Behavioral Health

Behavioral Health

•

The Consequences of Weight

Discrimination for Health and Social Life of

U.S. Adults

Tatiana Andreyeva, Ph.D., Rebecca Puhl, Ph.D.,

Kelly Brownell, Ph.D.

Presented By: Tatiana Andreyeva, Ph.D., Postdoctoral research associate, Rudd Center for

Food Policy and Obesity, Yale University, 309

Edwards Street, New Haven, CT 06520, Phone:

(203) 432-8432, Fax: (203) 432-9674, Email: tatiana.andreyeva@yale.edu

Research Objective: Weight stigma has significant costs for overweight people whether it is poorer marriage prospects, job promotion, or psychological wellbeing. Whereas evidence from case studies and experimental work suggests widely-spread prejudice towards the obese, limited data is available on the consequences of weight discrimination in a national sample.

This study examines how perceived weight discrimination is related to health, employment, income and medical care among U.S. adults ages 25-74, and compares the health and social consequences of weight prejudice with outcomes of race, gender, and age discrimination.

Study Design: We used a nationally representative cross-section of U.S. adults to evaluate life-time experiences of major discrimination and daily mistreatment in interpersonal relationships due to one's body weight or height. Discrimination was selfreported and covered a variety of settings

(employment, education, medical care) and ways of day-to-day interpersonal prejudice (less respectful treatment, poorer service). The outcomes included health (self-reports of physical and mental health, ADL-disability, chronic conditions), utilization of health care

(routine care, specialist visits, mental health), life perception, job and income status. Multivariate regression analysis was used to predict outcomes of weight discrimination across sociodemographic and body weight groups.

Population Studied: Data were from the Midlife

Development in the United States, a national

1995-96 survey of noninstitutionalized Englishspeaking adults ages 25 to 74.

Principle Findings: The consequences of weight discrimination were most pronounced for selfrated physical and mental health, life expectations, and utilization of specialized medical resources. After adjusting for compositional differences in socio-demographic and body weight status, weight-discrimination was linked to increased risk of adverse physical health (by 50%, p<0.01) and mental health (by

66%, p<0.01). Despite poorer health, people experiencing discrimination used less medical care, particularly in specialized settings. There were no systematic differences in personal income or job status associated with weight discrimination.

Conclusions: Weight discrimination is related to significant adverse conditions in physical and mental health, perception of life, and utilization of health care resources. It affects disproportionately more young obese women whose increased body weight already poses them at risk for reductions in health and quality of life.

Implications for Policy, Practice or Delivery:

Weight bias and discrimination occurs from employers, health care professionals, educators, and even family members. As mistreatment due to one's weight has significant negative implications for psychological well-being, health and use of health care services, institutional and interpersonal environment should become more sensitive to the needs of overweight and obese people.

Funding Source: Rudd Center for Food Policy and Obesity

• Primary Care Providers’ Use of Depression

Diagnostic Tools: ‘‘Planting a Seed in the

Patient’s Head’’

Seong-Yi Baik, Ph.D., R.N., Barbara J. Bowers,

Ph.D., R.N., Jean S. Anthony, Ph.D., R.N.,

Bassriou Tidjani, Ph.D., C. Jeffrey Jacobson,

Ph.D., Jeffrey L. Susman, M.D.

Presented By: Seong-Yi Baik, Ph.D., R.N.,

Assistant Professor, College of Nursing,

University of Cincinnati, 3110 Vine Street,

Cincinnati, OH 45221-0038, Phone: (513)-558-

5219, Fax: (513)-558-2142, Email: seongyi.baik@uc.edu

Research Objective: One of the three purposes of this qualitative (grounded theory) study was to explore primary care providers’ (PCPs) experiences with using currently available depression diagnostic/screening tools for the recognition and management of depression in their day-to-day practice.

Study Design: Thirty-four in-depth, in-person, semi-structured interviews along with investigators' filed notes on office environments

were conducted with PCPs in the Midwest area.

Interviews usually lasted over an hour (ranging from 30 to 90 minutes) and were audiotaped and transcribed for the analysis. Grounded

Theory methodology was used to collect and analyze the data.

Population Studied: Thirty-four PCPs in 23 primary care office settings: 13 General Internists

(GIs), 11 Family Physicians (FPs), and 10 Nurse

Practitioners (NPs); 11 male and 23 female; and

21 Caucasians, 7 African-Americans, and 3

Asians.

Principle Findings: Under usual primary care conditions, with multiple competing demands during a short office visit, PCPs do not routinely use depression instruments to aid in their recognition of depression. Nor do they have a preference for a particular depression screening tool; they use whichever is available in their offices. No difference was found among the three PCP groups. The majority of the providers in this study indicate that they use depression diagnostic tools as a strategy to make the symptoms of depression ‘‘visible’’ to the patient when they anticipate or encounter the patient’s resistance to accepting the diagnosis.

Occasionally, after the patient’s acceptance of the diagnosis, PCPs also use depression diagnostic tools to establish a baseline for treatment or when the provider wishes to confirm the diagnosis of depression. Several conditions influence their use of depression instruments. The most salient condition is that, unlike other physical illnesses that have separate objective diagnostic methods (e.g., blood tests), depression has no single confirmatory test.

