwan appeared to be older than women from other South
Asia contries (25.9 years vs. 23.4 years). The average rates of
HBsAg(+) and HBeAg(+)/HBsAg(+) for all pregnant women
were 14.8% and 33.2%, respectively. The pregnant women
from Taiwan had higher HBsAg positive rates but lower
HBeAg(+)/HBsAg(+) ratio (15.5% and 32.1%) than those of
pregnant women from other South East Asia countries (8.6%
and 51.5%). We also found that the HBeAg(+)/HBsAg(+) ratio
was decreased with older age. For women with age <21 years
from Taiwan and other South East Asia countries, the ratios
were 53.3% and 57.1%, respectively, while the ratios of women
with age>30 years from Taiwan and other countries were
19.1% and 28.6%. We also found that women from Taiwan
born before July, 1984 had higher HBsAg positive rate than
women from other countries (15.7% vs. 8.6%)but women born
after July, 1984 seemed to have the similar positive rates
(9.2% for Taiwanese women and 9.1% for women of other
countries).
Conclusions: Although women from Taiwan had higher
positive rate of HBsAg than women from other South East
Asia countries but they have lower HBeAg(+)/HBsAg(+) ratio.
This finding suggests that hepatitis B virus among women
from other South East Asia countries might be more active
than women from Taiwan and may result in more severe
health outcomes. The younger age of pregnant women from
other countries might partially explain the difference. The
lower HBsAg postive rate among Taiwanese women born after
July, 1984 suggests that the vaccination program has
effectively reduced the hepatitis B infection among Taiwan
women of child-bearing age.
Implications for Policy, Delivery, or Practice: For woman
born in Taiwan, the nationalwide vaccination program is
successful in reducing hepatitis infection and have further
started its beneficial influence in preventing hepatitis B
infection in second generation indirectly. Although the
hepatitis infection rate among women from other South East
Asia countries was lower than Taiwan female, the higher ratio
of HBeAg(+)/HBsAg(+) might result in more severe health
outcome in the future and should be further assessed.
Primary Funding Source: No Funding
●The First Trial of a Community-Based Diabetes Disease
Management Program in Japan.
Hirohisa Imai, M.D., Ph.D., Hisato Igarashi, M.P.H., Kazumi
Igarashi, M.P.H., Satoko Niwata, Ph.D., Hiroyuki Nakao, Ph.D.
Presented By: Hirohisa Imai, M.D., Ph.D., Director,
Epidemiology, National Institute of Public Health, 2-3-6
Minami, Wako-Shi, 351-0197; Tel: (48)458-6167; Fax: (48)4692677; Email: imaihiro@niph.go.jp
Research Objective: We developed a diabetes disease
management program including self-monitoring of blood
glucose, nutrition counseling and physical activity counseling,
and personal interviews with poorly controlled type II diabetes
patients. This is a community-based self-control education
program for local residents with diabetes mellitus. The
purpose of this study was to ascertain whether this program
would result in improved diabetes mellitus control.
Study Design: This was an intervention study. A communitybased disease management program of diabetes in Japan was
implemented for a one-year period. Hemoglobin A1C, fasting
blood sugar, and BMI as main outcomes were measured prior
to implementation and at the end of the program.
Population Studied: A general health check of local residents
was implemented in Takaoka town in Miyazaki prefecture
Japan in July, 2004. Individuals with type II diabetes were
invited to join the study as participants. A total of 41 patients
initially participated in baseline data collection after giving
their informed consent. They were enrolled in a once-monthly
diabetes class in our program.
Principal Findings: We examined differences in initial and
one-year outcome variables for participants enrolled in the
program. Average hemoglobin A1C; 6.0% vs. 5.4% (p=0.008),
average FBS; 122.1 mg/dl vs. 111.7 mg/dl (p=0.00028),
average BMI; 24.8 vs. 23.9 (p=0.0167). All main outcomes
showed statistically significant differences between the initial
values and ending outcomes. Ninety-six percent of
participants responded that their level of satisfaction with the
program was “excellent.”
Conclusions: These results suggest that the communitybased diabetes disease management program that was
implemented was an effective approach to encouraging better
self-control in patients. Further research is required to analyze
the cost-effectiveness of implementing the program.
Implications for Policy, Delivery, or Practice: Disease
management programs are not widespread in healthcare
delivery in Japan although they have been implemented in all
states of the United States of America. The results of this first
trial demonstrated the feasibility and effectiveness of a disease
management program for diabetes mellitus in Japan. In order
to further disease management in the future, the issues of
financial incentive and the nurturing of talented people should
be addressed.
Primary Funding Source: Japanese government
●A Study on the Attitude and Related Factor on the
Continuity of Medical Care Among the Korean
Heui Sug Jo, M.D., M.P.H., Ph.D, Heon Jae Jeong, M.D.
Presented By: Heui Sug Jo, M.D., M.P.H., Ph.D, Assistant
Professor, Department of Preventive Medicine, Medical
School, Kangwon National University, 192-1 Hyoja-dong,
Chuncheon City, 200-701; Tel: (82)33-250-8872; Fax: (82)33250-8875; Email: choice@kangwon.ac.kr
Research Objective: Continuity of medical care is a major
component for the appropriate care. However,doctor
shopping behavior has increased among the Korean patient
because patient can choose their doctors without restriction
under the current insurance system. Becasuse the patient
have no limitation in changing their doctors, they have a
tendency of changing their doctors frequently. The purposes
of this study are as follows; 1. To assess the general attitude
toward the importance of continuity in medical care among
the Korean 2. To analyze its related factors on changing their
doctors
Study Design: The cross sectional study was performed. The
questionnaire used in survey included the attitude of the
continuity of their clinic, the intention of medical service use
on a given case - doctor's order of admission, operation, and
special diagnosis- and the variables of the related factors.
Population Studied: Self administered questionnaire was
performed on the 1,120 office workers in Chuncheon city,
Gang-won province, Korea.
Principal Findings: As a result, 58.8% of the total
respondents agreed to sustaining treatment without changing
medical institutes; on the other hand, 41.2% showed negative
attitude. In case that a patient would gain a recommendation
of a surgery, hospitalization, or a specific examination, the
total respondents' 84.9%, 61.8%, and 50.8% of each
recommended situation said that they would visit another
doctor and gain a diagnosis. According to the result of
multiple logistic analysis of determinant factor on continuity,
reliability of doctors was statistically significant factor.
Conclusions: This results show that most Korean people have
the intention of changing their doctors in the case of several
condition such as admission,. operation, and special
diagnosis to seek their second opinion, and also reliability
and relation for doctors are the sigificant factor on changing
doctors.
Implications for Policy, Delivery, or Practice: In order to
reduce wastefully used medical resources and offer wellqualified medical service, a system of second opinion among
peer group or beforehand agreement could be possibly
adopted. In addition, improving the image and reliability of a
doctor could be an important factor to make better the
behavior of medical service shopping; therefore, an effort to
improve the relationship between a doctor and a patient, and
restore the reliability of doctors should be paralleled.
Primary Funding Source: This study was funded by Korea
Research Foundation (No. 2003-003-E00049)
●Are Early Adopters of a Web-Based Patient Portal More
Activated Than Matched Controls?
J.B. Jones, M.B.A., Nirav R. Shah, M.D., M.P.H., Zahra S.
Daar, MS, Walter F. Stewart, Ph.D.
Presented By: J.B. Jones, M.B.A., Research Associate, Center
for Health Research, Geisinger Health System, 100 North
Academy Avenue, M.C. 30-03, Danville, PA 17822; Tel: (570)
214-9322; Fax: (570) 214-9451; Email: jbjones@geisinger.edu
Research Objective: Web-based e-portals can provide access
to an institutional electronic health record, allowing patients to
view test results, schedule appointments, request prescription
refills, view visit notes, communicate electronically with their
providers, and possibly serve as a platform to deliver
personalized behavioral interventions. Growing interest and
research on the impact of e-portal usage on patient selfefficacy raises questions on whether and how e-portal users
differ from their peers who do not use e-portals. Our objective
was to examine this question, comparing portal and nonportal users, specifically focusing on patients with chronic
diseases.
Study Design: Random sample of 300 e-portal users meeting
eligibility criteria along with 129 matched control patients (i.e.,
matched on age, sex, chronic disease diagnosis, and clinic).
Participants completed an initial phone survey and a follow-up
mail questionnaire. The phone interview assessed decisionmaking preferences, information-seeking activities, medication
adherence, patient activation, and other factors potentially
related to e-portal use. The mail questionnaire was used to
collect additional data on patient characteristics, physical
activity, and use of the internet for health-related purposes.
Patient activation was assessed using the 13-item Patient
Activation Measure (PAM), a new instrument designed to
measure whether a patient has the knowledge, skills, and
confidence to self-manage their health and chronic condition.
Population Studied: Participants were patients who had a
diagnosis of diabetes mellitus, cardiovascular disease, or
chronic heart failure and who had a primary care physician in
one of the Geisinger Clinic´s 41 community practice sites (all
of which use an electronic health record).
Principal Findings: E-portal use was significantly associated
with gender, income, and education; portal users were more
likely to be male, have more education, and report a higher
annual income. The overall mean PAM score was 62,
suggesting that this population of patients is already actively
engaged in self-managing their conditions. After adjusting for
potential confounders, portal users were more likely to have
higher activation scores, but this association did not achieve
statistical significance. When patients were classified
according to their stage of activation, there were significant
differences between e-portal users and non-users; users were
more likely to be classified as Stage 4, the highest level of
activation. E-portal users were significantly more likely to
report high levels of confidence in their ability to complete
medical forms and reported higher levels of internet use for
carrying out health-related activities. Self-reported medication
adherence was higher among e-portal patients. There were no
between-group differences in preferences for involvement in
medical decision-making or in levels of self-reported physical
activity.
Conclusions: E-portal use is associated with male gender,
higher education and income, and use of the internet for
health related activities. This profile may reflect early-adopter
status or simply characterize differences in access to
technology, comfort with internet use, or other factors related
to care preferences. E-portal users showed a trend toward
greater patient activation.
Implications for Policy, Delivery, or Practice: Findings from
eHealth studies may have limited generalizability due to this
“volunteer” effect and future studies should attempt to
quantify these differences in meaningful ways.
Primary Funding Source: RWJF
●Nursing Home Quality and the Prevalence of Delirium
among Newly Admitted Patients to Post-Acute Care
Richard Jones, Sc.D., Dan K Kiely, MA, M.P.H., Margaret A.
Bergmann, GNP, MS, E. John Orav, Ph.D., Katharine M.
Murphy, RN, Ph.D., Edward R. Marcantonio, M.D., SM
Presented By: Richard Jones, Sc.D., Associate Research
Scientist, Institute for Aging Research, Hebrew SeniorLife,
1200 Centre Street, Boston, MA 02492; Tel: (617)363-8493;
Fax: (617) 363-8396; Email: jones@mail.hrca.harvard.edu
Research Objective: Patients admitted to post-acute care
facilities are expected to make gains in physical functioning.
We have previously shown that delirium and associated
symptoms are highly prevalent yet underrecognized among
newly admitted post-acute care patients, and when present
prevent or impede the pace of functional recovery. In this
study, we demonstrate that the prevalence of delirium among
patients admitted to post-acute care is tightly linked to quality
of nursing home care as reflected in nursing home deficiency
counts.
Study Design: Secondary analysis of data collected in the
screening process for a randomized controlled delirium
abatement trial nested within a prospective cohort study.
Prevalence of Confusion Assessment Method (CAM) research
diagnoses of delirium as completed by trained lay
interviewers.
Population Studied: We screened 4745 of 7794 persons
admitted to one of eight post-acute care facilities in the
Boston area over a three year period. Post-acute care facility
quality of care was operationalized with the count of
deficiencies noted by state surveyors.
Principal Findings: The correlation of deficiency count and
the prevalence of CAM delirium among new post-acute care
admissions was 0.81, (95% confidence interval 0.24-0.96,
Spearman rank correlation = 0.81). When facility data were
separated into discrete periods of observation punctuated by
sequential state survey reports, the correlation of deficiency
count and the prevalence of CAM delirium among persons
admitted in the preceding period was reduced but remained
significant (Pearson r = 0.52, 95% CI = 0.17, 0.76; Spearman
rank correlation = 0.50).
Conclusions: We have found that poorer quality nursing
homes, as reflected by a higher number of deficiencies, are
more likely to admit persons that satisfy criteria for delirium.
The causes of this phenomena are not clear. We suspect
preferential referral patterns based on impressions of recovery
risk rather than specifically delirium risk are driving this
phenomena.
Implications for Policy, Delivery, or Practice: Anticipated
changes in reimbursement highlight the need for effective
screening, prevention and treatment programs for delirium.
Primary Funding Source: NIA
●Demographic, Health Care Utilization, and Health
Insurance Trends for Veteran Medicare Beneficiaries
Yvonne Jonk, Ph.D., Andrea Cutting, MA, Heidi O'Connor,
MS, Jill Klingner, MS, RN, Bryan Dowd, Ph.D., Roger Feldman,
Ph.D.
Presented By: Yvonne Jonk, Ph.D., Health Economist, Center
for Chronic Disease Outcomes Research, Minneapolis VA
Medical Center, One Veterans Drive 1110, Minneapolis, MN
55417; Tel: (612) 467-3882; Fax: (612) 725-2118; Email:
yvonne.jonk@med.va.gov
Research Objective: Analyze trends in the demographic
characteristics, health status, health insurance, and utilization
of Veterans Health Administration (VHA’s) health care
services for veteran Medicare beneficiaries five years before
and after VHA 1996 administrative and eligibility reforms.
Study Design: An observational study utilizing longitudinal
cohort survey data. The Medicare Current Beneficiary Survey
identifies veterans and serves as the primary data source. VHA
administrative changes taking place in the mid-1990s are
believed to equally influence the utilization and cost of
services for the experimental and control groups, while these
groups differ in their response to the 1996 expansions in
eligibility. The control group consists of service connected
(SC) and low-income veterans, and the experimental group
are non-service connected veterans whose incomes fall above
the means test thresholds (NSCMT).
Population Studied: A nationally representative sample of
11,471 veteran Medicare beneficiaries in 1992-2002.
Principal Findings: Over the past decade, veterans
consistently comprised over a quarter of Medicare
beneficiaries. While the vast majority of veterans were white
males over the age of 65, veterans in the control group were a
more racially diverse group. They were more likely to be black
and report Hispanic ethnicity than the NSCMT group.
Although both groups tended to become better educated over
time, veterans in the control group were less educated, less
likely to be married, more likely to be divorced or widowed,
and had lower household incomes. While approximately onefourth of veterans in the control group were SC, the
percentage with SC ratings between 1-25% has been
decreasing, while those greater than 75% has been increasing.
While the percentage of veterans enrolled in Medicare HMOs
has been increasing, the rate of increase has been higher for
the control than the NSCMT groups. The percentage of
veterans in the control group dually enrolled in Medicaid is
higher than the NSCMT and has been increasing at a faster
rate. NSCMT veterans are more likely to carry supplemental
insurance, be in excellent to very good health, and report no
problems with Activities of Daily Living (ADLs) and
Independent ADLs than the control group. While a higher
percentage of the control group report having chronic
conditions, some of these differences are mitigated by the
influx of NSCMT veterans having these conditions post 1996.
Although use of VHA services was more prevalent within the
control group both pre and post 1996, usage rates for
outpatient and prescription drug services increased
significantly across both groups. No clear patterns in terms of
the percent of VA users within either group who report poor
health status, chronic conditions, or trouble with ADLs/IADLs
exist pre and post 1996.
Conclusions: VHA administrative and eligibility reforms have
increased reliance on the VHA. While veterans in the control
group are of lower socioeconomic and health status than the
NSCMT group, no clear evidence of adverse selection among
newly eligible NSCMT veterans using the VHA exists.
Implications for Policy, Delivery, or Practice: The growth of
the Medicare eligible veteran population and their reliance on
VHA coverage for outpatient and prescription drugs post 1996
will continue to challenge VHA’s budget in the coming years.
Primary Funding Source: VA
●Usefulness of Weight and I&O as Measures of Fluid
Balance
Toni Kaeding, MS, RN
Presented By: Toni Kaeding, MS, RN, Research Associate,
College of Nursing and Health Sciences, University of
Vermont, 55 Kaeding Road, Worcester, VT 05682; Tel: (802)
656-5496; Fax: (802) 656-2191; Email: toni.kaeding@uvm.edu
Research Objective: To examine the usefulness of daily
weights and intake-output (I&O) measurement as effective
measures of fluid balance in patients.
Study Design: This is a cross-sectional study of the
correlation between two tools generally employed in the
managmenet of fluid balance - daily weights and I&O
measurement. Both are considered valid measures, both are
generally employed as a means of planned redundancy and
both are time and labor intensive tasks usually performed by
nurses. Pearson's r and simple linear regression were used to
assess agreement between the two tools.
Population Studied: Medical records from a convenience
sample of hospital patients with congestive heart failure, in
which both daily weights and I&O measurement were
employed, were examined (n = 41).
Principal Findings: Weights and I&O differentials correlated
poorly for concurrent twenty-four hour periods (r = 0.23) and
only slightly better for entire hospitalization (r = 0.42).
Conclusions: Daily weight and I&O may be valid tools, but
current practices render them unreliable and poor guides for
patient treatment. The concurrent use of both tools is not an
effective means of cross-validation and often obscures the
truth. Further study must be aimed at the development of a
reliable measure in the management of fluid balance.
Implications for Policy, Delivery, or Practice: For many
patients, the effective management of fluid balance is critical
to survival. Unreliable treatment guides, especially those that
are both time and labor intensive, have serious implications
for patients and provide for the inefficient use of nurse
resources.
Primary Funding Source: No Funding
●Interpreting Physician Trust: Patient Characteristics and
the Validity of Responses
Michael Kallen, Ph.D., M.P.H., David H. Kuykendall, Ph.D.,
M.B.A.
Presented By: Michael Kallen, Ph.D., M.P.H., Senior
Methodologist, Medicine-Health Services Research Section,
Baylor College of Medicine, 2002 Holcombe Boulevard,
Houston, TX 77030; Tel: (713) 794-8822; Fax: (713) 748-7359;
Email: mkallen@bcm.tmc.edu
Research Objective: To establish the importance of validating
outcome measures on populations of interest in disparities
research.
Study Design: Summated scores on the 11-item Trust in
Physician Scale were used to categorize patients as having
high trust (responses physician favorable) or low trust
(responses neutral or unfavorable). Subpopulations differing
in levels of trust were identified using CHAID (Chi-squared
Automatic Interaction Detector), a recursive partitioning of
variance technique. Trust measures were then analyzed via
Rasch modeling techniques (IRT) to obtain person and
associated infit measures. Patients with low validity trust
measures were then identified using standard infit criteria.
Health and demographic status were investigated via
recursive partitioning to explore their possible relationship
with measurement validity status. With low validity measure
patients excluded, the initial analysis to identify
subpopulations differing in trust was re-run to determine if
disparities findings were influenced by use of a measurement
instrument not appropriate for all study subpopulations.
Population Studied: Consecutive patients from outpatient
clinics representing one public, one private, and one VA clinic
were recruited from waiting rooms prior to appointments.
Participants completed demographic questions and a battery
of scales about their health and health care. Completed
questionnaires were received from 104 African Americans and
131 White Americans. The overall sample composition was:
46% female; 57% incomes <= $20,000 per year; 36%
completed high school or less; 47% experienced moderate to
severe pain during the previous 4 weeks.
Principal Findings: 1) Overall, 20% of patients expressed low
physician trust, yet there was considerable variability in trust
among subpopulations. Low trust was reported by 44% of
male, lower income patients with at least moderate pain;
conversely, low trust was reported by only 9% of patients with
mild pain or less and at least some college education. 2)
Several patient characteristics were associated with tendencies
for trust scores to exhibit poor validity. One type of low validity
was identified by patient pain status, education, and income
level; another type was identified by patient education level
alone. 3) Conclusions about subpopulations with high or low
trust were highly dependent upon whether low validity
measure patients were excluded from analyses.
Conclusions: The validity of scale responses from all patient
subgroups may not be equivalent. Of great concern is the
extent to which low validity measurements may populate a
dataset and influence subsequent analyses. To better
understand and interpret score meaning and effect, inquiries
into measurement validity should be made, and validmeasure-only analyses conducted to confirm findings.
Implications for Policy, Delivery, or Practice: From a policy
perspective, there may be distinct patient subgroups
vulnerable to entering into physician encounters at low trust
levels. Yet some patient subgroups may also experience
conditions of low validity trust measurement. Disparities
research needs to distinguish between what is effect and what
is simply inappropriate measurement in subpopulations of
interest. To develop a model of patient trust, interactions
among predisposing circumstances must be recognized and
high quality measurement obtained in order to identify
patient-physician communication challenges and inform
educational initiatives.
Primary Funding Source: AHRQ,
●Cost Implications of Statins In Black Subjects With
Diabetes
Rukhsana Khan, MBBS, M.P.H., Paul Rheeder, MBChB,
MMed(Int), MSc, Ph.D, DG Van Zyl, MBCh.B, MMed(Int),
MSc, Dorothy Kekana, Dip.Nursing, M.B.A.
Presented By: Rukhsana Khan, MBBS, M.P.H., Doctor
(Lecturer), Biostatistics (National School Of Public Health),
University Of Limpopo (Medunsa), PO Box 215 Medunsa
0204, Pretoria, South Africa, Pretoria, Tel: +72 12 521 5032 (c)
+27 83 6363 951; Fax: +27 12 560 0172; Email:
rukhsana_khan@embanet.com
Research Objective: To determine the proportion of black
subjects with dyslipidemia seen at a secondary and tertiary
diabetes clinic and the cost implications thereof.
Study Design: Cross sectional
Population Studied: Secondary Clinic:As a part of
cardiovascular screening project blood lipids were determined
in a cross sectional convenience sample of black diabetic
subjects. Tertiary Clinic: lipids were determined as part of
routine care in black diabetic subjects
Principal Findings: Costs per month were calculated based
on 10 mg generic simvastin at tender price to Gauteng
province of SA assuming a clinic of 1000 patients. Results,
Secondary Clinic : n=123 patients mean age 62.8(9.5)yrs
66.7% female Cat A:LDL>=3.0 mmol/l 59.3%(49.9-68.3%)
Cat B:LDL>=2.6 mmol/l 71.2%(62.1-79.2%) Cat C:Tchol>=3.5
&age>40 82.9%(75.1_89.1) Costs/mo:CatA R14 071- R19 260
CatB R17 512 - R22 334 CatC R21 178- R25 126. Results, Tertiary
Clinic: n= 235 patients mean age 58.6(12.4) yrs 67.6% females
Cat A:LDL>=3.0 mmol/l 29.7% (22.9-37.1%) Cat B:LDL>=2.6
mmol/l 72.7% (65.4-79.2%) Cat C:Tchol>=3.5 &age>40
89.9% (84.3-93.8%) Costs/mo:CatA R6 457 - R10 462 CatB
R18 442- R22 334 CatC R23 772- R26 451
Conclusions: Dependent on which lipid cut-off is used there
are considerable cost implications for clinics starting lipid
therapy. This should be offset downstream by reduced
cardiovascular events.
Implications for Policy, Delivery, or Practice: Since
hyperlipidemia is quiet frequent in black population of South
Africa, the public hospital authorities must include in their
budget the costs for statins, which could eventually help
reduce the cardiovascular events..
Primary Funding Source: No Funding
●The 2004 Influenza Vaccination Shortage Effect on
Emergency Department Patients who met CDC guidelines
for Vaccination.
Damon Kuehl, M.D., K. John McConnell, Ph.D., Heather
Brooks, BS
Presented By: Damon Kuehl, M.D., Fellow, Center for Policy
and Research in Emergency Medicine, Oregon Health &
Science University, 3181 Southwest Sam Jackson Park Road,
Portland, OR 97239; Tel: (503) 341-6269; Email:
kuehld@ohsu.edu
Research Objective: Emergency Department (ED) patients
may have less access to primary care and health maintenance,
and may be more adversely affected if preventive health care
cutbacks or shortages occur. The objective of this study was to
determine the effect of the 2004 influenza vaccination
shortage on vaccination rates of ED patients.
Study Design: This was a cross-sectional survey of patients’
influenza vaccination history over a 2-year period. The survey
included a face-to-face interview, hospital admission data, and
insurance information. One of the enrollment criteria included
patients who met 1 of 2 categories for recommended
vaccination based on CDC guidelines: age (65 and older or
children 6 - 23 months) or preexisting condition of asthma or
COPD. Recent influenza vaccination, any efforts to obtain a
vaccination in the 2004-2005 season, and the previous year's
vaccination history were ascertained.
Population Studied: 2207 patients presenting for treatment
to a large, academic ED between November 1st, 2004 and
March 20th, 2005.
Principal Findings: 1142 patients met at least one of the two
CDC criteria to receive a vaccination in the shortage year. Of
the 802 patients older than 23 months that met CDC
guidelines for vaccination, 357 (44.5%, 95% CI 41.1-47.9) were
vaccinated, compared to 463 (57.7% CI 54.3-61.1) who
reported receiving one last year. Among patients meeting
criteria, 115 (10.1% CI 8.3-11.8) attempted to obtain vaccination
but were denied or unsuccessful. In 449 patients 65 or older,
272 (60.6% CI 56.8-64.4) stated they had been vaccinated in
the current season. However, 332 (74.0% CI 70.5-77.4)
persons in the same group reported vaccinations the previous
year. Of the 369 patients outside age criteria but having a
preexisting respiratory condition, 90 (24.5% CI 20.0-28.8)
received the vaccine, compared to 139 (37.7% CI 32.7-42.6)
who received it the previous year. Uninsured patients meeting
CDC guidelines had vaccination coverage that was lower
(14.3%, CI 8.2-20.4) than any other insurance category.
Conclusions: 2004-05 vaccination coverage in ED patients
was substantially lower than in the previous year. Patients with
high-risk conditions and the uninsured had very low
vaccination rates. A concerning number of ED patients
meeting CDC guidelines reported trying to obtain a
vaccination but were denied or failed. All coverage was well
below targets for Healthy People 2010.
Implications for Policy, Delivery, or Practice: National
estimates of vaccination rates during the 2004-05 shortage
have found priority groups did not have marked changes in
coverage from previous years. ED patients with high-risk
conditions in our study did report significant reductions. This
data further supports the idea that increasing ED-based
preventive health services may be part of a solution to
improve vaccination coverage and the health of this
population.
Primary Funding Source: No Funding
●Heavy Emergency Department Users in a State Medicaid
Population Have Multiple Chronic Illnesses and Unstable
Primary Care
Damon Kuehl, M.D., Robert A. Lowe, M.D., M.P.H., Charles A.
Gallia, Ph.D.
Presented By: Damon Kuehl, M.D., Fellow, Center for Policy
and Research in Emergency Medicine, Oregon Health &
Science University, 3181 Southwest Sam Jackson Park Road,
CR114, Portland, OR 97239-3098; Tel: (503) 341-6269; Fax:
(503) 494-4640; Email: kuehld@ohsu.edu
Research Objective: Frequent emergency department (ED)
users are sometimes said to misuse resources, but they may
have complex medical problems for which the ED is the best
site of care, or frequent ED use may reflect failures of the
medical care delivery system. Previous studies of heavy users
have been limited to local populations and single EDs. This
study reports on characteristics of frequent ED users from a
statewide database of Medicaid enrollees.
Study Design: Historical cohort study using an administrative
database
Population Studied: Using data on all enrollees in the
Oregon Health Plan (OHP), Oregon's Medicaid expansion
program, over a 4-year period (2001-2004), we identified
patients with at least 75 ED visits. Diagnoses from all claims
(not just ED claims) were grouped into clinically relevant
categories of chronic disease. We also counted the number of
different primary care providers to whom the patient was
assigned over the 4 years.
Principal Findings: Of 1,018,611 OHP enrollees, 202 (0.02%)
met the criteria of 75 or more visits. They accounted for 21,927
ED visits over 4 years (2% of all OHP ED visits). Their mean
number of ED visits was 109 (median 96, range 75-475); 196
(97 %) of the patients had psychiatric illnesses including 172
(85%) with depression and 154 (76%) with psychosis. Drug
use was present in 137 (68%) enrollees and alcohol use in 77
(38%). The highest physical-health categories were pulmonary
135 (67%), gastrointestinal 135 (67%), migraine 120 (59%) and
hypertension 107 (53%). The prevalence of other selected
illnesses was also high, including diabetes 60 (30%), coronary
artery disease 47 (23%), and CHF 25 (12%). The median
number of primary care providers was 2; 10 enrollees had 4
providers and 22 had 3 providers.
Conclusions: Over 95% of ED users had mental illness but
they also had many other illnesses and their primary care
providers shifted frequently.
Implications for Policy, Delivery, or Practice: Although ED
visits by heavy users represent only 2% of visits, these findings
imply the need for better case management to improve
continuity of enrollment and care and to coordinate the
physical and mental health needs of this vulnerable
population.
Primary Funding Source: RWJF, Emergency Medicine
Foundation
●Factors Affecting the Successful Treatment for
Tuberculosis Patients in Taiwan
Pei-Tseng Kung, Sc.D., Wen-Chen Tsai, Dr.P.H., Hsiao-Yun
Hu, M.H.A., Ya-Hsin Li, M.H.A.
Presented By: Pei-Tseng Kung, Sc.D., Associate Professor,
Healthcare Administration, Asia University, 11 Ln16 Sec3
Chungching Road, Taya, Taichung, 42805; Tel: (886)
425603149; Fax: (886) 425603149; Email: ptkung@seed.net.tw
Research Objective: The highest death rate of infectious
diseases is tuberculosis in Taiwan. This study investigated the
key factors of successful treatment for TB patients in Taiwan.
Study Design: This is a retrospective study. The samples
consist of two groups including successful treatment TB
patients and default TB patients within 18-month treatment.
Survival analysis was used to analyze the factors that
influenced the treatment outcome for TB patients within 18
months, and estimated the hazard ratios.
Population Studied: The study used Taiwan CDC dataset of
TB patients that included all nationwide TB cases.
Proportional random sampling was used to select patients
who were registered in CDC from June to November 2001.
Using the structured questionnaire, public health nurses
interviewed TB patients by phone to collect data. A total of 550
samples were collected.
Principal Findings: The results showed that personal
willpower and family support were the key factors for TB
patients to cure TB. The main problem was side effects for all
TB patients during treatments. According to the survival
analysis, male had a lower cure rate than female. When
patients had higher satisfaction with the treatment, they had a
higher cure rate. Patients who had the experience of changing
hospitals or stopping taking medicine during treatment had
lower successful treatment, but patients who changed jobs
during treatment had higher successful rate. Patients who had
knowledge about the TB transmission route and the time
needed for treatment had higher cure rates.
Conclusions: Side effects of medication, compliance, the
awareness of TB, and regular place of care were the key factors
for successful treatment.
Implications for Policy, Delivery, or Practice: We conclude
that patients need to be made aware of TB and the
appropriate treatment courses. The implementation of a case
management program may increase the rate of successful
treatment.
Primary Funding Source: Taiwan CDC
●Health Insurance Issues for Small Businesses
Linda Laliberte, J.D., MS, Susan M. Allen, Ph.D.
Presented By: Linda Laliberte, J.D., MS, Clinical Assistant
Professor, Center for Gerontology and Healthcare Research,
Brown University, Box G-ST, Providence, RI 02912; Tel: (401)
863-3819; Fax: (401) 863-1889; Email: Linda_LaliberteCote@brown.edu
Research Objective: According to Medical Expenditure Panel
Survey - Insurance Component data for 2003, there are nearly
117,000 private sector establishments in Rhode Island with
fewer than 25 employees. Forty-eight percent of these
establishments with fewer than 10 employees and 84% of
establishments with 10-25 employees offered health insurance
in 2003. The objective of this research was to better
understand the issues being faced by small businesses which
offer health insurance as an employee benefit.
Study Design: This qualitative research was carried out on 3
focus groups with a total of 29 participants. Convened in the
summer of 2005, each group was led by a professional
facilitator. The 90-minute sessions were audiotaped and
transcripts were reviewed independently by the research team
to identify key themes. Team members discussed their
findings, reached consensus on key themes, and extracted
from the manuscripts quotations of the participants which
best illustrated these themes. These quotations are printed in
upper case in this abstract because of submission format
restrictions.
Population Studied: The population consisted of small
businesses in the state of Rhode Island with fewer than 25
employees. These businesses offered health insurance as an
employee benefit. Most focus group participants were the
owners or chief financial officers of businesses with fewer than
15 employees.
Principal Findings: Providing health insurance was viewed by
small businesses as a moral obligation - WE CONSIDER
EMPLOYEES FAMILY AND WANT TO TREAT THEM
PROPERLY - and A MATTER OF PRIDE. Increasing health
insurance costs produced an underlying sense of despair - I
FEEL HELPLESS - for these businesses. Strategies used to
cope with increasing costs included selecting different plans YOU GIVE UP LOTS FOR MINIMAL SAVINGS, transferring
costs to employees - IT’S A BALANCING ACT BETWEEN
PAYING HEALTH INSURANCE AND PAYING HIGHER
HOURLY WAGES, greater reliance on part-time labor - AND
WE’RE THINKING NOW THAT WE’RE GROWING…ARE WE
GOING TO NEED MORE FULL-TIME PEOPLE OR GO
AHEAD WITH PART-TIME PEOPLE?, and hiring decisions WE’RE FORTUNATE THAT 3 OF OUR FULL-TIME
EMPLOYEES HAVE COVERAGE THROUGH THEIR
SPOUSES. Information on rates for small group plans was
CONFUSING and the methodology for pricing small group
plans LACKED TRANSPARENCY.
Conclusions: Although the smallest businesses are the least
likely to offer health insurance as a benefit, those which do
provide health insurance recognize the value of this benefit
and want to continue to make it available to their employees.
Creativity helped businesses to afford to offer this benefit in
the short-run, but this is not sustainable in the long-run.
Implications for Policy, Delivery, or Practice: The smallest
businesses are least able to absorb the increasing costs of
health insurance for their employees. States need to intervene
with insurers to develop affordable options for these
employers.
