Call for Panels
Call for Panels
Understanding Beneficiaries to Inform
Education to Improve Access to Medicare
Programs
Chair: Christopher Koepke, Centers for Medicare
& Medicaid Services
Sunday, June 25 • 8:30 am – 10:00 am
Panel Overview: The Medicare Modernization Act represents
the largest change in the Medicare program since its
inception. It included the initiation of the discount drug card
and the Medicare prescription drug coverage. It also
expanded health care choices. Delivering these programs
through a choice model allows beneficiaries to affect the
delivery of their own health care. It is the Centers for
Medicare & Medicaid Services responsibility to educate
beneficiaries so they can access these programs. To improve
CMS’ education efforts, it is important to understand how
beneficiaries behave when making choices, what factors are
important to them when exploring options, the level of
beneficiary awareness, knowledge, and attitudes and how
these factors affect behavior. This panel includes new
research that provides insight into these issues. One study is
a large survey that closely examines beneficiaries’ knowledge,
awareness, and experience with Medicare prescription
discount cards. Another provides in-depth analysis into
behaviors beneficiaries undertake when making plan choices
in the real world. A third uses conjoint analysis to examine
factors that are important to beneficiaries when making a plan
choice. A fourth examines the choice behaviors and
motivations of those who have disenrolled from MA plans.
Finally, results from tracking surveys during the Medicare
prescription drug coverage initial enrollment period are used
to assess the role of knowledge, attitudes, and other factors in
enrollment decisions. These studies provide invaluable
information to support CMS in its efforts to make programs
more accessible to beneficiaries.
●Medicare Prescription Drug Coverage: Tracking
Beneficiary Knowledge and Attitudes and their
Relationship with Intention to Enroll and Actual
Enrollment Throughout the Initial Enrollment Period.
Christopher Koepke, Ph.D., Beth Simon, Ph.D.
Presented By: Christopher Koepke, Ph.D., Deputy Division
Director, Center for Beneficiary Choices, Centers for Medicare
& Medicaid Services, 7500 Security Boulevard, Baltimore, MD
21244; Tel: 410-786-5877; Email:
christopher.koepke@cms.hhs.gov
Research Objective: Track changes in beneficiary knowledge,
attitudes, and enrollment throughout the Medicare
prescription drug coverage initial enrollment period. Assess
whether beneficiary knowledge or attitudes were related to
enrollment? Assess other factors that affect the relationship
between knowledge and attitudes and enrollment?
Study Design: The study utilizes five survey waves from
August 2005 to January 2006. Each survey was an
independent national sample of 400 randomly chosen
Medicare beneficiaries over 65 years of age. Knowledge was
measured using nine different items including knowledge that
you have to enroll to receive the benefit, it is available to
everyone with Medicare, there is a deadline for enrolling, and
there is a choice of plans. Attitudes measured included
overall favorability, belief the program is confusing, and belief
the program is a bad value. Prior to open enrollment, our
dependent variable was intention to enroll which was
measured as a four point scale of likelihood to enroll. After
November 15, respondents were also asked whether they had
enrolled. Control variables include type of insurance coverage,
existence and type of previous drug coverage, exposure to
Medicare prescription drug coverage information, and basic
demographics. January wave results will be included in the
final paper, but were not available for this abstract. The
surveys were conducted by Voter Consumer Research.
Population Studied: Medicare beneficiaries over 65.
Principal Findings: All knowledge items increased at least 20
percentage points from August 2005 to December 2005.
Knowledge that there was a deadline increased from 39% to
71%, knowledge that one had to sign up increased from 56%
to 74%, knowledge that there was a choice of plans increased
from 17% to 66%. Intention to enroll remained steady
throughout the survey periods. But when combined with selfreported actual enrollment, there was a 10% jump in
December. Attitudes remained fairly stable throughout the
five month period. In December, the following knowledge
items were related with the enrollment variables: missing the
deadline meant higher costs, there was a monthly fee, there
was a choice of plans, a low-income subsidy was available,
and a person with current coverage needed to find out if it was
as good as the Medicare coverage. Overall favorability
towards the program was strongly related with enrollment as
was belief in the value of the program. Belief the program was
confusing was not strongly related with enrollment. Multivariate investigation to test whether any inferences from these
relationships are spurious and to further investigate the
conditions under which knowledge and attitudes are related to
enrollment will be reported in June.
Conclusions: As an agency that offers health care consumers
choices in how they want their insurance delivered, CMS’
major communication goal is to make accurate information
available to beneficiaries. One expected outcome from these
activities would be an increase in knowledge. The results
demonstrate that Medicare prescription drug coverage
knowledge increased during the fall of 2005. There is also
evidence that this knowledge and attitudes are related to
intention to enroll.
Implications for Policy, Delivery, or Practice: It is possible
to educate aged beneficiaries on new programs. Knowledge
and attitudes alone do not always drive behavior, which
suggests the need for community based support systems to
help beneficiaries understand the enrollment process and
make decisions. Further investigation should be conducted
into how support systems can help beneficiaries turn
knowledge into behavior.
Primary Funding Source: CMS
●Mapping Enrollment Behaviors in Medicare Prescription
Drug Coverage
Beth Simon, Ph.D., Christopher Koepke, Ph.D., Barbara Allen,
MA, Donna Lloyd-Kolkin, Ph.D., David Newman, Ph.D.
Presented By: Beth Simon, Ph.D., Social Science Research
Analyst, Center for Beneficiary Choices, Centers for Medicare
& Medicaid Services, 7500 Security Boulevard, Baltimore, MD
21244; Tel: 410-786-6665; Email: beth.simon@cms.hhs.gov
Research Objective: To develop an understanding of the
actual behaviors of Medicare beneficiaries as they choose
whether to enroll in the new Medicare prescription drug
coverage. While accounting for socio-demographic and
environmental factors, we map a range of behaviors that
beneficiaries undertake (i.e., talking with family and friends;
reviewing materials from drug plans; talking with health
professionals, etc.) to create a series of typologies to
investigate access to drug coverage. Research findings will
inform how the Centers for Medicare & Medicaid Services
(CMS) develops communication tools and strategies that
educate Medicare beneficiaries about Medicare prescription
drug coverage.
Study Design: One hundred interviews (80 cross-sectional;
20 panel/prospective) are being conducted with Medicare
beneficiaries in three rounds from January-April, 2005.
Beneficiaries are segmented by current prescription drug
coverage and no coverage; current enrollment status/intention
to enroll in the Medicare prescription drug coverage; and
basic demographics. Interviews explore beneficiaries’
behavioral processes as they navigate how and whether to
enroll in drug coverage. Importantly, data are being gathered
as beneficiaries are being influenced and making decisions so
that reliance on retrospective recall of decision making is
minimized. And, some respondents will be tracked
prospectively before they’ve made a decision.
Population Studied: Interview data are being gathered from
Medicare beneficiaries aged 65 or older in seven
geographically and demographically diverse markets.
Respondents differ by current drug coverage status, intention
to enroll and current enrollment status in the Medicare
prescription drug coverage, along with basic demographic
characteristics. Beneficiaries with employer coverage, in a
Medicare Advantage plan, and those with Medicaid are
excluded from this sample because they do not have to make
the same decisions as the general Medicare population (i.e.,
due to existing coverage or facilitated enrollment).
Principal Findings: Data are being gathered and analyzed
from January-April, 2005. We anticipate this research will
illuminate the behavioral processes that Medicare
beneficiaries go through that, for some, culminates in
enrollment in a Medicare prescription drug plan while, for
others, the process ends in non-enrollment. Pre-testing
suggests that, in different combinations, beneficiaries’
behavior includes and is shaped by conversations with friends
and family, guidance from health professionals, marketing
materials from drug plans, Medicare information channels,
workshops, along with other influences and interactions.
Beneficiaries’ behavior, along with their socio-demographic
context, creates different pathways by which beneficiaries
choose whether to enroll. CMS will use these data to create
typologies of beneficiary behavior to better develop
quantitative measures that evaluate influences on enrollment
to, ultimately, improve beneficiaries’ access to prescription
drug coverage in a competitive market.
Conclusions: TBD when data are available
Implications for Policy, Delivery, or Practice:
Understanding influences on beneficiaries’ enrollment in
Medicare prescription drug coverage will inform CMS’
development of communication tools and strategies. As CMS
and others communicate with the Medicare population about
the Medicare prescription drug coverage, it is imperative to
understand—from the target audience’s perspective—what
influences their enrollment decisions so that communication
materials can best meet their needs.
Primary Funding Source: CMS
●Medicare Beneficiary Knowledge of, Awareness of, and
Experience with Prescription Drug Discount Cards
Noemi Rudolph, M.P.H., Sunyna Williams, Ph.D.
Presented By: Noemi Rudolph, M.P.H., Social Science
Research Analyst, Office for Research, Demonstrations, and
Information, Centers for Medicare & Medicaid Services, 7500
Secuity Boulevard, Baltimore, MD 21244; Tel: (410)786-6662;
Email: noemi.rudolph@cms.hhs.gov
Research Objective: To examine how knowledge and
awareness of prescription drug discount cards vary between
Medicare beneficiary cardholders and non-cardholders, and to
assess cardholder experiences. Findings will be compared
with those from a subsequent fielding focusing on Medicareapproved cards.
Study Design: Questions were developed and cognitively
tested, and then fielded as part of the 2003 Medicare Current
Beneficiary Survey (MCBS). Questions focused on awareness
of, knowledge of, and information-seeking behavior related to
prescription drug discount cards. Cardholders (9%) were also
asked about their experiences choosing a card and with
enrollment, and perceived savings.
Population Studied: The sample included 13,344 elderly and
disabled community-dwelling Medicare beneficiaries.
Principal Findings: Descriptive analyses showed that 60%
perceived that they knew nothing or almost nothing about
drug discount cards, over 70% found it somewhat difficult or
very difficult to understand how much they can save using a
card, and only 17% tried to find more information about cards.
For cardholders, more than half expressed difficulty choosing
a card and approximately 32% sought the help of others in
choosing a card. However, almost 90% found signing up for a
card to be very easy or somewhat easy. Two thirds of
cardholders used their card all of the time to buy prescription
drugs and approximately 75% were satisfied with their card(s).
Inferential analyses showed that current cardholders (vs. noncard holders) were more likely to be older seniors, female,
white, widowed, and lower income. There were no significant
difference between card and non-card holders in education
and perceived health status. A higher percentage of
cardholders had no other drug coverage, suggesting that
cardholders sought the cards because of lack of coverage.
Those with Original (fee-for-service) Medicare, with or without
a supplement, were more likely to be current cardholders.
Those with Medicare managed care and Medicare-Medicaid
dual eligibles were more likely to be non-card holders.
Cardholders had greater perceived knowledge, greater
perceived understandability of savings, were more likely to
have sought information and have a greater desire for more
information, and were more likely to have done something
else to reduce the cost of prescription drugs than were noncard holders. Card holders answered a higher proportion of
the drug card knowledge quiz item correctly than noncardholders (55% vs. 43%).
Conclusions: Beneficiary perceived knowledge of prescription
drug discount cards and perceptions regarding savings using
cards were low, and few were interested in more information.
Preliminary findings show differences between cardholders
and non-cardholders in terms of other sources of drug
coverage and knowledge about cards. Additional analyses
underway examine predictors of drug card knowledge and
comparisons with findings from the 2004 MCBS focusing on
Medicare-approved cards.
Implications for Policy, Delivery, or Practice: The choices
for Medicare beneficiaries increased with passage of the
Medicare Modernization Act that brought the Medicare
Prescription Drug Discount Card Program, and now the
Medicare Prescription Drug Coverage Program.
Understanding factors associated with knowledge of,
awareness of, and experiences with prescription drug discount
cards can help the Centers for Medicare & Medicaid Services
better target their educational efforts.
Primary Funding Source: CMS
●What Can be Learned from Assessing Disenrollment
Reasons from Medicare Advantage Health Plans: A
Qualitative Analysis.
Amy Heller, Ph.D., Lauren McCormack, Ph.D., M.S.P.H.,
Claudia Squire, MS, Jeremy Morton, MA, Lee Mobley, Ph.D.,
Philip Salib, BA, Amy Heller, Ph.D.
Presented By: Amy Heller, Ph.D., Social Science Research
Analyst, Center for Beneficiary Choices, Centers for Medicare
& Medicaid Services, 7500 Security Boulevard, Baltimore, MD
21244; Tel: 410-786-9234; Email: amy.heller@cms.hhs.gov
Research Objective: As part of the CAHPS Disenrollment
Reasons Survey, Research Triangle Institute (RTI) with the
Centers for Medicare & Medicaid Services, conducted
research with a sample of beneficiaries to explore why certain
subgroups are more likely than others to disenroll from their
Medicare Advantage (MA) plans, to learn about their
experiences during and after disenrollment and to gauge the
importance of prescription drugs in their disenrollment
choice.
Study Design: In Spring 2005, RTI conducted this focus
groups with Medicare beneficiaries who had responded to the
2004 Disenrollment Reasons Survey in three sites. In each
site, RTI also conducted sessions with disabled beneficiaries
under age 65. The result was 10 focus groups with 75 MA plan
disenrollees.
Population Studied: A sample of Medicare beneficiaries who
disenrolled from MA plans with representation from the
following groups: Disabled beneficiaries, beneficiaries who left
their MA health plan and went to another MA plan, and those
who returned to Original Medicare.
Principal Findings: Many participants were either actively
looking for a better plan or were open to the possibility of a
new plan. Disabled beneficiaries indicated that drug coverage
was an important factor for leaving their plan. Additionally,
the disabled participants, for the most part cited similar
reasons for disenrolling especially in regard to the drug
coverage. However, their reasons for leaving appeared to be
linked to their specific health care needs and a strong desire to
stay with their current doctor and/or hospital.
Across all three sites, a significant number of participants
were enrolled in a MA HMO and were planning on returning
to a MA plan. Being able to see the doctor they wanted or go
to the hospital of their choice was more important than type
of health plan. Participants’ experiences after disenrollment
were mixed. Some participants reported being more satisfied
with their new plan while others were either less satisfied or
felt about the same. Some participants wanted more plan
choice assuming that more plans would mean increased
competition and lower prices, while others preferred fewer
options. The role of prescription drug coverage in
beneficiaries’ decision to disenroll from a health plan varied.
Most participants across all sites had at least some drug
coverage and those that had coverage under their old plan
were likely to choose a new plan that also offered coverage.
There was some confusion surrounding drug benefits such as
drug tiers, use of a formulary and types of co-payments.
Conclusions: Participants across all sites were able to
articulate reasons for leaving their former health plan. Most
participants across sites identified more than one reason for
leaving their plan, but most were able to choose one most
important reason for leaving. Most often cited reasons for
disenrolling were the opportunity to save money or to follow a
health provider.
Implications for Policy, Delivery, or Practice: This research
helps to explain how beneficiaries understand and choose
among their health plan options, their enrollment behaviors
and the importance of their prescription drug coverage.
Primary Funding Source: CMS,
●Attributes Important to Medicare Beneficiaries Making
Health Plan Choices and Prescription Drug Plan Choices:
A Conjoint Analysis Decision-Making Experiment
Sunyna Williams, Ph.D., Jack Fyock, Ph.D.
Presented By: Sunyna Williams, Ph.D., Social Science
Research Analyst, Office for Research, Demonstrations, and
Information, Centers for Medicare & Medicaid Services, 7500
Security Boulevard, Baltimore, MD 21244; Tel: 410-786-2097;
Email: sunyna.williams@cms.hhs.gov
Research Objective: The research objectives were to examine
(a) how Medicare beneficiaries trade-off various attributes
when making health plan choices and prescription drug plan
choices; (b) how attribute preferences and trade-offs vary
across key beneficiary segments—FFS Medicare with Medigap
vs. managed care, high vs. low drug spending, and lowincome vs. higher-income; and (c) how preferences may
change with the introduction of the Medicare Modernization
Act (MMA) provisions for preventive services coverage in
2005 and prescription drug coverage in 2006.
Study Design: The study was conducted in July, August, and
September 2003. The primary method was a conjoint analysis
within-subjects decision-making experiment, for which each
participant made a series of choices among hypothetical plans
that varied in terms of several attributes. Each trial involved
making a choice among three hypothetical plan options. There
were 17 trials each for a health plan choice task and a
prescription drug plan choice task. Health plan attributes
included prescription drug coverage, as well as doctor choice,
preventive services, plan premium, etc. Prescription drug plan
attributes included coinsurance, deductible, maximum benefit,
coverage of generic and brand drugs, plan premium, mail
order and pharmacy access, , etc. Following the experiment,
brief focus groups were conducted to further explore
beneficiary perceptions of the health plan and drug plan
attributes.
Population Studied: Participants were nearly 300 Medicare
beneficiaries recruited by professional research facilities in
four cities across the U.S.—Philadelphia, Los Angeles, Atlanta,
and Chicago. All were seniors, approximately 65% of whom
were under 75 years of age, about 65% were female, and about
85% were white.
Principal Findings: Overall, for the health plan choice task,
after plan premium, drug coverage was the most important
attribute, and preventive services was moderately important.
Not surprisingly, therefore, with the incremental addition of
the MMA provisions, the very strong preference for managed
care-like plans decreases and then seems to disappear.
Interestingly, although the strength of the preference
decreases over time, those currently in managed care
consistently prefer managed care-like plans. Overall, for the
prescription drug plan choice task, deductible, maximum
benefit, and plan premium were the most important
attributes. Probably due to the cumulative changes in those
three attributes, the strong preference for managed care-like
plans, especially among those currently in managed care,
increases over time.
Conclusions: When making a health plan choice, the most
important attributes for beneficiaries are plan premium, drug
coverage, and preventive services, and when making a
prescription drug plan choice, the most important attributes
are annual deductible, maximum benefit, and plan premium.
Interest in managed care appears to change over time, as
Medicare adds preventive services coverage and then
prescription drug coverage. Future research should use actual
Part D plan attributes, and should examine other factors
affecting choices, such as preference for one-stop shopping or
motivation and skill to be an active consumer.
Implications for Policy, Delivery, or Practice: These findings
have implications for education and decision-support
initiatives by Medicare and other stakeholders for beneficiaries
making health plan and prescription drug plan choices.
Primary Funding Source: CMS
Call for Panels
Opening up the Black Box of Quality
Improvement Interventions:
Lessons from a Formative Evaluation of
Routine-Care Implementation of Depression
Collaborative Care
Chair: JoAnn Kirchner, Department of VA
Sunday, June 25 • 8:30 am – 10:00 am
Panel Overview: Spread of new technologies across
healthcare organizations is a complex process whose
determinants health service researchers are only recently
beginning to study systematically. Successful routine-care
implementation requires participation of stakeholders from a
broad spectrum of professional backgrounds, skill sets, and
organizational levels. Further, a variety of individual,
organizational, and cultural characteristics may differentially
affect stakeholder groups’ readiness and ability to embrace
evidence-based implementation efforts. Capitalizing on its 25year investment in health services research, the Veterans
Health Administration (VHA) has embarked on a series of
research-clinical partnerships through the Quality
Enhancement Research Initiative (QUERI). We conducted a
formative evaluation of one of these partnerships, the TIDES
program (Translating Initiatives for Depression Into Effective
Solutions). This panel will be composed of 4 major sections.
First, we will briefly describe the TIDES intervention and
implementation methodology. Second, we will describe details
of the multi-method formative evaluation conducted of this
multi-site intervention. This evaluation included managers’
and providers’ views of the strengths and weaknesses of the
implementation process, resulting in practical guidelines for
working with busy frontline healthcare staff and critical
methodological recommendations for improving the science
underlying implementation research. Third, we will describe
views of management and frontline staff on how best to
establish a two-way dialogue between implementers and QI
program participants, which is designed to facilitate program
marketing and provide a mechanism for obtaining on-going
feedback from local staff. Finally, we will discuss the effects of
contextual and organizational characteristics on the extent of
intervention penetration across practices.
●Improving Depression Treatment in Primary Care:
Dissemination and Implementation
Edmund Chaney, Ph.D., Lisa Rubenstein, M.D., M.S.P.H.
Presented By: Edmund Chaney, Ph.D., Staff Psychologist, ,
Department of Veterans Affairs, Seattle VAMC, 1100 Olive
Way, Suite 1400, Seattle, WA 98101; Tel: (206) 764-2815; Fax:
(206) 764-2652; Email: edmund.chaney@med.va.gov
Research Objective: Though effective and efficacious
interventions have been documented, depression is frequently
under-detected and under-treated in the primary care setting.
To address this problem, the Veterans Health Administration
of the U.S. Department of Veterans Affairs (VA) has funded
Translating Initiatives for Depression into Effective Solutions
(TIDES), an implementation process designed to introduce
and support an evidence-based care model for treating
depression in primary care. The goal of this implementation
effort is to maximize the ease of spread of an evidence-based
intervention through local, regional and national initiatives.
Study Design: Using an Evidence-Based Quality
Improvement (EBQI) protocol, TIDES establishes
partnerships between VA regional network leadership and
researchers who serve as implementation facilitators.
Implementation of the treatment model includes 3 phases:
primary implementation, regional dissemination and national
dissemination. Implementation activities, as well as evaluation
efforts, differ in each phase.
Population Studied: The primary implementation occurred in
7 different primary care clinics located in 3 different regional
networks. In addition, 3 sites (one in each regional network)
served as a randomized control for evaluation of the
implementation effort. Regional dissemination (currently
under way) targets sustainability of the intervention at the
primary implementation sites, as well as spread to additional
sites within the original networks and to a fourth regional
network. National dissemination efforts include linking
existing organizations to support the development of a
national organizational structure and capacity to support
implementation, ensuring the fidelity of the treatment model
in terms of existing treatment guidelines, linkage of the
treatment model to national performance monitoring
measures and the creation of stakeholder-specific marketing
plans.
Principal Findings: Findings from evaluation of the Primary
Implementation Phase indicate that the intervention resulted
in a stepped-care model of depression management
consistent with models validated in efficacy and effectiveness
trials. Findings also indicate patient adherence and
satisfaction with care, as well as remittance of depression
symptoms for 90% of patients followed in primary care and
50% of patients followed in mental health settings.
Conclusions: Design and conduct of implementation efforts
require a strong partnership between researchers and
clinicians. In addition, there are substantial upfront
investments required from both researchers and participating
clinical networks and sites. This varies by clinic site and
regional network. The average amount of time needed prior to
model implementation was 27 months. Appropriate selection
of a champion, tailored marketing, strong staff and
management buy-in and leadership support are key
components of the implementation process.
Implications for Policy, Delivery, or Practice: The Veterans
Health Administration is the largest publicly funded,
integrated health care system in the United States. Findings
with regard to the importance of using an EBQI process to
gain leadership support and involvement and facilitate
adaptation to local conditions may generalize to other
managed-care settings.
Primary Funding Source: VA
●The QI Implementation Process: Perspectives from
Providers and Managers
JoAnn Kirchner, M.D., Louise E. Parker, Ph.D., Laura Bonner,
Ph.D., Elizabeth M. Yano, Ph.D., Mona J. Ritchie, Ph.D.
Presented By: JoAnn Kirchner, M.D., Staff Physician, Health
Services Research, HSR&D / CeMHOR, 2200 Fort Roots
Drive, Building 58, (152/NLR), North Little Rock, AR 72114; Tel:
(501) 257-1719; Fax: (501) 257-1718; Email:
kirchnerjoanne@uams.edu
Research Objective: Spread of new technologies across
healthcare organizations is a complex process whose
determinants health service researchers are only beginning to
study. Successful implementation often requires participation
of stakeholders from a broad spectrum of professional
backgrounds, skill sets, and levels within the organization.
Readiness to participate in implementation efforts may differ
substantially among stakeholder groups. Further, a variety of
individual, organizational, and cultural characteristics,
structures, and processes may differentially affect stakeholder
groups’ readiness and ability to embrace and participate in
implementation efforts. The purpose of this presentation is
two-fold. First, we describe methods we used in a formative
evaluation of the TIDES program, a VA sponsored depression
care quality improvement (QI) initiative. Second, we describe
how we applied findings from this evaluation to identify
implementation barriers and inform the TIDES QI effort in an
ongoing process. We believe that our methods and findings
are applicable to a broad range of QI improvement efforts
within behavioral health as well as in other healthcare areas.
As such we offer them as a blueprint for utilizing formative
evaluation to guide quality improvement across the healthcare
industry.
Study Design: We conducted key informant interviews with
TIDES participants concerning their experience with the
implementation process as well as their perspectives
concerning barriers to and facilitators of the quality
improvement effort. We analyzed verbatim transcripts utilizing
a grounded theory approach. To enhance coding consistency,
a two-person team coded all the relevant text, refined their
coding scheme and resolved coding differences.
Population Studied: We interviewed a purposive sample of
72 stakeholders participating in the TIDES initiative.
Informants included depression care managers involved in the
QI effort and providers and managers from three VA service
networks, five medical centers, and five intervention clinics.
Principal Findings: Stakeholders provided cogent and
practical recommendations regarding who to involve in
implementation efforts, roles and characteristics of
champions, roles for leadership and resources needed to
support QI. They also offered general recommendations for
conducting quality improvement initiatives so as to foster
initial implementation, sustainability, and spread.
Conclusions: Providers and managers can articulate specific
activities to improve the implementation and spread of
evidenced based practices though there was some variation
across stakeholder groups. This type of information is useful
on two levels. First, it can provide valuable feedback to the
specific implementation effort studied. In fact, as the TIDES
program is an on-going effort, we are able to utilize our
findings to provide timely actionable feedback to the
implementation team. Second, much of what our informants
offered have broad implications for QI implementation and
thus can inform the field in general.
Implications for Policy, Delivery, or Practice: Quality
improvement efforts within healthcare organizations are most
likely to be effective when they are supported by the total
system including all its many stakeholders. Therefore,
successful implementation necessitates broad based inclusion
of stakeholder input from diverse organizational levels. Such
input can directly inform the implementation process and
support the development of an equal partnership between
managers and providers and those initiating the QI effort.
Primary Funding Source: VA
●Creating a Two-Way Intervention Dialogue: Practical
Suggestions for Facilitating Quality Improvement within
Healthcare Organizations
Louise Parker, Ph.D., JoAnn E. Kirchner, M.D., Laura Bonner,
Ph.D., Jacqueline J. Fickel, Ph.D., Elizabeth M. Yano, Ph.D.,
Mona J. Ritchie, M.S.W.
Presented By: Louise Parker, Ph.D., Consultant, 1 Warwick
Park, Unit 1, Cambridge, MA 02140; Tel: (617) 497-4952;
Email: parkerlouise@earthlink.net
Research Objective: There are two primary competing
healthcare quality improvement (QI) methods. Continuous
Quality Improvement is a bottom-up, participatory approach.
Evidence-Based Practice (EBP) is a top-down, expert-led
approach. Participation promotes buy-in and takes local
conditions and needs into account but can be burdensome.
EBP advocates argue that by following expert developed
guidelines, practitioners can provide quality care with minimal
burden. We propose melding the two approaches by creating
a two-way dialogue between implementers and healthcare
facility staff. Providers can then avail themselves of the latest
evidence while maintaining the ability to tailor interventions to
fit local conditions. It is not exactly clear, however, how to
conduct such a dialogue. We examined the ways in which
managers and frontline providers prefer to communicate with
QI implementers. We also examined the types of information
that they reported would be most likely to convince them to
adopt new ways of working. Our goal was to understand both
how implementers can market quality improvement to staff
and how staff, in turn, can convey information about local
circumstances and implementation problems to
implementers.
Study Design: We conducted semi-structured interviews with
frontline providers, frontline administrators, and middle and
upper managers across five VA practices participating in a
depression care QI initiative. Utilizing a grounded theory
approach, we conducted a content analysis during iterative
reviews of the verbatim interview transcripts. To enhance
conceptual development and ensure coding consistency, two
members of the research team coded all the relevant text and
met regularly to resolve differences and refine their coding
scheme and its underlying constructs.
Population Studied: We interviewed 53 frontline providers
and administrators and 19 middle and upper level managers.
Principal Findings: Informants believed that stakeholders
from all organizational levels should participate in QI
implementation, although they expressed concerns about
burden. Frontline staff offered practical suggestions for
maximizing participation while minimizing its costs (e.g.,
utilizing existing meeting structures). Informants indicated
that in-person communication is the most effective, although
managers appeared to be more amenable to written
communication (e.g., email) than were frontline providers.
Neither group expressed a clear preference for either
quantitative or qualitative information, although psychological
research suggests that vivid qualitative information is the
most persuasive. There were some differences between the
types of argument content that managers and providers would
find persuasive. For example, whereas both groups were
interested in quality of care, only managers were interested in
cost information. Both groups indicated that peers would be
convincing information sources; managers indicated that they
would also find experts convincing.
Conclusions: Although concerned about the time that
participation requires, informants believed that it was
important for stakeholders from all organizational levels to be
involved in QI efforts. They offered practical suggestions for
facilitating participation and for transferring information
between QI implementers and healthcare staff.
Implications for Policy, Delivery, or Practice: We believe
that successful QI requires two-way communication between
QI implementers and managerial and frontline staff. We
examined how best to communicate with and involve staff so
as to increase the probability that they will remain engaged in
QI efforts, thereby increasing the probability that those efforts
will succeed.