PCPs assume that the absence of objective diagnostic methods makes depression

‘‘personal’’ or unique to the patient. Moreover, care requires the patient’s acceptance of the diagnosis as a usual prerequisite to treatment.

Thus, unless the patient is suicidal or homicidal, it is necessary to give the patient time to ‘‘mull it over’’ and come to acceptance. During this process, PCPs often use depression instruments to ‘‘plant a seed in the patient’s head’’ that the patient may be depressed. This approach is more necessary for patients with whom the provider is not familiar, and PCPs may use this process while they are ruling out other physical illnesses. Very few PCPs describe using depression tools for case finding or screening, to follow the course of depression management, or to establish the severity of depression.

Conclusions: PCPs use depression tools primarily to enhance the process of patients’ acceptance of depression and coming to an agreement about diagnosis, rather than the initial recognition or the ongoing management of depression.


Depression care could be improved by using depression instruments to establish the severity of depressive symptoms, follow treatment through remission, and guide management decisions. By better understanding the culture of primary care, this technology can be better diffused into treatment decisions. Further research is needed to identify interactional factors that influence PCPs’ initial recognition of depression.

Funding Source: National Institute of Mental

Health (R34 MH071719)

• The Impact of a Depression Disease

Management Program on Productivity

Kara Bambauer, Ph.D., M.S., M.A., Kevin Kerber,

M.D., Julie Kuebler, M.S., A.P.R.N., B.C., Heather

Walters, M.S., Qingmei Jiang, M.S., Marcia

Valenstein, M.D., M.S.

Presented By: Kara Bambauer, Ph.D., M.S.,

M.A., Assistant Professor, Psychiatry, University of Michigan Medical School, 4250 Plymouth

Road Box 5765, Ann Arbor, MI 48109, Phone:

(734) 232-0538, Fax: (734) 761-2617, Email: karabamb@umich.edu

Research Objective: Collaborative treatment models have been difficult to translate into community practice due to their costs and the logistical difficulties of locating mental health providers ‘‘on-site’’ in primary care. The

University of Michigan’s Depression Disease

Management Program, the Michigan Depression

Outreach and Collaborative Care (M-DOCC) program, was developed by a multidisciplinary team and was designed to be usable for patients treated in geographically and administratively dispersed practice settings. Since depression is a leading source of work-related disability and diminished productivity, we sought to determine whether primary care and specialty patients enrolled in M-DOCC experienced improvements in both depressive symptoms and productivity levels.

Study Design: We used random effects models to evaluate how clinical and demographic characteristics of M-DOCC enrollees influenced self-reported productivity measures over time.

The Patient Health Questionnaire (PHQ-8) was used to measure depression, and patients were asked to specify the number of days that s/he performed less than usual level at work and in

their normal activities in the last 30 days. M-

DOCC care managers contacted enrolled patients by telephone regularly to monitor their levels of depressive symptoms, functional status, and medication adherence.

Population Studied: M-DOCC patients enrolled for up to one year between February 2003 and

October 2004.

Principle Findings: Among the 771 enrolled patients, 73% of participants were female and

76% of patients were seen in primary care rather than specialty mental health care settings. The average age of participants was 42.9 (13.5). The average baseline PHQ-8 score was 11.6 (5.8), whereas the average PHQ-8 score for patients at their last measurement was 8.2 (5.6), indicating overall improvement in depression scores. The number of days with functional impairment in the last month at baseline was 13.6 (10.7) days and the average last measurement of days with functional impairment in the last month was 10.3

(10.7) days also indicating improvement in productivity during the study period. Patients received an average of 5.8 (3.5) calls by M-DOCC care managers. Lower PHQ scores (ß=0.69, p<0.01), fewer calls (ß=0.17, p=0.03), and younger age (ß=0.05, p=0.02) were all significant predictors of fewer days with functional impairment. .There were no differences in productivity changes among patients seen in primary versus specialty care settings.

Conclusions: Patients enrolled in the M-DOCC program experienced significant reductions in days with functional impairment in addition to reduced depressive symptoms Prior studies indicate that depression management improves depressive outcomes. These programs may also reduce presenteeism and absenteeism associated with depression.


Depression is one of the most prevalent psychiatric disorders, and causes considerable morbidity and burden to patients and their employers. Although there are effective treatments, community treatment often falls short. Finding practical approaches for systematizing depression treatments that are acceptable to patients in diverse settings is imperative if treatment is to be improved.

Research that increases the applicability of depression management programs to real world settings is urgently needed and has substantial public health implications. Such programs may reduce disability and increase function in several domains of patient life, including employment.

Funding Source: University of Michigan

Medical School, Department of Psychiatry

• Expenditures in Chronic Illness with

Complexities:Mental Health and Substance

Abuse among Veterans with Diabetes

Ranjana Banerjea, Ph.D., Usha Sambamoorthi,

Ph.D., David Smelson, Psy.D., Pramod Meduru,

M.D., M.P.H., Leonard M Pogach, M.D., M.B.A.

