Student Posters
Poster Session A
Sunday, June 25 • 2:00 pm – 3:30 pm
● Reported Expectations for Nursing Home Placement and their Role as Risk Factors for Nursing Home Admissions
Adaeze Akamigbo, M.P.P., Frederic D. Wolinsky, Ph.D.
Presented By: Adaeze Akamigbo, M.P.P., Doctoral Student,
Health Management and Policy, University of Iowa, 5231
Westlawn, Iowa City, IA 52246; Tel: 319-248-3503; Fax: 319-335-
8814; Email: adaeze-akamigbo@uiowa.edu
Research Objective: Individual expectations among community-dwelling older adults and their subsequent effect on placement status have recently been considered. Previous studies, however, have been limited by eligibility and exclusion criteria, treating expectations as a continuous measure, omitting potential confounders, and ignoring race-gender interactions. We address these issues to determine the antecedents of 5-year expectations for nursing home placement, and the subsequent risk of NHP among older adults in five years.
Study Design: This study adopts a retrospective design using baseline data on individual expectations and characteristics.
Nursing home placement rates over the 5-year sudy period are also used. Expectations for nursing home placement over the next five years, as well as actual placement status are modeled using multivariable multinomial and binomial logistic regression models.
Population Studied: Data on 6,242 Black and White selfrespondents 70 years old or older when enrolled in the Survey of Assets and Health Dynamics Among the Oldest Old are used.
Principal Findings: Expectations are not normally distributed:
14% refuse to answer, 51% estimate no chance, 6% indicate a
10% chance, and 10% indicate a 50% chance. Age, gender, education, social supports, and health status were associated with expectations, as well as an interaction effect for Black men. Age, social supports, health status, prior hospital or nursing home use, and expectations were associated with subsequent placement.
Conclusions: Black and White older adults’ expectations for nursing home placement rationally reflect their individual risk profiles, and are associated with subsequent placement status.
Implications for Policy, Delivery, or Practice: The significant and consistent relationship between expectations and actual placement suggests that the former may be an efficient and effective summary screening measure for use in identifying elders who may have an elevated risk of nursing home placement. The expectations question may facilitate the early identification of high risk subjects for further evaluation.
Primary Funding Source: NIA
● Prescription Opiates and Heroin, Factors Associated with the Sequence of Use Among Opiate Addicts Entering
Drug Treatment
Caleb Banta-Green, M.P.H., M.S.W., Thomas M Wickizer,
Ph.D., Joseph O Merrill, M.D., M.P.H., T. Ron Jackson, M.S.W.
Presented By: Caleb Banta-Green, M.P.H. M.S.W., Health
Services, University of Washington, 1107 NE 45th, Suite 120,
Seattle, WA 98105-4631; Tel: (206) 685-3919; Email: calebbg@u.washington.edu
Research Objective: Increasing use and abuse of prescription-type opiates has been documented throughout the United States in recent years. Prescription-type opiates as the primary drug of abuse has increased from 3% to 12% of new admissions to all methadone treatment programs in King
County Washington (1999-2004). Mortality and morbidity associated with prescription-type opiates have increased substantially as well. This study examines the use of prescription-type opiates and heroin. Prescription-type opiates may be used legally to treat pain and, in the case of methadone, addiction. They may also be used illegally for euphoric effects or to prevent opiate withdrawal. The sequence of use of prescription-type opiates and/or heroin is hypothesized to represent different motivations for initiating use including chronic medical conditions, such as chronic pain, and psychological distress. Specifically, it is hypothesized that those initially using prescription opiates are more likely to have chronic medical conditions.
Study Design: An analysis of cross-sectional data was conducted with the outcome being one of the five patterns of opiate use as defined by the sequence of prescription-type opiate and/or heroin use (i.e. heroin prior to prescription-type opiates, prescription-type opiates prior to heroin, heroin only, prescription-type opiates only, or starting both in the same year). Multinomial logistic regression was used to compare factors independently associated with each of the drug use sequence patterns. Lifetime patterns of opiates used was documented with the Addiction Severity Index (ASI), a comprehensive bio-psycho-social assessment.
Population Studied: Data are drawn from adults newly admitted to a large non-profit methadone treatment program in the Seattle area between 2001 and 2005 (n=1,361). Subject characteristics: mean age of 41; 62% male; 72% white, 14% black, 7% American Indian/Alaskan Native and 5% Hispanic;
76% used prescription-type opiates and 72% used heroin for 6 or more months during their lifetime.
Principal Findings: Each of the five types of opiate users appear to define a distinct group based upon demographic and medical factors. For instance, prescription-type opiate only users were significantly more likely to have a chronic medical condition, be younger, white and female compared to heroin only users. Psychological symptoms were commonly reported across all types of users, with 40% reporting depression symptoms and 44% anxiety symptoms in the 30 days prior to admission. However, there were few differences in psychological symptoms between types of opiate users.
Conclusions: Patients entering methadone treatment have substantial medical and psychiatric problems. Demographic factors and chronic medical conditions vary significantly between types of opiate users.
Implications for Policy, Delivery, or Practice: As prescription-type opiate abuse increases, the high level of co-

morbidity and the resulting morbidity and mortality become more critical for health care providers and systems to identify and treat. Physicians and health plans need to be alert to the potential for misuse of prescription-type opiates while adequately and appropriately treating chronic pain. In order to adequately treat addiction it is also essential to treat underlying factors such as psychiatric and medical problems.
Primary Funding Source: AHRQ
● Sex-specific Results Are Not Reported in Cardiology
Trials
Lori Blauwet, M.D., Lori Blauwet, M.D., Sharonne N. Hayes,
M.D., Dave McManus, M.D., Rita F. Redberg, M.D., M.Sc.,
Mary Norine Walsh, M.D.
Presented By: Lori Blauwet, M.D., Physician (resident),
Internal Medicine, Mayo Clinic College of Medicine, 200 First
Street S.W., Rochester, MN 55901; Tel: 507-284-2511; Email: blauwet.lori@mayo.edu
Research Objective: Mandates from the National Institutes of Health (NIH) have stipulated the inclusion of women in federally funded studies and the analysis of study outcomes by sex, but women remain underrepresented in clinical trials and trial results are often not stratified by sex. We explored the extent to which sex specific result (SSR) reporting appears in recently published cardiology studies.
Study Design: All original adult cardiology clinical research articles published in Annals of Internal Medicine, Archives of
Internal Medicine, Journal of the American Medical
Association, New England Journal of Medicine, Journal of the
American College of Cardiology, American Journal of
Cardiology, and Circulation from July through December 2004 were reviewed. Trials with fewer than 50 subjects were excluded. A total of 65 articles from the internal medicine journals and 564 articles from the cardiovascular journals were examined. SSR was defined as presenting primary outcomes for women in a format allowing the data to be abstracted for use in a meta-analysis.
Population Studied:
Principal Findings: Of the 645 studies reviewed, 17 were excluded because they were appropriately single sex trials (16 women only and 1 men only). Of the remaining 628 studies, only 153 (24%) provided SSR. Several trials (17 or 3%) had no female subjects despite studying conditions affecting both sexes and 41 (7%) did not provide the sex of the participants.
Internal medicine journals published a greater percentage of articles with SSR than cardiovascular journals (38% vs 23%).
Among NIH-sponsored research, 31 of 61 trials (51%) analyzed outcomes by sex compared to 22% of non-NIH-sponsored trials.
Conclusions: Although the NIH policy requiring SSR has been in place for 15 years, only a small minority of current cardiology trials include sex-specific data. In addition, fully
10% of reported studies either failed to include women as subjects or did not specify the sex of the study participants.
Sex differences remain poorly understood and explored and this deficiency limits our ability to provide optimal care for women. As NIH-funded research includes significantly more
SSR, a similar mandate by journal editors that authors provide gender specific data may help to close this knowledge gap.
Implications for Policy, Delivery, or Practice: The broad implementation of editorial policies requiring SSR reporting in medical journals would have many positive implications for both men and women because in many cardiovascular conditions, risks, benefits, and outcomes are different in women than in men. When such policies are implemented and enforced, sex differences in disease manifestations and responses to therapy will be better understood, which will allow for the highest quality medical care to be provided for both men and women.
Primary Funding Source: No Funding
● Determinants of Medicare Service Use and Expenditures for Patients with Alzheimer's Disease and Related
Disorders
Catina Bradley, M.H.S.A., Ph.D. candidate, Linda Nichols,
Ph.D., Marshall Graney, Ph.D., Jennifer Martindale-Adams,
Ed.D., Allan Lummus, Ph.D.
Presented By: Catina Bradley, M.H.S.A., Ph.D. candidate,
Doctoral Student, School of Business, George Washington
University, 7406 Kingsland Drive, Memphis, TN 38125; Tel:
901-754-9922; Email: cbradley@gwu.edu
Research Objective: With four million Americans suffering from Alzheimer's disease and related disorders (ADRD), medical and societal care costs present major policy challenges. These costs are a result of the growing need for, and use of, formal health care (e.g., physician services, nursing home care) and informal care (care provided by a family member). Medicare is the primary payor for formal health care services for ADRD patients. This research: (1) identified the patterns of use and expenditures for Medicare services for 1,176 ADRD patients from three racial/ethnic groups; and (2) assessed the relationship between ADRD patient and caregiver characteristics, including demographic, clinical and caregiving variables, and service use and estimates of Medicare expenditures. This research is the first examination of Medicare payment and service use linked to
ADRD patient and caregiver individual level factors.
Study Design: ADRD patients were part of the Resources for
Enhancing Alzheimer’s Caregiver Health I (REACH I) study.
REACH I was a randomized, multi-site, 12-month study of family caregivers of people with ADRD, which examined burdens and intervention strategies in three racial/ethnic groups (Caucasian/White, African American/Black and
Hispanic/Latino). The ADRD patient variables included sociodemographics, health status, cognitive status, functioning and service use. Caregiver factors included sociodemographics, health status, depression, bother, and social support. Estimated Medicare payment data for the
REACH I study period (1996 to 2001) were obtained from the
Centers for Medicare & Medicaid Services' (CMS) Medicare
Statistical Supplement data for five services: physician, nurse practitioner or physician assistant, inpatient hospital services, nursing home care, and home health care. Medicare payment for ER services and Medicaid home health care payment data were analyzed from the Medical Expenditure Panel Survey
(MEPS). The MEPS data were used to compare home health care payments between Medicare and Medicaid.
Population Studied: The sample consists of 1,176 Medicareeligible REACH I patients: 660 Whites/Caucasians, 293
Blacks/African Americans, and 204 Hispanics/Latinos.
Principal Findings: Total estimated Medicare payments for the REACH I sample were over $2.9 million for the 12-month

study period, an average of about $12,700 per ADRD care recipient, more than double the average for the general
Medicare population ($5,875 per beneficiary in 2001).
Variations in service use and expenditures based on demographic and clinical characteristics differed among the three ethnic and racial groups. Age and gender of both the
ADRD patient and caregiver and caregiver's depression explained most of the variance for service use for Caucasians.
The ADRD patient's physical health and functioning limitations and caregiver's income explained most of the variance for service use for African Americans.
Conclusions: Understanding the relationship between
Medicare service use and expenditures and patient and caregiver characteristics could provide insights on what policy changes are needed to help improve the care to, and health outcomes for, patients with ADRD, which could ultimately help to control costs and decrease the burden on families.
Implications for Policy, Delivery, or Practice: As the population of patients with ADRD becomes more diverse,
Medicare policy considerations regarding service delivery will need to account for any different issues among diverse racial and ethnic groups.
Primary Funding Source: No Funding
● The Influence of Owning High-Tech Medical Equipments on Health Service Utilization
Chia-Yi Chang Chien, M.B.A., Shu-Chuan Yeh, Ph.D.
Presented By: Chia-Yi Chang Chien, M.B.A., Graduate
Student, Health Care Management, National Sun Yet San
University, No.70, Lianhai Road, Gushan District, Kaohsiung
City 804, Taiwan (R.O.C.), Kaohsiung, 804; Tel: +886-7-525-
4870; Fax: +886-7-525-1511; Email: chiayi12@ms41.hinet.net
Research Objective: The development and the utility of hightech medical equipments are increasing relative to the health expenditure growth. This high-tech equipment does not necessary benefit the quality of patient care but increase the service quantity for hospitals. This study aims to describe the difference of equipments distribution between regional hospitals and medical centers and to examine the association between the kinds, number, and utility of high-tech medical equipments and the health service utilization.
Study Design: Two databases were used in this study. First, a secondary data from the annual hospital survey published in
1994 by Taiwan Hospital Association was used. The data contained information on utilization, kinds, number and utility of 17 kinds of high-tech medical equipments, 5 hospital characteristics, and one kind of staff ratio. Second, Statistical
Yearbook of Interior provided data on the percentage of 65+ years old people in each location. The t-test showed differences between medical centers and regional hospitals in number, kinds, and utility of high-tech medical equipments.
Person correlation presented how these variables correlated to each other. Regression analyses predicted the health service utilization from those variables.
Population Studied: The sample involves 11 medical centers and 60 regional hospitals in 1994 from Taiwan Hospital
Association. Of the 570 subjects, 296 completed the questionnaire, which constituted a response rate of 51.93%.
Exclusion criteria included the community hospitals and psychiatric hospitals.
Principal Findings: The average kinds, number, and utility of high-tech medical equipments separate are 10.55, 21.27 and
20095.26 in medical centers and 4.95, 11.23, and 6969.86 in regional hospitals, respectively. The medical centers had higher kinds and utility of high-tech health equipments than regional hospitals did but there was no significant difference in number of high-tech health equipments between them(p =
0.20). Number of acute beds and physicians are the better predictors of health service utilization(p = 0.001 ). However, the number and utility of the high-tech medical equipments appeared to have no significant effect(p = 0.46, 0.17 )on health service utilization.
Conclusions: The kinds, number, and utility of high-tech medical equipments did not result in high health service utilization. Instead, other characteristics such as number of acute beds and physicians led to higher utilization of health service.
Implications for Policy, Delivery, or Practice: Although literature indicated that the kinds and number of high-tech medical equipments somehow may stimulate the demand for health service, we did not find the same results. Hospitals probably try to raise their own reputation and to attract patients so they have to purchase high-tech equipments.
Further research should continuously monitor whether the providers owning the equipments will increase demand of high-tech utilization to balance their financial operations. In addition, it is important to take account of cost-effect outcome and performance for hospitals to whether own or lease this type of equipment.
Primary Funding Source: No Funding
● Does Noncompliance in Hemodialysis Sessions Lead to
Higher Payments in Medicare Allowable Charges for ESRD
Patients?
Chien-Chia Chuang, MS, MAE
Presented By: Chien-Chia Chuang, MS, MAE, Graduate
Student Research Assistant, Health Management and Policy,
University of Michigan, Ann Arbor, 109 South Observatory
Street, SPH II, Ann Arbor, MI 48109-2029; Tel: (734) 623-2663;
Fax: (734) 623-2663; Email: ccchuang@umich.edu
Research Objective: Within the ESRD-related literature, issues concerning noncompliance of hemodialysis sessions have constantly been explored. Nevertheless, it is surprising to find that the economic consequences of noncompliance have rarely been investigated in the ESRD community. In
2003, the medical expenditures associated with treating dialysis patients has reached $18.1 billion, accounting for 6.7% of the Medicare budget. Facing the current cost-conscious
U.S. healthcare environment, understanding the economic consequences associated with noncompliance has become extremely important. This study attempts to examine the causal relationship as well as the magnitude of the impact between noncompliance in hemodialysis sessions and separately billable dialysis payments.
Study Design: In this study, noncompliance is a binary variable, defined by whether a hemodialysis patient skipped regular dialysis sessions during any month in 2003. Since there is considerable month-to-month variation in Medicare
Allowable Charges within hemodialysis patients, patientmonth was selected as the unit of analysis. Linear regression models weighted by hemodialysis equivalent dialysis session

were fitted to determine the slope of the trend in noncompliance on Medicare Allowable Charges per session.
Log-linear regression models weighted by hemodialysis equivalent dialysis session were also fitted to test for sensitivity.
Population Studied: Data were obtained from 212,034
Medicare hemodialysis patients in 2003. Data from 1.9 million patient-months were used in the analysis. Medicare
Allowable Charges were obtained for all hemodialysis patients with Medicare as the primary payer during 2003. Patient characteristics, including age, sex, low body mass index, and time on renal replacement therapy, and characteristics associated with partial dialysis months such as skipped sessions, transfer between facility, hospitalization, and transplantation, and comorbidities were measured using CMS
Form 2728 and/or Medicare claims.
Principal Findings: Descriptive statistics show that 23% of hemodialysis patients skipped sessions in 2003. Preliminary results suggest that noncompliance is associated with
$15/session increases in separately billable charges after controlling for patient demographics, time on renal replacement therapy, body size, baseline hematocrit, functional status, and comorbidities. This finding was supported when additional analyses were conducted to further explore the association between the current month of noncompliance with the following month’s Medicare
Allowable Charges per session. Regression results indicate that the subsequent month’s payment per session would increase by $14 if a patient is noncompliant in the current month.
Conclusions: Evidence from previous studies shows that noncompliance in hemodialysis sessions is negatively correlated with health outcomes and quality of life. The analyses presented in this study aim at investigating the economic consequences of noncompliance and found that the noncompliance measure does explain a significant fraction of the variation in per session payments.
Implications for Policy, Delivery, or Practice: Results from this study suggests that since noncompliance in hemodialysis sessions leads to $15 more Medicare Allowable Charges per session for dialysis patients, and a greater than 15% increments in predicted payments, policy makers should consider whether a monitoring system should be established to improve compliance. A pay-for-performance scheme could be designed to reward facilities with a high compliance rate in order to simultaneously contain cost pressures while assuring better quality to the ESRD patients.
Primary Funding Source: CMS
● Parents’ Views of Psychotropic Medication and the
Relationship to Help-seeking Strategies for their Child’s
ADHD
Sara Evans, M.H.S., Matthew Mychailyszyn, B.A., Susan dosReis, Ph.D.
Presented By: Sara Evans, M.H.S., Doctoral Student, Health
Policy and Management, Johns Hopkins Bloomberg School of
Public Health, 624 North Broadway, Room 661, Baltimore,
MD 21205; Tel: (248)212-3521; Email: sevans@jhsph.edu
Research Objective: Stimulant medication is generally the preferred medical practice for children and adolescents with attention-deficit/hyperactivity disorder (ADHD). However, parents are often skeptical of medication use for this population. Treatment is sought often after a considerable delay of the initial symptom onset. Furthermore, many children and adolescents discontinue medication within a year. Understanding how and why parents decide to seek and initiate psychotropic medication for their child might help to clarify the delay in access to care as well as the discontinuity of treatment. This study was undertaken to examine parents' views of psychotropic medication and how these views relate to the strategies employed to seek care for their children.
Study Design: Qualitative, semi-structured, telephone interviews were conducted with parents whose child was newly diagnosed with ADHD. The focus of this paper is the
28 parents who initiated professional care for their children’s
ADHD. All interviews were recorded and transcribed verbatim. Data were analyzed using a grounded theory approach to identify emergent themes, to describe the relationships among the codes, and to explore the meaning parents ascribe to psychotropic medication for ADHD. Two members of the research team independently coded transcripts, and discrepancies were resolved by group discussion.
Population Studied: Parents whose child was newly diagnosed with ADHD were recruited from primary care, developmental/behavioral pediatrics, and specialty mental health clinics affiliated with a large, urban teaching hospital.
Principal Findings: Many parents already had developed a specific view of medication before their children were diagnosed with ADHD. The emergent themes from the narrative data that best described these views were conceptualizations of the appropriateness of medication; both in terms of the child’s age and the illness, the anticipated effect that medication has on children, and the symbolic meaning of using psychotropic medication treatment for a child. These views were related to the individual strategies that parents used to manage their children’s ADHD problems.
The various strategies were categorized in terms of what is done within the family to help the child, what forms of medical treatment are sought, and how families work within the school system. Life circumstances or changes in personal and social environments were an important factor that affected what, when, and how long strategies were implemented.
Conclusions: Parents often engage in a variety of strategies before pursuing psychotropic medication for ADHD. These findings offer new insight into how parental views of medication may lead to delays in initiating treatment. The strategies employed by parents in seeking help for their children are deeply rooted in life circumstances, and are amenable to change based on changes in their home and work environment.
Implications for Policy, Delivery, or Practice: This study provides a deeper understanding of factors that may impede parental access to and continuity of evidence-based mental health care for children and adolescents. To the extent that these parental issues can be addressed early on in treatment carries important implications for improving practice and, ultimately, outcomes for children and adolescents.
Primary Funding Source: Other Government