Primary Funding Source: VA
●Relationship between Organizational Context and
Penetration of Quality Improvement Interventions: Case
Studies from Implementing Depression Collaborative Care
Elizabeth Yano, Ph.D., JoAnn E. Kirchner, M.D., Jacqueline J.
Fickel, Ph.D., Louise E. Parker, Ph.D., Mona J. Ritchie, M.S.W.,
Chuan-Fen Liu, Ph.D.
Presented By: Elizabeth Yano, Ph.D., Psychologist, VA GLA
HSR&D, Center of Excellence, 16111 Plummer Street,
Sepulveda, CA 91343; Tel: (818) 891-7711 x5483; Fax: (818) 8955838; Email: elizabeth.yano@med.va.gov
Research Objective: Capitalizing on its 25-year investment in
health services research, the Veterans Health Administration
(VA) has embarked on a series of research-clinical
partnerships through the Quality Enhancement Research
Initiative (QUERI) to accelerate implementation of effective
interventions into routine care. One of many national QUERI
disease targets, depression is particularly common and
disabling, with national implementation of collaborative care
for depression being one of VA’s top primary care strategic
priorities. Collaborative depression care forges shared care
between primary care providers and mental health specialists
through provider education, informatics-based decision
support, leadership support, and a depression care manager,
who provides telephone assessment of visit-based positive
screens and telephone management and follow-up of
depressed patients. Although substantial evidence
demonstrates the effectiveness of collaborative care for
improving depression management and patient outcomes,
little is known about the factors underlying intervention
penetration. We evaluated the influences of contextual and
organizational characteristics on the degree of penetration
during implementation of depression collaborative care in a
sample of primary care practices.
Study Design: We combined measures from administrative
data from VA’s national standardized data repository
(location, patient caseload, workload, staffing) with process
evaluation results on penetration (proportion of providers
referring patients to intervention; # consults made, # provider
education sessions) and qualitative data from semi-structured
interviews of VA managers, providers and patients to evaluate
links between organizational context and effectiveness of
implementation in VA primary care practices. Coder dyads
analyzed interview data utilizing a grounded theory approach.
We evaluated aggregated qualitative and quantitative data
using cross-case analysis.
Population Studied: Six first-generation primary care
practices in three VA networks spanning five states
participated in a depression QI initiative. We interviewed
primary care and mental frontline providers, clinic
administrators, senior and mid-level health care managers,
depression care managers, a small sample of consumers
enrolled in the intervention, and consumer representatives
(n=106).
Principal Findings: From 1-10% of primary care patients were
diagnosed with depression across participating practices. The
speed or extent of penetration was not influenced by primary
care and mental health provider relationships, area
characteristics, such as urban/rural location, or practice size
with the exception of large practices (>13,000 patients), where
penetration was poorest. Initiating an early collaborative care
referral did not predict future referral behavior. Highest
referral rates occurred among practices with the lowest levels
of perceived mental health staffing.
Conclusions: The extent of penetration of an otherwise
effective depression QI intervention varied widely not by area
or practice characteristics but by the extent to which clinics
perceived that MH access was poor because of low perceived
MH staffing levels.
Implications for Policy, Delivery, or Practice: Although the
VA represents an exceptional “laboratory” within which to
translate research into practice given common electronic
medical records, identifiable management structures, and
common policies and procedures, effective penetration may
have less to do with these enablers than local clinic
characteristics and needs.
Primary Funding Source: VA
Call for Panels
Early Results from the Cancer Care Outcomes
and Research Consortium
Chair: Nancy Keating, Harvard Medical School
Sunday, June 25 • 8:30 am – 10:00 am
Panel Overview: The Cancer Care Outcomes Research and
Surveillance (CanCORS) Consortium, funded by the National
Cancer Institute and the Department of Veterans Affairs, is a
national research study of the health care and outcomes of
patients newly diagnosed with lung or colorectal cancer. The
study examines care for a population-based cohort of more
than 10,000 patients diagnosed with lung or colorectal cancer
during 2003-2005 who were living in Northern California, Los
Angeles County, North Carolina, Iowa, or Alabama, or who
receive their care in one of 5 health maintenance organizations
or in the Veterans Administration Health Care System. Data
have been collected from multiple sources, including baseline
patient surveys conducted approximately 4 months after
diagnosis (or surveys of deceased patients’ surrogates),
follow-up surveys conducted 12 months after diagnosis,
medical record abstraction, surveys of physicians with key
roles in the care of these patients, and surveys of caregivers of
a sample of these cancer patients. The primary goals of
CanCORS include determining how patient, provider and
health system factors affect patterns of cancer care and how
treatments received are associated with cancer outcomes in
community populations. This panel will present results from 5
early analyses that address issues of patients’ preferences for
treatment, patients’ use of alternative medications, providers
seen by cancer patients, experiences of caregivers of cancer
patients, and physicians’ reports of discussing end-of-life
issues with terminally ill patients.
●Physician Factors Associated with Discussions about
End-of-Life Care
Nancy Keating, M.D., M.P.H., Mary Beth Landrum, Ph.D.,
Selwyn Rogers, M.D., Susan Baum, BS, Beth Virnig, Ph.D.;
Haiden A Huskamp, Ph.D., Craig C Earle, M.D., Katherine L
Kahn, M.D.
Presented By: Nancy Keating, M.D., M.P.H., Assistant
Professor of Medicine and Health Care Policy, Department of
Health Care Policy, Brigham and Women's Hospital and
Harvard Medical School, 180 Longwood Avenue, Boston, MA
02115; Tel: 617-432-3093; Fax: 617-432-0173; Email:
keating@hcp.med.harvard.edu
Research Objective: Guidelines recommend advanced care
planning for patients with terminal illness and life expectancy
of 1 year or less. We described physicians’ reports of when
they discuss prognosis, do not resuscitate (DNR) status,
hospice, and preferred site of death for terminally ill patients
and identified factors associated with timing of these
discussions.
Study Design: Self-administered survey (57% response rate)
where physicians were asked to assume they were caring for a
patient newly diagnosed with metastatic cancer who is
otherwise feeling well, with an estimated life expectancy of 4-6
months. Physicians were asked when they would discuss
prognosis, DNR status, hospice, and preferred site of death.
Response options were “now”, “when the patient first has
symptoms”, “when there are no more non-palliative
treatments”, “only if the patient is hospitalized”, and “only if
the patient or family bring it up”. We used logistic regression
models to identify physician factors independently associated
with having discussions “now”.
Population Studied: Physicians from 5 population-based
sites, 5 integrated delivery systems, and 10 VA sites named by
incident lung or colorectal cancer patients as providing key
roles in their care.
Principal Findings: The mean age of the 2,699 responding
physicians was 50.2, 82% were male, 25% were surgeons, 16%
medical oncologists, 7% radiation oncologists, and 52% noncancer specialists. Sixty-six percent of physicians would
discuss prognosis “now”, while 18% would have this
discussion only if the patient/family brings it up. Forty
percent would discuss DNR status “now” with 20% waiting
for the patient to have symptoms and another 25% waiting
until there were no more nonpalliative treatments. Only 25%
would discuss hospice “now” with 16% waiting for symptoms
and 50% waiting until there are no more nonpalliative
treatments. Finally, 20% would discuss preferred site of death
now. In multivariable analyses, younger physicians were more
likely to discuss prognosis, DNR status, hospice, and
preferred site of death “now” (all P<0.001). Surgeons were
more likely than noncancer specialists to discuss prognosis
“now” (P=0.008), but noncancer specialists were more likely
than cancer specialists to discuss DNR status, hospice, and
preferred site of death “now” (all P<0.001). Physicians with
more terminally ill patients were more likely than others to
discuss prognosis “now” (P=0.04), and physicians in office
(vs. hospital) practice were more likely to discuss hospice
“now” (P=0.001).
Conclusions: Many physicians do not discuss end-of-life
options with terminally ill patients while they are still feeling
well, instead waiting for onset of symptoms or until there are
no more non-palliative treatments to offer. Younger
physicians and noncancer specialists discuss end-of-life
options sooner than older physicians and cancer specialists.
Implications for Policy, Delivery, or Practice: Despite
guidelines recommending discussion of prognosis, DNR
status, hospice, and preferred site of death while patients are
well, our findings suggest that different types of physicians
have very different views regarding the appropriate timing of
these discussions. More research is needed to understand
physicians’ reasons for and patients’ preferences for timing,
and the role of physicians’ propensity to treat metastatic
cancer on the timing of discussions. Education and physician
interventions may be necessary to increase advanced care
planning for terminally-ill cancer patients.
Primary Funding Source: NCI, Veterans Administration
●Complementary and Alternative Medicine Use and
Correlates among Patients With Newly Diagnosed
Colorectal and Lung Cancer
Robert B. Wallace, M.D., MSc, Robert Fletcher, M.D., Jane
Weeks, M.D., Angela Kuehl, D.Pharm., Jane Pendergast, Ph.D.
Presented By: Robert B. Wallace, M.D., M.Sc., Professor of
Epidemiology and Internal Medicine, Epidemiology, University
of Iowa College of Public Health, 200 Hawkins Drive, Iowa
City, IA 52242; Tel: 319-384-5005; Fax: 319-384-5004; Email:
robert-wallace@uiowa.edu
Research Objective: To determine the level and correlates of
dietary supplement and alternative practitioner use among
patients with newly diagnosed colorectal (CRC) or lung cancer.
Study Design: Analysis of responses to a questionnaire that
included items on complementary and alternative medicine
practices and other factors potentially related to dietary
supplement use, such as socio-demographic and clinical
variables, satisfaction with care, and clinical trial participation.
The survey was administered by telephone 4-6 months (mean
4 months) after diagnosis, and included patient but not proxy
interviews.
Population Studied: Seven geographically and institutionallydefined cohorts of newly diagnosed CRC and lung cancer
patients throughout the United States (Total N = 4767).
Principal Findings: Approximate 13% of CRC and lung cancer
patients reported using alternative dietary supplements and
about 6% had consulted an alternative practitioner at the time
of the baseline survey, with little variation according to type of
cancer. Of those seeking an alternative practitioner, about
10% reported traveling over 100 miles for this activity. Dietary
supplement (DS) users were younger, more likely to be
women, somewhat more highly educated and had higher
reported family incomes. There was no significant difference
between whites and non-whites in usage rates. DS use had
increased substantially from the year before cancer diagnosis.
Patients reported taking supplements for a variety of reasons,
including for cancer treatment, lessening the side effects of
cancer therapy, relieving cancer symptoms and for unrelated
medical conditions. DS users were also more likely to use
alternative practitioners than non-users. For both CRC and
lung cancer patients, DS takers were less satisfied with the
quality of their initial surgical and chemotherapy care,
although this was statistically significant only for CRC patients.
CRC, but not lung cancer patients were less likely to
participate in any type of clinical trial during initial cancer
management.
Conclusions: The use of alternative dietary supplements and
alternative practitioners is common among newly diagnosed
CRC and lung cancer patients in this geographically dispersed
cohort. DS use appears to be somewhat greater among those
with higher education and income. DS use also appears to be
a possible indicator of greater dissatisfaction with cancer care,
and (at least among lung cancer patients) of lesser likelihood
of clinical trial participation.
Implications for Policy, Delivery, or Practice: Several patient
characteristics and behaviors were associated with dietary
supplement and alternative practitioner use is in patients with
CRC and lung cancer. and these could have important
implications for improving the therapeutic process. In followup analyses, we will explore the effects of these variables on
clinical cancer outcomes.
Primary Funding Source: NCI, Veterans Administration
●Physicians Involved in the Care of Patients with Recently
Diagnosed Lung and Colorectal Cancer
Katherine L Kahn, M.D., Nancy L Keating, M.D., M.P.H., Mary
Beth Landrum, Ph.D., John Z Ayanian, M.D., M.P.P., Robert
Boer, Ph.D., Carrie Klabunde, Ph.D.; Paul J Catalano, Ph.D.,
Presented By: Katherine L Kahn, M.D., Professor, Medicine,
UCLA, RAND, 911 Broxton Avenue, Los Angeles, CA 90095;
Tel: 310-794-2287; Fax: 310-794-0732; Email:
kkahn@mednet.ucla.edu
Research Objective: To understand the distribution of
physicians and roles fulfilled for patients with incident lung
and colorectal cancer.
Study Design: Approximately four months after diagnosis,
1810 lung cancer (LC) and 2371 colorectal cancer (CRC)
patients were surveyed by telephone to assess the types of
physicians fulfilling key clinical roles. We examined the
distribution of patients reporting a physician fulfilling 4 key
roles and how often that role was fulfilled by a cancer
(surgeon, medical or radiation oncologist) or non-cancer
doctor.
Population Studied: Incident LC and CRC patients diagnosed
during 2003-2005 in five regions, five integrated health-care
delivery systems, and 10 VA hospitals.
Principal Findings: LC patients receiving surgery,
chemotherapy, and radiation reported a mean of 3.6 (SD 1.3)
unique physicians involved with their care vs. mean 3.0 (SD
1.2) for patients receiving none of these treatments. CRC
patients receiving surgery, chemotherapy, and radiation
reported a mean of 3.1 (SD 1.1) unique physicians involved
with their care vs. mean 2.1 (SD 1.0) for patients receiving
none of these treatments. Most patients reported having a
primary-care physician (PCP) (80% for LC, 74% for CRC), a
doctor most important in helping them decide whether or not
to have tests or treatments (77%, 57%, respectively), a doctor
in charge of treatment for the next six months (81%, 59%),
and a doctor responsible for managing symptoms (79%,
56%). For more than 90% of patients reporting a PCP, that
doctor was someone other than their surgeon, chemotherapy
or radiation doctor. For 49% of LC and 31% of CRC patients,
the PCP was also the physician patients reported as most
important in at least one of three other key roles: helping them
decide whether or not to have tests or treatments, the doctor
in charge of treatments for the next six months, or the doctor
most likely to know about their symptoms. Among patients
reporting one doctor who was most important in helping
them decide whether or not to have treatments, this physician
was not a cancer specialist for 39% of patients with either LC
or CRC. The doctor in charge of treatments for the next six
months and the doctor responsible for managing symptoms
was a cancer doctor for most patients (77% and 62%); for the
remaining patients, a noncancer doctor fulfilled these roles.
Conclusions: Early after a diagnosis of LC and CRC, most
patients reported having several key providers of their care.
Within the first 4 months, patients often received care from
both primary care and cancer specialists. Across both cancers,
23% to 39% of patients reported a key management role
fulfilled by a non-cancer doctor. For more than two-thirds of
these patients, the non-cancer doctor fulfilled multiple roles.
Implications for Policy, Delivery, or Practice: The
management of patients with incident cancer typically
includes several physicians fulfilling multiple key roles,
including both primary-care and cancer physicians. These
findings underscore the need to develop and maintain
systems for coordinating care effectively among these multiple
physicians for patients with newly diagnosed lung cancer or
colorectal cancer.
Primary Funding Source: NCI, Veterans Administration
●Fatalism and Treatment Preferences of Lung and
Colorectal Cancer Patients: The Role of Demographic and
Socio-Economic Variables
Julie Ganther-Urmie, Ph.D., Elizabeth Chrischilles, Ph.D., Jane
Weeks, M.D., John Brooks, Ph.D., Jane Prendergast Ph.D.;
Dawn Provenzale, M.D., David Nerenz, Ph.D.; Dee West,
Ph.D.
Presented By: Julie Ganther-Urmie, Ph.D., Assistant
Professor, Pharmacy, University of Iowa, S519 Pharmacy
Building, Iowa City, IA 52242; Tel: 319-335-8616; Fax: 319-3535646; Email: julie-urmie@uiowa.edu
Research Objective: To examine the relationship between
fatalism/treatment preferences and socio-demographic factors
in lung and colorectal cancer patients.
Study Design: Data were from the Cancer Care Outcomes
and Research Consortium (CanCORS) baseline patient survey.
Preference measures included a summated four item fatalism
measure, a single item measure of whether patients preferred
treatment that extended life versus treatment that improved
quality of life, and a single item measure of whether patients
preferred treatment that extended life or treatment that
conserved financial resources. Survey data were collected
approximately 4 months after cancer diagnosis. Multivariate
linear and logistic regression models were used to examine
the relationship between socio-demographic variables and
each of the preference measures. Independent variables for
the model were: age, gender, marital status/living
arrangement, race, income, education, health insurance
status, and type of cancer.
Population Studied: Population-based cohort of newly
diagnosed lung and colorectal patients enrolled in the
CanCORS study. Patients were from seven geographically
diverse sites in the United States.
Principal Findings: Levels of fatalism varied widely, with
scores across the full scale range. Women, patients with
lower education levels, patients with lower income levels, and
patients who were married or living with a partner had
significantly higher levels of fatalism. African-Americans and
Asians had significantly higher levels of fatalism than white,
non-Hispanics. The model explained a limited amount of
variation in fatalism with an R squared of 12.6 percent (n =
4,129). About half of patients said they would prefer
treatment that extended quantity of life, even if it meant more
pain or discomfort, over treatment that focused on relieving
pain and discomfort but would mean not living as long (n=
4,127). Younger patients, men, and patients who were
married or living with a partner were significantly more likely
to prefer quantity of life over quality of life. African-Americans
were significantly more likely than white, non-Hispanics to
prefer quantity of life over quality of life. Sixty-one percent of
patients said they would prefer treatment that extended their
life as much as possible, even if it meant using up all of their
financial resources, over treatment that cost less but would
mean not living as long (n = 3,948). Younger patients, men,
and patients who were not married or living with a partner
were significantly more likely to prefer quantity of life over
conserving financial resources. African-Americans and Asians
were significantly more likely than white, non-Hispanics to
prefer quantity of life over conserving financial resources.
Type of cancer was not significant for any of the models.
Conclusions: There are some significant differences in
preferences among different socio-demographic groups, but
overall, socio-economic and demographic variables do a poor
job of explaining variation in preferences.
Implications for Policy, Delivery, or Practice: Some
differences in treatment rates across different patient groups
may be explained by patient preferences. However, socioeconomic and demographic variables explain only a small
amount of the variation in preferences so it is important to
explicitly assess patient preferences rather than make
assumptions about preferences based on socio-demographic
characteristics.
Primary Funding Source: NCI, Veterans Administration
●Characteristics, Care Tasks, and Unmet Needs of
Informal Caregivers of Cancer Patients
Michelle van Ryn, Ph.D., M.P.H., Audie Atienza, Ph.D.; Mary
Butler, M.B.A., Mark C Hornbrook, Ph.D.; Katherine L Kahn,
M.D., Michelle Martin, Ph.D.; Sara Sanders, Ph.D., Michelle
Sotak, BA; Julia Rowland, Ph.D., Courtney Van Houtven, Ph.D.
Presented By: Michelle van Ryn, Ph.D., M.P.H., Associate
Professor, Family Medicine & Community Health;
Epidemiology, University of Minnesota, Room 225, 925
Delaware Street, S.E., Minneapolis, MN 55414; Tel: 612-6259105; Fax: 612-624-3037; Email: vanry001@umn.edu
Research Objective: Changes in the health care system have
shifted much of cancer care to the outpatient and home
setting, resulting in increased family involvement in day-to-day
care. Yet, limited information exists about informal cancer
caregivers and the care they provide. We sought to identify the
characteristics of informal caregivers of newly diagnosed lung
and colorectal cancer patients, and assess the specific care
they provide.
Study Design: Caregivers of newly diagnosed CRC and lung
cancer patients were mailed self-admininistered
questionnaires soon after baseline interviews with the cancer
patients were completed. We conducted analyses focusing on
caregivers’ sociodemographic and health characteristics, type
and amount of care provided, and training received for
providing cancer care.
Population Studied: Caregivers (N=642) of seven
geographically and institutionally-defined cohorts of newly
diagnosed CRC and lung cancer patients.
Principal Findings: The majority (73%) of caregivers reported
they alone did all or most of the home care. Most of the
caregivers were spouses (60%) or other family members
(35%). While the majority of caregivers (70%) live with the
care recipient, 10% drove 30 minutes or more to provide care.
Most provided care every day (65%), though a significant
minority (20%) reported providing care one day a week or
less. In addition to assisting with activities of daily living,
many caregivers assisted with cancer specific care, including
managing symptoms such as pain, nausea or fatigue (40%),
making decisions about medications (30%) and monitoring
the care recipient for treatment side effects (65%). Around
50% of caregivers who reported performing a cancer care task
also reported not receiving any training to perform the task.
Over half of caregivers reported that they did not have a
choice in whether or not to provide care. Fifty percent reported
currently working for pay, and of these, 70% reported having
difficulty balancing work and care demands. Twenty percent
reported that they also cared for children in their home. Only
42% of caregivers reported being in very good or excellent
health. Caregivers reported various coping strategies with
10% reporting they use alcohol or other drugs to help them
cope. On the positive side, around 80% reported feeling very
close to their care recipient, and over 50% reported
experiencing one or more positive aspects of providing care.
Conclusions: A wide range of services for incident cancer
patients are delivered in the home, by unpaid family
caregivers, who are often untrained. A significant portion of
cancer caregivers have difficulty managing their work and
caregiving roles. Less than half of caregivers are in very good
or excellent health themselves.
Implications for Policy, Delivery, or Practice: Caregivers are
an important resource for patients with incident cancer. For
many, the challenges of caregiving, the lack of training, and
the need to deliver care while also managing employment is
problematic. A more systematic understanding of caregiver
tasks and challenges will facilitate health systems and families
to evaluate how to best provide caregiver services in a
sustained, high quality manner.
Primary Funding Source: NCI, Veterans Administration
Call for Panels
Impact of Medicare Critical Access Hospital
Program on Rural Hospital Financial Viability
and Access to Care in Rural Communities
Chair: Boyd Gilman, RTI International
Sunday, June 25 • 10:30 am – 12:00 pm
Panel Overview: Today nearly one-quarter of all acute care
hospitals in the United States receive cost-based
reimbursement from Medicare under the Critical Access
Hospital (CAH) program. The number of hospitals converting
to CAH status has increased from less than 50 in 1998 to
nearly 1,200 in 2005. As a result of the special financing
program, in several Midwestern states over three-quarters of
all acute care facilities now receive cost-based reimbursement.
The CAH program was created by Congress in the 1997
Balanced Budget Act (BBA) to provide special financial
dispensation to all limited-service hospitals located in isolated
rural areas. The purpose of the CAH program was to ensure
that Medicare beneficiaries in isolated rural communities had
reliable access to emergency room and limited inpatient
services, including the capacity to stabilize patients and
arrange transport to an appropriate larger hospital for
complex cases. The program was intended to provide more
favorable financing to small facilities that, because of their lack
of economies of scale, may have been financially
disadvantaged by the implementation of Medicare’s inpatient
and outpatient prospective payment system, The purpose of
this panel is to describe the history and purpose of the CAH
program; track the rapid and concentrated growth in the
number of hospitals that have received CAH designation; and
assess the impact of the CAH program on hospital financial
performance, hospital closures, and access to acute and
postacute care services in rural communities.
●Impact of Critical Access Hospital Status on Hospital
Revenue, Profit Margins, and Hospital Closures
Jeff Stensland, Ph.D.
Presented By: Jeff Stensland, Ph.D, Senior Analyst, MedPAC,
601 New Jersey Avenue, N.W., Washington, DC 20001; Tel:
202-220-3700; Email: Jstensland@medpac.gov
Research Objective: To quantify the impact of critical access
hospital (CAH) status on Medicare payments, profit margins,
and the closure of rural hospitals.
Study Design: We compare cost-based Medicare payment
rates per unit of inpatient, outpatient, and post acute care to
the Medicare prospective payment systems’ rates. Costbased payments are taken from Medicare cost reports and
prospective payment system rates are modeled using
Medicare claims data. Hospital closure data was obtained
from CMS.
Population Studied: A sample of 498 of the approximately
1,200 critical access hospitals along with a comparison group
of 551 small rural hospitals that had not converted to CAH
status by 2003.
Principal Findings: Critical access hospital revenues (and
Medicare expenditures) increased at a 9.5% annualized rate of
growth from 1998 to 2003. Comparison hospital revenues
increased at a 3.3% annualized rate. The faster revenue
growth at CAHs is almost all due to cost-based payment rates
being significantly larger than Medicare’s prospective payment
rates. Outpatient revenues and post-acute revenues per day
increased rapidly after conversion to cost-based
reimbursement. As Medicare revenues increased, profit
margins improved significantly, and closures almost ceased.
Conclusions: Much of the difference between payments
received by CAHs and traditional hospitals reflects the benefit
of cost-based outpatient payments and cost-based payments
for post-acute patients in swing beds.
Implications for Policy, Delivery, or Practice: The Medicare
Prescription Drug, Improvement, and Modernization Act of
2003 (MMA) essentially prevents new hospitals from entering
the CAH program. Most of the existing 1,200 to 1,300 CAHs
are expected to remain financially stable—many are even
remodeling their facilities or building new facilities.
Neighboring small rural hospitals that also lack economies of
scale may have difficulty competing with CAHs if the CAHs
receive significantly higher payment rates.
Primary Funding Source: Other Government Funding
●Growth in the Number of Rural Hospitals under
Medicare Cost-Based Reimbursement
Boyd Gilman, Ph.D., Kathleen Dalton, Ph.D.
Presented By: Boyd Gilman, Ph.D., Senior Economist,
Division for Health Services and Social Policy Research, RTI
International, 411 Waverley Oaks Road Suite 330, Waltham,
MA 02452; Tel: (781) 434-1718; Fax: (781) 434-1700; Email:
bgilman@rti.org
Research Objective: The purpose of this paper is to describe
the background and purpose of the Medicare Critical Access
Hospital (CAH) program; discuss the eligibility requirements
for conversion, with particular emphasis on state exemptions
from the federal requirements; and track the growth in the
number and the regional distribution of hospitals that have
been awarded a CAH designation.
Study Design: The presentation uses descriptive analyses of
the number and location of hospitals converting to CAH
status between 1998 and 2005 based on information from the
March 2005 update of the CMS OSCAR files, supplemented
by information through October 2005 from Flex Monitoring
Project.
Population Studied: Rural short-stay hospitals that converted
to CAH status before October 2005.
Principal Findings: The 41 facilities that were identified as
CAHs prior to 1999 were already receiving cost-based
reimbursement from Medicare under two existing rural
demonstration programs. An additional 78 rural hospitals
converted from PPS to cost-based reimbursement in 1999. By
October 2005, 1,163 rural short-stay hospitals had been
awarded a CAH designation, representing nearly one-quarter
of all Medicare participating short-stay acute care facilities in
the United States. However, given their small size, CAHs
represent less than three percent of all certified acute care
beds. Converting hospitals are geographically concentrated in
the Midwest. Roughly three-quarters of all acute care
hospitals in Montana, Nebraska and North Dakota, two-thirds
of all hospitals in Iowa, Indiana and South Dakota, and onehalf of all hospitals in Kansas and Minnesota have converted
to CAH status. One of the most important factors enabling
the growth in converting hospitals has been the ‘necessary
provider’ provision including in the enabling legislation. The
provision allowed states to develop their own definitions of
what constituted a necessary community service and these
definitions were allowed to take precedence over the federal
proximity criterion. More than 60% of the 959 hospitals that
had converted by August 2004 were certified on the basis of
their state designation as ‘necessary provider.’
Conclusions: There has been a rapid growth in the number of
short-stay acute hospitals converting to cost-based
reimbursement under the Medicare CAH program due in part
to expansions in the eligibility requirements under subsequent
legislation and in part to the authority of states to circumvent
the proximity requirement by designating hospitals as
‘necessary providers.’ However, as a result of the recent
elimination of the proximity waiver, there should be virtually
no future growth in the CAH program as more than 90
percent of all non-metropolitan hospitals with 25 or fewer
certified beds are already designated as CAH providers.
Implications for Policy, Delivery, or Practice: The Medicare
CAH program has been successful in getting rural hospitals to
limit the scope of their services in exchange for more
generous financing. By reimbursing hospitals on the basis of
their costs rather than under the prospective payment
systems, the CAH program has helped to ensure the
availability of limited acute care services in rural communities.
Primary Funding Source: CMS
●Impact of Critical Access Hospital Program on Financial
Performance
Mark Holmes, Ph.D., George Pink, Ph.D., Rebecca Slifkin,
Ph.D.,
Presented By: Mark Holmes, Ph.D., Senior Research Fellow,
Cecil G. Sheps Center for Health Services Research, University
of North Carolina at Chapel Hill, 725 Martin Luther King
Boulevard, CB 7589, Chapel Hill, NC 27599-7590; Tel:
(919_966-9694; Fax: (919)966-1634; Email:
mark_holmes@unc.edu
Research Objective: To determine whether and to what
extent conversion to Critical Access Hospital (CAH) status
affected hospital financial performance.
Study Design: The Flex Monitoring Team has developed
twenty financial performance indicators specifically for Critical
Access Hospitals using Medicare Cost Report data. We
compare these measures pre- and post- conversion to CAH
status for approximately 700 hospitals, controlling for the
timing of the conversion.
Population Studied: Critical Access Hospitals for which a
complete year of Medicare Cost Report data are available postconversion
Principal Findings: Although some financial performance
measures (such as profitability and liquidity) improved after
conversion to CAH, other measures showed no correlation
with conversion to CAH. Most measures exhibited a decline
in the year immediately subsequent to conversion.