Presented By: Ranjana Banerjea, Ph.D., Health

Services Research Scientist, Center for

Healthcare Knowledge Mgmt, VHA, 385 Tremont

Ave. (129), East Orange, NJ 07018, Phone: 973-

676-1000, x2552, Fax: 973-395-7114, Email: banerjea@njneuromed.org

Research Objective: The prevalence of mental illness (MI) and substance use disorder (SUD) are very high among veterans. The cooccurrence of these conditions in individuals with a chronic illness such as diabetes increases the complexity and average costs of care. Prior research on the prevalence of SUD and MI in diabetes has focused on specific mental illness categories(e.g depression, bipolar) and there have been few attempts to systematically look at the impact of costs across different diagnostic clusters based on all three conditions. Differing levels of combinations of MI and SUD present different challenges for both treatment and cost management. The primary objectives of the paper are: a) estimate the prevalence of cooccurring substance abuse and mental illness within various clusters of SUD/MI; and b) to compare the utilization and expenditures of patients with complexities in diabetes to their counterparts without substance abuse and mental health conditions.

Study Design: Cross-sectional and longitudinal analysis of a merged Veteran Health

Administration (VHA) and Medicare fee-forservice claims database of VHA clinic users with diabetes (FY1999-2000). Prevalence, utilization and expenditures in FY1999 are compared to follow-up year (FY2000). Multinomial logistic regressions were used to examine the associations between SUD/MI and demographics, Medicare enrollment, other comorbid physical conditions and disability/income status. Generalized linear models were used to predict expenditures and utilization in the various SUD/MI categories.

Measures: Substance abuse and mental health in FY1999 were identified using ICD-9-CM codes. Expenditure variables include total and type of expenditures in FY2000 and change in expenditures between FY1999 and FY2000.

Patient with diabetes were derived from the

FY1999 Diabetes Epidemiologic Cohort (DEpiC),

a dataset which identifies annual cohorts of veterans with diabetes using Medicare and VHA administrative data from FY1997 onward.

Population Studied: VHA clinic users with diabetes in FY1999, who were alive by end of

FY2000, who were not enrolled in Medicare

HMO and had positive expenditures in FY1999

(N = 455,855).

Principle Findings: Among VHA users with diabetes, 30% had either MI or SUD diagnosis,

12% had alcohol, tobacco or drug use,17% had serious mental illness (SMI) and 7% other mental illness(OMI).In FY2000, the average expenditures were lowest ($7,040) for individuals in the ‘‘No MI & No SUD’’ group and highest ($17,443) for individuals in ‘‘SMI &

Alcohol/Drug’’ group. Individuals with alcohol/drug use incurred highest total average expenditures over time; the adjusted odds ratios

(AOR) for ‘‘SMI & alcohol/drug’’ group were

12.64; ‘‘OMI & alcohol/drug’’ group: 5.09;’’No

MI & Alcohol/drug’’ group: 3.80 (95%CI). Most of the expenditures were due to greater inpatient use in these groups. Tobacco use conferred a higher cost burden when associated with OMI

(AOR=2.15) or SMI (AOR=4.32).

Conclusions: Alcohol and drug use increased expenditures due to greater use of inpatient services regardless of the presence or severity of mental illness. New care coordination approaches with prioritization of conditions are required for better cost optimization.


These findings can be used by policy makers regarding which cohorts to target for interventions to reduce healthcare expenditures.

Funding Source: VA

• Cost of Diabetes and Hypertension among

California Medicaid Beneficiaries with Serious and Persistent Mental Illness

Jim E. Banta, Ph.D, M.P.H., Mark G. Haviland,

Ph.D.

Presented By: Jim E. Banta, Ph.D, M.P.H.,

Assistant Professor, School of Public Health,

Loma Linda University, 26490 Veronica Court,

Loma Linda, CA 92354, Phone: (909) 558-7753,

Fax: (909) 558-0469, Email: jbanta@llu.edu

Research Objective: Determine the cost of diabetes and hypertension among Medicaid beneficiaries with mental illness.

Study Design: A cross-sectional study of adults served by the San Bernardino County (California)

Department of Behavioral Health Health.

Birthdates and Social Security Numbers for the

5,302 patients seen between November 1 and 15,

2004 were matched against the State’s Medicaid claims database. Paid claims for services provided between May 2004 and April 2005 were extracted. Chronic diseases were identified by the primary diagnosis in claims and costs calculated as the sum of actual Medicaid and Medicare payments.

Population Studied: Medicaid-eligible adults between the ages of 18 and 59 who received services through a Southern California county mental health department in late 2004.

Principle Findings: Medicaid claims were obtained for 4,071 adults. Schizophrenia (ICD-9-

CM 295.xx) was recorded in 37% of patients and affective disorders (296.xx) in 46%. Total annual payments were $49.9 million, with medications accounting for 35%, county mental health (Short-

Doyle) for 28%, inpatient (general and psychiatric) 23% and other 15%. A diabetes diagnosis was found in 405 patients (10%) and hypertension in 409 (10%). Among those with

Schizophrenia, 11.7% had diabetes and 14.2% had hypertension. Among those without diabetes or hypertension, average total costs for patients with schizophrenia were $11,900.