Primary Funding Source: HRSA
●Lessons from a Decade of Performance Purchasing of
Behavioral Health Services
Aniko Laszlo, Debra Hurwitz
Presented By: Aniko Laszlo, 222 Maple Avenue, Shrewsbury,
MA 01545; Tel: (508)856-8817; Email:
aniko.laszlo@umassmed.edu
Research Objective: The Massachusetts Medicaid agency
(MassHealth) serves about 300,000 individuals (1/3 of its
eligible membership) through the Primary Care Clinician Plan
(PCCP), a state-run managed care plan. MassHealth contracts
with the Massachusetts Behavioral Health Partnership
(MBHP) to purchase mental health and substance abuse
services for PCCP members. Above core contract
requirements, MassHealth has included specific performance
incentives in its contract with the vendor (MBHP). Since
1997, bonus payments to the vendor have been available for
meeting specific target performance measures. Providers
participating in PI projects may share MBHP’s performance
payments or receive non-monetary incentives. This study’s
objective was to determine the value of performance
purchasing with respect to program design, operation and
outcome over time. Specific research goals included assessing
the extent to which the performance incentives (PI): a) were
aligned with program objectives b) were met c) were
sustainable after the projects’ pilot phase was over, and d)
improved patient outcomes.
Study Design: A record review tool containing 26 data fields
was designed in May – June 2004. During record review,
project team reviewed Performance Evaluation and
Compliance Reports for 111 PI projects. The record review tool
collected information about populations served, PI project
design, operation, and outcomes. The study period was 19972003.
Population Studied: The study population included those
behavioral health providers in MBHP’s provider network who
participated in the PI projects and PCCP members including
children under the Care and Custody of the Commonwealth,
individuals with dual diagnosis, pregnant women with
substance abuse disorders, and homeless individuals. 81% of
the study population was disabled and at least 16% had cooccurring disorders.
Principal Findings: PI project goals were aligned with the
Medicaid agency’s behavioral health program objectives of
accessibility, quality of care and system efficiency in 100% of
the cases analyzed. Twelve new programs and services were
added to the broader delivery system since 1997. In
collaboration with providers, patient advocacy groups and
other stakeholders, MBHP met performance targets 94% of
the time. However, most project targets were process oriented
as opposed to consumer outcome measures. The impact of
PIs on consumers could not be determined. Over the study
period, MassHealth paid MBHP a total of $32.4 million in
bonuses or an average of $291,900 per PI project. Total bonus
payments represented 1%-2% of the total annual BH program
budget.
Conclusions: In most cases, performance purchasing
appeared to afford the provider organization with the flexibility
and financial incentives to move beyond core contract
requirements and to pilot and introduce innovative services
into the behavioral health system of care. It also fostered state
agency and stakeholder collaboration However, further
refinement in outcome measurement is needed to be able to
measure the PI projects’ ultimate impact on consumer health
and well-being.
Implications for Policy, Delivery, or Practice: A new round
of PI contracting for managed care organizations serving
Medicaid populations is under way in Massachusetts for FY
2007. New PI contracting requirements should include
consumer-oriented outcome measures, establish benchmarks
for those measures, and clearly articulate improvement goals.
Primary Funding Source: University of Massachusetts
Medical School
●Aging in Place: Are Services Available to Meet the Health
and Safety Needs of Elders?
Denys Lau, Ph.D., Karen Scandrett, M.D., Mary Jarzebowski,
BS, Kami Chin, MS, Tawana Bandy, BA, Linda Emanuel, M.D.,
Ph.D.
Presented By: Denys Lau, Ph.D., Assistant Professor, Director
of Health Services Evaluation and Policy Research, Buehler
Center on Aging, Northwestern University, Feinberg School of
Medicine, 750 North Lake Shore Drive, Suite 601, Chicago, IL
60611; Tel: (312) 503-1231; Fax: (312) 503- 5868;
Email: d-lau@northwestern.edu
Research Objective: More elders are favoring to stay in their
homes and communities as they age. In a previous pilot
study among older adults, we found four major causes of
adverse events leading to an emergency room visit: lack of
care coordination, financial barriers to medical care, lack of
knowledge regarding medical services, and unsafe home
environments. In this study, we will review the literature on
current home and community-based programs to assess their
adequacy in keeping elders living at home.
Study Design: We reviewed online sources, including
Medline, as well as websites sponsored by the U.S. Health
and Human Services (including Medicare and Medicaid),
Government Accounting Office, Administration on Aging,
National Program of All-Inclusive Care for the Elderly (PACE)
Providers, National Association of State Units on Aging, and
American Association of Retired People. Search terms
included Home and Community Based Programs, Healthy
Aging, Community Saftey for Elders, Aging in Place, and
related terms. Only literature and evaluation reports of
nationwide programs were reviewed.
Population Studied: Home and Community Based Programs
for people aged 65 years and older.
Principal Findings: There are publicly and privately
sponsored home and community-based programs for elders.
Considered the most comprehensive public program, PACE
coordinates healthcare, nutritional, social and transportation
services to low-income, frail elders. PACE is found to lower
unnecessary use of health services and increase the quality of
life and functional status of enrollees; however, these benefits
are often short-run. Available in only 18 states, PACE is
operated within local communities, leaving large areas without
services. Medicaid waiver programs are also available, but
they are operated by individual states and provide varying
medical, social, and personal services to elders. Private
programs are even less comprehensive. Examples of such
organizations include Visiting Angels (home health services),
Meals on Wheels (meal preparation), and Accessible Space
(home repair and modification services). Private programs
are not available consistently, are not coordinated in a holistic
manner, and can be prohibitively expensive for many elders.
Conclusions: Although public and private programs assist
community-dwelling elders, these services are fragmented in
scope, operation, and/or geography.
Implications for Policy, Delivery, or Practice: As more
elders age in place, comprehensive and well-run home and
community-based programs will be important for promoting
health and safety among elders.
Primary Funding Source: No Funding
●The Effects of Workplace Drug Testing Policy on the use
of Tobacco, Alcohol, and Drugs
Doohee Lee, Ph.D., M.P.H., MA
Presented By: Doohee Lee, Ph.D., M.P.H., MA, Assistant
Professor, Health Care Administration and Public Health,
Cleveland State University, 2121 Euclid Avenue, BU 438,
Cleveland, OH 44115; Tel: (216) 875-9793; Email:
d.lee1@csuohio.edu
Research Objective: To examine the effects of workplace drug
policy on the current use (last month usage) of tobacco,
alcohol, and illicit drugs
Study Design: The 2003 National Survey on Drug Use and
Health (NSDUH) was used to examine the effects of
workplace drug testing policy on the use of tobacco, alcohol,
and other illicit drugs. NSDUH is a cross-sectional study
designed to measure the prevalence and correlates of drug
use in the United States. Descriptive analysis was performed.
Three dependent variables examined in the study are: (1)
alcohol and drug written policy at work, (2) drug testing at
work, and (3) workplace drug testing in the hiring process.
Population Studied: A nationally representative sample of
28,682 individuals in the U.S. Study participants were
members of United States households aged 12 and older.
Principal Findings: : individuals at workplaces with alcohol
and drug written policy (ADWP) and drug testing (DT) were
less likely to smoke than those individuals at workplaces
without ADWP (34% vs. 36.3%) and DT (35% vs. 39%).
However, there was no difference found between alcohol use
and drug testing workplace policies. Results show that
marijuana was less used among those individuals with alcohol
and drug policy at work (10.7% vs. 15.2%). It was statistically
significant that individuals who had drug testing in the hiring
process were also less likely to use cocaine than those
individuals who did not have drug testing in the hiring process
(1% vs. 1.6%).
Conclusions: the results suggest that having alcohol and drug
written policy and drug testing at work and in the hiring
process is effective in reducing the current prevalence rate of
cigarette, marijuana, cocaine, and hallucinogen.
Implications for Policy, Delivery, or Practice: Study findings
provide implications of the need for public and private
organization to develop and maintain their own alcohol and
drug policy. Careful prevention and treatment efforts are to be
made when implementing alcohol and drug testing policy.
Primary Funding Source: No Funding
●Market Structure and Quality in Medicare Managed Care
Woolton Lee, BS, Ph.D. expected 2006
Presented By: Woolton Lee, BS, doctoral candidate, Health
Policy and Administration, Penn State University, 15A North
Henderson Building, University Park, PA 16801; Tel: (814) 8630874; Email: wwl107@psu.edu
Research Objective: To examine the effect of Medicare HMO
competition on performance of Health Employer Data and
Information Set (HEDIS) measures for mammography,
diabetes and heart disease.
Study Design: Observational data of a longitudinal panel of
Medicare HMOs during the period 1998-2002. The study
uses longitudinal variation in measures of Medicare HMO
competition to identify the effects of competition on
performance for 11 separate HEDIS measures.
Population Studied: Medicare HMOs operating in the United
States during 1998-2002.
Principal Findings: Increased competition was found to be
related to jointly significant reductions in performance for
LDL-C screening (heart disease), eye exams (diabetes), and
lipid screening (diabetes). Although not jointly significant,
increased competition also appears to be associated with
reductions in poor hemoglobin A1c control. By comparison,
increased competition is associated with higher performance
for the HEDIS mammography measure.
Conclusions: Competition among Medicare HMOs may
result in worse performance on publicly avaiable measures of
health plan quality if improved performance attracts high cost
Medicare beneficiaries.
Primary Funding Source: Other
●Racio-ethnic Differences in Perceived Organizational
Cultural Competence and the Impact on job Satisfaction in
Long-Term Care
Jennifer Leigh, Ph.D., Donald Allensworth-Davies, M.Sc., Scott
Miyake-Geron, M.S.W., Ph.D., Eric Hardt, M.D., Ryann L
Engle, M.P.H., Victoria Parker, D.B.A.
Presented By: Jennifer Leigh, Ph.D. Clinical Psychology,
Health Services Research Fellow, Center for Health Quality,
Outcomes, and Economics Research, 200 Springs Road,
Bedford, MA 01730-1114; Tel: (781) 687-2000 x6728; Email:
jleigh@bu.edu
Research Objective: With annual turnover rates over 70%,
long-term care facilities are facing a dire staffing situation for
nursing assistants (NA’s). Researchers and practitioners alike
have been trying to determine the correlates of job satisfaction
to address this increasingly untenable situation. Racial
differences in job satisfaction, across a range of occupations,
is a widely established finding in the literature. However, the
direction of observed differences has not been consistent. In
some studies, whites report greater levels of satisfaction than
people of color, while in others, the reverse is found. Could
another factor related to job satisfaction have influenced these
findings, thereby explaining the apparently contradictory
results? One factor that has received little empirical attention
in the long-term care literature is cultural competence.
Cultural competence is defined as a set of attitudes,
behaviors, and policies that enable organizations and staff to
work effectively in cross-cultural situations. The purpose of
this study was to examine the impact of perceived
organizational cultural competence on job satisfaction across
racio-ethnic groups.
Study Design: Primary data collected from a cross-section of
NA’s at four nursing homes. Demographics, perceptions of
organizational cultural competence, and ratings of job
satisfaction were collected. A linear regression model was
created with job satisfaction as the dependent variable and
race, age and perceived organizational cultural competence as
independent variables. Facility was not included in the model
since there were no significant differences in either job
satisfaction or perceived cultural competence between the
four nursing homes.
Population Studied: Ninety-nine NA’s from four New
England nursing homes. Racio-ethnic groups were: Haitian-
born Black 35.4%, African-born Black 24.2%, US-born Black
8.1%, Asian 5.1%, Hispanic 6.1%, White 21.2%. The sample
was almost exclusively female. Ages were evenly distributed
among three categories: 25-34, 35-44, and 45-54.
Principal Findings: Perception of organizational cultural
competence is the strongest predictor of job satisfaction; as
competency decreases, job satisfaction also decreases, even
after adjusting for age and race (p < 0.001). African-born NA’s
were most satisfied with their jobs (p < 0.02); US-born Black
NA’s viewed their organizations as being the least culturally
competent, and they reported the lowest levels of job
satisfaction (p < 0.01).
Conclusions: Perceived cultural competence is an important
adjustor in evaluating job satisfaction and may help explain
contradictory findings in the literature. Moreover, differences
between racio-ethnic groups in job satisfaction appear to be
influenced by varying perceptions of organizational cultural
competence. Differences in immigration/employment
histories and/or in workgroup composition may help explain
the contrasting subjective experiences between African-born
NA’s and US-born Black NA’s. More research is needed to
understand the underlying reasons for the lower ratings of
perceived cultural competence and job satisfaction reported
by Black NA’s born in the US.
Implications for Policy, Delivery, or Practice: These findings
highlight the need for long-term care organizations to
understand individual employee needs while considering the
impact of racio-ethnic differences on staffs’ experience of the
work environment. Doing so may increase staff satisfaction
and ultimately result in more consistent and higher quality
long-term care.
Primary Funding Source: RWJF
●Impact of a 3-tier Drug Benefit on Expenditures for
Pharmacy and Medical Services Among Patients Receiving
Cardiovascular Medications
Musetta Leung, M.S., M.Ed., Dominic Hodgkin, Ph.D., Cindy
Parks Thomas, Ph.D., Sebastian Schneeweiss, M.D., Sc.D.,
Stanley Wallack, Ph.D.
Presented By: Musetta Leung, M.S., M.Ed., Research
Associate, Health Care Quality Program, RTI International, 411
Waverley Oaks Road, Suite 330, Waltham, MA 02452-8414;
Email: mleung@rti.org
Research Objective: To investigate how a change in
prescription drug benefits affects total patient and plan
payments for pharmacy and medical expenditures among
enrollees treated with cardiovascular (CV) medications.
Study Design: This study uses administrative claims data
from a health maintenance organization, and includes
enrollment, prescription drug, and medical claims from 1999
to 2001. The plan implemented a shift from a 2-tier
(generic/brand) to a 3-tier (generic/preferred brand/nonpreferred brand) formulary for outpatient drug benefits on a
rolling basis, beginning in January 2000. Late- and nonadopters served as a ‘control’ group. Changes in utilization of
and spending for drugs and medical services were evaluated
for all-cause and cardiovascular disease-related services,
including office visits, laboratory tests, emergency care, and
hospitalizations. A difference-in-difference technique, using ttests for bivariate analysis and linear regression of log
expenditures adjusting for repeated measures, was used to
ascertain changes between the pre- and post-implementation
periods. A ‘three-tier’ effect was identified by the difference in
pre-post changes between the intervention and control
groups.
Population Studied: Continuously-enrolled patients under 65
years old who had 2 or more fills for an ACE-inhibitor,
angiotensin receptor blocker, beta-blocker, calcium channel
blocker, or statin in the 6 months prior to the policy change
were included.
Principal Findings: The study included 6,477 patients, with
71% of patients in the intervention group and 29% of patients
in the control group due to the rolling 3-tier adoption.
Gender, age and severity of illness (i.e., DxCG score) were
similar in both groups. Although total out-of-pocket and plan
spending increased for both control and intervention groups
in the post-period, difference-in-difference showed that the
intervention group had a larger post policy increase of $97 per
patient for all-cause OOP costs compared to an increase of
$56 in the control cohort (p<0.0001). For disease-related total
OOP payments, patients in the intervention group paid $41
more per patient in the post-period, compared to an increase
of $23 in the control group (p<0.0001). Multivariate analysis
confirmed this ‘three-tier effect’ for all-cause and diseaserelated OOP spending. This may be due, in part, to higher
patient costs for prescription drugs in the intervention group
in the post-period (by $9 per patient; p=0.0018). Patients in
the intervention group also had a higher number of physician
visits and higher OOP costs for these visits in the post-period
compared to controls (by 0.19 visits per patient, p=0.0075;
and by $1.60 per patient, p<0.0001). There was no significant
3-tier effect on total plan spending after adjusting for other
factors.
Conclusions: Implementation of a three-tier formulary
resulted in increased total patient cost-sharing among the
intervention group, but had little influence over plan
expenditures.
Implications for Policy, Delivery, or Practice: Multi-tiered
drug co-payment systems can result in substantial cost
shifting from plans to patients who require medications for
treating chronic conditions. Plans should ensure that
formularies include therapeutically equivalent agents at low
prices to avoid underutilization of essential medicines. This is
particularly important for plans provided under the Medicare
Part D drug benefit, given aging enrollees’ special needs.
Primary Funding Source: AHRQ
●Utilization of Selected Diabetes Services Before and After
the Medicare Expansion
Rui Li, Ph.D., Ping Zhang, Ph.D., DeKeely Hartsfield, M.P.H.
Presented By: Rui Li, Ph.D., Prevention Effectiveness Fellow,
Division of Diabetes Translation, Centers for Disease Control
and Prevention, 4770 Buford Highway, N.E. MS K-10, Atlanta,
GA 30341; Tel: (770)488-1070; Fax: (770)488-1148; Email:
Rli2@cdc.gov
Research Objective: To improve access to care and quality of
care for diabetes patients, the Budge Balance Act (BBA) of
1997 authorized Medicare to expand its coverage, leading to
enhanced reimbursements of blood self glucose monitoring
strips, diabetes self-management education, and nutritional
therapy for all persons with diabetes, effective in year 1998.
The purpose of this study is to examine the changes of the
utilization of key diabetes services before and after the
expansion in Medicare coverage.
Study Design: We used a logistic regression model to
examine changes of three diabetes care services before and
after the Medicare expansion, the daily Self-monitoring Blood
Glucose (SMBG), annual eye exam, and foot exam, among
Medicare population with diabetes. Disease conditions,
person’s demographic characteristics and time effect were
adjusted. We used STATA 8 survey commands to count
survey design effect.
Population Studied: Data for analysis was from the 19962000 Behavioral Risk Factor Surveillance System (BRFSS), an
annual, state-based, random telephone-survey of 150,000210,000 community-dwelling US adults. Persons with
diabetes and Medicare coverage were included in the analysis.
The final sample size was 10801.
Principal Findings: Among the Medicare population with
diabetes, 39% had daily SMBG; 73% received annual eye
dilated exams; and 64% received annual foot exams before the
expansion of Medicare coverage. The changes of utilization
after the Medicare expansion varied by diabetes service type.
On average, after the expansion, a person’s probability of daily
SMBG increased by 8 percentage points (p<=0.001).
However, a person’s probability of receive annual eye exam
and feet exam didn’t have significant changes.
Conclusions: After the expansion of Medicare diabetes
coverage, rates of SMBG increased but rates of eye and foot
exams had little changes. Rates of receipt of the three
diabetes care service remain below the Healthy People 2010
goals, indicating a need for focused efforts to increase the
proportion of persons who receive the effective diabetes care.
Implications for Policy, Delivery, or Practice: More efforts
should be made to reach the national goals on the proportion
of persons who receive the diabetes care services. Laws and
regulations may be an effective policy tool to reach these
goals.
Primary Funding Source: No Funding
●Non-urgent Visits to Hospital Emergency Departments:
A Tale of One Taiwan Regional Hospital
Yia-Wun Liang, Ph.D., Che-Hung Tsai, M.D., M.P.H., Ying Lin
Cheng, M.S.H.A.
Presented By: Yia-Wun Liang, Ph.D., Associate Professor,
Health Care Administration, Central Taiwan University of
Science and Technology, 11, Po-Tze Lane, Takun, Taichung,
40605; Tel: 011886-4-22391647; Fax: 011886-4-22391000;
Email: liang6288@hotmail.com
Research Objective: Emergency departments(EDs), as a
safety net provider, serve as an important role in providing
health care, with almost 6 million visits annually in Taiwan.
Crowded EDs represent a system that is operating beyond
capacity; a high-risk environment for medical errors; a patient
unsafe environment. ED overcrowding is a complex and
multifactor problem, however, the use of hospital EDs for
nonurgent(NU) health problems has been a subject of
considerable controversy in recent years. Before diversion of
NU patients is adopted as a management strategy, this
population should be better understood with respect to their
characteristics and reasons for not presenting to primary care
providers (PCPs) instead of EDs.
Study Design: This was a cross-sectional study with
sequential sampling in the ED of a Taiwan regional hospital
ED, using individual Taiwan hospital ED patients as unit of
analysis. Data on medical history, social support, awareness
and utilization of health care, ED visits, referrals, and
sociodemographics were collected. The Canadian Triage and
Acuity Scale(CTAS), a five-level promising new tool for triage
acuity assessment in the ED, was used as a measure of
patient acuity.
Population Studied: Eight hundred and forty patients were
surveyed with the structured questionnaires. The NU group
included patients with triage code 5. Patient characteristics
were structured into the Andersen behavioral model for health
care utilization.
Principal Findings: Of 840 patients approached, 814
patients(97%)were eligible and agreed to participate. In the
multivariate model for NU ED visits, age, sex, income,
education, dissatisfaction with the usual source of care, and
CTAS were significant.
Conclusions: Nonurgent ED patients have multiple reasons
for not seeking primary care before going to EDs. The positive
associations between the characteristics of individuals and
dissatisfaction with USC and nonurgent ED use persisted
even in a miltiple logisitc regression.
Implications for Policy, Delivery, or Practice: Predicting
which patients are at risk for using EDs for nonurgent care
provides the policy makers a means of identifying specific
patients and may help explain why various diversion strategies
have been unsuccessful and indicate that a multifaceted
approach may be better suited to this group of patients.
Primary Funding Source: Central Taiwan University of
Science and Technology; Cheng Ching Hospital
●Use of Nurse Practitioners as Medicare Providers
Susan Lin, Dr.P.H.
Presented By: Susan Lin, Dr.P.H., Assistant Professor, School
of Nursing, Columbia University, 617 West 168th Street, New
York, NY 10032; Tel: (212)305-6929; Fax: (212)305-6937; Email:
XL18@columbia.edu
Research Objective: Nurse practitioners (NPs) have not only
grown in numbers but also increasingly gained in legal status
to practice and prescribing authority. The enactment of the
Balanced Budget Act in 1997 changed the Medicare policy that
allowed the reimbursement to nonphysician providers only for
services provided in freestanding, physician-directed rural
clinics located in health professions shortage areas. Since
1997, these nonphysician providers have been granted direct
reimbursement for Part B services provided in any settings.
However, the amount of nonphysician providers who provide
care and bill Medicare for their services has not been
quantified. This study examined the NP workforce as Medicare
providers in the calendar year 2003 across the United States.
Study Design: The study analyzed the Medicare provider data
in the UPIN directory which contains a unique physician
identification number (UPIN) issued to each provider. The
UPIN directory which is publicly accessible was obtained from
Government Printing Office. Other data included in the UPIN
director are provider’s state, credentials and specialties. The
provider specialty variable was used to identify NPs.
Proportion of NPs with UPIN was calculated using the
number of NPs reported by State License Board. Mean
proportions was generated.
Population Studied: Nurse practitioners in each state with
UPIN in 2003.
Principal Findings: There were about 33,420 nurse
practitioners with UPIN in the UPIN directory in the year
2003. The top five states with the largest number of NPs in
the UPIN directory ranked from Massachusetts with 2306,
New York with 2246, Florida with 2169, California with 1899,
to Texas with 1465. About 30% of NPs across the country had
a UPIN. States with 50% or more of NPs who had a UPIN are
Minnesota, North Dakota, Arkansas, Alaska, Montana, New
Mexico, Nebraska, Kansas, Tennessee, New Hampshire and
Iowa. As Medicare also allows NPs to bill their services under
a physician's provider number, this study using the UPIN
directory data underestimated the NP workforce in caring
Medicare population.
Conclusions: Differences exist in the distribution of NPs with
UPIN among states. While a large number of NPs with UPIN
was found in some states, the larger proportions of NPs with
UPIN were observed in other states. These differences may
reflect the legal environment of the NP practice in different
states and the impact of supply of physician workforce on the
utilization of NPs in providing care to Medicare beneficiaries.
Implications for Policy, Delivery, or Practice: The study
findings have the policy and clinical implications. As health
care delivery system is under constant change, it is important
to track and monitor the supply, demand and utilization of
nonphysician workforce. In 2003 Medicare Modernization Act
(MMA) changed Medicare to allow NPs to serve as ‘attending
physician’ for patients who enrolled in hospice. The impact of
NPs and other nonphysician providers on access to quality of
care among Medicare beneficiaries warrants further research.
Primary Funding Source: Oncology Nursing Society
●Washington Medicaid Disease Managment Program
Alice Lind, B.S.N., M.P.H.
Presented By: Alice Lind, B.S.N., M.P.H., Chief, Deptartmen
of Social and Health Services, Care Coordination, PO Box
45530, Olympia, WA 98504-5530; Tel: (360) 725-1629; Email:
lindar@dshs.wa.gov
Research Objective: To show whether contracted Disease
Management services can improve health outcomes and cost
of care for disabled Medicaid clients.
Study Design: The third year of Disease Management has
just been completed for clients with heart failure, diabetes,
COPD, asthma, end stage renal disease, and chronic kidney
failure. 20,000 clients were enrolled and offered nurse case
management and education, both telephonic and in person.
Population Studied: Medicaid disabled clients with one or
more of six chronic conditions.
Principal Findings: Will present results of an acturial study of
cost-effectiveness; self-reported client outcomes and medical
record review; and client satisfaction measures from a
statewide survey.
Conclusions: Cost-savings were produced for certain
conditions in Years 1 and 2. Year 3 results will be available by
June. Certain client outcomes and processes of care
improved. Client satisfaction is high with those who
participate.
Implications for Policy, Delivery, or Practice: While Disease
Management is difficult to implement in a Medicaid Fee-forservice environment, it does provide some measurable
improvements. Will include recommendations for which
populations to include in a DM program, and typical pitfalls to
expect.
Primary Funding Source: No Funding
●Disparities in Health Care among Children with Autism
Gregory Liptak, M.D., M.P.H., Lauren Benzoni, BS, Daniel W.
Mruzek, Ph.D., Karen W. Nolan, PT, MS, PCS, Melissa A.
Thingvoll, M.D., Christine M. Wade, PsyD
Presented By: Gregory Liptak, M.D., M.P.H., Professor of
Pediatrics, University of Rochester Medical Center, 601
Elmwood Avenue, Rochester, NY 14642; Tel: (585) 275-5962;
Fax: (585) 275-3366; Email:
Gregory_Liptak@urmc.rochester.edu
Research Objective: Racial and ethnic disparities affect health
care in the United States. The purpose of this study was to
test the hypotheses that: 1) disparities exist in the prevalence
of autism among children of traditionally disadvantaged
populations, specifically non-white ethnic groups, and 2)
disparities exist in utilization of and access to care for families
of children with autism.
Study Design: Secondary analysis of data obtained from the
National Survey of Children's Health (2003-4), a nationally
representative sample developed by the Centers for Disease
Control and Prevention (102,353 interviews, weighted sample
size 73,162,900). Data were analyzed using SUDAAN
statistical software. Both parametric and non-parametric
statistical analyses were employed.
Population Studied: 473 children (weighted sample size
309,793) were identified by their families as having autism.
Principal Findings: The prevalence of autism per 1,000 was
reported to be 2.60 for Latinos and 4.98 for non-Latinos
(p<0.001), with a lower rate for Latinos of all ages. Autism
was more common in children of mothers born in the United
States than in those with mothers born outside the U.S.
(p<0.001). Families of Latino children with autism reported
difficulty getting primary medical care or advice, problems
accessing specialists, and getting care in a timely fashion (all
p<0.003). The prevalence of autism per 1,000 in AfricanAmerican children was similar to that for non-AfricanAmericans (4.65 v. 5.15). Families of African-American children
with autism were significantly less likely to identify one or
more persons that they would think of as their child’s personal
doctor, get care in a timely fashion, and receive preventive
medical care (all p< 0.003).
Conclusions: Latinos have a significantly lower reported
prevalence of autism than non-Latinos. This may be due to
genetic differences (not confirmed in other studies) or to a
lower rate of diagnosis. The lower rate of diagnosis may be
related to disparities in care. Both Latinos and African
Americans are less likely than white, non-Latinos to utilize or
have access to specific aspects of healthcare.
Implications for Policy, Delivery, or Practice: Policy-makers
and practitioners need to be aware of problems with
diagnostic assessments and access to care among certain
minorities. Policies should be designed to maximize
information, access to diagnostic services, and to healthcare.
Communication may be a special problem for Latinos.
Miscommunication between white primary care providers and
minority patients can occur in many ways, potentially
contributing to disparities in healthcare. Improvements in
continuity of care, time spent in the clinical encounters, and
the provision of information and support should improve the
quality of and satisfaction with healthcare services for all
children with autism and their families.
Primary Funding Source: DHHS: Maternal and Child Health
Bureau; Leadership Education for Neurodevelopmental and
Related Disabilities
●Children with Autism: Morbidity, Co-Morbidity and
Family Burden
Gregory Liptak, M.D., M.P.H., Christine M. Wade, Psy.D.,
Melissa A. Thingvoll, M.D., Lauren Benzoni, BA, Karen W.
Nolan, PT, MS, PCS, Daniel W. Mruzek, Ph.D.
Presented By: Gregory Liptak, M.D., M.P.H., Professor of
Pediatrics, University of Rochester Medical Center, 601
Elmwood Avenue, Rochester, NY 14642; Tel: (585) 275-5962;
Fax: (585) 275-3366; Email:
Gregory_Liptak@urmc.rochester.edu
Research Objective: The purpose of this study was to: a)
investigate the occurrence of clinical conditions in children
with autism, and b) quantify the burden of care experienced by
families of children with autism, compared to the general
population.
Study Design: Secondary analysis of data obtained from the
National Survey of Children’s Health (2003-04), a nationally
representative sample developed by the Centers for Disease
Control and Prevention (102,353 interviews, weighted sample
size 73,162,900). Data were analyzed using SUDAAN
statistical software. Both parametric and non-parametric
statistical analyses were employed.
Population Studied: 473 children (weighted sample size
309,793) were identified by their families as having autism.
Principal Findings: 11% of children with autism were reported
to have fair or poor general health, compared to 3% of
children without autism. Conditions related to the definition of
autism were more common in children with autism. These
(compared with rates for those without autism) included
difficulties with emotions or behavior (89% v. 17%), learning
disability (78% v. 9%), and developmental delay or physical
impairment (68% v. 3%) [all p<0.001]. In addition, other
health problems were found to have a significantly higher
prevalence in children with autism, e.g., depression or anxiety
(38% v. 4%), bone joint or muscle problem (22% v. 3%), and
gastrointestinal allergy (14% v. 4%) [all p<0.001].
Furthermore, a significantly greater percentage of parents of
children with autism reported that their children were much
harder to care for than most children of the same age (54% v.
6%); parents had to make greater sacrifices than expected to
meet their children’s needs (38% vs. 14%); and the mental
and emotional health of the child put a great burden on the
family (30% vs. 9%) [all p<0.001].
Conclusions: Children with autism are at significantly higher
risk for a broad range of health concerns, including mental
health problems and physical illness. Also, families of children
with autism experience significantly greater stressors across a
broad range of categories (e.g., mother’s self-reported
emotional and mental health).
Implications for Policy, Delivery, or Practice: Health and
education professionals should be especially vigilant for comorbid health concerns in children with autism. Additionally,
providers must remain attentive to the potential impact of the
children’s disabilities on their families’ well-being. Systems of
care that address the needs of children with autism need to
provide access to medical, mental health, and related services.
Primary Funding Source: Other, DHHS: Maternal and Child
Health Bureau; Leadership Education for Neurodevelopmental
Disabilities and Related Disorders
●The effects of Taiwan’s prescription drug reimbursement
rate reduction policy on the expenditure of drugs for
healing hypertension for elderly persons
Shuen-Zen Liu, Ph.D., Chi-Liang Chen, Ph.D. Candidate
Presented By: Shuen-Zen Liu, Ph.D., Professor, Department
of Accounting, National Taiwan University, No.1, Sec. 4,
Roosevelt Road, Taipei, Taiwan 106, Taipei, 106; Tel: 886-233661122; Fax: 886-2=23638038; Email:
sliu@management.ntu.edu.tw
Research Objective: Due to pressure from rapidly growing
health care expenditure and the significant proportion of drug
expenditure, many countries have tried to utilize price
regulation in the pharmaceutical market to control health care
expenditure. This study aims to investigate the outcomes of
implementing prescription drug reimbursement rates
reduction policy in Taiwan’s National Health Insurance
Program (NHIP) so as to furnish knowledge regarding the
effect of price control in the pharmaceutical market on health
care expenditure.
Study Design: We utilize multivariate analysis to investigate
the specific cohort’s average expenditure of drugs for healing
hypertension in an outpatient visit mainly for hypertension
before and after an action of reimbursement rate reduction.
To filter the influences of factors other than the price control
policy, we control for several other explanatory variables,
including an individual’s gender and age range, the
characteristics regarding the size (a medical center, a regional
hospital or a smaller hospital) and the ownership (public
versus private, profit versus nonprofit) for a hospital, the
length of prescription (measured by day), and the number of
types of drugs for healing hypertension in a prescription. We
also carefully pick periods for our analysis so as to control for
seasonal effects and impacts from other policies regarding
financing and payment in the NHIP, and utilize the fixedeffects model to control for the unobservable features of
hospitals in our sample.
Population Studied: This study uses data from Taiwan’s
National Health Insurance Research Database. As persons
aged 65 or older are a group consuming many drugs and
hypertension is a common health problem for the elderly, so
we select Taiwanese aged 65 or older and with hypertension as
the sample. For each time of reducing prescription drug
reimbursement rates, the sample for our analysis is a national
representative cohort with hypertension and aged 65 or older
one year before the price reduction action. In our analysis,
there are 2947 patients and 75120 outpatient visits.
Principal Findings: Results from our analysis indicate that
these actions of reducing drug reimbursement rates did not
decrease the drug expenditure of drugs for healing
hypertension. In contrast, our results show that prescriptions
in later years in our observational periods tended to include
more expensive drugs.
Conclusions: Such findings suggest that simply reducing
drug reimbursement rates is not necessarily useful for
controlling drug expenditures. It is likely that the extent of
price reduction and the possibility for physicians to change the
types of drugs for their prescriptions play very influencing
roles in determining the effects of drug reimbursement rate
reduction policy. Exploring the effects of these two factors in
depth is our next step in our analysis for this study.
Implications for Policy, Delivery, or Practice: When
intending to utilize price control in the pharmaceutical market
to reduce health care expenditure, a government has to take
into account the magnitude of price reduction and the
possibility for physicians to change their prescriptions under
its reimbursement scheme.