Conclusions: Conversion to CAH status has generally
increased financial performance of CAHs, thus improving the
potential for their long term survivability. The pre-conversion
dip underlines the importance of accounting for the decision
to convert to CAH status in pre-post comparison studies.
Implications for Policy, Delivery, or Practice: Rural
residents depend on the survival of their community hospitals
to have access to timely, quality healthcare. The CAH
program was instituted to increase the survivability of small
rural hospitals by alleviating financial pressures. Evidence that
CAH conversion has improved the financial performance, and
therefore the expected survivability of these hospitals,
supports continuation of this program.
Primary Funding Source: HRSA
●Participation in Skilled Nursing and Swing-bed Care in
Rural Hospitals Following Conversion to Cost-Based
Reimbursement
Kathleen Dalton, Ph.D., Rebecca T Slifkin, Ph.D.
Presented By: Kathleen Dalton, Ph.D., Senior Health Services
Researcher, Health Care Finance & Payments, RTI
International, 3040 Cornwallis Road, Research Triangle Park,
NC 27709; Tel: (919) 451-5919
Research Objective: The supply and organization of postacute care is sensitive to changes in Medicare payment
regulation. Between 1998 and 2003 Medicare transitioned
from cost-based to prospective payments for all skilled
nursing facilities (SNFs), and returned from prospective to
cost-based payments for acute and swing-bed care in nearly
half of rural hospitals as a result of the Critical Access
Hospital (CAH) program. CAHs face new incentives to close
SNF units and expand swing-bed care in order to maximize
hospital cost-based payments. This study tracks changes in
availability and use of inpatient skilled nursing services in rural
areas during the period from 1996 to 2003, focusing on CAH
participation in post-acute and long-term care before and after
their conversion from PPS to CAH status.
Study Design: Retrospective, observational study combining
data from CMS certification files through September 2004
with hospital and nursing facility cost reports filed for periods
ending through 2003. Descriptive analyses are provided by
core-based statistical areas (CBSAs). These are supplemented
by multivariate models of the probability of hospital-based
SNF closure and of average swing-bed census, as functions of
CAH status controlling for size, location, SNF case-mix or
previous survey findings.
Population Studied: Rural short-stay hospitals and Medicarecertified SNFs that were open between 1996 and 2003.
Principal Findings: Contrary to expectation hospital-based
SNFs have not closed more often in CAHs than in other rural
hospitals, and swing bed use has grown only slightly faster in
CAH settings than elsewhere. The proportion of Medicare
SNF care delivered in swing-bed or hospital-based settings
has declined steadily in both rural and urban counties, but the
decline is less pronounced in the very rural counties where the
majority of CAHs are located. In the six years following the
1998 implementation of SNF PPS, 15% of hospital-based
facilities in very rural counties closed compared to 26% in
micropolitan rural and 43% in metropolitan counties. Only
8% of CAH converters that operated SNFs in 2000 had closed
their units by end of 2004, compared with 19% of other rural
hospitals with SNFs. Multivariate models found hospitalbased unit closure was associated with for-profit ownership,
higher Medicare utilization, higher wage-adjusted cost per day
and lower average therapy case-mix. Closure was not
significantly associated with CAH status, swing-bed
participation or a history of survey deficiencies. Swing bed use
increased substantially in a small group of CAHs but not
overall; in regressions with multi-year data, increased swing
census was not associated with CAH conversion.
Conclusions: Although the reintroduction of cost
reimbursement to rural hospitals creates strong
reimbursement incentives to close non-cost-based units, there
is no evidence yet that CAHs are more likely to close their PPS
SNF units or substitute swing-bed for SNF unit care. Changes
in swing-bed use following conversion vary strongly by region.
Implications for Policy, Delivery, or Practice: Many CAHs
have operated under cost reimbursement for only one or two
years and these findings could change as managers grow
more familiar with reimbursement maximization strategies.
CAH participation in non-cost-based services should continue
to be monitored.
Primary Funding Source: HRSA
Call for Panels
Quality Improvement Programs to Improve
Outcomes of Patients with Anxiety and
Depression in Medical Settings
Chair: Wayne Katon, University of Washington
Sunday, June 25 • 10:30 am – 12:00 pm
Panel Overview: Most people in the United States with
depressive and anxiety disorders are treated in primary care
and medical settings not by mental health professionals.
However accurate diagnosis and treatment of
depressive/anxiety disorders in these settings has been shown
to be suboptimal. This symposium will describe four
innovative programs tested in randomized trials that have
been shown to markedly improve quality of mental health care
and outcomes of patients with depression/anxiety disorders in
medical settings. Dr. Katon will describe the Pathways study
that tested a depression collaborative care intervention in
patients with depression and diabetes compared to usual care
which showed marked improvement in depression as well as a
savings in medical costs over a two year period. Dr. Unützer
will review results from the IMPACT trial which randomized
1801 elderly depressed patients in 8 health care settings to a
nurse collaborative care program versus usual primary care.
This study showed that the intervention was associated with
improved depression, decreased functional impairment and
decreased pain compared to usual care at a small increment
in cost. Dr. Roy-Byrne will describe the results of a combined
cognitive behavioral and medication intervention for primary
care patients with panic disorder that was associated with
improvement in anxiety and depressive symptoms and
improved functioning compared to usual primary care. Dr.
Zatzick will describe a randomized trial of a case management
intervention for patients hospitalized for motor vehicle trauma
who suffered from PSTD and/or substance abuse that was
shown to be associated with a significant decrease in PTSD
symptoms as well as use of alcohol over a 1-year period
compared to usual care.
●Cost-Effectiveness and Probability of Cost-Offset of a
Stepped Care Intervention in Patients with Diabetes and
Depression
Wayne Katon, M.D., Gregory Simon, M.D., M.P.H., Jurgen
Unutzer, M.D., M.P.H., Ming-Yu Fan, Ph.D., Michael
Schoenbaum, Ph.D., Michael Von Korff, Sc.D.
Presented By: Wayne Katon, M.D., Professor and Vice-Chair,
Psychiatry & Behavioral Sciences, University of Washington,
1959 NE Pacific St., Box 356560, Seattle, WA 98195-6560; Tel:
(206) 543-7177; Fax: (206) 221-5414; Email:
wkaton@u.washington.edu
Research Objective: Patients with diabetes have a high
prevalence of major depression, estimated at up to 15%.
Patients with diabetes and comorbid depression compared to
those with diabetes alone have increased symptom burden,
functional impairment and medical costs as well as poorer
self-care (adherence to diet, exercise and medication), higher
HbA1c levels and higher mortality rates. These research
projects tested the effect on depressive outcomes and costs of
a quality improvement depression intervention for patients
with diabetes and depression.
Study Design: We will describe the 2-year incremental costeffectiveness of two trials that randomized 414 older adults
with diabetes and depression (IMPACT) and 329 mixed-aged
patients with diabetes and depression (Pathways Trial),
respectively, to a collaborative stepped care intervention
versus usual care. The stepped care intervention in each trial
provided patients with a choice of problem-solving therapy,
antidepressant medication and behavioral activation with
potential augmentation of initial choice of treatment based on
persistent depressive symptoms.
Population Studied: In Pathways mixed age and in IMPACT,
elderly (60 or older) patients with major depression and/or
dysthymia and diabetes.
Principal Findings: In the IMPACT trial, the two-year total
ambulatory costs were $25 (95% CI -1638, 1689) higher in
intervention versus usual care patients over a 2-year period
and the incremental number of depression-free days
associated with the intervention was 115 (95% CI 72, 159). The
incremental cost per depression-free day was -$0.25 (95% CI 14, 15). A bootstrap analysis suggested a 50% chance of
dominance of the intervention (the total ambulatory costs
were less with greater clinical benefit). In the Pathways trial,
the two-year total ambulatory costs were $605 (95% CI -1767,
556) less in intervention versus usual care patients and the
incremental number of depression-free days associated with
the intervention was 70 (95% CI 26, 114). The incremental
cost per depression-free day in Pathways was -$9.7 (95% CI 31, 14).
Conclusions: The results of the two trials suggests in patients
with diabetes and depression that for no greater costs the
depression stepped care intervention compared to usual
primary care was associated with a marked increase in
depression-free days and health care benefits in primary care
patients with comorbid diabetes and depression.
Implications for Policy, Delivery, or Practice: Improving
recognition and treatment of depression in patients with
diabetes is associated with decreased patient suffering and
may save medical costs.
Primary Funding Source: National Institute of Mental Health
●Project IMPACT: Improving Primary Care for Late-Life
Depression
Jurgen Unutzer, M.D., M.P.H.
Presented By: Jurgen Unutzer, M.D., M.P.H., Professor and
Vice-Chair, Psychiatry & Behavioral Sciences, University of
Washington, 1959 NE Pacific Street, Box 356560, Seattle, WA
98195-6560; Tel: (206) 543-3128; Fax: (206) 221-5414; Email:
unutzer@u.washington.edu
Research Objective: Depressive disorders affect 5-10% of
older adults seen in primary care. Late-life depression is
associated with substantial suffering and impairment, high
medical costs and poor adherence to medical treatment, and
increased mortality. Although efficacious treatments exist, few
depressed older adults receive adequate care. This study
reports the cost-effectiveness of a collaborative care model to
improve care for depressed older adults.
Study Design: Adults aged 60+ with major depression or
dysthymia were randomly assigned to usual care or to the
IMPACT care model, which involved 12-month access to a
depression care manager supported by a psychiatrist and a
primary care expert. The study involved 1,801 depressed older
adults from 18 primary care clinics in 8 organizations across
the US. Independent surveys assessed clinical status, quality
of life, functioning, and health care use at 3, 6, 12, 18 and 24
months; practices provided administrative data on health care
costs and use over the study period. We assess intervention
effects on depression, functional impairment, quality-adjusted
life years (QALY), and costs per QALY, using intent-to-treat
analyses.
Population Studied: 1801 elderly patients (60 or older) with
major depression and/or dysthymia enrolled in 8 health
organization in 7 states.
Principal Findings: Over two years, intervention patients had
107 more depression-free days (DFD) than those in usual care
(P is less than 0.01), corresponding to a gain of 0.056-0.113
QALYs. Intervention participants also had less functional
impairment and better physical functioning than usual care
patients over a 2-year follow-up. There were no significant
differences in total health care costs in intervention and
control patients and the incremental outpatient cost / DFD
was $2.76 (95 % CI -4.95, 10.47).
Conclusions: The IMPACT intervention is highly effective for
depressed older adults, relative to usual care and a high value
investment when compared to other commonly provided
medical treatments.
Implications for Policy, Delivery, or Practice: The IMPACT
model markedly improves depressive, functional and quality of
life outcomes for depressed patients at a modest cost.
Primary Funding Source: John A. Hartford Foundation
●Developing and Implementing Acute Care Collaborative
Interventions Targeting PTSD & High-Risk Behaviors
Douglas Zatzick, M.D., M.P.H., Peter Roy-Bryne, M.D., Joan
Russo, Ph.D., Frederick Rivara, M.D., Gregory Jurkovich, M.D.,
Amy Wagner, Ph.D.
Presented By: Douglas Zatzick, M.D., M.P.H., Associate
Professor, Psychiatry & Behavioral Sciences, University of
Washington, 325 Ninth Avenue, Box 359911, Seattle, WA
98104; Tel: (206) 731-4867; Fax: (206) 731-3236; Email:
dzatzick@u.washington.edu
Research Objective: Injured survivors of individual and mass
trauma initially receive treatment in the acute care medical
setting. Epidemiological investigations suggest that injured
trauma survivors are at risk for the development of
posttraumatic stress disorder (PTSD) and related comorbidities, yet few symptomatic patients attain high quality
behavioral health services. The goal of this research is to
develop a health services intervention to improve mental
health outcomes of hospitalized trauma patients.
Study Design: A team of clinician-investigators from mental
health services, clinical psychology/efficacy, pediatric and,
surgical backgrounds developed a collaborative care
intervention that was delivered from a level I trauma center.
The team combined injury care management, motivational
interviewing targeting reductions in injury risk behaviors, and
evidence-based cognitive behavioral psychotherapy and
medications targeting PTSD, in a stepped care procedure.
Clinical epidemiological methods were used to recruit a
population-based sample of 120 acutely injured hospitalized
patients. Inpatients were randomized to early collaborative
care intervention or care as usual.
Population Studied: 120 acutely injured patients hospitalized
initially in a community care intervention versus usual care.
Principal Findings: Over the 12-months after the injury
patients receiving the combined intervention demonstrated
significant reductions in PTSD symptoms (p less than .02)
and high risk alcohol use (p less than .05). Intervention
patients also demonstrated a non-significant reduction in
recurrent traumatic injury as documented by automated
trauma center health service utilization records (adjusted odds
ratio = 0.43, 95% CI = 0.10, 1.96).
Conclusions: A mental health services intervention aimed at
trauma patients with PTSD and/or substance abuse markedly
improved mental health and alcohol abuse outcomes over a 1year period compared to usual care.
Implications for Policy, Delivery, or Practice: The
discussion will highlight how the interdisciplinary team is
using the results of effectiveness trials to impact American
College of Surgeons’ acute care policy mandates for
sustainable mental health services as a requisite for trauma
center accreditation.
Primary Funding Source: National Institute of Mental Health
●Collaborative Care for Primary Care Anxiety Disorders
Peter Roy-Byrne, M.D., Michelle G. Craske, Ph.D., Murray B.
Stein, M.D., Greer Sullivan, M.D., Alexander Bystrisky, M.D.,
Wayne J.Katon, M.D.
Presented By: Peter Roy-Byrne, M.D., Professor and Vice
Chair, Psychiatry & Behavioral Sciences, University of
Washington, 325 Ninth Avenue, Box 359911, Seattle, WA
98104; Tel: (206) 341-4201; Fax: (206) 731-3236; Email:
roybyrne@u.washington.edu
Research Objective: Like depression, anxiety disorders in
primary care are prevalent, disabling, and inadequately
identified and treated. In addition, anxiety may be unique in
being less well recognized, possibly because patients less
often seek help or feel they have a treatable problem, and
posing potentially greater problems with treatment
engagement and adherence. This presentation will describe a
series of studies designed to improve the delivery of evidence
based treatment to primary care patients with anxiety.
Study Design: Two randomized trials of mental health
services interventions (psychiatrist collaborative care model,
therapist cognitive behavioral and medication enhancement
model) were compared to usual primary care for patients with
panic disorder.
Population Studied: The first study randomized 115 patients
with panic disorder from 3 primary care clinics in the Seattle
region. The second study randomized 232 patients with panic
disorder from 3 geographic regions of the US (Seattle, San
Diego, Los Angeles).
Principal Findings: The first demonstrated the clinical and
cost effectiveness of a psychiatrist-based intervention focusing
on delivery of pharmacotherapy to primary care patients with
panic disorder. The second demonstrated the clinical and
cost effectiveness of a care manager-based intervention
focusing on delivery of cognitive behavior therapy and primary
care physician prescribed medication to primary care patients
with panic disorder. The third study, currently underway, aims
to test the clinical and cost effectiveness of an intervention
program targeting the four most prevalent primary care
anxiety disorders (panic, generalized anxiety, social anxiety
and PTSD), accommodating patient preference for either
medication or cognitive behavior therapy, employing
motivational intervention strategies to maximize treatment
engagement, utilizing a stepped-care paradigm to maximize
treatment response over time, and employing personnel with
no prior cognitive behavioral therapy experience who are
systematically trained for the care manager role, to maximize
generalizability and potential ease of dissemination.
Conclusions: The quality of care and outcomes of patients
with panic disorder can be markedly improved with
collaborative care interventions with the potential of cost
savings in overall medical costs.
Implications for Policy, Delivery, or Practice: Improvements
in outcomes of primary care patients with panic disorder can
be accomplished with modest increments or no greater costs.
Primary Funding Source: National Institute of Mental Health
Call for Panels
Hospice and the Challenge of Improving
End-of-Life Care
Chair: Melinda Beeuwkes Buntin, RAND Health
Sunday, June 25 • 10:30 am- 12:00 pm
Panel Overview: The Medicare Hospice benefit and payment
system were implemented in 1983 and have changed very little
since then. This panel will explore the current role of the
hospice benefit in providing high-quality end-of-life care. One
paper will examine how well the current hospice payment
system reflects patient costs and how it might be improved.
This is critical given that the types of patients seen by
hospices, and the technology available to treat them, have
changed dramatically since 1983. Two other papers explore the
characterics of hospices. In particular, one looks at whether
the incentives in the current payment system have led forprofit hospices to selectively enroll patients more likely to be
profitable. The other examines cost reports and the financial
perfomance of hospices directly to determine factors
associated with hospice profitability. Finally, we conclude with
a discussion of quality measurement in end of life care and
the implications of the state of the science for our ability to
monitor hospice performance. The panel will focus the
insights these analyses provide on how some potential
modifications of hospice financing and regulation might affect
providers, Medicare, and patients and families.
●Hospice Ownership Status and the Delivery of Care
Sabina Ohri, Ph.D. Candidate
Presented By: Sabina Ohri, Ph.D. Candidate, Department of
Economics, University of California, Irvine, 3151 Social Science
Plaza, Irvine, CA 92697; Tel: (949) 824-7376; Email:
sohri@uci.edu
Research Objective: To study the effect of ownership status
among hospices on a number of outcomes related to quality,
referral sources and the type of care provided.
Study Design: We estimate negative binomial regressions to
estimate the effect of for-profit status on quality deficiencies.
We also test for differences between for-profit and non-profit
agencies in terms of overall staffing levels and the skill mix of
the staff employed. Finally, we use ordinary least squares
regressions to estimate the effect of for-profit status on
referral sources.
Population Studied: The analysis is based on a facility-level
data set constructed by combining data from the California
Office of Statewide Health Planning and Development,
OSHPD, on all Medicare-certified hospices in California from
2002 through 2004 with data on hospice quality from the
Automated Certification and Licensing Administrative
Information and Management Systems, ACLAIMS, of the
California Department of Health Services. The OSHPD data
provides detailed measures on key facility characteristics, such
as length of stay, staffing ratios, patient demographics, and
other facility information. The ACLAIMS data provide annual
counts of quality citations, based on audits by the California
Department of Health Licensing and Certification Program.
These direct quality measures pertain to several aspects of
care.
Principal Findings: The results suggest that there are
significant differences across ownership types with respect to
various outcomes. After controlling for facility and patient
characteristics, for-profit agencies have more quality
deficiencies. We find sizeable differences in the types of labor
employed. While non-profit and for-profit hospices report
similar numbers of visits per patient, for-profits make much
less use of skilled providers, such as registered nurses. Forprofit and non-profit agencies also have very different referral
networks, with for-profits receiving significantly more patients
from long-term care facilities. Because of these different
referral patterns, patients with dementia make up a larger
share of the case-mix in for-profit hospices than in non-profit
hospices.
Conclusions: Medicare reimburses hospices on a fixed per
diem basis, regardless of patient diagnosis. Because under
this system patients with lower expected costs are more
profitable, hospices have an incentive to selectively enroll low
cost patients. While hospices cannot reject potential patients
explicitly, we find evidence that is consistent with the fact that
they influence their patient mix through their referral networks.
We also find that the fixed per diem rate creates an incentive
for for-profits to shirk on quality and to substitute lower skilled
for higher skilled labor.
Implications for Policy, Delivery, or Practice: These results
suggest that the current Medicare reimbursement rate
encourages for-profit hospices to enroll low cost patients from
specific referral sources. The adoption of case-mix
adjustments to the Medicare reimbursement rate could help
eliminate these differences across ownership status.
Primary Funding Source: No Funding
●Case Mix Adjustment and Hospice Costs
Nancy Nicosia, Ph.D., Melinda Beeuwkes Buntin, Ph.D., Elaine
Reardon, Ph.D., Karl Lorenz, M.D., Joanne Lynn, M.D.
Presented By: Nancy Nicosia, Ph.D., Associate Economist,
RAND, 1776 Main Street, Santa Monica, CA 90407; Tel: (310)
393-0411; Fax: (310) 393-4818; Email: nancy_nicosia@rand.org
Research Objective: To examine potential refinements to the
Medicare hospice payment system with an emphasis on
understanding how patient characteristics impact service
utilization. An important element of the analysis is our use of
a proprietary dataset from a large hospice chain provider,
which allows us to explore more detailed measures of service
utilization.
Study Design: The Medicare payment system for hospice care
has remained largely unchanged since per diem rates were
instituted in 1983. During the past two decades, payment
levels have been updated for inflation based on a market
basket, but otherwise the payment methodology has remained
largely unchanged. Unlike other Medicare payment systems,
hospice payments are not adjusted for case mix, urban/rural
location (apart from the wage index), costly outliers or other
potentially relevant factors. There is increasing concern that
the payment methodology no longer accurately reflects costs
because of changes in provider, patient, and service
characteristics. This concern is compounded by the rapid
expansion in the number of hospice providers, hospice use,
and associated Medicare expenditures. These recent changes
have raised interest in potential case mix adjustments to
hospice payments. Given the current per diem payment
structure and the change in the hospice population over time,
we focus on three questions: How well does the current per
diem system reflect hospice costs? Should case mix adjusters
such as diagnoses be considered? Are the beginnings and
ends of hospice stays more intensive? The proprietary dataset
from a large chain provider comprises a rich set of variables
that are useful in characterizing service utilization and
examining the relationship between utilization and patient
characteristics. The data allow us to examine the number of
days of care, the number of visits, the timing of visits, and the
labor costs associated with visits. Using multivariate
regression analyses, we first examine how well the current per
diem system explains service utilization. We then explore
additional regressors available in the proprietary dataset to
determine whether patient characteristics improve the
predictive power of the model. Characteristics include
diagnosis, nursing home residence, marital status, gender,
race/ethnicity, and discharge status. Finally, we examine
whether the intensity of care varies over a patient's stay. A
critical issue is whether variation in the intensity of care
(within a stay) creates incentives under the per diem system
for providers to seek patients with longer lengths of stay.
Population Studied: Analyses are conducted using a sample
of Medicare beneficiaries admitted to the chain provider's
facilities in 2002 and 2003. The sample is compared to the
universe of Medicare hospice beneficiaries to examine
generalizability
Principal Findings: The findings are embargoed until the
June MedPAC report is issued.
Conclusions: The conclusions are embargoed until the June
MedPAC report is issued.
Implications for Policy, Delivery, or Practice: The findings
will inform policymakers on potential adjustments to
Medicare hospice payment policies. They will also speak to
the benefits of increased hospice data collection.
Primary Funding Source: The Medicare Payment Advisory
Commission
●A Systematic Review to Identify Measures of the Quality
of Symptom and End-of-Life Cancer Care
Anne M Wilkinson, Ph.D., Karl Lorenz, M.D., M.S.H.S., Joanne
Lynn, M.D., Sydney Dy, M.D., Richard A Mularski, M.D.; Lisa
R. Shugarman, Ph.D., Ronda G. Hughes, Ph.D., Cony Rolon,
Afshin Rastegar, M.D., Paul G. Shekelle, M.D., Ph.D.
Presented By: Anne M Wilkinson, Ph.D., Behavioral/Social
Scientist, RAND, 1200 South Hayes Street, Arlington, VA
22202; Tel: (703)413-1100; Fax: (703)413-8111; Email:
Anne_Wilkinson@rand.org
Research Objective: To systematically identify quality
measures and the evidence for them to support quality
assessment and improvement in the palliative care of patients
with cancer in the areas of pain, dyspnea, depression, and
advance care planning (ACP), and to identify important gaps
in related research.
Study Design: A systematic review of the literature (Medline,
CINAHL, PsychInfo) in English 1995-2005 using terms for
each domain for patients living with a cancer diagnosis
throughout the continuum of care. (e.g., diagnosis to death)
Pain and depression searches were limited to cancer, but we
searched broadly for dyspnea and ACP - because the evidence
base for dyspnea is more limited and experts advised that ACP
measures would be generalizable to cancer.
Population Studied: We undertook an extensive Internet and
grey literature search and contacted authors. Measures were
included if they expressed a normative relationship to quality
and included a measurable numerator and denominator.
Citations and articles were dual reviewed / abstracted by six
palliative care researcher / clinicians who described
populations, testing, and attributes for each measure.
Principal Findings: The literature search identified 5,182 titles,
and excluded 4,599 at abstract review. Of 532 articles, citations
with measures included 19 for advance care planning, 6 on
depression, 5 on dyspnea, and 20 on pain. We identeified 10
relevant measure sets (ACOVE, QA Tools, Cancer Care
Ontario, Cancer Care Nova Scotia, Dana-Farber, Georgia
Cancer Coalition, University Health Consortium, NHPCO,
VHA, ASCO) We identified a total of 40 operationalized and
19 non-operationalized measures. The most measures were
available for pain (15) and ACP (35), compared with only 5
available for dyspnea and 4 for depression. Few of the
measures were published and few had been specifically tested
in a cancer population.
Conclusions: A large number of measures are available for
addressing palliative cancer care, including many that are
appropriate for hospice, but testing them in relevant
populations is urgently needed. Basic research is urgently
needed to address measurement in populations with impaired
self-report.
Implications for Policy, Delivery, or Practice: Hospices are
not currently required to report quality measures. Few
measures are suitable for accountability, but funding field
testing of highest quality measures should be an urgent
patient and family-centered priority to meet the needs of
patients.
Primary Funding Source: AHRQ
●A Systematic Review of Quality Measures for Evaluating
Palliative Cancer Care
Karl Lorenz, M.D. M.S.H.S., Sean O'Neill, BS, Susan Ettner,
Ph.D.
Presented By: Karl Lorenz, M.D. M.S.H.S., VA Greater Los
Angeles Healthcare System; Email: Karl.Lorenz@va.gov
Research Objective: To evaluate factors affecting the
profitability of hospice in the context of a study of for-profit
(FP) / not-for-profit (NFP) care.
Study Design: We evaluated data from the California Office of
Statewide Health Planning and Development 2003 Annual
hospice survey, including cost reports. We evaluated as
outcomes revenues, costs, and profits, as well as the intensity
and skill mix of care, and the provision of charitable and
special palliative services. To evaluate the influence of length
of stay (LOS), we evaluated all outcomes on a per patient and
per patient day basis. We estimated regression-adjusted
differences in these outcomes by profit status, controlling for
other organizational features and aggregate patient
characteristics.
Population Studied: 185 operational hospices
Principal Findings: Hospices reported median revenue of
$6865 / patient and $138 / patient-day (FP vs. NFP difference
= -$20, p=0.045), median cost of $6737 / patient, and $135 /
patient-day (difference = -$55, p=0.002), and median pre-tax
profit of $334 / patient and $6 / patient-day (difference = $34 ,
p=0.026). Patients received a median of 29.9 visits / patient
(difference = 8.8 visits, p=0.010), but there was no difference /
patient-day. A median of 50.8% of all nursing visits were
skilled (difference = -14.1%, p NFP (p=0.002). The proportion
of non-cancer patients was associated with long term care
referral, but in multivariate analysis, only the proportion of
non-cancer diagnoses was independently associated with
LOS (25th-75th percentile difference of 7.11 days, p=0.004).
Few hospices provided charity care, and only 4% of hospices
reported expenditures on chemotherapy and only 9% on
radiation therapy.
Conclusions: Overall hospice profitability is low, but FPs are
more profitable than NFPs. Few hospices provide charitable
care or special costly services. LOS is strongly associated with
financial performance, and greater FP profitability is related to
lower costs. FP hospices also provide less skilled care.
Implications for Policy, Delivery, or Practice: Our findings
raise the issue of how to improve access to hospice care for
non-cancer patients while containing Medicare's hospice
budget due to the longer LOS (and known higher overall costs
to Medicare) of these patients. The impact of FP-NFP
differences will require quality measures to understand the
impact of these differences on patients, their caregivers, and
the healthcare system.
Primary Funding Source: No Funding
Call for Panels
Assessing the Value of Performance
Measurement from Different Perspectives
Chair: Irma Mebane-Sims, Joint Commission on
Accreditation of Healthcare Organizations
Sunday, June 25 • 3:45 pm – 5:15 pm
Panel Overview: Nationally standardized performance
measurement has become an integral component in the drive
toward health care quality improvement. Hospital
performance measures, developed by the Joint Commission
on Accreditation for Healthcare Organizations and the Centers
for Medicare and Medicaid Services, have been adopted by the
Hospital Quality Alliance, become key components of the
accreditation process and are now used in a wide variety of
public and private programs that link financial incentives to
the quality of patient care. It is important to evaluate both the
utility and impact of these measures in a variety of contexts.
Among the questions that should be addressed: How are
these measures perceived by the hospitals that implement
them? To what extent is the perception of the value of these
measures linked to improvement actions undertaken? How do
standardized performance measures compare with other
indicators of hospital quality and patient mortality? And to
what extent will quality incentive payments and public
recognition relate to improvements in the quality of patient
care? This panel will provide a variety of quantitative and
qualitative perspectives to address these questions, as well as
their implications for health care policy.
●Influence of Perceptions About Performance
Measurement on Actions Taken to Improve the Quality of
Patient Care
Irma Mebane-Sims, Ph.D., Scott C Williams, PsyD, Stephen P
Schmaltz, Ph.D., Richard G Koss, MA, Jerod M Loeb, Ph.D.