● The Impact of Nursing Professional Practice and Other
Organizational Attributes on Organizational Quality
DiJon Fasoli, R.N., M.S.N., M.B.A., M.A., Ph.D. ABD
Presented By: DiJon Fasoli, R.N., M.S.N., M.B.A., M.A., Ph.D.
ABD, Doctoral Candidate; AHRQ Fellow 1999 - 2002, Heller
School for Social Policy and Management, Brandeis
University, 18 Saddle Hill, Amherst, NH 03031; Tel: (603)672-
5855; Email: dfasoli@brandeis.edu
Research Objective: This study-in-progress examined hospital organizational characteristics that significantly influence hospital quality and explored the professional practice environment in an organizational systems framework, using Nadler and Tushman’s Congruence Model of organizational analysis and Hoffart and Woods’ Nursing
Professional Practice Model.
Study Design: The quantitative research design involved primary data collection, utilizing the NWI-R tool to survey
Registered Nurses and an investigator-developed survey for
Nurse Executives to measure the professional practice environment, and secondary data collection to evaluate hospital organizational attributes and hospital quality.
Statistical analyses, including descriptive techniques, hypothesis testing, and multiple regression analysis, were conducted to understand the relationships between professional nursing practice and other organizational attributes and their impact on organizational outcomes.
Population Studied: A simple random sample of 28 hospitals was recruited from 71 midsize general medical-surgical acute care hospitals. 1,815 Registered Nurses (30.9%) and 28 Senior
Nurse Executives (100%) participated.
Principal Findings: Average length of stay (-.618), RN:LPN
Staffing mix (- .302), admission growth(-.324), health system affiliation (- .326), and net income (– .407) explained 52% (p <
.01) of the variance in the HQA Hospital Quality Measure in the best model. The three quality variables (HQA Hospital
Quality Measures and JCAHO Accreditation Decision and
Overall Evaluation Score) were not correlated. Magnet hospitals did not have significantly higher quality ratings than non-Magnet hospitals, but magnet status is associated with reduced costs (r = -.480, p < .05) and reduced lengths of stay
(r = -.452, p < .05).
Conclusions: Quality is most improved by decreased utilization and less profitability. To a more moderate extent, quality is improved by leaner skill-mix, less market growth in terms of admissions, and not belonging to a health system. A
CMS purpose for publicly reporting HQA measures is to determine if financial incentives help to improve care quality; in this study, measures typically associated with financial health decrease the likelihood of higher HQA scores.
Incentives may be effective if higher expenses are related to hospital quality improvement investments. Findings on length of stay are consistent with the literature; however the literature is mixed on findings related to admission growth, staff mix and affiliation.
Because quality variables are not correlated, conclusions must be viewed cautiously. Possible explanations for the inconsistency are 1) inherent study limitations related to index construction, or 2) the measures evaluate different aspects of quality, i.e. patient-focused processes (HQA) vs. organizational functions and structures that support caregiving (JCAHO). The finding that magnet hospitals, exemplars of professional practice, do not have higher quality ratings is unexpected since elements of professional practice are directly and moderately related to quality; this may further support the explanation that HQA and JCAHO are measuring different quality concepts.
Implications for Policy, Delivery, or Practice: This study raises significant questions about the validity of quality measures, factors that influence organizational quality, and value of these measures to consumers. It also places nursing professional practice in an organizational theoretical framework and explores its impact on the organization and organizational quality. Finally, a survey instrument and new methods to measure nursing professional practice and quality are introduced.
Primary Funding Source: Brandeis University Heller Annual
Fund Dissertation Grant - 2003; Brandeis University Provost's
Dissertation Award - 2004; Sigma Theta Tau, Epsilon Tau
Chapter Research Award - 2004
● Market Economics of Hospital Quality
Ronald Fisher, Ph.D. Candidate
Presented By: Ronald Fisher, Ph.D. Candidate, Research
Associate, Health Administration, Virginia Commonwealth
University, PO Box 980203, Richmond, VA 23298; Tel: (804)
873-7844; Fax: (804) 828-1894; Email: rlfisher@vcu.edu
Research Objective: Profound change towards more marketoriented governance has transformed US healthcare in the last decades. Though research has characterized many attributes of this social movement, uncertainty persist as to whether objectives such as more efficient pricing and market differentiation are, in fact, being realized. The study aims to contribute to empirical findings that relate hospital quality performance to economic market factors. Three research questions were addressed: 1) Is economic competition raising the bar for quality performance? 2) Does quality cost more?
And, 3) Is hospital quality performance differentiated as rationally expected by supply and demand relationships.
Study Design: A four year longitudinal multi-level design was employed to model relationships between hospital quality and economic performance. A quality performance measurement model was developed through selection of indicators that met statistical and face validity criteria. Four risk-adjusted indicators where found acceptable and included three AHRQ patient safety measures (PSIs) and a rather global, if qualified, mortality rate. Factor analysis justified the use of two indexed measures (e.g., mortality and errors) comprising two indicators each. Economic measures included both revenue and production function expense models to assess pricing mechanism effects on quality outputs. Local market structure factors of competition, health plan purchasing leverage, and market wage index where also modeled within the hierarchical dataset.
Population Studied: Acute hospitals operating in Virginia during 1998 and 2001
Principal Findings: Significant between hospital variance was demonstrated, with hospital specific effects accounting for approximately 50% of the total variance of both quality performance measures. No significant trend of quality improvement was found for either quality measure, though the trajectory indicated a general lowering of Error events over time. Comparisons between economic and market dynamic

models and “empty models” did not reveal any expected market effect on the variance component of the growth curve.
No pricing mechanism fixed-effects were evidenced. Hospital quality does not cost more, even when market structure dynamics are accounted for. A significant relationship between
“competition” and Error performance was found. Distribution of market share amongst a number of hospitals in a local market was associated with lower Error rates. Some hospital characteristics included as economic control variables, such as staffed bed occupancy rates, where found to positively associate with the adverse events; though these associations are not readily explained by expected market efficiency assumptions.
Conclusions: Validation is provided for the measurement of hospital quality outcome indicators as revealing significant hospital specific effects. The rationally expected utility of increasing reliance on market-oriented governance, at least as assessed by the pricing and market differentiation of quality outputs, has yet to be revealed. The finding continues to support the notion of healthcare quality performance as a
“public good,” undifferentiated by expected pricing mechanisms.
Implications for Policy, Delivery, or Practice: While neoclassic theory has shown to be useful tool in many economic situations and industrial sectors, healthcare research and policy may find guidance from alterative theoretical and methodological approaches of merit. The empirical findings of this study, considered as stylized facts, suggest Herbert Simon’s adaptive rationality or institutional economic theory may be more productive.
Primary Funding Source: No Funding
● Effects of Insurance Type and Insurance Stability on
Childhood Asthma Diagnosis and Management
Jemima Frimpong, M.P.H.
Presented By: Jemima Frimpong, M.P.H., Doctoral Student,
Health Care Systems, Wharton School, University of
Pennsylvania, 3641 Locust Walk, Room G7, Philadelphia, PA
19104; Tel: (215)417-8230; Email: frimpong@wharton.upenn.edu
Research Objective: The current paper examines the effects of access to health care on asthma diagnosis and management. The study aims to determine and explain the relationship of insurance type (Medicaid and Private
Insurance) and stability in insurance (changes in insurance status across years) to diagnosis and management of asthma
(measured in terms of asthma attacks and asthma-related emergency treatments) for young children. Prior research has shown that children with asthma who receive health insurance through Medicaid use the emergency room more frequently.
However, the effects of changes in insurance type on asthma management by parents are less investigated.
Study Design: Three years of longitudinal data from the
Fragile Families and Child Wellbeing Study were used in the analysis. The Fragile Families and Child Wellbeing Study is a longitudinal study of about 5,000 children born in large U.S. cities between 1998 - 2000. The study over samples births to unmarried couples and is representative of non-marital births in large U.S. cities. Logistic regression was used to identify the independent effects of child insurance type and stability in insurance on asthma diagnosis and asthma management controlling for socio-demographic factors such as smoking, employment status, mother’s age and education.
Population Studied: A sample size of 3,747 children was included in the analysis. Interviews were completed by 87% unmarried and 82% married mothers at baseline. The response rate for all mothers at first year follow up was 90% and the rate at third year follow up was 89% for married and
87% for unmarried mothers.
Principal Findings: Children whose births were paid for by
Medicaid were 44% more likely to report asthma diagnosis at first year follow-up (p >.000). Children with public insurance
(Medicaid) are more likely than children with private health insurance to have asthma-related emergency treatments.
Asthma management improved significantly for children covered by private insurance from year 1 to 3 and declined for children covered by Medicaid. Perceived health status of child was strongly correlated with asthma management (p > .000).
Children perceived to be in excellent health (33%) had more asthma-related emergency treatments than children perceived to be in fair health (12%). Usual source of care and well-child visits did not explain the relationship between insurance type and asthma diagnosis and management.
Conclusions: The asthma management behaviors of parents with children covered by public insurance may be attributed to the minimum cost associated with Medicaid. The cost (i.e. co-payments) associated with private health insurance for parents of children with asthma may be associated with the parents being more likely to manage asthma attacks at home and less likely to seek emergency treatment. The possible reverse causality between perceived health of child and use of emergency treatments must be explored.
Implications for Policy, Delivery, or Practice: The greater likelihood of children with Medicaid to have asthma-related emergency treatments may be an indication of inefficiencies in public insurance programs. Medicaid programs should consider an education program targeted at new parents that provides mothers with effective tools to managing childhood asthma.
Primary Funding Source: No Funding
● Factors Associated with Hospital Commitment to the
Provision of Child/Adolescent Psychiatric Services
Lea Anne Gardner, R.N., M.S.P.H.
Presented By: Lea Anne Gardner, R.N., M.S.P.H., Doctoral
Candidate, Health Administration, Virginia Commonwealth
University, 1008 East Clay Street, Richmond, VA 23298; Tel:
434-971-3512; Email: laharrell@adelphia.net
Research Objective: Psychiatric services are often identified as stigmatized and unprofitable leading many hospitals reluctant to provide them. Limited community psychiatric services for children leave hospitals as a safety net for crisis situations. There are no studies assessing general acute care and childrens hospitals provision of child psychiatric services or the level of commitment (number of psychiatric services) in a hospital. This study identified environmental and organizational factors associated with non-federal acute care general and childrens hospitals in the United States that provide child/adolescent psychiatric services and the level of commitment.
Study Design: This study is a cross-sectional design utilizing the AHA survey and ARF from 2002 and 2003. A conceptual

framework was developed based on two macro level theories,
Resource Dependence and Institutional theory. Two statistical models were created that utilized variables selected to operational key constructs of the theories. The first model identified hospitals providing any child psychiatric services.
The second model identified the extent of hospital commitment, a measure based on six different child psychiatric services. Organizational and market characteristics were included in the analysis.
Population Studied: Study examined all non-federal general acute care hospitals and childrens hospital within the United
States nested in county-defined local markets.
Principal Findings: Findings suggest that hospital commitment to providing child/adolescent psychiatric services is associated with the presence of child psychiatric residency programs, status as a designated children's hospital, public ownership, and high community service orientation. Market characteristics associated with commitment include a percentage of non-profit hospitals in a market, levels of non white children and adolescents, and median family income. Results for hospitals providing a high level of commitment (number of services) were weaker but include location in metropolitan statistical areas, system affiliation, and children's hospital status
Conclusions: Two different macro level theories were suitable in identifying organizational and market factors associated with hospitals providing child psychiatric services. Each theory provided approximately half of the variables found significant for factors associated with a hospitals decision to provide child psychiatric services. The second model, level of commitment, didn't show very significant results in associations with environmental and organizational characteristics. Further research into more hospital specific variables is needed to determine associations with the actual number of services.
Implications for Policy, Delivery, or Practice: Offering child psychiatric services by hospitals are limited and there appear to be patterns to the decision to offer these services. Results are consistent with other studies that have looked at ownership and likelihood of unpopular and unprofitable services. It is unclear if there are access problems as a result.
It is also unclear if children psychiatric services are more or less subject to stigmatizing and potentially adverse consequences for hospitals than adult psychiatric services.
For hospitals that offer these services, there is less information concerning patterns with the choice of specific services. Differences in specific service offerings between child and adult psychiatric services in hospitals are also unknown. Future research is required to identify factors with stronger associations to the choice of specific service offerings.
Primary Funding Source: No Funding
● Client Satisfaction with Mental Health Services in a
University Student Population
Jennifer Hefner, M.P.H., Sarah Gollust, Ezra Golberstein
Presented By: Jennifer Hefner, M.P.H., Doctoral Student,
Health Management and Policy, University of Michigan,
School of Public Health, 1833 McIntyre Road, Ann Arbor, MI
48105; Tel: (734) 763-3769; Email: jhefner@umich.edu
Research Objective: Mental health is one of the most significant health concerns among college students and the number and severity of students seeking mental health services has increased during the past decade. Given the increasing demand and importance of services for this population, our aim is to assess client satisfaction with these services. Specifically, what aspects of a university counseling service – hours, location, therapist quality, privacy, and initial appointment delays – provoke dissatisfaction? Previous research has shown that satisfaction with university counseling centers is generally high, yet there has been no prior research comparing satisfaction with university and nonuniversity providers.
Study Design: We collected primary data through the Healthy
Minds study, a web-based survey of undergraduate and graduate students at a large, public university in the Midwest
(N=3,013, 60% response rate). The survey instrument included validated screening tools for depression and anxiety
(the Patient Health Questionnaire, or PHQ), as well as questions about mental health service utilization and potential barriers. If respondents reported receiving counseling or therapy in the past year they were asked to rate their satisfaction with the services of each provider visited using a
6-pt. scale that ranged from 1=very dissatisfied to 6=very satisfied.
Population Studied: 403 students (14% of the overall sample) reported receiving counseling or therapy for a mental health problem in the past 12 months and responded to questions regarding their satisfaction with those services.
Principal Findings: 68% of service users were female, 71% were Caucasian and 63% were graduate students. Based on the PHQ screening instrument, 27% had probable depression and 23% had probable anxiety disorders (as opposed to 12% and 10%, respectively, of the full sample). About half were frequent users, reporting six or more visits in the past 12 months. 55% of respondents who visited the University
Counseling Center were satisfied or very satisfied, as compared to the 71% who were satisfied or very satisfied with their visits to mental health providers in the local community or in the respondent’s hometown. The most prominent reason for dissatisfaction with university services was the inability to schedule an initial appointment without long delays (33% dissatisfied). There was also dissatisfaction with the quality of therapists and the hours of operation.
Conclusions: Satisfaction with the campus counseling service was relatively high, but not on par with non-university providers. This difference may be due at least in part to differences (e.g. greater motivation to find a good match with a therapist) in those who seek services outside the university counseling center.
Implications for Policy, Delivery, or Practice: The difference in client satisfaction between university and non-university providers may be indicative of differences in quality of care.
Further investigation of university counseling centers along