Primary Funding Source: No Funding
●Association of Nurse Staffing with Surgical Patient
Mortality in VHA Acute Care Units
Elliott Lowy, Ph.D., Anne E Sales, M.S.N., Ph.D., RN, Yu Fang
Li, RN, Ph.D., Nancy D Sharp, Ph.D., Gwendolyn T Greiner,
M.S.W.
Presented By: Elliott Lowy, Ph.D., HSR&D, VHA, 1100 Olive
Way, #1400, Seattle, WA 98115; Tel: (206) 277-4789; Email:
elliott.lowy@va.gov
Research Objective: Several large scale studies have found
associations between nurse staffing and mortality for
hospitalized patients, aggregated to the facility level.
However, nurse staffing varies greatly across inpatient units
within a hospital. In this study we use nursing unit-level data
to examine the association between staffing and patient
mortality among surgical patients - at the facility level and at
the unit level, across different types of post-surgery units.
Study Design: We present an observational, cross-sectional
study using archival data. We used the DSS department
budget and cost report (ALBCC) for number of nursing
personnel hours per month by type of nurse. Patient data, for
surgeries in VHA facilities between February and June 2003,
came from the National Surgical Quality Improvement
Program (NSQIP), and include patient characteristics, preexisting conditions, complications, and outcomes of surgery.
Data on nursing units come from the DSS TRTIPD files, which
can link inpatients to nursing units. We developed a 2-step
multilevel regression model with patient, nursing unit and
hospital level data corrected for clustering at the unit and
facility levels. The first step predicted patient probability of
developing a serious complication using patient-level
predictors. The second step estimated overall mortality on
predicted patient complications, nursing unit and facility-level
predictors. The nurse staffing and other unit characteristics
were assigned to patients based on their first post-surgical
units. All analyses were conducted using the generalized
linear latent and mixed models procedure in STATA v9.0 with
two levels of clustering (unit and facility).
Population Studied: All surgical patients (as determined by
NSQIP) who stayed on an acute med/surg unit at any of 124
VHA facilities between February 1, 2003 and June 30 2003.
Principal Findings: Analyses included 22,467 patients from
454 nursing units in 111 VAMCs. 186 units were intensive care,
and 268 non-intensive acute care units. Analysis of patients on
med/surg units yielded a significant effect of RN hours per
patient day (hppd) on mortality (OR 0.83, p<.05). No
significant improvements in mortality were found for patients
on ICU units, for patients on all units combined, or for
patients aggregated to the facility level. Similarly, no
significant effects were found for skill mix or non-RN hppd, for
any type of unit or level of aggregation.
Conclusions: This first large-scale analysis with nursing unitlevel data corroborates earlier studies in finding a beneficial
effect of increasing RN hppd on surgical patient mortality.
However, the effect reported here is more specific, being
limited to nurses and patients on acute medical-surgical units,
and to the amount, but not ratio, of RN care.
Implications for Policy, Delivery, or Practice: Using nursing
unit-level data and multi-level modeling adjusting for
clustering at the unit and facility level, this study reports a
much more specific effect of nursing care than previous
studies using facility level data. Nursing hours, and the dollars
to pay for them, are in short supply; distributing them where
and how they are most effective would undoubtedly make a
significant contribution to national health care.
Primary Funding Source: VA
●Out-of-Pocket Expenditures for Medical Care Use by
Adults with Major Depression: Does Insurance Parity
Exists?
Ithai Zvi Lurie, MA, Dorothy D. Dunlop, Ph.D, Larry M.
Manheim, Ph.D.
Presented By: Ithai Zvi Lurie, MA, Institute for Healthcare
Studies, Northwestern, 339 East Chicago Avenue, Chicago, IL
60611; Tel: (312) 503-8815; Email: i-lurie@northwestern.edu
Research Objective: The study explores issues related to
overall out-of-pocket expenditures and insurance parity for
major depression by examining three related questions. First,
do individuals with depression pay more in total and out-ofpocket expenses relative to individuals without depression?
Second, is there insurance parity in overall insurance coverage
between depressed and non-depressed individuals? And to
the extent overall parity does not exist, for what type of
medical services do depressed adults pay a higher or lower
share of out-of-pocket relative to non-depressed people?
Study Design: The study identifies individuals with (and
without) major depression using the Composite International
Diagnostic Interview-Short Form (CIDI-SF) from the 1999
National Health Interview Survey (NHIS). Using respondent
baseline (1999) demographic and health characteristics from
the , we follow adults aged 18-64 who also took part in the
Medical Expenditure Panel Survey (MEPS) of 2000 to
determine the out-of-pocket and total expenditure for both
groups. A propensity scoring match is used to control for
individual characteristics, including co-morbidities, we
estimate the mean difference in out-of-pocket (and total)
expenditures for the major depression group relative to the
comparison group (matched individuals without major
depression).
Population Studied: This study uses data from the NHIS who
answered the 1999 mental health supplement and were
selected to participate in the MEPS study: 2,553 non elderly
individuals. Individuals with major depression represent about
5% of the sample, consistent with other national studies.
Principal Findings: Individuals with major depression pay on
average about 28% of their total expenditure out-of-pocket
relative to 20% for individuals with out major depression.
Most of the difference in out-of-pocket expenditure for
individuals with major depression relative to individuals
without is due to a higher expenditure for prescription drugs.
Since on average the co-payment for prescription drugs is
higher than other services (40% relative to about 20% for
office base visits, for example) the higher use of prescription
drugs among individuals with major depression increases
their relative share of out-of-pocket expenditures. However,
the insurance parity (the share of out-of-pocket expenditure)
per service does not differ for individuals with major
depression compared with individuals without.
Conclusions: The higher share of out-of-pocket expenditures
for individuals with major depression is mainly due to a larger
total expenditure for prescription drugs and not because of
higher co-payments for services. We cannot reject the
hypothesis of insurance parity for each service i.e. depressed
and non-depressed individuals paying the same share out-ofpocket expenditures from total medical bill for similar services.
Implications for Policy, Delivery, or Practice: The wave of
“parity” legislation has targeted making health insurance
benefits similar between mental and physical health. However,
the main differences in economic burden for individuals with
major depression results from higher expenditures on
prescription drugs combined with higher co-payment for drug
benefits relative to other services
Primary Funding Source: NICHD; NIAMS
●The Effect of Medicaid Managed Care on Prenatal Care:
the case of Puerto Rico
Heriberto Marín, Ph.D., Roberto Ramirez, Ph.D., Paul Wise,
M.D., Marisol Peña, MS, Yelitza Sanchez, MS.c.
Presented By: Heriberto Marín, Ph.D., Associate Professor,
Health Services Administration, University of Puerto Rico, PO
Box 365067, San Juan, 00963-5067; Tel: (787)758-2525 x1423;
Fax: ; Email: hmarin@rcm.upr.edu
Research Objective: The objective of this study is to asses the
effect of Medicaid managed care (MMC) on the access,
initiation, utilization, and adequacy of prenatal care services
during the implementation period of the health care reform in
Puerto Rico from 1995 to 2000.
Study Design: The study could be considered as having an expost-facto evaluation design where the selection of individuals
into “treatment”, in our case insurance status, is decentralized
rather than centralized. In other words, there is no central
authority assigning pregnant women to a particular insurance
status. It is a design which combines retrospective,
observational, cross-sectional and time-series elements.
Population Studied: The population in this study is all the
infants born alive and their mothers in Puerto Rico from the
year 1995 to 2000.
Principal Findings: First, the statistical results indicates that
even after adjusting for confounders and selection bias MMC
had a positive and significant effect on the amount and
adequacy of prenatal care compared to those under traditional
Medicaid. But, second, after adjusting for confounders and
selection bias MMC did not improve acces or the timely
initiation of care compared to traditional Medicaid. However,
MMC was never able to achieved the levels of access,
initiation, frequency, and adequacy of pregnant women with
private insurance.
Conclusions: At least for the period of 1995 to 2000 the
health care reform in Puerto Rico through Medicaid managed
care was not able to achieve its objective of equalizing the
access, initiation, amount, and adequacy of prenatal care
received by the Medicaid population to that of the private
sector.
Implications for Policy, Delivery, or Practice: In order to
eliminate disparities in prenatal care is not enough to put the
Medicaid population under managed care organizations. It is
also important to deal with other factors that affect the
demand and supply of health services.
Primary Funding Source: AHRQ
●The Impact of Private Prescription Drug Coverage on
Access to Care for Working-Age Adults
Michael Martinez, M.P.H., M.H.S.A., Robin Cohen, MS, Ph.D.
Presented By: Michael Martinez, M.P.H., M.H.S.A.,
Statistician, Division of Health Interview Statistics, National
Center for Health Statistics, 3311 Toledo Road, Hyattsville, MD
20782; Tel: (301)458-4758; Email: MEMartinez@cdc.gov
Research Objective: There is much concern about the quality
and delivery of health services for persons covered by private
health insurance. This paper explores differences in access to
care between working-age adults with private health insurance
with prescription drug coverage and working-age adults with
private insurance without prescription drug coverage. Persons
without insurance are also included in the analysis for
comparison purposes.
Study Design: This study uses the 2004 National Health
Interview Survey (NHIS), a nationally representative sample of
the U.S. civilian noninstitutionalized population, conducted by
face-to-face household interviews. The data used for this
paper is from two NHIS questionnaires, the Family Core and
the Sample Adult Core. In 2004, a total of 25,307 sample
adults 18-64 years of age provided information about their
health insurance status and health care access. The overall
response rate for this combined file is 72.5 percent which takes
into account household, family, and sample adult nonresponse.
Population Studied: Working-age adults 18-64 years of age
Principal Findings: Working-age adults with private insurance
without prescription drug coverage were more likely to have
unmet medical needs compared to those with prescription
drug coverage. Privately insured persons with drug coverage
are more likely to have a usual source of medical care and are
more likely to have seen or talked to a doctor in the past year
than privately insured adults without prescription coverage.
The impact of prescription drug coverage on access and use
of health care is greater for working-age adults who are
financially impoverished.
Conclusions: The findings suggest differences exist in access
to healthcare services for working-age adults with private
health insurance depending on whether prescription drugs are
covered.
Implications for Policy, Delivery, or Practice: These results
suggest that prescription drug coverage may possibly be used
as a proxy for “quality” or “comprehensiveness” for a private
health insurance plan.
Primary Funding Source: No Funding
● The Relationship Between Workplace Integration and the
Likelihood of Leaving a Practice
Leah E. Masselink, BA, Thomas R. Konrad, Ph.D., Shoou-Yih
D. Lee, Ph.D.
Presented By: Leah E. Masselink, BA, Ph.D. Student,
Department of Health Policy and Administration, University of
North Carolina at Chapel Hill, 1101 McGavran-Greenberg,
CB#7411, Chapel Hill, NC 27599-7411; Tel: (919) 641-7077; Fax:
(919) 966-6961; Email: leah_masselink@unc.edu
Research Objective: International medical graduates (IMGs)
constitute about twenty-seven percent of the US physician
workforce. Studies have shown that IMGs play a crucial role
in meeting the health care needs of underserved populations
and communities. Few studies have compared patterns of
workplace integration between IMGs and US medical
graduates (USMGs). How do IMGs see themselves fitting
into the everyday world of medical practice in the US? Is
IMGs’ perception of workplace integration different from that
of USMGs? Is the relationship between workplace integration
and likelihood of leaving practice different between IMGs and
USMGs? These questions are examined in the study.
Study Design: Data used in the study come from a crosssectional, community-based Physician Worklife Survey in
1996-97. Survey questions asked physicians to indicate their
agreement with statements about socio-cultural climate in
their practice settings and job satisfaction on a 5-point scale
with response options ranging from “strongly agree” to
“strongly disagree”. The relationship between workplace
integration and the expectation of leaving current practice
within two years is analyzed using multivariable logistic
regression models for IMGs and USMGs.
Population Studied: A nationally representative sample of
2,326 generalists and sub-specialists in medicine and
pediatrics.
Principal Findings: IMGs were more likely than USMGs to
report that they felt threatened financially by competition with
other physicians and isolated from colleagues by ethnic,
cultural or gender differences. They also were significantly
less likely than USMGs to describe their work environments as
supportive. Workplace integration was not a significant
predictor for the likelihood of leaving practice among USMGs
(OR=1.06; p=0.48), but it had a significant and negative
relationship with expected departure from current practice
among IMGs (that is, higher degrees of workplace integration
were associated with lower likelihood of leaving practice for
IMGs—OR=0.57; p<0.01).
Conclusions: IMGs reported greater degrees of competition
and isolation and felt less supported in the workplace than
USMGs. These factors were significant predictors of expected
departure from current practice for IMGs, but not for USMGs.
Implications for Policy, Delivery, or Practice: IMGs play a
significant role in many underserved areas in the US. In order
to promote retention of IMG physicians, greater efforts to
support their development of positive, supportive
relationships in the workplace are needed.
Primary Funding Source: No Funding
●The National Hospital Quality Acute Myocardial
Infarction Measures: Patterns of Variation and
Improvement Over Time
Nikolas Matthes, M.D., Ph.D., M.P.H., M.Sc., Devayani Sinha,
MHS Candidate
accrediting organizations. With such strong and wide-ranging
health policy expections performance measures and their
properties must be well understood.
Primary Funding Source: Quality Indicator Project, Maryland
Hospital Association
Presented By: Nikolas Matthes, M.D., Ph.D., M.P.H., M.Sc.,
Department of Health Policy and Management, Johns
Hopkins Bloomberg School of Public Health, 624 North
Broadway, Baltimore, MD 21205; Tel: (410) 540-5052; Fax:
(410) 379-9551; Email: nmatthes@jhsph.edu
Research Objective: Examine the variation in publicly
reported patient-level hospital acute myocardial infarction
performance data over time for over 400 acute care hospitals,
identify patterns of improvement in performance, and discuss
the role of hospital characteristics.
Study Design: Data from process and outcomes measures
for treatment of acute myocardial infarction for the past three
years were studied for patterns in performance with regard to
both overall improvement and variation in performance
between hospitals over this time span. These National
Hospital Quality Measures include Aspirin on arrival, betablocker at discharge, time to thrombolysis, and risk-adjusted
AMI mortality. An exploratory analysis was conducted to
determine patterns of improvement in hospital performance
based on selected characteristics of the cohort of hospitals
studied. Statistical process control and inferential statistics
were used to determine variation in hospital performance and
improvement, stratifying the data by hospital characteristics.
Population Studied: Approximately 450 acute care hospitals
submitting data for the National Hospital Quality Acute
Myocardial Infarction Measures through the Quality Indicator
Project, a not-for-profit performance measurement system for
hospitals. The study included hospitals who have submitted
data consistently for the past three year for all AMI measures.
These hospitals have been submitting data to the QI Project
for submission to the Joint Commission on Accreditation of
Healthcare Organizations (JCAHO) and the Centers for
Medicare and Medicaid Services (CMS).
Principal Findings: Hospital characteristics such as teaching
status, hospital size, local setting, profile of services, affect
performance and improvement in different measures and
account for differences in the rate of improvement.
Conclusions: Top performing hospitals share characteristics
such a regional location and staffed bed size, that moderately
or poorly performing hospitals do not share. Additionally,
there is a higher level of variation in the performance of
consistently poor performers than in top performers. In order
for performance measurement, public reporting, and pay-forperformance to be effective these differences between hospital
need to be examined further and considered when publicly
reporting data and comparing hospitals. In addition to
providing finicial incentive for providing a high standard for
care, hospitals need the tools to hone in on opportunities for
improvement.
Implications for Policy, Delivery, or Practice: Mandated
performance measures are rapidly expanding and gaining
importance for public reporting and pay-for-performance. The
properties of the measures, the variation in performance, and
the underlying reasons for a hospital's performance must be
well understood if such measures should be used by multiple
stakeholders including hospitals, patients, payor, and
●Evaluation of Multi-state Multi-Disciplinary Agricultural
Security Conference
Lisa McCormick, M.P.H., Maziar Abdolrasulnia, M.P.H.,
M.B.A., Andrew C. Rucks, Ph.D., Peter M. Ginter, Ph.D.
Presented By: Lisa McCormick, M.P.H., Program Director,
South Central Center for Public Health Preparedness,
University of Alabama at Birmingham, 1665 University
Boulevard, Room 330N, Birmingham, AL 35294-0022; Tel:
(205) 975-8971; Fax: (205) 934-3347; Email:
lmccormick@ms.soph.uab.edu
Research Objective: Since the terrorist attacks of September
11, 2001 there has been considerable focus on improving
disaster detection, response, and coordination among public
and private organization. The Department of Homeland
Security, the Federal Bureau of Investigation, the Centers for
Disease Control and Prevention, as well as state and local
agencies have identified vulnerable areas, which require
preparedness training. One specific area of concern is the US
food supply (e.g. disasters, livestock, crop, or soil
bioagricultural). The objective of our study was to examine the
effectiveness of a multi-disciplinary conference addressing
planning and response to zoonotic disease terrorism and
outbreaks.
Study Design: Data from conference participants was
gathered on knowledge gain and understanding of
agroterrorism issues, satisfaction with content and venue, and
role in the public health system. Differences in knowledge
gain was compared using chi-square test between public
health and non-public health participants, as well as an effect
size to determine the impact of the conference between the
two groups. Finally, we tested the difference between the
public health and non-public health groups with regard to the
application of content to practice.
Population Studied: A total of 130 participants attending the
2005 Agricultural Security Conference responded to the
survey. Forty-five percent of survey respondents stated that
their occupation was public health and 55% self-reported their
occupation to be in non-public health fields. The majority of
non-public health respondents were veterinarians (31%) and
emergency responders (21%).
Principal Findings: Overall 80.1% of respondents reported
greater understanding and knowledge of zoonotic disease and
outbreaks. When public health and non-public health
respondents were compared based on their understanding
and knowledge of zoonotic disease and outbreaks, public
health respondents scored higher than their non-public health
counterparts (68% vs. 45%, p=0.012). This results
corresponds to a 52% difference in knowledge and
understanding between public health and non-public health
respondents. When asked if the content and skills learned in
this conference would be useful to their current job, 86.2% of
public health and 75.0% of non-public health participants
stated always or frequently (p = .112).
Conclusions: Overall, this multi-disciplinary agriculture
security conference was effective in increasing awareness,
knowledge and understanding of zoonotic disease and
outbreaks. Public health participants had a greater increase in
knowledge and awareness than non-public health participants,
however both groups were equally as likely to apply what was
learned into practice.
Implications for Policy, Delivery, or Practice: Our findings
demonstrate that there is great need for education related to
agroterrorism and agriculture security in both public health
and non-public health populations. These findings also
suggest that future educational initiatives need to address the
application of this knowledge in a multi-disciplinary setting.
Primary Funding Source: CDC
●Procedures in U.S. Hospitals, 2003
Chaya Merrill, M.P.H., Anne Elixhauser, Ph.D.
Presented By: Chaya Merrill, M.P.H., Health Services
Researcher, Thomson Medstat, 4301 Connecticut Avenue,
N.W., Suite 330, Washington, DC 20008; Tel: (202) 719-7826;
Email: chaya.merrill@thomson.com
Research Objective: Procedures in U.S. Hospitals, 2003
summarizes information about hospital procedures from the
Nationwide Inpatient Sample (NIS), an all-payer hospital
database maintained by AHRQ. This report updates an earlier
Fact Book that described hospital procedures in 1997. This
Fact Book describes: How many procedures did patients
receive? What were the most common procedures? How did
procedures vary by body system, age, and gender? What
share of the Nation’s hospitals were high-volume providers?
What procedures were associated with the highest charges
and longest lengths of stay? Who was billed for hospital care?
Which procedures were performed most often during hospital
stays that resulted in death?
Study Design: This study is a descriptive analysis of
secondary administrative hospital data. It is based on hospital
discharge data within the Healthcare Cost and Utilization
Project (HCUP) NIS database. The NIS data are weighted to
obtain estimates representing the total number of inpatient
hospital discharges in the U.S.; in 2003, this figure totaled
38,220,659. The 2003 NIS is based on a sampling frame of 37
states.
Population Studied: The population studied includes
individuals who had an inpatient hospitalization(s) in a U.S.
community hospital during 2003.
Principal Findings: There were significant increases in blood
transfusions, Cesarean sections (C-sections), and operating
room (OR) procedures for obesity. On the other hand, in
2003, there were large decreases in episiotomies, coronary
artery bypass grafts (CABG), and extracorpeal cardiac
procedures. These differences will be highlighted and
elaborated upon in this poster.
Conclusions: While the use of hospital procedures from 1997
to 2003 remained largely unchanged, there were significant
changes in specific procedures.
Implications for Policy, Delivery, or Practice: The United
States (U.S.) spends approximately one-third of its health care
dollars on hospital care, making hospitalizations the single
most expensive component of the health care system. In
2003, U.S hospitals reported over 38 million hospital
discharges. Most of these stays – over 60 percent – involved
some type of procedure and many individuals underwent
more than 1 procedure during their stay. Procedures are
defined as any type of diagnostic or therapeutic interventions
(invasive or noninvasive) that appear on the discharge records
of hospitalized patients. Understanding the characteristics of
hospital procedures is an integral component of improving
the cost and quality of hospital care.
Primary Funding Source: AHRQ
●Race Differences in Psychiatric Service Utilization Among
Veterans with Long-term Survival after AIDS
William Mkanta, MS, Ph.D.
Presented By: William Mkanta, MS, Ph.D., Research
Coordinator, Health Services Research, Management and
Policy, University of Florida, 4700 SW Archer Road C22,
Gainesville, FL 32608; Tel: (352) 273-5933; Email:
wmkanta@phhp.ufl.edu
Research Objective: We examined how race impacts
psychiatric service utilization and how this impact varies with
long-term survival after AIDS diagnosis
Study Design: A cross-sectional study that analyzed the
Immunology Case Registry (ICR) for the year 2003.
Population Studied: Male veterans with HIV who receive care
within the Veterans Affairs (VA) health care system. The
sample consisted of 2,163 African American and 2,096 white
patients.
Principal Findings: There was no racial difference in the
prevalence of psychiatric comorbidity, but blacks had higher
rates of outpatient visits among all patients (16.7 vs. 10.2,
p<.05) and among patients with long-term survival (17.6 vs.
10.2, p<.05). At the multivariate level, black patients with longterm survival after AIDS had higher rates of psychiatric service
utilization. In addition, presence of AIDS-defining illnesses
and injection drug use were associated with greater use of the
psychiatric services among patients of both races.
Conclusions: Our findings suggest that long-term survival
after AIDS diagnosis is important in predicting patterns of
psychiatric service utilization.
Implications for Policy, Delivery, or Practice: HIV/AIDS
patients with long-term survival present an emerging
population with specific needs related to their survivorship.
Psychiatric problems may influence preventive health
behavior, management of illness, and costs of care. Therefore,
knowledge of the patterns of psychiatric service utilization,
which might be unique for patients with long-term survival,
becomes an important tool for identifying areas for service
improvement among service providers.
Primary Funding Source: Partly supported by the Sherri
Aversa Memorial Foundation
●Nursing Home Staffing and Acuity: Do They Match Up?
Vincent Mor, Ph.D., Zhanlian Feng, Ph.D.
Presented By: Vincent Mor, Ph.D., Professor, Community
Health, Brown University, Box G-H1, Providence, RI 02912;
Tel: (401) 863-3492; Fax: (401) 863-3713; Email:
Vincent_Mor@brown.edu
Research Objective: Inadequate staffing in U.S. nursing
homes has been a growing concern in recent years among
consumers of long-term care, quality initiative organizations
and advocates, and state and federal policy makers.
Accompanying this concern has been increasing acuity of
nursing home residents, coupled with a chronic shortage of
direct care workers in the nursing home industry. The
objective of this study is to examine the association between
nursing home staffing and acuity levels, and to describe the
overall fit between them.
Study Design: Facility staffing was measured by total direct
care staff (RN+LPN+CNA) hours per patient day (HPPD),
obtained from the Online Survey Certification and Reporting
data. Acuity was measured by facility averaged Nursing CaseMix Index from the Minimum Data Set annual resident
assessments. Both overall and partial Spearman rank-order
correlation analyses were performed to measure the strength
of association between staffing and acuity. The latter adjusts
for state averaged acuity and staffing levels in order to “partial
out” the potential confounding due to inter-state
heterogeneity in staffing and/or acuity. In addition, we
identified facilities that were relatively understaffed, where
staffing is substantially lower, and acuity significantly higher,
than the national or state averages. Specifically, facilities
whose acuity level was above the median while staffing was
ranked lower by at least 2 quartiles were considered
understaffed (e.g., staffing level in the bottom quartile but
acuity in the 3rd or top quartiles; or staffing in the 2nd quartile
but acuity in the top quartile).
Population Studied: All freestanding (i.e., non-hospital
based) nursing homes in the 48 contiguous U.S. states in
2002 (N=14,115).
Principal Findings: Nationally, the overall correlation between
staffing and acuity across all facilities is 0.3. Within-state
correlation was even lower—below 0.1 in 10 states (close to
nil in South Carolina and Pennsylvania), above 0.1 but under
0.2 in 17 states, between 0.2 and 0.3 in 12 states, within the
range of 0.3-0.4 in 8 states, and reaching 0.5 in only 1 state
(Nevada). After adjusting for state-averaged staffing and acuity
levels, the partial correlation across all facilities was reduced
by nearly half, from 0.30 to 0.17. Nationally, 13% of all facilities
were substantially understaffed relative to their acuity profile.
There is considerable variation in the proportion of
understaffed facilities across the states, ranging from just
under 3% in New Hampshire and Florida, to 36% in Kentucky
and West Virginia.
Conclusions: The correlation between nursing home staffing
and acuity levels is weak. Much of this weak correlation
appeared to be attributable to inter-state differences in average
staffing and acuity levels. On a facility-specific basis, there was
generally a poor alignment between staffing and acuity levels.
Implications for Policy, Delivery, or Practice: Arguably, the
lack of fit between staffing and acuity implies inefficiency in
the delivery of care. The glaring gap between low staffing and
high resident care needs in a substantial minority of facilities
is especially of concern. Initiatives aimed at improving staffing
in nursing homes should focus on the need to consider casemix acuity in setting appropriate staffing standards.
Primary Funding Source: NIA
●Are Breakthrough Drugs Driving Pharmaceuticals
Expenditures?
Steve Morgan, Ph.D., Kenneth L Bassett, M.D., Ph.D., James
M Wright, M.D., Ph.D., Robert G Evans, Ph.D., Morris L Barer,
Ph.D., Patricia A Caetano, Ph.D.
Presented By: Steve Morgan, Ph.D., Assistant Professor,
Centre for Health Services and Policy Research, University of
British Columbia, 429 - 2194 Health Sciences Mall, Vancouver,
BC, V6T 1Z3; Tel: 604-822-7012; Fax: 604-822-5690; Email:
morgan@chspr.ubc.ca
Research Objective: Given the scale and escalation of
prescription costs, drug spending deserves careful scrutiny.
The objective of this study was to determine the proportion of
drug expenditure inflation that was due to the use of new
“breakthrough” medicines.
Study Design: The Canadian Patented Medicine Prices
Review Board (PMPRB) classifications of the therapeutic
novelty of patented drug products were applied drug
expenditure data for British Columbia. We expanded definition
of "breakthroughs" to include PMPRB-classified breakthrough
drugs, all subsequent formulations and dosages of a PMPRBclassified breakthrough, and all competing drugs to enter a
chemical subgroup established by a PMPRB-classified
breakthrough. All other patented drugs marketed after 1990
were classified as "me-too" drugs. Drugs first marketed prior
to 1990 were classified as "vintage brand" or "vintage generic"
depending on manufacturer.
Population Studied: All 4.1 million residents of British
Columbia.
Principal Findings: From 1996 to 2003, per capita
expenditure on prescription drugs in British Columbia
increased 123% while per capita days of therapy supplied
increased 56%. Cost per day supplied rose 43%.
Breakthrough drugs accounted for 6% of expenditures and 1%
of utilisation in 1996, and 10% of expenditures and 2% of
utilisation in 2003. Me-too drugs accounted for 44% of
utilisation and 63% of expenditures by 2003.
Conclusions: In British Columbia, most (80%) of the increase
in drug expenditure between 1996 and 2003 was explained by
the use of new, patented drug products that did not offer
substantial improvements less expensive alternatives available
prior to 1990. The rising cost of using these me-too drugs at
prices far exceeding those of time-tested competitors deserves
careful scrutiny.
Implications for Policy, Delivery, or Practice: Using
approaches to drug pricing that encourage competition
between new and old options, such as those employed in New
Zealand, there may be opportunities for savings that could be
diverted toward other health care needs.
Primary Funding Source: Canadian Institutes of Health
Research
●Prescription Drug Expenditures and Population
Demographics
Steve Morgan, Ph.D.
Presented By: Steve Morgan, Ph.D., Assistant Professor,
Centre for Health Services and Policy Research, University of
British Columbia, 429 - 2194 Health Sciences Mall, Vancouver,
BC, V6T 1Z3; Tel: 604-822-7012; Fax: 604-822-5690; Email:
morgan@chspr.ubc.ca
Research Objective: Growth in prescription drug costs since
1996 has set a new record. Not since World War II has drug
spending escalated so rapidly for such a prolonged period.
Given the scale and pace of expenditure growth, patterns of
prescription drug utilization and spending deserve careful
scrutiny. This analysis provides detailed demographic profiles
of prescription drug utilization and expenditures in order to
isolate the impact of demographic change from other factors
that affect drug expenditure trends.
Study Design: Demographic information and drug utilization
data were extracted for virtually the entire British Columbia
population of 1996 and 2002. Drug use and expenditure
information was extracted from the BC PharmaNet, a
computer network connecting all pharmacies in the province.
A series of research variables were constructed to illustrate
profiles of drug expenditures and drug utilization across 96
age/sex strata. Indexes of change in 5 determinants of
expenditure were calculated using non-stochastic methods.
Population Studied: All 4.1 million residents of British
Columbia.
Principal Findings: Per capita drug expenditures increased at
an average annual rate of 10.8 percent between 1996 and
2002. Population aging explained 1.0 points of this annual
rate of expenditure growth; the balance was attributable to
rising age/sex-specific drug expenditures. Almost half of the
increase in expenditure was due to increased rates of polytherapy.
Conclusions: Relatively little of the observed increase in drug
expenditures in BC could be attributed to demographic
change. Most of the expenditure increase stemmed from the
age/sex-specific quantity and type of drugs purchased. The
sustainability of drug spending therefore depends not on
outside forces but on decisions made by policy makers,
prescribers, and patients.
Implications for Policy, Delivery, or Practice: Policy makers
and drug plan managers should pay close attention to trends
in product selection decisions and to the rising rate of polytherapy among residents of all ages.
Primary Funding Source: Canadian Institutes of Health
Research
●Switching, Augmentation and Titration of Lipid Lowering
Agents of Medicare/Medicaid Dual Eligible Patients by
Ethnicity
Lisa Mucha, Ph.D., Tami Mark, Kirsten Axelsen, MS
Presented By: Lisa Mucha, Ph.D., Lead Researcher, Thomson
Medstat, 125 Cambridge Park Drive, Cambridge, MA 02140;
Tel: (617) 492-9331; Fax: (617) 492-9365; Email:
lisa.mucha@thomson.com
Research Objective: The goal of this study was to examine
prescribing patterns of statins among Medicaid/Medicare
dual eligible patients by ethnicity.
Study Design: Data came from the Thomson Medstat
Marketscan Medicare and Medicaid claims databases.
Medicaid data were from five large states representing
approximately 23% of Medicaid beneficiaries nationwide.
None of the states had any access restrictions on statins.
Logistic regression models estimated the probability that
beneficiaries, by ethnicity, switched to a different statin
medication, augmented with another statin, or titrated up the
dosage of the statin over the course of the year. Switching
was defined as a change in statin prescribed during the year,
augmentation was at least 30 days of overlapping therapy, and
titration upwards was two consecutive prescriptions with an
increase in dosage.
Population Studied: Beneficiaries who were prescribed
statins during 2003 and enrolled for the full year in Medicaid
and Medicare were included in the study sample.
Principal Findings: Descriptively, there were 102,693
Caucasians, 22,570 African Americans, 32,675 Hispanic, and
81,592 other ethnicity statin users who were dually eligible for
Medicare and Medicaid. Fewer African Americans (9%)
switched statins than Asians, Hispanics, Caucasians or other
ethnicities (14%, 13%, 12%, 13%, respectively) did. Also, fewer
African Americans (3%) augmented with another statin than
Asians, Hispanics, Caucasians or other ethnicities (6%, 5%,
6% 5%, respectively) did. The logistic regressions showed that
African Americans were statistically significantly less likely to
switch statins (odds ratio 0.68; 95% CI 0.60-0.78), augment
statins (odds ratio 0.53; 95% CI 0.43-0.66), or titrate up (odds
ratio 0.75; 95% CI 0.67-0.84) than Caucasians. The models
controlled for age, gender, state of residence, total days on
therapy, number of outpatient visits, and health status as
proxied by use of the Chronic Disease Score.
Conclusions: Results of this study showed statin prescribing
for African Americans tended to be less aggressive as
evidenced by fewer switches, less augmentation and less
upward titration than other ethnicities. All patients were
Medicare/Medicaid dual eligibles so there was no influence of
drug coverage on these results.
Implications for Policy, Delivery, or Practice: These results
are consistent with the literature showing treatment of
hyperlipidemia is less aggressive for African Americans than
Caucasians. The statin treatment for African Americans
relative to Caucasians in this study may reflect less treatment
differentials such as a clinician being less likely to increase
doses of statins to help these patients reach goal. However, it
may also reflect the effectiveness of statins in lowering lipid
levels and keeping patients at a consistently low level. These
treatment disparities merit further observation as dual
eligibles move into Medicare part D plans with differing
coverage levels and formulary restrictions.
Primary Funding Source: Pfizer, Inc.