Among those with schizophrenia and diabetes or hypertension, average total costs were approximately $29,000, with inpatient averaging

$10,000, Short-Doyle $7,000 and medications

$8,000. Among those with affective disorders and diabetes or hypertension, average total costs were approximately $15,500, with inpatient averaging $3,200, Short-Doyle $2,800, and medications $6,000. Among those with affective disorders and no diabetes or hypertension, average total costs were approximately $11,300, with inpatient averaging $1,400, Short-Doyle

$2,900, and medications $5,100. After adjusting for age, gender, race/ethnicity and presence of schizophrenia, patients with hypertension were more likely to have a psychiatric hospitalization

(OR 2.4, 95% C.I. 1.8-3.0), though diabetes was not a significant predictor.

Conclusions: In this sample, 20% of Medicaideligible county mental health patients had a chronic medical condition such as diabetes or hypertension. Among patients with schizophrenia, payments for these patients were approximately 2.5 times as much as those without diabetes or hypertension. Among patients with affective disorders, the comorbid conditions resulted in average payments being

1.4 times as much as for those without diabetes or hypertension. Although much of this increased cost was due to hospitalization, outpatient county mental health costs of

schizophrenia patients with comorbid conditions were more than double that of other patients.


States are responsible for providing health care to Medicaid enrollees with serious and persistent mental illness. This is a challenge in California, where county mental health programs annually serve more than 200,000 adults in a system that is carved-out from physical health care. Although substantial public funds are spent on treating mentally ill beneficiaries with diabetes and hypertension, specialty mental health costs are much greater among patients with schizophrenia. Better management of these chronic health conditions may reduce specialty mental health costs and hospitalizations.

Funding Source: Loma Linda University School of Public Health Seed Grant

•

Correlates of Unmet Need in Two Service

Systems: The Impact of Rural Residence

Ana Maria Brannan, Ph.D.

Presented By: Ana Maria Brannan, Ph.D., Senior

Research Faculty, Center for Evaluation and

Program Improvement, Vanderbilt University,

Peabody #151, 230 Appleton Place, Nashville, TN

37203, Phone: (615) 322-8694, Fax: (615) 322-

7049, Email: ana.m.brannan@vanderbilt.edu

Research Objective: This study examined the predictors of unmet need for mental health services among children in two service systems.

Of special interest was whether living in a rural area was related to children receiving services for their mental health problems.

Study Design: Children met criteria for unmet need if they 1) had psychiatric symptomatology in the clinical range at baseline data collection, and 2) received no formal mental health services in the subsequent 12 months. Data on child symptoms, psychosocial functioning, and demographic variables were collected from primary caregivers. Service use data were compiled from Medicaid claims. Identical methods were used across systems for reporting and managing service encounter data. Rural residence was operationalized as the proportion of the county’s population who lived in Censusdefined rural areas. Logistic regression analysis was applied to explore the predictors of unmet need for mental health services. Using a model building approach, we tested whether adding a new block of variables improved X2 given the change in degrees of freedom. The first block included rural and state variables. The second block added child and family demographic variables. The final block added child psychiatric clinical variables. The full model including all predictor variables was found to be the best fitting model using the likelihood ratio test [R2 =

.21; X2 (10, p < .0001) = 94.69].

Population Studied: This study included 592 children (4-17 years old) with emotional and behavior disorders who were Medicaid enrollees in two southeastern states. The Medicaid program in one state was operating under managed care while the other was a fee-forservice system.

Principle Findings: Being served in the managed care system was significantly associated with unmet need. The proportion of county residents living in rural areas did not predict overall unmet need. However, the significant rural*system interaction term indicated that rural residence was positively related to unmet need in the managed care system. Although severity of psychiatric symptoms did not predict unmet need, children with more impaired psychosocial functioning were less likely to have unmet need. Other variables associated with unmet need were being a girl, and being African-American.

Conclusions: These findings suggest that the cost cutting mechanisms of managed care systems may increase unmet need among children with emotional and behavioral disorders. Only in the managed care system did living in a more rural county increase the risk for unmet need for mental health services. It is possible that as access is curtailed, those in rural areas are more affected than those living in urban or suburban areas. In both states, girls and African-American children were at greater risk for unmet need.

Implications for Policy, Practice or Delivery: It is notable that the impact of rural residence differs across states and service systems. This finding suggests that efforts to improve access to services need to be tailored to local communities. It appears that comprehensive models for studying rural behavioral health services may not be as useful as carefully considered and specifically targeted efforts.

Research suggests that efforts to increase access to care for girls and African-American children would be worthwhile across communities.

Funding Source: NIMH

•

Provider Burden is a Barrier to the

Identification of Mental Health Problems in

Pediatric Primary Care

Jonathan Brown, Ph.D., M.H.S., Anne W. Riley,

Ph.D., Lawrence S. Wissow, M.D., M.P.H.