other quality dimensions is warranted. In addition to serving as a quality of care indicator, client satisfaction can influence service use. Given that cost is not a factor at most university counseling centers, client satisfaction could serve as an important determinant of whether students receive needed mental health services.
Primary Funding Source: University of Michigan, Office of the Vice President for Research and The School of Public
Health
● Assessing Financial Burden Among the Near-Elderly,
1977-2003
Erin Holve, M.P.H. M.P.P., Leslie Conwell, MHS, D.E.B.
Potter, MS
Presented By: Erin Holve, M.P.H. M.P.P., Ph.D. Candidate,
Health Policy and Management, Johns Hopkins Bloomberg
School of Public Health, 44 Philadelphia Avenue, Takoma
Park, MD 20912; Tel: (703) 725-0555; Email: eholve@jhsph.edu
Research Objective: This study examines trends in out-ofpocket (OOP) spending and financial burdens that may limit access to healthcare services among the near-elderly aged 55-
64 between 1977 and 2003, including differences based on sex and health status, using alternative measures of OOP burden.
Study Design: Data are from the 1996-2003 Medical
Expenditure Panel Survey (MEPS) and 1977 and 1987 MEPS predecessor surveys (National Medical Care Expenditure
Survey and National Medical Expenditure Survey).
This study assesses the distribution of individuals with high levels of financial burden for health services using a threshold of >10% of per capita household income spent on OOP healthcare, a common measure of defining excessive healthcare spending as a percentage of annual household income. Further comparisons assess distribution of spending on health services based on >20% and >40% of household income of household income. Per capita household income is calculated by summing the reported personal income of all family members and averaging income across family members. Percent of out-of-pocket spending is calculated by dividing all reported OOP medical utilization expenses for each household member by per capita household income.
This study compares the distribution of near-elderly with OOP spending over time.
Population Studied: The population for this study is US civilian, non-institutionalized persons. The sample size of near-elderly ranged from 1,723 to 3,861 participants.
Principal Findings: Previous research has shown that mean
OOP spending for the near-elderly significantly increased from an average of 5.2% of annual income in 1977 to 7.3% in 2003.
The largest increase was among the poor and near-poor, rising from an average of 16.1% in 1977 to 29.9% in 2003.
Spending rose among those in poor/fair health, from 8.7% in
1977 to 13.3% in 2003. Subsequent analyses with alternative measures of OOP burden are hypothesized to show significant variation in the distribution of those near-elderly with high financial burdens over the period of the study.
Conclusions: On average, both OOP healthcare spending by the near-elderly as a percent of annual income and the proportion of near-elderly with high financial burdens increased between 1977 and 2003. These trends indicate growth in health-related cost pressures among near-elderly, despite a relative increase in incomes.
Implications for Policy, Delivery, or Practice: These findings offer additional information on the burden of health care expenses among the near-elderly, with increases potentially fueled by a decline in employment-based insurance coverage as previously reported. These data inform policymakers on how financial burdens with respect to health care have grown over the last 25 years.
Primary Funding Source: AHRQ Intramural Research
Funding
● The Effects of Payment Changes on Health Care
Utilization and Expenditures: An Experience from Patients with Hepatitis B or C in Taiwan
Ching-Hui Hsieh, MA, Shu-Chuan Jennifer, Yeh, Ph.D.
Presented By: Ching-Hui Hsieh, MA, Student, Institute of
Health Care Management, National Sun Yat-sen University, 70
Lien-hai Road Kaohsiung 804, Taiwan ROC, Kaohsiung; Tel:
(886)7525-2000 x4870; Fax: (886)7525-1511; Email: m934070804@student.nsysu.edu.tw
Research Objective: Chronic hepatitis B and C are the important risk factors for liver cirrhosis and hepatocellular carcinoma. In 2004, chronic liver disease was the seventh leading cause of death and hepatocellular carcinoma (HCC) was the second common cancer in Taiwan. Early effective therapies on patients with chronic hepatitis B or C can prevent such patients from progression of disease to late stages and decrease the burden of health care expenditures. The purpose of this study was to investigate the effects of changing payment due to changing care protocols on the health care utilization and expenditures for chronic hepatitis B or C.
Study Design: The new payment policy for chronic hepatitis B or C was implemented on October of 2003. The contents of the policy are paying for patients with chronic hepatitis B or C who fit the therapeutic criteria. We retrospectively and continuously observed those patients with chronic hepatitis B or C after they participated the new modules with new payment policy for 6 months by analyzing the database from
Bureau of National Health Insurance (BNHI) in 2002 and
2004. Then, the utilization and expenditures were compared before and after the new payment policy. We used number of visits and interval between visits to measure health care utilization. Health care expenditures included costs of treatments, prescriptions, totals, total claim amount and averages of prescription costs.
Population Studied: We searched for the patients who enrolled the new policy from the database since January to
June of 2004. Fifty-six patients were identified in this study.
Principal Findings: We found that there were statistically significant difference on health care utilization and health care expenditures. Number of visits, costs of treatments, prescriptions, totals, total claim amount and averages of prescription costs increased significantly after the new policy implemented. Besides, compare with 2002, interval between visits was significantly decreasing in these patients.
Conclusions: The new payment policy changes health care utilization and expenditures on patients with hepatitis B or C, especially increasing costs of prescription.
Implications for Policy, Delivery, or Practice: The new payment policy improves the burden of health care expenditures on patients with chronic hepatitis B or C because it encourages patients to participate earlier therapies.

Understanding the differentiation between health care utilization and expenditures before and after the new payment policy can provide cost-effective care for patients with chronic hepatitis B or C and also guide the practice behavior for physicians.
Primary Funding Source: No Funding,
● The Antecedents to Knowledge and Attitudes to
Prevention Health Among the “Self-Paid Physical
Examination” Clients
Hsiao-Ting Huang, M.B.A., Chih-Liang Yaung, Ph.D., Shu-
Chuan Jennifer Yeh, Ph.D.
Presented By: Hsiao-Ting Huang, MBA, Graduate Student,
Institute of Health Care Management, National Sun Yat-Sen,
70 Lien-hai Road, Kaohsiung, 804; Tel: (07)5254870; Fax:
(07)5251511; Email: meluting@yahoo.com.tw
Research Objective: Physical examination is the best way to detect diseases earlier. The Bureau of National Health
Insurance (BNHI) provides preliminary health examination for those aged 40 and above and focus on hypertension and DM detection. The self-paid physical examination was getting popular in Taiwan. This examination generally includes the use of endoscopic examination and ultrasonography to prevent or screen dread diseases. The goal of our study was to understand what factors influence their knowledge of and attitude to prevention health. We examined the relationship between knowledge and attitude among the clients of self-paid physical examination.
Study Design: This study was a cross-sectional design with the client as the unit of analysis. We used questionnaire to survey self-paid clients on December of 2005. The questionnaire contained the information on demographics
(sex, age, education, occupation, etc.), health belief and health attitudes which were assessed using a 5-point Likert scale
(from 1=strongly disagree to 5=strongly agree), and health knowledge measured by a scale where 1=yes, 2=no, and 0=did not know. Descriptive and multivariate analyses were conducted.
Population Studied: The total sample was 47. The majority of the study sample was male (69.6%), with age around 30-40 years old. Approximately 70 percent were married and 85% with education above undergraduate.
Principal Findings: The average salary per month for the individual was NT$ 79,558(U.S. $1=NT$32), while the average household income was NT$ 195,392, which were almost three times of the average in Taiwan. Around 62% and 49% of the surveyed clients did not know BNHI offers a free annual and triennial physician examination for insured over 65 years and
40 years, respectively. Only 15% knew how to prevent osteoporosis accurately. Clients received health care information via newspaper and magazines, television and broadcast, and websites. People got materials about physical examination from hospitals, friends or related, and websites.
Women had more knowledge than men (t=-2.36, p=.023) in general prevention health knowledge. Clients with junior high education was quite different with senior high in health attitudes (F=4.88, p=.006). If clients who had relatives or friends with chronic or severe disease had higher scores in health knowledge than those who did not (t=-2.02, p=.05).
Clients whose individual income per month above NT$60,000 were higher scores in attitude levels than those under NT$ 60,
000(t=-2.66, p=.013).
Conclusions: Sex, marital status, and whether someone has chronic or severe disease are associated with knowledge of prevention health care. Individual income per month, who encourage taking this examination and belief of detection are related to attitude to prevention. Prevention knowledge for health care is highly correlated with people’s attitude.
Implications for Policy, Delivery, or Practice: Most of people who take self-paid physical examination did not know that BHNI provides free examinations for age above 40s and
65. The health care providers should take the opportunity to educate public for health prevention and early detection. The further research may compare the difference between free physical examination offered by BNHI and self-paid physical examination in terms of cost-effectiveness manner.
Primary Funding Source: No Funding
● The Effects of Depression in Adolescence on Educational
Attainment
Jennifer Humensky, M.P.P.
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 determine how depression in adolescence, as measured by the CES-D depression scale, affects educational attainment, how this varies among subpopulations, and how access to mental health care may affect this.
Study Design: Multivariate regression models analyzing the probability of dropping out of high school, and being enrolled in college or graduating college by Wave III of AddHealth data collection, controlling for depressive symptoms in Wave I, as measured by CES-D, and other student and family characteristics.
Population Studied: Students interviewed in Waves I and III of the National Longitudinal Survey of Adolescent Health
(AddHealth), a nationally representative survey of students in grades 7-12 at Wave I (1994-1995). Wave III follow-up was conducted in 2001-02, when respondents were 18-26 years old. 23 respondents who were still enrolled in high school at
Wave III were excluded.
Principal Findings: Preliminiary findings indicate that higher
CES-D scores in adolescence for white, non-Hispanic females and for Hispanic females were associated with higher probability of dropping out of high school and lower probability of being enrolled in or graduated from college.
Controlling for IQ somewhat mitigated these effects. No effects of depression score in adolescence were found for blacks or males. Receiving counseling at school may help to increase school attachment. Planned future analyses include examining family fixed effects and the effects of mental health clinics in schools.
Conclusions: Depressive symptoms appear to have an effect on educational attainment, but only for white, non-Hispanic females and Hispanic females.
Implications for Policy, Delivery, or Practice: Depression has high prevalence in adolescence, with some estimates as high as 10-20% of adolescents meeting diagnostic criteria for depression. Understanding the effects of depression can help

policy-makers target appropriate interventions to help improve outcomes for aolescents with depression.
Primary Funding Source: AHRQ, National Research Service
Award T32
● The Relationship between Patient-Centered Care
Program Philosophy and Capitation in Community Mental
Health Centers
Jenny Hyun, M.P.H.
Presented By: Jenny Hyun, M.P.H., Doctoral Student, Health
Services and Policy Analysis, University of California Berkeley,
140 Warren Hall, c/o Bloom Research, Berkeley, CA 94720-
7360; Tel: 510-540-9556; Email: jhyun@berkeley.edu
Research Objective: In the Institute of Medicine’s seminal work on health care quality, “Crossing the Quality Chasm,” and in the President’s New Freedom Commission on Mental
Health, the delivery of individualized, patient-centered health care is listed as one of the top priorities for health organizations and delivery systems. No research to date has investigated the relationship of financing arrangements on organization-level patient-centered care program philosophy.
This study seeks to understand how patient-centered care
(PCC) program philosophy is associated with capitated financing arrangements in community mental health centers.
Study Design: Data on patient-centered program philosophy is derived from the Community Program Philosophy Scale
(CPPS), which was administered to program employees in 17 community mental health centers (CMHCs) in Colorado. The
PCC program philosophy scale encompasses six subscales-- 1) family involvement/orientation; 2) coordination with other agencies and services; 3) addressing the multiple needs of severely mentally ill (SMI) consumers; 4) individualized care;
5) cultural competence; and 6) user education and advocacy— and had an internal reliability coefficient of 0.78. Fourteen
CMHCs in Colorado were capitated, taking on two forms of capitation—a direct capitation (DC) model with non-profit managed care organizations created by the CMHCs themselves or a joint-venture with a for-profit managed behavioral health organization (MBHO). Three CMHCs remained fee-for-service (FFS). Data is collected one year precapitation and two years post-capitation. The unit of analysis is the community mental health center. OLS regression analyses are used to assess the relationship between capitation and organization-level PCC program philosophy scores.
Population Studied: The CPPS was administered to a total of
483 individuals over three years (one year pre-capitation and two years post-capitation). Eighty-one respondents were in
FFS, 166 respondents were in DC, and 191 respondents were in MBHO models. Responses were averaged and aggregated to the organizational level.
Principal Findings: Bivariate OLS regression analyses showed that mean PCC program philosophy scores increased over time. PCC program philosophy scores increased in both capitated models the second year post-capitation, although differences did not exceed the p<0.05 significance level. PCC program philosophy scores were 5.95 units higher in the DC model (p<0.10) and 2.85 units higher in the MBHO model.
Variance between individual PCC scores within organizations decreased over time (p<0.10).
Conclusions: There was a significant increase in PCC program philosophy over time and a trend toward decreased variance in organizational responses to PCC program philosophy questions. There was no significant relationship between PCC program philosophy and capitation in community mental health centers.
Implications for Policy, Delivery, or Practice: System-level changes in health organizations emphasize leveraging the alignment of environmental and organizational qualities.
Organization-level PCC program philosophy presents one aspect of organizational goal alignment. Findings from this study suggest that capitation does not exert a negative influence on PCC program philosophy. Rather, the study implies that organizational profit status may direct a greater influence on organizational PCC program philosophy.
Primary Funding Source: National Institute of Mental Health
● Factors Affecting Adherence to Highly Active
Antiretroviral Therapy and its Association with Patient
Satisfactions among HIV/AIDS Patients
Yunho Jeon, M.S., Jong-Deuk Baek, Ph.D., Carleen H.
Stoskopf, Sc.D.
Presented By: Yunho Jeon, M.S., Research Assistant, Health
Services Policy and Management, University of South
Carolina, 6 Doral Court, Columbia, SC 29229; Tel: (803)777-
2772; Email: jeon@sc.edu
Research Objective: To examine the association of patient satisfaction with adherence to highly active antiretroviral therapy (HAART) among HIV-infected people who are receiving medical care, and to investigate the factors affecting adherence to HAART.
Study Design: Crosssectional study. Good adherence was defined that patients took their medication more than 95% as their doctors prescribed over the past week.
Population Studied: A national probability sample of 2,267 adults receiving HIV care who completed second follow-up interviews (HIV Cost and Services Utilization Study) conducted in 1997-1998.
Principal Findings: Those who rated higher quality for their received medical cares and last clinic visits were more likely to adhere to highly active antiretroviral therapy than those who rated lower. After controlling for other variables, however, patient satisfaction variable was no longer significant. Based on multivariate logistic regression, those who were older, whites, men, illicit drug users and heavy drinkers were more likely to adhere to HAART.
Conclusions: High level of patient satisfaction with medical care they received and last visit to a doctor, clinic or HMO was significantly associated with the adherence to HAART.
Implications for Policy, Delivery, or Practice: These results suggest that interventions aimed at improving adherence to
HAART should focus on patient satisfaction by reinforcing patient-provider communications and patient-oriented medical services.
Primary Funding Source: No Funding

● Worker Productivity:How Job Status Can Moderate the
Economic Impact of Illness
Cameron Kaplan, BA, Charles J. Neighbors, Ph.D., M.B.A.,
Donald Shepard, Ph.D.
Presented By: Cameron Kaplan, BA, Graduate Student,
Economics, University of California, Santa Barbara, 2127 North
Hall, University of California, Santa Barbara, CA 93106-9210;
Tel: (858) 245-3690; Email: kaplan@econ.ucsb.edu
Research Objective: To examine the effects of health status on worker productivity for workers in different socio-economic groups.
Study Design: Two measures of productivity were used: absenteeism, which is a measure of the amount of time missed from work, and presenteeism, which quantifies work productivity lost to illness. The study evaluated the moderating effects of socio-economic factors (including job prestige) on the relationship between health status and the two measures of productivity. Health status was measured using the EuroQol EQ-5D, which is a validated utility-based generic measure of health-related quality of life.
Population Studied: Absenteeism data were from interviews with 1,582 adult participants in the Transdisciplinary Tobacco
Use Research Centers (TTURC) study at Brown University.
The presenteeism analysis was based on a subsample of 218 subjects who completed a validated Work Limitations
Questionnaire (WLQ).
Principal Findings: Negative Binomial regression analysis suggested that, on average, workers in the 75th percentile of job prestige miss one extra day of work for every 0.13 decrease in health status as measured by the EQ-5D. Workers in the
25th percentile of job prestige miss one extra day of work for every 0.05 decrease in EQ-5D. The relationship between health and presenteeism was not significantly different between high and low status workers.
Conclusions: Health status can affect worker productivity and impact the labor market. Based on the results of this study, we predict that the effect of illness on the supply of labor is significantly greater for lower prestige workers than for high prestige workers, while the demand effect is not significantly different. This would imply that low prestige workers have lower employment and possibly lower earnings compared to the efficient level.
Implications for Policy, Delivery, or Practice: Illness may have a much larger impact on productivity for low prestige workers in comparison to high prestige workers. In addition, these differences may be much greater for workers without benefits.
Primary Funding Source: NCI
● Patient Benefits from Participating in an Integrated
Delivery System? Impact on Coordination of Care,
Satisfaction, Willingness to Recommend and Clinical
Outcomes
Cori Kautz, M.A., Ph.D. ABD, Jody Hoffer Gittell, Ph.D., R.
William Lusenhop, S.W., Ph.D. ABD, Dana Beth Weinberg,
Ph.D., John Wright, M.D.
Presented By: Cori Kautz, M.A., Ph.D. ABD, Student, Heller
School for Social Policy and Management, 704 West Hollis
Street, Nashua, NH 03062; Tel: (603) 598-2826; Email: ckautz@brandeis.edu
Research Objective: One goal of integrated delivery systems has been to improve the coordination of care and associated quality outcomes for patients. This study assesses whether receiving care from providers who belong to the same integrated delivery system improves patient-perceived coordination, patient satisfaction, willingness to recommend the care team, and/or patient’s clinical outcomes.
Study Design: To minimize differences arising from surgery itself and to isolate the effects of provider membership in the integrated delivery system, we enrolled patients who received surgery from the same surgical department in the same acute care hospital. Depending on the network membership of their post-acute care providers (rehabilitation, home care, and primary care providers), these patients had differing levels of participation in the integrated delivery system after discharge.
We used hospital records to determine membership of a patient’s post-acute care providers in the integrated delivery system. We used baseline, six-week, and twelve-week surveys of patients to assess the impact of participation in the integrated delivery system on patient-perceived coordination, patient satisfaction, willingness to recommend, and clinical outcomes. Patients who were enrolled in the study received surgery from one of four participating surgeons. We used random effects linear regression methods to control for correlated errors arising from patients who received surgery from the same surgeon.
Population Studied: A study was conducted of 222 patients who received primary unilateral total knee arthroplasty between November 2003 and March 2004 at an acute care hospital in a large integrated delivery system.
Principal Findings: We found that network membership of a patient’s post-acute care providers has few observable effects on coordination, patient satisfaction, willingness to recommend, or clinical outcomes.
Conclusions: Our results are inconsistent with expectations that integrated delivery systems will improve coordination and associated quality outcomes for patients. We discuss potential reasons for this lack of observed effects and argue for the usefulness of the approach developed here for assessing patient benefits from participating in an integrated delivery system.
Implications for Policy, Delivery, or Practice: Our study has important implications for healthcare researchers, providers, and policymakers. While much of the research on integrated delivery systems focuses on more macro outcomes such as financial performance, our study focuses on patient benefits.
Furthermore, we offer a novel approach for assessing the impact of an integrated delivery system on patient outcomes.
The approach developed here takes advantage of the fact that patients receiving similar treatments typically have varying