●A Critical Case Study of Program Fidelity in TennCare
Carole Myers, Ph.D., M.S.N., BS
Presented By: Carole Myers, Ph.D., M.S.N., BS, Assistant
Professor, College of Nursing, University of Tennessee, 1200
Volunteer Boulevard, Knoxville, TN 37996; Tel: (865) 414-7218;
Fax: (865) 974-3569; Email: cmyers9@utk.edu
Research Objective: The purpose of this study was to
evaluate the fidelity of the design of Tennessee’s Medicaid
managed care program in comparison to the actual program
operation.
Study Design: The retrospective recollections of 26
informants, including two former Governors of Tennessee, a
former HCFA Administrator, state government and managed
care executives, advocates and provider representatives,
captured in recorded interviews, were triangulated with timestable documents in this single case study design to reveal an
intricate web of people and circumstances that have shaped
the program.
Population Studied: The TennCare program was the focus of
the study.
Principal Findings: Thematic analysis illuminated both
promises and failures of TennCare. Three themes were
prominent: authority, management and fragmentation.
Governor McWherter, TennCare’s creator, established strong
executive authority to model and implement TennCare; a void
was created when he left office. Subsequent administrations
have not transitioned to a more balanced and inclusive
authoritative structure, nor have they developed an adequate
oversight model. Continued mismanagement of the
administration of benefits and failure to meet established care
standards set the stage for the imposition of federal judiciary
authority.
Management of TennCare operations has been reactionary
and politicized and, in many instances, inappropriately
abdicated or conferred upon the wrong or unprepared people
or entities. Turmoil in state government hindered
stabilization of the program. Evolution of the marketplace has
not been broadly realized; the state has retreated from basic
managed care principles.
The state failed to integrate the management of TennCare
carve-outs. This fragmentation resulted in diffuse
management accountability, duplication of services, gaps in
patient care and patient hassle.
The web of connectivity between themes changed over time,
with themes presenting as causes, catalysts or consequences
of the others at different times. A cardinal example of this is
how the mismanagement of TennCare program led to the
breakdown in key alliances and the imposition of consent
decrees resulting in reactive and disjointed management
which significantly contributed to the gap between what was
envisioned for TennCare and what actually resulted.
Conclusions: Although TennCare has been successful in
increasing access to health care coverage, this success has
been overshadowed by pervasive problems, a failure to
implement basic building blocks of managed care, such as
risk-sharing and competition, and effectively manage
employed vendors.
Implications for Policy, Delivery, or Practice: In the span of
only 15 years, the introduction of managed care and other
market-based strategies from the private sector precipitated a
transformation of the delivery of Medicaid services in the
United States. These monumental changes remain poorly
understood. The implementation of managed care in
Tennessee’s Medicaid program is an excellent public policy
exemplar because of the far-reaching scope of the program
and the ongoing development of the program. The themes
illuminated by this study will be informative to planners of
similar state initiatives.
Primary Funding Source: Sigma Theta Tau
●Implementation of a Medication Reconciliation Process
in an Ambulatory Internal Medicine Clinic
Claudia Nassaralla, M.D., Ph.D., James M. Naessens, M.P.H.,
Raveej Chaudhry, M.D., M.P.H., Melanie A. Hansen, RN,
Sidna M. Scheitel, M.D., M.P.H.
Presented By: Claudia Nassaralla, M.D., Ph.D., Second Year
Resident, Internal Medicine, Mayo Clinic, 200 First Street,
S.W., Apartment 3, Rochester, MN 55905; Tel: (507) 529-0956;
Email: nassaralla.claudia@mayo.edu
Research Objective: The objectives of this study were to
evaluate the causes of medication list inaccuracy, and
implement interventions to enhance the overall accuracy of
medication lists.
Study Design: The setting of this prospective study was a
primary care internal medicine clinic outpatient practice which
consisted of 8 staff physicians and 23 residents. The study
took place over 4 months with two multi-interventions. Prior
to the first intervention baseline data was collected and
analyzed assessing the completeness of medication
documentation in the electronic medical record.
Completeness defined as including medication name, dose,
frequency and route. The first intervention consisted of: 1)
standardization of the rooming process with initiation of a
preliminary note by the licensed practical nurses (LPNs); 2)
review of the medication list by the patient; 3) E-mail
commmunication to staff defining what constitutes a
complete medication list and providing feedback of baseline
measures. A second data collection was undertaken two
months after the intervention to re-assess the medication list
completeness and correctness. The second intervention was
two-fold.:1) all members of the health care team were trained
regarding the definition of medication reconciliation and
composition of a complete and correct medication list; 2) the
entire visit process from the scheduling of the appointment to
the physician´s signing of the final clinical note was reviewed,
and each health care team member was instructed in their
role to enhance medication reconciliation since the accuracy
of the medication lists is directly related to the completeness
and correctness of the documented medication list.
Population Studied: A subset of the adult population of the
City of Rochester who are patients of the Primary Internal
Medicine Clinic outpatient practice at Mayo Clinic.
Principal Findings: Completeness of specific medication
items improved from 13.5% (baseline) to 62.3% (post second
intervention), p<0.001. However, the completeness of the
entire medication lists only improved from 4% to 17%,
p<0.001. The major causes of incomplete documentation of
medication lists prior to implementing interventions were the
lack of route (84.6%) and frequency (22.3%) of medication
items within a medication list. In addition, documentation of
over-the-counter and “as needed” medications was often
incomplete. The major causes of incorrectness in a
medication list were due to misreporting of medications by
patients or failure of clinicians to update the medication list
when changes were made. We found it easier to improve
completeness than correctness of a medication list.
Conclusions: To improve the accuracy of medication lists it is
necessary for the patient and for all members of the health
care team to participate.
Implications for Policy, Delivery, or Practice: Improving the
access to the electronic medical record by the patient and
health care providers would allow for real time updating of the
medication lists. This improved access would increase the
medication list accuracy and efficiency of the office visit.
Primary Funding Source: No Funding
●Failure of Customized Error Feedback to Improve
Diabetes Care
Patrick O'Connor, M.D., M.P.H., JoAnn M. Sperl-Hillen, M.D.,
Paul E. Johnson, Ph.D., William A. Rush, Ph.D., Todd P.
Gilmer, Ph.D., A. Lauren Crain, Ph.D.
Presented By: Patrick O'Connor, M.D., M.P.H., Senior Clinical
Investigator, HealthPartners Research Foundation, 8100 34th
Avenue South, MS 21111R, Minneapolis, MN 55440; Tel: (952)
967-5034; Fax: (952) 967-5022;
Email: Patrick.J.OConnor@healthpartners.com
Research Objective: Diabetes medical errors are frequent and
lead to many preventable adverse events. Effective
interventions to reduce such errors are needed. We
conducted a group randomized trial to assess whether
providing medical error information to patients and physicians
reduces diabetes medical errors.
Study Design: Study Subjects were randomly assigned to
customized feedback of medical error information to patient
only, to physician only, to both the patient and physician, or
control group with no feedback. Analysis included hierarchical
models with covariate adjustment.
Population Studied: 123 primary care physicians and 3,703
eligible diabetes patients.
Principal Findings: Among patients with errors at baseline,
59.3% of errors were resolved by the end of the study followup period. However, study interventions had a negative effect
on A1c testing within 6 months of intervention (p=0.01) that
resolved by 12 months (p=0.35). When baseline A1c>= 7%
interventions had no effect on A1c values (p=0.10), but when
baseline A1c>= 8%, interventions unfavorably affected A1c
values (p<.01). Interventions negatively affected LDL test
ordering (p<.001), but had no effect on LDL values (p=.64),
which improved overall. Interventions failed to reduce errors
of commission (inappropriate use of medications)(p>0.05), or
errors of omission (failure to intensify therapy when
indicated)(p>0.05). Numerous interaction effects were
observed. Economic evaluation identified some effect of error
status on subsequent health care utilization.
Conclusions: Customized feedback interventions to patients
and physicians failed to reduce errors of omission or
commission related to diabetes care.
Implications for Policy, Delivery, or Practice: Care
improvement initiatives that intend to provide feedback of
health information directly to patients or providers must
carefully consider the content, format, timeliness, and delivery
method to avoid unintended negative consequences.
Primary Funding Source: AHRQ
●When Less is More: A Randomized Trial of a Physician
Intervention to Reduce Errors in Diabetes Care
Patrick O'Connor, M.D., M.P.H., JoAnn M. Sperl-Hillen, M.D.,
Paul E. Johnson, Ph.D., William A. Rush, Ph.D., P. Dutta,
Ph.D., George R. Biltz, M.D.
Presented By: Patrick O'Connor, M.D., M.P.H., Senior Clinical
Investigator, HealthPartners Research Foundation, 8100 34th
Avenue South, MS 21111R, Minneapolis, MN 55440; Tel: (952)
967-5034; Fax: (952) 967-5022;
Email: Patrick.J.OConnor@healthpartners.com
Research Objective: Frequent errors of omission and errors
of commission are a barrier to high quality diabetes care. This
randomized trial assesses two intervention strategies
designed to reduce errors of omission and errors of
commission in office-based diabetes care.
Study Design: Physicians were randomized to one of 3 study
conditions: a control group (Group A); a case-based physician
learning intervention with customized feedback (group B) ; or
the same case-based physician learning intervention with
customized feedback, plus physician opinion leader feedback
(Group C). Glycated hemoglobin (A1c) values, LDLcholesterol values, A1c and LDL drug treatment intensification
in patients not at clinical goals, and risky prescribing events.
Hierarchical analysis accommodated the nesting of patients
within physicians.
Population Studied: Study Subjects were 57 eligible primary
care physicians from one multispecialty group and their 2,020
eligible adult patients with diabetes mellitus.
Principal Findings: Compared to control, Group B achieved
significantly better A1c values (p=0.04). Group C had
significantly fewer errors of omission related to glycemic
control (p=0.04). Group B and Group C both had
significantly fewer commission errors related to metformin
use in the setting of renal impairment (p=0.026). There were
no significant differences across groups in management of
lipids or in other measures of diabetes care.
Conclusions: This inexpensive, simulated, customized casebased learning intervention and the combination of this
intervention with opinion leader feedback improved several
measures of diabetes care and significantly reduced some
diabetes-related medical errors.
Implications for Policy, Delivery, or Practice: This
customized interactive learning technology may be a
promising way to modify physician behavior and improve
pharmacotherapy for chronic diseases.
Primary Funding Source: AHRQ
●Public Reporting of Nursing Home Staffing Levels Usefulness for Facility Selection
Janis O'Meara, M.P.A., Charlene Harrington, Ph.D.
Presented By: Janis O'Meara, M.P.A., Project Director, Social
and Behavioral Sciences, University of California San
Francisco, 3333 California Street, Suite 455, San Francisco, CA
94122; Tel: (415)502-7098; Fax: (415)476-6552; Email:
janis.omeara@ucsf.edu
Research Objective: The focus of the study is on
demonstrating that staffing levels are a good measure to use
when comparing and selecting a nursing home.
California Nursing Home Search (www.calnhs.org) is an
Internet-based public reporting tool that provides measures of
the quality of care of California’s long-term care providers,
including: nursing homes, home health agencies, hospices
and residential care facilities. The primary goal of the website
is to educate consumers in California about nursing home
quality, give them access to information about providers,
allow them to search for providers in their area, and help them
translate performance data so they are able to make an
informed choice when selecting a provider. This study
presents California nursing home quality indicators used on
the website.
Study Design: Data from the California Department of Health
Services, Office of State Health Planning and Development
and the Licensing and Certification Program were used to
analyze staffing levels, financial information, deficiencies and
complaints for nursing homes in California.
Population Studied: Nursing homes in California.
Principal Findings: Analyses found that 24 percent of
California nursing facilities do not meet the minimum nurse
staffing levels required by the state (3.2 hours per resident
day) and 95 percent do not meet staffing levels recommended
by experts. California nursing homes that meet the
recommended staffing level have lower turnover rates, fewer
deficiencies and fewer complaints than those that do not meet
the recommended level. For-profit nursing homes and
freestanding facilities have lower staffing and more
deficiencies than non-profit and hospital-based facilities. Staff
turnover rates are also a good measure of quality of care. Staff
turnover rates are higher in for-profit and freestanding nursing
homes. Facilities with higher staff turnover rates had more
deficiencies. Higher wages are found in facilities with lower
staff turnover rates.
Conclusions: Staffing levels and turnover play an important
role in quality of care and therefore can be used as measures
of quality when selecting a facility. We will show graphical
analyses and screen shots of the Web site.
Implications for Policy, Delivery, or Practice: Public
reporting of nurse staffing information, along with other
quality indicators, can help consumers translate performance
data so they are able to make an informed choice when
selecting a nursing home.
Primary Funding Source: California HealthCare Foundation
●An Evaluation of the Impact of Antidepressant
Adherence on Healthcare Charges within the Managed
Care Setting
Caron Ory, RN, M.S.N., Ann Vanderplas, MS, Eunice Chang,
Ph.D.
Presented By: Caron Ory, RN, M.S.N., Outcomes Researcher,
Health Informatics and Outcomes Research, Prescription
Solutions, 2300 Main Street, MS CS57-404, Irvine, CA 92614;
Tel: (949) 252-4345; Fax: (949) 474-4237; Email:
caron.ory@rxsol.com
Research Objective: To evaluate the difference (posttreatment minus pre-treatment) in total healthcare charges
incurred by patients newly treated for depression and
antidepressant adherent to those of patients who were not
antidepressant adherent among two cohorts: 1) patients
treated for depression (DEP) and 2) patients treated for
depression and diabetes (DEP/DM).
Study Design: This study was a retrospective cohort analysis
of members newly treated for DEP or newly treated for DEP
and treated (new or continuing) for DM during the
identification (ID) period of 01/01/03 through 12/31/03. The
index date was defined as the date of the first fill for an
antidepressant during the ID period. Members treated for
diabetes had to possess a pharmacy claim for an antidiabetic
medication during the ID period. The pre-index period
consisted of the 360-day period prior to the index date. The
post-index period consisted of the 360-day period after the
index date. Patients were required to be continuously enrolled
during the pre-index period through the post-index period.
Patients with no pharmacy claims for antidepressants during
the pre-index period were considered newly treated. Members
in both cohorts (DEP and DEP/DM) were further stratified
according to level of antidepressant adherence.
Antidepressant adherence was determined by taking the sum
of the days covered for all antidepressant fills divided by the
total number of days in the post index period (360 days).
Treatment adherence was defined as having a treatment
adherence rate of 0.78 or greater. The primary outcome of
interest was total healthcare charges. Analysis of Covariance
(ANCOVA) was used to adjust for age, gender, and the
following pre-index variables: chronic disease score, presence
of diabetes-related complications or coronary artery disease,
regular insulin use, and total health care charges.
Population Studied: Enrollees (age 18 or older) of a large
managed care organization covering approximately 2.2 million
lives within five states (California, Oklahoma, Oregon, Texas,
and Washington).
Principal Findings: A total of 36,293 met study criteria and
were newly treated for DEP. Of these, 69.3% were female, the
mean age was 57.8 ± 19.3 and 20.1 % were deemed
antidepressant adherent. Among patients who were deemed
adherent, adjusted mean total healthcare charges decreased
by $646 while non-adherent patients had an increase of $1,569
(p = 0.012). A total of 4,534 met study criteria for the
DEP/DM cohort. Of these, 60.7% were female, the mean age
was 67.1 ± 13.9 and 21.3 % were deemed antidepressant
adherent. Among the patients treated for DEP/DM and
deemed adherent, adjusted mean total healthcare charges
decreased by $3,074 while non-adherent patients had an
increase of $1,208 however, this difference was not statistically
significant (p = 0.1638).
Conclusions: In both populations studied, patients who were
antidepressant adherent incurred lower total healthcare
charges compared to those who were not antidepressant
adherent.
Implications for Policy, Delivery, or Practice: Among
patients who are newly treated with an antidepressant, use of
a cost-effective intervention aimed at increasing
antidepressant adherence would provide an opportunity to
improve patient care and potentially provide a positive
economic impact.
Primary Funding Source: No Funding
●Promising Practices in the Application of QI in
Preparedness Efforts
Kavita Patel, M.D., MSHS, Debra Lotstein, M.D., M.P.H.,
Nicole Lurie, M.D., MSHS, Michael Seid, Ph.D., Christopher
Nelson, Ph.D.
Presented By: Kavita Patel, M.D., MSHS, Associate Scientist,
Health, The RAND Corporation, 1776 Main Avenue, Box 2138,
Santa Monica, CA 90407; Tel: (310) 393-0411; Fax: (310) 2608160; Email: kpatel@rand.org
Research Objective: The terrorist attacks of September 11,
2001 and the subsequent anthrax attacks rekindled interest in
strengthening the public health (PH) infrastructure. The 2004
SARS outbreak, and the aftermath of Hurricane Katrina further
highlighted the need for a strong PH system. Assessments of
public health emergency preparedness (PHEP) have found
significant variation in local PH agency’s levels of
performance. Other sectors, including airline safety,
manufacturing and health care services, have used quality
improvement (QI) strategies as a way to systematically close
gaps in performance. This study set out to identify promising
practices in the application of QI in preparedness efforts to
understand how QI strategies can be applied to improve
PHEP.
Study Design: Through recommendations of experts in the
field, we identified a sample of 22 state and local public health
departments that were reportedly engaged in quality
improvement programs for public health emergency
preparedness. Screening phone calls were used to select a
sub-sample of nine (9) sites that were selected for site visits
between March – August 2005. We explored the performance
goals identified by the public health department and how
performance is measured and improved at the site via semistructured interviews. We also explored organizational and
contextual factors that contribute to QI implementation at the
state and local level. Detailed notes from each visit serving as
a primary data source. A team of three (3) public health
researchers then reviewed the notes to identify examples and
implementation issues related to the elements of quality
improvement.
Population Studied: Public health officials in local and state
health departments.
Principal Findings: All 9 sites had some element of quality
improvement in place for public health emergency
preparedness. State and local PH agencies with high levels of
preparedness planning customized national preparedness
performance goals and specified measurable and timesensitive targets. Agencies were able to use measurement to
improve performance by creating measures targeted on the
desired outcomes for preparedness, and by measuring
emergency preparedness based on frequently recurring
events. Sites described the value of frequent testing of
preparedness roles via drills, exercises and proxy events.
Traditional QI strategies such as cyclic improvement cycles
and learning collaboratives were also described. Key
facilitators to quality improvement identified include
leadership and the culture of the public health department.
Also important is the presence of an information technology
infrastructure and appropriate training in QI methodology.
Conclusions: QI strategies can play a role in improving the
effectiveness and efficiency of public health emergency
preparedness. Several current initiatives and promising
practices are identified. PHEP can be improved by providing
PH agencies practice in applying QI strategies, and by
integrating QI for PHEP into the daily jobs of public health
employees so that it is not perceived as an add-on
responsibility.
Implications for Policy, Delivery, or Practice: Policy changes
at the state and federal level could promote incentives to
engaging in QI efforts.
Primary Funding Source: HRSA
●Use of Emergency Department Diagnosis to Determine
Medical Necessity of Emergency Medical Services
Transports
Paul D Patterson, Ph.D., M.P.H., EMT-B, Charity G Moore,
Ph.D., MSPH, Jane Brice, M.D., M.P.H., Elizabeth Baxley,
M.D.
Presented By: Paul D Patterson, Ph.D., M.P.H., EMT-B,
AHRQ-NRSA Post Doctoral Research Fellow, Cecil G Sheps
Center for Health Services Research, University of North
Carolina at Chapel Hill, 725 MLK JR Boulevard, CB 7590,
Chapel Hill, NC 27599; Tel: (919)-966-0047; Fax: (919)-9665764; Email: dpatterson@schsr.unc.edu
Research Objective: Experts agree that Emergency
Department (ED) diagnosis should be included as an criterion
for investigating the medical necessity of Emergency Medical
Services (EMS) transports. Experts, however, have not
reached agreement on which individual diagnoses are
indicators of medically necessary or unnecessary EMS
transports. The potential for multiple interpretations warrants
that a closer look at ED diagnosis.
Study Design: This cross-sectional study involved three
attending Emergency Medicine (EM) physicians and two
attending Family Medicine (FM) physicians classifying 913
ICD-9 codes as medically necessary, unnecessary, or
uncertain. Overall agreement and agreement within 17 major
disease categories were measured using kappa statistics in
SAS (v9.1, Cary, North Carolina).
Population Studied: Five medical physicians from two
specialities that dominate the EMS medical director
profession.
Principal Findings: Physicians rated between 25 and 65% of
diagnoses codes as “Medically Unnecessary.” Overall
agreement between the five physicians was fair (k=0.31, 95%CI
0.30, 0.33). Agreement among EM providers was fair (k=0.22,
95%CI 0.19, 0.24), whereas agreement among FM physicians
was moderate (k=0.52, 95%CI 0.48, 0.57). Fair to moderate
agreement was reached between all physicians for the
medically necessary and unnecessary categories. Agreement
was much lower between all physicians for diagnoses
classified in the “uncertain” category (k=0.14, 95%CI 0.12,
0.16). Agreement across all raters was highest for diseases
classified as Symptoms, Signs, and Ill-Defined Conditions
(k=0.40, 95%CI 0.29, 0.51) and lowest for diseases of the
Blood and Blood Forming Organs (k=-0.17, 95%CI -0.33, 0.01).
Conclusions: Based on study findings, ED diagnosis, by itself,
is not very useful and may not be an appropriate indicator or
component of an indicator for determining medical necessity
of EMS transports.
Implications for Policy, Delivery, or Practice: Standards and
benchmarks in EMS developed through a process of
consensus building and agreement ensure patients receive
consistent and high quality health care (Dunwoody, 2005, Ch.
10). For those in support of its use; failure to develop a
common catalog of unnecessary ED diagnoses will result in
ineffective comparisons between studies and EMS systems.
Primary Funding Source: This research was supported in
part by a National Research Service Award Post-Doctoral
Traineeship from the Agency for Healthcare Research and
Quality sponsored by the Cecil G Sheps Center for Health
Services Research at the University of North Carolina at
Chapel Hill. Grant No: T32-HS000032.
●Assessment of Heart Disease and Stoke Prevention
Programs Among Local Health Departments in Illinois
Karen Peters, Dr.P.H., William Baldyga, Dr.P.H., Sunanda
Gupta, M.D., M.P.H.
Presented By: Karen Peters, Dr.P.H., Assistant Professor,
Illinois Prevention Research Center/IHRP, University of Illinois
School of Public Health, 1747 West Roosevelt, Suite 500,
Chicago, IL 60608; Tel: (312) 413-4944; Email:
kpeters@uic.edu
Research Objective: To assess the current state of practice,
policy, plans and needs related to heart disease and stroke
prevention, treatment and control in the state of Illinois
Study Design: A cross sectional assessment survey using an
online survey tool was utilized. The instrument consisted of
sections on local health department characteristics, control of
high blood pressure and cholestterol, knowledge of the signs
and symptoms of heart attack and stroke, emergency
response capacity, quality of care issues, health disparity,
training needs and use of epidemiologic data. The survey was
deployed over the course of three months to all 94 local health
departments in the state with two follow-up email invitations.
A response rate of 100% was achieved.
Population Studied: Local health department (county based)
personnel responsible for heart disease and stroke prevention,
treatment and control programming were asked to complete
the survey on behalf of the populations served in their
jurisdictions
Principal Findings: Findings indicate local health
departments have: widespread but varied collaborative
relationships with both health-related and community-based
partners in both the public and private sectors; low utilizations
rates of established guidelines (<20%); high rates of screening
for blood pressure (>90%) and cholesterol (>70%); moderate
access to AEDs (41%)and low awareness of established heart
attack or stroke centers (~30%); interests in receiving
additional staff training in heart disease and stroke prevention,
treatment and control and specific concerns over lack of
funding (94%).
Conclusions: While heart attack and stroke prevention,
treatment and control were identified as high priority areas for
local health departments, significant gaps remain related to
funding, training, reduction of health disparity and specific
data needs at the county population level.
Implications for Policy, Delivery, or Practice: This research
suggests that at the policy level, there is a need to continue to
inform the public about cardiovascular disease risk and
prevention strategies. At the local health department practice
and delivery level there are needs for increased public health
workforce training and outreach to community based
organizations and residents about prevention, treatment and
control strategies concerning heart disease and stroke.
Primary Funding Source: CDC, Illinois Department of Public
Health
●Does Accounting for Veteran Status Change Conclusions
about Gender Disparities?
Ciaran Phibbs, Ph.D., Susan Frayne, M.D., Wei Yu, Ph.D.,
Elizabeth Yano, Ph.D., Lakshmi Ananth, MS, Samina Iqbal,
Ann Thrailkill, M.D., RNP
Presented By: Ciaran Phibbs, Ph.D., Health Economist,
Health Econmics Resource Center, VA Medical Center (152),
795 Willow Road, Menlo Park, CA 94025; Tel: (650) 493-5000
x22813; Fax: (650) 619-2639; Email: cphibbs@stanford.edu
Research Objective: Given the push to assure equitable
access to high quality care for the rapidly expanding
population of women Veterans Health Administration (VHA)
patients, studies of gender disparities have been given high
priority in VHA. To accurately characterize gender differences,
patient-level factors must be carefully considered. While
researchers typically take the younger age of women VHA
patients into account, potential gender differences in veteran
status have received less attention. We examined whether
accounting for veteran status alters conclusions about genderrelated disparities in VHA care.
Study Design: We used ICD9 diagnosis codes to identify the
presence of common medical and mental health conditions.
We compared mean health care utilization (total outpatient
encounters and total length of stay over the year, and total
outpatient, inpatient and pharmacy costs, weighted by
resource use) by gender, first in the full cohort and then in
veterans only. In the veteran subset, we used log linear
regression to assess the effect of gender on utilization,
controlling for age and medical conditions.
Population Studied: In a cross-sectional assessment of
centralized VHA administrative and clinical files for all
(N=4,444,577) users of VHA care in fiscal year 2002
(excluding patients with missing gender, age, veteran status,
or costs of care). VHA eligibility files were used to identify the
subset who were veterans.
Principal Findings: Veterans represented 49.1% of women
VHA patients and 96.8% of men VHA patients; among
women, the most common non-veteran category was
employee, followed by other categories such as spouse of a
veteran. The prevalence of medical and mental health
conditions is low among all women VHA patients, but when
the denominator is restricted to women veterans only, the
prevalence is similar to men. There is a similar paterns for
apparent gender differences in use of inpatient and outpatient
services and cost of care when the denominator is restricted
to veterans only. Indeed, after using regression to adjust for
age and medical conditions, women veterans had 1.3% more
outpatient encounters, 10.9% less inpatient days, and 2.7%
lower total cost than men veterans (p<.001 for each
comparison).
Conclusions: Among the patients VHA serves, non-veterans
(who receive fewer diagnoses in VHA data and use VHA
services less heavily) represent a much larger proportion of
women than of men. As a result, apparent gender disparities
in expenditures and in outpatient and inpatient utilization
decrease when the cohort is restricted to veterans only.
Regression analysis that control for age and chronic
conditions show virtually no gender differences in the amount
of care provided to veterans. .Before implementing practice or
policy interventions to improve equity, disparities must be
carefully characterized.
Implications for Policy, Delivery, or Practice: Researchers
quantifying gender disparities in VHA care should specify
whether their focus is upon all VHA patients or upon veteran
VHA patients, and account for veteran status in their analyses.
Reports that fail to correct for veterans status will dramatically
over-state the disparities in VHA care received by female and
male veterans.
Primary Funding Source: VA
●Comparison of Diabetes Quality of Care for Medicare
Managed Care and Commercial Managed Care Enrollees,
2000-20004
Donna Pillittere, M.S., Philip Renner, M.B.A., Sarah Sampsel,
M.P.H.
Presented By: Donna Pillittere, M.S., Director, Quality
Measurement, National Committee for Quality Measurement,
2000 L Street, N.W., Suite 500, Washington, DC 20036; Tel:
(202) 955-1736; Fax: (202) 955-3599; Email: pillittere@ncqa.org
Research Objective: To examine the differences in quality of
diabetes care on several measures for Medicare Managed
Care and Commercial Managed Care Enrollees over the span
of five years. It is commonly believed that Medicare
populations are less likely to perform well on standardized
measures of diabetes care than Commercial populations.
Study Design: A comparison of rates for several diabetes
measures (Eye Exam, HbA1c Testing, Poor HbA1c Control,
Lipid Screening, LDL < 130, LDL <100 and Monitoring
Diabetic Nephropathy) in two Health Plan Employer Data
Information Set (HEDIS) populations collected from
administrative data supplemented by medical record review
over five years. All data are reported based on a standardized
set of performance measures using detailed specifications.
Population Studied: Approximately 300 commercial and 160
Medicare managed care plans submit data to NCQA. From
2000-2004, plans submitted data for each of the diabetes
quality indicators for their enrollees meeting the following
criteria: adults 18-75 years of age with a diagnosis of diabetes
(type 1 and type 2).
Principal Findings: HEDIS managed care data show a steady
increase in performance for both the Medicare and
Commercial population with Medicare performance exceeding
Commercial performance for each measure, each year. For
example, from 2000-2004, mean Commercial Eye Exam rates
increased from 48.1 to 51.0 and mean Medicare rates
increased from 62.8 to 67.1. For the same time period, mean
Commercial HbA1c Testing rates increased from 78.4 to 86.5
and mean Medicare rates increased from 82.5 to 89.1. Mean
commercial Poor HbA1c Control rates (where a lower rate
indicated better performance) decreased from 42.5 to 30.7 and
mean Medicare rates decreased from 33.4 to 22.5. Mean
Commercial LDL Screening rates increased from 76.5 to 91.0
and mean Medicare rates increased from 80.5 to 93.5. Mean
LDL < 130 Commercial rates increased from 44.3 to 64.8 and
mean Medicare rates increased from 50.9 to 71.4. For the first
time in 2003, NCQA collected rates of LDL<100 with the
Commercial population achieving 34.7, and in 2004 achieving
30.5. In comparison, Medicare rates increased from 41.9 in
2003 to 47.5 in 2004. And finally, over the 5 year span, mean
Commercial Monitoring Diabetic Nephropathy rates increased
from 41.4 to 52.0 and mean Medicare rates increased from
45.0 to 58.5
Conclusions: This study indicates quality of diabetes care for
Americans enrolled in managed care plans that report HEDIS
improved from 2000-2004, and performance is higher in
Medicare managed care enrollees. Diabetes, a common
chronic disease among the elderly, is a major contributor to
morbidity, mortality and cost. Studies and medical practice
have shown both the severity of complications and the
potential risks associated with treatment are greater in the
elderly. Treatment strategies must be aggressive enough to
prevent the acute and chronic complications while also
avoiding equally dangerous outcomes. The little evidence that
we have regarding care of older diabetic patients suggests
inadequacies, however, this study indicates the Medicare
population has better performance on these standardized
measures than the Commercial population.
Implications for Policy, Delivery, or Practice: While the
Medicare population is thought of as harder to manage and
less likely to meet criteria for quality measures, we have found
that Medicare is doing better than Commercial. The difference
in performance of these diabetes measures between the
Commercial and Medicare populations suggest that quality
improvement and Disease Management programs focused
specifically on the Medicare managed care population have
contributed to improving the quality of diabetes care in this
vulnerable population.
Primary Funding Source: NCQA
●Polypharmacy is Associated with Seeing Multiple Unique
Physicians
David Radley, M.P.H., Julie P. W. Bynum, M.D., M.P.H., Elliott
S. Fisher, M.D., M.P.H.
Presented By: David Radley, M.P.H., Ph.D. Student, Center
for Evaluative Clinical Sciences, Dartmouth Medical School,
HB 7252, Hanover, NH 03755; Tel: (603) 650-1746; Fax: (603)
650-1225; Email: david.c.radley@dartmouth.edu
Research Objective: Medicare beneficiaries use many drugs
often prescribed by multiple different providers. While
patient-level determinants of polypharmacy, a recognized and
costly risk factor for adverse drug reactions among the elderly,
are well understood, little is known about the relationships
between physician utilization, polypharmacy, and the type of
drugs prescribed. The objective of this study was to
determine the effect of seeing multiple physicians on
prescription drug use among Medicare beneficiaries.
Study Design: The Medicare Current Beneficiary Survey
(MCBS), a nationally representative survey of community
dwelling and institutionalized Medicare beneficiaries, was
linked to the CMS Medpar and Part B evaluation and
management claims files for the year 2000. We performed a
cross-sectional analysis of prescription drug use identified in
the MCBS. For each respondent, we recorded up to 20
distinct prescription medications during the study year. Each
prescription drug was categorized by therapeutic class and
then classified as either disease-targeted or symptomtargeted. The number of different medications taken was then
modeled, using as covariates the following independent
variables: patient age, gender, race, education, income, selfreported health, functional status, claims-documented chronic
conditions, presence of drug insurance, the number of
outpatient visits, and the number of unique outpatient
physicians seen during the year. Number of symptom and
disease-targeted drugs were modeled similarly. Crosssectional sample weights were applied. Regression models
were fit using a general estimating (GEE) modeling approach
to correct for overdispersion in the data.
Population Studied: We studied non-institutionalized MCBS
participants who were: older than 65 years, continuously
eligible for Medicare Parts A and B , had no managed care
enrollment, and were alive thru June of 2000. Respondents
with no outpatient physician visits were also excluded because
they were unlikely to be receiving active management of their
prescription drugs (n = 6,367).
Principal Findings: Prescription drug use was common with
96% of participants reporting at least one prescription drug.
Respondents received an average of 5 prescription
medications, 4 of which targeted specific diseases and 1
targeted symptoms. The number of physicians seen during
an outpatient office visit during the year varied among
respondents, 12% of whom saw one physician, 58% saw 2-5
different physicians and 30% saw more than 6 different
physicians. After adjusting for age, gender, health status and
socioeconomic characteristics, and number of outpatient
office visits, beneficiaries who saw 2-5 different physicians
received 35% more drugs than those who saw 1, (IR = 1.35;
p<0.001), while those seeing 6 or more physicians receive
nearly 70% (RR = 1.66; p < 0.001) more prescription drugs.
Controlling for the total number of drugs, seeing more unique
physicians was associated with 37% more symptom-targeted
drugs.
Conclusions: Medicare beneficiaries whose care is provided
by more physicians receive more prescription drugs and are
more likely to receive a greater number of symptom-targeted
drugs than similar beneficiaries who see fewer unique
physicians.