Presented By: Jonathan Brown, Ph.D., M.H.S.,

Researcher, Mathematica Policy Research, Inc.,

600 Maryland Avenue Suite 550, Washington,

DC 20024, Phone: (202) 264-3446, Email: jbrown@mathematica-mpr.com

Research Objective: Primary care is the second most common gateway through which youth access mental health services. However, primary care providers (PCPs) do not identify most youth with mental health needs, and many youth subsequently do not receive appropriate treatment. Conceptual models of the use of health services have suggested that a range of characteristics that describe the provider influence the quality of care the patient receives.

This investigation applied the Gateway Provider

Model of child mental health services to investigate whether characteristics of the provider were related to the identification of youth mental health problems during primary care visits.

Study Design: Cross-sectional secondary analysis of data collected during visits at 13 clinics located in Maryland, Washington, DC and rural New York from December 2003 to August

2005. Parents reported the child’s mental health symptoms and functioning using the Strengths and Difficulties Questionnaire. Providers reported their burden and attitudes associated with treating mental health problems (Physical

Belief Scale), accessibility of mental health specialists (Ease of Consultation Scale), job control (General Job Satisfaction Scale), and job satisfaction (Generic Job Stress Questionnaire).

Random effects logistic regression was used to model the identification of youth psychosocial problems. Interactions between the child’s mental health status and provider characteristics were examined.

Population Studied: Participants were youth (n

= 774) age 5-16 (54.7% Caucasian, 31.5% African

American and 13.5% Hispanic) and the parent who accompanied the youth to the visit (74.4% mothers). PCPs (n = 54) included pediatricians

(64.8%) and family practitioners (35.1%).

Principle Findings: PCPs reported generally high job satisfaction and control, but reported varying access to mental health specialists.

PCPs generally had positive attitudes and beliefs about treating youth mental health problems but many reported that doing so was burdensome.

There was a negative interaction between provider burden and the presence of mental health symptoms, suggesting that identification of a mental health problem was less likely when the PCP reported greater burden associated with treating mental health problems. The sensitivity and specificity of identification of youth with psychosocial problems was significantly worse when the PCP reported greater burden associated with treating mental health problems.

Conclusions: Provider burden associated with treating mental health problems interfered with the quality of services youth with mental health needs received during primary care visits. Other

PCP and youth characteristics did not explain the strong inverse relationship between identification of youth mental health needs and burden.


Efforts to improve the delivery of mental health services in pediatric primary care should focus on reducing the burden associated with treating mental health problems. Strategies to reduce burden may include communication training for providers, decreased workloads, computerassisted technologies, nurse support teams, and better reimbursement for mental health services.

A multilevel conceptual framework such as the

Gateway Provider Model should guide the design and evaluation of quality improvement efforts.


• Participant Factors and Treatment

Completion in the Dane County Drug Court

Randall Brown, M.D.

Presented By: Randall Brown, M.D., PhD

Candidate, Assistant Professor, Population

Health Sciences, Family Medicine, University of

Wisconsin School of Medicine and Public

Health, 777 s mills st, Madison, WI 53715, Phone:

(608)263-6558, Fax: (608) 263-5813, Email: rtbrown@wisc.edu

Research Objective: To examine the relationship between participant characteristics and the likelihood of completing court-mandated substance abuse treatment in the Dane County

Drug Court Treatment Program.

Study Design: The current study is a restrospective cohort study using adminstrative data collected by drug court treatment staff and behavioral health professionals during subject participation in drug court. The primary dependent variable is substance abuse treatment completion (yes/no). Independent variables include: gender, age, ethnicity, income, educational attainment, marital status, indicators of living situation/social support, indicators of previous involvement in the criminal justice system, and indicators of substance use disorder severity (frequency and amount of use,

substance/substances used, route of use, prior treatment contacts, and types of treatment).

After examination of variable distributions and unadjusted correlations, stepwise regression modeling was pursued using treatment completion as the dependent variable to determine significant associations with failure to complete treatment. Gender, ethnicity, and age were maintained in the final model to maintain control for these covariates.

Population Studied: All participants in the Dane

County Drug Court from June 1996-December

2004 (n=572).

Principle Findings: Even among drug court participants, where specific treatment of alcohol use disorders is most often not pursued, alcohol was frequently either a primary or secondary substance (33% and 35% of sample, respectively) of abuse or dependence. Alcohol was followed, in descending order of prevalence, by cannabis, cocaine, opioids, and "other substances."

Of all of the examined covariates, the only indicator achieving statistical significance as a predictor of failure to complete substance abuse treatment was the presence of a cocaine use disorder (Adj OR 2.12; 95% CI 1.34, 3.03).

Conclusions: Primary conclusions for this study were 1) In the population of all participants in the Dane County Drug Court, substance use factors appear to be of greater importance than demographic/social factors when considering likelihood of treatment completion. The presence of a cocaine use disorder, as opposed to the presence of problem use of other substances, is strongly associated with tx failure.


While examination of treatment modality has yet to be examined at the time of the writing of this abstract, these findings may indicate that case management may need to be modified (possibly intensified) for individuals with stimulant use problems vs. other substance use disorders.

(Data is available on treatment conditions during drug court participation and will be included in final analysis.)