Presented By: Irma Mebane-Sims, Ph.D., Associate Project
Director, Division of Research, Joint Commission on
Accreditation of Healthcare Organizations, 1 Renaissance
Blvd, Oakbrook Terrace, IL 60181; Tel: 630.792.5981; Fax:
630.792.4981; Email: imebanesims@jcaho.org
Research Objective: The Joint Commission requires
accredited hospitals to collect core performance measurement
data in any 3 of 5 areas: Acute myocardial infarction, AMI;
heart failure; pneumonia; pregnancy and related conditions;
and surgical infection prevention. A subset of these measures
have been adopted by the Hospital Quality Alliance. The goal
of this project was to assess how perceptions about the
measures influence actions taken to improve quality.
Study Design: Nearly 2000 hospitals accredited by Joint
Commission were invited in 2005 to participate in a survey on
the usefulness of performance measurement for quality
improvement purposes. They were also asked about actions
taken at their hospital in response to performance
measurement data. In-person interviews were conducted with
a subset of responders in 2006.
Population Studied: Approximately 600 completed surveys
were received. No significant differences were observed in
survey responder/nonresponder hospitals in terms of
urban/rural, bedsize and teaching/nonteaching. Not-forprofits were more likely to respond than for-profit and
government-owned facilities. Some regional differences were
seen -- a higher response rate in Mid-Atlantic states and a
lower one in East-SouthCentral states. Quality Assurance
Officers were interviewed in-depth at 40 hospitals.
Principal Findings: Preliminary results indicate that the AMI,
heart failure, pneumonia and surgical infection prevention
measure sets were viewed as being useful for generating good
questions about the quality of care--High/VeryHigh: 62.3%,
77.2%, 77.1%, and 75.1%, respectively; for identifying
opportunities for improving hospital processes/outcomes-High/VeryHigh: 64.9%, 80.6%, 79.5%, 75.1%, respectively;
and for identifying areas with the greatest potential for positive
improvement--High/VeryHigh 59.5%, 73.3%, 73.4%, 71.1%,
respectively. The pregnancy measures were perceived as being
less useful for generating good questions about the quality of
care, identifying opportunities for improvement, and
identifying areas with the greatest potential for improvement-VeryLow/Low: 60.6%, 60.6%, 64.1%, respectivly. Correlations
between how well hospitals performed on the measures and
perceived value were not significant. The most common
improvement actions taken by hospitals in response to AMI,
heart failure and pneumonia measure data were: staff
education--implemented by 88%-97% of responders;
development/enforcement of clinical pathways/practice
guidelines--75%-87%; development/modification of existing
hospital processes--77%-91%; development/revision of
documentation systems--73%-95%; development of preprinted
order sets--75%-88%; and communication/dissemination of
core performance measures results--94%-97%. Fewer of these
improvement actions were undertaken in response to surgical
infection prevention--44%, 24%, 40%, 32%, 23%, 44%,
respectively, and pregnancy measures--13%, 5%, 6%, 5%, 4%,
22%, respectively.
Conclusions: Preliminary analysis suggests a relationship
between the perceived value of measure sets and the
implementation of a variety of quality improvement actions.
Further analysis of the impact of the improvement actions on
measure rates is indicated.
Implications for Policy, Delivery, or Practice: A better
understanding of the impact of perception on behavior may
lead to the development of ways to improve scores for
performance measures and, ultimately, the quality of patient
care.
Primary Funding Source: AHRQ
●Choosing Low Mortality Hospitals: How Does the
Hospital Quality Alliance Program Compare to Other
Quality Metrics?
Ashish Jha, M.D., M.P.H., E John Orav, Ph.D., Zhonghe Li,
MA, Arnold Epstein, M.D., MA
Presented By: Ashish Jha, M.D., M.P.H., Assistant Professor
of Health Policy, Health Policy and Management, Harvard
School of Public Health, 677 Huntington Avenue, Boston, MA
02115; Tel: 617.432.5551; Fax: 617.432.4494; Email:
ajha@hsph.harvard.edu
Research Objective: The Hospital Quality Alliance, HQA,
program is the first national program to report publicly on the
quality of hospital care. We sought to determine how the
HQA program compares with other publicly available hospital
rating programs and how effectively it identifies low mortality
hospitals.
Study Design: We calculated the HQA summary score for
process-based quality indicators for acute myocardial
infarction, AMI; congestive heart failure, CHF; and pneumonia
for each hospital and examined its relationship with three
other metrics of hospital quality: reporting to Leapfrog; being
named a top hospital by the U.S. News and World Report
ranking program; and being a teaching hospital. We also
examined the relationship between performance and the four
quality markers; HQA, Leapfrog reports, U.S. News and World
Report rank, and hospital teaching status, and risk-adjusted
mortality.
Population Studied: Quality metrics were calculated for all
acute-care hospitals for whom the data were available. Riskadjusted mortality rates were calculated among fee for service
Medicare enrollees greater than or equal to 65 years. Mortality
analyses were carried out for each clinical condition; AMI,
CHF and pneumonia.
Principal Findings: There were 3,720 hospitals that reported
sufficient data to the HQA program to allow generation of at
least one HQA summary score. Significantly higher HQAbased performance on AMI and CHF, but not pneumonia,
was found among hospitals that reported data to the Leapfrog
Group, hospitals that were highly ranked by U.S. News and
World Report, and teaching hospitals. Patients treated at
hospitals that were in the top quartile of performance on the
HQA indicators had 11% lower odds of dying from AMI, 95%
confidence interval, CI, 0.85 to 0.94, p<0.001; 7% lower odds
of dying from CHF, 95% CI 0.88 to 0.98, p=0.006; and 15%
lower odds of dying from pneumonia, 95% CI 0.81 to 0.89,
p<0.001 than patients treated at hospitals in the bottom
quartile of performance. Similarly, patients treated at
hospitals that reported to Leapfrog had 5% to 12% lower odds
of dying depending on the condition, p<0.05 for each, than
those that did not, while patients in the U.S. News hospitals
had 18% o 25% lower odds of dying, p<0.001 for each, than
those in hospitals not ranked by U.S. News. Teaching hospital
status was not associated with lower mortality rates for any of
the three conditions.
Conclusions: Patients choosing hospitals based on the
ratings in the Leapfrog program, U.S. News rakings, or on
teaching status will identify hospitals with better process
quality. Patients that are treated at hospitals that perform well
on the HQA program, U.S. News rankings or report data to
the Leapfrog Group have lower odds of dying.
Implications for Policy, Delivery, or Practice: Publicly
available programs that rate hospital quality can aid patients,
payers, and policymakers identify hospitals with better
outcomes.
Primary Funding Source: CWF
●Financial Incentives Work! Results from the CMS
Hospital Quality Incentive Demonstration Project, Year 1
Denise Remus, Ph.D.
Presented By: Denise Remus, Ph.D., Vice President, Clinical
Informatics, Clinical Informatics, Premier, Inc, 404 West
Greenbriar LA, Dallas, TX 75208; Tel: 214.212.7774; Fax:
704.733.5634; Email: Denise_Remus@Premierinc.com
Research Objective: The CMS/Premier Hospital Quality
Incentive Demonstration, HQID, project was set up to
examine the following question: Can economic incentives
effectively improve quality of care?
Study Design: The study design is observational using both
prospective and retrospective components; participants were
self-selected and all had to be enrolled in the Premier
PerspectiveTM database.
Population Studied: All adult patient (age > 18) admissions
to participating hospitals with any of four clinical conditions:
acute myocardial infarction (AMI), heart failure, pneumonia
and coronary artery bypass graft, CABG, procedures; and all
Medicare patients, primary or secondary payer = Medicare,
admitted for hip or knee replacement procedures.
Principal Findings: The HQID uses data from individual
quality measures, within each clinical area, to create an
aggregate score or the Composite Quality Score, CQS,
representing overall quality. The project incorporates both
process; e.g., ASA on admission, oxygen assessment, and
outcome measures; e.g., mortality, readmissions; 33 total for
Year 1, across the five areas. Analyses of final validated data
from Year 1 identified statistically significant improvements; all
p < 0.001 from the first quarter of the project, Q4-03 to the
fourth quarter of the project, Q3-04 in the CQS in all five
clinical areas. Hospitals were placed in deciles based on CQS
and the top 10% of hospitals, in each clinical area, received a
2% quality incentive payment from Medicare; the next 10%
received a 1% bonus; $8.85 million was awarded to 123 top
performers in year 1. The top 50% received public recognition.
HQID participant data was compared to data of nonparticipating hospitals from Hospital Compare for the time
period of Q2-04 to Q1-05 for the 17 process measures similar
across the two projects. Preliminary analyses found that the
average measure rate, percent of patients receiving
intervention, was significantly higher, p < 0.001 for HQID
participants compared to non-participants in 10 measures;
significantly higher p < 0.05 in 2 measures; higher, but not
significant, rates in 3 measures; lower, but not significant,
rates in 2 measures; and significantly higher, p < 0.001 overall
composite process score; 82.2% vs 73.2%. HQID n=259,
Hospital Compare n=3303, limited to measure denominators
> 24 cases. Preliminary data from Year 2 demonstrates
continued improvement. Additional results will be presented
including analysis of CQS by hospital characteristics and
further evaluation of Year 2 data
Conclusions: The HQID project, incorporating both quality
incentive payments and public recognition, resulted in
statistically significant improvements in the first year of the
project and, for the majority of comparative measures,
average rates significantly higher than a national sample of
publicly reported data.
Implications for Policy, Delivery, or Practice: The
demonstration project has two more years of data to report,
however initial findings based on performance in Year 1
indicate that financial incentives, along with public
recognition, resulted in statistically significant improvement in
quality as measured by CQS in five clinical areas. While
additional research is necessary to examine other factors
associated with the overall improvement, the preliminary data
supports efforts to link financial payments to quality.
Primary Funding Source: CMS, Premier, Inc
Call for Panels
How You Count is What You Get: Measuring
Hospital Adverse Events Using Incident Reports,
Patient Surveys, and Chart Reviews
Chair: Joel Weissman, Institute for Health Policy,
Massachusetts General Hospital
Sunday, June 25 • 3:45 pm – 5:15 pm
Panel Overview: This panel will include reports of research
based on work from a collaborative federal grant to improve
reporting and disclosing of medical errors in Massachusetts
hospitals. Two papers will address the use of patient reports
of adverse events. Based on a survey of about 2500 recently
hospitalized patients from 16 hospitals, one paper will
describe the frequency and type of adverse events as reported
by discharged patients, and discuss the challenges in
collecting medical data from patients. A second paper will
compare the results from the survey with the results from a
medical chart review. The chart review used methods similar
to that of the original Harvard Practice Study on medical
errors and malpractice. This is the first study to our
knowledge to examine the concordance of patient-reported
events with those found via traditional chart review. A third
paper in the panel will examine data from the Massachusetts
public reporting system, and assess its comparability with the
reporting of “never-events” from the NQF.
●What do Patients Know that Hospitals Might Not? A
Comparison of Adverse Events using Patient Reports and
Chart Reviews
Joel Weissman, Ph.D., Eric Schneider, M.D., MSc, Arnold
Epstein, M.D., MA, Floyd Fowler, Ph.D., Catherine Annas, JD,
Leslie Kirle, M.P.H.
Presented By: Joel Weissman, Ph.D., Associate Professor,
Institute for Health Policy, MGH/Harvard, 50 Staniford Street,
9th floor, Boston, MA 02114; Tel: (617)724-4731; Email:
jweissman@partners.org
Research Objective: To compare the frequency and
concordance of patient reports of hospital adverse events
(AEs) with adverse events discovered by medical record
reviews.
Study Design: A probability sample of recently hospitalized
patients in 16 Massachusetts hospitals were interviewed by
telephone to ask them to report on complications and
“negative effects” from treatment that occurred during their
hospital stay. A physician and nurse confirmed whether the
events were injuries that could reasonably be attributed to
medical care management, and then classified them into one
of 19 categories of AEs. Trained nurses reviewed the same
patients’ hospital medical records and likewise grouped AEs
into the same 19 categories.
Population Studied: We interviewed 2582 patients, 18 or
older, hospitalized for medical/surgical care in Massachusetts
between April 1, 2003 and October 1, 2003, who were
discharged alive. Of these respondents, 998 verbally agreed
to a review of their hospital medical records and mailed in a
signed authorization, and hospital staff were able to locate the
record.
Principal Findings: Of the 998 study patients, 221 patients
reported a total of 272 AEs, compared with 124 patients with
156 AEs found via chart review, resulting in 78% agreement.
Although there is no single best source of medical error data,
using hospital medical records as a “gold standard” yielded
the following results for the use of patient report as a measure
of the occurrence of an adverse event: Sensitivity = 61 / 124 =
49.2%; Specificity= 714 / 874 = 81.7%; Positive Predictive
Value = 61 / 221 = 27.6%; ; Negative Predictive Value = 714 /
777 = 91.9%. The relative frequency of AE types was similar.
Approximately 54% of patient-reported events were adverse
drug events, compared with 50% from chart review. Likewise,
8% of patient-reported events were post-operative wound
infections, compared with 11% from charts. After preliminary
review, nurses searched the record for events reported by
patients. Approximately 1/3 of all patient-reported events were
identified post-hoc, but these events did not satisfy the clinical
criteria established for nurses to record an event. No evidence
was found in the chart for about ½ of patient-reported events.
Conclusions: Agreement between patient reports and chartbased adverse events is moderate, although some of the
disagreement is due to strict clinical criteria used in chart
review. Patients identified many more events than were found
by nurses conducting medical record review. If a patient
reported no problems there was unlikely to be an injury
documented in the charts.
Implications for Policy, Delivery, or Practice: Until now,
patients have been an under-utilized source of information on
the occurrence of adverse events in hospitals. As with other
survey tools that rely on patients to report on their medical
experiences, in the future hospitals might consider postdischarge patient surveys as a tool for identifying adverse
events that are not routinely available from medical records.
Such an approach may prove to be a cost-effective method for
screening cases for further investigation for quality problems.
Primary Funding Source: AHRQ
●Patient Reports of Adverse Events While Hospitalized in
Massachusetts
Dragana Bolcic-Jankovic, MA, Floyd Fowler, Ph.D., Brian R.
Clarridge, Ph.D., Eric C. Schneider, M.D., M.Sc., Catherine
Annas, J.D., Joel S. Weissman, Ph.D.
Presented By: Dragana Bolcic-Jankovic, MA, Assistant Study
Director, Center for Survey Research, UMass-Boston, 100
Morrissey Boulevard, Boston, MA 02125; Tel: (617) 287-7200;
Fax: (617) 287-7210; Email: dragana.bjankovic@umb.edu
Research Objective: To describe the types of adverse events
that patients report during recent hospitalizations and to
examine the correlates of those events.
Study Design: A probability sample of hospitalized patients in
Massachusetts was interviewed by telephone. They were
asked about adverse experiences that occurred during a recent
hospital stay. Their reports were then reviewed by specially
trained physicians to confirm that they were events that could
reasonably be attributed to procedures, tests and care received
in the hospital.
Population Studied: 2582 adults, 18 or older, hospitalized for
medical or surgical care (excluding maternity care) in a
Massachusetts hospital between April 1, 2003 and October 1,
2003 who were discharged alive to a private residence in
Massachusetts
Principal Findings: Of the 2582 patients who were
interviewed (~57% response rate), about 25 percent reported
an adverse event that physician reviewers confirmed could
reasonably be attributed to tests, treatments, procedures or
hospital care. The most common type of report was an
adverse reaction to drugs; injuries to nerves, blood vessels or
organs were a distant second. Those who were given
medications, had surgery, or spent time in ICUs were
significantly more likely than average to report an adverse
event. Gender and age were related to the likelihood of an
adverse event (women and younger patients had more), but
race and self-rated health status were not. About a third of the
events reported were still said to be having an effect on
patients’ lives at the time of the interview. Patients believed
about half of the events were potentially preventable; the
physician raters estimated more than a third were preventable.
Conclusions: A significant number of patients say they
experience adverse events as a result of the care they receive
in hospitals, with reactions to new drugs being by far the most
common. Many of these adverse events have long-lasting
effects on patients. While the majority of these events, in the
opinion of the patients, could not reasonably have been
prevented, nearly as many think they could be prevented. In
the majority of those instances, physician reviewers agree.
Implications for Policy, Delivery, or Practice: Patients are
rarely utilized as reporters of adverse events during hospital
stays. Their voices should be heard in the effort to identify and
reduce negative outcomes and medical errors.
Primary Funding Source: AHRQ
●Public Reporting on Patient Safety by Acute Care
Hospitals: Assessing the New National Quality Forum
(NQF) ‘Never Event’ Standard
Eric Schneider, M.D., MSc, Joel S. Weissman, Ph.D., Catherine
Annas, J.D., Nancy Ridley, M.S., Arnold Epstein, M.D., M.A., ,
Presented By: Eric Schneider, M.D., MSc, Assistant Professor,
Health Policy and Management, Harvard School of Public
Health, 677 Huntington Avenue, #406, Boston, MA 02115; Tel:
617-432-3124; Fax: 617-432-4494; Email:
eschneid@hsph.harvard.edu
Research Objective: The Institute of Medicine has
recommended that states establish reporting systems for
serious incidents that occur in acute care hospitals, but states
differ on the types of incidents considered reportable. To
standardize reporting, the National Quality Forum (NQF)
defined 27 never events: specific types of safety incidents that
are preventable and serious enough that hospitals should
report them to a state agency for disclosure to the public.
Since 1986, the Massachusetts Department of Public Health
DPH has required hospital reporting of serious incidents. Our
objective was to evaluate the proportion of serious incidents
reported by Massachusetts hospitals that fulfill the NQF never
event criteria.
Study Design: In this observational study, key data elements
from the DPH database were abstracted from a sample of
serious incident reports submitted by hospitals. Trained
reviewers attempted to match each abstracted incident to an
NQF-defined category. With these data, we assessed the
prevalence of NQF never events among all serious incident
reports and compared the characteristics of the NQF and nonNQF incidents, including the severity of injury, contributing
factors, agency disposition, and corrective actions.
Population Studied: A stratified, random sample of 762
serious incident reports submitted by 72 acute care hospitals
in Massachusetts during 1999-2004.
Principal Findings: Most of the serious incidents reported to
the state involved serious injury with 20% judged fatal or life
threatening, 58% judged serious, and 21% judged significant.
The most common types of incidents were patient protection
events (52%), surgical and procedure-related events (12%),
care management events (7%), hospital environment events
(4%), and product or device events (1%). Twenty-three
percent of events were serious but did not fit one of these
categories. Approximately one third of the incidents reported
to DPH matched at least one NQF-defined never event. The
matching within event categories was highly variable. The
most common matches were for surgical and procedurerelated events, care management events, and product or
device events. In contrast, patient protection events reported
to DPH matched the NQF-defined never events much less
frequently.
Conclusions: The NQF “never events” define a relatively
narrow set of patient safety incidents that occur in hospitals
and have been reported in Massachusetts.
Implications for Policy, Delivery, or Practice: Adopting the
National Quality Forum standard for patient safety reporting
might enhance comparability across state reporting systems,
but would exclude serious incidents currently of interest to at
least some states. Potentially, the NQF list could be expanded
to include some of the types of serious incidents that have
been reported in Massachusetts.
Primary Funding Source: AHRQ,
Call for Panels
Prescription Benefits, Use, Spending, and
Outcomes in the Elderly: Implications for
Medicare Part D
Chair: Jalpa Doshi, University of Pennsylvania
Sunday, June 25 • 5:45 pm – 7:15 pm
Panel Overview: With the implementation of Medicare Part D
on January 1, 2006, researchers and policymakers are
concerned about how the new program will affect different
groups of Medicare beneficiaries. This panel presents a series
of empirical papers which evaluate various aspects of the drug
benefit and have direct implications for what may be observed
under Part D. The first paper evaluates whether providing drug
coverage itself will be sufficient to improve medication therapy
patterns in Medicare beneficiaries with diabetes. The next
paper evaluates price and substitution effects of multi-tiered
copayment formularies, which have been widely used by Part
D prescription drug plans. The third and fourth papers
evaluate the impact of Part D and gaps in drug coverage,
respectively, on prescription utilization and spending in
Medicare beneficiaries with mental illness, a medically
vulnerable group that most policy makers have been
concerned about. The last paper complements the other
panel papers on drug use and spending by evaluating how
cost-sharing increases, which some beneficiaries will face
under Part D, impact health outcomes using the example of
blood pressure control in elderly veterans.
●Disease Burden and the Intensity of Medication Therapy
for Medicare Beneficiaries with Diabetes: Will Part D Make
a Difference?
Bruce Stuart, Ph.D., Thomas Shaffer, MHS, Linda SimoniWastila, RPH, Ph.D., Ilene Zuckerman, PharmD, Ph.D.
Presented By: Bruce Stuart, Ph.D., Professor, Peter Lamy
Center, University of Maryland Baltimore, 515 West Lombard
Street, Room 157, Baltimore, MD 21201; Tel: (410) 706-5389;
Fax: (410) 706-1488; Email: bstuart@rx.umaryland.edu
Research Objective: Guidelines for treating diabetes
emphasize the need to maintain glycemic control and to take
preventive measure to avoid hypertension, hyperlipidemia,
and common infections like influenza and pneumonia.
Medicare already covers flu shots and pneumonia
vaccinations, but coverage for blood glucose regulators,
antihypertensive agents, and lipid lowering agents has not
been universally available until this year under the MMA. This
paper is intended to assess the potential impact of Part D
coverage on Medicare beneficiaries with diabetes taking into
account the difficulties of managing diabetes for beneficiaries
with significant disease burden.
Study Design: This study categorized a national sample of
Medicare beneficiaries with diabetes into 10 mutuallyexclusive, equal-sized groups based on their cumulative
medical spending in 2001 (a proxy for disease burden). We
then computed the prevalence and annual utilization rates
within each group for 6 drug categories recommended for
treatment of diabetes (blood glucose regulators,
dyslipidemics, ACE-inhibitors, other antihypertensive agents,
annual flu shot, and pneumonia vaccination in the past 5
years). Group-specific robust regression models were
estimated for each drug class. Explanatory variables included
domains for demographic characteristics, income, drug
coverage, health status, and medical encounters. Chow tests
for significant differences in coefficient values across the 10
groups were conducted to identify the differential impact of
disease burden on factors predictive of the prevalence and
intensity of drug use.
Population Studied: 1,746 elderly and disabled Medicare
beneficiaries with 2 or more paid claims indicating diabetes
(ICD-9=250.xx, 357.2, 362.00-362.02, 366.41) in 2001 drawn
from community-dwelling respondents in the 2001 Medicare
Current Beneficiary Survey weighted to be nationally
representative.
Principal Findings: Annual population prevalence rates for
the 6 drug categories ranged from a low of 42% for
dyslipidemics to a high of 86% for antihypertensive agents.
The lowest prevalence rates were found in the groups with the
least disease burden. For 4 of the 6 drugs (blood glucose
regulators, dyslipidemics, flu shots and pneumonia
vaccinations) prevalence rates increased with disease burden
but then sharply declined in the top two groups. A similar
inverted “U” shape pattern was observed in the annual
utilization rates for the 4 chronic care drug categories.
Preliminary analysis indicates that these patterns are not
significantly reduced by adjustments for demographics,
income, drug coverage, and health status, but are highly
sensitive to medical encounters, particularly the number of
different physicians seen in the year.
Conclusions: Medicare beneficiaries with diabetes receive
suboptimal treatment for recommended drug therapies
particularly among those with minimal or significant disease
burdens (the highest prevalence rates and intensity of
treatment were found in the middle of the range of disease
burden).
Implications for Policy, Delivery, or Practice: Our analysis
indicates that expanded prescription coverage under the
Medicare Part D drug benefit is unlikely to significantly
improve medication therapy patterns for Medicare
beneficiaries with diabetes. However, changes in disease
management programs that may be associated with the new
benefit may prove beneficial.
Primary Funding Source: CWF
●Decomposing the Price and Substitution Effects Under
Multi-Tiered Drug Copayment Programs
Boyd Gilman, Ph.D., John Kautter, Ph.D.
Presented By: Boyd Gilman, Ph.D., Senior Economist,
Division for Health Services and Social Policy Research, RTI
International, 411 Waverley Oaks Road Suite 330, Waltham,
MA 02452; Tel: (781) 434-1718; Fax: (781) 434-1700; Email:
bgilman@rti.org
Research Objective: Tiered copayments are one of the most
commonly used cost containment tools and are being widely
used by private plans under the new Medicare Part D benefit.
Copayments are designed to achieve two goals. First, by
increasing the cost of all drugs paid by the enrollee, tiered
copayments are design to promote a more efficient use of
prescription medications and control plan spending. Second,
by increasing the cost differential between brand named drugs
and generics (or between preferred and non-preferred brand
named drugs), tiered copayments are designed to encourage
the substitution of cheaper drugs for more expensive
equivalents. The purpose of this study is to decompose the
overall impact of tiered copayments on drug utilization and
spending into its price and substitution effects.
Study Design: The study uses data from the 2002
MarketScan Medicare Supplemental and Benefit Plan Design
Databases. Pharmacy claims for 400,000 retirees were
merged with drug benefit design information for 24 employersponsored health plans. Plans were classified into 1-, 2- and 3tiered copayment groups. The price effect was estimated
using the lowest plan copayment amount. The substitution
effect was estimated using the mean copayment differential
between tiers. Model covariates included demographic,
health status, and medical plan characteristics. The models
were estimated over all enrollees and enrollees with chronic
conditions separately.
Population Studied: Medicare beneficiaries with employersponsored drug coverage and their dependents.
Principal Findings: A $5 increase in the lowest copayment
amount resulted in an 8.8% decline in the number of
prescriptions filled, a $1.2 decrease in total payments, a $154
increase in enrollee payments, and a 10.9% reduction in the
number of prescriptions filled with generics. A $5 increase in
the differential between the lowest and highest copayment
amounts resulted in a 6.1% decline in the number of
prescriptions filled, a $5.4 increase in total payments, an $18.5
increase in enrollee payments, and a 3.3% increase in the
number of prescriptions filled with generics. All results were
statistically significant at the 5% level or higher, except for the
increase in total payment price effect.
Conclusions: Both the price and substitution incentives
under tiered copayments result in a lower number of
prescriptions filled and higher out-of-pocket expenditures.
However, by achieving these results through the substitution
of cheaper generics or preferred brand named drugs for more
expensive drug equivalents, the copayment differential
incentive has a less deleterious effect on drug use than the
copayment price incentive.
Implications for Policy, Delivery, or Practice: Medicare
retirees are sensitive to enrollee copayments in terms of both
the quantity and type of medications used. By relying more on
the cost differential between generic and brand named drug
equivalents (rather than the price amount of all drug
equivalents) to control risk, prescription drug plans can help
reduce the potentially deleterious effect of cost containment
on access to necessary medications.
Primary Funding Source: No Funding
●Economic Implications of Medicare Part D for Persons
with Mental Illness
Dennis Shea, Ph.D., Linda Simoni-Wastila, Ph.D., Karen
Volmar, M.P.H./J.D., Matthew Guldin, M.P.H.
Presented By: Dennis Shea, Ph.D., Department Head and
Professor, Health Policy and Administration, Penn State, 116
Henderson Building, University Park, PA 16802; Tel: 814-8632901; Fax: 814-863-2905; Email: dgshea@psu.edu
Research Objective: This project examines the impact of
Medicare Part D on drug coverage, utilization and spending
among Medicare beneficiaries with mental illnesses.
Study Design: The study includes a detailed literature review
of the mental health economic issues in prescription drug
coverage and use and an economic microsimulation of
effects. Information from the literature review is applied to the
microsimulation model to estimate the impact of subsidized
drug coverage on enrollment by beneficiaries and the impact
of coverage changes coverage on total spending and out-ofpocket costs in total and among important subgroups.
Population Studied: The sample is drawn from individuals in
the 2000 Medicare Current Beneficiary Survey who self-report
or have a claim for a mental illness. Data for these individuals
is projected to a 2006 baseline and the effects of Medicare
Part D are simulated.
Principal Findings: Medicare beneficiaries with mental
illness, in some ways, had better drug coverage than the
typical Medicare beneficiaries prior to Medicare Part D, due
primarily to Medicaid. More than 60% had full-year coverage,
and fewer than 1 in 5 had no drug coverage. Despite having
higher total spending, they had lower out-of-pocket spending.
Medicaid dual eligibles are generally protected from high costs
through the low-income subsidies, although formularies may
be a concern. Approximately one-fifth of Medicare
beneficiaries with a mental illness face far larger challenges.
These individuals are primarily work disabled with coverage
through a family member or retired with employer coverage.
Nearly half of this group has spending above the doughnut
hole and could face increases in out-of-pocket costs of 10 to
20 percent if employers adopt standard plans. About 10
percent of Medicare beneficiaries with a mental illness had
prior coverage with an HMO, Medigap plan, or state
pharmaceutical assistance plan. The impact of Medicare Part
D for this group, as well as for those without any prior
coverage, hinges on their income. Those with modest
incomes maintain or improve their current protection from
high drug costs, but those with incomes above 150 percent of
the poverty line will struggle with premium and cost-sharing.