levels of participation in a given network. By assessing the impact of patient participation in that network on patient outcomes, researchers can achieve a baseline measure of network effectiveness.
Primary Funding Source: CWF
● Effects of Health Insurance on Physical Activity in US
Adults
Eric Keuffel, M.P.H.
Presented By: Eric Keuffel, M.P.H., Ph.D. Candidate, Health
Care Systems Department, Wharton, University of
Pennsylvania, 6 Reaney Court, Philadelphia, PA 19103; Tel:
(215) 546-9286; Email: ekeuffel@wharton.upenn.edu
Research Objective: This study estimates the effects of health insurance status on physical activity decisions.
Epidemiological evidence links physical activity with reductions in relative risk for a variety of costly chronic diseases. In theory, the expected effect of insurance coverage on primary prevention effort is ambiguous. Moral hazard may reduce the probability of engaging in prevention behaviors by beneficiaries. However, many insurers now offer benefits and programs that promote physical activity. Prior research found a complementary relationship between coverage and physical activity. This study disaggregates effects by source (public vs. private) and type (HMO vs. Non-HMO) of insurance.
Study Design: Physical activity (PA) is defined as “vigorous activity 3 or more times per week for at least 30 minutes per session”. Logit models regressed the bivariate physical activity measure in 2002 (1-yes, 0-no) on insurance variables, demographic characteristics, occupation, income, education, health status measures and medical expenditures.
Independent variables either measure 2002 levels or changes
(when appropriate) and help extract out variation due to underlying health status, demographic, educational and occupational factors. Variance Inflation Factors (VIF) from linear specifications reject excessively collinear specifications.
Marginal effects (ME) are estimated using mean values and reflect the change in probability of being physical active for an
“average” individual for each one unit increase in the relevant independent variable. The analysis was conducted using
STATA version 9.2.
Population Studied: The Individual Component of the
Medical Expenditure Panel Survey (MEPS) Panel 6 (2001-
2002) is a weighted representative panel of the civilian noninstitutionalized US population. PA was only measured for adults.
Principal Findings: Just over half of adults are physically active (.55). Although the primary specification results in a positive, but insignificant, association between insurance coverage and physical activity; the specification which differentiated between public and private coverage shows that private insurance complements physical activity (+.03 marginal effect, p=.06) while public insurance has insignificant effects. Interaction models indicate that, after accounting for type of insurance (public and private), those enrolled in HMO plans within Medicaid have significantly higher probabilities for PA (+.06 ME, p=.03). Much of the effect associated with private insurance depends on employment status. The main private insurance coefficient is positive (+.08 ME, p<.01), but the interaction term between private insurance and employment is negative (-.07 ME, p<.01). Lastly exposure to out-of-pocket costs (measured as a ratio to total health expenditures) is significant but of modest magnitude (+.03 ME, p=.05)
Conclusions: To the extent that the covariates eliminate important confounders such health status and account for selection, these regressions suggest that private plans and
HMOs increase probability of physical activity for at least portions of the population. Greater exposure to out-of-pocket costs increases the probability of PA, but only modestly.
Implications for Policy, Delivery, or Practice: Incentives embedded in private and HMO style plans appear to increase
PA behavior modestly. While the precise mechanism is unknown, future identification of these economic fulcrums that promote physical activity and potentially reduce long run health care costs may affect both private and government payers. Further study on the mechanism of action and subgroup analyses are warranted.
Primary Funding Source: NRSA
● The Impact of Cost Containment Strategies Employed By the Michigan Medicaid Program on the Dual Eligible
Population
Jennifer Kibicho, MA, BA
Presented By: Jennifer Kibicho, MA, BA, Ph.D Candidate,
Economics, Wayne State University, 615 Hancock West, #201,
Detroit, MI 48201; Tel: (313) 832-0214; Email: ak3241@wayne.edu ; jwkibicho@hotmail.com
Research Objective: To evaluate the effect of the Michigan
Pharmaceutical Product List (MPPL), multistate purchasing pool plan and maximum allowable cost (MAC) reimbursement cost containment strategies, on prescription drug expenditures for the dual eligible population. The hypothesis tested is that each of these policies resulted in a shift in prescribing patterns to preferred drugs not subject to prior authorization and did not impact overall utilization, as measured by total days supply. Further, policies resulted in reduced per unit reimbursement costs. Hence, the study seeks to find whether reported program savings are mainly due to price and not volume effects.
Study Design: Prescription drugs claims data were obtained for the period commencing October 1999 (prior to any cost containment policies being implemented) to September 2004
(the researcher is in the process of securing fiscal year 2005 data). A pre-post framework is employed to evaluate the impact of each of the three cost-containment strategies. The main unit of analysis is day's supply of prescription drugs
(which avoids the problems associated with using dosage as a measure of quantity). Using regression analysis, the study employs a two step approach. First, aggregated monthly data is used to test the hypothesis that there was no statistically significant difference in average monthly per capita day's supply of prescription drugs. Per capita analysis is carried out to control for changes in number of beneficiaries due to changes in eligibility rules and other economic factors.
Secondly, patient level data is used to test the factors that determine dual eligible prescription drug expenditure.
Population Studied: Michigan's Medicaid dual eligible population in the Fee-For-Service program that are noninstitutionalized, older than 65 years and taking prescription drugs relating to cardiovascular conditions (congestive heart failure, angina, arrhythmia and hypertension) is utilized.

Principal Findings: The main findings were that average monthly day's supply of prescription drugs did not change significantly over the duration of the study. However, average reimbursement costs declined significantly over time.
Conclusions: Michigan Medicaid cost containment policies did not have any statistically significant effect on dual eligibles access to prescription drugs for cardiovascular conditions.
Changes in prescription patterns were observed, with increased utilization of cheaper drugs. Further, these policies were successful in reducing the cost per claim, generating considerable savings to the program.
Implications for Policy, Delivery, or Practice: These findings suggest that the implementation of cost containment policies, when properly carried out can generate considerable savings to a program without necessarily negatively impacting access to needed prescription drugs.
Primary Funding Source: University Teaching Assistantship and summer internship
● An Examination of Hospital Capital Investment,
Operational Efficiency, and Quality of Care
Tae Hyun Kim, M.P.H.
Presented By: Tae Hyun Kim, M.P.H., Research Assistant,
Health Administration, Virginia Commonwealth University,
1008 East Clay Street, Richmond, VA 23298; Tel: (919)914-
6591; Email: kimth@vcu.edu
Research Objective: Capital investment in the latest medical equipment and the replacement of aging facilities are important hospital decisions because it involves major dollar spending and is critical to long-term success. The literature on hospital capital investment suggests that hospitals may improve operational efficiency and quality of care by spending capital in their facilities. The primary aim of the study is to assess the relationship between capital investment, operational efficiency and quality of care.
Study Design: Using longitudinal data from 1998 through
2002, the study applies fixed effect models to analyze the data.
Data sources include the Centers for Medicare and Medicaid
Services (CMS) (capital investment, financial performance),
American Hospital Association (AHA) (operational characteristics), Area Resource Files (ARF) (market characteristics), and Healthcare Cost and Utilization Project
(HCUP) (quality measures-in-hospital mortality ratio and the complication ratios).
Population Studied: Study population is U.S. short-term, general acute care hospitals. Specifically, a panel of hospitals from 11 states (AZ, CA, CO, FL, IA, MA, MD, NJ, NY, WA, and
WI) comprises the sample.
Principal Findings: Using Donabedian’s framework of structure, process, outcome, this study tests the following three hypotheses: 1) hospital capital investment will be positively associated with quality of care, 2) hospital capital investment will be positively associated with operational efficiency, 3) the association between hospital capital investment and quality of care will be different depending upon the level of operational efficiency. In addition, selected hospital characteristics, market characteristics, and financial performance will be tested to see if there are other independent effects on quality measures and operational efficiency.
Conclusions: The study will confirm whether hospitals can improve quality of care through investing in capital assets, and how investments affect operational efficiency. The study will also provide a reasonable basis for explaining how capital investment affects operational efficiency, and how in turn operational efficiency affects quality of care.
Implications for Policy, Delivery, or Practice: From a managerial perspective, one of the most important findings will be the association between capital investment and quality of care. Findings about the association of capital investment and operational efficiency will provide hospital managers information on whether capital investment is an efficient way to improve quality of care. The results of the study also will enable hospital managers to decide how to spend their budgets to improve efficiency and quality of care. While hospitals are operating under increasing pressure for efficiency and cost control, the findings will provide policy makers implications regarding whether a growing emphasis on efficiency might compromise quality of care in hospitals.
Primary Funding Source: No Funding
● Nurse Surveillance: An Empirical Analysis of the Concept
Ann Kutney, RN, M.S.N.
Presented By: Ann Kutney, RN, M.S.N., Pre-Doctoral Fellow,
Center for Health Outcomes and Policy Research, University of Pennsylvania, 420 Guardian Drive, Philadelphia, PA 19104-
4210; Tel: 215-898-4908; Fax: 215-573-2062; Email: akutney@nursing.upenn.edu
Research Objective: The objective of this manuscript was to define the organizational capacity for nurse surveillance within a hospital. A secondary objective was to profile the existing organizational capacity for nurse surveillance among
Pennsylvania hospitals.
Study Design: A secondary analysis was used to explore the organizational capacity for nurse surveillance within
Pennsylvania hospitals using descriptive and correlational methods. The data source was the 1999 Pennsylvania nurse survey conducted by Aiken and colleagues at the Center for
Health Outcomes and Policy Research at the University of
Pennsylvania. Pennsylvania hospitals were ranked on each organizational capacity variable and a ranking profile was created for each institution. The association between overall ranking and nurse-assessed quality of care was examined in the highest and lowest ranked institutions.
Population Studied: 171 Pennsylvania hospitals
Principal Findings: The highest ranked hospitals' nurses reported good or excellent quality of care more frequently than nurses in the lowest ranked institutions. Nurses in the highest ranked hospitals also reported less occasional or frequent adverse events.
Conclusions: This is the first study to define and empirically explore the organizational capacity for nurse surveillance within a hospital. Organizational-level variables fundamental to nurse surveillance are the proportion of baccalaureateprepared nurses, clinical expertise level of the nurses, years of unit experience, the nurse-to-patient ratio, and the nurse practice environment.
Implications for Policy, Delivery, or Practice: This study established an empirical construct of nurse surveillance within a hospital into individualized profile form. The results are

useful for benchmarking, as well as hospital administration resource allocation.
Primary Funding Source: National Institute of Nursing
Research
● Quality of Care for Veterans in Non VA Nursing Home
Alexandre Laberge, M.B.A., B.Sc., P.T., Robert Weech-
Maldonado, Ph.D., Christopher Johnson, Ph.D., Huangang Jia,
Ph.D., Lloyd Dewald
Presented By: Alexandre Laberge, M.B.A., B.Sc., P.T., Student,
Health Services Research, Management and Policy, University of Florida, Gainesville, FL 32611; Tel: (352)871-0589; Email:
Laberger5@comcast.net
Research Objective: Over the past decade, veterans with long term care needs have been increasingly admitted to state veteran nursing homes and community nursing homes as opposed to VA nursing homes. There are no studies that have examined the difference in the quality of care between the community nursing home and the state veteran nursing homes. Using Donabedian’s structure, process, and outcomes framework for quality assessment, this study compares the quality of care of community nursing homes with veterans (VCNH), state veteran homes (SVNH), and community nursing homes without veterans (CNH) in an effort to determine which among these facilities best serve veterans.
Study Design: In a retrospective observational cohort study, the study uses facility level data from the 1999-2002 Online
Survey Certification and Reporting (OSCAR). Structural measures of quality include whether a facility met CMS recommended staffing levels for certified nursing assistants
(CNAs) and registered nurses (RNs). Process measures of quality include the proportion of residents that required tube feeding, new catheterization, and mobility restraints. Outcome measures of quality include quality of care deficiencies, quality of life deficiencies, total deficiencies, actual harm citations, and proportion of residents with new pressure sores. Analysis of variance was used to test quality differences across the three different sites of care.
Population Studied: The sample includes all
Medicare/Medicaid certified nursing homes between the years
1999 and 2002. It included 42 state veteran nursing homes,
9912 community nursing homes without veterans and 6823 community nursing homes with veterans.
Principal Findings: Structure: Significantly more state veteran nursing homes (SVNH) met CMS standard levels for CNAs
(p<.01) and RNs (p<.05) than either community nursing homes without veterans (CNH) or Community nursing homes with veterans (VCNH) (n=6823). Significantly more CNH met
CMS standard levels for CNAs (p<.01) and RNs (p<.01) than
VCNH. Process: SVNH and CNH had significantly less tube feeds (p<.01) than VCNH, VCNH had significantly less tube feeds (p<.01) than CNH. CNH and VCNH had significantly less new catheters (p>.01) than SVNH, and CNH had significantly more restraints (p>.01) than VCNH. Outcomes:
CNH had significantly less (p<.01) quality of care deficiencies
(p>.01), quality of life deficiencies (p>.01), total deficiencies
(p>.01) and actual harm citations (p>.01) than VCNH. SVNH had significantly less quality of care deficiencies (p>.01) and total deficiencies (p>.01) than VCNH.
Conclusions: The quality of care in state veteran nursing homes (SVNH) was at a level that was comparable to that of community nursing homes (CNH) that did not have veterans.
Both SVNH and CNH provided relatively better quality of care when compared to community nursing homes with veterans.
Implications for Policy, Delivery, or Practice: When considering quality of care, state veteran nursing homes
(SVNHs) could serve as a viable discharge location for veterans when compared to average community nursing homes. The findings also suggest that SVNH may have higher quality of care for veterans when compared to the community nursing homes with veterans.
Primary Funding Source: VA
● Facilitating the Implementation of Health Information
Technology in the State of Louisiana Through Medicaid
Michelle Lim Warner, M.P.H.c.
Presented By: Michelle Lim Warner, M.P.H.c, Master in
Public Health Candidate, School of Public Health and Health
Services, George Washington University, 4615 North Park
Avenue, Number 909, Chevy Chase, MD 20815; Tel: (202) 841-
9639; Email: milim@gwu.edu
Research Objective: Louisiana has a unique opportunity to re-design its health care system by focusing its re-building efforts on creating an interoperable health information technology (HIT) infrastructure. Medicaid, as the single largest purchaser of health care in a state, is in a unique position to further this effort. This analysis will explore and identify optimal strategies for Medicaid to employ in order to facilitate the implementation of HIT in the State of Louisiana.
Study Design: Involves an extensive review of the literature related to HIT and discussions with thought leaders from
Louisiana state government, the federal government and experts in the field of health care financing, health policy,
Medicaid administration, and electronic health information systems.
Population Studied: Louisiana Medicaid Agency, Louisiana
Medicaid recipients and providers serving Medicaid covered individuals
Principal Findings: HIT has the potential to improve health care quality and the efficiency of a health care delivery system.
Yet widespread adoption and use of such technology has been occurring at a far slower pace than is desirable. Many barriers, such as cost and legal and regulatory impediments, have limited the rapid adoption of HIT. However, the ramification of Hurricane Katrina to the Louisiana health care system illustrated the critical need for HIT to preserve and protect patient health records and maintain a working health care delivery system.
As any state’s largest single purchaser of health care,
Medicaid is in a position to facilitate the implementation of
HIT. Medicaid has many levers from which to further this effort – one of which is purchasing for quality. Louisiana is currently ranked 49th in the nation in terms of health care quality, and can benefit from having an HIT infrastructure supporting its health care system. Specifically, Medicaid can employ payment strategies such as pay-for-performance to incentivize its providers to utilize HIT. Medicaid can also employ regulatory and other provider-related approaches, as well as partnering with other funders to facilitate and achieve
HIT implementation.

Conclusions: Medicaid has a significant impact on furthering the HIT movement and can be leveraged to facilitate the implementation of HIT in states.
Implications for Policy, Delivery, or Practice: This analysis provides a new lens from which to view the evolution of HIT implementation in two ways: (1) by focusing on HIT implementation at the state-level and (2) by identifying strategies for Medicaid to leverage in facilitating the effort and furthering the HIT movement. Much of the visible activity around HIT adoption and implementation are occurring at the national level. Yet the problems and issues related to health care delivery are addressed at the local level. Furthermore, the potential of HIT to improve health care is first realized at the local level. As such, taking a look at how the largest purchaser for a state can move the HIT agenda forward is critical to identifying ways to achieve widespread implementation at the national level.
Primary Funding Source: No Funding
● Association of Maternal Depression Symptoms with
Utilization of Well-Child Visits for Young Children
Lisa Lyman, Doctoral Candidate
Presented By: Lisa Lyman, Doctoral Candidate,
AcademyHealth/National Center for Health Statistics Health
Policy Fellow, Johns Hopkins University Department of Health
Policy and Management, National Center for Health Statistics,
3311 Toledo Road, Room 6112, Hyattsville, MD 20785; Tel:
(301) 458-4769; Fax: ; Email: LLyman@cdc.gov
Research Objective: The objective of this study was to examine the association between symptoms of depression among mothers and the use of well-child visits in early childhood.
Study Design: Utilizing data from the 1988 National Maternal and Infant Health Survey (NMIHS) and the 1991 NMIHS
Longitudinal Follow-Up Survey (NMIHS-LF), cross-tabulations were conducted in order to examine the association between the presence or absence of depression symptoms in the week prior to each survey, as well as at both points in time, and the aggregate use of well-child visits over the four year period.
Maternal depression symptoms are self-reported by the mother in each survey using the Center for Epidemiologic
Studies Depression Scale (CES-D). Aggregate well-child visits are provided by reports from the child’s respective medical provider(s) from birth to the date of the NMIHS-LF. Children were between the ages of two and four years at the time of the
NMIHS-LF.
Population Studied: The study sample was comprised of
5,323 women who experienced a live birth in 1987, whose child was still alive in 1991, and was living with the respondent during both study time periods. Mothers in the study sample were representative of the original 9,953 mothers surveyed.
Principal Findings: Depression symptoms were associated with lower total use of well-child visits within each study year and across the full four year period. More children of mothers with scores in the clinical range (i.e., CES-D score greater than or equal to 16) in either 1988 or 1991 had five or fewer wellchild visits, compared to mothers with a score of less than 16.
Associations between presence of depression symptoms and use of well-child visits persisted when controlling for a number of factors, including the child’s age, birth weight, insurance status, type of insurance, and poverty.
Conclusions: Symptoms of depression and their persistence are associated with well-child care utilization during early childhood. Despite the potential bias with looking at total visits for this cohort of 2-4 year olds, the results did not differ when controlling for child's age.
Implications for Policy, Delivery, or Practice: Developers of programs and policies aimed at improving use of well-child services may want to further consider the mother’s experience with symptoms of depression in their design and execution.
Addressing the mental health needs of young mothers may further improve the outcomes of such efforts.
Primary Funding Source: National Center for Health
Statistics
● A Ranking of Successful Quality Improvement Strategies to Reduce Time to Reperfusion for STEMI
Kelly McDermott, BA, MA, Anne Sales, M.S.N., Ph.D., RN,
Christian Helfrich, M.P.H., Ph.D.
Presented By: Kelly McDermott, BA, MA, Student/Research
Assistant, Health Services, University of Washington, 511 East
Roy Street, #313, Seattle, WA 98102; Tel: (206) 366-5271;
Email: kmcdermo@u.washington.edu
Research Objective: Mounting evidence suggests that expeditious reperfusion in the event of ST elevated myocardial infarction (STEMI) decreases the damage to myocardial tissue and improves survival. In recent guidelines, the American
College of Cardiology and the American Hospital Association
(ACC/AHA) recommend the time from emergency department (ED) arrival to administration of fibrinolytic therapy (“door to needle time”) not exceed 30 minutes, and the time from ED arrival to percutaneous coronary intervention (PCI) (“door to balloon time”) not exceed 90 minutes. The research objective for this analysis is to evaluate and rank quality improvement strategies implemented to reduce time to reperfusion.
Study Design: A systematic review of the literature resulted in a list of quality improvement strategies implemented to improve times from door to reperfusion to meet the
ACC/AHA recommended guidelines. This analysis calculates a summary statistic for each quality improvement strategy to reflect the composite decrease in median time to reperfusion across those studies weighting for study design and sample size. Differences among the strategy summary statistics will be evaluated and the statistics will be ranked based on effectiveness in reducing time to reperfusion.
Population Studied: The inclusion criteria used for study selection included patient populations with STEMI and data collection and publication in or after 1990. The list of quality improvement strategies found in the literature review include: critical pathways, continuous quality improvement (CQI), audit and feedback, physician leadership/opinion leaders, physician education/guideline dissemination, assessing points of delay, pre-hospital ECG, administration of fibrinolytics in the ED, use of cardiac nurse specialist to administer fibrinolytics, PCI without surgical back up, ED physician activation of the catheterization laboratory, established transfer protocol, use of bolus fibrinolytics, and the use of a Thrombolytic Predictive Instrument.