Funding Source: NIDA

•

Evidence-Based Practice In Public Mental

Health Settings: Are Children Receiving The

Same Attention As Adults?

Kellie Cody, M.S.W., Ph.D. Student

Presented By: Kellie Cody, M.S.W., Ph.D.

Student, Ph.D. Student, Interdisciplinary Health

Studies, Western Michigan University, 1903 West

Mic higan Avenue, Kalamazoo, MI 49008,

Phone: (269) 731-2366, Fax: (269) 731-2366,

Email: k4cody@wmich.edu

Research Objective: The Purpose of this study was to determine if there are differences between the number of adults and children receiving EBP services, to identify primary funding streams for

EBP and barriers that mental health agencies experiencing in implementing EBP.

Study Design: Analysis of a secondary data set based on survey information.

Population Studied: State Mental Health

Directors were administered a survey regarding children with emotional disorders and adults with mental illness.

Principle Findings: The data shows that there are more adults per 1000 eligible for EBP services in each of the EBP services (ACT the highest with 23.4 per 1000 eligible) than children per 1000 eligible (MST the highest with 1.4 per

1000 eligible) for the EBP services for children.

Significant barriers exist to the implementation of Evidence-Based Practice in public mental health settings with resistance from providers being reported by the most states.

Conclusions: Children receive Evidence-Based

Practice services in public mental health settings at a much lesser rate per 1000 eligible than adults. Significant barriers continue to exist to the implementation in public mental health settings and a variety of funding streams are being used to fund Evidence-Based Practice services. More than twice the number of states report using Medicaid to fund ACT (N=36, the highest for adults than Therapeutic Foster Care

(N-15) the highest for children.


While EBP services have been utilized in medicine for many years we are only in the beginning stages of development with mental health and especially with children. There is no central authority established to ensure standards are in place and that models that presume to be

EBP are in fact EBP. SAMSHA has attempted to do this through making tool kits available to states to implement adult models and is developing some for children but there is no comprehensive system in place to implement

EBP. This leaves states to develop their own system, which are in differing stages of development. Effort should be put in place to develop a central authority for the development and implementation of EBP services. SAMSHA would appear to be the right place for this.

States would have to participate in the process, which could be time consuming. Barriers to implementation need to be addressed if the

‘‘transformation’’ of the mental health system is to occur. More funding is needed not only for implementation but maintenance cost of these programs. Research needs to be done to develop the evidence, not only that these services have good outcomes but also better outcomes than traditional services at a lower cost. Regional differences need to be researched to determine why there are disparities and differences in the usage of EBP service models and to determine if regional issues are considered. For example are programs being developed for native peoples in different regions that may have a large population of native people? Hawaii is attempting to do this in their attempt to implement EBP. More research needs to be done regarding adapting EBP services to different population, which allow for local differences. Because a program works in

Hawaii, the same program may not work in

Oregon without adapting the model. More research needs to be done in the private sector to determine if they are implement EBP services and what barriers they may be facing. This data was only collected on public mental health agencies. The disparities that exist between adult and children needs to be addressed. More effort needs to be in place to ensure that children have access to EBP services and more EBP services for children need to be developed.

More longitudinal studies need to be conducted to look at the outcomes and cost over time and more focus needs to be placed on recovery and prevention not just on treatment. The NRI needs to continue their collection of data, however I would recommend they not use MST and Therapeutic Foster Care as their child models. MST was developed for juvenile delinquent children who are not primarily served by the mental health system and Therapeutic

Foster Care tends to be used more by placing agencies like the Department of Social Services.

Mental Health agonies for the most part are trying to reduce out of home placements.

• An Instrument to Assess Patient Safety

During Medical and Surgical Hospitalizations for Persons with Severe Mental Illness:

Development and Pilot Test

Gail Daumit, M.D., M.H.S., Jennifer Hayes,

M.Ed., M.P.H., Daniel Ford, M.D., M.P.H., Lisa

Dixon, M.D., M.P.H., Peter Pronovost, M.D.,

Ph.D., David Thompson, D.N.Sc., M.S.

Presented By: Gail Daumit, M.D., M.H.S.,

Associate Professor, Medicine, Johns Hopkins

Medical Institutions, 2024 East Monument

Street, Baltimore, MD 21205, Phone: (410) 614-

6460, Fax: (410) 614-0588, Email: gdaumit@jhmi.edu

Research Objective: Persons with severe mental illness (SMI) have a high risk for premature death, primarily due to medical causes. Patient safety issues are not well described in this population, yet persons with SMI may be at elevated risk for adverse events during nonpsychiatric hospitalizations. The objective of this study was to develop and pilot test an instrument targeted to persons with SMI to detect adverse events during medical and surgical hospitalizations.

Study Design: Cross-sectional study.