Conclusions: The impact of Medicare Part D on mentally ill
Medicare beneficiaries depends primarily on prior coverage
and income levels. The majority of such beneficiaries will find
coverage maintained or improved; however, significant
pockets among those with private sources of coverage or no
prior coverage will not find their circumstances improved
substantially. A minority, representing as much as 10 to 20
percent of Medicare beneficiaries with a mental illness, will
find their coverage eroded.
Implications for Policy, Delivery, or Practice: As policymakers and others implement Medicare Part D, careful
attention should be paid to Medicare beneficiaries with a
mental illness. In the initial phases, individuals with prior
private coverage or no prior coverage may provide the greatest
implementation challenges. In the longer term, the formulary
and other care management issues will impact the large group
of Medicaid dual eligible beneficiaries with a mental illness.
Primary Funding Source: SAMHSA and Commonwealth
Fund
●Drug Use in Severely Mentally Ill Medicare Beneficiaries:
Impact of Discontinuities in Drug Coverage
Ilene Zuckerman, PharmD, Ph.D., Linda Simoni-Wastila,
BSPharm, Ph.D., Christopher Blanchette, MS, Bruce Stuart,
Ph.D.
Presented By: Ilene Zuckerman, PharmD, Ph.D., Associate
Professor, Lamy Center on Drug Therapy and Aging,
University of Maryland Baltimore, 515 West Lombard Street,
1st Floor, Baltimore, MD 21201; Tel: (410) 706-3266; Fax:
(410) 706-1488; Email: izuckerm@rx.umaryland.edu
Research Objective: The purpose of this study is twofold: To
1) describe the extent of drug benefits possessed by severely
mentally ill Medicare beneficiaries and 2) determine how gaps
in drug benefits influence use of prescription medications
used to treat mental illness.
Study Design: This study uses an observational cohort
analysis using ordinary least squares regression, adjusting for
sociodemographics, health status, comorbidities, and death.
The primary outcome measures are total mental health drug,
antidepressant and antipsychotic utilization, assessed as total
counts of drugs used over 3 years. Gaps in drug benefits are
measured as proportion of months not covered over three
years, and reported categorically (0 gaps (full drug coverage),
1-24% gaps, 25-49% gaps, 50-74% gaps, 75-99% gaps, and
100% gaps (no coverage). Outcome and drug coverage gap
measures are annualized, and account for time lost to death
and loss-to-follow-up.
Population Studied: The population studied is a pooled
sample of three, 3-year cohorts of community-dwelling,
severely mentally ill disabled and aged Medicare beneficiaries
derived from the 1997 - 2001 Medicare Current Beneficiary
Survey. Severe mental illness is assessed based on the
existence of 2 or more relevant ICD-9 codes extracted from
Part A and B claims.
Principal Findings: Among our sample representing over 2.5
million SMI beneficiaries, over half (54.4%) had full drug
coverage and 18.9% had no coverage. Controlling for
sociodemographic and clinical confounders, beneficiaries with
drug coverage gaps received 2.2 to 3.8 fewer mental health
drugs annually than their fully covered peers, with those
experiencing a 25-49%, 75-99% and 100% drug coverage gaps
impacted the most severely (-3.7, -3.8, and -3.7 prescriptions,
respectively). Drug coverage gaps involving the antipsychotics
followed a similar pattern, while antidepressant use was not
as dramatically impacted. Among antidepressant users, only
those experiencing 50-74% and 100% coverage gaps receiving
significantly fewer antidepressants annually (-1.3 and -1.7,
respectively).
Conclusions: This study is the first to demonstrate that any
discontinuity in drug benefits can adversely impact use of
mental health drugs in severely mentally ill Medicare
beneficiaries. Because such coverage gaps in drug coverage
are possible under the Medicare Modernization Act's
"doughnut hole" design, this study provides an important first
glimpse at what might happen to severely mentally ill
individuals who enroll in the Part D plan. Such reductions in
utilization of these important medications for this frail
population may lead to adverse consequences, including
symptom breakthrough, impaired cognitive function, and even
mortality.
Implications for Policy, Delivery, or Practice: As state and
Federal policy-makers implement and evaluate the Part D
component of the Medicare Modernization Act, further
scrutiny of its impact on this medically vulnerable group is
warranted. Further research is needed to examine outcomes
associated with disruptions in pharmacologic treatment.
Primary Funding Source: RWJF
●Impact of a Prescription Copayment Increase on Blood
Pressure in Elderly Patients
Jalpa Doshi, Ph.D., Bruce Y. Lee, M.D., MBA, Kevin G. Volpp,
M.D., Ph.D.
Presented By: Jalpa Doshi, Ph.D., Research Assistant
Professor, Division of General Internal Medicine, University of
Pennsylvania, 1222 Blockley Hall, Philadelphia, PA 19104; Tel:
215-898-7989; Fax: 215-898-0611; Email:
jdoshi@mail.med.upenn.edu
Research Objective: Medicaid dual eligibles in many states
will pay higher prescription copayments under the new
Medicare Part D than they paid under their state Medicaid
programs. Near poor beneficiaries previously enrolled in state
pharmacy assistance programs which have been abandoned
in light of Part D may also face cost-sharing increases.
Numerous studies suggest that small prescription copayment
increases significantly reduce medication use, particularly
within low income populations. However, little research has
examined how copayment increases impact health outcomes.
In February 2002, the Veterans Administration (VA) increased
prescription co-payments from $2 to $7 for many veterans.
This study takes advantage of this policy change and
availability of electronic medical records in the VA system to
examine how prescription copayment increases impact blood
pressure (BP) among elderly patients of different income
levels.
Study Design: The study used VA medical records to examine
antihypertensive medication use and BP during the 24-months
pre- and post- copayment increase. Veterans with serviceconnected disabilities rated 50 percent or greater, and those
with income below the VA pension level remained copay
exempt and were a natural control group. However, given
substantial differences in baseline characteristics and health
trajectories of the two groups, we used a difference in
difference (D-in-D) approach to compare changes in BP
across patients of different income levels among elderly
veterans who were subject to the copayment increase. Patient
household income was derived from zip-code matched census
data. D-in-D multivariate regressions examined changes in
the days supply of antihypertensive prescriptions, mean
systolic BP (SBP), and likelihood of SBP > 140 mm Hg
following copayment increase across income quartiles (Q1:
<=$37,959; Q2: $37,960 –$50,206; Q3: $50,207 – $60,000;
Q4: >=$60,001). Patients in the highest income quartile were
the reference group. Subgroup analyses were conducted
among elderly patients with and without coronary artery
disease(CAD) or diabetes.
Population Studied: Veterans from the Philadelphia VA
Medical Center who were aged >= 65 years and used
antihypertensive medications in the pre-period and had BP
readings in the pre- and post-periods(n=4,433).
Principal Findings: Elderly patients in the lowest income
quartile had, on average, a 1.9 mm Hg increase in mean SBP
between the pre- and post-periods compared to decreases of
1.1 in the second quartile, 1.7 in the third quartile, and 1.7 in
the highest income quartile. D-in-D multivariate regressions
confirmed significant differences between the lowest and
highest income quartile in terms of antihypertensive days
supply [Q1*Post: - 31 days, p<0.001], mean SBP [Q1*Post: +
3.53 mm Hg, p<0.001], and odds of SBP>140 mm Hg
[Q1*Post: OR 1.5; 95% CI (1.1 to 2.0)]. Similar results were
observed in both higher-risk patients with and without a
history of CAD or diabetes.
Conclusions: Our results indicate that increases in
medication co-payments may have negatively impacted BP
control in lower income elderly veterans, including those at
high cardiovascular risk.
Implications for Policy, Delivery, or Practice: These findings
suggest that the VA co-payment increase may have worsened
disparities in cardiovascular outcomes between high and low
income elderly veterans. Our findings also have important
implications for poor and near poor Medicare beneficiaries
who may face cost sharing increases under Part D. It will be
critical for policymakers to monitor whether access to effective
medications and the health of such seniors is adversely
affected.
Primary Funding Source: Pennsylvania Department of
Health
Call for Panels
The Impact of Medicaid Program Changes on
Low Income Adults: The Oregon Health Plan
18 Months Later
Chair: Jeanene Smith, Office for Oregon Health
Policy and Research
Sunday, June 25 • 5:45 pm – 7:15 pm
Panel Overview: This panel will discuss the most recent
evidence of the effect of higher premiums and co-payments
on a Medicaid population, using three distinct data sources to
examine the effects of the 2003 introduction of higher
premiums and co-payments on 100,000 members of the
Oregon Health Plan (OHP), the Oregon Medicaid program.
The three distinct studies are designed to capture perspectives
of the OHP cutbacks at the individual level, program level, and
system level. The first study, focusing on effects at the
individual level, uses a longitudinal survey to collect selfreported data on utilization and health status on individuals
who remained on the plan, as well as those who became
uninsured when they could not afford the higher monthly
premiums. The second study, focusing on the program
effects, uses administrative claims data to assess the impact
of higher co-payments on OHP enrollees’ cost and utilization.
The third study, designed to capture the system-wide effects of
the OHP cuts, uses administrative data from a statewide
sample of emergency departments. These data provide an
insight on the changes in emergency department utilization by
payer-mix, allowing for an assessment of the effect of
decreases in OHP enrollment on the use of the emergency
department by the uninsured. Taken together, the three
analyses provide a complete and robust assessment of the
impacts of co-payments and premiums on a Medicaid
population.
●The Impact Of Cost-Sharing and Benefit Changes On
Adult Medicaid Beneficiaries: The Oregon Health Plan
Matthew Carlson, Ph.D., Bill Wright, Ph.D., Tina Edlund, MS,
Jeanene Smith, M.D., M.P.H.
Presented By: Matthew Carlson, Ph.D., Assitant Professor,
Department of Sociology, Portland State University, PO Box
751, Portland, OR 97207; Tel: 503-725-9554; Fax: 503-725-3957;
Email: carlsonm@pdx.edu
Research Objective: In March, 2003, changes were made to
the Oregon Health Plan (OHP) including increased premiums
and copays, benefit reductions, and a 6-month lockout for
non-payment of premiums. In June, 2004 there were
additional changes: copays were removed and some benefits
reinstated. This prospective cohort study assesses the impact
of OHP changes on enrollees’ insurance status, health care
access and utilization, medical debt, and health status over
the 18-month study period.
Study Design: Data come from a prospective cohort study of
a subset of OHP beneficiaries who were affected by OHP
changes. A baseline, mail-return survey was conducted in
October, 2003, 6 months after initial OHP changes were
implemented (n=1378, 34% response rate). Twelve months
later, a follow-up survey was conducted by mail and telephone
(n=991, 72% response rate). Surveys were conducted in
English and Spanish.
Population Studied: Adults age 19 and older who were
enrolled in the OHP for at least thirty days prior to February
15, 2003, just prior to the initial wave of program changes.
Principal Findings: Eighteen months after OHP changes
were implemented, 37% of the sample maintained continuous
enrollment, 18% lost coverage for 1 to 6 months and 46% lost
coverage for 6 months or longer. Most who lost coverage
(53%) indicated program changes were the main reason.
Length of time uninsured was strongly associated with unmet
need, medical debt, and health status. For example, the rate
of unmet need nearly doubled from 38% to 72% after 3
months without coverage. Rates of medical debt also doubled
from 16% to 39% after 3 months without coverage. Selfreported health status significantly declined for those without
insurance for more than six months. In this group, the
percentage reporting “very good” or “excellent” health
declined from 37% to 20% between the baseline and follow-up
surveys. By contrast, individuals maintaining continuous
coverage reported improved access to care, less financial
impact, and stable health status over the 18-month study
period.
Conclusions: Increased costs and benefit reductions resulted
in involuntary loss of coverage for thousands of low-income
Oregonians. Most who lost coverage reported having no
insurance for more than 6 months of the 18 month study
period. Loss of coverage resulted in diminished access to care,
increased medical debt, and for many, declining health status.
By contrast, reducing cost-sharing and reinstating benefits
may have had a positive impact on individuals who
maintained coverage. This group reported improved access,
reduced financial hardship, and stable health status over the
18-month study period.
Implications for Policy, Delivery, or Practice: Even nominal
cost sharing can impact Medicaid enrollees’ ability to
maintain coverage. This is particularly true for those with very
low incomes or the unemployed. Moreover, impacts of
coverage loss including poor access, increased debt, and
worsening health status dramatically increase after the first 3-6
months without coverage. Policies that promote continuous
coverage are essential. In 2006, the OHP will no longer
charge premiums for the lowest income beneficiaries (0-10%
FPL) and will remove the lock-out period for non-payment of
premiums.
Primary Funding Source: CWF, Robert Wood Johnson
Foundation
●Expenditure and treatment patterns after cost-sharing
and benefit reduction in the Oregon Health Plan
Neal Wallace, Ph.D., K. John McConnell, Ph.D., Charles A.
Gallia, Ph.D.
Presented By: Neal Wallace, Ph.D., Assistant Professor,
Public Administration, Portland State University, PO Box 751,
Portland, OR 97207; Tel: 503-725-8248; Fax: 503-725-8250;
Email: nwallace@pdx.edu
Research Objective: In response to state budget shortfalls in
2003, the Oregon Health Plan imposed cost-sharing and
eliminated some benefits for adult beneficiaries who were not
part of the categorically eligible Medicaid population. Copayments were imposed for inpatient care; emergency
department use; hospital and individual practitioner
ambulatory care; lab and radiology services; and, prescription
drugs. Coverage of specialty outpatient treatment for mental
health and substance abuse, durable medical equipment and
some general medical supplies, eye care and dental services
were eliminated. This study estimates the impact of costsharing and benefit reductions on average monthly
expenditures, rates of utilization per beneficiary and average
expenditures per service user, in total and by service type
(inpatient, hospital outpatient, ambulatory professional, lab &
radiology, emergency department and pharmaceuticals).
Study Design: The study uses a quasi-experimental design
with a non-equivalent comparison group. Policy effects are
identified as the difference in difference between noncategorically eligible adults affected by the policy change
(known as “Standard” beneficiaries) and TANF eligible adults
before and after policy implementation. FFS claims, MCO
encounter data and monthly enrollment data for Oregon
Health Plan beneficiaries were the primary data sources. Only
services covered pre- and post- policy were analyzed.
Expenditures per claim/encounter were calculated at the
average “full” FFS payment rate during the study period (i.e.
without reductions for co-pays, third party reimbursement or
other adjustments). Subjects were grouped into 61 service
areas based on 130 designated primary care service areas in
Oregon. Expenditure and utilization measures were calculated
for the two eligibility groups, four 6-month study periods and
61 service regions yielding 488 aggregate observations. Fixed
effects estimation is used to identify policy impacts.
Population Studied: Individuals were included in the study
sample if they were from 18-64 years old; had at least 6
months enrollment in each of two 12-month periods before
and after the policy; and had at least 3 months enrollment in
each of the two 6-month periods within the pre- and postpolicy study periods. This yielded a study sample of 15,200
Standard and 7,540 TANF eligible subjects. Within this
sample, 9,999 Standard and 4,548 TANF eligible subjects had
complete pharmacy data.
Principal Findings: Average expenditures per beneficiary
increased by 8% after cost-sharing and benefit reductions
were imposed relative to the TANF control group. Hospital
inpatient and outpatient expenditures increased and pharmacy
expenditures decreased. The percentage of subjects using
services in a month dropped overall, and for ambulatory
professional services and pharmacy, while increasing for
hospital inpatient and outpatient services and lab/radiology
services. Expenditures per service user increased overall and
for ED and ambulatory professional services, while decreasing
for lab/radiology.
Conclusions: The imposition of cost-sharing and benefit
reductions for low-income adults in the Oregon Health Plan
were found to raise expenditures per beneficiary within the
remaining covered benefits and shift expenditures and
treatment from ambulatory professional services and
medications to inpatient and other hospital based services.
Implications for Policy, Delivery, or Practice: Cost-sharing
and benefit reductions may not provide expected cost-savings
when applied to low-income individuals.
Primary Funding Source: RWJF
●Changes in Emergency Department Use after Cutbacks in
the Oregon Health Plan
Robert A. Lowe, M.D., M.P.H., Molly E. Vogt, MA, K. John
McConnell, Ph.D., Jeanene Smith, M.D., M.P.H.
Presented By: Robert A. Lowe, M.D., M.P.H., Associate
Professor, Center for Policy & Research in Emergency
Medicine, Oregon Health & Science University, 3181 SW Sam
Jackson Park Road, Mail Code CR-114, Portland, OR 97239;
Tel: 503-494-7134; Fax: ; Email: lowero@ohsu.edu
Research Objective: Although there has been widespread
speculation that decreasing public insurance coverage will
lead to higher rates of visits to the emergency department
(ED) by the uninsured, there is a paucity of information to
support this claim. We use a large scale disenrollment of
50,000 Oregon Health Plan (OHP, Oregon’s Medicaid
expansion program) beneficiaries over a 3 month period
(February 2003 through April 2003) to test this claim. The
objective of this study was to measure the effect of the
disenrollment on ED visits by uninsured, Medicaid, and
privately insured patients.
Study Design: Observational study using hospital
administrative data.
Population Studied: We obtained data from 15 of Oregon’s
59 EDs on all patient visits from 8/1/2001 to 2/28/2005. The
1,648,868 ED visits represent over 40% of all ED visits in the
state. We used these datasets to ascertain date of visit, payer
class, patient demographics, and clinical information. To
avoid confounding by seasonal variation and to avoid data
from a period of instability around the time of the cutbacks,
we compared payer mix in 2002 versus 2004. We calculated
relative risks (RRs) to compare the proportion of patients in a
payer category in 2004 versus 2002 – supplementing this
quantitative analysis with inspection of trends by month.
Principal Findings: In 2002 ED visits by the uninsured
averaged 4,704/month. Coinciding with the disenrollment of
50,000 OHP beneficiaries, ED visits by uninsured patients
rose abruptly, from 4,637 visits in January 2003 to 6,424 in
May 2003. The increase in uninsured visits was sustained,
with ED visits by the uninsured averaging 6,819/month in
2004. As a percentage of all visits to the ED, visits by
uninsured patients rose from 12.5% of visits in 2002 to 17.3%
in 2004 (RR 1.39, 95% CI 1.38-1.40). ED visits by OHP
enrollees fell from a mean of 9,440/month in 2002 to
8,942/month in 2004, and the proportion of visits by OHP
enrollees fell from 25.0% to 22.7% (RR 0.91, 95% CI 0.900.91). ED visits by commercially insured patients showed a
gradual decrease over the study period, falling from
13,027/month in 2002 to 12,183/month in 2004, and the
proportion of commercially insured visits fell from 34.5% to
31.0% (RR 0.90, 95% CI 0.89-0.90). Although the admission
rate for uninsured ED users was less than for any other payer
category, there was a suggestion of increased illness severity
among uninsured ED users after the cutbacks, as the
admission rate increased from 4.4% to 6.2% (RR 1.41, 95% CI
1.35-1.48).
Conclusions: Disenrollment of about 50,000 Oregon
Medicaid beneficiaries in 2003 was followed by a 45% increase
in uninsured ED visits, more than 25,000 uninsured
visits/year, to our sample of 15 hospitals.
Implications for Policy, Delivery, or Practice: With cuts in
Medicaid programs pending around the nation, we should
prepare for substantial increases in ED use by the uninsured.
Primary Funding Source: RWJF
Call for Panels
Do Consumers Behave Differently in a CDHP?
Chair: Judith Hibbard, University of Oregon
Monday, June 26 • 8:30 am – 10:00 am
Panel Overview: Consumer driven health plans are built on a
number of assumptions about what will motivate consumers
to change how they use care. It is assumed that financial
incentives will increase information seeking, cost awareness,
and stimulate more cost effective choices. In this panel four
studies are presented that explore the validity of these
assumptions. Three studies are based on longitudinal data
that includes two years of claims data linked with two waves of
survey data. Employees from a large manufacturing company
who were newly enrolled in a CDHP, as well as employees
who chose to stay in a traditional PPO plan are followed for a
2 year period. One study explores the degree to which CDHP
enrollees are changing overtime in terms of their information
seeking, engagement in health decisions, and if they are taking
a more active role in managing their health, as compared to
enrollees in a PPO. A second study examines whether these
behaviors, (information seeking, decision engagement, and
active management of health) are linked with lower utilization
and costs. A third study examines the degree to which plan
type affects patient consistency in taking prescribed
medications for specific chronic illnesses. A fourth study is
based on a controlled experiment, and examines how literacy
affects consumer understanding of CDHPs and the choice of
a CDHP. All four studies shed light on how consumers are
likely to behave in this new environment and indicate what
changes may be necessary for these plans to be successful.
●How well do Consumers Understand their Choice of a
CDHP? An Experimental Study
Ellen Peters, Ph.D., Judith Hibbard, DrPH, C.K. Mertz
Presented By: Ellen Peters, Ph.D., Senior Research Scientist,
Decision Research, 1201 Oak St, Eugene, OR 97401; Tel: 541485-2400; Email: empeters@uoregon.edu
Research Objective: This study examines the relationship
between numeracy skill, literacy level, and the comprehension
of plan descriptions, including a CDHP and a PPO plan. We
assessed how well those at different literacy and numeracy
levels understood what a CDHP was, and whether
comprehension affected choice.
Study Design: A convenience sample (N=303) of employed
age adults stratified by education chose between two health
plans and completed six comprehension questions. The
health plans were described as a new plan (a CDHP with an
HSA account) and a more traditional plan similar to a PPO.
Numeracy and reading literacy were assessed using standard
approaches. Different approaches for presenting the
information were tested using an experimental design.
Principal Findings: Both literacy levels and numeracy skill
provided significant independent prediction of comprehension
of the two health plans with lower scores on both measures
being associated with less comprehension. Despite
understanding less about the health plans, the low numerate
were more likely to choose the CDHP. Having the information
side-by-side (instead of separating out the information that
was common and unique to the plans) helped comprehension
for those low and high in numeracy. Providing a framework
for understanding the information helped comprehension only
for those high in numeracy. Different ways of presenting the
information did not influence choices.
Conclusions: Understanding written materials which describe
health plan design is difficult for consumers, particularly those
who are low in literacy and numeric skills. Since a significant
portion of the population is low in numeracy this is of
concern. Choosing a CDHP with little understanding of what
one is choosing would likely lead to dissatisfaction,
inefficiencies and possibly serious health and financial
consequences for the individual.
Implications for Policy, Delivery, or Practice: The findings
suggest that CDHP offerings made to a lower skilled
population, should be done cautiously and with considerably
more assistance than is typically provided to those making
health plan choices.
Primary Funding Source: Blue Cross Blue Shield Association
●The Influence of CDHPs on Enrollees’ Prescription Drug
Utilization
Jessica Greene, Ph.D., Judy Hibbard, DrPH, Martin Tusler, ,
Marc Berger, M.D., James Murray, Ph.D., Steven Teutsch,
M.D., M.P.H.
Presented By: Jessica Greene, Ph.D., Assistant Professor,
Department of Planning, Public Policy and Management,
University of Oregon, 1209 University of Oregon, Eugene, OR
97403; Tel: 541-346-0138; Fax: 541-346-2040; Email:
jessicag@uoregon.edu
Research Objective: In this study we examine the degree to
which enrollment in consumer driven health plans influences
prescription drug utilization. We examine cost effective
changes, such as switching to generic and lower cost drugs,
as well as reductions in utilization. CDHPs’ impact on
prescription drug utilization is of particular importance given
prescription drugs’ widespread use, essential role in
controlling chronic illness, and rapidly increasing costs.
Study Design: Using pharmaceutical claims data we examine
whether the first year of enrollment in either a high deductible
or lower deductible CDHP results in changes in prescription
drug utilization patterns from the prior year, compared with
those who were continuously enrolled in a three-tiered drug
formulary plan. We assess whether there were changes in
generic substitution, within class switches to lower priced
drugs, the medication possession ratio, and discontinuation
rates for eight classes of prescription drugs.
Population Studied: We study the influence of health plan
design based on the experience of one large employer in the
manufacturing sector that first offered CDHP options in 2004.
Our study sample includes company employees and their
dependents, totaling 28,105 individuals.
Principal Findings: Preliminary analysis suggests that
enrollment in both high and lower deductible CDHPs leads to
changes in prescription drug utilization that are cost effective.
In some cases, enrollment in high deductible CDHPs,
however, may also lead to reductions in use. We observe
different patterns by drug class.
Conclusions: We find that changes in pharmaceutical plan
design influence enrollees' prescription drug utilization and
that CDHP deductible levels matter. Enrollment in CDHPs is
associated with cost effective prescription drug utilization,
regardless of plan deductible level. Enrollment in high
deductible CDHPs, in some cases, results in reductions in
utilization.
Implications for Policy, Delivery, or Practice: As enrollment
in high deductible CDHPs increases, and plan designs
change, it will continue to be important to monitor for
reductions in prescription drug utilization and the impact that
they may have on health outcomes.
Primary Funding Source: RWJF, Merck
●How Does Enrolment in CDHPs Impact on Consumerist
Behaviours?
Anna Dixon, BA Cantab MSc (Econ), Judith Hibbard, DrPH,
Jessica Greene, Ph.D.
Presented By: Anna Dixon, BA Cantab MSc (Econ), Harkness
Fellow in Health Policy, Planning, Public Policy, &
Management, University of Oregon, 119 Hendricks Hall,
Eugene, OR 97403-1209; Tel: 541 346-0874; Fax: 541 346-2040;
Email: adixon@uoregon.edu
Research Objective: To compare consumerist behaviours
between enrolees in consumer directed health plans and a
traditional PPO. Specifically to address the following research
questions: How does use of health and cost information vary
between enrolees of different plans? How do appropriate cost
sensitive health care decisions and risky cost saving decisions
vary between enrolees of different plans? Do self reported
changes in awareness of costs and quality, and information
use vary by plan type? How has use of health and cost
information changed over one year among enrolees of
different plans? How have cost sensitive health care decisions
changed over one year among enrolees of different plans?
Study Design: Employees completed either web-based or
telephone surveys in summer 2004 and 2005. Included
questions on health plan enrolment, employee health status,
consumer characteristics, socio-demographics and selfreported behaviours.
Population Studied: 2,104 employees of a large
manufacturing company that offered employees choice of high
or low deductible CDHPs in 2004, in addition to traditional
coverage options including a PPO. Employees were eligible for
the survey if they had worked for the company for at least a
year, and were sixty years of age or younger.
Principal Findings: Enrolees in the low deductible CDHP
were more likely to have used health information and cost
information in 2005 than either enrolees in the high
deductible CDHP or PPO. There is weak evidence that
enrolees in the CDHPs were more likely to make appropriate
cost sensitive decisions. Enrolees in the CDHPs were
significantly more likely to take risky cost-saving decisions. A
smaller proportion of enrolees in CDHPs than in the PPO
reported being more aware of quality than last year and a
greater proportion reported being more aware of costs. A
significantly greater proportion of enrolees in CDHPs than in
the PPO reported feeling more in charge than last year. There
were some significant differences in changes in use of health
information and cost information over time between enrolees
of different plans.
Conclusions: The impact of CDHPs on information use
differs between enrolees in high and low deductible plans.
Enrolees in CDHPs appear more likely to forego, postpone or
delay medical care than enrolees in PPOs. CDHPs have a
small effect on changes in consumer behaviours over time.
Implications for Policy, Delivery, or Practice: The
expectation that exposure to cost sharing and increased
availability of information resources under a CDHP would
result in more active health care consumers appears not to be
supported by data. The lack of positive expected benefits and
evidence that health care consumers forego medical care in
face of greater financial risk may prompt employers and other
purchasers to re-evaluate the overall justification for
introducing CDHPs.
Primary Funding Source: CWF, Robert Wood Johnson
Foundation
Call for Panels
Assessing Quality of Nursing Home Care Using
the 2004 National Nursing Home Survey
Chair: Judith Kasper, Johns Hopkins University
Monday, June 26 • 8:30 am – 10:00 am
Panel Overview: This panel’s objectives are to present the
first analyses related to the quality of care based on the 2004
National Nursing Home Survey (NNHS) and to introduce the
first National Nursing Assistant Survey. The moderator will
relate the current state of knowledge regarding quality of care
in nursing homes and give an overview of the surveys.
Presentations will then focus on quality issues related to endof-life care, medication use, electronic information systems,
and staffing. Discussants expert in the field from public policy
and academia will relate the findings to current policy issues.
The 2004 NNHS is one of a series of national probability
sample surveys that collect data on nursing homes, their
residents, and their staff. A major redesign in 2004 added
survey items and a supplemental survey of nursing assistants.
The data offer opportunities to evaluate residents’ quality of
care in relation to facility organization and practices and staff
training and certification. Data on residents include
emergency department use and hospitalizations, medications,
pain management, and end-of-life care. Data on nursing
assistants address several relevant policy and practice issues:
recruitment, health insurance access and coverage, use of
public benefits, choice of profession, reasons for turnover,
satisfaction and staying in the job, citizenship, education and
training, and work-related injuries.
The session will inform public and private policies on topics
with important implications for quality of care received by a
vulnerable segment of our population.