Principal Findings: There was evidence of successful reduction in time to reperfusion for most of the quality improvement strategies. Eleven of the 14 strategies provided evidence for successful reduction in median time to reperfusion to meet the ACC/AHA guidelines. The largest time reductions were accomplished using physician education with a 14.5 minute decrease in median time to reperfusion across 7 studies implementing this strategy. CQI decreased median times by nearly 8 minutes across 8 studies and audit and feedback decreased median time by 3.5 minutes across 5 studies.
Conclusions: Fourteen quality improvement strategies were identified and ranked based on their effectiveness in reducing median time to reperfusion. While hospital specific factors such as volume affect times to reperfusion, differences in time reduction across these strategies suggest that the type of strategy implemented is also important. Additionally, success has been demonstrated for many of these strategies across multiple hospital settings.
Implications for Policy, Delivery, or Practice: This analysis not only provides an overview of current practices in quality improvement and reperfusion therapy, it also provides quality improvement strategy rankings which can enable hospitals to make more informed decisions regarding implementation and resource allocation.
Primary Funding Source: VA
● Validating the Underlying Cause of Dealth in the Death
Certificate against Medicaid Inpatient Claimes
Rachael Molnar, BS, Heather Beaird, Ph.D., Siran Koroukian,
Ph.D.
Presented By: Rachael Molnar, BS, Student, Epidemiology &
Biostatistics, Case Western Reserve University, 10900 Euclid
Avenue, Cleveland, OH 44106; Tel: (440)670-5317; Email: rlm26@case.edu
Research Objective: The validity of death certificate data for cancer deaths has not been explored using Medicaid data.
Given that the diagnosis codes recorded in inpatient claims originate from chart review, we aimed to validate the underlying cause of death on death certificates with Medicaid inpatient claims carrying a discharge status of death.
Study Design: We utilized Ohio Medicaid inpatient claims data for patients who died while in the hospital and limited our scope to cancer diagnoses only. The ICD-9 diagnosis codes in the claims records were compared with the ICD-9 codes listed as the underlying cause of death in the Ohio death certificates. Overall and cancer-specific percent agreements were calculated. Variation by patient characteristics was assessed by stratifying the data by age, sex, and race. For beneficiaries who did not have an underlying cause of death listed as cancer in the death certificate, the underlying cause of death was reviewed.
Population Studied: The cohort for this study was comprised of Ohio Medicaid beneficiaries with an inpatient claim indicating a discharge status of death, and a diagnosis of cancer in at least one of the five diagnosis codes available in that claim record.
Principal Findings: Cancer was listed as the underlying cause of death in the death certificate in approximately 86% of
Medicaid cancer patients who died in the hospital. Breast cancer was listed as the underlying cause of death in nearly
87% of Medicaid patients who had breast cancer listed in their claim. Prostate, colorectal, and lung agreed in 71%, 79%, and
86% of cases, respectively. These statistics did not differ significantly by age, sex, or race. The most frequent cause of death listed when the underlying cause of death on the death certificate was not cancer was Human Immunodeficiency
Virus (HIV). Many of these patients had a HIV-related neoplastic illness listed in their Medicaid claim. Other frequent causes of death were ischemic heart disease, pneumonia, chronic obstructive pulmonary disease.
Conclusions: This study implies that physicians do relatively well at identifying the underlying cause of death of Ohio
Medicaid cancer patients who die while in the hospital. The data sources agreed in the majority of cases. When death was not due to cancer, a plausible underlying cause of death was listed for the patient.
Implications for Policy, Delivery, or Practice: Researchers extract data from death certificates to report mortality statistics and trends, assess the effectiveness of public health interventions, and describe disparities in disease burden and outcomes. The National Center for Health Statistics utilizes information from death certificates to publish reports that influence future research, health policies, and resource allocation. Previous studies have challenged the accuracy of data from death certificates and have cited lack of physician training in filling out these forms as one contributor to this inaccuracy. This study suggests that physicians are frequently accurate in reporting cancer as the underlying cause of death in this population and defends the validity of this important data source.
Primary Funding Source: No Funding
● Women's Midlife Reproductive Health: New Directions for Research
Mercy Mvundura, M.A. Economics; B.Sc. Economics
Presented By: Mercy Mvundura, M.A. Economics; B.Sc.
Economics, Ph.D. candidate, Economics, Georgia State
University, 14 Marietta Street, N.W., Atlanta, GA 30303; Tel:
(202)386-2176 ; Email: mercymvu@hotmail.com
Research Objective: The North American Menopause Society
(NAMS) reports that in the year 2000, 1.8 million women in the U.S. experienced natural menopause while 263,000 women became surgically post menopause. Menopause is associated with poor health for some women with the most prevalent symptoms during the transition to post menopause being hot flushes, night sweats, depression, nervous tension, headaches, insomnia and lack of energy. Although research in labor economics shows that health is a significant determinant of both labor force participation and labor supply, no studies have analyzed the effect of women’s mid-life reproductive health problems on labor market outcomes.
Thus the objective of this research is to review the existing literature to develop a framework to explore the relationship between mid-life reproductive health problems and women’s labor market decisions.
Study Design: Literature searches on the following topics were undertaken using Medline, Sociological Abstracts, and
EconLit: menopause and health; the effect of overall health on labor market outcomes; and the effect of reproductive health problems on labor market outcomes. Key words for the first search were menopause, depression, health, physical

functioning, reproductive health, and mid-life; for the second, labor, employment, labor force participation, and health; and for the third, employment and menopause, work and menopause, labor market and menopause, employment and reproductive health, work and reproductive health, and labor market and reproductive health.
Population Studied: Women from ages 35 to 60 years in various stages of reproductive aging. The studies, dating from
1992 to 2004, encompass premenopause to postmenopause women residing in the US, Australia, Canada and the
Netherlands.
Principal Findings: Most of the literature on menopause and women’s health has explored the association between menopause and depression. The findings on this linkage are inconclusive with some studies reporting that women in perimenopause are more likely to be depressed than women in premenopause, while others found no greater likelihood of depression during perimenopause. Other literature exploring the link between physical functioning and reproductive aging found that women in perimenopause experienced a greater decline in physical health compared to women in other stages of menopause. The literature exploring the effect of depression and overall health on labor market outcomes concluded that people with health problems are less likely to participate in the labor market and are less likely to be employed. Poor health also has negative effects on hours worked with the decline in labor supply ranging from 1% to over 30% depending on the severity of the health condition being explored. These studies acknowledge that measures of health are not exogenous to labor market outcomes, so they use instrumental variables estimation methods to correct for the endogeniety. Other studies also emphasize the need to explore the effects of specific health conditions on labor market outcomes because such studies use more objective measures of health. However, no previous studies have explored the link between women’s mid-life reproductive health problems and labor market outcomes.
Conclusions: Some women experience poor health during the transition to menopause. Women in perimenopause are more prone to depression and also to having problems with physical functioning than women in premenopause.
Furthermore women who had early menopause, hysterectomies, or surgical menopause and those who took hormones to control menopause symptoms reported poor health outcomes. Since health is an important determinant of labor market outcomes, these reproductive health problems may impact women’s labor market decisions. The empirical methodology in other health-labor market research described above can be used to examine these impacts.
Implications for Policy, Delivery, or Practice: As with other disease- or condition-specific studies of the effect of health on the workplace, it is important to know if poor health resulting from reproductive aging has any negative effect on women’s earnings and ability to participate in the labor market. These results can influence not only future diagnosis, treatment, and insurance coverage decisions for this health condition but also workplace policy related to menopause.
Primary Funding Source: No Funding
● The impact of Medicare’s Prospective Payment System on Long Term Acute Care Hospitals: the early evidence
Preethy Nayar, M.S., M.Phil.
Presented By: Preethy Nayar, M.S., M.Phil., Doctoral Student,
Health Administration, Virginia Commonwealth University,
3412 Andover Hills Place, Richmond, VA 23294; Tel: (804)
346-0782; Email: nayarp2@vcu.edu
Research Objective: The decade of the 1990s saw spiraling health care costs across all health care settings, particularly post acute care settings. The Balanced Budget Act mandated the use of prospective payment systems for all post-acute settings; including Long Term Acute Care Hospitals
(LTACHs). In October 2002 Medicare changed its mode of payment to LTACHs from a cost-based system to Prospective
Payment System (PPS). In response to this shift in reimbursement mechanism are LTACHs changing their operating characteristics? The purpose of this study is to analyze the effect of changes in reimbursement consequent to the implementation of Medicare PPS on the operating costs and staffing of long term care hospitals. This study attempts to answer the following research questions: 1) How did the
Medicare’s shift from a cost based reimbursement system to prospective payment system (PPS) affect the operating costs and staffing of LTACHs? 2) What are the organizational and environmental factors associated with changes, if any, in operating costs and staffing of LTACHs?
Study Design: The study design is a Multiple time series
Non-equivalent comparison group design and the study uses panel data of measures of hospital and market characteristics in years 2001 through 2004.
Population Studied: The study sample includes all long term care hospitals in the U.S. that were operational during the study period, and uses data from secondary databases including the American Hospital Association Survey database, the CMS database, and the Area Resource File.Multivariate pooled Ordinary Least Squares and fixed effect regression models are estimated. The results and policy implications are discussed.
Principal Findings: Findings are forthcoming.
Implications for Policy, Delivery, or Practice: Developing payment and insurance systems for long-term care that work better than existing ones is a challenge for policymakers(Knickman et al, 2002). Medicare spending for
LTCHs increased nearly five times from $400 million in 1993 to $1.9 billion in 2001. CMS estimates that this figure will be
$2.8 billion by 2008 (MEDPAC, 2004). Under the PPS
Medicare pays LTACHs at predetermined rates based on the patient’s principal diagnosis rather than facility costs. The payment system, thus, allows facilities to make profits by reducing their operating costs and becoming more efficient.
However, whether managerial efforts to reduce costs and become more efficient will actually result in reduced hospital operating costs is still unclear. There is a paucity of empirical literature on the subject of the early effect of Medicare’s shift in payment system on LTACHs.
Primary Funding Source: No Funding

● The Effect of State Minimum Staffing Regulation on
Quality of Nursing Home Care
Jeongyoung Park, M.P.H., Sally C. Stearns, Ph.D.
Presented By: Jeongyoung Park, M.P.H., Doctoral Candidate,
Health Policy & Administration, University of North Carolina at Chapel Hill, 1103F McGavran-Greenberg Hall, CB#7411,
Chapel Hill, NC 27599-7411; Tel: (919)824-1696; Fax:
(919)966-6961; Email: jypark@email.unc.edu
Research Objective: Quality of nursing home care is an important public policy issue, and inadequate staffing levels may directly affect the quality of care received by residents. In an effort to improve quality of care and resident outcomes, many states are pursuing legislation to mandate higher minimum staffing ratios in nursing homes. However, the cost of increasing staffing levels under the current nursing workforce shortage can be substantial for both nursing homes and the government. Therefore, it is important to identify whether minimum staffing regulation affects quality of nursing home care. The purpose of this study was to evaluate the effect of changes in minimum staffing regulation on quality of nursing home care and resident outcomes.
Study Design: From 1998 to 2001, 16 states changed their minimum staffing regulation, enabling a natural experiment.
Under the assumption that unobserved state-level factors
(such as population health and state Medicaid generosity) may be correlated with changes in state minimum staffing regulation, state fixed effects models were estimated.
Resident outcomes were measured by the rate of pressure sores, contractures, and catheter use, while overall facility quality was measured by restraint use and the number of facility survey deficiencies. Treatment effects were specified as
‘first year effects’ and ‘steady state effects’. The persistent
(steady state) effects of state policy changes were estimated with a one year lag specification. Facility and market level variables were used to provide additional controls over time.
Population Studied: The data came from the Online Survey
Certification and Reporting System (OSCAR) from 1998 through 2001. The OSCAR data were linked to data on market conditions and state staffing regulation. A total of 56,595 facility-year observations from 15,568 non-hospital-based facilities were analyzed.
Principal Findings: Changes in minimum staffing regulation resulted in a first year decrease in restraint use by 0.81 percentage points, with a steady state reduction in restraint use of 1.46 percentage points. These results were statistically significant at 1% and were relative to an overall level of restraint use of 11.85%. Similarly, the policy changes resulted in steady state reductions in the number of total survey deficiencies (IRR=0.96) which was statistically significant at
5%. None of the resident outcome measures (pressure sores, contractures, or catheter use) were significantly associated with changes in minimum staffing regulation.
Conclusions: Study findings indicate that changes in state minimum staffing regulation affect two measures of overall facility quality of nursing home care, though effects were not found for the resident outcome measures analyzed.
Implications for Policy, Delivery, or Practice: The results from the study will be useful for understanding the contributions of staffing regulation to the quality of nursing home care. However, the findings should be interpreted with caution because of potential lack of control for confounding variables associated with state policy change. Changes in state minimum staffing regulation may be caused by unobserved quality-related shocks such as a reaction to publicity about quality problems in nursing homes, which could cause bias in the assessment of the effect of the policies.
Primary Funding Source: No Funding
● Effect of Prescription Copayment Level on ACE Inhibitor
Adherence in Heart Failure Patients
Mark Patterson, M.P.H, Michael Murray, M.P.H, PharmD
Presented By: Mark Patterson, M.P.H, Ph.D. Student,
Pharmaceutical Outcomes and Policy, UNC-CH School of
Pharmacy, Kerr Hall, CB 7360, Chapel Hill, NC 27510; Tel:
(919) 923-8227; Email: mpatters97@gmail.com
Research Objective: Clinical practice guidelines recommend prescribing angiotensin-converting enzyme (ACE) inhibitors for patients with heart failure. However, out-of-pocket expenses from prescription copayments may likely affect patients’ ability to obtain their medications from the pharmacy. For example, copayments for multiple medications may increase the probability of heart failure patients skipping doses in order to save monthly prescription costs. Because of the potentially detrimental effect copayments may have on medication adherence, we conducted a study to determine the effect of ACE inhibitor copayment levels on ACE inhibitor adherence in commercially insured heart failure patients. We hypothesize that increased copayment levels are associated with decreased ACE inhibitor adherence.
Study Design: This retrospective cohort analysis uses claims from a proprietary database containing a over 38 million commercially insured individuals in the United States between
1996 and 2005. Adherence to ACE inhibitors was defined using medication refills to compute the Medication
Possession Ratio (MPR). An MPR of 1 indicates that a patient’s prescription refill pattern is exactly as prescribed.
ACE inhibitor copayments, ranging from $0 to $50, were defined in $5 range intervals. The refill-level analyses contain
68,795 prescription refills for 2,035 heart failure patients with an average follow-up of 2.9 years. Fixed-effect multivariate linear regression was used to model the effect of copayment level on MPR. Logistic regression was used to model the association between ACE inhibitor non-compliance
(MPR<0.80) and ACE inhibitor copayment level. Models accounted for individual level clustering, demographics, health plan type, number of comorbidities, and concomitant use of beta-blockers or diuretics.
Population Studied: Patients were 50 years of age or older with either 1 inpatient or 2 outpatient claims with a primary diagnosis of heart failure (ICD-9 428.x) and at least 2 prescription claims for an ACE inhibitor. Patients had continuous health care and prescription coverage for 3 years.
Follow-up began on the date of the first ACE inhibitor prescription after the diagnosis of heart failure was established and ended either upon medication discontinuation or the date of the last observed claim.
Principal Findings: Compared to the lowest refill claim of
($0) ACE inhibitor refills with copayment levels ($26 to $30) and ($31 and above) were significantly associated with a 4% increase (p=0.04) and 3% decrease (p=0.09) respectively, in medication coverage during any particular refill interval. ACE