Population Studied: We developed a medical record abstraction instrument to assess patient safety events, contributing factors and types and degree of harm during medical and surgical hospitalizations for patients with SMI. In addition to hospital course and treatments, the instrument domains incorporate relevant patient factors (e.g., mental health status, social support, comorbidity) and provider factors (e.g., psychiatric consultation, communication.) A multidisciplinary team of psychiatrists, internists, and a critical care physician and critical care nurse both specializing in patient safety developed and tested the instrument. For the pilot, we selected a convenience sample of adult patients with an outpatient diagnosis of schizophrenia (ICD-9 295) admitted to one urban hospital’s medical or surgical inpatient services from 1996-2004. Two reviewers sequentially reviewed each chart and adjudicated results. Patient safety events, contributing factors and harms were the result of consensus between reviewers. We used an iterative process to continually modify and enhance the instrument during the period of chart reviews.

Principle Findings: We reviewed 52 hospitalizations for 38 patients. The mean patient age at hospitalization was 48 years; 55% of patients were female, 84% were African

American and 16% were White. Sixty-nine% of hospitalizations were medical and 31% surgical.

We found 136 patient safety events, with a mean of 2.6 (SD 2.2) per hospitalization and 3.6 (SD

3.2) per patient. The most common patient safety events were medication-related (44 events,

32% of events, 42% of hospitalizations.)

Medication events included 2 cases of decreased conciousness from antipsychotic prescribing errors, 4 cases where outpatient antipsychotics were not continued during hospitalization, and 8 cases where maintenance psychotropics were

not prescribed at discharge. Events related to general patient management were also common

(42 events, 31% of events, 56% of hospitalizations) including 1 unanticipated surgery, 1 unanticipated admission after an outpatient procedure and 10 cases of incomplete or incorrect treatment. Patient safety events also included general inpatient events (e.g., falls, hemorrhage, respiratory distress) (n=14), 6 nosocomial infections and 5 surgical complications. We found 69 events where provider factors may have contributed including:

23 episodes of miscommunication; 22 of not providing complete treatment and 15 of not following protocols. Patient’s mental status or nonadherence to treatment recommendations were thought to contribute to 27 patient safety events. We categorized 50 events (37% of events, 56% of hospitalizations) as resulting in at least one known undesirable outcome or harm:

24 had physical injury; 29 had increased health care utilization during hospitalization (e.g, procedure) and 12 had a discharge to another inpatient facility or a readmission.

Conclusions: Initial pilot testing of this patient safety chart abstraction instrument with consensus among reviewers from multiple disciplines found high rates of adverse events during non-psychiatric hospitalizations for persons with schizophrenia diagnoses, including a high prevalence of psychotropic-related events.

In comparison, inpatient medication-related events are thought to be approximately 10% or lower in the general population.


These safety concerns underscore the critical need to develop and test tools to identify inpatient quality of care problems in this vulnerable population. The results also suggest the testable hypothesis that greater attention to medication prescribing and provider communication may reduce patient safety events, mitigate patient harm and possibly reduce mortality for persons with SMI.


•

Impact of State Funded Recovery Oriented

Residency Training on the Delivery of

Recovery Oriented Services to Patients

Jonathan Delman, J.D., M.P.H., Ds.C. (pending)

Presented By: Jonathan Delman, J.D., M.P.H.,

Ds.C. (pending), 132 Kemble Street,Roxbury, MA

02119, Phone: 617-427-0505,

Email: jdelman@cqi-mass.org

Research Objective: In 2002, the President’s

New Freedom Commission on Mental Health released a report (Transforming Mental Health

Care in America), stating that the system must

‘‘…move forward as quickly and efficiently as possible to achieve a more competent and expanded workforce necessary to ensure the full opportunity for recovery, resiliency, and wellness for all Americans with mental illnesses.’’ To address this concern, the Massachusetts

Department of Mental Health (‘‘DMH’’) funds several medical schools to educate and train residents to utilize recovery-oriented, client centered, and evidenced based practices.

This mixed methods study was initiated by DMH

(Dr. Foti), in collaboration with Consumer

Quality Initiatives, Inc. (J. Delman, M.

Goodman), in order to assess the degree to which residents in such education/training programs are providing recovery-oriented and client-centered services. As an exploratory study without a comparison group, the findings will generate hypotheses regarding associations with resident and training program characteristics and the degree to which residents are providing services with a recovery, client centered focus.

Study Design: To assess the degree to which residents are offering recovery-oriented client centered services, we decided to examine the patient perspective. Thus, a survey instrument

(RESI-1) was developed based the Recovery

Enhancing Environment Measure (‘‘REE’’), and adapted for this study to reflect the treatment activities of psychiatric residents. The survey consists of 19 quantitative questions, three openended questions and a series of demographic regarding the patient interviewed. We’re also identifying which of the 4 training programs the patient’s resident is part of.

Population Studied: The subjects are adults diagnosed with a serious mental illness who are being treated at a DMH operated service programs (day treatment, clinic) by a resident of

DMH’s Psychiatry Residency Fellowship Training

Program. To be a candidate for an interview, that person must have met with a resident at least 2 times. Prior to collection of the data, the investigators received IRB approval from DMH

Central Office Research Review Committee.

Principle Findings: The final report will be a mixed methods assessment of the degree to which DMH residency training programs in the aggregate are teaching residents to have a recovery-focus, based on the perspectives of consumers being treated by the residents.