Implications for Policy, Delivery, or Practice: Our findings
suggest that reducing the fragmentation of care across
multiple providers may decrease the occurrence of expensive
and potentially harmful polypharmacy among Medicare
beneficiaries.
Primary Funding Source: NIA
●Measuring the Quality of Patient-Centered Cancer
Nursing Care
Laurel Radwin, RN, Ph.D., Christine Saba, RN, BS, Mary
Hackel, RN, BS, Lisa Tracey, RN, M.S.N., John Whitehouse,
RN, BS, Gail Wilkes, RN, M.S.N., AOCN, Camille Sanabria,
RN, BS, Linda Curtin, RN, Ph.C., Leslie Chen, BS, Joanne
Garvey, RN, Ph.C., Liliana Teixeira, Howard Cabral, Ph.D.,
Amber Schrantz, BS
Presented By: Laurel Radwin, RN, Ph.D., Associate Professor,
Nursing, University of Massachusetts, Boston, 44 High Street,
Chelmsford, MA 01824; Tel: (617) 287-7572; Email:
laurel.radwin@umb.edu
Research Objective: To evaluate the factor structure of five
scales measuring the quality of cancer nursing care in an
urban sample of cancer patients of diverse racial/ethnic
backgrounds. The Oncology Patients’ Perceptions of the
Quality of Nursing Care Scale (OPPQNCS) measures the
quality of patient-centered nursing interventions. Four desired
patient outcome scales are the Trust in Nurses, Cancer
Patient Optimism, Authentic Self-Representation and
Fortitude Scales.
Study Design: Characteristics of excellent nursing care, as
described by participants in a previous qualitative study, were
conceptualized as patient-centered nursing interventions.
These were operationalized by the OPPQNCS (the
development of which in a more general patient population
has been previously reported) and comprise the following:
responsiveness, individualization, coordination and
proficiency. Desired outcomes of excellent patient-centered
nursing care based on the qualitative study were
operationalized by the Trust in Nurses, Cancer Patient
Optimism, Fortitude, and Authentic Self-Representation
Scales (also previously reported). In the current sample,
exploratory factor analysis was used to examine the factor
structures of the quality of patient-centered nursing
intervention scale and the four desired health outcome scales.
In addition, analyses were conducted using Cronbach’s alpha
to assess the reliability of items in the assumed operational
domains.
Population Studied: Participants were recruited over an 18month period from a 29-bed inpatient hematology-oncology
unit at an urban medical center that is the largest safety net
hospital in New England (N=231). The majority of participants
were male (52.4%) and participant characteristics revealed a
racially diverse sample: 59.2% White, 30.3% African
American/Black, 1% Asian, 2.6% American Indian or Native
Alaskan. Seventeen percent were Hispanic. Most participants
(63.3%) had a high school education or less. The mean age
was 59.3 years (13.8). Participant diversity provides an
opportunity to analyze the psychometric properties of the
OPPQNCS and the outcome scales in a racially, ethnically,
and educationally diverse sample.
Principal Findings: Exploratory factor analyses indicated that
the item by which domains were operationalized showed the
anticipated structure for the OPPQNCS consistent with our
research in other populations. The structure for the desired
health outcome scales were different in the current sample for
two of the scales (Fortitude, Cancer Patient Optimism).
Moreover, the psychometric assessment via Cronbach's alpha
analysis showed adequate reliability for most of the domains
studied, ranging from .720 to .863.
Conclusions: The results of this study provide estimates of
the psychometric properties of scales measuring the quality of
care for hospitalized cancer patients at an urban safety net
hospital. This analysis is preliminary to a larger study in which
the structural relationship between factors will be formally
assessed using structural equation modeling.
Implications for Policy, Delivery, or Practice: The National
Quality Forum and the Robert Wood Johnson Foundation
have endorsed the NQF-15, which is a set of measures for
monitoring and improving the quality of nursing care. The
NQF-15 does not include a measure of patient-centered
nursing care nor measures of desired health outcomes that
result from such care. This analysis will provide an initial
understanding of the structure of scales that measure the
processes and outcomes of patient-centered nursing care.
Primary Funding Source: AHRQ
●Influence of Payment Sources on the Diagnostic Tests
Prescribing for Pediatric Asthma in Hospital Ambulatory
Patients
Ateequr Rahman, M.B.A., Ph.D.
Presented By: Ateequr Rahman, M.B.A., Ph.D., Assistant
Professor, School of Pharmacy, Shenandoah University, 1775
Norht Sector Court, Winchester, VA 22601; Tel: (540)-6784365; Fax: (540) 665-1283; Email: arahman@su.edu
Research Objective: Asthma affects an estimated 17 million
Americans or 6.4 percent of the U.S. population. Children
account for 4.8 million of the nation's asthma sufferers.
Asthma is associated with severe asthmatic bronchitis and
various pulmonary complications. According to the Center of
Disease Control, the total cost to the society related to asthma
were estimated to be $14.5 billion for the year 2000.
Diagnostic tests constitute a significant cost in the treatment
of Asthma. Literature review indicates that patients’ payment
sources might influence the types and the number of tests
prescribed for Asthmatic patients. This study examines the
influence of various patients payment source on the number
of diagnostic tests prescribed for pediatric asthma in hospital
ambulatory patients.
Study Design: A retrospective secondary database analyses
technique was used to study the patient population. Patient
payment sources such as Self Pay, Medicare, Medicaid,
HMO’s, PPO’s and Private Insurance were used as
independent variables to determine their influence on the
number of diagnostic tests prescribed. Patients with principal
diagnosis of Asthma (ICD-9-CM code 493.00) with age less
than or equal to 12 years were analyzed using Anova, multiple
linear and binomial logit regression models.
Population Studied: Data from the National Hospital
Ambulatory Medical Care Survey (NHAMCS) 2003 were
utilized. The (NHAMCS) is designed to collect data on the
utilization and provision of ambulatory care services in
hospital emergency and outpatient departments annually.
Data are obtained on demographic characteristics of patients,
expected source(s) of payment, patients' complaints,
physicians' diagnoses, diagnostic/screening services,
procedures and medication therapy.
Principal Findings: Patients with Federal source of payments
(Medicaid and Medicare) were prescribed more diagnostic
tests than other patients (R2 = 0.345). Patients with HMO’s
and PPO’s as their primary source of payments were
prescribed fewer diagnostic tests compared with other form of
payments (R2 = 0.1643). Patients with self-pay as their primary
source of payments were prescribed fewer diagnostic tests
compared with other form of payments (R2 = 0.1792).
Conclusions: The numbers of diagnostic tests prescribed are
significantly influenced by patients’ source of payments.
Diagnostic tests constitute a significant portion of the cost of
asthma therapy. Medicare and Medicaid should undertake
measures to control utilization of diagnostic tests. HMO’s,
PPO’s and Private Insurance sources seem to control
utilization of diagnostic tests in asthma.
Implications for Policy, Delivery, or Practice: Controlling the
utilization of diagnostic tests could significantly lower the
health care costs for asthma. Efforts should be directed
toward controlling/minimizing the utilization of diagnostic
tests by the third part payers.
Primary Funding Source: Shenandoah University
●Changes in Physician Productivity 1993 – 2003
Mary RImsza, M.D., Mark Speicher, M.H.A., William G.
Johnson, Ph.D., Michael Grossman, M.D.
Presented By: Mary RImsza, M.D., Professor, School of
Health Management and Policy, Center for Health
Information and Research Seidman Research Institute,
Arizona State University, PO Box 874506, Tempe, AZ 852874506; Tel: (480) 965 1622; Fax: (480) 965 6654; Email:
mary.rimsza@asu.edu
Research Objective: Conventional wisdom holds that
physician workloads have changed, and not for the better.
Both patients and physicians believe that doctors have less
time for patients, and that physicians are seeing more patients
that ever. There has been recognition of a number of
workload issues as a cause for physician dissatisfaction, active
doctors leaving medicine and an inability to recruit new
physicians to certain areas or specialties. Reasons for this
change in workload may include population demographics,
the continuing increase in managed care, changes in access to
care caused by economic swings or levels of insurance
coverage, and physician lifestyle issues such as gender, worklife balance, choice of specialty and practice location (rural vs.
urban), etc.
Study Design: The Arizona Medical Board and the Arizona
Board of Osteopathic Examiners collect information on
physicians as a part of the license renewal process. This data
includes specialty, office location, education, age and other
information. Between 1992 and 1997, an Arizona State
University project added survey questions to the license
renewal packet. In 2003, the project was resumed as a joint
effort of Arizona State University and the University of
Arizona. The survey of practicing physicians from 2003 was
used to compare data on licensed allopathic and osteopathic
physicians practicing in Arizona in 1993, 1994, 1996, 1997, and
1998 and 2003 to determine the change in time spent in
practice as well as number of patients seen during the survey
periods. (Results for 1998 were self-reported by survey
respondents in 2003.) The direction and magnitude of
changes are reviewed by age group, specialty and geographic
location in Arizona.
Population Studied: All licensed allopathic and osteopathic
physicians were surveyed during the survey years. The survey
of practicing physicians is distributed and collected as a part
of the annual or biennial license renewal process for all
allopathic and osteopathic physicians through a cooperative
agreement with the physician licensing boards.
Principal Findings: As estimated by the survey respondents,
the number of patients seen for all practicing physicians
increased from 69 per week in 1994 (n=11,794) to 88 in 1997
(n=8,451) to 84 in 1998 and 84 in 2003 (both reported on the
2003 survey; n=7,675). Productivity (patients seen per week
and hours worked per week) increased across all specialty and
practice settings in roughly the same pattern; while patients
seen per week varied greatly between specialties. In 2004, for
example, anesthesiologists reported seeing an average of 37
patients per week, cardiologists 106, family practitioners 95,
internists 85, obstetricians 90, and surgeons 52.
Conclusions: The number of patients seen per week in rural
areas is significantly higher than in urban areas (though the
gap is narrowing over time) but hours worked per week do not
differ as greatly between urban and rural areas.
Implications for Policy, Delivery, or Practice: Models of the
need for health care providers are important for health
planning and policy decisions. The productivity of physicians
is an important but generally unknown component of
workforce planning models.
Primary Funding Source: Flinn Foundation, St. Luke's Health
Initiatives, BHHS Legacy Foundation
●Is There a Difference in Productivity Between Men and
Women Physicians?
Mary Rimsza, M.D., Mark Speicher, MHA, William G.
Johnson, Ph.D., Michael Grossman, M.D.
Presented By: Mary RImsza, M.D., Professor, School of
Health Management and Policy, Center for Health
Information and Research Seidman Research Institute,
Arizona State University, PO Box 874506, Tempe, AZ 852874506; Tel: (480) 965 1622; Fax: (480) 965 6654; Email:
mary.rimsza@asu.edu
Research Objective: In discussing physician productivity, one
assumption has been that female physicians have primary
responsibility for child and family care, and so are less
productive than their male counterparts. This assumption is
largely untested, but has great implications for models of
physician productivity.
Study Design: Between 1992 and 1997, an Arizona State
University project added survey questions to the license
renewal packet. In 2003, the project was resumed as a joint
effort of Arizona State University and the University of
Arizona. The survey of practicing physicians from 2003 was
used to compare data on licensed allopathic and osteopathic
physicians practicing in Arizona in 1993, 1994, 1996, 1997, and
1998 and 2003. (Results for 1998 were self-reported by survey
respondents in 2003.) This data was used to analyze
differences in number of hours worked, patients seen, and
other productivity issues between male and female physicians.
The data allowed a comparison of gender differences by age
group and specialty, to determine whether there are
differences in productivity between male and female
physicians of the same age group and specialty, as well as to
look at changes between age groups and specialties of the
same gender.
Population Studied: All allopathic and osteopathic physicians
in Arizona were surveyed during thestudy years. The Arizona
Medical Board and the Arizona Board of Osteopathic
Examiners collect information on physicians as a part of the
license renewal process. This data includes specialty, office
location, education, age and other information.
Principal Findings: In 2003, the mean number of hours
reported worked by male and female anesthesiologists were
64 and 64, cardiologists 66 (males) and 74 (females), family
practitioners 53 and 52, internists 57 and 58, obstetricians 58
and 61, pediatricians 96 and 87, and surgeons 57 and 60.
Conclusions: An analysis of gender differences in specialty
choice shows that while female physicians do choose different
specialties than their male counterparts, within most
specialties there are only small differences between the hours
worked and patients seen for male and female physicians.
Implications for Policy, Delivery, or Practice: Models of the
need for health care providers are important for health
planning and policy decisions. The productivity of physicians
is an important but generally unknown component of
workforce planning models. In addition, cohort changes in
specialty choice, practice location and practice setting is
important information for educators and planners.
Primary Funding Source: Other, Flinn Foundation, St. Luke's
Health Initiatives, BHHS Legacy Foundation
●Determinants in Antidepressant Treatment Selection
Following the Introduction of Duloxetine
Rebecca Robinson, MS, Michael Pollack, MS, Michael Bullano,
PharmD, Stephen Able, Ph.D., Ralph Swindle, Ph.D., ,
Presented By: Rebecca Robinson, MS, Research Consultant,
Health Outcomes, Eli Lilly and Company, Lilly Corporate
Center, Indianapolis, IN 46285; Tel: (317) 433-1323; Email:
rlrobinson@lilly.com
Research Objective: We compared factors associated with
antidepressant treatment selection for managed care patients
initiating on duloxetine versus other select antidepressants
(SSRIs, bupropion, venlafaxine XR, escitalopram). We tested
differences in subgroups with and without depression
diagnoses.
Study Design: Retrospective administrative claims from five
US managed care health plans were obtained for adult
patients initiating on new prescriptions for select
antidepressants between 8/31/04 to 12/31/04. Diagnostic and
treatment histories were established through prior medical
and pharmacy claims (12 months before index medication
date). The subgroup with depression included all patients
with ICD-9 codes including: 296.20-296.26, 296.30-296.36,
300.4, 309.1, and 311.0. Multivariate logistic regression
analyses were employed to control for selection bias.
Population Studied: Adults with depression
Principal Findings: Of the overall population (N=230,738),
most patients initiated therapy on SSRIs (77.9%), followed by
bupropion (18.6%), duloxetine (1.9%), and venlafaxine XR
(1.6%). Among the SSRIs, escitalopram accounted for 24.8%
of the class and was selected as a separate comparator group.
The SSRI category also included sertraline (25.2%), fluoxetine
(21.8%), paroxetine (19.1%), and citalopram (9.2%). The
mean age of the overall population was 44.6 years, 71.4% were
female, and 29.7% were included in the depression subgroup.
Within the depression subgroup, patients initiating on
duloxetine (n=2061) versus all other antidepressants were
associated with more intensive prior use of healthcare factors
including; prior pain diagnoses (Odds Ratio {OR} 1.11 with
95% confidence interval {CI} of 1.05-1.18), depression-related
diagnoses (OR 1.52; CI 1.32-1.74), major depressive disorder
recurrent episode diagnoses (OR 1.27; CI 1.08-1.50),
psychotherapy (OR 1.14; CI 0.99-1.32), pain medications (OR
1.27; CI 1.22-1.32), and antidepressants (OR 1.46; CI 1.37-1.56).
Duloxetine patients also were more likely to initiate therapy
later in the study (OR 1.04; CI 1.03-1.04), be older (OR 1.02; CI
1.01-1.02), and were more often prescribed therapy by mental
health (OR 2.32; CI 2.0-2.7) or other specialists (OR 1.40; CI
1.13-1.74) versus primary care. All factors associated with
duloxetine initiation in the depression subgroup remained
significantly associated with duloxetine in the absence of
depression diagnoses. In addition, duloxetine initiators in the
nondepression subgroup (n=2346) were more likely to be
female (OR 1.21; CI 1.08-1.35). Five factors (higher prior pain
medication use, higher prior antidepressant use, receipt of
mental health specialty care, greater claims for prior
depression-related diagnoses, and initiation later in the study)
were consistently significantly associated with duloxetine use
in subgroups with and without depression when drug cohorts
were tested separately. Sensitivity analyses found that
increased rates of pain were associated with duloxetine use
when pain was measured in terms of pain medication use,
type of pain, and number of pain diagnoses experienced.
Conclusions: In the first four months after launch, duloxetine
initiators were associated with worse prior diagnostic and
treatment histories than all other antidepressants. These
findings were robust in the presence and absence of
depression diagnoses and across multiple measures of pain.
Case mix adjustments should be made when comparing drug
cohorts. Findings may be influenced by the restrictiveness of
plans. Trends over time are necessary to determine the
robustness of results.
Implications for Policy, Delivery, or Practice: These findings
imply that antidepressant medication choice varies based on
patient demographics, prior medical comorbidities, and
treatment history. Designing delivery of care systems that
provide multiple treatment options to patients may improve
the effectiveness of care by allowing health care professions to
prescribe the right treatment for each unique patient.
Primary Funding Source: Eli Lilly and Company
●The Relationship of Psychiatric Disorders, Diabetes, and
Diabetic Peripheral Neuropathy to Pain in Primary Care
Patients
Rebecca Robinson, MS, Kathryn Magruder, M.P.H., Ph.D.,
Derik E Yeager, MBS, Libby Dismuke, Ph.D., DE Clancy, M.D.,
MSCR
Presented By: Rebecca Robinson, MS, Research Consultant,
Health outcomes, Eli Lilly and Company, Lilly Corporate
Center, Indianapolis, IN 46285; Tel: 317-433-1323; Email:
rlrobinson@lilly.com
Research Objective: Diabetic complications raise the total
burden among patients with diabetes. Comorbid depression
also has been found to remain strongly associated with higher
costs regardless of the level of diabetes severity. Less is
known of the unique contribution of pain, a common
complication of diabetes and depression, on outcomes.
Therefore we examine the contribution of psychiatric
disorders, diabetes, and diabetic peripheral neuropathy (DPN)
to patients’ assessment of pain.
Study Design: Socio-demographic characteristics and
functional status were collected using the SF-36, including 2
items of bodily pain (SF-BP). Using the median pain score
(62.5) patients were classified as having “more pain” or “less
pain”. The electronic medical record provided ICD-9
diagnoses for a 2-year period with interview date as the
midpoint.
Population Studied: Patients were randomly selected
(oversampling women) from primary care clinics at four
Veteran’s Affairs (VA) hospitals.
Principal Findings: 73% (n=938) of invited patients
consented and had complete data. 32.7% of patients were
diabetic, 10.2% of whom had DPN; 41.3% had a psychiatric
diagnosis (23.8% major depression or depression not
otherwise specified; 9.5% posttraumatic stress disorder
(PTSD)). Pain scores indicated more pain than published
normative data on patients with either diabetes or depression.
In a logistic regression analysis with diabetes, DPN,
depression, PTSD, age, sex, and race in the model, only
depression (OR=2.56; 1.81-3.61), PTSD (OR=3.16; 1.81-5.54),
and being female (OR=.68; .47-.99) were significantly (p<.05)
associated with higher levels of pain.
Conclusions: Patients with psychiatric diagnoses are more
likely to report higher levels of pain regardless of a diagnosis
of diabetes or DPN.
Implications for Policy, Delivery, or Practice: Further
investigation of the impact of pain in these conditions with
total health care service use and pain medication use may
provide useful information in policy and practice settings.
These individuals may benefit from treatment practices and
guidelines that address the duality of these conditions
throughout the process of care in the VA system.
Primary Funding Source: VA, Eli Lilly and Company
●Family Practice Physician Capacity to Manage Patients
with Chronic Illness
Kent Rondeau, Ph.D., Neil Bell, M.D.
Presented By: Kent Rondeau, Ph.D., Associate Professor,
Public Health Sciences, University of Alberta, 13-103 Clinical
Sciences Building, Edmonton, Alberta, T6G 2G3; Tel: (780)
492-8608; Fax: (780) 492-0364; Email:
kent.rondeau@ualberta.ca
Research Objective: To assess the capacity and capability of
family physicians to manage patients with chronic illness and
to identify the medical practice and health system barriers
towards improving the delivery of care provided by family
physicians to patients with chronic illness.
Study Design: A two-wave, mail survey questionnaire was
sent to 1500 Alberta family physicians in late 2005. In total,
200 questionnaires were returned which constitutes the study
database.
Population Studied: Family physician medical practices
located in Alberta, Canada were studied. Using the Wagner
Model for Chronic Care Management as a comparative
prototype, characteristics of family physicians and their
practices were examined to assess their overall readiness to
deliver effective care to patients with chronic illness. Practice
type and size, resource sufficiency and organization, physician
remuneration, and level of patient chronicity were evaluated as
explanatory factors for physician and practice capacity for
effective chronic care management.
Principal Findings: The capacity of Alberta family practices to
deliver effective care to their patients with chronic illness is
highly variable. Size and location of practice, access to
community resources, sufficiency and alignment of
appropriate incentives, and level of patient chronicity, were
found to be significant factors in explaning practice
orientation, capacity and readiness for effective chronic care
management.
Conclusions: Significant practice and health system barriers
currently exist for improving care to patients with chronic
illness. Characterization of these practice and system barriers
is made on the basis of practice type and size.
Implications for Policy, Delivery, or Practice: Improvements
in the delivery of care by family physicians for patients with
chronic illness are unlikely without significant
structural/system changes in how family physicians currently
deliver care to patients with chronic illness.
Primary Funding Source: Caritas Health Group-Edmonton
●Use of Interpreter Services Among Health Care Providers
Treating Women with Breast Cancer, Findings from Los
Angeles County, 2004
Danielle Rose Ash, M.P.H., Katherine Kahn, M.D., Jennifer
Malin, M.D., Ph.D, May Tao, M.D., Ph.D, Patricia Ganz, M.D.,
Diana Tisnado, Ph.D
Presented By: Danielle Rose Ash, M.P.H., Doctoral
Candidate, Health Services, UCLA, School of Public Health,
2017 Camden Avenue, Los Angeles, CA 90025; Tel: (310)
3971214; Email: droseash@ucla.edu
Research Objective: According to US Census data, 28% of
Los Angeles County residents do not speak English well.
Studies have documented that quality of care for patients with
Limited English Proficiency (LEP) may be compromised
without interpreter use (Flores 2005). The objective of this
study is to determine predictors of interpreter use among
health care providers treating women with breast cancer.
Study Design: This was a cross-sectional, observational study
of cancer physicians involved in the management of breast
cancer patients. Physicians reported the proportion of
patients that do not speak English well enough to give an
adequate history and strategies they used to facilitate
communication with LEP patients: themselves as interpreters,
trained medical interpreters, bilingual staff not specifically
trained in medical interpretation, telephone language
interpretation services, or patient’s friends or family members.
Logistic regressions were conducted with dependent variables
characterizing interpreter use: 1) physician serves as
interpreter; 2) formal interpreter use: interpreters, bilingual
staff or telephone services; and 3) ad hoc interpreter use:
patient’s friends or family. In analyses weighted for nonresponse, we used individual logistic regressions to predict
each strategy used for communication with LEP patient.
Population Studied: Surveyed medical oncologists, radiation
oncologists and surgeons practicing in Los Angeles County
identified by a population-based cohort of women with breast
cancer retrieved from the cancer registry (76% response rate,
n=346).
Principal Findings: According to survey responses, the mean
proportion of patients who are LEP in Los Angeles County was
16.9% (range: 0-98%, 95% CI: 15, 19). Bivariate analyses
exploring potential predictors of the proportion of LEP
patients showed no statistically significant differences in the
proportion of LEP patients by practice size.
After adjusting for physician age, gender, race/ethnicity and
specialty; practice type and size (1, 2-5, 6-15, 16-49, or 50 or
more physicians) and the proportion of patients who are LEP,
we find a greater likelihood of formal interpreter use among
larger practices compared to solo practices (OR=11, 95% CI: 1,
111 for size 2-5; OR=20.5, 95% CI: 2, 264 for size 6-15; OR:
20.9, 95% CI: 1, 343 for size 16-49, and OR=17.2, 95% CI: 2, 155
for practices with 50 physicians or more).
Conclusions: After adjusting for physician race/ethnicity, the
proportion of patients who are LEP, and other covariates, we
find that practice size appears to be associated with formal
interpreter use. Thus, LEP patients with physicians in a solo
practice may be less likely to have access to formal interpreter
services, compared to LEP patients seeing physicians in larger
practices.
Implications for Policy, Delivery, or Practice: This study
suggests that LEP patients who see solo practitioners may
face less access to formal interpreters. Further study is
needed to evaluate whether this translates into quality of care
differences.
Primary Funding Source: California Breast Cancer Research
Program
●Association of Unit-level Perceptions of Work
Environment with Patient Mortality in VHA Acute Care
Units
Anne Sales, M.S.N., Ph.D., Yu-Fang Li, Gwendolyn Greiner,
Elliott Lowy, Chuan-Fen Liu
Presented By: Anne Sales, M.S.N., Ph.D., Health Services
Research & Development Service Northwest Center for
Outcomes Research in Older Adults, VA Puget Sound Health
Care System, 1100 Olive Way, Suite 1400, Seattle, WA 98101;
Tel: 206-764-2068; Email: ann.sales@va.gov
Research Objective: Several large scale studies have found
associations between nursing factors including perceptions of
work environment, and mortality for hospitalized patients,
aggregated to the facility level. However, nurse staffing and
perceptions of work environment vary greatly across inpatient
units within a hospital. In this study we provide the first largescale analysis using nursing unit-level data to examine the
association between staffing, perceptions of work
environment and patient mortality, conducted in the Veterans
Health Administration (VHA).
Study Design: Data came from several sources: VHA nursing
labor files; and data from VHA national databases for data on
all patients admitted to VHA inpatient acute care nursing
units between 2/03-6/03. Nurse perceptions of work
environment, as well as overall job satisfaction, emotional
exhaustion came from a mailed survey administered to all
nursing personnel in 125 VHA hospitals. We defined staffing
as quartiles of RN and non-RN hours per patient day (HPPD),
based on prior modeling. We developed a 2-step multilevel
regression model with patient, nursing unit and hospital level
data corrected for clustering at the unit and facility levels. The
first step predicted patient probability of developing a serious
complication using patient-level predictors. The second step
estimated overall mortality on predicted patient
complications, nursing unit and facility-level predictors. We
stratified the analysis by whether or not the patient received
any intensive care (versus those with no intensive care stay).
All analyses were conducted using the generalized linear latent
and mixed models procedure in STATA v9.0 with two levels of
clustering (unit and facility).
Population Studied: The analyses included 115,047 patients
from 408 nursing units in 119 VAMCs. 175 units were
intensive care, and 233 non-intensive acute care units.
Nursing factors came from a survey of all nursing personnel in
125 VHA hospitals. Overall response to the survey was 26%.
Principal Findings: Mean proportion of nursing personnel
reporting positive job satisfaction on ICU units was 67%, and
62% on non-ICU acute care units. On multivariate regression
among ICU patients, the fourth quartile of RN HPPD and
higher proportion of nurses reporting positive job satisfaction
(OR 0.54, p<.001) were related to decreased risk of mortality.
The second quartile of RN HPPD, predicted patient risk of
complications, and being a medical (vs. surgical) patient were
associated with increased risk of mortality. Among non-ICU
patients, the fourth quartile of RN HPPD was associated with
decreased risk of mortality, while patient predicted risk of
complications and being a medical patient were associated
with increased risk of mortality.
Conclusions: Adjusting for patient risk, staffing levels and
other facility factors, the only nurse-reported aspect of the
work environment that was significantly associated with inhospital mortality was the proportion of nurses reporting they
were satisfied with their jobs, and this finding held only for
patients who had an ICU stay during their admission.
Implications for Policy, Delivery, or Practice: There is
considerable interest in the association between nurse
perceptions of their work environment and patient outcomes,
in part because these perceptions are more likely to be
modifiable than patient characteristics. In our work, we find
that patient characteristics dwarf other factors in their
association with overall mortality.
Primary Funding Source: VA
●Practices Associated with Superior Outcomes in Chronic
Disease Care: An Observational Study
Julie Schmittdiel, Ph.D., Jim Bellows, Ph.D., Anne Frølich,
M.D., Martin Hefford, MA
Presented By: Julie Schmittdiel, Ph.D., Staff Scientist, Division
of Research, Kaiser Permanente Northern California, 2000
Broadway, Oakland, CA 94612; Tel: (510) 891-3872; Fax: (510)
891-3106; Email: Julie.A.Schmittdiel@kp.org
Research Objective: To examine the use of population care
practices in a naturalistic setting, and to identify those
practices associated with superior process and outcome
measures in the case of diabetes care.
Study Design: Observational study linking 13 defined
population care practices (including use of action plans, care
coordination, patient education, provider alerts and feedback,
and patient inreach and outreach) with 7 diabetes
performance measures (glycemic screening, lipid screening,
renal screening, retinal screening, angiotensin-converting
enzyme inhibitor use, glycemic control, and lipid control).
Population care practices were measured using a telephone
survey of practice sites, while performance measures were
obtained from patient-level computerized databases.
Multivariate, hierarchical regression models were used to
assess the strength of association between practice scores
and performance measures.
Population Studied: 553,556 patients with diabetes treated at
41 participating sites in all 8 national Kaiser Permanente
regions.
Principal Findings: Stronger implementation of population
care practices was positively associated with performance on
all process and outcome measures. High performance was
positively associated (p < 0.01) with robust implementation of
three practices: personalized patient action plans, proactive
outreach and follow-up, and provider alerts.
Conclusions: Greater use of population care practices is
positively associated with better results on diabetes process
and outcome measures in a non-experimental setting
Implications for Policy, Delivery, or Practice: This study
helps to isolate the population care practies that have the
most effect on patient outcomes in diabetes. Practices most
strongly associated with high performance would make good
candidates for quality improvement efforts elsewhere.
Primary Funding Source: Care Management Institute, Kaiser
Permanente
●Does Payer Type Influence Treatment Modality Among
Adults with Depression?
David A. Sclar, B.Pharm., Ph.D., Tracy L. Skaer, B.Pharm.,
Pharm.D., Linda M. Robison, MSPH
Presented By: David A. Sclar, B.Pharm., Ph.D., Professor of
Health Policy and Administration, Health Policy and
Administration, Washington State University, P.O. Box
646510, Pullman, WA 99164-6510; Tel: (509) 335-1865; Fax:
(509) 335-0162; Email: lrobison@wsu.edu
Research Objective: To examine whether the use of single
and combination treatment modalities varies by public versus
private payer, among adults age 18-64 years diagnosed with
depression. Treatments include: 1) antidepressant
pharmacotherapy alone; 2) psychotherapy and/or mental
health counseling alone; 3) the combination; or 4) no
treatment.
Study Design: Data from the 2002 U.S. National Ambulatory
Medical Care Survey (NAMCS) were used for this analysis.
The NAMCS is an annual survey designed to yield national
estimates of office-based physician-patient visits. Office-based
visits documenting a diagnosis of depression (ICD-9-CM
codes 296.2 - 296.36; 300.4; or 311) along with a known
primary payer were extracted from the NAMCS. Treatment
modalities utilized in the management of depression are
reported as percentiles by public versus private payer. Subset
analyses were conducted for individuals with and without
comorbid mental disorders.
Population Studied: U.S. population age 18-64 years old,
diagnosed with depression during calendar year 2002.
Principal Findings: During 2002, 19,673,068 office visits
documented a diagnosis of depression. Twenty-two percent
suffered additional comorbid mental disorders. Treatment
modalities by public versus private payer respectfully were: 1)
antidepressant alone, 40.6%, 30.4%; 2) psychotherapy and/or
mental health counseling alone, 9.2%, 17.0%; 3) the
combination, 37.0%, 44.4%; 4) no treatment beyond the office
visit, 13.2%, 8.1%. Results stemming from subset analyses
will also be presented.
Conclusions: Patients with a public payer were more likely to
receive antidepressant pharmacotherapy alone, or no
treatment, and less likely to receive psychotherapy and/or
mental health counseling, or combination treatment
compared to patients with a private payer. Reasons for these
inequities warrant further examination.
Implications for Policy, Delivery, or Practice: Results
stemming from randomized clinical trials indicate that among
adults with depression receipt of psychotherapy in concert
with pharmacotherapy optimizes patient outcomes, especially
among persons with comorbid mental disorders.
Stakeholders (both clinical and administrative) need to
address the reasons for observed differences by health
insurance category in the use of treatment modalities, and
focus on the physician-patient relationship, current practice
guidelines, and the wider social context in which an officebased visit occurs.
Primary Funding Source: Pharmacoeconomics and
Pharmacoepidemiology Research Unit
●Disparity in the Rate of Depression and Use of
Antidepressant Pharmacotherapy by Ethnicity/Race: An
Assessment of Office-based Visits in the U.S., 1992-2003
David A. Sclar, B.Pharm., Ph.D., Tracy L. Skaer, B.Pharm.,
Pharm.D., Linda M. Robison, MSPH
Presented By: David A. Sclar, B.Pharm., Ph.D., Professor of
Health Policy and Administration, Health Policy and
Administration, Washington State University, P.O. Box
646510, Pullman, WA 99164-6510; Tel: (509) 335-1865; Fax:
(509) 335-0162; Email: lrobison@wsu.edu
Research Objective: Depression is one of the most common
psychiatric disorders, however, data are sparse and
inconsistent as to the actual rate of depression among African
Americans (blacks) and Hispanics as compared to whites.
Building on our previous research, this study was designed to
discern ethnic/race-specific (black; Hispanic; white)
population-adjusted rates of U.S. office-based physician visits
documenting a diagnosis of depression, or a diagnosis of a
depression in concert with the use of antidepressant
pharmacotherapy.
Study Design: The National Ambulatory Medical Care Survey
(NAMCS) is an annual survey designed to yield national
estimates of office-based physician-patient visits. Data from
the NAMCS for the time-period 1992-97, and 2003, were
utilized for this analysis. The interim years were excluded
because of excessive missing data for the variable ethnicity
thereby mitigating use of this variable to discern national
trends. The data were partitioned into four time intervals as
follows: 1992-93; 1994-95; 1996-97, and 2003. In each time
interval, data from office-based visits for patients 20-79 years
of age were extracted to evaluate: (i) the number of visits
documenting a diagnosis of a depression (ICD-9-CM codes
296.2 - 296.36; 300.4; or 311), by ethnicity/race; and (ii) the
number of visits documenting a diagnosis of a depression and
the use of antidepressant pharmacotherapy, by ethnicity/race.