●The National Nursing Assistant Survey: A First-time
Direct Care Worker Survey of Certified Nursing Assistants
Employed in Nursing Homes
Marie Squillace, Ph.D., R. Katz, R. Remsburg, E. Rosenoff
Presented By: Marie Squillace, Ph.D., Senior Policy Analyst,
DHHS/OS/ASPE, Hubert H. Humphrey Building, 200
Inependence Avenue, SW, Washington, DC 20201; Tel: 202690-6250; Email: marie.squillace@hhs.gov
Research Objective: Collect a nationally representative
sample of Certified Nursing Assistants (CNAs) working in
nursing homes surveyed by the National Nursing Home
Survey (NNHS) to provide an evidence base for
understanding what draws individuals to careers as nursing
assistants and to work in nursing homes, and what
contributes to their satisfaction and likelihood of staying in
their jobs.
Study Design: Cross-sectional survey. CNAs were selected
from a sub-sample of 790 nursing homes from the 1500
sampled in the 2004 NNHS. The National Nursing Assistant
Survey (NNAS) was a telephone interview conducted
separately from the NNHS.
Population Studied: 3,014 CNAs responded out of 4,357
selected and eligible for the survey (69%).
Principal Findings: Data on nursing assistants will address
several issues that are important for policy and practice.
These include questions related to how nursing assistants are
recruited, health insurance access and coverage, use of public
benefits, why nursing assistants choose their profession,
reasons for turnover, what contributes to satisfaction and
likelihood of staying in the job, citizenship status, role of
education and training, and the extent and type of work-related
injuries. Preliminary analyses will cover this spectrum and
provide national statistics on these topics for the first time.
Conclusions: The NNAS will provide current, in-depth
information on several issues of importance for policy and
practice that warrant special attention, including factors
associated with job satisfaction and turnover. Although the
major focus of the NNAS is to provide descriptive data, the
survey also has exploratory, confirmatory, and developmental
aspects. Information from this national sample survey will be
linked to the NNHS data to examine associations between
facility and resident characteristics and CNAs.
Implications for Policy, Delivery, or Practice:
Paraprofessional workers constitute the backbone of the
formal long-term care industry providing assistance with
activities of daily living to over 15 million Americans. Yet
numerous studies point to a future labor force imbalance
between the demand for long-term care supports and supply
of the paraprofessional workforce. Reasons for this imbalance
include the growing demand for long-term care from the aging
baby boomer generation and recruitment and retention
challenges faced by long-term care providers. While the U.S.
Bureau of Labor provides employment estimates monitoring
the labor force, no nationally descriptive information is
collected directly from the paraprofessional workforce to
describe what motivates individuals to choose careers as
direct care workers in long-term care settings, and what
contributes to the likelihood that they will continue in these
positions based on their job satisfaction, environment,
training, and advancement opportunities. The breadth and
depth of information collected in the NNAS will inform
federal, state and provider efforts aimed at recruiting a
qualified and committed workforce.
Primary Funding Source: DHHS/OS/ASPE
●End of Life Care in Nursing Homes: Skilled Nursing
Homes with special programs and trained staff for
hospice
Robin Remsburg, Ph.D., R.N.Beth Han, Ph.D., M.D., M.P.H.
Presented By: Robin Remsburg, Ph.D., R.N.., Deputy
Director, Division of Health Care Statistics, Long-term Care
Statistics Branch, CDC, National Center for Health Statistics,
3311 Toledo Road, Hyattsville, MD 20782; Tel: 301-458-4416;
Fax: 301-458-4693; Email: rqr3@cdc.gov
Research Objective: To estimate the prevalence of skilled
nursing homes with special programs and trained staff for
hospice in the U.S., and to examine factors associated with
skilled nursing homes with special programs and trained staff
for hospice.
Study Design: This cross-sectional study, using the 2004
National Nursing Home Survey, provides the first nationally
representative data on hospice, palliative, and end of life care
among U.S. nursing homes. We examined ownership status;
chain affiliation; the current number of nursing home beds;
characteristics of facility administrator, director of nursing,
and medical director; the percent of certified nursing
assistants and registered nurses employed more than 1 year;
the percent of beds certified by Medicaid only and by both
Medicare and Medicaid; having special programs and trained
staff for hospice; pain management; and formal contracts with
outside hospice programs; staffing/patient ratios; region; and
metropolitan/micropolitan area status. Chi-square tests at the
bivariate level and multivariate logistic regression modeling
were used. SUDAAN software was used to adjust for the
complex sampling design and sampling weights.
Population Studied: A total of 1167 skilled nursing homes.
Principal Findings: In 2004, less than 19% of nursing homes
had special programs and trained staff for hospice (SPTSH),
compared to 26% of nursing homes had special programs
and trained staff for pain management and 78% of nursing
homes had formal contracts with outside hospice programs.
Our multivariate results indicate that nursing homes with
special program and trained staff for pain management
compared to those without had more than fivefold (odds ratio
(OR) = 5.67, 95% confidence interval (CI) = 3.48, 9.24) the
odds of having SPTSH; the odds were more than 3 to 1
(OR=3.32, 95% CI=1.69, 6.51) that nursing homes with formal
hospice contracts compared to those without would have
SPTSH; private non-profit nursing homes had almost double
the odds of having SPTSH (OR=1.99, 95% CI=1.22, 3.24)
compared to their for-profit counterparts; nursing homes in
the South had more than double the odds of (OR=2.48, 95%
CI=1.45, 4.26) having SPTSH compared to those in the
Midwest; and nursing homes with metropolitan or
micropolitan status were associated with having fewer SPTSH
than those without.
Conclusions: Having a formal contract with outside hospice,
having special programs and trained staff for pain
management, South region, and nonmetropolitan/micropolitan status are associated with nursing
homes’ having more special programs and trained staff on
hospice.
Implications for Policy, Delivery, or Practice: Hospice care
in nursing homes offers a collaborative opportunity for
nursing homes and hospices to provide end-of-life care to
nursing home residents. To prepare special programs and
trained staff for hospice, it is valuable for nursing homes to
establish special programs and trained staff for pain
management, a critical component of hospice care. Future
studies are needed to examine why nursing homes in the
South or in non-metropolitan/micropolitan areas are more
likely to have special programs and trained staff for hospice.
Primary Funding Source: CDC, NCHS
●Medication Practices for the Elderly in U.S. Nursing
Homes
Lisa Dwyer, M.P.H., Robin Remsburg, Ph.D., R.N.
Presented By: Lisa Dwyer, M.P.H., Health Scientist, Longterm Care Statistics Branch, CDC, National Center for Health
Statistics, 3311 Toledo Road, Hyattsville, MD 20782; Tel: 301458-4714; Fax: 301-458-4693; Email: ldwyer@cdc.gov
Research Objective: (1) Present preliminary estimates of the
use of medications by nursing home residents. (2) Determine
the top ten therapeutic classes of medications taken by
residents; and (3) Determine if nursing home residents are
taking selected medications that are currently excluded from
Medicare Part D Drug Benefit reimbursement.
Study Design: Cross-sectional analysis of preliminary, unweighted data on medication usage by a sub-sample of
nursing homes residents in the 2004 National Nursing Home
Survey (NNHS). The specific survey questions were as
follows: (1) what medications did the resident receive
yesterday, including standing, routine, and as-needed
medications; (2) what medications does the resident receive
on a regularly scheduled basis but were not administered
yesterday; (3) why were the medications prescribed; and (4)
did the resident have any type of reaction to a drug or
medication since admission or during the past 30 days.
Population Studied: 11,885 nursing home residents, 65 or
older, who were sampled in the 2004 National Nursing Home
Survey (NNHS) and taking at least one medication.
Principal Findings: Preliminary un-weighted data reveal the
mean number of medications per resident was 9.0. Residents
took prescription medications, over-the-counter medications,
and vitamin/mineral and herbal supplements. The top ten
therapeutic drug classes taken by these nursing home
residents included vitamins/minerals, laxatives, analgesics,
antidepressants, diuretics, and antipsychotics. Some
medications considered potentially inappropriate for the
elderly and other medications currently excluded from
Medicare Part D Drug Benefit reimbursement, such as
benzodiazepines and prescription vitamin and mineral
products, were also administered to residents.
Conclusions: Elderly nursing home residents take numerous
medications for various medical conditions. The large number
of medications taken per resident, many of whom are
potentially very frail and sick, may raise patient safety
concerns, such as drug interactions. The data also reveal that
some residents took medications currently excluded from
Medicare Part D reimbursement.
Implications for Policy, Delivery, or Practice: Using the
2004 NNHS medication data, long-term care planners,
researchers, and policy makers can gain a better
understanding of the medications taken, therapeutic classes,
the reasons they were prescribed, the prevalence of polypharmacy and potential interactions and thus implications for
patient safety and quality of care. Current medication practices
in U.S. nursing homes demonstrate that (1) patient safety
initiatives are critical to monitoring the number and types of
medications administered to residents and addressing their
potential negative consequences and (2) the Medicare Part D
Drug Benefit exclusions affect nursing home residents and the
long-term care industry.
Primary Funding Source: CDC
●Electronic Information Systems Use for Patient Care in
US Nursing Homes: Data from the 2004 National Nursing
Home Survey
William S. Pearson, Ph.D., M.H.A.
Presented By: William S. Pearson, Ph.D., M.H.A., Health
Scientist, Long-term Care Statistics Branch, CDC, National
Center for Health Statistics, 3311 Toledo Road, Hyattsville, MD
20782; Tel: 301-458-4699; Fax: 301-458-4693; Email:
wpearson@cdc.gov
Research Objective: To estimate the number of US nursing
homes using electronic information systems and to examine
how these systems were used.
Study Design: Secondary analysis of the 2004 National
Nursing Home Survey. National estimates were made for the
numbers of homes using an electronic information system
and the specific patient care activities they performed. These
activities included management of patient records,
management of medication orders and drug dispensing,
physician order entry, laboratory orders and procedures,
management of medication administration records, nursing
assistant notes, and dietary notes.
Population Studied: Nationally representative sample of 1,174
nursing homes from the 2004 National Nursing Home
Survey, which represented 16,079 nursing homes nationally.
Principal Findings: Almost one-half (47.2%) of the estimated
16,079 US nursing homes in 2004 were using an electronic
information system for the management of patient records.
51.1% of all nursing homes were using an electronic system for
medication orders and drug dispensing; 48.4% for physician
order entry; 41.4% for laboratory orders and procedures, 38.1%
for management of medication administration records, 17.5%
for daily nursing assistant notes and 51.2% for dietary notes.
Approximately 20% of all US nursing homes were not using
an electronic information system for any of seven patient care
activities. Seventeen percent were using their information
system for at least one activity, and approximately 55% of
nursing homes were using their information systems for 2 to
6 patient care activities. Just over seven percent of all homes
were using their information system for all seven of the
patient care activities.
Conclusions: By 2004, many US nursing homes had adopted
the use of an electronic information system for some type of
patient care activity. However, the use of the information
systems for patient care varied among the homes.
Implications for Policy, Delivery, or Practice: This study
presents data that allow researchers and policy makers to see
where nursing homes stand at the beginning of our nation’s
move toward a wired health information network. The use of
information technology, primarily in the form of an electronic
health record, has been proposed as a way to increase the
efficiency of delivered services, raise the level of the quality
care provided and decrease the number of medical errors.
This study suggests that many nursing homes are using the
technology for patient care services, although at varied levels.
In 2004 Executive Order 1335 set forth a Federal Health IT
initiative with the goal of having the majority of the US health
care system wired and having most Americans covered by an
interoperable health record within the next decade. Nursing
homes are a large sector of the overall US healthcare system
that provides care to an especially vulnerable population.
Therefore, the use of electronic health records may help to
ensure quality of care to this population. This survey will allow
researchers to conduct studies on outcomes of patients that
were treated in homes which utilized electronic information
systems for patient care and will help to determine how the
use of electronic information systems for patient care affect
quality and outcomes.
Primary Funding Source: No Funding
Call for Panels
Impact of Pay-for-Performance Programs on
Quality and Costs of Health Care: Lessons from
Massachusetts, New York, and California
Chair: Eric Schneider, Harvard School of
Public Health
Monday, June 26 • 10:30 am – 12:00 pm
Panel Overview: In health care, traditional forms of payment
offer little incentive to physicians to assess or improve the
quality of health care. Pay-for-performance (P4P) programs
may remedy this by basing a portion of payment to physicians
on the results achieved on measures of the quality of health
care. While P4P programs have become increasingly popular
and are under consideration as a new payment model for the
Medicare program, little is known about their impact. Do they
improve quality? Will they temper the rising costs of care? In
this panel, 3 speakers will present the results of P4P evaluation
projects in Massachusetts, New York, and California. The
Massachusetts project is analyzing changes in physician
group performance on standardized measures of the quality of
primary care in response to P4P incentives initiated by
competing health plans. The New York project is estimating
both improvements in quality and the return on investment
generated by a P4P program administered by a large health
plan in partnership with a large physician organization. The
California project is evaluating changes in performance of
physician organizations on standardized quality measures in
the wake of a statewide implementation of financial incentives
and public reporting of performance scores. The panel
presentations will offer valuable lessons about the optimal
scope and structure of P4P programs.
●Rewarding Performance: Two-year Results from
California’s Statewide Pay-for-Performance Experiment
Cheryl Damberg, Ph.D., Kristiana Raube, Ph.D., Claude
Messan Setodji, Ph.D.
Presented By: Cheryl Damberg, Ph.D., RAND, 1776 Main
Street, Santa Monica, CA 90407; Tel: 310-393-0411; Fax: 310260-8155; Email: damberg@rand.org
Research Objective: 1) To examine changes in performance
on a set of measures (clinical, patient experience, and
Information Technology (IT)) between 2003 and 2005 among
the universe of Physician Organizations (POs) exposed to a
statewide pay-for-performance program in California. 2) To
examine the distribution of payouts to POs by size, type of
group, and region, and changes in winners and losers over the
3-year period.
Study Design: 225 POs in California that contract with 7
largest health plans were exposed to financial and nonfinancial incentives (i.e., public reporting of performance
scores). POs were scored on 6 clinical measures, 4 patient
experience domains, and 2 IT domains (integrating clinical
electronic data at group level for population management and
supporting clinical decision-making at the point of care
through electronic tools). The study uses clinical performance
data (aggregated from 7 health plan administrative sources
and self-reported, audited PO encounter data sources),
patient survey data from an annual group-level CAHPS survey
conducted in California, and PO self-reported information on
IT capability. Data are reported for 2002, 2003, and 2004
(used to make payouts in 2004 and 2005; baseline is 2002).
The unit of analysis is the PO (n=225, the universe of capitated
POs contracting with the 7 health plans). Year-to-year
changes in performance scores are computed; we examine
relative improvements by rank position (e.g., quartiles of
performance). Using a multivariate regression model, we also
examine characteristics of the PO (e.g., size, region,
IPA/medical group, # of physicians) that are associated with
better performance. Lastly, we rank order POs by total
payouts and assess year-to-year changes in the rank positions
of POs based on bonus payments.
Population Studied: 225 Physician organizations (medical
groups and IPAs) in California; HMO and POS capitated
enrollees of the 7 health plans (7 million enrollees).
Principal Findings: Year-to-year improvements were observed
in clinical measures (e.g., 56.3% of POs saw an average 1.1%
point improvement in mammography screening rates; 77.4%
saw an average 5.4% point improvement in cervical cancer
screening, and 60.2% of groups saw an average 3.5% point
improvement in HbA1c screening between 2003 and 2004),
and patient experience improved on average between 1.1 and
8.8% points), and there was an increase from 34.4% of groups
receiving bonus dollars for IT capability in 2004 to 52.9% in
2005. Performance scores and bonus dollars were higher on
average among POs located in Northern CA and that were
larger in size. Small, Independent Practice Association (IPA)
groups tended to score lowest, in part because of difficulty
obtaining complete encounter data from all of their practice
sites to demonstrate performance on the indicators.
Conclusions: Although performance improvement was
observed between 2003 and 2005, the improvement was
relatively modest. For some measures, the year-to-year
change is likely due more to improvements in data capture
rather than real performance improvement, as POs focused
heavily in the initial years on ensuring data capture to
demonstrate performance. The largest relative year-to-year
changes in performance scores were observed among the
lowest performers and these were the same POs that saw little
or none of the bonus money. Incentive payments tended to
reward those groups with historically high performance.
Implications for Policy, Delivery, or Practice: Pay-forperformance programs are still in the early stages of
development and implementation. At this stage, POs in
California are focused heavily on modifying data systems to
track performance and using enhanced IT capabilities to feed
performance information back to individual physicians to drive
behavior change and to create physician-level incentive
structures. To gauge the ultimate impact of pay-for-
performance on driving quality improvements will require
sustained evaluation work.
Primary Funding Source: California Healthcare Foundation
●Can Underuse Measures Reduce Cost? The ROI for
Diabetes and Coronary Artery Disease
Howard Beckman, M.D., Kathy Curtin, RN, MBA, Robert
Greene, M.D.
Presented By: Howard Beckman, M.D., Medical Director, ,
Rochester Individual Practice Association, 3540 Winton Place,
Rochester, NY 14623; Tel: 585-242-9445; Fax: 585-242-0682;
Email: hbeckman@ripa.org
Research Objective: 1) To determine whether a P4P program
involving a partnership between a large health plan and a large
physician organization can generate a positive return on
investment (ROI). 2) To describe a successful approach to
engaging physicians in quality improvement and P4P.
Study Design: P4P measures include patient satisfaction,
quality and efficiency. Quality measures include acute diseases
(sinusitis and Otitis media), chronic diseases (diabetes, CAD,
asthma) and preventive services (mammography). Efficiency
scoring was based on ETG comparisons within specialty
groupings. Performance targets were set at the 90th national
percentile if available. Year-end payments were based on a
formula that encouraged both high levels of performance and
interval improvement. Profiles were distributed three times a
year and included updated lists of patients that had received
services. ROI for the P4P program was estimated by
calculating savings against trend. Total costs for patients with
diabetes and coronary artery disease were compared to a
rolling two year trend for the period 2000-2004. Costs
included practitioner payments, inpatient and outpatient
reimbursement, pharmaceutical costs, ancillary costs and
other patient related plan payments such as durable medical
equipment. Patients with total year costs greater than
$100,000 or with other catastrophic illnesses from trauma or
in addition to CAD and diabetes were excluded (liver
transplantation from Hepatitis C, kidney transplantation from
polycystic kidneys). Savings from other aspects of the P4P
program are being analyzed.
Population Studied: The RIPA/Excellus P4P partnership is
based on services provided to 300,000 members of an HMO
product serviced by 3500 practitioners.
Principal Findings: The savings from diabetes and CAD in
2004 against the two year rolling trend amounted to
$3,500,000 with a cost of the P4P program estimated at
$1,150,000 yielding an ROI result of 3:1 for these two
programs alone. In the chronic disease arena, reduction in
costs was associated with increased use of pharmacologic
agents and a resulting decline in hospitalizations. Increased
use of pharmacologic agents led to lower LDL cholesterol and
HbA1c. For example, the percentage of diabetic Excellus
patients with an LDL<100 increased from 29% in 2003 to 39%
in 2004 (based on HEDIS specifications). Over time, we
observed that practitioners passed through Kubler-Ross’s
stages of mourning. To physician’s anger, we responded with
listening and non-judgmental understanding. In those seeds
of anger were important concerns about how our program
needed to be improved. Physicians asked us to be clearer
about what we were incenting, and to explicitly define what
they needed to change. Over the three years of the program,
we have made more than 20 changes to our process. After we
created increasingly actionable information, our reports
became the template for change, not judgment. Now we
receive many more requests for help with improvement than
complaints about being evaluated.
Conclusions: Promoting an evidence-based pathway for
chronic disease and paying for improvement is both
achievable and cost effective, generating, in this program, a
minimum ROI of 3:1. Our results depended on integrating
accurate, understandable, actionable reporting tools with a
respectful, transparent process of interacting with the
practitioner community.
Implications for Policy, Delivery, or Practice: An optimal
pay-for-performance program requires integrating evidencebased measures with dissemination of accurate, actionable
data in a respectful, non-judgmental fashion. Attention to each
of these components of the program is considered essential
to success.
Primary Funding Source: RWJF
●Performance of Physician Groups after Pay-forPerformance: Natural Experiments in Massachusetts
Steve Pearson, M.D, M.Sc., Kathy Coltin, M.P.H., Ken
Kleinman, Ph.D., Janice Singer, M.P.H., M.A., Barbra Rabson,
M.P.H., Eric Schneider, M.D., M.Sc.
Presented By: Steve Pearson, M.D, M.Sc., Special Advisor,
Technology and Coverage Policy, Centers for Medicare and
Medicaid Services and the NIH, Building 10, Room 1C118,
Bethesda, MD 20892; Tel: 301-435-8717; Email:
spearson99@yahoo.co
Research Objective: There are now a wide variety of pay-forperformance contracts between health plans and physician
groups, yet most evaluations of these initiatives have focused
on a single intervention by a single health plan. As part of the
Robert Wood Johnson Rewarding Results study, the
Massachusetts Health Quality Partners (MHQP) project was
designed to evaluate the impact on physician groups of the
diverse set of pay-for-performance contracts initiated by all five
major commercial health plans in the state between 2001 and
2003.
Study Design: We created a Master Physician Database that
aggregated Health Employment Data Information Set
(HEDIS) performance across all health plans to provide a
complete and annually updated profile of the quality
performance of all individual physicians and physician groups
in the state. In addition, a comprehensive survey of health
plans’ pay-for-performance contracts was undertaken during
the years 2001-2003, collecting information on the structure,
scope, and magnitude of each contract containing a pay-forperformance element. The evaluation compares the change in
quality performance between 2001 and 2003 of physician
groups that have a pay-for-performance contract with the
change in quality performance of matched comparison
physician groups with comparable baseline quality
performance in 2001.
Population Studied: The 5 health plans participating in the
MHQP collaborative contracting with over 90% of the state’s
practicing primary care physicians and covering nearly 4
million enrollees (60% of the state’s population).
Principal Findings: The Master Physician Database includes
HEDIS performance data on 4,358 physicians practicing in 174
physician groups. In the baseline year of 2001, there were 4
contracts that included a financial incentive linked to quality
performance, rising to 20 separate contracts by 2003. The
HEDIS measures that were targets of financial incentives in
2001 included: diabetes management; mammography;
cervical cancer screening; well-child visits; and pediatric and
adult asthma management. By 2003, Chlamydia screening
and antidepressant management had been added as quality
targets. The incentive contracts were of different models: 1
was a withhold; 4 were grants to support quality improvement
programs; and 15 were bonuses. The money tied to quality
performance ranged from less than $5,000 for single
physician groups to contracts with networks of physician
groups that exceeded $2,000,000. At the time of abstract
submission, the comparison of changes in quality
performance between 2001 and 2003 in physician groups with
pay-for-performance incentives (intervention) and concurrent
comparison groups is ongoing. Results, including those from
a multivariate model, will be available for presentation at the
conference.
Conclusions: A wide range of pay-for-performance contracts
have been initiated in Massachusetts during the years 20012003. The variety of their structure, scope, and magnitude
suggests that further analyses will be able to identify features
of pay-for-performance contracts that are most closely
correlated with significant improvements in quality
performance (independent of secular performance trends).
Implications for Policy, Delivery, or Practice: Distinguishing
these critical features of pay-for-performance contracts will
inform future efforts to reap the maximum gain from an
incentive concept that has spread rapidly but is still quite early
in its development.
Primary Funding Source: RWJF
Call for Panels
Predicting Consumer Responses to New Types
of Health Plans
Chair: Sharon Arnold, AcademyHealth
Discussant: Adam Atherly, Emory University
Monday, June 26 • 2:00 pm – 3:30 pm
Panel Overview: This panel will present and discuss recent
research regarding potential consumer responses to new
types of health insurance plans either created or encouraged
by the Medicare Modernization Act (MMA). Most prominent
among these are stand-alone prescription drug plans (PDPs).
These plans are central to the goal of making affordable drug
coverage available to all Medicare beneficiaries, but it is not
known whether they will attract large and stable enrollments.
For the working age population, MMA created tax advantages
for health savings accounts, spurring substantial new interest
in consumer-directed health plans (CDHPs). These plans
feature combinations of deductible, co-insurance, donut hole,
and catastrophic coverage, and consumer preferences with
regard to these product features are not well understood.
The session will start with a presentation by Austin Frakt,
Ph.D., giving a descriptive overview of the Medicare PDPs that
began enrolling beneficiaries in January. Costs to consumers
and generosity of available coverage will be assessed. The
second speaker, Steven Pizer, Ph.D., will present analysis of
predicted market shares and adverse selection for PDPs,
based on statistical modeling of beneficiary choices as
reported on the Medicare Current Beneficiary Survey. Stephen
T. Parente, Ph.D., will speak third, using data from four large
employers to analyze consumer responses to a discrete set of
product features of CDHPs. The panel will be chaired by
Sharon Arnold, Ph.D., Senior Research Manager,
AcademyHealth, and Adam Atherly, Ph.D., Associate
Professor of Public Health, Emory University, will serve as
discussant.
●Storm Clouds on the Horizon? Predicting Adverse
Selection in Medicare Prescription Drug Plans
Steven Pizer, Ph.D., Austin Frakt, Ph.D., Roger Feldman, Ph.D.
Presented By: Steven Pizer, Ph.D., Health Economist, Health
Care Financing & Economics, VA & Boston University, 150
South Huntington Ave. (152H), Boston, MA 02130; Tel: 857364-6061; Fax: 857-364-4511; Email: pizer@bu.edu
Research Objective: To predict enrollment and selection into
newly created Medicare prescription drug plans under a
variety of competitive scenarios, and to assess the likely cost
implications for different types of beneficiaries. Outpatient
prescription drug coverage has not been available from
Medicare except through HMOs. HMOs have limited appeal
to beneficiaries because they restrict choice of provider and
are not available in all areas. The Medicare Modernization Act
of 2003 created new types of plans to expand access to drug
benefits to beneficiaries who could not or would not join
HMOs. The most important of these is the stand-alone
prescription drug plan (PDP), which will provide coverage only
for prescription drugs starting on January 1, 2006. As
Congress considered creating these plans in 2003, some
argued that prescription drug utilization is too persistent a
phenomenon to be separately insurable, suggesting that PDPs
would suffer from crippling adverse selection. Others argued
that PDPs could thrive if subsidized deeply enough to attract
broad enrollments.
Study Design: We pool data from the Medicare Current
Beneficiary Survey from 1999 through 2001 and merge with
data on benefits and premiums from Medicare Personal Plan
Finder and a major Medigap insurer. We estimate a nested
logit model of insurance plan choice, separating HMOs,
Medigap plans, and traditional fee-for-service (FFS) Medicare
into three nests. Finally, we use the parameters of the model
to simulate plan enrollments after the introduction of PDPs,
with and without competition from HMOs.
Population Studied: All non-institutionalized Medicare
beneficiaries over the age of 65 and not enrolled in Medicaid
or an employer-sponsored Medicare supplement.
Principal Findings: In general, after excluding those enrolled
in Medicaid and employer-sponsored plans, approximately
44% of the remaining beneficiaries will enroll in a PDP and
drug expenditures for this group will be about 5% higher than
the population average, indicating adverse selection. Most of
this group (27%) is predicted to enroll in a non-drug Medigap
plan as well as a PDP. These beneficiaries will have drug
expenditures typically about 13% higher than the population
average. A smaller number (17%) will enroll in a PDP without
an additional supplement. Drug expenditures for this group
will be about 7% lower than the population average.
Beneficiaries enrolling in FFS and non-drug Medigap (10%)
will have average drug expenditures about 30% higher than
average. By contrast, HMO enrollees (30%) and enrollees in
FFS only (17%) will have drug expenditures about 12% lower
than the population average. Adverse selection into PDPs will
be substantially worse in counties where HMOs are available.
Conclusions: PDPs will acquire substantial market shares and
experience mild and stable adverse selection. It will be
ameliorated by risk-adjustment and risk-sharing
arrangements, but the residual effects will cause premiums to
escalate and benefits to be reduced relative to Medicare
HMOs. Because PDPs will be offered on a regional basis,
adverse selection caused by HMOs in urban areas will drive
up premiums in rural areas where HMOs are not available.
Implications for Policy, Delivery, or Practice: PDPs have the
potential to provide stable prescription drug coverage to large
numbers of Medicare beneficiaries. This study suggests that if
Congress seeks to reduce future spending on Medicare,
premium subsidies for PDP enrollees ought to be protected.
In addition, permitting PDPs to further segment their service
areas would improve equity between rural and urban areas.
Primary Funding Source: RWJF
●The New Medicare Prescription Drug Plans: Availability,
Costs, and Benefits
Austin Frakt, Ph.D., Steven Pizer, Ph.D.
Presented By: Austin Frakt, Ph.D., Health Systems Research
Scientist, Health Care Financing & Economics, Department of
Veterans Affairs, 150 South Huntington Ave. (152H), Boston,
MA 02130; Tel: 857-364-6064; Fax: 857-364-4511; Email:
frakt@bu.edu
Research Objective: As of January 2006, for the first time all
Medicare beneficiaries have the option to purchase subsidized
coverage for outpatient prescription drugs through Medicare
Part D. This new drug benefit is also significant in that it is
the first universally available benefit financed by Medicare
exclusively through private insurers. Three main types of
private plans contract with Medicare to provide this coverage:
local health maintenance organizations (HMOs), regional
preferred provider organizations (PPOs), and regional
prescription drug plans (PDPs). This paper examines the
availability, costs, and benefits of the new drug plans.