inhibitors with copayment levels ($31 and above) were significantly associated with an increased risk of nonadherence [OR=1.58, 95% CI (1.03 – 2.43)].
Conclusions: High ACE inhibitor copayments are associated with significant decreased medication adherence in commercially insured heart failure patients.
Implications for Policy, Delivery, or Practice: Heart failure patients must adhere to ACE inhibitors to derive the benefits and achieve optimal outcomes. Because ACE inhibitor copayments are inversely associated with adherence, higher copayments could result in a risk of poorer health status.
Future studies should examine the effect of ACE inhibitor copayment levels on health outcomes.
Primary Funding Source: American Foundation of
Pharmaceutical Education (AFPE)
● Neighborhood Disadvantage and Adolescent Violent
Behavior
Tracy Patterson, M.H.S., Philip J. Leaf, Ph.D.
Presented By: Tracy Patterson, M.H.S., Student, Mental
Health, Johns Hopkins Bloomberg School of Public Health,
624 North Broadway, Baltimore, MD 21205; Tel: (443) 520-
2724; Email: trpatter@jhsph.edu
Research Objective: We propose to extend prior research on neighborhood effects on youth violent behavior utilizing selfreports of neighborhood disadvantage and violent outcomes assessed by both self-reports and official court records.
Study Design: Utilizing data from a prospective longitudinal study, we will use logistic regression analyses to examine the association between youth self-reports of neighborhood disadvantage in the sixth grade with both self-reported violence in grades 6, 7 and 8 and with official juvenile court arrest records. Adjustment will be made for individual-level, family-level and socioeconomic factors.
Population Studied: The urban sample consists of predominately African American male and female adolescents of lower socio-economic status. This study is based upon 2311 youth who participated in a prospective longitudinal study conducted by the Prevention Research Center at the Johns
Hopkins University School of Public Health. Two cohorts of children from 19 public elementary schools in Baltimore City participated in an evaluation of two school-based interventions targeted at academic achievement and aggressive behavior. Participants were assessed in face-to-face interviews in grades 1 through 8 and were re-interviewed as part of a young adult follow-up at the ages of 19 to 20.
Principal Findings: Youth reports of neighborhood disadvantage were associated with youth violent outcomes regardless of how those outcomes are measured. Increasing levels of neighborhood disadvantage were positively associated with engagement in violent behavior. The strongest associations were found for sixth grade self-reported violence.
Assessment of neighborhood disadvantage in the sixth grade was associated with self-reported violence in later years
(grades 7 and 8) in addition to violent court records. After controlling for risk factors for youth violence, including individual level, family level and socioeconomic factors, reports of neighborhood disadvantage maintain significant associations with engagement in violent behavior. Being
African American was positively associated with having a youth violent court event by age 14, but was not positively associated with self-reported violence in grades 6, 7 or 8.
Conclusions: Youth reports of neighborhood disadvantage are predictive of engagement in violent behavior as assessed by both official records and self reports. Youth reports of neighborhood disadvantage in the sixth grade are predictive of engagement in violent behavior in future years. Of particular note, this study lends support to the problem of racial disparities in the juvenile justice system. African Americans were more likely to have juvenile court records for violence compared to youth of other races, yet there were no race differences for self-reported violence during the three years of assessment.
Implications for Policy, Delivery, or Practice: Youths’ experiences of their neighborhoods should be taken into consideration when designing violence prevention and intervention studies. Preventive interventions targeting neighborhoods to reduce youth violent behavior should consider subjective reports of neighborhood in addition to more formally utilized objective data such as that from the US
Census. Subjective reports of the neighborhood can better assess youths’ experiences of their neighborhoods and can be collected more frequently than data restricted to the decennial census. Future research in policy and practice should also address the issue of racial disparities in the juvenile justice system.
Primary Funding Source: NIMH
● Sexual Risk Behavior Among Central Region
Mozambicans Initiating Highly Active Antiretroviral
Therapy (HAART)
Cynthia Pearson, Ph.D. (C), Ann Kurth, CNM, Ph.D., Stephen
Gloyd, M.D., M.P.H.
Presented By: Cynthia Pearson, Ph.D. (C), Research Scientist,
Psychology, University of Washington, Box 351525, Seattle, WA
98105-1525; Tel: (206) 330-1997; Fax: (206) 685-3157; Email: pearsonc@u.washington.edu
Research Objective: Currently the HIV/AIDS rate in central
Mozambique is among the highest reported in Africa ranging from 29%-36%. Examining sexual behaviors across partnerships, and understanding how sexual partnerships influence behaviors associated with HIV transmission risk, can inform new strategies for behavior change interventions. Like many HIV-negative persons, HIV-positive patients do engage in sexual activity, and may engage in behaviors that carry risk to their own health as well as to the health of their partners.
Our study research objectives were 1) to determine the prevalence of unprotected sex and 2) to describe sexual behaviors and secondary HIV transmission risk factors among
HIV-positive Mozambicans initiating highly active retroviral therapy (HAART).
Study Design: We present baseline data from a longitudinal study assessing sexual behavior after initiating HAART. Data was collected from 9/2004–4/2005. Face to face interviews were conducted by trained interviewers in Portuguese, Sena or
Ndau. Descriptive statistics are used to describe patterns of sexual behavior in a life time, among the last three partners and in the past three months.
Population Studied: During this period 423 persons HIV+ persons initiating HAART at a public HIV clinic in Central
Mozambique, were eligible for the study. Of these, 350

persons between the ages of 18 – 70 (mean (M)=35.7, SD=8.8) were interviewed (54% females). CD4 count was low (M=125,
SD=95) and most knew of their HIV+ status for less than a year (M=9.2 months, SD=10.3)
Principal Findings: Lifetime partners for men nearly tripled that for women (M=13.8 vs. 4.5) and about 50% of men and women reported a concurrent relationship among the last three partners. About a quarter (21%) of the women reported involuntary first sex, as compared to 2% of the men. General belief about practicing safer sex, such as abstinence, condom use, and monogamy were very similar for men and women.
About 70% believed condoms and 15% believed abstinence to be the most effective way to protect others from HIV.
Although 91% said they were more likely to use a condom in the next 3 months, only 25% actually used a condom the last time they had sex (20% women, 33% men). The primary reasons condoms were not used were: ‘trusted’ their partner
(43%), partner (or respondent) does not like condoms (16%), condoms were unavailable (6%) and respondent and partner was trying to get pregnant (5%). In the three months prior to initiating HAART, 45% (n=157) of the participants had sexual relationships among 191 partners. Unprotected sex with HIVnegative or unknown serostatus partners took place in 66% of these relationships. Most (72%) disclosed their HIV status to their sexual partner. There was no significant difference in gender, disease stage, or age between those who did not disclosure their status and those that did not.
Conclusions: These findings suggest that unprotected sex continues to occur amongst some HIV+ persons on HAART in low-resource settings.
Implications for Policy, Delivery, or Practice: Sexual behavior risk reduction counseling and intensive secondary transmission prevention should be an important and provided component of HAART treatment support for HIV+ persons.
Primary Funding Source: PEPFAR, TAP
● Provision of Mental Health and Substance Abuse
Services in Rural Juvenile Justice Facilities
Michael Pullmann, M.S., Craig Anne Heflinger, Ph.D.
Presented By: Michael Pullmann, M.S., Pre-Doctoral Research
Fellow, Center for Evaluation and Program Improvement,
Vanderbilt University, Peabody 151; 230 Appleton Place,
Nashville, TN 37203; Tel: (615)343-1652; Email: michael.d.pullmann@vanderbilt.edu
Research Objective: The rate of youth with mental health and substance abuse problems in the juvenile justice system is high. Youth in facilities located in rural areas may be at high risk because the availability of behavioral health care in rural areas may be limited. However, research on behavioral health care in rural juvenile justice facilities is lacking. The purpose of this study is to provide a description of the resources available for identifying and treating behavioral health problems in the juvenile justice system in rural areas in Tennessee.
Study Design: This is a secondary analysis of data collected from a survey of juvenile facilities in Tennessee in 2003.
Sixteen questions asked about mental health and substance use services. There are two research questions for this analysis. First, what are the differences between Juvenile
Detention Centers (JDCs) located in rural or urban counties in screening, referral, and provision of services? Second, are there different findings when using different definitions of rural? This study used three different definitions of rural to classify counties; in this abstract, findings are based on the
1990 U.S. Census definition of major metropolitan areas.
Population Studied: Forty (91%) of the forty-four juvenile justice facilities responded. This analysis focuses on JDC’s, one of several different types of facilities in Tennessee used to hold delinquent youth. All eighteen of the JDC’s responded to the statewide survey. Seven (39%) of the state’s 18 JDC’s were in rural counties, and these facilities were holding 29% of the detained youth.
Principal Findings: The JDC facilities’ activities in screening and referral for mental health and substance abuse did not appear to be related to rurality. Only one item, screening for developmental disabilities, was significant; all of the facilities in rural areas reported screening for MR/DD, compared to
46% of the urban areas (?2 = 5.7, p = .017). Every other area of screening, training, services, and referral were not offered in any significantly different way. However, the range of facilities reporting these activities varies widely depending on the activity, ranging from a low of 27% of facilities having a procedure to link youth with behavioral health services after discharge, to a high of all (100%) of JDCs having pastoral counseling offered within their facilities. Tables with detailed findings and further analyses will be presented.
Conclusions: While there was only one statistically significant difference found in facilities’ screening, training, services, and referral, the rate of behavioral health resources varies widely and few of the facilities provided a full range of behavioral health screening, referral, or treatment services.
Implications for Policy, Delivery, or Practice: There has recently been a push by U.S. federal agencies to focus on rural areas. Rural residents have been designated as special populations for health, mental health, drug and alcohol abuse
(NIH, 2004) issues and service delivery. The President’s New
Freedom Commission on Mental Health (2003) specifically addressed the need to improve access to quality care in rural areas. This study is a first step in examining the resources available to youth in rural areas with complex behavioral health problems.
Primary Funding Source: NIMH Training Grant T-32
● The Effect of Community-Level Unemployment on
Preventive Oral Health Care Utilization
Brian Quinn, BA
Presented By: Brian Quinn, BA, Doctoral Student, School of
Public Health, Program in Health Services and Policy Analysis,
University of California, Berkeley, 1801 Rose Street #1,
Berkeley, CA 94703; Tel: (510) 524-8318; Email: bcquinn@berkeley.edu
Research Objective: The preventive oral health care services that are provided during a routine dental visit are important and cost-effective tools for improving oral health. A large body of literature has examined the individual-level characteristics that predict utilization of these services.
However, no known research has studied the impact of community-level factors on utilization of preventive oral health care services. This study examines the association between community-level unemployment and aggregate preventive oral health care utilization by a dentally insured population in that community. Specifically, it tests the hypothesis that unexpectedly high community-level unemployment is

associated with a reduction in the aggregate use of preventive oral health care services. Unemployment is predicted to reduce utilization of preventive oral health care services through the two mechanisms of impedance and distraction.
Study Design: The study uses monthly data on aggregate preventive oral health care visits and community-level unemployment in the Seattle-Bellevue-Everett Primary
Metropolitan Statistical Area (PMSA) and the Spokane
Metropolitan Statistical Area (MSA) for the 120 months from
January 1995 to December 2004. Utilization data come from
Washington Dental Services (WDS), the Delta Dental plan in
Washington. Area unemployment data were obtained from the Bureau of Labor Statistics. The study uses a Box-Jenkins
ARIMA time series method to determine the presence and magnitude of an association between the two variables over time. This approach controls for autocorrelation and seasonality in the time series.
Population Studied: WDS is the largest dental insurer in the state and covered nearly 1.2 million enrollees in the Seattle-
Bellevue-Everett PMSA and the Spokane MSA at the end of
2004. Aggregate monthly preventive oral health care visits range over the 120-month period ranged from 30,873 to
60,664 in the Seattle-Bellevue-Everett PMSA and from 7,607 to 15,313 in the Spokane MSA.
Principal Findings: Findings from preliminary analysis indicate that community-level unemployment has a negative and statistically significant association with preventive oral health care utilization in both communities.
Conclusions: The analysis suggests that utilization of preventive oral health care services declines during periods of high community-level unemployment. These findings imply that community-level unemployment may impede or distract dentally insured individuals from utilizing preventive oral health care services they would otherwise have accessed when the local economy was performing better.
Implications for Policy, Delivery, or Practice: The study’s findings have several important implications. First, for administrators of public and private sector health systems, the results further contribute to the understanding of factors that can reduce the use of preventive services that can improve long-term health benefits and control costs. Second, the results provide important information for dentists who must cope with the impact of shifting economic cycles on the financial well-being of their practice. Third, for policymakers, the negative relationship between the two measures signals a key time to conduct outreach efforts to encourage utilization.
Finally, the findings contribute to the larger health services research literature on the role of community-level factors on health care utilization. Such evidence is also important for other non-acute preventive services and for treatment of chronic conditions.
Primary Funding Source: No Funding
● Relationship Between Health Service Effectiveness and the Identification of Infants and Toddlers with
Communication Delay
Janice Ranne, BA, MA, Clare Houseman, Ph.D., John L.
Echternach, Ed.D.
Presented By: Janice Ranne, BA, MA, Student, College of
Health Sciences, Old Dominion University, 4939 Entiat River
Road, Entiat, WA 98822; Tel: (509) 784-1487; Email: jrann001@odu.edu
Research Objective: The purpose of this study is to test the power of portions of the New Model of Children’s Health and
Its Influences (National Research Council and Institute of
Medicine 2004) to predict health service effectiveness.
Communication delay affects a large number of children in the
U.S. Communication ability begins at birth. Delays in communication ability are identifiable in the first few months following birth.
Study Design: We use a concurrent mixed methods design to examine longitudinal, quasi-experimental and phenomenological data to understand the influences of social and physical environments, biology and behavior, as predictors of children’s receipt of developmental screenings.
Population Studied: The sample population involved children from 4 weeks to 36 months old from the Healthy Steps for
Young Children Program national evaluation by the
Bloomberg School of Public Health, Johns Hopkins University.
Principal Findings: The likelihood of infants and toddlers receiving developmental screenings to identify potential communication delay is mediated individually and/or interactively by social and physical environments, biology, and behavior which may cue health service providers to provide developmental screenings and to refer young children to early intervention services.
Conclusions: Various influences in the lives of infants and toddlers cue health service providers to become more effective in the care of young children through provision of developmental screenings.
Implications for Policy, Delivery, or Practice: Public policy provides for early intervention services for all children, birth to three years old. Most children with communication delay are not identified until kindergarten age. Health promotion through early identification of communication delay in infants and toddlers is essential for appropriate functioning in social interactions and for learning. Various influences on the changing lives of young children may impact development of communication skills. Developmental screenings can identify young children at risk for communication delay.
Primary Funding Source: Old Dominion University Doctoral
Research Fellowship
● Exploration of Child Health Service Effectiveness
Through Health Practice Retention
Janice Ranne, MA, Yan Zhang, Ph.D., Clare Houseman, Ph.D.
Presented By: Janice Ranne, MA, Ph.D. Student, College of
Health Sciences, Old Dominion University, 4939 Entiat River
Road, Entiat, WA 98822; Tel: (509) 784-1487; Email: jrann001@odu.edu
Research Objective: The pediatric medical community asserts that children receive the most optimal and comprehensive health care through the environment of a

‘medical home’. In order for children to experience a medical home, the mothers must consistently bring the children to health care practices. However, mothers occasionally withdraw the children from the practices. When children are withdrawn from a routine health care service, health service effectiveness may be diminished. It is important to investigate the various reasons that result in mothers’ withdrawal. Purpose: The purpose of this study is to examine child health service effectiveness through analysis of the relationships between mothers’ reasons for withdrawing from child health practices and mothers’ characteristics. The study uses the Social Cognitive Theory to aid in understanding the mothers’ interactions within personal and health service environments.
Study Design: Methods: We use quantitative analysis to examine longitudinal, experimental as well as quasiexperimental data to understand the relationships between the mothers’ involuntary and voluntary actions in withdrawing the children from health care practices and the mothers’ personal and environmental characteristics.
Population Studied: The dataset was obtained from the
Healthy Steps for Young Children Program, National
Evaluation, designed and executed by the Bloomberg School of Public Health, Johns Hopkins University. The data was collected on children 4 weeks to 36 months old and their caregivers.
Principal Findings: Some behavior changes of the mothers, which result in withdrawal of children from the health care practices, appear to emerge from the bi-directional interactions between personal and health care environments and certain personal characteristics. The observational learning and the modeled interactions of the health community appear to influence the mothers’ decision-making capacity.
Conclusions: The health service community may improve effectiveness in children’s health care and improve practice retention through increased understanding of the interactions between health service environments and personal characteristics.
Implications for Policy, Delivery, or Practice: Improvement in health service effectiveness inpediatric practices may enhance health service delivery and quality of care.
Primary Funding Source: Old Dominion University Doctoral
Fellowship
● Factors Associated with Generic Competition: Effect of
Patent Holder’s Multiple Patents Listing on Generic Entry
Jinnie Rhee, M.P.H.
Presented By: Jinnie Rhee, M.P.H., Ph.D. Candidate, Health
Services, University of California at Los Angeles, 11811 Venice
Boulevard, #301, LA, CA 90066; Tel: (310)915-5247; Email: jinnie@ucla.edu
Research Objective: Patent system for pharmaceutical innovation can fail under the presence of multiply listed patents per branded drug. This study examines the factors that influence generic entry upon initial patent expiration of brand name drugs, specifically focusing on additional patents filing as a strategic entry barrier tool by patent holders, which possibly leads to delay in generic competition. Additionally, we investigate what are generic firm’s incentives to enter the market.
Study Design: For 138 drugs (approved through New Drug
Application process between 1970 and 1990) whose initial patent expired over the period 1994-2003, the expiration dates of all related patents listed and their generic version’s approval dates (if generic entry happened) were obtained from the FDA. At different follow-up time point - 6, 12, 18, and 24 months after the initial patent expiration, probit analyses of the likelihood of generic entry were done to identify the determinants of the entry. We reported the relative risks (RRs), highlighting those with statistically significant results.
Additionally, we examined the relationship between total number of patents listed per drug and the drug’s profitability using negative binomial regression analysis to investigate whether patent holders filed more patents for their future topselling products.
Population Studied: N/A
Principal Findings: Generic competition was less likely to occur under the presence of any unexpired patent significantly even after initial patent expiration at each time point (RRs =
0.13, 0.33, 0.30 and 0.32). Top-selling drugs had more patents compared to non-top-selling drugs (p<0.000). Top-selling drugs as well as the drugs for geriatric care were more likely to attract generic entry at every time point (RRs for top-selling drugs = 33.84, 6.76, 6.04, and 3.90; RRs for geriatric drug =
3.97, 2.35, 1.82, and 1.43 respectively). The likelihood of generic entry increased as the initial patent expiration year increased in last decade (p<0.05).
Conclusions: Additional patent filing strategy was a powerful barrier to deter generic entry especially in early period after the initial patent expiration. Delay in generic competition was associated with patent holder’s intention to extend patented period by filing more patents. The generic industry has targeted top-selling products, which guarantee lasting profitability for several more years. Entry also depended on stable demand and prospective profitability of the drugs, such as geriatric drugs, a future-growing market as the population ages. The level of generic competition increased under
‘favoring generics policy’ and ‘cost containment efforts’ in last decade.
Implications for Policy, Delivery, or Practice: Current pharmaceutical innovation system could fail under patent holder’s strategies to maintain monopoly power and thus limit timely access to financially affordable medicine. Generic competition solely focus on generic industry’s financial interests do not provide sufficient incentives to make nonprofitable generics that people still need.
Primary Funding Source: No Funding
● State Legislation Expanding the Role of Nurse
Practitioners in a Workers’ Compensation System: Effects on Rural Access to Care
Jeanne M. Sears, MS, RN, Thomas M. Wickizer, Ph.D.,
M.P.H., Bobbie Berkowitz, Ph.D., CNAA, FAAN, Gary M.
Franklin, M.D., M.P.H.
Presented By: Jeanne M. Sears, MS, RN, Pre-Doctoral
Occupational Health Services Research Trainee, Health
Services, University of Washington, Box 357660, Seattle, WA
98195; Tel: (425)828-4241; Email: jeannes@u.washington.edu
Research Objective: Substitute House Bill (SHB) 1691 was implemented 7/1/04 in Washington State amid concern about disparities in access to care for injured workers in rural areas.