Annualized ethnic/race-specific rates of office-based visits per
100 U.S. population age 20-79 years were calculated.
Population Studied: U.S. population age 20-79 years old,
diagnosed with depression during 1992-97 or 2003.
Principal Findings: Between 1992-93, and 2003, the rate of
office-based visits documenting a diagnosis of depression
increased 43.1% for whites (from 10.9 to 15.6 per 100; p <
0.05), 61.9% for blacks (from 4.2 to 6.8 per 100; p < 0.05),
and 14.6% for Hispanics (from 4.8 to 5.5 per 100; p < 0.05).
The rate of office-based visits with a recorded diagnosis of
depression in concert with the use of antidepressant
pharmacotherapy increased 86.2% for whites (from 6.5 to 12.1
per 100; p < 0.05), 84.6% for blacks (from 2.6 to 4.8 per 100;
p < 0.05), and 60.0% for Hispanics (from 3.0 to 4.8 per 100; p
< 0.05).
Conclusions: By 2003, the population-adjusted rates for
blacks and Hispanics had increased significantly and were
similar. However, the rates for both minority groups
remained far less than half that observed in whites. The
divergence in population-adjusted rates by ethnicity/race
warrants further prospective research.
Implications for Policy, Delivery, or Practice: Our findings
reveal disturbing trends as it regards population-adjusted
rates of diagnosis of depression and/or receipt of
antidepressant pharmacotherapy by ethnicity/race.
Stakeholders (both clinical and administrative) need to discern
the reasons for observed differences in rates of depression by
ethnicity/race, and focus on the physician-patient relationship,
sensitivity and specificity of diagnostic techniques and
instruments, and the wider social context in which an officebased visit occurs, inclusive of access to, and type of health
insurance, and coverage for mental health services.
Primary Funding Source: Pharmacoeconomics and
Pharmacoepidemiology Research Unit
●Access to Gynecologic Services in the Department of
Veterans Affairs
Michelle Seelig, M.D., MSHS, Elizabeth Yano, Ph.D., Andy B.
Lanto, MA, Caroline Goldzweig, M.D., MSHS, Donna L.
Washington, M.D., M.P.H.
Presented By: Michelle Seelig, M.D., MSHS, VA Women's
Health Fellow, VA Greater Los Angeles, 10880 Wilshire
Boulevard, Los Angeles, CA 90024; Tel: (310) 794-6049; Fax:
(310) 794-6097; Email: mseelig@mednet.ucla.edu
Research Objective: Women’s healthcare is typically
fragmented between reproductive and non-reproductive
healthcare services. We evaluated the degree to which
adoption of dedicated women’s care programs that aim to
combine these services whether through primary care
women’s health centers or gynecology clinics, influences
service availability in a national healthcare system where
women are a vulnerable minority.
Study Design: Using data from the VHA Survey of Women
Veterans Health Programs and Practices, a national census of
VA sites conducted in 2001, n=136, 83% response rate, we
compared the on-site availability of selected gynecologic
services by the women’s health service delivery arrangement.
Service delivery arrangements were a gynecology clinic (GYN),
a women’s health clinic for primary care (PC-WH), both GYN
and PC-WH at a site, or neither. Statistical comparisons are
for sites with GYN and/or PC-WH versus those with neither.
Population Studied: senior women’s health clinicians who
were key informants regarding women’s health organization
and services for centers serving at least 400 women.
Principal Findings: Nationally, 31.6% of Veterans Affairs
Medical Centers have a GYN clinic only, 27.9% of have a PCWH only, 26.5% have both, and 14.0% have no separate
women’s care programs. 78.6% of sites with GYN clinics,
73.7% of sites with PC-WH clinics, and 88.9% of sites with
both arrangements offered endometrial biopsies on-site. In
contrast, 11.1% sites with neither of these arrangements
offered this service on-site (p<0.01). 68.3% of sites with GYN
clinics, 64.7% of sites with PC-WH clinics, and 84.4% of sites
with both offered IUD placement on-site. In contrast, 10.5%
sites with neither offered this service on-site (p<0.01). 42.9%
of sites with GYN clinics, 59.5% of sites with PC-WH clinics,
and 58.8% of sites with both offered on-site infertility
counseling and evaluation. 16.7% of sites with neither offered
on-site infertility counseling and evaluation (p<0.01). 20% of
sites with GYN clinics, 28.6% of sites with PC-WH clinics, and
20.0% of sites with both offered onsite infertility treatment.
Only sites with a PC-WH or GYN offered this service on-site.
50% of sites with GYN clinics, 60.5% of sites with PC-WH
clinics, and 75.0% of sites with both offered general
gynecologic surgery whereas 26.3% of sites with neither of
these arrangements offered onsite availability of this service
(p<0.01).
Conclusions: Having GYN clinics significantly increases onsite availability of select gynecologic services for which women
veterans are eligible, yet there are still some services which are
available on-site only on a limited basis. PC-WH expertise was
also associated with high levels of on-site gynecologic service
availability.
Implications for Policy, Delivery, or Practice: Congressional
reforms recently mandated that in addition to the full
spectrum of primary and specialty services for which all
veterans are eligible, women veterans who use VA healthcare
facilities are eligible for a full spectrum of gender-specific
services. Many women VA users obtain gynecologic health
care services through contract and fee basis care in the
community. Fragmentation of care may be reduced by
identifying ways to assure on-site provision of gynecologic
services.
Primary Funding Source: VA
●Improving Inpatient Transportation System to Boost
Patient Satisfaction
Shital Shah, Ph.D., Prakash Venkataramani, BS, Rebecca
Dowling, Ph.D., RD, FADA
Presented By: Shital Shah, Ph.D., Assistant Professor, Health
Systems Management, Rush University Medical Center, 1700
West Van Buren Street, 126B, Chicago, IL 60612; Tel: (312)
942-7926; Fax: ; Email: Shital_C_Shah@rush.edu
Research Objective: Analyze the inpatient transportation
system within an academic hospital to match the anticipated
demand to the available resources. Based on the study of the
demand-supply relationship, specific suggestions will be
developed to reduce total transportation time for the patients.
Study Design: The research involves determining demand
patterns (per hour of the day), potential bottleneck demand
periods, available resources, ideal resource requirements per
hour of the day, and scheduling. The call request data consist
of time stamps for different transportation status such as
appointment, pending, dispatched, in-progress, and
completed. Thus the total transportation time is divided into
multiple components which were analyzed using univariate
statistics. Based upon the analysis of demand, available
resources, and actual transportation time, various operating
scenarios were developed. Linear programming determined
ideal resource levels for each scenario by matching the
number of transportation calls per hour to the potential call
handling capacity of resources.
Population Studied: The data consist of all inpatient
transportation call requests within an academic hospital for a
period of six months.
Principal Findings: Analyzing different components of the
total transportation time identified morning peak hours, after
lunch hour, and afternoon change of shift hours as potential
bottleneck time periods. During these periods, the transporter
assignment constituted a significant portion of total
transportation time due to larger call (per-scheduled and ondemand request) queue formation. The delays were caused
due to equipment availability as well as patients, physician,
and nurse related holdups which resulted in variation of the
transporter travel time to the patients. The actual
transportation time of the patient was fairly uniform through
out the day.
Conclusions: The research provided insight into the
operation of the inpatient transportation system. The analysis
of various components of total transportation time identified
potential bottleneck operations resulting into patient wait
time. Efficient pre-scheduling process, designated equipment
storage locations, and other improvements will reduce patient
wait time and improve the transportation systems overall
efficiency. Demand-supply relationship and ideal resource
requirements per hour of the day will aid in workforce
planning, scheduling, and training.
Implications for Policy, Delivery, or Practice: This research
will result into reduced wait time for the patients, which may
increase patient satisfaction. Also the transportation
operations will be streamlined to better utilize the resources
and reduce the backed-up transportation calls.
Primary Funding Source: No Funding
●Using GIS to Visualize and Analyze How the U.S. Federal
Government Defines Rural
Michael Shambaugh-Miller, Ph.D., Keith Mueller, Ph.D.d, Erin
Wilson, M.A.
Presented By: Michael Shambaugh-Miller, Ph.D., Assistant
Professor, Preventive and Societal Medicine, University of
Nebraska Medical Center, 984350 Nebraska Medical Center,
Omaha, NE 68198-4350; Tel: (402) 559-7858; Fax: (402) 5597259; Email: mdmiller@unmc.edu
Research Objective: This presentation will review progress
being made in an ongoing project designed to gather data on,
construct a GIS of, and analyze the definitions of rural in use
by the federal government.
Study Design: Data collected from Federal agencies, existing
data bases and other research institutions will be used to
create a geographical information system (GIS). Once
constructed spatial analysis packages will be used to
determine populations and impacted and their sociodemographic characteristics. The differing definitions will be
analyzed so as to determine their origins, intent, and level of
use.
Population Studied: Rural
Principal Findings: Initial research has found numerous
definitions (thirteen at this time) in use by the federal
government, all with widely disparate spatial parameters, thus
affecting a wide range of populations and policies differently.
Conclusions: The multitude of rural definitions in use by the
Federal government leads to confusion among policy makers,
rural constituencies, and researchers. This confusion along
with replication of effort in program development leads to
waste and inefficiency.
Implications for Policy, Delivery, or Practice: The argument
will be presented that using a GIS based upon a single preexisting hierarchy of rural definitions would be a more
economical, spatially coherent, and politically neutral method
for the government to create, implement and manage federally
supported rural programs.
Primary Funding Source: Federal Office of Rural Health
Policy
●A Comparison of Elderly Medicare Hispanic Diabetics
with their White Counterparts
Ravi Sharma, Ph.D.
Presented By: Ravi Sharma, Ph.D., Analyst, MCBS Survey
Operations, RB3127, Westat, 1650 Research Boulevard,
Rockville, MD 20850; Tel: (301) 738-3589; Fax: (301) 251-2286;
Email: RaviSharma@Westat.com
Research Objective: In light of the greater incidence of
diabetes among the elderly Hispanic Medicare population
relative to the White population, I compare key characteristics,
health services use, and cost for each population.
Study Design: Using the Medicare Current Beneficiary Survey
data for 2002, I performed a weighted cross-sectional analysis
comparing Hispanics with Whites by demographic
characteristics, health status measures, health insurance,
health services usage, costs, and sources of payment.
Population Studied: All noninstitutionalized, elderly Hispanic
(n=173) and White (n=1290) Medicare beneficiaries with
diabetes in the 2002 MCBS Cost & Use File.
Principal Findings: Elderly Hispanic diabetics with Medicare
coverage differ from their White counterparts in several
respects. Their age distribution is weighted toward the
youngest age group, and to a lesser extent, the oldest (85 and
over) age group. A larger proportion reports 3 to 5 ADL
limitations and fair/poor health status. Hispanics are three
times as likely to have income below $10K. They are half as
likely to have private insurance coverage, but more than three
times as likely to be dually covered by Medicare and Medicaid.
Hispanics are twice as likely to be living with their children.
They have lower incidence of heart disease, osteoporosis, and
cancer, but comparable incidence of other major chronic
diseases. In terms of health services usage, Hispanics are
about half as likely as Whites to use inpatient hospital
services, and if used, the number of episodes is two-thirds
that of Whites. Moreover, Hispanics have fewer medical
provider visits. For every major health service/product,
Hispanics spend less. Indeed, their total average (and
median) health care expenditure for these services is nearly
one-forth below that for Whites. Public sources, particularly
Medicaid, fund a larger share of the Hispanic population’s
health care bill.
Conclusions: Our comparison of elderly Medicare Hispanic
diabetics with their White counterparts reveals significant
contrasts. Notably, Hispanics are more likely to be dually
eligible and have low-income. A larger proportion reports
severe functional limitations and fair/poor health status, but
have report lower incidence of heart disease and cancer.
Hispanics use fewer inpatient and medical provider services,
and spend about 25% less on all major health
services/products.
Implications for Policy, Delivery, or Practice: Because
public sources fund such a large share of healthcare
expenditures of the rapidly growing Hispanic population, an
understanding of key differences between elderly Hispanic
diabetics and their White counterparts is crucial for informed
policy. There are clearly disparities in health status, health
insurance, income, and in the health services usage (and cost)
between the two populations. It is unclear what accounts for
the disparities in usage. If health services usage for the White
population provides a rough benchmark for appropriate care,
it is possible that some medically necessary care may be
foregone by the Hispanic population. Thus, the likelihood of
the need for future, more expensive, medical services may
rise, as will the expected future outlay for Medicare and/or
Medicaid for the elderly Hispanic population.
Primary Funding Source: CMS,
●Family History and Prevnetion of Diabetes: Screening for
Pre-diabetes in Taiwan Population with Family History
Wen-Hsin Shen, BA, HsinChia Hung, Dr.PH, Horn-Che
Chiang, Ph.D., Mei-Tsun Su, BA, Meng-Chuan Huang, Ph.D.,
Yi-Ching Sung, BA, Mei-Ching Chiu, MS
Presented By: Wen-Hsin Shen, BA, Student, Institute of
Health Care Management, National Sun Yat-sen University, 70
Lien-Hai Road, Kaohsiung, 804; Tel: (011886)75252000-4870;
Fax: (011886)7525-1511; Email: nonoingto@yahoo.com.tw
Research Objective: Health intervention program to change
the lifestyles of subjects with pre-diabetes can prevent or delay
the incidence of diabetes. Hence, we evaluate the efficacy of
screening for pre-diabetes among the population with family
history of diabetes and the effectiveness of health education
program for this population in this study.
Study Design: A cross-sectional survey was conducted among
subjects with family history of diabetes and subjects from a
community-based population. The data on demographic
characteristics, height, weight, blood pressure, waist length
and fasting blood glucose was measured by trained nurses. At
the same, the serum was also collected for examinations of
triglyceride amd total cholesterol. Subjects of family history
identified with pre-diabetes or dyslipidemia were further
invited to participate an intervention program including at
least four health education courses.
Population Studied: The blood glucose levels of 174 subjects
with family history were compared with levels of 1,379 subjects
from a community population. 28 subjects of family history
identified with pre-diabetes or diabetes completed the
intervention program and were examined after the program.
Principal Findings: Subjects with family history appeared to
have higher blood glucose levels compared with comunitybased sample (98.4 mg/dl vs. 93.2 mg/dl, p-value=0.04). 47
of 174 subjects (27%) of family history were identified with
pre-diabetes (>=100 md/dl) while 258 of 1379 communitybased participants (18.7%) had pre-diabetes. In the
multivariates-adjusted analysis, subjects with family history, of
age >=65 years, with body mass index >=24 and with
hypertension were 2.05, 1.84, 1.79, and 2.13 times, respectively,
more likely to have pre-diabetes compared with others. For 28
subjects completing the health intervention program, there
were improvements in weight, waist length, blood glucose
level and lipid profiles but only the change in waist length
reached to the significant level (from 86.9 cm to 81.5 cm, pvalue=0.014) and improvement in blood glucose was of
borderline significance (from 109.5 mg/dl to 93.8 mg/dl, pvalue=0.074).
Conclusions: Our findings showed that family history of
diabetes combined with other criteria such as overweight, age
and hypertension can increase the efficacy of screen program
for pre-diabetes and the health education program might be
useful in reducing the risk among this population.
Implications for Policy, Delivery, or Practice: Subjects of
family history of diabetes and other risk factors should be of
priority to be screened for pre-diabetes and receive the health
promotion program in preventing further development of
diabetes in allocation public health resources for prevention of
diabetes.
Primary Funding Source: Bureau of Health Promotion,
Department of Health, Taiwan
●Geographic factors for regional disparity of the quality
and efficiency of the health care in Japan
Sayuri Shimizu, M.Sc., Kiyohide Fushimi, M.D., Ph.D.,
Noritoshi Yoshii, M.D.
Presented By: Sayuri Shimizu, M.Sc., Department of Health
Care Informatics, Tokyo Medical and Dental University, 1-5-45
Yushima, Bunkyo-ku, Tokyo, 1138519; Tel: +81-3-5283-5788;
Fax: +81-3-5283-5788; Email: sshimizu.hci@tmd.ac.jp
Research Objective: Japan has been administrating the
nationwide universal social health insurance system for more
than forty years, however, anticipated very rapid aging of the
population have been urging us to increase the efficiency of
the system. As more medical expenses have been spent by
ambulatory care and long hospital stay in Japan than in other
OECD countries and considerable regional differences in
these expenses are known to exist, the rationalizations of
these expenses are urgently needed. In this research, we have
investigated geographic factors affecting regional differences
of the quality and efficiency of the ambulatory care and
inpatient care.
Study Design: A national patient database with case mix
classification and geographic information was constructed
from the administrative data of the Patient Survey of Japan.
The distances between patient residences and hospitals were
determined from the location of the hospitals and the
representative points of patient residence areas. Hospital
factors were obtained from the Survey of Medical Care
Institutions. Descriptive mapping of regional and diseasespecific differences in the distance to admitted hospitals were
performed. For the examination of the factors affecting the
regional admission rate of selected ambulatory care sensitive
conditions (ACSC), stepwise multivariable regression models
were used. DM, asthma, and hypertension were chosen as
ACSCs. Independent variables included the average age and
male-to-female ratio of the population, the bed number per
population, the intervals of GP visits, the distance from
patient residence to admitted hospitals, average length of
hospital stay. Statistical analyses were performed by Stata/SE
8.0.
Population Studied: A nationally representative sample of 1.5
million out patients and 2 million discharged patients from
the Patient Survey of Japan in 1996, 1999, and 2002 were
analyzed.
Principal Findings: Geographical analyses of patient
residencies showed regional and disease specific differences
of the average distances between hospitals and patient
residencies for acute inpatient care. It was shown that
significant number patients with non-emergent diseases that
require technically-demanding procedures such as PCI or
brain surgery traveled further to admitted hospitals indicating
patients’ preference to specific hospitals. Quality of regional
out patient care was evaluated from the admission rate of
ambulatory care sensitive conditions (ACSC). Crude yearly
admission rates varied from 0.098 to 0.209 for asthma, from
0.085 to 0.129 for DM, from 0.006 to 0.017 for hypertensive
diseases. Regional difference of ACSC admission rate was
explained by male-to-female ratio (b=0.19, p < 0.001) and
average distance to admitted hospitals (b=0.014, p = 0.002,
constant = -0.19, p < 0.001, adjusted r2 = 0.85) by stepwise
multivariable regression analysis. Our results showed that the
regional difference of ACSC admission rate in Japan is mainly
determined by the average distance to the admitted hospital,
and that 1 km increment in the distance to the hospital
increases admission rate of ACSC by 14 %.
Conclusions: Our results implicated that the small number of
high-level surgical hospitals are needed to increase the quality
of the acute care, whereas sufficient regional allocations of
hospitals for primary inpatient care may increase the quality of
ambulatory care and decrease unnecessary admission events.
Implications for Policy, Delivery, or Practice: Health policy
measures to promote stratified allocations of high level
hospitals and primary care hospitals will increase the quality
and efficiency of inpatient and outpatient care.
Primary Funding Source: Other Government
●Types and Strategic Approach of Special Hospitals in
Free Economic Zone, Koera
Euichul Shin, M.D., Ph.D., Hae Jong Lee, Ph.D., Young Dae
Lee, Ph.D., Soo Mi Choi, M.P.H., Jung Sik Woo, M.P.H., YeSoon Kim, BS, Yong Moon, Ph.D.
Presented By: Euichul Shin, M.D., Ph.D., Associate Professor,
Preventive Medicine, Catholic University of Korea, 505 BanpoDong, SochO-gu, Seoul, 137-701; Tel: 82-2-590-1238; Fax: 82-2532-3820; Email: eshin@catholic.ac.kr
Research Objective: There have been strong social debates
related with special hospitals in free economic zone, Korea.
Besides domestic patients coverage, authorization of for-profit
hospitals, level of medical service fee, and coverage by
National Health Insurance are the ones among major issues.
This study is to predict possible impacts and suggest
appropriate types and strategic approach.
Study Design: Authors did literatures review, experts
brainstorming and site visits to the leading countries, which
have prior experiences in free medical market with foreign
countries such as Singapore and Shanghais, China.
Principal Findings: There could be eight types of special
hospitals based on three characteristics: legislative purpose,
medical service level and beneficiary type. Only two are
feasible considering confirmity to its purposes and
profitability. The type 1 hospital provides basic medical
services to foreigners only with domestic resources
(Foreigners Only Hospital, FOH). Otherwise, type 8 hospital
provides supreme medical services to anyone who needs it by
recruiting foreign investments as well (Market Nich Hospital,
MNH).
Conclusions: MNH type seems appropriate in the context
that it could enable Korean economy and healthcare industry
compatible. However, it needs to develop mechanisms to
minimize adverse effects on the Korean healthcare system.
There could be three strategic approaches by regional
characteristics: 1) market nich hospital focusing on valueadded specialties within free economic zone; 2) strong
government support for hospitals entering into foreign
markets; and 3) attraction of foreign patients by utilizing
Korean healthcare infrastructures - introduction of special
beds to existing hospitals.
Primary Funding Source: Korean Medical Association
●Gender Differences Among Desert Storm Veterans with
Post-Traumatic Stress Disorders
Kris Siddharthan, Ph.D, Elizabeth Bass, Ph.D.
Presented By: Kris Siddharthan, Ph.D, Health Services
Researcher, James Haley Veterans Administration Medical
Center, Department of Veterans Affairs, 11605 North Riverhills
Drive, Tampa, FL 33612; Tel: (813) 558-3950; Fax: (813) 5583990; Email: kris.siddharthan@med.va.gov
Research Objective: Posttraumatic stress disorders or PTSD
are a prevalent disorder that has been associated with elevated
rates of medically unexplained physical symptoms significant
functional impairment and high health care use. Little is
known about gender differences in resource utilization
associated with PTSD among combat returnees in the
Veterans Administration or VA. We analyzed inpatient
healthcare use among veterans who were admitted with a
primary diagnosis of PTSD during fiscal years 2003 and 2004
and who were veterans of Operation Desert Storm to
determine if any gender differences exist in the utilization of
VA health services associated with PTSD.
Study Design: The study design involves retrospective VA
utilization data analysis. We obtained national cost estimates
of inpatient utilization for every identified patient from the VA
Health Economics Resource Center. Ordinary regression
analysis was conducted to research the effect of gender on
utilization after adjusting for confounfding variables such as
age, marital status, race, income and LOS.
Population Studied: The population studied was all veterans
admitted with PTSD for fiscal years 2003 and 2004 and whose
period of service included Operation Desert Storm i.e. the
First Iraq war: January-March, 1991. This infromation was
obtained from VA administrative data. Though women do not
serve in combat units they could be subjected to non front line
attacks such as from roadside bombs. We were unable to
determine if veterans actually experienced such combat
conditions
Principal Findings: A total of 612 unique veterans comprising
512 males and 90 females were admitted an average of 1.13
times over the two fiscal years with a primary diagnosis of
Prolonged PTSD (ICD-9-CM code: 30981). Veterans admitted
with PTSD averaged 36 years of age with a mean income of
$18,600. Patients had an average LOS of 15 days at an average
cost of $ 18,368. After adjusting for age, marital status at time
of first admission, income, race and LOS women veterans on
average were likely to cost $2,335 (p<.05) more for the
treatment of PTSD even while incurring approximately 4 days
less in inpatient stays suggesting a possible greater severity of
illness upon admission.
Conclusions: This preliminary study indicates that women
veterans are more prone to severe PTSD. Other studies have
indicated that women disproportionately suffer PTSD due to
sexual assault. We were unable to distinguish among causes
of PTSD in our limited study though our findings indicate a
need for more preventive measures among combat returned
female veterans.
Implications for Policy, Delivery, or Practice: Previous
trauma studies in women veterans have focused on sexual
trauma but have not evaluated the extent to which women
veterans may have experienced multiple types of trauma.
More research needs to be initiated on better understanding
of multiple trauma types over the life course that may have
significant therapeutic implications for women veterans with
PTSD
Primary Funding Source: No Funding
●Evaluation of Pandemic Influenza Plans Within the
United States
Jennifer Sinibaldi, M.P.H., Peter Rumm, M.D., M.P.H., Curtis
Cummings, M.D., M.P.H., Irini Daskalaki, M.D., Ali Rizvi, B.S.
Presented By: Jennifer Sinibaldi, M.P.H., Research
Coordinator, EOH- Center for Public Health Readiness and
Communication, Drexel University School of Public Health,
1505 Race Street Bellet Building 11th Floor, Philadelphia, PA
19102; Tel: (215) 762-7345; Fax: (215) 762-4088; Email:
jls85@drexel.edu
Research Objective: To evaluate various Pandemic Flu Plans
throughout the United States and compare and contrast with
the New Health and Human Services Pandemic Influenza
Plan released in November of 2005.
Study Design: State Pandemic Flu plans were selected by
several individuals within the CPHRC and then reviewed and
evaluated by 3 individuals. Data was then entered into SPSS to
compare state ratings. Each variable constituted one
characteristic per section and there were a total of 11 overall
sections. Those sections include the following: Surveillance,
Laboratory Diagnostics, Healthcare Planning, Infection
Control, Clinical Guidance, Vaccine Distribution, Antiviral
Distribution, Community Disease Control and Prevention,
Management of Travel-Related Risk of Disease Transmission,
Public Health Communications, and Psychosocial Workforce
Support Services. Within each category there was a maximum
of 10 points to be earned.
Population Studied: No particular population is being
studied. It is more reflective of a Literature Review of the
Pandemic Flu Plans for states within the United States. These
states are representative of the U.S. Department of Health and
Human Services 10 regions.
Principal Findings: Many states have capabilities
representative of the New HHS Pandemic Flu plan and there
are many capabilities that need to be enhanced to meet the
needs of the new guidelines for states and local governments.
First, states need to work with local governments to accurately
disseminate timely information to their communities; this
requires cooperation from all three parties involved. Secondly,
there needs to be consideration of psychosocial workforce
support services for those responding to the pandemic and is
not addressed fully in many of the state plans. Finally,
pandemic plans need to take into account real time and
should be exercised as appropriate.
Conclusions: With continuing education and trainings for
preparedness, states and local governments will be able to
meet the capabilities requested of the U.S. Department of
Health and Human Services. Adequate planning for a
pandemic requires the involvement of every level of our
nation. It will compel federal, state, and local governments,
communities, corporations, families and individuals to learn
about, prepare for, and collaborate in efforts to slow, respond
to, mitigate, and recover from a potential pandemic.
Implications for Policy, Delivery, or Practice: There is
potential for states to which the CPHRC will be working with
closely for another project to adopt some suggestions
addressed within this review within their own plans to
enhance their own capabilities.
Primary Funding Source: Pennsylvania Department of
Health, U.S. Department of Health and Human Services
(Region III)
●The Impact of Direct-to-Consumer Advertising (DTCA) in
Orthopaedics: Results of an Opinion Survey Sent to
Patients
Amanda Smith, M.P.H., Sanjo Adeoye, M.B.A.
Presented By: Amanda Smith, M.P.H., Research Director,
Orthopaedic Surgery, UCSF, 3333 California Street, #265, San
Francisco, CA 94143; Tel: (415) 439-9472; Email:
smitha@ucsf.edu
Research Objective: Over the past decade, there has been
significant demand from healthcare consumers for
information related to the diagnosis and treatment of chronic
illness. During this same time period, physicians, health
plans, hospitals, pharmaceutical companies, and medical
device manufacturers have all recognized the benefits of
marketing their products and services directly to the end user.
As a result, there has been tremendous growth of direct-toconsumer advertising (DTCA) including an increase in
spending on DTCA related to prescription drugs from an
estimated $55 million in 1991 to a staggering $3.2 billion in
2003. In the past, orthopaedic surgery had been relatively
insulated from this expanding trend I DTCA. However, this is
no longer the case as physicians, hospitals, and device
manufacturers are starting to utilize this marketing strategy to
attract patients, hoping to replicate the success of DTCA in
the pharmaceutical industry. Although there are numerous
studies evaluating the of DTCA in the pharmaceutical industry,
there are no equivalent studies in orthopaedic surgery.
Study Design: This study utilized an opinion survey given to
the patient before their surgery for a total knee or total hip
replacement. The anonymity of the patient was protected.
This survey included questions about:(1) Awareness and
exposure of direct-to-consumer advertising in orthopaedics;
(2) Processes they may have used to seek additional
information about advertised products and technologies; (3)
Level of satisfaction with the quality and accuracy of
information provided in direct-to-consumer advertising; and
(4) General opinion of direct-to-consumer advertising.
Population Studied: Patients presenting at a single academic
medical center for their pre-operative appointment for either a
total knee replacement or total hip replacement. Seventy-six
patients completed the opinion survey, and 24 patients
refused.
Principal Findings: The patients who completed the survey
were predominately well educated, with 69.4% finishing at
least some college, female (55.3%) and Caucasian (69.3%).
Exactly half the patients were there for knee replacements, the
other half for hip replacements. Before talking with their
doctors, 63.2% had an opinion about a type of surgery they
thought was right for them, and 23.7% had an opinion about a
type of surgery they thought was right for them. Only one
patient out of 39 learned about the implant or surgery from an
advertisement (print, not television), while the other 38 cited
family and friends as their biggest source of information. For
the most part, patients had positive opinions about DTCA,
including 32.6% of patients who said they like seeing
advertisements for surgeries and/or implants, 56.7% said
advertisements make them more aware of new technology,
joint implants or surgeries, and 51.4% thought that
advertisements educate them about medical conditions they
might have or potentially have.
Conclusions: Very few patients endorsed bringing
information with them to their physician visit, or questioning
the doctor about a particular type of surgery or implant,
although most had an opinion about what was right for them
before seeing their doctor. Overall, patients seemed to feel
DTCA had a positive impact and the majority saw multiple
surgeons and looked for information from multiple sources
before agreeing to their surgery. Current research is being
conducted to determine if there is geographic variability in the
consumer's exposure to DTCA in orthopaedics.
Implications for Policy, Delivery, or Practice: DTCA often
confuses/misleads the consumer which can lead to
inappropriate demand for a particular surgical technique or
implant technology. If the physician disagrees with the
patient’s request for a particular surgical technique or implant,
this strains the patient-physician relationship and consumes a
very important resource, the physician’s time. Physician
compliance with the demand, if inappropriate, creates an
environment of decreased quality of care, inappropriate use of
technology, increased utilization of valuable resources and a
diminished role of the physician in clinical decision making.
Primary Funding Source: No Funding
●A Comparison of Magnet and Non-Magnet Hospitals on
Better Quality Measures: Heart Attack, Heart Failure, and
Pneumonia Adult Patients
Teresa Tai, Ph.D.
Presented By: Teresa Tai, Ph.D., Associate Professor,
Management, Quinnipiac University, 275 Mount Carmel
Avenue, Hamden, CT 06518; Tel: (203)582-8279; Fax:
(203)582-8664; Email: teresa.tai@quinnipiac.edu
Research Objective: The purpose of this study was to
examine whether “magnet hospitals” known to be good places
to practice nursing continue to provide better quality care to
patients with heart attack, heart failure, and pneumonia than
non-magnet hospitals. This study presents a unique
opportunity to investigate the effects of excellence nursing
services on quality of care in a large case-control analysis.
Study Design: Case-control study
Population Studied: To compare the quality of care provided
to patients with heart attack, heart failure, and pneumonia by
magnet status, a case-control study was conducted in Fall,
2005. Magnet hospitals were identified from the American
Nursing Credentialing Center website. All hospitals in United
States that received magnet designation as of September 8,
2005 were eligible for inclusion in this study (n=154).
Children’s, cancer, surgical, and rehabilitation hospitals were
excluded from this study because they did not provide heart
attack, heart failure, and pneumonia care to adult patients.
The final study group consisted of 133 magnet hospitals
across the country. The control group consists of 266 general
medical and surgical hospitals that did not received a magnet
designation as of September 8, 2005. Using the US News
Directory of America’s Hospital website, two control nonmagnet hospitals were matched by the nearest driving
distance from each magnet hospital. Matching magnet
hospitals with non-magnet hospitals with comparable
geographic, economic and demographics characteristics helps
control confounding bias in case-control study. Next, 18
hospital quality performance measures – 8 heart attack, 4
heart failure quality, and 6 pneumonia care quality indicators –
were obtained for each magnet and non-magnet hospital from
the CMS’s Hospital Compare website.
Principal Findings: Heart Attack: Magnet hospitals
outperformed non-magnet hospitals in five of the eight heart
attack quality measures. Magnet hospitals were significantly
more likely to give heart attack patients aspirin at arrival,
aspirin at discharge, Beta Blocker at arrival, Beta Blocker at
discharge, and adult smoking cessation advice/counseling
than non-magnet hospitals. Heart Failure: Two of the four
heart failure quality measures were statistically significant.
Magnet hospitals were significantly more likely to give heart
failure patients assessment of left ventricular function and
adult smoking cessation/counseling than non-magnet
hospitals. Pneumonia: Only one of the six pneumonia quality
measures was statistically significant. Magnet hospitals were
significantly more likely to give pneumonia patients
oxygenation assessment than non-magnet hospitals.
Conclusions: Consistent with prior research, magnet
hospitals continue to provide better care to patients when
compared with non-magnet hospitals.
Implications for Policy, Delivery, or Practice: Magnet
hospital as an "employer of choice" model was long known to
be a long term solution to the recruitment and retention of
high qualified nurses. Magnet program is still attractive after
all these years because it uses team- and culture-building, high
degree of nurse autonomy, participative management, good
communications with physicians, strong and visible nursing
leadership, and strong board commitment for measurably
improved patient care, rather than rely on quick fixes such as
wages, sign on bonus, and agency workers to solve nursing
shortages. In an environment common with controversy
about patient safety in hospitals, medical error rates, and
nursing shortages, consumers need to know how good the
care is at their local hospitals. It can also regain public trust in
quality patient care. Considerable research has examined the
benefits of magnet program. Yet no research has examined
the variations of quality performance by magnet designation
or not. This study explained the variations and reaffirmed the
long-term competitive advantage of a magnet status.
Primary Funding Source: No Funding
●The Impact of Aging on Morbidity and Utilization
Deborah Taira, Sc.D., Richard Chung, M.D.