Study Design: Using data collected from the Centers for
Medicare & Medicaid Services in late 2005, we built a dataset
consisting of all Medicare PPOs, all PDPs and a sample of
Medicare HMOs that were to be offered in 2006. The dataset
includes information on plan name, premium, deductible, gap
(a.k.a. donut hole) coverage, percent of top 200 drugs
covered, and minimum and maximum co-payments. For a
specific set of frequently prescribed brand-name drugs for a
restricted set of nationally-available PDPs offered by large
insurers we built a second dataset that included variables
coding whether the drug was covered and, if so, its tier and
co-payment/co-insurance. All analyses using these two
datasets were descriptive.
Population Studied: This is a study of private Medicare plans
that offer outpatient prescription drug coverage in 2006.
While it is relevant to the Medicare population, all analyses are
at the plan level.
Principal Findings: Where they exist, local HMOs tend to
offer outpatient prescription drug coverage for premiums
below those of PDPs or PPOs. Regional PPOs are not being
offered in large numbers and are absent from some regions.
PPOs are vastly outnumbered by regional PDPs. Even
restricting attention to the small number of national PDPs,
beneficiaries have meaningful choices, with substantial
variation across plans in cost-sharing and formulary
generosity as well as premium. Among PDPs, a small
minority of plans offer coverage in the gap. Only one national
plan offers gap coverage for brand-name drugs.
Conclusions: The success of the new Medicare outpatient
prescription drug benefit will hinge on the viability of regional
PDPs. This study has shown that PPOs are not participating
in large numbers and our other work suggests they face stiff
competition from HMOs. Meanwhile, HMOs will continue
but are unlikely to be offered in rural counties. Thus, for many
beneficiaries, PDPs are the only option for drug coverage. The
stability of the PDP sector is, therefore, central to the vitality of
this new drug benefit.
Implications for Policy, Delivery, or Practice: Variations in
PDP benefit design expose plans to varying degrees of adverse
selection. What design(s) will prove stable over time will
become evident over the next several years. Another
development to watch is how PDPs will react if Congress
begins to reduce spending on subsidies, as recently proposed.
Some plans could make up for a loss in government
payments by increasing their deductibles or changing their
formularies. Plans already offering the statutory minimum
benefit and restrictive formularies would have to increase their
premiums to make up the loss. If this happens, low-risk
beneficiaries judging the increased premium not worth the
benefit will decline coverage, potentially destabilizing these
plans. Given the importance of PDPs to the vitality of Part D,
it would be unwise for Congress to make swift or steep cuts to
PDP subsidies. On the other hand, since PPOs are not a
major component to Part D, targeting cuts to PPO subsidies
is less likely to destabilize the program.
Primary Funding Source: RWJF
●Health Insurance Demand Responses from New Price
Structures Offered by Consumer Directed Health Plans
Stephen Parente, Ph.D., Roger Feldman, Ph.D., Jean Abraham,
Ph.D., Jon Christianson, Ph.D.
Presented By: Stephen Parente, Ph.D., Assistant Professor,
Carlson School of Management, University of Minnesota, 321
19th Avenue South, Rm 3-149, Minneapolis, MN 55455; Tel:
612-624-1391; Fax: 612-624-8804; Email:
SParente@csom.umn.edu
Research Objective: Consumer directed health plans
(CDHPs) are attracting attention from consumers, employers,
and policy-makers. CDHPs are high-deductible health
insurance plans coupled with a tax-advantaged account that
can be used to pay for eligible medical expenses. CDHP
enrollment is currently estimated at approximately three to five
million covered lives. The purpose of this paper is to examine
the effect of ‘price’ on health plan choice. More specifically,
we will determine whether the health care spending account in
the new CDHP designs provides an incentive for consumers
to choose these plans over conventional health insurance
plans; and we will estimate the extent to which the ‘donut
hole’ (i.e. the gap between the account and point where
insurance coverage begins) is a disincentive for health plan
choice. These two ‘prices’ are largely absent from the design
of traditional health insurance plans, which feature relatively
low deductibles and do not have health spending accounts.
The research questions of this examination are: How does the
introduction of Consumer Directed Health Plans (CDHPs)
into mainstream health insurance affect plan choice?
Specifically, what is the impact of the account, donut hole and
deductible on the own-price elasticity of CDHPs?
Study Design: This paper builds upon the plan choice
estimation analysis from an earlier CDHP investigation. In
that analysis, a logistic regression conditional upon the
number of plan choices offered to a given employee was used.
Our primary source of data for this analysis is the employee
health plan choices from four large employers participating in
a Robert Wood Johnson Foundation (RWJF) funded study. The
data from employers represented approximately 250,000
covered lives. Each of these employers offers a CDHP along
with traditional managed care plans.
Population Studied: This is a study of employers that have
offered CDHPs from 2003 to 2005. The analysis is relevant to
the entire self-insured insurance market, as well as the
individual market through simulation.
Principal Findings: Early results show a positive impact of the
health care spending account from which medical expenses
are debited and negative responses to the new CDHP
deductible developed as the difference between a traditional
high deductible health plan and the consumer’s spending
account. With respect to their respective elasticities, the
CDHP deductible, known as the ‘donut hole,’ has a far more
elastic price response than the health spending account. We
examined the price elasticities in our health plan choice
model, including employee premium, health account, donut
hole and coinsurance. The largest of the elasticities is for the
tax-adjusted employee premium. The least elastic response is
for the employee health account. An interesting finding is the
greater elasticity of coinsurance compared with the donut
hole, or the difference between the deductible and the health
account.
Conclusions: Our results suggests that consumers have
greater sensitivity to variations in coinsurance than to changes
in the donut hole structure. These findings may challenge
some detractors of CDHP plans who suggest consumers will
not embrace a plan design with obvious increased cost
sharing in the form of a large potential deductible, compared
with coinsurance, a much more conventional method of costsharing.
Implications for Policy, Delivery, or Practice: The evolution
of CDHP benefit plan design has moved beyond early
experiments. For these designs to be effective and attractive,
the impact of their pricing structures must be understood. If
CDHP designs are to be price to avoid the moral hazard
potential suggest by our earlier work in Health Services
Research (2004), attractive cost-sharing will have to be offered
that encourages participation, while at the same, reduces the
potential for higher than expected, risk-adjusted, medical
expenditure.
Primary Funding Source: RWJF, DHHS
Call for Panels
The Genomics Revolution: Challenges in
Translating New Drugs and Diagnostics into
Practice & Policy
Chair: Kathryn Phillips, University of California,
San Francisco
Monday, June 26 • 2:00 pm – 3:30 pm
Panel Overview: The genomics “revolution” is changing the
inherent nature of the diagnostics, pharmaceutical, and
biotech sectors and how medicine is practiced. The increasing
ability to understand disease at the molecular level is a critical
component of the larger trend towards “personalized
medicine”. Personalized medicine is the targeting of
interventions to individuals based on their specific
characteristics, with the hope that such targeting will decrease
costs and improve health outcomes. Our increased ability to
target health care, however, raises many issues about
translation from research into clinical practice and health
policies. The genomics revolution has far-reaching
implications across many sectors. Important questions
include: What factors will determine the adoption of
personalized medicine? How should new genetic tests be
evaluated? Will health disparities increase if medicines are
targeted only to specific populations? Can our system afford
the high cost of many biological drugs? Who is in the driver’s
seat in determining the value of new drugs and diagnostics
and whether they should be reimbursed? This panel will
address these challenging questions from several perspectives
that will provide both an overview of key health services and
policy issues as well as an update on what are currently the
“hot” issues. Presentations will cover the economic and
regulatory challenges to implementation of personalized
medicine, the high cost of biological drugs in the US, recent
changes in Medicare coverage and payment policies and the
impact of the new Medicare prescription benefit, and
evidence-based approaches to evaluating the use of genetic
tests. We will draw from several sources and use multiple case
studies to illustrate our points.
●The Paradigm Shift of Personalized Medicine: Economic
& Policy Challenges
Kathryn Phillips
Presented By: Kathryn Phillips
Research Objective: Quality of care, patient safety, and drug
safety and effectiveness continue to be major issues. One
proposed approach to addressing these concerns is
personalized medicine, particularly the use of genetics to
target medications (pharmacogenomics). The increased
interest in personalized medicine, targeted therapies, and
pharmacogenomics signals a paradigm shift from one-sizefits-all, “blockbuster” drugs toward niche markets. This
paradigm shift has important implications across the board –
for patients, providers, industry, insurers, and regulatory
agencies. The objectives of this presentation are to: (1)
Review the challenges in appropriately regulating the
implementation of personalized medicine, focusing
particularly on the role of the FDA, and (2) Review the
challenges in implementing personalized medicine in clinical
practice, using case studies to illustrate the larger issues.
Study Design: We used case studies, literature review, and
semi-structured interviews with key thought leaders from
industry and government.
Principal Findings: The advent of personalized medicine
presents challenges to the FDA in pursuing its mandate of
protecting the health and safety of the public. The FDA has
responded by taking a proactive approach and has developed
a variety of initiatives including development of advisory
groups and inter-agency collaborative efforts, sponsorship of
conferences, development of staff expertise, and development
of guidance for genomic data submission, new testing
approaches, and co-development of tests and drugs. Our
case studies illustrate both currently successful uses of
personalized medicine as well as future challenges. HER2/neu
testing for Trastuzumab (Herceptin®, Genentech) therapy for
breast cancer is one of the most familiar examples of
biotechnology drugs used in clinical practice today and is
considered a great success for the company that developed it
and for the patients that have benefited. However, the story
behind its development and approval illustrates many ongoing
challenges that will increasingly be more widely relevant. For
example, the lack of a clear gold standard test for HER2/neu
was an obstacle to approval and continues to generate debate.
In addition, Herceptin therapy is expensive and has not been
shown to be cost-effective, and its approval was delayed in
other countries because of the lack of evidence about costeffectiveness. Given the ongoing debate about the relevant
diagnostic for identifying responders and uncertain costeffectiveness, Herceptin offers insights into the future of other
biotech drugs with companion diagnostics. Another
illustration is provided by microarray tests for mutations in
CYP450 drug metabolizing enzymes, e.g., the AmpliChip
CYP450® test (Roche Diagnostics), which was noted to be
the “world’s first gene chip for broad diagnostic use”. These
types of tests represent a significant increase in the potential
application of pharmacogenomics because they are relevant to
a wide range of individuals and drugs rather than only to a
narrowly defined, high-risk population such as women with
HER2/neu positive tumors. However, there are numerous
challenges to their widespread application including regulatory
ambiguities and the current lack of evidence about their
clinical utility.
Conclusions: Important economic and policy challenges
include: Challenges in moving from the blockbuster model to
personalized medicine; Challenges in the movement of
biotech drugs and diagnostics through the pipeline from
discovery to development to application; Challenges in
regulating and evaluating drugs and diagnostics based on
genetic information, including the role of the FDA, technology
assessment, economic evaluation, and reimbursement
policies.
Implications for Policy, Delivery, or Practice: The
experiences in implementing personalized medicine illustrate
the complex issues involved in regulation of new technologies.
This is particularly challenging when new technologies require
integration of historically separate industries and regulations,
as in the case of pharmacogenomics because it emerges from
both the diagnostic and drug industries. The experiences also
indicate the difficulties of health care assessment regulation in
the U.S., which does not have a cohesive and comprehensive
approach to technology assessment.
Primary Funding Source: NCI, FDA
●High Cost, Low Coverage Drugs:Expenditures and
Medicare Formulary Coverage For Biotechnology Drugs
Jennifer Haas
Presented By: Jennifer Haas
Research Objective: The utilization of biotechnology drugs
(“biologics”) has grown dramatically, yet little is known about
expenditures and formulary coverage for these costly drugs.
Objective is to examine: (1) recent trends in expenditures for
the top 10 biotechnology drugs and (2) formulary coverage for
these drugs under the Medicare Prescription Drug Plan.
Study Design: Cross-sectional analysis of US sales of the top
10 biotechnology drugs from 2002 to 2004. Pharmaceutical
sales data were extracted from the Knowledge Express Data
Systems (UTEK Corporation). Formulary coverage was
obtained from the Centers for Medicare and Medicaid
Services. We calculate the percentages of prescription drug
plans that include these biotechnology drugs in their
formularies. We examine whether formulary coverage varies
by drug, state (California vs Massachusetts), and plan type
(stand-alone prescription drug plans vs Medicare Advantage
drug plans).
Population Studied: Medicare prescription drug plans in
California (n=471) and Massachusetts (n=293).
Principal Findings: Sales of the top 10 drugs have increased
47% from 2002 to 2004, with the biggest increase in sales of
Aranesp (495%). A minority of these Medicare prescription
drug plans included these drugs in their formularies, ranging
from 12% for Rituxan to 35% for Remicade and Enbrel.
Coverage for these drugs varies between California and
Massachusetts. Stand-alone prescription drug plans are more
likely to cover these biotechnology drugs than Medicare
Advantage plans (77% vs 19%).
Conclusions: Despite increasing sales of the top
biotechnology drugs, a minority of Medicare plans in two
states cover these products. Coverage varies by drug, state,
and plan type. Stand-alone prescription drug plans may have
better coverage for biotechnology drugs compared to
Medicare Advantage drug plans.
Implications for Policy, Delivery, or Practice: Careful
evaluation of the value and formulary coverage of
biotechnology drugs is needed.
Primary Funding Source: NCI
●Medicare and New Technology
Patricia Keenan
Presented By: Patricia Keenan
Research Objective: CMS national coverage decisions hold
consequences for beneficiary health, Medicare costs, and
availability of new treatments. Biotechnology in particular
poses challenges for Medicare given its high cost, the
potential for individualized treatments, and the lack of
generics. Research Objectives: 1) Assess major changes in
Medicare coverage and payment policy for new treatments,
including biotech treatments. 2) Qualitatively examine the
role of evidence quality, political attention, and costs in
Medicare national coverage decisions.
Study Design: Synthesis of regulatory changes in Medicare
coverage and payment, and case studies and interviews of
Medicare coverage decisions for 13 treatments.
Principal Findings: Since 1999, the Medicare program has
made substantial changes to incorporate a greater role of
clinical evidence and expand opportunities for public input in
coverage and payment decisions for new treatments. The case
studies suggest that national coverage decisions show more
variability in scope of coverage relative to the evidence for
treatments with greater uncertainty in clinical evidence and
policy goals. CMS creates tailored conditions of coverage to
respond to uncertainty in clinical evidence and balance safety,
access, and cost considerations. Some decisions interpret
uncertain evidence more broadly, particularly for salient
diseases with limited treatment alternatives. Other decisions
interpret uncertain evidence more narrowly, particularly when
treatment costs are potentially very high, and/or political input
is mixed or limited.
Conclusions: Medicare new technology policy poses
substantial challenges for policymakers seeking to balance
goals to promote access to beneficial treatments while
minimizing the pressure of rising Medicare spending.
Implications for Policy, Delivery, or Practice: Medicare
policies for new medical treatments are likely to attract further
attention as the Medicare prescription drug benefit expands
the set of treatments that may be considered in the national
coverage process. Challenges are also likely to become more
pronounced as additional costly new technologies, such as
specialized biotech treatments, become available to treat rare
or life-threatening diseases with limited treatment alternatives.
Primary Funding Source: RWJF, NIA
●Moving Forward on Evidence Based Assessment of
Genomic Applications: The EGAPP Project
Katrina Armstrong
Presented By: Katrina Armstrong
Research Objective: Background: The genomics revolution
has created a pressing need for reliable and unbiased
assessments of the utility of genetic tests and genomic
technologies that can be used by a diverse set of stakeholders
including providers, consumers, payers, public health officials
and other policy makers. Objectives: The Evaluation of
Genomic Applications in Practice and Prevention (EGAPP)
Project is a three year model project funded by the CDC to
develop a systematic, evidence-based process for evaluating
genomic applications in transition from research to clinical
and public health practice. The key characteristics of the
EGAPP project are: (1) inclusion of a broad range of expertise;
(2) independent, objective review linked to evidence; (3) focus
on genomic technologies not addressed by other evidence
based review processes; (4) engagement of a wide range of
stakeholders; and (5) integration of experience from genetics
advisory panels and existing U.S. and international processes
for evidence based technology evaluation.
Study Design: A 13 member Working Group was assembled
representing a broad range of expertise (e.g. evidence based
review, primary care, medical genetics, laboratory practice,
epidemiology, health economics and bioethics). This
independent Working Group meets quarterly and has formed
subcommittees to accomplish concrete goals. Pilot studies
and literature reviews have been used to answer preliminary
questions related to the development and implementation of
the EGAPP procedures.
Principal Findings: The three initial subcommittees (Topics,
Methods and Outcomes) have created novel approaches for
prioritizing and selecting topics for review, developing analytic
frameworks for the complex clinical and public health
questions raised by genomic technology, and identifying the
relevant outcomes across a broad set of domains including
clinical, psychological, social and ethical consequences.
Working titles for the first two topics selected for evidence
review were “Screening for Hereditary Nonpolyposis
Colorectal Cancer in Newly Diagnosed Colorectal Cancer
Patients” and “Testing for Cytochrome P450 Polymorphisms
in Adults with Non-Psychotic Depression Treated with
Selective Serotonin Reuptake Inhibitors.” The evidence based
reviews for these topics are underway through contracts with
the Agency for Healthcare Research and Quality Evidence
Based Practice Centers. The next steps are to identify and
develop the products that will be disseminated to the target
audiences once the reviews are completed, create sustainable
processes for topic identification and selection, develop
frameworks for incorporating the “gray” literature in the review
process, and involve diverse stakeholders.
Conclusions: Since its inception in 2005, the EGAPP Working
Group has made substantial progress towards developing and
implementing systematic processes for the evaluation of
genomic technologies. This progress has built upon prior
experiences with evidence based review, genetics advisory
panels and public health policy.
Implications for Policy, Delivery, or Practice: EGAPP has
the potential to influence the translation of genomic
technology into clinical and public health practice. The
implications for the move to personalized medicine will be
highlighted.
Primary Funding Source: CDC
Call for Panels
Medical Surge Capacity
Chair: Shayne Brannman, The CNA Corporation
Monday, June 26 • 3:45 pm – 5:15 pm
Panel Overview: Given the threat of terrorism and natural
disasters, medical and public health systems face an
increasing probability of a major public health emergency that
will severely challenge their ability to adequately care for large
numbers of patients. The response to a large-scale public
health or medical emergency is generally a local responsibility.
Initially, this response could involve multiple jurisdictions in a
region, until sufficient external assistance arrives from
neighboring states and/or the Federal government. Our panel
explores how public health emergency preparedness research
is currently being used in “real world” policy and operational
settings to address surge capacity issues, and how the
outcomes of this research are helping policy-makers shape
future plans. We will discuss how research sponsored by the
Agency for Healthcare Research and Quality (AHRQ) was
used as the foundation for the development of the Federal
Medical Station prototype, which was used during hurricanes
Katrina and Rita to address bed capacity needs. Moreover, we
will discuss gaps in preparedness legislation and policies.
Management systems that need to be in place to better
integrate medical resources during large-scale emergencies
will be highlighted. An official with significant research and
government health experience will moderate our panel. Panel
membership includes an emergency medicine director from a
large medical center; a senior policy manager within the
Department of Health and Human Services; the project
manager of the recently published Medical Surge Capacity and
Capability Handbook; and a senior policy analyst with firsthand experience working on interagency medical issues.
●Rocky Mountain Regional Care Model
Stephen Cantrill, M.D.
Presented By: Stephen Cantrill, M.D., Associate Director of
Emergency Medicine, Emergency Medicine, Denver Health
Medical Center, 777 Bannock Street, Denver, CO 80204; Tel:
(303) 436-7174; Fax: (303) 436-7541; Email:
stephen.cantrill@dhha.org
Research Objective: Rural areas face unique and demanding
challenges when assessing the best potential solution to
address hospital surge capacity needs, by either augmenting
hospitals' capabilities or establishing alternative care sites.
Federal Region VIII represents 3 percent of the country's
population, but comprises about 16 percent of the land area.
This region is the most rural region of the country with a
significant portion classified as frontier. There are 28,100
community hospital beds in the region, but almost half of the
beds are in Colorado and Utah, which comprise 70 percent of
the region's population. Under an Agency for Health
Research and Quality (AHRQ) grant, a Rocky Mountain
Regional Care Model for Bioterrorist Events (RMBT) Working
Group was established to address medical surge capacity
issues/needs for Federal Region VIII (Colorado, Montana,
North Dakota, South Dakota, Wyoming, and Utah).
Study Design: The RMBT was an inter-agency and multidisciplinary working group that brought together key
stakeholders in the region to identify surge capacity issues
that were considered important and where solution
development was necessary. Two well-known emergency
medicine physicians, from a large academic medical center in
Denver, led the RMBT Working Group. Through this
collaboration and experience of the RMBT working group
members, several products and tools were developed to
address surge capacity issues for this region. Most notably,
U.S. Northern Command identified a need to develop a tool to
assist planners in selecting an alternative care site for
providing medical care to victims of a bioterrorist incident. A
tool was created through collaboration between the RMBT
Working Group members and facility engineers that assists
medical planners in ranking and scoring alternative care sites
based on adequacy of facility characteristics such as
ventilation, plumbing, and food supply and preparation areas.
Potential alternative care sites could include schools, motels,
recreation centers, churches, National Guard facilities, and
stadiums. In order to address supplying and staffing these
alternative care sites, the RMBT group discussed several
alternatives.
Population Studied: Federal Region VIII (Colorado, Montana,
North Dakota, South Dakota, Wyoming, and Utah).
Principal Findings: The group's solution to address bed,
supply and equipment needs was the creation of medical
caches that are stored for use in a fixed location or that can be
transported to a remote site in a trailer. Three cache level lists
were developed: -Level I, Hospital Augmentation Cache
-Level II, Regional Alternative Care Site Cache
-Level III, Comprehensive Alternative Care Site List
Each of these lists includes cots and other supplies, but does
not include a "facility." These caches are to be used in
conjunction with an existing structure: either hospital or
alternative care site. Pharmaceuticals are not included in the
caches as the Strategic National Stockpile addresses this
need.
Conclusions: For mass casualty events, surge bed capacity
can be created by pre-identifying alternative care sites and
establishing caches of required materials and supplies.
Implications for Policy, Delivery, or Practice: The findings
from this research was used by the Office of Public Health
Emergency Preparedness at HHS to help shape the national
federal medical station prototype(deployable hospital
program) used in hurricanes Katrina and Rita.
Primary Funding Source: AHRQ
●Federal Medical Station
Eric Trabert, M.P.H., Epidemiology, Monica Giovachino, M.S.
Presented By: Eric Trabert, Masters Public Health,
Epidemiology, Research Analyst, Healthcare Operations Team,
The CNA Corporation, 4825 Mark Center Drive, Alexandria, VA
22311-1850; Tel: (703) 824-2260; Fax: (703) 824-2256; Email:
trabere@cna.org
Research Objective: The Office of Mass Casualty Planning
within the Department of Health and Human Services (HHS)
has developed a federal contingency care program to provide
quarantine and bed surge capability during a catastrophic
event in coordination with state and local health authorities.
The prototype of this program is the Federal Medical Station
(FMS), which was deployed after Hurricanes Katrina and Rita
in response to the severe damage to the health infrastructure
and expected demand for hospital beds. In a study sponsored
by HHS, we performed an evaluation of FMS operations
during Hurricanes Katrina and Rita. The study focuses on the
integration of the FMS program into state and local
emergency response operations. Since 9/11, Federal, state,
and local authorities have been preparing for mass casualty
events and developing plans to address shortfalls in surge bed
capacity. Both HHS and the U.S. Department of Homeland
Security are developing programs to provide extra capacity.
Similar surge capacity initiatives are in place at state and local
levels through HHS grant programs administered by the
Centers for Disease Control and Prevention (CDC), the Health
Resources and Services Administration (HRSA), and other
agencies.
Study Design: Our study used a three-step process of
observation, reconstruction, and analysis. We deployed
analysts to observe FMS operations during Hurricanes Katrina
and Rita. These analysts kept detailed logs of their
observations, conducted structured interviews with personnel
involved in the response, and collected field data (e.g.,
operational logs, situation reports, and administrative
records). We supplemented these data by conducting
structured interviews with personnel located in other areas,
such as Washington, DC and regional command centers, to
gain additional information and insight on the response. We
used the data that we collected to develop a timesynchronized database that included decisions, events, and
actions related to FMS operations. We used the interviews to
identify common themes and validate the reconstruction
database. We also compiled data on personnel deployments
and patient care where available. We analyzed key issues and
identified lessons learned, performed a descriptive analysis of
the types of medical and public health needs, and provided
recommendations for improving FMS operations in the
future.
Population Studied: Site visits were conducted in Lousiana,
Mississippi, Texas, and the Strategic National Stockpile.
Principal Findings: Even as a prototype, the FMSs cared for a
wide variety of patients in Louisiana, Mississippi, and Texas.
As a result of this program status, many of the standard
operating procedures for activating, deploying, setting up, and
managing operations during an emergency were still in
development. As one would expect, the training program
associated with the FMS was also under development
resulting in a very limited number of personnel trained to use,
deploy, operate, and manage the asset. As a result, FMS
assets were not always used effectively. One of our key
findings is the need to institutionalize the FMS program at the
regional level by engaging state and local public health
authorities into a coordinated planning and training effort.
Conclusions: The final report is still being prepared therefore
final conclusions are still being developed as of this writing.
Implications for Policy, Delivery, or Practice: Our analysis
and recommendations can help guide public health
authorities at all levels of government prepare for the next
hurricane and other mass casualty events.
Primary Funding Source: HHS
●Medical Surge Capacity and Capability Handbook
CAPT Ann Knebel, Ph.D., Joe Barbera, M.D., Anthony
Macintyre, M.D., Eric Trabert, M.S., Shayne Brannman, M.S.
Presented By: CAPT Ann Knebel, Ph.D., Acting Deputy
Director, Office of Mass Casualty, U.S. Department of Health
and Human Services, Office of Public Health Emergency
Preparedness, 200 Independence Avenue, SW, Washington,
DC 20201; Tel: (202) 205-5129; Email: ann.knebel@hhs.gov
Research Objective: Medical and health systems in the
United States face the increasing probability of major
emergencies or disasters involving large numbers of
casualties and/or victims with highly specialized medical
needs. An effective and coordinated response to such
incidents requires the implementation of management
systems that establish a methodology for managing medical
and health response, as well as the development and
maintenance of preparedness programs. Under sponsorship
of the Department of Health and Human Services (HHS), the
authors developed the Medical Surge Capacity and Capability
(MSCC) Management System. The MSCC applies valid
principles of emergency management and the Incident
Management System (IMS) to describe how to manage,
within a single system, the diverse health and medical entities
involved in incident response.
Study Design: The MSCC is based on the Medical and Health
Incident Management (MaHIM) System, the first published
U.S. effort to conceptually address the medical and health
management issues that arise during major emergencies or
disasters. We worked with the authors of MaHIM to translate
their academic concepts into a practical, operationally
oriented guidance for medical and health emergency planners.
The study team also convened a panel of subject matter
experts from across the country representing such diverse
disciplines as public health, emergency medicine, emergency
management, public safety, and the private sector to identify
the most important themes to be presented in the handbook
and to synthesize key and difficult concepts into an readily
understandable format.
Population Studied: Not Applicable
Principal Findings: The MSCC Management System
describes a framework of coordination and management
integration across six tiers of response, ranging from the
individual healthcare facility through jurisdictional, state, and
federal government levels. It is designed to promote the
integration of existing incident management programs used
by hospitals, public health, and traditional response entities
into an overarching management system for major medical
response. Thus, health and medical disciplines can use the
MSCC to coordinate effectively with each other, and to
integrate with other response disciplines (e.g., public safety).
Moreover, the MSCC guides the development of a health and
medical response that is consistent with the National Incident
Management System (NIMS).
Conclusions: Examinations of major public health and
medical emergencies reveal exceptionally complex
management scenarios. The MSCC Handbook describes a
management structure, based on valid emergency
management and incident management principles, for the
medical and health response to be orchestrated as a single
system.
Implications for Policy, Delivery, or Practice: The
completed MSCC Handbook was distributed to HRSA and
CDC regional and program coordinators, in additional to key
health and medical response policy makers involved with
coordinating emergency support function 8 of the National
Response Plan.
Primary Funding Source: HHS
●Integration of Federal, State, and Local Medical
Resources in Catastrophic Events
Matthew Payne, M.P.A.