The bill authorized nurse practitioners (NPs) to independently perform most functions of an attending physician in the workers’ compensation (WC) system. This role expansion may have encouraged NPs to enroll as WC providers, improving access by increasing provider availability. The research objective was to evaluate the effects of SHB 1691 on 1) the number and geographic distribution of NPs enrolled in the
WC system and 2) timely access to care for injured workers.
Study Design: The evaluation of this natural experiment is based on a discrete time shift design using administrative data. Descriptive measures by county include change in the number of enrolled NPs, proportion of claims filed by provider type, and the ratio of NPs enrolled in the WC system to NPs with an active state license. Quantile regression will be used to assess pre-post change in time from injury to first medical visit. Final analyses will use Rural Urban Commuting Areas.
Population Studied: The study population included enrolled providers and injured workers with claims filed between
7/1/03 and 6/30/05. The Washington State Department of
Labor and Industries provided population-based data for 2/3 of the nonfederal employees in the state. The Washington
State Department of Health provided county-level data for licensed NPs.
Principal Findings: The number of enrolled NPs increased nearly 25% over the year after implementation. As of 8/05, the ratio of enrolled NPs to licensed NPs was 0.80 (1272/1585), and was higher for rural than for urban counties, 1.05
(325/309) compared to 0.74 (947/1276). 45.6% of claims filed by NPs were from rural counties, compared with 28.1% for all providers. Statewide, NPs filed essentially no claims from 1/04 to 6/04, 3.4% of all claims (n=1634) from 7/04 to 12/04, and
3.8% (n=1669) from 1/05 to 6/05. Claims filed by physicians and chiropractors decreased, and the total number of claims increased by only 0.3%.
Conclusions: NPs are important providers of WC-related care, particularly in rural areas, and NPs practicing in rural counties are more likely to be enrolled as WC providers. The increased supply of enrolled NPs after implementation of SHB 1691 could decrease travel distance and appointment delays for injured workers and potentially lead to better outcomes.
Implications for Policy, Delivery, or Practice: Due to disparities in provider distribution, NPs are the sole source of care in many rural communities. Within their scope of practice, NPs deliver primary health care that is equivalent in quality to that of physicians, yet few state WC systems designate NPs as attending providers and little information is available on NP-provided WC care. Legislation that would expand the Federal Employees Compensation Act’s definition of physician to include NPs and physician assistants is currently under consideration. The evaluation of SHB 1691 provides information of importance to policy makers on the role of NPs in mitigating access barriers specific to WC systems.
Primary Funding Source: NIOSH
● Effect of the Prospective Payment System on Case-Mix of
Medicare Home Health Care Users
Huai-Che Shih, MS, Bruce Friedman, Ph.D., Helena Temkin-
Greener, Ph.D., Andrew Dick, Ph.D., Kathryn Votava, Ph.D.
Presented By: Huai-Che Shih, MS, Ph.D. Candidate in Health
Services Research and Policy, Department of Community and
Preventive Medicine, University of Rochester School of
Medicine, 601 Elmwood Avenue Box 644, Rochester, NY
14642; Tel: (585) 275-3432; Fax: (585) 461-4532; Email: huaiche_shih@urmc.rochester.edu
Research Objective: The Balanced Budget Act (BBA) of 1997 changed the reimbursement model for Medicare home health care. The prospective payment system (PPS), which took effect in October 2000, assigns patients to a pre-determined rate schedule, the Home Health Resource Group (HHRG), based on their clinical, functional, and services utilization characteristics. A recent study (Schlenker, 2005) has observed a shift in the HHRG distribution toward more clinically complex and functionally dependent patients. The resource group measure used in that study is, however, directly influenced by PPS and therefore should not be used to properly evaluate the shift in patient case-mix as a result of the new payment model. The study reported here uses the distribution of chronic conditions and the Centers for
Medicare and Medicaid Services (CMS) Hierarchical
Condition Categories (HCC) model to examine the impact of
PPS on the case-mix of Medicare home health care users.
Study Design: This study compared Medical Expenditure
Panel Survey (MEPS) data from two pre-PPS years (1997 and
1998) and two post-PPS years (2001 and 2002). Data from each full year consolidated data file, home health event file, and medical conditions file were used in the analysis. Chronic conditions were defined using criteria developed by Hwang
(2001). The number of chronic conditions associated with a
Medicare home health event was categorized into 4 groups
(0, 1, 2, and 3+) for a Chi-Square Test. A Poisson regression model was estimated in which the number of chronic conditions was the dependent variable, PPS status was the independent variable of interest, and sociodemographic variables and Medicaid/private insurance status were covariates. The model was adjusted by sampling weights and clustered by the individual identifier. The CMS-HCC risk score is compared to characterize the change in the case-mix of
Medicare home health users.
Population Studied: 4070 Medicare home health person months identified from MEPS data.
Principal Findings: The Chi-Square Test shows that there was not a significance change (p=0.214) in the distribution of number of chronic conditions for Medicare home health events after the implementation of PPS. Results from the
Poisson model shows that PPS status was not significantly associated (p=0.239) with the number of chronic conditions.
Results from the CMS-HCC model will be presented during the poster session.
Conclusions: Using the number of chronic conditions as a risk measure, the case-mix of Medicare home health events does not appear to significantly change after the implantation of PPS. These results suggest that the observed changes in the HHRG distribution may be accounted for by changes in reporting accuracy with regard to patients’ conditions or by deliberate manipulation of the PPS payment system.

Implications for Policy, Delivery, or Practice: More unbiased risk adjustors are needed to further investigate this issue. Proper measures should be used to monitor the quality of the Medicare home health care reimbursement mechanism in the PPS era.
Primary Funding Source: University of Rochester
● The Financial and Operational Impact of an Observation
Unit and Holding Area on an ED and Its Inpatient
Hospital
Veronica Sikka, M.H.A., M.P.H., Joseph P. Ornato, M.D.,
Michael S. Gonzalez, M.D.
Presented By: Veronica Sikka, M.H.A., M.P.H., Student,
Health Administration, Virginia Commonwealth University,
12601 Hogan's Alley, Chester, VA 23836; Tel: (804) 530-0950;
Fax: (804) 530-0950; Email: s2vsikka@mail1.vcu.edu
Research Objective: Several studies have proven the cost savings associated with providing extended ED care in an observation unit (OU) versus an inpatient unit. However, the opportunity costs lost to the hospital without an OU have not been determined. In addition, holding areas (HAs), where patients are cared for after an ED physician’s decision to admit but prior to bed assignment, have gained popularity as improving ED efficiency. The exact time savings associated with an HA has yet to be determined.
Study Design: Fiscal year (FY) 2004 data was used to retrospectively determine the volume of patients who presented to the ED with 22 predetermined diagnoses who could have utilized the OU and HA. The resulting bed need was determined using a resource need-based calculation. The
ED costs for provision of observation care versus the inpatient costs were compared. A revenue differential between inpatient observation care versus higher acuity inpatient care was determined for the Medicare population as a cohort. In addition, a time analysis of patient flow from triage to discharge/admission was performed using data collected by
VCU’s information system with predetermined time points.
Population Studied: All ED admissions for FY 2004
Principal Findings: During FY 04, the model predicted an
OU volume of 5,418 with a bed need of 11 and a HA volume of
7,719 with a bed need of 16. At our institution, our calculations indicate that the ED can provide observation care for $7,490 less than the inpatient side. Due to lower costs, the ED would have generated an additional $550,440 in revenue in FY 2004. For the Medicare population as a cohort with a length of stay less than 2 days (comparable to the length of stay of an observation inpatient), the hospital could have generated $8,456,749 in additional revenue had the beds been utilized for higher acuity inpatient care versus observation care. The addition of a HA reduced the average
ED length of stay (LOS) by 66.3% from 9 hours and 36 minutes to 3 hours and 14 minutes.
Conclusions: A HA has the potential to significantly decrease
ED LOS while the OU has significant opportunity costs for the
ED and the inpatient side.
Implications for Policy, Delivery, or Practice: Addition of
OUs and HAs to existing ED floorplans could potentially solve the "ED crisis" many studies have described by decreasing waiting room time, time on diversion, patients who leave before being evaluated. These additions can also increase patient and employee satisfaction, bed turnover, and quality of care.
Primary Funding Source: Alpha Omega Alpha
● Inpatient Deaths during Childhood Injury-Related
Hospitalizations: Trends and Variations by Payer Status,
Florida 1998-2002
Lisa Simpson, MB, BCh, M.P.H., FAAP, Jean Lee, MS, Robyn
Cheung, Ph.D., Etienne Pracht, Ph.D., Barbara Langland
Orban, Ph.D., Karen Liller, Ph.D., Lisa Simpson, Ph.D.
Presented By: Lisa Simpson, MB, BCh, M.P.H., FAAP, Chief,
Division of Child Health Outcomes, Pediatrics, College of
Medicine, University of South Florida, 601 4th Street South,
St. Petersburg, FL 33701; Tel: 727-553-3672; Fax: 727-553-3666;
Email: lsimpso1@hsc.usf.edu
Research Objective: The purpose of this study was to evaluate trends and variation in mortality associated with childhood, injury-related hospitalizations in Florida by payer status from1998 to 2002.
Study Design: A secondary analysis of hospital discharge data from the Florida State Inpatient Database (SID) was performed. The Florida SID is an all-payer, inpatient care database which contains discharge abstracts from all community, non-rehabilitation hospitals in Florida. Univariate and bivariate analyses were performed with significance testing. A multivariate model was constructed to examine the factors associated with increased mortality among uninsured patients.
Population Studied: The sample included all children aged 0-
17 years discharged with a principal diagnosis of injury.
Excluded were discharges of children with a principal diagnosis of injury related to complications and late effects of surgical or medical care. Also excluded were discharges with an external cause of injury code (Ecode) for injury due to medical or surgical care or adverse reactions to drugs and substances used in a therapeutic manner.
Principal Findings: The proportion of childhood, injuryrelated hospitalizations with private coverage also remained fairly stable during the study period and ranged from 54.1-57.4 percent per year. The proportion of childhood, injury-related hospitalizations with public coverage increased from 30.2 to
37.4 percent, while the proportion those without coverage decreased from 12.4 to 8.5 percent during the study period.
The number of hospitalized, injured children who experienced an inpatient death versus the number who were alive at discharge in each payer group differed significantly (p<.05) in
2000-2002. Generally, the inpatient mortality rate per 100 discharges (unadjusted for severity) decreased for children with private and public coverage each year of the study period.
The unadjusted, inpatient mortality rate for uninsured children, however, increased each year rising from 1.53 in 1998 to 2.60 in 2002. Except for 1998, uninsured children had the highest unadjusted, inpatient mortality rate of any payer group each year for injury-related hospitalizations. Traffic-related injuries were the leading mechanism of injury associated with an inpatient death in hospitalized, injured children every year.
Multivariate results are pending.
Conclusions: Despite decreasing proportions of uninsured children among all hospitalized, injured children in Florida, uninsured children experienced increasing unadjusted, inpatient mortality rates. In fact, uninsured children

experienced the highest unadjusted, inpatient mortality rates in four out of the five years studied compared to children with private or public coverage. Potential explanations for these findings include delays in seeking care, more severe injuries, and decreased quality of care for uninsured children.
Implications for Policy, Delivery, or Practice: Findings from this project have implications for the need to extend quality health care coverage to uninsured children.
Primary Funding Source: Pediatric Clinical Research Center
● Unmet Need for Mental Health Care Services in Children with Disabilities: Impact of State Medicaid Managed
Behavioral Health Care Coverage Policy
Laura Smith, Ph.D. Candidate, Susan M. Allen, Ph.D.
Presented By: Laura Smith, Ph.D. Candidate, Graduate
Student, Community Health - Epidemiology, Brown University,
167 Angell Street, Providence, RI 02906; Tel: (401) 863-7708;
Email: Laura_Smith@brown.edu
Research Objective: This study seeks to answer whether children with special health care needs, in states where behavioral health is covered by fee-for-service Medicaid, are more likely to have unmet need for mental health (MH) services than similar children in states where benefits are administered through managed care. Whether children with special-needs enrolled in Medicaid have more unmet need for
MH services than non-special-needs children enrolled in the
Medicaid was also investigated.
Study Design: This is a descriptive cross-sectional study using data from the 1999 National Survey of American
Families (NSAF). This study uses measures of unmet need, based on NSAF child-level data on types of health professionals seen, services utilized, and need for services as indicated by emotional or behavioral problems. State-level data on type of public MH financing and level of penetration of Medicaid managed behavioral health were obtained from
The Lewin Group publication State Profiles, 1999, on Public
Sector Managed Behavioral Health Care.
Population Studied: This study focuses on the NSAF sample of 12 states (state-level samples from the general sample were small). For the primary question, the study population was special-needs children (having physical, learning or MH condition that limits participation in activities or ability to do school work) enrolled in Medicaid, SCHIP or other state coverage at survey. For the second question all children identified as currently enrolled in state-financed health care were included.
Principal Findings: Rates of unmet need for MH care for special-needs children varied widely within and among types financing. Capitated programs (AL, CA, FL) had rates near
60%, but CO, at 12%, had lowest rate of all states. Combined capitation and fixed fees (MI, WA, WI) clustered around 30%.
Fee-for-service (NJ, MS) had 50% unmet need. Special-needs children uniformly had lower rates of unmet need than nonspecial-needs children, regardless of whether services were managed.
Conclusions: Data are unadjusted and sample of states small. Caution must be used in interpreting. States have varying penetration of managed behavioral health, and types of financing.
Implications for Policy, Delivery, or Practice: Unmet need for MH services may lead to preventable hospitalizations and other serious outcomes. Mental illness is the major cause of hospitalization for children with disabilities on Medicaid. State programs are important providers of MH to children in part due to a high prevalence of emotional disturbance in this population. It is unclear whether managed care cost control mechanisms adversely restrict use of MH services. Children may actually have better coordinated access to MH services than those not in managed care.
Primary Funding Source: No Funding
● Racial Differences and Other Risk Factors Associated with Mortality Following Non-cardiac Surgery in Newborns
Jennifer Son, BS, Craig Lillehei, M.D., Kimberlee Gauvreau,
Sc.D, Oscar J Benavidez, M.D./M.P.P., Kathy J Jenkins,
M.D./M.P.H.
Presented By: Jennifer Son, BS, Student Researcher,
Cardiology, Children's Hospital, Boston, 300 Longwood
Avenue, Boston, MA 02115; Tel: (617) 529-6236; Email: jennifer_son@student.hms.harvard.edu
Research Objective: To identify patient characteristics associated with in-hospital mortality among non-premature infants age 30 days or less at admission undergoing noncardiac surgery.
Study Design: Data for infants 30 days or less undergoing non-cardiac surgical procedures were obtained from the
Healthcare Cost and Utilization Project Kids Inpatient
Database (KID) 2000 using ICD-9-CM codes. Patients undergoing endoscopic and closed procedures, catheterizations, cardiac procedures, circumcisions, and superficial laceration repair, premature infants, and those from 5 states that did not record age in days were excluded.
Procedures were stratified following ICD-9-CM body system classification. Patient characteristics included age at admission (in weeks, 1 through 4), gender, race (white, black,
Hispanic, other), insurance status (Medicaid, private, other), admission source (ER, transfer from another hospital/facility, routine/birth/other), number of systems undergoing surgery
(1 or >1), and system type. Univariate analysis and multivariate logistic regression were used to identify independent risk factors associated with in-hospital mortality relative to selected reference groups. Magnitude of risk was estimated using odds ratios.
Population Studied: Non-premature newborns admitted at age 30 days or less undergoing non-cardiac surgical procedures in 22 states, year 2000.
Principal Findings: Of 7543 cases, there were 167 deaths
(2.2%). Most were male (66%), had private insurance (56%) and were white (60%); blacks accounted for 11%, Hispanics
18% and other 11%. Most cases were admitted the first week of life (65%) and involved a single system (95%), most commonly the digestive system (56%). In unadjusted analysis, younger admitted patients (p<0.001), males (OR 1.5, p=0.01), transfers (OR 3.1, p<0.001), patients undergoing surgery on >1 system (OR 2.1, p=0.004), and non-white patients (black OR
2.7; Hispanic OR 2.1; other OR 2.5, all p<0.001 vs. white) were more likely to die. Cases with surgery on the respiratory, musculoskeletal, vascular, and endocrine systems had significantly higher odds of death than the others. Insurance type was not associated with mortality. After simultaneous adjustment for age in weeks at admission, gender, race, insurance status, admission source, number of systems, and

the higher risk systems, the following factors remained significant: non-white race (black OR 2.4, p=0.001; Hispanic
OR 1.9, p=0.007; other OR 2.1, p=0.004), age at admission <3 weeks (week 1 OR 3.2, p=0.001; week 2 OR 5.4, p<0.001), transfer status (OR 2.5, p<0.001), and the higher risk systems
(respiratory OR 2.3, p=0.001; musculoskeletal OR 2.7, p=0.001; vascular OR 4.6, p<0.001; endocrine OR 4.6, p=0.026).
Conclusions: Despite adjustments for many patient and case complexity characteristics, non-white newborns undergoing non-cardiac surgery had a two-fold higher risk of dying than white newborns. Further study is needed to determine the cause of this increased risk.
Implications for Policy, Delivery, or Practice: Identification of system-wide practices may help reduce hospital mortality of groups identified at higher risk for death.
Primary Funding Source: Doris Duke Foundation and
Harvard Medical School
● Adequacy of Prenatal Education and Emergency Room
Visits
Sindhu Srinivas, M.D., George A. Macones, M.D., MSCE,
Barbara Curbow, Ph.D., Sarah Millet, M.P.H.
Presented By: Sindhu Srinivas, M.D., Graduate Student,
Center for Epidemiology and Biostatistics & Department of
Obstetrics and Gynecology, University of Pennsylvania, 3400
Spruce Street 2000 Courtyard, Philadelphia, PA 19104; Tel:
215-662-2982; Fax: 215-349-5625; Email: ssrinivas@obgyn.upenn.edu
Research Objective: Theories of health behavior often include the concept of knowledge as a key component to health care behaviors and decision-making. Pregnancy is a period when many women are closely tied to the health care system and are motivated to increase their knowledge of their health. The major prenatal clinic at the Hospital of the University of
Pennsylvania is an urban, hospital-based clinic with both resident-physician and nurse practitioner providers with approximately 2000 deliveries per year. Uniquely, in addition to scheduled prenatal visits, every woman is assigned a prenatal nurse coordinator to arrange visits and provide resources. Despite the prenatal care structure of the clinic, the hospitalís 24 hour obstetric emergency room seems to be over-utilized for non-emergent visits causing increased cost, decreased personnel available for true emergent visits, and long waiting times. Our objective was to assess utilization of emergency services and patient satisfaction with prenatal education and care in the clinic in order to create a targeted educational intervention to reduce non-emergent visits to the obstetric emergency center.
Study Design: We performed one-on-one, semi- structured qualitative interviews to assess utilization of emergency services and patients' views on prenatal education and care at our clinic. Content analysis of interview data was used to reveal common themes. The administrative records of the emergency center were sampled to obtain the average number of triage visits as well as the percentage of late gestation visits.
Population Studied: Low-risk, primaparous women who were at least 33 weeks gestation and had at least five prior clinic visits. Thirty-three antenatal (33-38 weeks gestation) and 27 post delivery (1-2 days postpartum) interviews were conducted. Six post delivery interviews were not completed due to delivery at another institution or discharge prior to interview. Women who received care at the high-risk or diabetic clinics or who were multiparous were excluded from enrollment since they may already have an increased knowledge about pregnancy and/or their medical condition.
Women who were interviewed received care from a variety of providers in the clinic.
Principal Findings: Of the 750-900 emergency room triage visits per month, on average, 36% of the visits per day are by women (37 weeks gestation or more) complaining of contractions or membrane rupture. On average, 56% of these women are sent home after evaluation. In-depth discussions with clinic patients revealed that approximately 50% of patients reported using the emergency service during their pregnancy. Though these women were very satisfied with the prenatal care received at the clinic, they often used the emergency room without first calling their care provider.
Interviews also revealed that clinic patients were eager for increased information about labor.
Conclusions: Women expressed inadequate knowledge about labor and childbirth. A significant number of triage visits to the emergency room appear to be later in gestation. It is possible that lack of education during prenatal care leads to over-utilization of emergency services due to patientsí inadequate understanding of labor.
Implications for Policy, Delivery, or Practice: The addition of targeted education regarding labor during prenatal care may increase patient satisfaction and reduce a significant proportion of emergency visits due to these complaints.
Primary Funding Source: NIH T32
● The Prevalence and Performance of Electronic Medical
Records in Hospitals
Abby Swanson, B.A., M.T.
Presented By: Abby Swanson, B.A., M.T., Research Assistant,
Doctoral Student, Department of Health Administration,
Virginia Commonwealth University, 3416 Grove Avenue #19,
Richmond, VA 23221; Tel: 804-615-4246; Email: swansonaj@vcu.edu
Research Objective: Some health care policymakers, practitioners, payer groups, and patients have suggested that health information technology (HIT) is an essential part of improving health care in the United States. This study examines hospital electronic medical record (EMR) use.
Specifically, the goals are to examine organizational and environmental factors associated with EMR use and to assess the association between EMR use and hospital performance.
Study Design: The design of this study is a retrospective, nonexperimental design that examines organizational factors and environmental factors associated with EMR use and differences in hospital performance associated with EMR use.
The conceptual model is developed using the Resource
Dependency framework and Donabedian's structure, process, outcome model. Environmental factors include competition and rurality. Organizational factors include size, ownership, system affiliation, financial resources, and teaching status.
Hospital performance is measured through both efficiency and quality. Date Envelopment Analysis (DEA) efficiency scores are calculated using multiple inputs and outputs including capital assets, employees, number of beds, discharges, and training hours. Quality is measured through