Presented By: Deborah Taira, Sc.D., Research Manager, Care
Management, HMSA (BCBS of Hawaii), 818 Keeaumoku
Street, Honolulu, HI 96825; Tel: (808) 948-5337; Fax: (808)
948-6043; Email: deb_taira@hmsa.com
Research Objective: To describe the demographics,
morbidity, utilization, and costs of pre-elderly (age 50-64) and
elderly enrollees by 5-year age interval
Study Design: Retrospective cross-sectional observational
study.
Population Studied: All enrollees of a large health plan in
Hawaii who were age 50+ and were enrolled at any time
during 2004 in all lines of business except Medicaid.
Principal Findings: The pre-elderly population was
approximately 53% female, while the elderly population (age
65+) was 71% female. Examining Adjusted Clinical Group
(ACG) morbidity levels, we found that 6% of members aged
50 to 54 had a high morbidity level, compared to 19% of
members aged 70 to 74 and 36% of members over age 90.
The percentage of members with a hospitalization during the
year was 4 percent at age 50-54, 11% at age 70-74, and 30% at
age>90. The mix of diagnoses differed as well with younger
members being hospitalized more often for digestive issues
and older members being hospitalized for injury and
respiratory problems. Similarly, the percentage of members
with an emergency department visit increased with age, from
10% at age 50-54 to 12% at age 70-74, and 20% at age>90.
Conclusions: Morbidity and utilization rise at an increasing
rate as members age. Also, the mix of diagnoses changes
with more members being hospitalized for injuries and
respiratory problems.
Implications for Policy, Delivery, or Practice: In
implementing health promotion and disease management
programs, health plans may wish to develop age-specific
interventions.
Primary Funding Source: No Funding
●Examining Population Characteristics, Utilization, and
Costs of Patients with Chronic Obstructive Pulmonary
Disease (COPD)
Deborah Taira, Sc.D., Jun Zhu, Ph.D., Jeremy Martins, BA,
Ronald Y. Fujimoto, DO, John Berthiaume, M.D.
Presented By: Deborah Taira, Sc.D., Research Manager, Care
Management, HMSA (BCBS of Hawaii), 818 Keeaumoku
Street, Honolulu, HI 96808-0860; Tel: (808) 948-5337; Fax:
(808) 948-6043; Email: dataira@yahoo.com
Research Objective: To quantitatively describe the
demographics of COPD population. To assess the impact of
COPD disease management program conducted on medical
cost and utilization of the COPD patients over time. To
examine the factors which may have significant influences on
the medical cost among COPD patients.
Study Design: We tracked the COPD population by quarters
from January 1999 to June 2005. A descriptive analysis was
conducted on the COPD population and the variation of total
medical cost over time prior to and after the implementation
of the COPD disease management program. A linear multiple
regression model was used to determine the factors that had
significant impacts on the medical cost for the COPD patients.
Population Studied: All COPD patients in the COPD disease
management program database with this insurer between
January 1999 and June 2005 (n=6356).
Principal Findings: Number of COPD patients per 1000
members (COPD patients per 1000) peaked at age 71 to 90.
There were 10-12% more male patients than female in this age
group. COPD patients per 1000 persistently increased from
2.3 in 1999 to 9.1 in 2004, and new COPD patients per 1000
increased from 1.0 in 1999 to 1.8 in 2004. The lowest COPD
patients per 1000 (4.1) occurred in the island of Molokai and
the highest number (8.1) occurred in the island of Kauai. Total
eligible cost for COPD patients increased with age, and was
significantly higher for the COPD patients having higher ACG
morbidity levels (4-5) than those having lower morbidity levels
(0-3). Patients using oxygen had significantly higher medical
expense than those without oxygen usage. Per-member-permonth costs for both medical and drug consistently increased
from 1999 to 2003, but leveled off after the initiation of the
COPD disease management program in early 2004.
Conclusions: Members between ages 71 and 90 and
members living in Kauai had the highest COPD patients per
1000, and therefore need to be targeted for more intense
intervention under the COPD disease management program.
The COPD disease management program appears to have
helped to reduce growth in medical and drug expenses among
COPD patients.
Implications for Policy, Delivery, or Practice: The COPD
disease management program should pay special attention to
the population over 71 years old, especially the male
population, and the members in Kauai. This program seems
to have reduced the medical and drug expenses for COPD
patients. Continued efforts are needed for better understand
the factors associated with this cost reduction in order to
improving the management of the program.
Primary Funding Source: No Funding
●The Long-Term Impact of Disease Management on the
Quality of Life in Patients ith Coronary Artery Disease,
Diabetes or Heart Failure.
Michael Taitel, Ph.D., David R. Walker, Ph.D
Presented By: Michael Taitel, Ph.D., Research and
Development, CorSolutions, 9500 Bryn Mawr Avenue, Suite
500, Rosemont, IL 60018; Tel: (800) 343-6311 x2650; Fax:
(847) 671-6853; Email: Mtaitel@Corsolutions.com
Research Objective: To assess the long-term impact of
disease management (DM) on patient quality of life (QoL).
This study looked at three major DM programs including:
coronary artery disease (CAD), diabetes and heart failure (HF).
Study Design: : The study sample included patients from
three DM programs including CAD, diabetes, and HF.
Patients had to be in the program at least 90 days and
completed two SF8 QoL surveys. The study period was from
2003 through 2005. Specific QoL indicators from the SF8
survey included a physical health component (PCS) and a
mental health component (MCS). Patients were considered
short-term if the time between the baseline SF8 survey date
and the last SF8 survey date was less than 1 year and longterm if the time was one year or greater. Paired t-test was
used to assess the statistical significance of a mean change in
PCS and MCS scores. The 95% confidence interval for
estimating a clinically significant change in mean score is +/6.3 for MCS and +/- 5.7 for PCS.
Population Studied: The total study population was 3,337
high-acuity patients enrolled for at least 90 days in one of
three DM programs including CAD (271), diabetes (743) and
HF (2,323). Average age for the total study population was 58.1
years, ranging from 29 to 65 years. Approximately 60% was
female.
Principal Findings: For the overall study population, MCS
improved significantly for both short-term patients (47.6 to
48.7, p <.001), and long-term patients (45.9 to 48.6, p < .001).
For PCS, long-term patients had a statistically significant
increased PCS (42.7 to 44.7, p<.001), whereas short-term
patients had a non-significant increase (41.8 to 42.1, p = 0.45).
For CAD patients, only short-term patients had a statistically
significant increase in MCS (48.5 to 50.7, p < .01) and no
statistically significant increase in PCS. Short-term diabetic
patients had statistically significant increases in MCS (47.5 to
49.3, p < .01) and PCS (43.3 to 44.7, p < .05). Long-term
diabetic patients also had increases in MCS (46.2 to 48.8, p <
.001) and PCS (41.9 to 44.2, p < .001). Short-term HF
patients did not have statistically significant increases in either
MCS or PCS. However, long-term HF patients had statistically
significant increases in MCS (46.2 to 48.8, p < .001) and PCS
(42.6 to 44.8, p < .001). With respect to clinical significance,
for all long-term patients, 27.8% had significant clinical
improvement in MCS and only 10.3% had become clinically
worse. For PCS, 32.9% improved clinically and 19.5%
worsened clinically.
Conclusions: These initial results provide evidence that DM
positively impacts patient QoL, especially for those that
continue beyond a year in the program. Importantly, these
results generally hold across programs.
Implications for Policy, Delivery, or Practice: These initial
analyses implies that it is important for patients with chronic
diseases to have DM support services for at least a year to
realize statistically and clinically significant improvements in
quality of life. Importantly, recent research has shown that
QoL improvement is associated with reduced healthcare
costs.
Primary Funding Source: No Funding
●Cost-Effectiveness of Atypical Antipsychotics
Jeffery Talbert, Ph.D.
Presented By: Jeffery Talbert, Ph.D., Professor and Chair,
Health Management and Policy, University of North Texas
Health Science Center, 3500 Camp Bowie Boulevard, Fort
Worth, TX 76107; Tel: (817) 735-5027; Email:
jtalbert@hsc.unt.edu
Research Objective: Given the wide range of medication
costs for atypical antipsychotic agents, what is the impact of
medication choice on overall health cost and patient
outcomes? Most studies of antipsychotic use compare older
first generation agents (Haloperidol) with one or two of the
newer atypical agents (Olanzapine or Risperidone). With the
introduction of Aripiprazole in late 2002, there are five atypical
antipsychotic agents available. This study compares the costeffectiveness of all five agents.
Study Design: A retrospective analysis of administrative
claims data for patients with a diagnosis of schizophrenia
(ICD-9 295.xx) enrolled in the Kentucky Medicaid from 20032005. The analysis uses a multivariate regression to compare
total and component payments for all medical services the
twelve month period after (2005) new treatment initiation
(2004). The analysis includes adjustment for prior year
(2003) demographics, comorbidities, medication use, and
other medical service use. Thus, the study design uses three
years of data to make one cohort--2003 data is used as a
control for patients who begin new therapy during 2004 to
predict patient experience in 2005.
Population Studied: Patients enrolled in the Kentucky
Medicaid program with a diagnosis of schizophrenia during
2004. After reducing the sample for patients eligible over the
three year period and for those patients who began new
therapy during 2004, there are about 4000 patients used for
the analysis.
Principal Findings: There are significant cost differences
between the five atypical antipsychotic agents used to treat
patients with schizophrenia. The newest agent, aripiprizole,
has the lowest overall medical cost of the five agents reviewed
and appears to offer the best choice to treat patients with
schizophrenia.
Conclusions: The atypical antipsychotic drug class is the
most costly drug class for state Medicaid programs. While
some states initiate step therapy or prefered drug list to
control access to costly agents in the class, there may be
better overall cost savings by increasing availability of specific
agents. This analysis finds that airpiprazole provides the most
cost-effective outcome for treating patients with
schizophrenia.
Implications for Policy, Delivery, or Practice: Schizophrenia
has a lifetime prevalence of 1-2% yet consumes about 3-4% of
health expenditures. Since states are the largest purchasers of
antipsychotic agents, efforts to determine the most cost
effective use of these agents is of great value to state and
federal policymakers.
Primary Funding Source: Other Government
●Comparing Decision Aids for PSA Screening: Going
Beyond the Blood Test
Steven Tally, Ph.D., Vibha Bhatnagar, M.D., Dominick L.
Frosch, Ph.D., Robert M. Kaplan, Ph.D.
Presented By: Steven Tally, Ph.D., Project Manager, Family
and Preventive Medicine, University of California, San Diego,
9500 Gilman Drive 0994, La Jolla, CA 92093-0994; Tel: (858)
964-4572; Fax: (858) 630-4469; Email: stally@ucsd.edu
Research Objective: To compare Internet-based decision aids
for prostate specific antigen (PSA) screening to publicly
available websites from the Centers for Disease Control (CDC)
and the American Cancer Society (ACS).
Study Design: 234 volunteers (mean age = 58.6 years)
received recruitment letters inviting them to participate in a
study about PSA testing. Participants were required to have
Internet access. Those offering electronic consent were
randomized to one of four intervention arms that provided
information regarding PSA testing. The Internet sites
corresponding to the four study arms provided the following
types of information: Group 1: Traditional didactic decision
aid providing comprehensive information about PSA
screening and prostate cancer. Group 2: Decision aid using a
chronic illness trajectory model for prostate cancer followed by
a time trade-off exercise. Group 3: Both didactic and time
trade-off decision aids Group 4: Directions (links) to PSA
testing information on publicly available websites sponsored
by the CDC and ACS. After reviewing the information,
subjects were asked to re-visit the study website after their
scheduled health exam. During this second login, patients
were asked whether they had chosen to have a PSA test, and
to answer a validated 10-item PSA Knowledge Questionnaire.
Population Studied: Participants were recruited from a
national health care provider when they were contacted to
schedule a routine health maintenance exam. Participants
were predominantly married (78.6%), educated (62.2%
college graduate), and Caucasian (88.2%).
Principal Findings: General knowledge scores for the
combined 10-item PSA Knowledge Questionnaire were higher
for those in Group 1 (didactic decision aid) as compared with
those in Group 4 (publicly available Internet links) (p = .005).
Men randomized to Group 1 (didactic decision aid), or
Group 2 (utility-TTO) were more likely to know that if you have
an abnormal PSA it may lead to a biopsy in comparison to
Group 4 (Internet links) (p = .006; 002). Men randomized to
Group 1 (didactic decision aid) were more likely to know that
the PSA test will not pick up all prostate cancers in
comparison to Group 4 (Internet links) (p = .031). Knowledge
scores for both Group 2 (trajectory/time trade-off), and Group
3 (combination) were also higher than those of Group 4;
however, the differences were not significant.
Conclusions: · Men randomized to decision aids designed
to inform about PSA screening scored higher on a knowledge
measure than men who reviewed reputable websites.
Commonly used websites need to be formally evaluated to
ensure viewers have an understanding of disease specific
information. Websites designed to enhance decision making
may lead to different choices than reputable websites that
summarize recommendations.
Implications for Policy, Delivery, or Practice: Cancer
screening is an important factor in health care costs.
Engagement of patients in shared decision making may lead
to reductions in utilization. Information offered by reputable
organizations may be inadequate for engaging patients in the
decision process. It is suggested that organizations need to
develop a new generation of websites that more actively
engage patients and require a higher level of patient
involvement in decision making.
Primary Funding Source: CDC
●Access to Employer-Sponsored Insurance with Fully Paid
Premiums: Employees’ Enrollment Decisions
Amy Taylor, Ph.D., Alice Zawacki, Ph.D.
Presented By: Amy Taylor, Ph.D., Senior Economist, Center
for Financing, Access, and Cost Trends, Agency for Healthcare
Research and Quality, 540 Gaither Road, Rockville, MD 20850;
Tel: (301)427-1660; Fax: (301)427-1276; Email:
ATaylor@ahrq.gov
Research Objective: In 2003, 44 percent of establishments in
the U.S. offered at least one health insurance plan that
required no contribution from the employee for single
coverage. However, not all eligible employees enrolled in
these plans. Some eligible employees might want family
coverage, while only single coverage is fully paid, or perhaps
these plans are unattractive. The objective of this study is to
examine health insurance enrollment in establishments that
pay 100 percent for at least one plan and to study the plans
that employees were enrolled in.
Study Design: Bivariate analysis is used to look at the percent
enrolled at both the establishment and plan level. We look at
employers offering only one plan and more than one plan,
further subsampled into those that paid 100 percent of the
premium cost and those that did not. To help explain why all
eligible employees do not enroll in fully paid plans, we will
compare enrollment in plans where single coverage is fully
paid, but family coverage is not, and enrollment in plans with
both single and family coverage fully paid. To examine the
impact of a plan’s attractiveness on enrollment in fully paid
and not fully paid plans we compare their characteristics. We
focus on attributes that might make a plan more attractive,
such as provider choice, coverage for pre-existing conditions,
and no gatekeeper. Multivariate analysis will also be done to
explain the impact of multiple dimensions of attractiveness on
enrollment and compare the plans paid 100 percent with
those that are not. This will focus only on plans from
establishments offering more than one plan, in order to
control for workforce characteristics.
Population Studied: The nationally representative sample of
private establishments found in the MEPS-IC from 1997-2003.
Principal Findings: In 2003, only 87 percent of eligible
employees in establishments that offered only one plan, with
fully paid single coverage, enrolled in the plan. At the same
time, only 33 percent of eligible employees in establishments
that offered more than one plan enrolled in plans that had
fully paid single coverage. Plans that were paid 100 percent by
employers generally had gatekeepers, did not cover preexisting conditions or outpatient prescriptions, and had the
highest out-of-pocket expense limits.
Conclusions: Preliminary results indicate that some eligible
employees may not be enrolling in fully paid health plans
because the plans are not attractive to them. Further analysis
will be done to examine whether employees do not opt for
plans with fully paid single coverage because they want family
coverage.
Implications for Policy, Delivery, or Practice: Even when
employers provided access to health insurance with fully paid
premiums, all eligible employees did not enroll in the plan.
This study will investigate reasons for this, including the
possibility that only single plans were fully paid while workers
wanted family coverage, or because these plans were
unattractive. Looking at who enrolls and the plans chosen
when employers pay the full cost of health insurance for at
least one plan will improve our understanding of employee
preferences and enrollment decisions and thus help decision
makers concerned about increasing the number of workers
with health insurance coverage.
Primary Funding Source: No Funding
●Predicting Antihypertensive Drug Utilization: An
Application of Latent Class Models
Patrick Thiebaud, Ph.D., Bimal V. Patel, Pharm.D., MS, Ken S.
Wong, Pharm.D.
Presented By: Patrick Thiebaud, Ph.D.,10680 Treena Street,
Sand Diego, CA 92131; Tel: (858) 790-6264; Email:
Patrick.thiebaud@medimpact.com
Research Objective: To construct a predictive model that can
analyze patterns of antihypertensive drug utilization, forecast
utilization of antihypertensive agents, and identify patients
who are likely to become non-compliant with their medication
treatment.
Study Design: Patients on antihypertensive therapy were
followed for 3 ½ years and utilization was summarized for
each quarter. The first two quarters represented baseline
utilization, and the following 12 quarters determined individual
utilization trajectories. Latent class panel models were used to
estimate drug utilization trajectories and to divide patients
into subgroups with specific longitudinal drug utilization
patterns. The estimated trajectories and groups were used to
identify patients with low compliance. The sample was divided
into a training set for model development and a test set for
validation. Two models were developed to forecast the
number of prescriptions filled and the probability of exceeding
a specific cost threshold in each quarter. The accuracy of each
model was tested by comparing predicted and actual
outcomes.
Population Studied: Patients were included in the study if
they had at least one antihypertensive drug claim during the
baseline period. The sample consisted of 23,272 commercial
patients who were continuously eligible for drug benefits for a
minimum of 3½ years. Demographic characteristics, drug
benefit details, and concurrent prescriptions served as
covariates in the models.
Principal Findings: Latent class models accurately separated
patients into low or high cost groups using only baseline
information. The estimated number of prescription claims in
the quarter following baseline was within 0.1 prescriptions of
the actual figure of 3.5 (average of absolute deviation).
Forecasting five quarters ahead was less precise and fell within
1.0 prescriptions of the actual figure of 2.2. Finally, quarterahead forecasts using information collected up to the fourth
quarter resulted in estimates 0.4 prescriptions off the actual
figure of 2.9.
Conclusions: The latent class panel models in this study
produced reasonably accurate forecasts of antihypertensive
drug utilization considering the limited amount of information
available from prescription claims only.
Implications for Policy, Delivery, or Practice: Our
antihypertensive predictive models demonstrate that
parsimonious models (i.e. models requiring only a limited
amount of information on patients) can successfully forecast
future resource utilization and stratify patients into dynamic
compliance groups. This type of model can provide important
insights into populations at high risk for low compliance and
can help employers and managed care organizations create
targeted clinical intervention programs to address this
problem.
Primary Funding Source: Novartis Pharmaceuticals Corp.
●Healthcare Demand, Utilization, Satisfaction for the
Prisoners in Taiwan
Wen-Chen Tsai, Dr.P.H., Pei-Tseng Kung, Sc.D., Wu-Long
Chang, M.H.A.
Presented By: Wen-Chen Tsai, Dr.P.H., Associate Professor,
Health Services Management, China Medical University, 11
Ln16 Sec3 Chungching Road, Taya, Taichung, 42805; Tel:
(886)425-603149; Fax: (886) 425-603149; Email:
wtsai@mail.cmu.edu.tw
Research Objective: This study investigated healthcare
demand and supply in prisons in Taiwan. Prisoners'
healthcare demand, utilization, and satisfaction were
examined.
Study Design: This is a cross-sectional research and a
retrospective study. The structured questionnaire was used to
collect data. The multiple regression analysis was conducted
to examine the factors influencing prisoner's satisfaction of
healthcare services. In order to understand current supply of
medical utilization in each prison, we obatined related
information from the public health office in eah prison.
Population Studied: One-tenth of all prisoners were stratified
sampling from 47 prisoners in Taiwan. There were 5369
questionnaires being collected.
Principal Findings: Average number of medical utilization is
14.6 per prisioner per year. The major three diseases of
prisoners are skin disease,intestines and stomach digestive
system related diseases and hypertension. The major nonprescription drugs prisoner taking are analgestic tablet, cold
drug and skin ointment. Approximate 26 percent of prisoners
satisfied with medical services whereas 25% did not. The
prisoners have higher satisfaction inmedical care environment
and patients' privacy, but they have higher dissatisfaction in
time of outpatient services, types of healthcare services and
doctor's explanation of sickness. The influencing factors of
healthcare satisfaction include the speed of going to a doctor
after claim, the degree of medicines offered meeting
prisoner's needs, types of medical services, days of outpatient
services weekly, ratio of the number of public outpatients
services to the number of prisoners and other satisfaction for
specific medical services such as doctor's explanation of
sickness, doctor's explanation of drug use, and attitudes of
other medical staffs. The shortage of specialists is the main
problem for 68% of prisons. The insufficient manpower of
nurses and physicians at night or on holidays is also the
problem for most of the prisons. Furthermore, the scanty
isolated wards for infection diseases and debts of prisoners
for healthcare services are also the major issues.
Conclusions: The prisons in Taiwan provide acceptable
healthcare services to meet the prisoners' basic needs.
However, owing to the shortage of government's budget or
the problem of salary system for physicians to provide
healthcare services in prisoners, most of the jail cannot
provide adequate physicians and nurses.
Implications for Policy, Delivery, or Practice: This study
recommendatios that in order to attract full-time physicians to
work for the prisons, government should improve the
payment system for physicians to provide healthcare services
in prisoners.
Primary Funding Source: Department of Health, Taiwan
●Predicting Costs of Acute Hospitalization for First-Ever
Ischemic Stroke in Taiwan
Mei-Chiun Tseng, Ph.D., Ku-Chou Chang, M.D., Huey-Juan
Lin, M.D., Tsu-Kung Lin, M.D., Ph.D., Teng-Yeow Tan, M.D.
Presented By: Mei-Chiun Tseng, Ph.D., Professor, Business
Management, National Sun Yat-Sen University, 70 Lian-Hai
Road, Kaohsiung, 804; Tel: +886 (7) 5252000 x4629; Fax:
+886 (7) 5254698; Email: mctseng@mail.nsysu.edu.tw
Research Objective: To predict the direct costs of acute
hospitalization for patients with first-ever ischemic stroke in
Taiwan.
Study Design: Data from a hospital-based registry were used
for developing a regression model. The hospital is a 2400-bed
nonprofit proprietary hospital, providing medical-center-level
healthcare in an area with a population of approximately 3
million in southern Taiwan. Patients who received acute
thrombolytic therapy were excluded. In this study costs were
hospital charges, which were the reimbursement claims made
to the Bureau of National Health Insurance in Taiwan.
Because the intent is for the model to be predictive, we
considered only those factors that could be assessed at the
time of admission, including age, sex, comorbidity (any of
hypertension, diabetes mellitus or hypercholesterolemia),
smoking, congestive heart failure, valvular heart disease, atrial
fibrillation, history of cardiac disease, National Institutes of
Health Stroke Scale (NIHSS) score, and Barthel Index.
Stepwise variable selection was used to identify the most
significant predictors. The model was validated on
subsequent patients prospectively and independently collected
in the same study hospital.
Population Studied: The model was generated from 360
patients consecutively admitted with first-ever acute ischemic
stroke within 48 hours of onset between September 1998 and
October 1999. An independent cohort of stroke patients that
were prospectively collected (September 2002 to April 2003)
in a similar way from the same hospital was used for
validation.
Principal Findings: Major predictors were NIHSS score at
admission (NIHSS 7-15, or NIHSS 16-38, versus NIHSS 0-6),
Barthel Index score at admission (60-100 versus 0-55), sex,
smoking and congestive heart failure. The model performed
reasonably well, judging by the model statistics (model
F=32.2, 6 df, P<0.0001, adjusted R-squared equals 0.3427).
The reliability of the fitted model was evaluated by obtaining
shrinkage on cross-validation of 0.0534.
Conclusions: The regression model allows for prediction of
the direct costs of acute hospitalization for patients with firstever ischemic stroke in Taiwan, which may have important
uses in budgetary planning.
Implications for Policy, Delivery, or Practice: Stroke severity
measured by NIHSS strongly affects costs. Clearly, disease
severity should be included in any decisions regarding
healthcare resource allocation and when the impact of certain
therapeutic strategies is assessed.
Primary Funding Source: National Science Council, Taiwan
●Improving the Quality of Care for Cardiovascular
Disease: Using National Medicare Managed Care
Performance Data to Investigate Race (White and Black)
Differences in HEDIS? Measures Related to Heart
Disease—Controlling High Blood Pressure
Sally Turbyville, MA, Ann Chou, Ph.D., M.P.H.
Presented By: Sally Turbyville, MA, Senior Health Care
Analyst, Quality Measurement, NCQA, 2000 L Street, N.W.,
Suite 500, Washington, DC 20036; Tel: (202) 955-1756; Fax:
(202) 955-3599; Email: turbyville@ncqa.org
Research Objective: Race disparities in health outcomes are
a well documented occurrence in the US. We examined the
relationship between health plan characteristics and racial
disparities in plan performance for controlling high blood
pressure among Medicare Managed Care plans.
Study Design: Data collected using HEDIS 2005
specifications (2004 measurement year) were used to
examine the relationship between controlling patient’s high
blood pressure and health plan characteristics. Patient level
race data located in CMS enrollment data was linked to the
member level detail of HEDIS health plans submit to CMS.
NCQA applied geo-coding method and census data to
estimate plan mean income. Performance rates were
calculated by black and white enrollees; a disparity score was
derived by subtracting the black performance rate from the
white performance rate within a health plan. Health plan
characteristics include: HEDIS performance, profit status,
geographic location (census regions), accreditation status
(NCQA MCO Accreditation ), enrollment size, percent black
enrolled, the income mean of plan members and plan model
(network, staff/group).
Population Studied: For this report, NCQA limited the
analysis to those health plans with at least 30 blacks and 30
whites in the Controlling High Blood Pressure HEDIS
denominator. Meeting these criteria, 67 health plans were
included in this analysis. During 2004 approximately 33
percent of members enrolled in Medicare managed care who
were diagnosed with hypertension did not have their blood
pressure controlled.
Principal Findings: Among the 67 plans included in this
analysis, the average performance for Controlling High Blood
Pressure was 60.8 percent; the average disparity score was 5.8,
ranging from -8.3 to 24.9. Health plans performing below the
mean had an average disparity score of 3.9 and those
performing above the mean had an average disparity score of
7.5. 16.4 percent of the health plans had a disparity score
below -2.00, 16.4 percent had a disparity score between -1.99
and 2.00, 32.8 percent had a score between 2.01 and 8.00,
and the remaining 34.4 percent of health plans had a disparity
score above 8.01. The mean difference in disparity scores
between health plans’ profit status and accreditation status
were less than one point. Small health plans had lower
disparity scores (3.7) than large health plans (7.1). Health
plans with less than 10 percent black enrollees had a disparity
score of 4.5 and health plans with more than 30 percent black
enrollees had a disparity score of 4.8. Mean disparity scores
for health plan’s with a member mean income of less than 30
thousand dollars was 5.4, between 30 and 35 thousand dollars
6.6, and more than 35 thousand dollars 4.4. Health plan
disparity scores by region ranged from 12.4 (Mountain) to 0.9
(Pacific).
Conclusions: An intended purpose of this analysis was to
elucidate solutions by identifying health plan structural or
demographic characteristics related to disparities in
controlling high blood pressure. We found some differences in
disparity scores by health plan size, region, and HEDIS
measure performance. Because this analysis was limited to 67
health plans, it may be worthwhile to explore these
relationships with a larger data set.
Implications for Policy, Delivery, or Practice:
Understanding managed care health plans’ structural or
demographic characteristics which may affect, directly or
indirectly, disparities in the population that it serves may
contribute to our ability to eliminate racial disparities
throughout the US health care system.
Primary Funding Source: No Funding
●Prostate Cancer Screening Practice Style Among Primary
Care Providers
Ann Von Worley, RN, CCRP, Maggie Gunter, Ph.D., Shelley
Carter, RN, M.P.H., Eva Lydick, Ph.D.
Presented By: Ann Von Worley, RN, CCRP, Clinical Research
Associate, Lovelace Clinic Foundation, 2309 Renard, S.E.,
Suite 103, Albuquerque, NM 87106; Tel: (505) 262-7569; Fax:
(505) 262-7598; Email: Ann@LCFresearch.org
Research Objective: Identify how prostate cancer screening
styles differ among primary care providers.
Study Design: Despite insufficient evidence to either
recommend for or against routine screening for prostate
cancer (USPSTF), almost half of men over 40 in the
Albuquerque area reported having a PSA screening in the
previous year. It is unclear if screening rates are driven by
provider beliefs or information disseminated to the public at
large. This study reports on the findings of a small survey of
physician and midlevel providers regarding their practice
styles when ordering prostate cancer screening tests. From
answers to the survey questions regarding attitudes toward
prostate cancer screening, respondents were categorized as
Routine Screeners, RS - generally order PSA screening and do
not discuss possible harms and benefits, Informed Decision
Makers, IDM - generally discuss harms and benefits and allow
patients to decide whether or not to be screened, and InBetween Screeners, IBS - generally discuss harms and benefits
of screening, and then recommend screening.
Population Studied: In the summer of 2005, the authors
identified physicians and midlevel providers, MLPs, i.e., nurse
practitioners and physician assistants, practicing in an
integrated delivery system in Albuquerque, New Mexico. The
provider survey was mailed to 89 providers. Of the 63
providers (71 percent) who returned surveys, 45, (71 percent)
were physicians and 18, (29 percent) were MLPs.
Principal Findings: Most providers 51 percent were identified
as IBS, with roughly equal numbers of RS 25 percent and IDM
24 percent. A small difference that was not statistically
significant existed between MLP and physician responses.
More MLPs were considered IDM 28 percent than physicians
22 percent, and fewer MLPs were deemed RS 11 percent than
physicians 31 percent. RS providers were more likely than
IDM and IBS to discuss possible benefits and less likely to
discuss possible harms of screening.
Conclusions: The data show that a majority of these
providers are likely to routinely screen for prostate cancer,
even with no consensus about the benefits of and support for
routine screening. Screening styles vary somewhat between
physicians and MLPs, but there is little difference between the
two professions in discussing harms and benefits once
screening styles are identified.
Implications for Policy, Delivery, or Practice: Primary care
providers are divided about the value of prostate cancer
screening among asymptomatic men. Since there is no
consensus among nationally recognized organizations
regarding prostate cancer screening, preparatory education for
providers should emphasize discussion with their patients to
identify individual patient values and their preference to
prostate cancer screening.
Primary Funding Source: Lovelace Clinic Foundation
●Developing a Culturally Sensitive Cancer Screening
Survey for Middle-aged and Older Unmarried Latina
Women
Melanie Wasserman, Ph.D, Melissa Clark, Ph.D.
Presented By: Melanie Wasserman, Ph.D, Postdoctoral
fellow, Center for Gerontology and Health Care Research,
Brown University, Box G-S311, Providence, RI 02912; Tel: (401)
863-9036; Email: melanie_wasserman@brown.edu
Research Objective: The Cancer Screening Project for
Women is a study about the experiences of legally unmarried
middle-aged and older women undergoing breast, cervical and
colorectal cancers screening. The objective of this pilot study
was to test a Spanish-language version of the questionnaire
used in the Cancer Screening Project for Women, for use
among unmarried middle-aged and older Latina women.
Study Design: A qualitative, participatory research design was
used. In a first stage, the questionnaire from the Cancer
Screening Project for Women was translated into Spanish and
presented to Latino community leaders. Based on their
comments, the wording of individual survey questions was
revised, and content was added to cover research participants’
migration histories and receipt of culturally and linguistically
competent health services. Cognitive-based interviewing was
then used to evaluate questions asked. A Latina interviewer
and a bilingual, non-Latina researcher conducted the
interviews. Respondent interpretations of each item were
examined for emergent themes, and responses were
summarized and tabulated along with illustrative quotes.
Finally, the tables were examined for emergent themes cutting
across response items.
Population Studied: Women were eligible for the study if they
resided and received the majority of their health care in the
state of Rhode Island, were between the ages of 40 and 75,
spoke Spanish, and had limited English proficiency. A
purposive sampling strategy was used to recruit 15 women
from different countries of origin through group meetings at
Latino advocacy agencies, public housing, and a Latino
grocery store.
Principal Findings: Women interviewed for the study ranged
in age from 44 to 75. Twelve had a regular source of care, and
9 had health insurance. Respondents were of Colombian,
Puerto Rican, Dominican, Mexican, Honduran and
Venezuelan origin. Two arrived in the U.S. in their teen years,
the remainder came as adults. Three principal themes
emerged from data analysis. The first theme is that of lexical
differences. For some of the concepts covered in the study,
no one Spanish-language word could convey the intended
meaning to all respondents. For example, a Pap test is known
as “la citología” by 3 respondents from Colombia and
Venezuela, while other women identified it as a
“Papanicolaou”. Lexical problems were particularly salient for
questions related to colorectal cancer screening, because
respondents had little exposure to the topic. The second
theme is that of socially desirable answers. Despite careful
question wording, women tended to provide socially desirable
answers to closed-ended questions, which were contradicted
by their responses to open-ended probes. The third theme
relates to several respondents’ reluctance to respond to
cancer risk assessment questions, for example, questions
asking whether older women or younger women are more
likely to develop breast cancer. In-depth probes revealed that
5 women knew of several cancer risk factors, but did not wish
to give responses that might single out any particular group of
women. In the words of one respondent, “El cáncer no va a
escoger. A quién le tocó, le tocó” (Cancer does not
discriminate. If it’s your turn, it’s your turn.)
Conclusions: Mere translation of cancer screening survey
questions into Spanish is insufficient for research with middleaged and older unmarried Latina women. Surveys should
allow for lexical differences, minimize socially desirable
answers, and avoid risk assessment questions that appear to
single out certain groups of women.
Implications for Policy, Delivery, or Practice: Unmarried
middle-aged and older Latina women are a small group with
particularly low cancer screening rates. Research is needed to
identify and remove their barriers to screening. In conducting
this research, special attention should be paid to potential
cancer screening lexical differences for Latina women from
different countries of origin. Additionally, open-ended
questions may reduce the likelihood of socially desirable
answers and may be an acceptable substitute for culturally
unacceptable questions related to cancer risk assessment.