Presented By: Matthew Payne, M.P.A., Senior Advisor, Public
Health, Healthcare Operations Team, The CNA Corporation,
4825 Mark Center Drive, Alexandria, VA 22311-1850; Tel: (703)
824-2043; Fax: (703) 824-2256; Email: paynem@cna.org
Research Objective: The responses to Hurricanes Katrina,
and Rita exposed the fragile relationship between
communities, states and the Federal government as it relates
to the provision of medical support to disasters. In the face of
a catastrophic emergency, medical requirements can quickly
overwhelm the capabilities of a community, state, region and
the Federal government. Key to any successful response is
the requirement of planners to understand the assets available
in their inventory, the capabilities offered and the timeliness of
their response. To better understand these relationships and
provide recommendations for future system improvements,
we are conducting an independent study that highlights the
inherent roles and responsibilities of both governmental and
non-governmental organizations. Additionally, the study
identifies the challenges associated with providing a timely
medical response to catastrophic disasters. All disasters are
inherently local. Regardless of the eventual size, the first
impacts of a disaster are felt locally. However, local resources
are sometimes overwhelmed by the magnitude and resource
requirements of the event. In these cases, assistance is
required from community neighbors, the state, neighboring
states and sometimes the Federal government. Using the
experience and history of an actual response, this study
examines the commonalities and constraints present in the
authorities used by each organization to provide medical
support.
Study Design: Legislative and regulatory searches are being
used to establish the inherent roles and responsibilities of the
respective organizations. Internet searches and organizational
interviews are being used to establish the types, capabilities
and quantities of resources available and used to support the
response. The combined products address: (1) the roles and
responsibilities of individual facilities / organizations (e.g.,
hospitals and healthcare institutions) to care for their patients
during catastrophic disasters; (2) the roles and responsibilities
of the state to support these institutions, particularly private
facilities; (3) non-Federal resources that can independently
support an institution or state in the provision of care; and (4)
the roles of the Federal government in supporting states and
individual institutions.
Population Studied: N/A
Principal Findings: Study begun in December 2005 and will
be completed in May 2006.
Conclusions: Study begun in December 2005 and will be
completed in May 2006.
Implications for Policy, Delivery, or Practice: Throughout
the study, we are comparing the relative costs and benefits of
the different capabilities, assets and mechanisms. In
assessing the relative benefits of particular approaches and
assets, costs and benefits are weighed by timeliness of the
asset, the capabilities provided and the cost burden to request
its use. Based upon these results, we are drawing conclusions
regarding the current systems to support the medical
response to catastrophic disasters, making recommendations
to improve the timeliness and efficiency of the overall
response.
Primary Funding Source: CNA Corporation (Self-Initiated)
Call for Panels
Implications of Public and Private Reporting of
Performance Data: Mechanisms for Driving
Quality Improvement
Chair: Deirdre Mylod, Press Ganey Associates, Inc
Tuesday, June 27 • 8:45 am – 10:15 am
Panel Overview: Public vs. private reporting of quality
information creates differential impact on hospitals’ response
to feedback about their levels of performance. It is suggested
that creating concern regarding public image and reputation
and the provision of feedback itself may be the primary
mechanisms by which organizations are prompted to engage
in quality improvement activities following public reporting
initiatives. These mechanisms may be strongest for
organizations receiving public feedback that their performance
is sub-par. This panel will begin with results and discussion of
an experimental study comparing the effects of public, private
and no reporting of data on hospitals and consumers.
Information will then be provided regarding a statewide effort
for cyclical public reporting in the state of Rhode Island
interspersed with interim periods of private reports to
hospitals. Rates of change will be compared between the
public and private reporting cycle times with comparisons to
national normative rates of change for hospitals receiving
private reports. Finally data will be presented describing
national trends in change based upon private reporting of
patient perceptions of care. These trends will note facility
characteristics that are associated with greater or lesser rates
of change over time. Discussion throughout will focus on the
mechanisms for change and the extent to which data from
different research activities support these mechanisms.
●Impact of Public and Private Hospital Performance
Reports on Quality, Market Share and Reputation
Judith Hibbard, Dr. P.H.
Presented By: Judith Hibbard, Dr. P.H., Professor,
Department of Planning, Public Policy & Management,
University of Oregon, 1209 University of Oregon, Eugene, OR
97403-1209; Tel: (541) 346-3364; Fax: (541) 346-2040; Email:
jhibbard@uoregon.edu
Research Objective: The purpose of these studies was to
understand the effects of public vs. private reporting of clinical
performance data on hospitals’ initiation and adoption of
quality improvement activities and subsequent improvement
in quality and on consumers’ knowledge about quality
differences and choices regarding health care providers.
Study Design: This study uses an experimental design in
which hospitals received a public report of their clinical
performance data, a private report of their data, or no report
showing how their organization fared as compared to others.
Hospitals were then surveyed regarding their beliefs about
public reporting as well as their subsequent quality
improvement activities. Patients were surveyed regarding
their recall and use of the publicly reported information. Two-
years later a follow up investigation showed actual hospital
improvement and sustained changes in hospital reputation.
Choice and market share were largely unaffected.
Population Studied: The population studied included a set of
hospitals included in a public report of clinical data. The other
hospitals in the state were randomly assigned to receive either
private confidential reports or no feedback on their
performance.
Principal Findings: The public reporting condition was
associated with a higher mean number of quality
improvement activities initiated related to the areas identified
in the public report. In particular, hospitals with poor
performance had significantly greater efforts for quality
improvement if their data were made public. Hospitals in the
public report condition were in general more likely to take
some action toward quality improvement in the reported
areas. Subsequent follow-up showed that public report
hospitals made significantly more improvements in care
especially for those with poor initial performance. Consumers
who received evaluable information regarding hospital
performance recalled the information and were able to more
accurately identify high and low performers. Impact on
hospital reputation was sustained over time. Market share did
not change as a result of the public reporting.
Conclusions: Public reporting of clinical quality information
stimulated more quality improvement activities and more
positive results over and above what was seen for hospitals
receiving only private results. It is expected that in order for
this effect to be noted, reports must be highly evaluable and
widely disseminated and hospitals must anticipate that future
public reports will occur.
Implications for Policy, Delivery, or Practice: The data
suggest that the use of evaluable public reporting may
stimulate change in performance primarily through the
mechanisms of concern regarding reputation as well as
through the provision of feedback. These mechanisms may
be particularly strong in situations where larger variations in
care exist and may be felt most by hospitals with poorer initial
performance.
Primary Funding Source: RWJF
change are compared to a national sample of hospitals
receiving only private reports.
Population Studied: Study population focuses on general
acute care inpatient hospitals in the state of Rhode Island. The
study uses continuous performance data as measured by
patient surveys of care over the last 3 years.
Principal Findings: Rates of improvement did not differ
between public reporting periods and periods where only
private reporting of data was available to hospitals. Rates of
improvement were not greater for the Rhode Island sample
than for a national sample of hospitals receiving public
reports. Rhode Island hospitals used collaborative sessions
immediately following public reporting cycles to share best
practices and to focus collective efforts on areas where care
could be improved.
Conclusions: Findings suggest that in this particular climate
where public reporting of data had become the norm, the
differential impact of publicly reported data was not
discernable. Instead, continuous rates of incremental change
were noted regardless of the timing of public reporting. These
findings may support the hypothesis that feedback itself
promotes change. Alternatively, the relatively high
performance of Rhode Island hospitals may preclude the
public report from having the differential effect that has been
noted elsewhere. Finally, the climate in Rhode Island which is
accustomed to public reporting as an corollary of QI efforts
rather than a feared impetus for QI may have effected the way
hospitals responded to public and private reporting of data.
Implications for Policy, Delivery, or Practice: Creating an
environment where public reporting is both accepted and
considered secondary to the purpose of quality improvement
may reduce hospital concerns regarding initial reports and
allow them to work together to learn effective means of
improving care.
Primary Funding Source: No Funding
●Rates of Change During Public and Private Reporting
Cycles of Hospital Performance: Implications for
Mechanisms Driving Quality Improvement
Cathy Duquette, Ph.D., RN, CPHQ
Presented By: Deirdre Mylod, Ph.D., Vice President, Research
and Public Policy, Research & Development, Press Ganey
Associates, Inc., 404 Columbia Place, South Bend, IN 46601;
Tel: (574) 232-3387; Fax: (574) 232-3485; Email:
dmylod@pressganey.com
Research Objective: The objective of this research was to
understand the normative amount of change in patient
evaluations of quality over a 12 month time frame and to
determine if hospitals’ success with making improvements in
quality based upon private report of patient survey data varies
by hospital characteristic, such as: size of hospital, religious
affiliation, teaching status, region of the country, etc.
Study Design: The study uses retrospective quantitative data
gathered from patients in a continuous fashion over a 15
month time frame and compares hospital level performance
from fourth quarter calendar year 2004 with fourth quarter
calendar year 2005.
Population Studied: The population studied included 815
general acute care hospitals that continuously survey their
patients regarding the quality of care and service provided
during an inpatient stay. Patient populations surveyed include
Presented By: Cathy Duquette, Ph.D., RN, CPHQ, Vice
President, Nursing and Patient Care Services, Nursing and
Patient Care Services, Newport Hospital, 11 Friendship Street,
Newport, VA 02840; Tel: 401.846.6400; Email:
cduquette@lifespan.org
Research Objective: The purpose of this study was to
understand the effect of public vs. private reporting of patient
survey information on rates of change in patient perception of
hospital quality.
Study Design: The paper describes the rates of improvement
in scores from patient surveys following the legislation of
regular cycles of public reporting of patient survey data in the
state of Rhode Island. Comparisons are made between rates
of change near, that is pre or post, public reporting time
frames to rates of change when only private reporting with
benchmarking is available to participating hospitals. Rates of
●Hospital Characteristics and Normative Rates of
Improvement Using Private Feedback for Quality
Improvement
Deirdre Mylod, Ph.D., Jessica Langager, B.A.
a random sample of all discharges of all insurance types, ages
and medical service lines.
Principal Findings: Hospitals vary in their ability to effect
positive change based upon private reporting of patient
evaluations. Some hospital characteristics are associated with
an organization's ability to respond effectively with quality
improvement efforts. Specifically, a Chi-square test indicated
significant associations between region of the country, bed
size and teaching status with the hospitals' demonstrated rate
of change over a year cycle. Additionally, the hospitals'
baseline performance was significantly and inversely
associated with the amount of change seen over time
indicating that lower performers had greater rates of positive
change.
Conclusions: From these data we can conclude that not all
organizations are able to respond to private feedback in the
same fashion. Some hospitals are able to respond positively
and to use the data for quality improvement. Other types of
organizations may face greater challenge in changing the
quality of care for the better.
Implications for Policy, Delivery, or Practice: From this
study we learn about factors that may be important for
managing change in the face of public reporting. Hospitals
that respond well to private feedback may be best poised to
show dramatic improvements when the stakes are raised and
public reporting of patient views are available. However, other
types of organizations may need significant support and
direction to effect positive change. As in findings from public
report studies, the effect of private reporting appears most
positive for those organizations with lower baseline
performance.
Primary Funding Source: Press Ganey Associates
Call for Panels
Challenges in Developing a Quality Monitoring
System for Cancer Care
Chair: Melissa Hughes, Dana-Farber Cancer
Institute
Tuesday, June 27 • 10:30 am – 12:00 pm
Panel Overview: In recent years, based on the evidence
available, the quality of cancer care has been reported as
uneven at best. In 1999, the Institute of Medicine released a
report “Ensuring Quality Cancer Care”, concluding that there
are no uniform standards to measure the quality of cancer
care and therefore, tremendous gaps in our knowledge of the
level of quality of care exist. The report recommended that “a
cancer data system is needed to provide quality benchmarks
for use by systems of cancer care.” Many efforts are now
underway to create a routine quality-monitoring system for
populations of patients with cancer. To this end, the National
Comprehensive Cancer Network (NCCN) has developed a
multi-institutional quality monitoring system to assess quality
of breast cancer care for its participating cancer centers. The
NCCN’s evidence-based guidelines and a uniform prospective
data system provide a framework with which to measure
quality of care. First, the panel will describe the components of
the quality monitoring system, specifically the features of the
outcomes database. We will then discuss institutional
variation in quality indicators as defined by the NCCN
guidelines; whether performance on selected quality indicators
is associated with overall institutional performance; measures
demonstrating underuse and overuse of post-mastectomy
radiation; the impact of age on receipt of guidelinerecommended treatment; and a methodological approach to
select priorities for quality improvement from this unique set
of quality measures. Presentations will address the goals,
implications and generalizability of NCCN’s quality
monitoring system and highlight practical and methodological
challenges to date.
●Development and Applications of Quality Measures:
Studying Guideline-Concordant use of Radiation Therapy
after Mastectomy in the National Comprehensive Cancer
Network
Rinaa S. Punglia, M.D., M.P.H., Melissa E. Hughes, MSc,
Michael A. Bookman, M.D., Rebecca A. Ottesen, MS, Joyce C.
Niland, Ph.D., Jane C. Weeks, M.D., MSc
Presented By: Rinaa S. Punglia, M.D., M.P.H., , Center for
Outcomes and Policy Research, Dana-Farber Cancer Institute,
44 Binney St, Boston, MA 02115; Tel: 617-632-3972; Fax: 617632-2270; Email: rinaa_punglia@dfci.harvard.edu
Research Objective: The National Comprehensive Cancer
Network (NCCN) publishes comprehensive clinical practice
guidelines and collects detailed clinical information about
patients treated in its participating centers. Both of these
functions are essential to the development of the NCCN’s
quality monitoring system to assess the quality of cancer care
delivered. We present an example of using quality measures to
examine underuse and overuse of post-mastectomy radiation
(PMRT), as defined by the NCCN practice guidelines, among
women with Stage I-II breast cancer.
Study Design: Current NCCN guidelines recommend PMRT
for women at high risk of recurrence, as defined by tumor
involvement in four or more axillary nodes, tumor size greater
than 5 centimeters, and/or positive surgical margins. The
guidelines also define patients at low risk of recurrence for
whom PMRT is not recommended. Finally, the guidelines
identify a cohort of women, those with one to three positive
axillary nodes and/or close surgical margins, for whom the
value of PMRT is uncertain. Using the framework created by
the NCCN treatment guidelines, patients who received
mastectomy were classified into three cohorts according to
whether guidelines (1) recommended PMRT, (2)
recommended against PMRT, or (3) made no definitive PMRT
recommendation. We defined the absence of PMRT in the
first cohort as underuse, and receipt of PMRT in the second
cohort as overuse. Multivariable logistic regression was
applied to each cohort to investigate the association of clinical
and sociodemographic factors with receipt of PMRT.
Population Studied: We analyzed consecutive patients at
eight NCCN institutions with newly diagnosed unilateral Stage
I or II breast cancer who received mastectomy as definitive
surgery between 7/97-12/03 and continued to receive care at
the institution for at least 365 days after presentation.
Principal Findings: We identified 2,945 eligible women for
our analysis who were then separated into treatment cohorts.
We found that 87.0% (367/422) received PMRT in the
“recommend PMRT” cohort, 4.6% (79/1710) in the
“recommend against PMRT” cohort, and 33.2% (258/777) in
the “consider PMRT” cohort. The only factor associated with
underuse in the “recommend PMRT” cohort was not receiving
chemotherapy (OR=0.07, p<0.0001). In addition to tumor
characteristics, factors associated with overuse in the
“recommend against PMRT” cohort included NCCN
institution (OR=0.26-1.48, p=0.02) and receipt of
chemotherapy (OR=2.31, p=0.02). Factors associated with
PMRT in the “consider PMRT” cohort included NCCN
institution (OR=2.0-13.8, p<0.0001), patient age (under 50
years: OR=3.24, 50-70 years: OR=1.92, relative to above 70
years; p=0.003), lack of early breast reconstructive surgery
(OR=0.60, p=0.01 for those with reconstruction), and tumor
characteristics.
Conclusions: Concordance with definitive treatment
recommendations was high in our centers. However, when
current evidence does not support a definitive
recommendation for PMRT, treatment decisions appear to be
influenced not only by patient age and clinical characteristics,
but especially by institution-specific patterns of care.
Implications for Policy, Delivery, or Practice: NCCN’s
evidence-based guidelines and a uniform data system provide
an informative framework with which to measure and study
quality of care received.
Primary Funding Source: NCCN
●Institutional Variation in Concordance with Guidelines
for Breast Cancer Care in the National Comprehensive
Cancer Network: Implications for Choice of Quality
Indicators
Melissa E. Hughes, MSc, Jane C. Weeks, M.D., MSc, Melissa
E. Hughes, MSc, Joyce C. Niland, Ph.D., Rebecca A. Ottesen,
MS, Richard L. Theriault, DO, MBA, Stephen B. Edge, M.D.
Presented By: Melissa E. Hughes, MSc, Project Manager of
NCCN Breast Cancer Outcomes Database, Center for
Outcomes and Policy Research, Dana-Farber Cancer Institute,
44 Binney St, Boston, MA 02115; Tel: 617-632-2268; Fax: 617632-2270; Email: melissa_hughes@dfci.harvard.edu
Research Objective: Concordance with the National
Comprehensive Cancer Network (NCCN) breast cancer
guidelines is examined annually across the NCCN institutions
as part of an overall quality monitoring strategy. Using these
concordance analyses, we tested the potential to differentiate
performance at an institutional level. We also examined
whether institutional performance on two widely accepted
guidelines were valid indicators of overall performance across
all guidelines.
Study Design: To examine institutional performance on
guideline concordance, we calculated and compared each
institution’s standardized mean percent concordance for 19
guidelines spanning treatment recommendations for DCIS,
Stage I, II and III breast cancer patients. Multivariable logistic
regressions were used to determine whether inter-institutional
differences in concordance for local and systemic therapy
guidelines existed, after controlling for patient sociodemographic and clinical characteristics. We selected two
candidate quality indicators of breast cancer care based on the
strength of the evidence base: radiation therapy after breastconserving surgery in Stage I-II patients and adjuvant
chemotherapy in Stage II, node positive, ER negative patients.
We then used correlation analyses at the institution level to
determine whether an institution’s performance on these two
quality indicators was associated with its overall guideline
concordance.
Population Studied: From the NCCN outcomes database, we
selected all women newly diagnosed with Stage 0, I, II, and III
breast cancer who presented for care at eight participating
NCCN institutions between July 1, 1997 and June 30, 2000.
Patients were included in the analyses if they were followed at
the NCCN institution for at least 365 days post presentation.
The final sample was 4,315 women.
Principal Findings: Mean concordance with NCCN breast
cancer guidelines was generally high. However, guideline
concordance varied across institutions, from a low of 74%
(95% CI: 70-77) to a high of 84% (95% CI: 82-85). Interinstitutional differences in concordance with local (p<.0001)
and systemic therapy (p=0.0006) guidelines persisted, even
after controlling for patient socio-demographic and clinical
characteristics. Concordance also varied by the level of
evidence upon which the guidelines are based, with centers
consistently demonstrating higher levels of concordance with
guidelines based on higher-quality evidence. Mean percent
concordance ranged from 81% to 91% for guidelines based on
higher-level evidence, as compared to 59% to 73% for
guidelines based on lower-level evidence. No significant
correlations were found between an institution’s performance
on the two candidate quality indicators and its performance
on the other breast cancer treatment guidelines.
Conclusions: Even among these NCI-designated
comprehensive cancer centers, we found significant variation
in concordance with guidelines across institutions. Since
performance on two commonly recommended indicators did
not predict an institution’s overall performance across all
guidelines, we are exploring other strategies that might serve
as efficient but robust alternatives to comprehensive
concordance monitoring.
Implications for Policy, Delivery, or Practice: Our
experience suggests that comprehensive quality monitoring
not only supports assessment of institutional performance,
but also identifies opportunities for improvement and
achievable quality benchmarks. Therefore, if a practical
strategy for widespread dissemination of such monitoring can
be identified, it could generate substantial improvements in
the outcomes of women with breast cancer.
Primary Funding Source: NCCN
●The National Comprehensive Cancer Network (NCCN)
Internet-based Outcomes Database System
Joyce C. Niland, Ph.D., Layla Rouse, MS, Monir Corona, Doug
Stahl, Ph.D.
Presented By: Joyce C. Niland, Ph.D., Director of Data
Coordinating Center, Division of Information Sciences, City of
Hope National Medical Center, 1500 East Duarte Road,
Duarte, CA 91010-3000; Tel: 626-359-8111; Fax: 626-301-8802;
Email: jniland@coh.org
Research Objective: While variations in care have been
associated with both sub-optimal patient outcomes and
increased treatment costs, it remains extremely difficult to
measure and monitor quality of care routinely. An obstacle in
quality measurement is inadequate information systems to
support the effort. The NCCN Oncology Outcomes database
was developed to support the creation of a multi-institutional
quality monitoring system for the NCCN.
Study Design: The NCCN Oncology Outcomes Database was
designed for prospective data collection of detailed
sociodemographic, clinical, treatment and outcomes data on
eligible cancer patients across multiple sites into a single
centralized data repository. Selection of clinical data to be
collected included elements essential for measuring
concordance with the NCCN oncology care guidelines. The
database system accommodates two data input strategies:
web-based forms to accommodate chart review and data entry
based on inpatient and outpatient medical records by
dedicated data managers, as well as downloads from existing
institutional databases to achieve maximum efficiency.
Population Studied: To date, the NCCN database collects
data on patients with breast cancer, Non-Hodgkin Lymphoma
(NHL), and colorectal cancer, with additional major cancer
diagnoses planned for incorporation in the future.
Principal Findings: As the NCCN Data Coordinating Center,
the Division of Information Sciences at City of Hope National
Medical Center is responsible for the development and
deployment of this multi-institutional prospective database.
In continual use since 1997, over 25,000 cancer patients have
been enrolled in the database to date, including over 300
variables within data records collected longitudinally from
different data sources. Not only does the system support the
detailed data collection needed to measure quality, but it also
provides the functionality to feedback performance on
guideline concordance to NCCN providers via patient
summary reports. Combining the familiarity of the Web
environment with its cross-platform compatibility and secure
real-time data access/submission capabilities, the NCCN
database has been readily adopted by 15 participating centers
to date. In user surveys, the majority rated the system as
“good” to “excellent” with respect to layout and flow of the
Web site, ease of downloading documents, ease of use as a
database entry system, usefulness of on-line logic checks, and
ease of use as a database reporting system. Requirements for
a successful outcomes database will be described, and a
demonstration of the NCCN system provided.
Implications for Policy, Delivery, or Practice: Our
experience with the NCCN system has shown that a robust
health quality information system has the potential to support
efforts to implement routine quality measurement and
monitoring through the capture, codification, and analysis of
information about patient treatments and related outcomes.
The additional presentations within this panel will highlight
some of these important healthcare quality findings and
insights to date, made possible through the NCCN database.
Primary Funding Source: NCCN
●The Impact of Age on the Receipt of GuidelineRecommended Systemic Therapy for Breast Cancer
Eva M. Lepisto, MSc, Richard L. Theriault, DO, MBA, Joyce C.
Niland, Ph.D., Eva M. Lepisto, MSc, Stephen B. Edge, M.D.,
Rebecca A. Ottesen, MSc, Jane C. Weeks, M.D., MSc
Presented By: Eva M. Lepisto, MSc, Director of Outcomes
Database Operations, , National Comprehensive Cancer
Network, 500 Old York Road, Suite 250, Jenkintown, PA
19046; Tel: 908-918-1020; Fax: 908-918-1021; Email:
lepisto@nccn.org
Research Objective: Because older women are
underrepresented in clinical trials, optimal care for many
women with breast cancer has not been well-defined.
Furthermore, comprehensive data on adjuvant treatment
choice in non-Medicare enrollees, and on use of tamoxifen in
all age groups, are limited. To inform the development of
quality indicators for use in older women, we evaluated the
impact of age on the receipt of guideline-recommended
systemic therapy for breast cancer in the National
Comprehensive Cancer Network (NCCN).
Study Design: We developed adjuvant therapy quality
measures from the NCCN breast cancer guidelines, and
applied them to patients in the NCCN Breast Cancer
Outcomes Database. Based on detailed clinical
characteristics, each patient was assigned to a specific
guideline node, according to the guideline version in place at
the time of patient’s presentation. Univariate and
multivariable analyses were conducted to evaluate predictors
of treatment among women for whom guidelines
recommended chemotherapy (with or without tamoxifen) and
those for whom guidelines recommended tamoxifen alone.
Multinomial logistic regression, controlling for patient, tumor,
and clinical factors, was applied to assess whether age (in
decades) was associated with 3 possible outcomes: receipt of
recommended therapy, non-recommended therapy, or no
therapy.
Population Studied: An inception cohort of 3,405 women
with Stage I-III breast cancer presenting for care to one of
eight participating institutions between July 1, 1997 and June
30, 2000 was assembled. To be eligible for analyses, patients
were required to be followed at the NCCN institution for a
minimum of 365 days post-presentation.
Principal Findings: Among patients for whom guidelines
recommended chemotherapy +/- tamoxifen, age was strongly
associated with treatment choice. Compared to age less than
50, each decade was associated with an increasing likelihood
of treatment with tamoxifen alone (age 50-59: OR=3.2, 95%CI
[1.2, 8.2]; 60-69: OR=14.9 [6.4, 34.5]; and 70+: OR=174.4, [75.6,
402.0]). Older women were also more likely to receive no
treatment (age 60-69: OR=3.3 [1.5, 7.0]; 70+: OR=20.1 [9.7,
41.9]). Among women for whom the guidelines
recommended tamoxifen alone, those over 70 were
significantly more likely to receive no therapy (OR=3.81 [1.1,
12.9]). Treatment choice was influenced by NCCN institution
in both models. For example, among women over 60 with
node positive, ER positive cancers, the proportion treated with
chemotherapy ranged from 41% to 91% across the centers.
Conclusions: In these centers, systemic treatment choices,
particularly, decisions about adjuvant chemotherapy are highly
influenced by patient age.
Implications for Policy, Delivery, or Practice: Clinical trials
in older breast cancer patients are critical to determine
whether the dramatic drop-off in chemotherapy use among
women over 70 represents appropriate tailoring or poor
quality care. Of greater concern, we found that the age
gradient in chemotherapy use begins well before 70, despite
evidence that chemotherapy in 50-69 year olds may decrease
recurrence risk and/or mortality. The surprising variation in
patterns of care across NCCN institutions suggests that
physician biases and preferences play an important part in
explaining this pattern. This highlights the potential value of
linking comprehensive quality measurement programs to
improvement efforts groups found to be at risk for suboptimal
care.
Primary Funding Source: NCCN
●Identifying Quality Targets for Breast Cancer Care
Michael J. Hassett, M.D., M.P.H., Melissa E. Hughes, MSc,
Rebecca A. Ottesen, MS, Stephen B. Edge, M.D., Richard L.
Theriault, DO, MBA, Jane C. Weeks, M.D., MSc
Presented By: Michael J. Hassett, M.D., M.P.H., , Center for
Outcomes and Policy Research, Dana-Farber Cancer Institute,
44 Binney St, Boston, MA 02115; Tel: 617-632-6631; Fax: 617632-2270; Email: michael_hassett@dfci.harvard.edu
Research Objective: While high quality scientifically valid
quality measures are in great demand, few exist. Those that
do have not been tailored to the different applications for
which they are used, such as grading providers, paying for
performance or identifying priority areas for quality
improvement. Our objective was to describe an explicit and
systematic approach for selecting quality measures based
upon their ability to improve outcomes for a population of
women with breast cancer.
Study Design: We developed a comprehensive set of 31
breast cancer quality indicators using the National
Comprehensive Cancer Network’s (NCCN) clinical practice
guidelines. To derive quality measures, we assessed practice
performance relative to the standards outlined by the
guidelines in 9,019 women less than 70 with newly diagnosed
stage 0-III breast cancer treated at one of ten member
institutions. We then ranked measures based on their ability
to improve disease-free survival and quality of life for a
population of women with breast cancer. Four attributes were
used to rank the measures: 1) number of non-concordant
patients, 2) mean concordance across all institutions, 3)
highest concordance at any one institution, and 4) magnitude
of benefit on disease free survival and quality of life
experienced by patients who received the recommended
rather than a non-concordant treatment. Values for the first
three attributes were derived from the concordance analysis.
Magnitude of benefit estimates were derived from a survey of
the expert panel that developed the NCCN breast cancer
guidelines. A simple algorithm was designed to incorporate
all four attributes and create a numerical score for each quality
measure. Scores were used to prioritize quality measures and
identify those with the greatest potential to impact outcomes.
Population Studied: Discussed within study design.
Principal Findings: The top three quality measures were 1)
whole breast radiation for stage I-II breast cancer treated with
breast conserving surgery, 2) axillary lymph node surgery for
stage I-II breast cancer treated with breast conserving surgery,
and 3) adjuvant chemotherapy for stage II, node positive,
hormone receptor positive breast cancer. Of the four
attributes contributing to each quality measure’s score, the
number of non-concordant patients correlated most highly
with the final ranking. Quality measures based on lower
quality evidence, containing few patients, or offering little
room for improvement were less likely to rank highly.
Magnitude of benefit values influenced the ranking where
differences in the numbers of non-concordant patients were
modest. Altering the relative weights of the attributes did not
substantially affect the rankings.
Conclusions: We describe an explicit and systematic method
of identifying breast cancer quality measures that are unique
because of their ability to impact patients’ outcomes. Our
approach could also be used to rank quality measures across
different disease or according to different outcomes.
Implications for Policy, Delivery, or Practice: When
developing quality measures it is essential to consider how
they will be used; different quality measures may be required
for different applications, goals, and populations. Identifying
quality measures based on their potential to improve survival
and quality of life may increase the efficiency and efficacy of
quality improvement efforts and improve the outcomes of
people who rely on our health care system.
Primary Funding Source: NCCN