ten Health Quality Alliance (HQA) Program hospital measures developed by the Center for Medicaid and Medicare Services
(CMS). The observation of hospitals takes place in 2004.
Logistic regression, Data Envelopment Analysis (DEA), and
Analysis of Variance (ANOVA) are used to compare the hospitals with and without EMRs.
Population Studied: The population of interest in this study includes all non-federal, acute care hospitals in the United
States. The hospitals in this study are grouped according
EMR use and size. The size-groupings are based on beds set up and staffed and are intended to stabilize estimated relationships in the DEA analysis and allow for reasonable comparisons of hospital performance.
Principal Findings: The preliminary findings of this study indicate significant correlations between several organizational and environmental factors. The strongest correlations exist between EMR use and system affiliation, ownership, and competition. Preliminary findings also indicate that hospitals with EMRs are more efficient than those hospitals without
EMRs. Hospitals with EMRs are not associated with higher quality outcomes when compared to hospitals without EMRs.
Conclusions: Hospital EMR use, though in the early stages of use, provides some promise of improving hospital performance. While efficiency improvements associated with hospital EMR use are present, the evidence of hospital quality improvement based on EMR use is not clear. The significant relationships between EMR use and hospital environmental and organizational factors indicate that some hospitals may face more challenges in the adoption of EMR systems.
Smaller, independent, and rural hospitals appear to be much slower in EMR adoption, indicating that they may need additional resources to adopt EMR systems.
Implications for Policy, Delivery, or Practice: The results of this study may guide both policy makers and practitioners. As hospitals seek to control costs while improving performance, many will look to health information technology such as electronic medical records. While EMRs may improve some aspects of hospital performance, not all hospitals have equal access to EMR implementation based on the expense of this technology. Additionally, hospitals that are considering EMR adoption should know the potential benefits and challenges of
EMR use before investing in an EMR system.
Primary Funding Source: No Funding
● Health-Related Disparities Among Adolescents in
Substance Abuse Treatment: Do Race or Gender Make a
Difference?
Kelly Taylor-Richardson, M.S.W., MS
Presented By: Kelly Taylor-Richardson, M.S.W., MS, Predoctoral Fellow, Center for Evaluation and Program
Improvement, Vanderbilt University, Peabody # 151, 230
Appleton Pl, Nashville, TN 37203; Tel: (615)322-8343; Fax:
(615)322-7049; Email: kd_taylor@hotmail.com
Research Objective: The racial, ethnic and gender health disparities that exist in this country in health status and health care are the topic of a vast body of research and are of public health concern. The primary focus of researchers in this area has been on health services for adults. This poster will focus on behavioral health services for adolescents. This study attempts to fill a knowledge gap by combining the general child and adolescent health literature with the disparities literature to provide information in the context of substance abuse services regarding the health, mental health, and substance use of adolescents in public sector.
Study Design: The relationship of race and gender to mental and physical health status and substance use are examined in a sample of 258 adolescents entering publicly-funded substance abuse services. Univariate statistics were used to describe the characteristics of the population. Differences between males and females and blacks and whites on health, mental health and substance use variables were examined using chi-square statistics for categorical variables and t-tests for continuous variables. Next, ordinary least squares regression was used to test the multivariate relationships among three models predicting health, mental health and substance use.
Population Studied: This secondary analysis used existing interview data of children entering publicly-funded substance abuse treatment in Tennessee as part of a national study of the impact of managed care on vulnerable populations. The youth were 62% white and 29% African-American and twothirds male (76%). A proportion of 3:1 male to female ratio is similar to other reports of treated children and youth. The youth interviewed from inpatient/residential services were three-quarters male (78%), corresponding to those in all treatment settings (76%) and slightly more than those in outpatient programs (65%). Females outnumbered males only for those in outpatient programs who were in state custody (58% female).
Principal Findings: Although adult research shows significant race and ethnic disparities in a number of health categories, univariate and bivariate analysis demonstrated that there are not significant differences between black and white substance abusing adolescents in this sample. Using these same methods however, differences between genders were found in health and substance abuse related variables. Two important findings emerged from regression analyses, 1) girls were being admitted to substance abuse treatment with more psychosocial problems than boys and 2) blacks were being admitted to treatment with fewer alcohol and other drug dependencies.
Conclusions: Findings indicate that gender has a greater impact on the health of adolescents in this sample than race and ethnicity.
Implications for Policy, Delivery, or Practice: Despite the growing information on race and gender issues in child and adolescent behavioral health, there has been little systematic study of the interaction between race and gender in this group. Studies have cited different risk factors for female vs. male substance abusers therefore warranting gender-sensitive assessments of risk. Additionally minority youth have experienced disparate consequences for substance abuse problems. These results warrant additional study to determine if these differences are true of other child and adolescent populations as the findings are contrary to the adult literature in the area of health disparities.
Primary Funding Source: National Institute of Mental Health

● Effect of depression treatment on outcomes for people with chronic pain
Carrie Farmer Teh, B.A., Paul D. Cleary, Ph.D., Alan M.
Zaslavsky, Ph.D.
Presented By: Carrie Farmer Teh, B.A., Doctoral Candidate,
Health Policy, Harvard University, 934 Beech Avenue,
Pittsburgh, PA 15233; Tel: (617) 510-4472; Fax: (724) 656-5616;
Email: cfarmer@fas.harvard.edu
Research Objective: People with chronic pain and depression have worse health outcomes, including higher health-care costs, greater number of work days lost, and an increased risk of chronicity, than those with chronic pain alone. Treatment of depression in chronic pain patients has the potential to improve both medical and social outcomes related to these disorders. However, little is known about the effectiveness of depression treatment for this population. This study assessed the effects of depression treatment on a variety of outcomes for people with both chronic pain and depression.
Study Design: Propensity score weighted analyses using both waves, 1997-1998 and 2000-2001, of the National Survey of
Alcohol, Drug, and Mental Health Problems, also known as the Healthcare for Communities study, which is part of the
Community Tracking Study. Analyses examining the effect of any depression treatment and minimally adequate depression treatment on medical and social outcomes were weighted by the inverse probability of treatment - 1/propensity score - to account for selection effects. Outcomes included: persistence of depression symptoms, depression severity, pain severity, overall health, mental health status, physical health status, social functioning, employment status, and number of work days missed. To account for the complex sample design, the
SUDAAN statistical program was used to adjust standard errors.
Population Studied: Analyses were limited to those who met
CIDI-SF criteria for major depressive disorder, reported having at least one chronic pain condition, and completed both interviews; N=553.
Principal Findings: Receiving any depression treatment was associated with 2.26 fewer days of work missed, p<0.03, and
0.43 lower odds of reporting poor health status, p<0.05. In addition, there was a non-significant trend toward a higher likelihood of being employed, fewer depression symptoms, and less interference of pain on work for people who received any depression treatment. Receiving minimally adequate depression treatment was not significantly associated with any of the outcomes.
Conclusions: Depression treatment is associated with positive outcomes for people suffering from chronic pain and depression.
Implications for Policy, Delivery, or Practice: Depression treatment can increase work productivity and subjective sense of health for people with cormorbid chronic pain and depression. Understanding the effect of depression treatment on outcomes for people with chronic pain is important not only to health care practitioners who work with this population, but also to policy-makers working in this Decade of Pain Control and Research to create policies for people suffering from chronic pain conditions.
Primary Funding Source: NIMH
● Identifying People with Mobility Impairments: Second
Field Test Results
Amira Wali, MS, Susan Palsbo, Ph.D.
Presented By: Amira Wali, MS, Research Assistant, Center for
Health Policy, Research & Ethics, George Mason University,
4400 University Drive, MS 3C4, Fairfax, VA 22030; Tel: (703)
993-2173; Fax: (703) 993-1953; Email: awali@gmu.edu
Research Objective: CAHPS is developing new questions about health care quality as perceived by people with mobility impairments (PWMI). Starting with 6 screening questions, we wanted to determine the fewest number of questions for
PWMI to self-identify.
Study Design: A survey of a stratified random sample of adults with varying ability to move around their environment.
Population Studied: English-speaking adult Medicaid beneficiaries in a California Medicaid HMO.
Principal Findings: There were 1595 survey respondents. 37% of respondents had severe disabilities, 19% had no disabilities, and the balance had some disabilities. Half of the respondents used more than 10 medications. The respondents were disproportionately female (82%) but reflected the makeup of the study HMO. 96% of respondents were between age 20-60. 49% of respondents rated their health as "fair" or "poor". 30% used one or more assistive ambulatory devices. The first field test, in Massachusetts, identified two questions (use of assistive ambulatory devices; difficulty walking 1/4 mile) as capturing most people. For the second field test in California, we conducted additional cognitive testing and slightly reworded the test questions.
About 15-20% of people who use assistive devices to ambulate report they do not have difficulty walking ¼ mile. Therefore, both questions should be asked (confirming the first field test findings). When asking about difficulty climbing stairs, specifiying that it be "10 stairs without a railing" captures additional people. Across the screening questions, people reporting difficulty with stairs were most likely to also report a fall in the past three months (69%, compared to 65% of people reporting difficulty walking 1/4 mile).
Conclusions: (1) Asking about "climbing 10 stairs without a railing" - a questing about balance - identifies more PWMI than asking about "walking 1/4 mile" - a question about endurance. This is different from the first field test findings.
(2) An additional 4% of PWMI who do not use AT and can climb stairs, report difficulty walking 1/4 mile. (3) When some people obtain assistive mobility devices, they do not report difficulty walking a short distance. Therefore, all three questions should be asked. (4) When targeting a very heterogenous population such as "people with mobility impairments", screening questions should be cognitively tested on larger numbers of people than would be adequate for a population without disabilities.
Implications for Policy, Delivery, or Practice: Most PWMI can be identified by asking 3 questions. Using ADLs and
IADLs in large national surveys as proxies for disability may miss a large percentage of people who are medically defined as "disabled".
Primary Funding Source: U.S. National Institute on Disability and Rehabilitation Research

● Patient Characteristics and Symptoms from Breast
Cancer Treatment
Jean Yoon, M.H.S., Jennifer Malin, M.D., Ph.D., Diana
Tisnado, Ph.D., May Lin Tao, M.D., MS, Patricia Ganz, M.D.,
Katherine Kahn, M.D.
Presented By: Jean Yoon, M.H.S., Doctoral Student, Health
Services, UCLA, Campus Box 951772, Los Angeles, CA 90095-
1772; Tel: (310) 206-1975; Fax: (310) 825-3317; Email: jeanyoon@ucla.edu
Research Objective: With breast cancer diagnosis occurring at earlier stages and more patients receiving indicated treatments, survival has increased, and quality of life for patients has never been more of an important issue. We used a diverse, multi-ethnic, multi-lingual population-based cohort of women with incident breast cancer to learn populationbased rates of five symptoms believed to be prevalent amongst breast cancer patients.
Study Design: In 2001 we conducted a survey of breast cancer patients in Los Angeles County. The survey queried women about the presence of morbid symptoms interfering with their daily mood or function. Patients were also asked about demographics and if they had received chemotherapy, radiation therapy, tamoxifen, mastectomy, and lumpectomy.
Multivariate analyses were conducted using a two-part model to predict any severe symptom and the number of symptoms if any symptoms were experienced. Regression covariates in addition to treatment included patient age, race/ethnicity, language, education, income level, marital status, physical and mental health status, employment status, insurance coverage, depression, comorbid conditions, and stage at diagnosis.
Population Studied: The sample was drawn from a census of incident breast cancer cases diagnosed during 10 consecutive months in 2000 in Los Angeles County. Patients were initially identified by Rapid Case Ascertainment from 103 hospitals or other settings in which breast cancer was diagnosed, and
1,219 of these patients participated in the survey, conducted in both English and Spanish.
Principal Findings: Almost half of breast cancer patients studied (46%) had at least one severe symptom that interfered with her daily functioning or mood. The most prevalent symptoms reported were difficulty sleeping (28%) and hot flashes (19%). Multivariate analysis controlling for patient characteristics and treatment showed that older (OR=
0.90; P<0.000), black (OR= 0.50; P<0.000), Hispanic
Spanish-speaking (OR= 0.37; P<0.000), widowed or never married (OR= 0.68; P=0.049), and working (OR= 0.72;
P=0.024) women were less likely to report severe symptoms than other women. The number of comorbid conditions
(OR= 1.21; P<0.000) and receipt of chemotherapy (OR= 1.48;
P=0.040) were positively associated with reporting symptoms.
Conclusions: After accounting for stage and type of treatment, these findings raise questions about whether women of different race/ethnic groups vary in their threshold for reporting symptoms or whether they truly have fewer symptoms. This analysis also documents comorbidity as a significant predictor of patient report of symptoms overall, and especially amongst women who received chemotherapy.
Further research studying the effects of comorbidity on symptoms and longer-term outcomes is necessary to determine how, if at all, various degrees of comorbid disease should influence treatment intensity.
Implications for Policy, Delivery, or Practice: Having accurate population-based estimates of the probability of symptoms for women with incident breast cancer may prove valuable as providers attempt to educate patients about the probabilities for various outcomes during the months following her breast cancer diagnosis. Quality of care can be improved as women collaborate with providers in reporting symptoms and in developing treatment plans.
Primary Funding Source: NCI
● Health Insurance Coverage of Young Adults Aged 22-29 in Florida
Jingbo Yu, M.H.A., Paul Duncan, Ph.D., Allyson Hall, Ph.D.,
Mark Allen, MA
Presented By: Jingbo Yu, M.H.A., Research Assistant, Health
Service Research, Management and Policy, University of
Florida, 1700 SW 16th Court, J-4, Gainesville, FL 32608; Tel:
(352) 273-5245; Email: JYu@phhp.ufl.edu
Research Objective: Young adults aged 22-29 currently have high rates of uninsurance in Florida, and the rates of uninsurance for this age group have been rapidly rising in recent years. In general, there are two competing explanations for this issue. Some commentators note that many young adults aged 22-29 are just starting careers out of college and are less likely to have jobs that include health care coverage.
Others argue that young adults are healthy, have other preferences for the allocation of their limited resources and hence decline offered health insurance. Our objectives were to identify the demographic factors associated with being uninsured for young adults aged 22-29 in Florida, and to examine the effect of uninsurance on health care access for this population. Gender difference in health insurance coverage for this population will be examined.
Study Design: Data comes from the 2004 Florida Health
Insurance Survey (FHIS). A stratified random sampling method was used in this survey, in which various strata are defined around key population characteristics. Within each stratum samples were drawn disproportionately. In 2004, telephone interviews were conducted with 17,435 households, yielding data about 46,876 individuals from 17 districts of
Florida. For this study, data were examined for 4,284 young adults aged 22-29 who provided information on demographic variables, health insurance status, and perceived inability to afford care. Males and females were examined separately to see the differences in health insurance coverage and related factors between two gender groups. Multiple logistic regression was used to estimate the odds of being uninsured and to estimate the odds of reporting the inability to afford needed health care in the last year.
Population Studied: Young adults aged 22-29 in Florida
Principal Findings: Among the young adults studied, 36.8% of males and 28.7% of females were uninsured. For both genders, the odds of being uninsured increased for Hispanics, those with less education, unmarried people, those not in excellent health status, those without full-time employment, and those with lower income. Among young adults employed full-time, 62% of males and 49% of females had insurance, with rates dropping off dramatically for young adults not employed full-time. Young males with 101%-150% FPL incomes were significantly more likely than those of other income groups to have no health insurance. Young females

uninsurance rates for those in the 101%-150% of FPL were not higher relative to the income group of less than 100% FPL, perhaps due to higher rates of Medicaid coverage. Compared with the insured groups, uninsured young adults of both genders were shown to have significantly higher odds (males:
2.67, females: 2.71) of delaying or not receiving health care in the past 12 months because of cost. Compared with male young adults, female young adults were 1.82 times more likely to delay or not receive health care, controlling for other demographic variables and health insurance status.
Conclusions: Certain subgroups of 22-29-year-old Floridians are at high risk of not having health insurance, especially males, Hispanics, those without full-time employment, unmarried people, those not in excellent health status, those without full-time employment, and those with lower income.
Young males of lower income are more likely to be uninsured than young females. Uninsured young adults of both genders were shown to have significantly higher odds of not receiving health care in the past 12 months because of cost; this indicates that the problem is of immediate importance.
Implications for Policy, Delivery, or Practice: This study has identified subsets of the population that might be the targets of any public health policy initiatives to improve insurance coverage. Programs that give businesses an incentive to insure their younger workers, or that provide a subsidized form of insurance similar to those available to full-time students could potentially increase insurance rates in this population.
Primary Funding Source: HRSA