Primary Funding Source: Center for Gerontology and Health
Care Research, pilot funding
●Functional Disability and Health Provider Use in African
American Women with Self-Reported Lupus
Gayle Weaver, Ph.D., Pei-Fen Chang, Ph.D., OTR, Courtney
Young, BS
Presented By: Gayle Weaver, Ph.D., Associate Professor,
Division of Rehabilitation Sciences, University of Texas
Medical Branch, 301 University Boulevard, Galveston, TX
77555-1137; Tel: (409) 772-9446; Fax: (409) 747-1638; Email:
gweaver@utmb.edu
Research Objective: Lupus disproportionately affects African
American women through its serious morbidity and early
mortality. That is, African American women are more likely
than their white counterparts to experience greater morbidity
and earlier mortality. Although many improvements have
made in diagnosis and treatment, lupus’ broad spectrum of
disease and treatment-associated complications continues to
place a significant burden on the physical, mental, and social
ability of patients. This study explored physical and emotional
functional limitations to illuminate the burdens of lupus on
African American women. It also examined use of a variety of
health providers and services, with a particular focus on the
use of mental health and allied health services.
Study Design: This was descriptive study of African American
women with self-reported systemic lupus erythematosus.
Trained interviewers administered face-to-face structured
interviews that lasted approximately one hour and thirty
minutes.
Population Studied: Forty-three African American women
over the age of 18 and had been diagnosed with systemic
lupus erythematosus participated in this study.
Principal Findings: The findings revealed that over half of the
women reported a moderate level of lupus symptomatology
and some difficulty with vigorous activities, walking several
blocks, and sleeping. Over 50% of the respondents reported
high depressive symptomatology (i.e., on the CES-D scale)
and severe pain most days of the week. Nearly all respondents
had visits in the past year to primary care physicians,
rheumatologists and pharmacists, but less than 20% had
seen a pain specialist, mental health provider, physical
therapist, or occupational therapist.
Conclusions: These findings suggest a need to reduce the
accumulated effects of lupus on functional ability through
better referral to pain and mental health providers. More
research is needed to follow women over time to determine
the course of functional limitations and determine they are
treated and by whom.
Implications for Policy, Delivery, or Practice: Although this
study used a small sample of women, it was clear that they
rely on primary care physicians and rheumatologists for their
care. However, their phusical mental complaints maybe better
served by other health providers. Efforts are long overdue to
educate traditional health providers and patients about the
wide range of services available to respond specifically to their
health needs.
Primary Funding Source: AHRQ
●Race, Sex, and General Internists' Incomes in the 1990's
William Weeks, M.D., M.B.A.
Presented By: William Weeks, M.D., M.B.A., Department of
Veterans Affairs, Dartmouth Medical School, VAMC (11Q),
WRJ, VT 05009; Tel: (802) 291-6285; Fax: (802) 291-6286;
Email: wbw@dartmouth.edu
Research Objective: Specialty, work effort, and sex have been
shown to be associated with physicians’ annual incomes;
however, racial differences in physician incomes have not
been examined. This analysis was designed to determine the
influence of race and sex on general internists’ annual
incomes.
Study Design: Retrospective design that used survey
responses and survey weighted linear regression was used to
determine the influence of race and sex on the annual
incomes of general internists after controlling for work effort,
provider characteristics, and practice characteristics.
Population Studied: 1748 actively practicing general internists
worked in an office setting, had graduated from a US medical
school and who responded to the American Medical
Association’s annual survey of physicians between 1992 and
2001.
Principal Findings: Compared to white males, white females
saw 22% fewer patient visits and worked 12.5% fewer hours,
while black males and females reported seeing 17% and 2.8%
more visits and worked 15% and 5.5% more annual hours,
respectively. White males had practiced medicine
considerably longer than the other groups. While only 36% of
white male general internists were employed physicians, 50%
of black males, 62% of white females, and 68% of black
females were. Black physicians of both sexes were markedly
less likely than their white counterparts to be board certified:
86% of white males and females were board certified, but only
41% of black males and 48% of black females were. A
substantially higher proportion of black physicians’ patients
were enrolled in Medicaid: 22.4% for black males and 36.6%
for black females compared to 9.3% for white males and 11.3%
for white females. A regression model that incorporated work
effort, provider characteristics and practice characteristics
explained 19% of the variance in physician incomes and had
strong face validity: the anticipated inverted-U lifetime
earnings curve was reflected in the model; greater numbers of
visits, board certification, and living in highly populated areas
were associated with higher incomes; and being employed
and having a greater proportion of Medicaid patients was
associated with lower incomes. After adjustment for work
effort, provider characteristics, and practice characteristics,
white male general internists could expect a mean annual
income of $196,024. Black male general internists’ expected
mean annual income was $188,831, or $7,193 (4%) lower than
that for white males (95% CI: $31,054 lower to $16,669
higher, p=.6); white females’ was $159,415, or $36,609 (19%)
lower (95% CI: $25,585 to $47,633 lower, p<.001); and black
females’ was $139,572, or $56,452 (29%) lower (95% CI:
$93,383 to $19,520 lower, p=.003).
Conclusions: During the 1990’s, both black race and female
sex were associated with lower annual incomes among
general internists. While differences for black males were
modest, differences for females of both races were substantial.
Black race and female sex appeared to have a negative,
additive or multiplicative effect on general internists’ incomes.
Implications for Policy, Delivery, or Practice: These findings
warrant further exploration to ensure that income differences
among physicians are not unjustly driven by race or sex.
Managers should set objective salary criteria to ensure that
neither race nor gender bias influence physicians' incomes.
Primary Funding Source: VA
●Financing Rural Public Health Activities in Chronic
Disease Prevention
Leigh Ann White, Ph.D., Michael Meit, MA, M.P.H., Lorraine
Ettaro, Ph.D., Tiffany Fitzpatrick, M.S.W., Lauren Silver, BA
Presented By: Leigh Ann White, Ph.D., Senior Research
Scientist, Health Studies, NORC at the University of Chicago,
7500 Old Georgetown Road, Bethesda, MD 20814; Tel: (301)
951-5076; Fax: (301) 951-5082; Email: white-leighann@norc.org
Research Objective: Changing national objectives and
regional variation in public health financing influence rural
communities' ability to conduct public health functions. We
investigate how federal funds for chronic disease prevention
are applied at the local level.
Study Design: The study consists of two phases. First, we
compile data for a 50-state profile which includes
characteristics of each state's public health infrastructure,
local public health agencies (LPHAs), and chronic disease
funding from the Centers for Disease Control (CDC). We
conduct descriptive analyses of the state profile data to
examine correlations between infrastructure and funding
characteristics, and differences in rural and non-rural areas.
Second, we conduct in-depth case studies of six states,
examining how state health departments, LPHAs, and other
public health entities apply funding for chronic disease
prevention.
Population Studied: Our approach reflects a health systems
perspective, with a focus on localities and public health needs
of rural populations. Areas of study include state and local
public health infrastructure, state funding for chronic disease
prevention, and local public health activities in chronic disease
prevention (e.g., physical activity and obesity, diabetes, heart
disease, cancer). Case study states are: Kentucky, Nebraska,
New Mexico, Pennsylvania, South Carolina, and Wyoming.
Principal Findings: A central hypothesis is that federal
funding for chronic disease prevention reaches communities
having the infrastructure to support initiatives.
Conclusions: We present data from the 50-state profile,
supplementing findings by examples from each of the six case
study states.
Implications for Policy, Delivery, or Practice: Study findings
will have implications for delivery of chronic disease
prevention services in underserved and rural areas. Case
study results will relate local infrastructure characteristics to
service delivery barriers.
Primary Funding Source: HRSA, ORHP and NACCHO
●Provider Practices and Barriers in Blood Lead Level
Testing
Tammy Wiese, M.S., Jan Swaney, M.D.
Presented By: Tammy Wiese, M.S., Manager, Quality
Management, Medical Quality Management, Schaller
Anderson of Missouri, 2404 Forum Boulevard, Columbia, MO
65203; Tel: (573)441-2123; Fax: (573)441-2169; Email:
Tammy.Wiese@MissouriCare.com
Research Objective: The purpose of this research was to
identify current blood lead level testing practices and
perceived barriers to blood lead level testing of children age 24
months and younger among providers in a Medicaid
Managed Care Program in Missouri. The state is divided into
universal and targeted lead screening areas. Universal
screening areas are geographical areas where there is a high
risk for lead poisoning. In these areas blood lead testing is
required annually for all children up to the age of 6 years.
Regardless of geographical area, current state guidelines
mandate that all children on Medicaid receive a blood lead
level test at both 12 and 24 months of age.
Study Design: Data was collected through a survey mailed to
providers. Both closed and open-ended questions were
included in the survey.
Population Studied: Surveys were mailed to all primary care
providers who were participants in a Medicaid Managed Care
program in Central Missouri. Seventy-seven of the
approximately 300 primary care providers responded to the
survey resulting in a response rate of approximately 25%.
Providers were not asked to include their names or any
identifying information on the survey, thus it is not possible to
determine how representative the providers who returned the
survey are to the population of providers who were mailed
surveys.
Principal Findings: In regards to blood lead level testing
practices, there were no consistent practice patterns among
providers in testing children at 24 months of age and younger.
Additionally, providers did not vary in their frequency of
testing based on whether or not they identified themselves as
being in a universal versus a targeted screening area.
Furthermore, nearly 23% of the providers surveyed reported
being unsure of whether or not their practice was located in a
universal screening area (i.e. high risk area), and 33% of
providers were either inaccurate about the risk status of their
county or were unsure of the status of the county in which
they practice. The barriers to blood lead level testing listed by
providers fell into five categories: parents, payment, personal
attitudes, lab issues, and discontinuity of care. The major
barriers were parents and personal attitudes.
Conclusions: Both parent and provider attitudes will need to
be overcome in order to achieve more consistent blood lead
level testing of children under the age of 24 months by
providers.
Implications for Policy, Delivery, or Practice: A change in
blood lead level testing among providers will require
education aimed at both providers and parents. Providers
require education on both the testing guidelines and both
parents and providers need to be educated on the dangers of
elevated blood lead levels. It is also believed that providers
are in need of resources to make lead screenings and testing
more efficient.
Primary Funding Source: No Funding
●Financial Impact Of A Medicaid Eligibility Change On
One Nursing Home
Ronald Wiewora, M.D., M.P.H., Barbara Landy, M.B.A., MHA,
Michael Greene, M.P.A.
Presented By: Ronald Wiewora, M.D., M.P.H., Chief Medical
Officer, Health Care District of Palm Beach County, 324
Datura Street, West Palm Beach, FL 33458; Tel: (561)659-1270;
Fax: (561)802-3968; Email: rwiewora@hcdpbc.org
Research Objective: In April 2003, the state of Florida began
providing SSI-related Medicaid benefits only to those
individuals who met the federal disability criteria. Prior to this
date, the federal criteria were not uniformly utilized. The
objective of this study is to examine the financial impact of
this change in Medicaid eligibility guidelines on a public
nursing home.
Study Design: A retrospective review of third party payer
sources for all residents admitted to the nursing home
between October 1, 2000 and September 30, 2005 was
performed. The period from October 1, 2000 through
September 30, 2002 was analyzed as the baseline, before the
change was made. The period from October 1, 2003 through
September 30, 2005 was also analyzed and compared to the
baseline.
Population Studied: The study reviewed all the residents
admitted to the nursing home between October 1, 2000 and
September 30, 2005. The nursing home where the study was
performed is a public facility and admits eligible residents of
Palm Beach County. The population served is younger than
residents of a community nursing home. The residents are
also more severely ill and more likely to have a social and/or
psychiatric issue that prevents placement in a community
facility.
Principal Findings: In the two years prior to the change,
Medicaid days reimbursed averaged 42,003 annually. For the
two years after the change, that number dropped dramatically
to 35,755. As a result of the decrease of residents qualifying for
Medicaid disability coverage, the Charity days, which are
funded by local, county taxpayer dollars, increased by an
average of 5,674 annually. The resulting loss in Medicaid
revenue to the nursing home was $1,166,751 annually.
Conclusions: A change in the interpretation of Medicaid
eligibility guidelines resulted in a loss of state Medicaid
revenue for one public nursing home. The nursing home
continued to provide the same level of services for eligible
residents. The lost state revenue was replaced with local,
county tax dollars.
Implications for Policy, Delivery, or Practice: Medicaid
reform is being discussed at state and federal levels.
Medicaid currently is the largest single payer for nursing home
services. Any future changes in the program will have
significant impact on the financial health of nursing homes.
Primary Funding Source: Other Government
●Assessing Laboratory Quality Systems in a Rural State
Burton Wilcke, Ph.D., Barbara McIntosh, Ph.D., Mary Val
Palumbo, DNP,APRN, Robert Ross, Ph.D., Betty Rambur,
DNSc, RN
Presented By: Burton Wilcke, Ph.D., Associate Professor and
Chair, Medical Laboratory and Radiation Sciences, University
of Vermont, 302 Rowell Building, Burlington, VT 05405; Tel:
(802) 656-3811; Fax: (802) 656-2191; Email:
burton.wilcke@uvm.edu
Research Objective: To determine the level of quality
systems, as perceived by laboratorians that exists within the
medical laboratories in one rural state.
Study Design: The survey collected demographic information
using the minimal data set recommended by the Colleagues
in Caring for nurses. In addition, this medical laboratorian
survey incorporated: the knowledge level of quality assurance
measures being carried out within laboratories, the extent to
which those measures were being assessed and the
laboratorians’ perspective of whether the measures
contributed to quality outcomes. The quality measures
selected were derived from the CLSI (formerly NCCLS)
standard for quality systems in laboratory settings. The survey
was reviewed by two laboratory quality content experts for
content validity and was piloted test with eight laboratorians
in an academic health center outside of the state.
Population Studied: The entire population of medical
laboratorians (n=474) in Vermont identified as performing
moderate or high complexity laboratory analyses under the
definition of CLIA 88 was surveyed. Laboratorians were
identified as working in four major settings: community
hospitals, academic health center, government laboratories,
and physician offices. The response rate was 51% (n=241).
Principal Findings: Most medical laboratorians (95%)
believed that their laboratory had a full range of quality
assurance measures in place. However, 12% disagreed or did
not know if those measured exceeded the CLIA minimums.
Most laboratorians believed that education (70%) and
experience (73%) had a significant impact on meeting quality
objectives. Fewer laboratorians (56%) believed that having a
nationally-recognized professional laboratorian credential had
a significant impact on quality. While most laboratorians(95%)
stated they were familiar with the quality measures used in
their laboratory, fewer (77%) stated that they personally had a
significant impact in meeting those quality objectives and
even fewer (51%) said they were personally involved in
deciding what quality measures are used.
Quality measures that were most frequently reported to be in
place were those that are required under federal regulations.
Quality measures that are recommended as part of a
complete laboratory quality system but are not specifically
required by federal regulations were less likely to be in place.
Conclusions: All laboratories that perform diagnostic
procedures in the United States have been covered by
regulations under CLIA since 1992 when the regulations were
promulgated. However, recommendations from national and
international standard setting organizations that deal with
quality systems have recommended standards that exceed
minimums. This medical laboratory workforce survey indicates
substantial knowledge of most CLIA requirements but the
survey also indicates that there are components of a
comprehensive quality system that are either not in place or
the workforce is unaware of their existence.
Implications for Policy, Delivery, or Practice: It is estimated
that 70% of all medical decisions rely at least in part on
laboratory-generated data. In order to help ensure quality
health outcomes it is essential that there be ongoing
assessments of quality measures for laboratories.
Primary Funding Source: HRSA
●Access to Psychiatrists in the Public Sector and in
Managed Health Plans
Josh Wilk, Ph.D., Joyce C. West, Ph.D., M.P.P., William E.
Narrow, M.D., M.P.H., Donald S. Rae, M.A., Darrel A. Regier,
M.D., M.P.H.
Presented By: Josh Wilk, Ph.D., Director, Workforce Studies,
APIRE, American Psychiatric Association, 1000 Wilson
Boulevard, Suite 1825, Arlington, VA 22209; Tel: (703) 9078618; Fax: (703) 907-1087; Email: jwilk@psych.org
Research Objective: To assess the extent to which
psychiatrists are accepting new patients with different types of
insurance (Medicaid, Medicare, and private insurance) and
with different types of care plans (managed and
nonmanaged). Additionally, we identified psychiatrist variables
and geographic regions that were strongly associated with
accepting patients with public sources of insurance or with
managed care plans.
Study Design: Cross-sectional observational data from the
2002 American Psychiatric Practice Research Network (PRN)
National Survey of Psychiatric Practice (NSPP) were used. A
national sample of 2,323 psychiatrists were randomly selected
from the American Medical Association’s Masterfile of
physicians (N=49,000). The final response rate was 52
percent (N=1,203). Analyses were performed using SAS and
SUDAAN software to adjust for the weights and the nested
sampling design.
Population Studied: A national sample of 2,323 psychiatrists
were randomly selected from the American Medical
Association’s Masterfile of physicians (N=49,000). The final
response rate was 52 percent (N=1,203).
Principal Findings: Psychiatrists’ willingness to accept new
patients was significantly associated with the type of health
plan to which the patient belonged (Fisher exact test, p<.001).
Although most psychiatrists (77 percent) accepted patients
who used self-pay, less than half (44 percent) accepted
patients who used Medicaid. Sixty-five percent of psychiatrists
surveyed accepted new patients who used unmanaged private
insurance, whereas significantly fewer (53 percent) accepted
new patients from managed private insurance plans. Only 48
percent of psychiatrists reported serving in any managed care
networks or physician panels; more than 25 percent of those
who were in these networks or on panels did not accept new
patients from those networks or panels. Psychiatrists were
significantly more likely to accept new patients with Medicaid
if the psychiatrists were foreign medical school graduates, not
board certified, nonwhite, and younger than 45 years old.
Conclusions: The results of these analyses are troubling
because they present evidence of limited access to
psychiatrists, particularly among patients with Medicaid and
with managed private insurance plans. This finding is
particularly disconcerting because a majority of individuals
with private insurance in the United States are enrolled in
private managed plans and because of trends in the psychiatry
workforce.
Implications for Policy, Delivery, or Practice: Reductions in
the number of psychiatrists who accept new patients in an
already declining workforce will likely be associated with delays
in treatment and a potential decrease in quality of care. Delays
in treatment are associated with substantial personal and
economic costs related to increases in severity of mental
illness and decreases in general health status.
Primary Funding Source: No Funding
●Comparability of Functional Assessments in Inpatient
Rehabilitation and Skilled Nursing Facilities is Only Fair.
Richard Wilson, M.D., Patrick K. Murray, M.D., MS
Presented By: Richard Wilson, M.D., Resident Physician,
Physical Medicine and Rehabilitation, MetroHealth
Rehabilitation Institute Ohio, 4690 Dornur Dr, Cleveland, OH
44109; Tel: (216)749-1503; Email: rwilson75@yahoo.com
Research Objective: Studies of functional outcomes after
rehabilitation for patients in the settings of inpatient
rehabilitation facilities, IRFs, or skilled nursing facilities, SNFs,
have been inconsistent as to which setting produces better
outcomes. Bias related to different reimbursement and
program evaluation schemes in the two settings may occur if
methodology includes functional measurement by the IRF-PAI
or MDS datasets. This pilot study aims to assess the
comparability of functional assessment evaluations conducted
in IRFs and SNFs.
Study Design: Retrospective chart review of a convenience
sample. Conversion tools were used to convert discharge
Functional Independence Measure, FIM, and admission
Minimum Data Set, MDS, scores to nine Barthel Index, BI,
variables for each subject. Intraclass correlation for each
variable and Pearson correlation coefficient for the summary
BI were calculated.
Population Studied: SForty eight subjects were patients that
were discharged from an IRF to a SNF at a large academic
institution from January 1, 2004 through December 31, 2004.
All subjects had FIM evaluations at discharge and admission
MDS evaluations within 10 days of admission to SNF.
Principal Findings: The mean of intraclass class correlation
coefficients for the nine BI variables is ICC of 0.59 with a range
ICC 0.33 to 0.76, and standard deviation ICC of 0.15. Pearson
correlation coefficient of discharge and admission BI was 0.76
with p value less than 0.0001. At lower BI scores the discharge
scores from IRF were higher than those of the admission
scores at SNF. At higher BI scores, the discharge scores from
IRF were lower than those of the admission SNF scores.
Conclusions: In the nine BI variables examined, the average
agreement was in the fair range. The range of agreement
varied considerably across variables ranging from poor to
excellent. At lower functional levels, the IRF tended to score
patients higher than the SNF, and the opposite was true for
higher functional levels. This pilot study indicates that there
may be significant measurement bias in the functional
assessment in different sites of post acute care. These
differences may be related to different reimbursement and
program evaluation schemes in the two settings.
Implications for Policy, Delivery, or Practice: Further study
of this issue in a prospective manner is indicated.
Primary Funding Source: No Funding
●The Effects of Health Status and Education on
Participation in Care in Later Life Adults
Jacqueline Wiltshire, M.P.H., Ph.D., Velma Roberts, MS,
Ph.D., Roger L. Brown, Ph.D., Gloria E. Sarto, M.D., Ph.D.
Presented By: Jacqueline Wiltshire, M.P.H., Ph.D.,
Postdoctoral Fellow, Center for Women's Health Research,
University of Wisconsin Medical School, 700 Regent Street,
Madison, WI 53715; Tel: (608)-265-9299; Fax: (608)-265-9301;
Email: wiltshire@wisc.edu
Research Objective: Although participation in care is
endorsed as essential for optimal health outcomes, opinions
vary as to whether aging adults want to participate in their
medical care. This study assesses the effects of health status
and education on seeking health information and subsequent
use of this information during the medical encounter.
Study Design: Study data were drawn from the 2000-01
Household Component of the Community Tracking Study, a
nationally representative survey. Participation in care was
operationalized through yes/no responses to questions on
seeking health information about a medical concern in the
past 12 months, and mentioning the acquired health
information to the physician. Key independent variables were
self-rated health and education level. Binomial logistic
regressions accounted for survey design and possible
confounders.
Population Studied: The sample included 20,017 adults, aged
45+ with at least one visit to the physician in the previous year.
Principal Findings: Overall, 22.9% of the sample was in
poor/fair health, 29.9% in good, and 47.1% in very
good/excellent health. Sixteen percent of respondents had less
than a high school education, 34.6% were high school
graduates, 24.4% had some college and 24.6% had a college
degree and above. Forty percent (8,368) of the sample
(N=20,017) reported getting medical information. Of those
who obtained health information (N=8,368), 26.3% (2,290)
mentioned it to their physician. The probability of seeking
health information (N=20017) decreased with better health
(poor/fair health: OR=1.83, 95% CI: 1.48-2.28; good health:
OR=1.42, 95% CI: 1.20-1.67) and increased with higher levels
of education (< high school: OR = 0.45; 95% CI: 0.36-0.56,
high school: OR = 0.47; 95% CI: 0.41-0.53, and some college:
OR = 0.68; 95% CI: 0.60-0.76). Only individuals in poorer
health with less than a high school education were
significantly less likely to seek health information than their
counterparts. Respondents in poor/fair and good health were
also more likely to mention acquired health information to
their physician than those in very good/excellent health (OR =
1.87; 95% CI: 1.37-2.56, OR = 1.29; 95% CI: 1.03-1.62,
respectively). In addition, the likelihood of mentioning health
information to the physician increased with higher levels of
education.
Conclusions: Overall, regardless of education, poorer health
appears to increase participation in care.
Implications for Policy, Delivery, or Practice: Participation
in medical care is a complex phenomenon, and needs
continuing study in order to determine the factors that will
enhance patient communication with the health care delivery
system.
Primary Funding Source: NIA
●The Complementarity and Substitution between
Unconventional and Mainstream Medicine among Racial
and Ethnic Groups in the US
Tom Xu, Ph.D., Tommie Farrell, M.D.
Presented By: Tom Xu, Ph.D., Assistant Professor, Family &
Community Medicine, Texas Tech University Health Sciences
Center, 3601 4th Street, MS 8161, Lubbock, TX 79430; Tel:
(806)743-6983; Fax: (806)743-1292; Email: Ke.Xu@ttuhsc.edu
Research Objective: To describe racial and ethnic differences
in the utilization patterns of 12 common types of
complementary and alternative medicine (CAM) and
mainstream medicine and to test whether a specific CAM type
is a substitute for or a complement to mainstream medicine
among 5 racial and ethnic groups in the US.
Study Design: The Medical Expenditure Panel Survey in 1996
and 1998 were used. The sample of 46,673 respondents was
stratified into non-Hispanic whites, Hispanics, blacks, Asians
and other races. Twelve types of CAM visits, visits to officebased and outpatient physicians were used to describe the
pattern of CAM and mainstream medicine use. Utilization
patterns among each racial and ethnic group were established
and compared. Multivariate analyses were conducted to test
whether each type of CAM and mainstream medicine were
complements or substitutes within a racial and ethnic group,
controlling for respondents’ socio-demographics and health.
Population Studied: Adults.
Principal Findings: Significant inter-group differences in the
prevalence rates of using various types of CAM were found. In
particular, differences in CAM utilization were observed
between blacks and any other racial/ethnic groups. The
utilization patterns between Asians and other races were
similar. More complementary relationships between CAM
and physician visits were found in non-Hispanic whites and
Asians than in other groups. All significant relationships
between CAM and physician visits among Hispanics and
other races (predominantly Native American Indians) were
substitution.
Conclusions: Complementarity and substitution of CAM and
mainstream medicine varied by racial and ethnic groups and
by type of CAM. Culturally sensitive approaches are needed in
successful integration of CAM in treatment management.
Implications for Policy, Delivery, or Practice:
Primary Funding Source: No Funding
●Impact of a Transit Intervention on Access to
Preventative Care for Urban Children
Serena Yang, M.D., M.P.H., Sujata R. Tipnis, M.D., M.P.H.,
Celina Saenz, B.S., Nancy R. Kelly, M.D., M.P.H.
Presented By: Serena Yang, M.D., M.P.H., Assistant
Professor, Pediatrics, Baylor College of Medicine, 6621 Fannin
Street, MC-1540.00, Houston, TX 77030; Tel: (832) 822-3441;
Fax: (832)825-3435; Email: sxyang1@texaschildrenshospital.org
Research Objective: The study objective was to determine the
effect of a mass transit intervention on the attendance of wellchild visits.
Study Design: In collaboration with Houston’s mass transit
organization, we developed a clinic-based intervention that
provided transit education and fare for families at risk for
missing appointments. Primary caregivers of patients aged
less than 12 months were randomized to receive either: (1)
standard discharge instructions [control] or (2) standard
discharge instructions plus the transit intervention at wellchild visits. The primary outcome was whether or not infants
arrived for their recommended number of well-child visits
during a 6-month period.
Population Studied: This intervention was tested in a
minority, Medicaid population attending a hospital-based
pediatric primary care clinic in Houston, Texas.
Principal Findings: We enrolled 120 infants. A Chi-squared
analysis comparing control and intervention groups showed
no difference in the proportion of patients arriving for all their
recommended well-child appointments (p=0.58). An
exploratory analysis examining the subgroup of caregivers who
stated at baseline that they had missed an appointment in the
past due to transportation problems (n=33) revealed 42% in
the intervention group arrived for all well-child visits compared
to 29% in the control group. However, subsequent tests for
interaction revealed that the effect of the intervention was not
different between those who did or did not report missing an
appointment due to transportation problems. Children who
take longer than 30 minutes to travel to clinic, are of AfricanAmerican ethnicity, are covered by Medicaid or SCHIP, or
have a chronic health condition were at decreased odds of
arriving for all their recommended number of preventive visits;
however these findings did not reach statistical significance.
The lack of significant findings may be related to the study’s
inadequate power to detect differences between the groups, as
we did not reach our target sample size of 194 enrollees.
Conclusions: This study investigated the option of using
mass transit as a mode of non-emergency medical
transportation in an ethnically diverse, low-income urban
population. The effect of a transit intervention on access to
well-child care for those with transportation needs cannot be
stated conclusively.
Implications for Policy, Delivery, or Practice: Further
investigation with a larger sample size and a longer follow-up
period will be needed to identify effective means of
overcoming barriers such as transportation difficulties in the
access of preventive care for low-income children.
Primary Funding Source: American Academy of Pediatrics
●The Use of Recommended Health Care Services Among
Elderly Caner Survivors
Xinhua Yu, M.B., Ph.D., Alexander McBean, M.D., M.Sc., Beth
A. Virnig, Ph.D., M.P.H.
Presented By: Xinhua Yu, M.B., Ph.D., Research Associate,
Division of Health Services Research & Policy, University of
Minnesota School of Public Health, MMC 97 420 Delaware
Street, S.E., Minneapolis, MN 55455; Tel: (612) 624-1411; Fax:
(612) 378-4866; Email: xinhuayu@umn.edu
Research Objective: Feinstein (1970) theorized that persons
with a chronic disease such as cancer would be more likely to
be screened or provided other preventive or healthcare
services because of regular contact with medical providers. On
the other hand, Jean, et al.’s (1994), “competing demands
model”, suggests that persons with cancer might receive
fewer recommended health care services. In the past two
years, Earle and colleagues (2003, 2004) have published
conflicting information regarding recommended services
among cancer survivors: breast cancer survivors had higher
rates of health service use than persons without cancer
(2003); and colorectal cancer survivors received had lower
rates than the controls. (2004). We examined the use of
preventive services and recommended diabetes care in 19992002 among elderly Medicare beneficiaries who were longterm survivors of 5 different types of cancer: bladder, breast,
colorectal, prostate and uterine.
Study Design: We conducted a retrospective cohort analysis
useing the linked Surveillance, Epidemiology and End Results
(SEER)/Medicare database including the associated control
population to compare the rates of influenza vaccine and
breast cancer screening, as well as diabetes care services
between cancer survivors and elderly persons who were never
diagnosed with cancer. Crude and multivariate adjusted rates
were calculated and compared.
Population Studied: Elderly fee-for service Medicare
beneficiaries living in the SEER areas who survived 5 years
after bladder, breast, colorectal, prostate or uterine cancer
diagnosis and a 5% random sample of Medicare fee-forservice beneficiaries with no history of cancer residing in the
same areas.
Principal Findings: During 1999-2002, cancer survivors were
between 20 and 50% more likely to receive preventive services
(influenza vaccine or mammography) than persons who never
had cancer (women with breast cancer excluded from
mammography analysis. Cancer survivors with diabetes were
more likely to have least one annual HbA1c test or eye
examination than those without cancer. These differences
were smaller than for influenza vaccine or mammography,
from 1 to 16%, but all were statistically significant, p < 0.05,
when adjusted for age-group, gender (if needed), and race.
There were no important differences in the serum lipid level
determination rates between the cancer survivors and
controls, with no pattern of either the cancer survivors or the
comparison group receiving testing more or less frequently
than the other. Multivariate adjustment including other
sociodemographic variables, comorbities and other relevant
covariates confirmed these findings.
Conclusions: Elderly persons who have survived cancer were
generally more likely to receive preventive and other
recommended services compared with those without cancer.
Implications for Policy, Delivery, or Practice: The good
news is that cancer survivors received the same, or better
preventive care than persons who never had cancer. However,
the rates of service use remained below national goals in both
cancer and non-cancer populations. Improving the use of
these appropriate, recommended services among the elderly
remains a high priority.
Primary Funding Source: NIA
●From Bedside to Bench: How the Epidemiology of
Clinical Practice Can Inform Pharmacological Intervention
Development in the Secondary Prevention of
Posttraumatic Stress Disorder
Douglas Zatzick, M.D., Peter Roy-Byrne, M.D.
Presented By: Douglas Zatzick, M.D., Associate Professor,
Psychiatry & Behavioral Sciences, Harborview Medical
Center/University of Washington, 325 Ninth Avenue, Box
359896, Seattle, WA 98104; Tel: (206) 731-6701; Fax: (206) 7313455; Email: dzatzick@u.washington.edu
Research Objective: Approximately 37 million acute care
injury visits are made in the United States each year and 2.5
million individuals are so severely injured that they require
inpatient hospitalization. Between 10-40 percent of injured
trauma survivors go on to develop posttraumatic stress
disorder in the weeks and months after injury. The biological
rationale for a diverse group of candidate compounds
including corticosteroids, beta-adrenergic antagonists, and
opiate analgesics in the secondary prevention of
posttraumatic stress disorder has been articulated. Few
investigations have used pharmacoepidemiologic methods to
determine which medications with strong theoretical
rationales for secondary posttraumatic stress disorder
prevention can be most feasibly delivered in acute care
settings. Therefore, the current investigation aimed to
document patterns of acute care inpatient pharmacotherapy
administration.
Study Design: We conducted a population-based crosssectional assessment of medication administration for
adolescents and adults hospitalized at a level I trauma center
after physical injury. Medication prescription at the time of
surgical inpatient discharge was assessed by medical record
review.
Population Studied: A random sample of 113 adolescent and
152 adult, male and female survivors of intentional and
unintentional injury.
Principal Findings: Opiate analgesic medications were
prescribed to between 82 percent-88 percent of injury
survivors; 34 percent-46 percent of patients also received nonopiate analgesic prescriptions. Between 11 percent-16 percent
of patients were prescribed antihistamines. Benzodiazepines,
anticonvulsants, corticosteroids, beta-adrenergic blockers, and
all other psychotropic medications were prescribed to less that
10 percent of adolescent and adult patients.
Conclusions: The results of this investigation substantiate the
ubiquitous use of analgesic medication in the acute care
inpatient setting. These data suggest initial feasibility tests
and efficacy trials of compounds targeting pain in the
secondary prevention of posttraumatic stress disorder after
injury. Basic research could also be conducted on compounds
that simultaneously target pain and anxiety.
Implications for Policy, Delivery, or Practice: A major
challenge facing clinical services research is the development
of interventions that can be robustly applied across diverse
real world settings. The investigation demonstrates how
population-based data derived from real world practice
settings can enhance the efficiency and trajectories of
pharmaceutical intervention development.
Primary Funding Source: Other Govt, National Institute of
Mental Health and AHRQ