Based on all data, we hope to generate hypotheses about the effects of key aspects of

the training programs on resident performance in relation to recovery orientation and clientcenteredness. We will also assess the RES-1 for internal reliability and concurrent criterion validity.

Funding Source: State DMH

• Using the MEPS to Explain Current Mental

Health Service Sector Use

Ashley Dunham, Ph.D., M.S.P.H., Marisa Elena

Domino, Ph.D., Bradley N. Gaynes, M.D.,

M.P.H., Joseph P. Morrissey, Ph.D.

Presented By: Ashley Dunham, Ph.D., M.S.P.H.,

Postdoctoral Fellow, Cecil G. Sheps Center for

Health Services Research, University of North

Carolina at Chapel Hill, 725 Martin Luther King,

Jr. Boulevard, Chapel Hill, NC 27599, Phone:

(919) 966-6156, Fax: (919) 966-1634, Email: adunham@schsr.unc.edu

Research Objective: Using the Medical

Expenditure Panel Survey, the objective of this research was to explore differences in service sector use for the treatment of depression by children, adults, and the elderly. Specifically, what patient characteristics explain whether mental health care is received in the general medical care sector, the mental health care sector, or a combination of the two. Designing service delivery for mental health to meet the needs of all different age groups requires knowledge of which service sectors are utilized to meet current needs for depression treatment.

Study Design: Data was pooled from the 2002-

2004 MEPS (Medical Expenditure Panel Survey), a nationally representative panel survey sponsored by the Agency for Healthcare

Research and Quality. The main purpose of this survey is to collect detailed information regarding the use and payment for health care services from a nationally representative sample of United States residents.

Initial analyses include chi-square and logit models to both explore and explain mental health service sector use for depression treatment. The dependent variable was service sector use for depression, defined as (1) psychiatry only, (2) general medical care plus other non-MD mental health care, (3) general medical care only, and (4) non-MD mental health care only. Due to a complex sampling design employed by MEPS, we used special techniques to estimate the variance and conduct valid statistical interference from these data.

Population Studied: The MEPS provides a nationally-representative sample of children, adults and the elderly. Only those reporting depression as a medical condition and receiving services (identified by office-based medical provider visits and prescription records) were included in the study. After necessary exclusions, a sample of those aged 65 and over

(n=346), aged 18-64 (n=2103) and under age 18

(n=224) were used in the analyses.

Principle Findings: Initial results show that the elderly primarily receive mental health care for depression from the general medical care sector

(65%), while children primarily receive services from a psychiatrist (58%). Approximately 42% of adults receive services from the general medical care sector, while another 43% receive services from only a psychiatrist. A smaller proportion of all three groups receive services from either a combination of general medical care plus non-

MD mental health care, or non-MD mental health care only. Initial logit results for the three different age groups show mixed results. For the elderly, having a usual source of care, age, physical health, and education significantly predict service sector type for depression treatment. For adults, gender, mental health, marital status, and mental health comorbidities predict service sector use for depression. For children, gender, having a usual source of care, and mental health comorbidities affect service sector use for depression.

Conclusions: Service sector use for depression varies among age groups, and is affected by a wide variety of factors. The elderly tend to use the general medical care sector, while children tend to utilize psychiatry.


Many recent studies have documented how depression can be effectively delivered in both the primary care and specialty care sector. As evidenced by this research, mental health services for depression are received in a wide variety of settings, and vary by age and other important factors. In particular, 60% of the elderly population in this study received their care from the general medical care sector only, indicating no receipt of psychotherapy. Further research should explore why many prefer using this sector for depression treatment, and how the organization and financing of health care can be structured to deliver optimal depression treatment across service sectors.


•

The Relationship Between Caregiver Needs and Community Stabilization among Children and Adolescents With a Mental Health Crisis

Richard Epstein, Ph.D., Neil Jordan, Ph.D.,

YongJoo Rhee, Dr.P.H., John Lyons, Ph.D.

Presented By: Richard Epstein, Ph.D.,

Postdoctoral Fellow, Institute for Healthcare

Studies, Northwestern University, 676 N St Clair

Suite 200, Chicago, IL 60611, Phone: (312) 695-

6986, Fax: (312) 695-4307,

Email: r-epstein@northwestern.edu

Research Objective: Clinical decision making is of critical importance to systems of care that are attempting to provide children and adolescents with appropriate mental health services in the least restrictive setting. Although considerable research has been devoted to identifying factors that predict a decision to hospitalize children and adolescents with a mental health crisis, less is known about factors that predict a decision to stabilize such referrals in the community. The current paper tests the hypothesis that, after adjusting for the effects of potential confounding variables, children and adolescents whose caregivers have significant needs are more likely than those whose caregivers do not have significant needs to be referred for community stabilization.

Study Design: The current study is a secondary analysis of administrative data from the

Screening, Assessment and Support Services

(SASS) program of the Illinois Department of

Human Services (DHS), Department of

Healthcare and Family Services (HFS), and

Department of Children and Family Services

(DCFS). The SASS program serves as a single point of entry for all children experiencing a mental health crisis whose psychiatric care will require public funding from one of these agencies. Logistic regression models used the binary SASS decision to stabilize in the community or refer for inpatient psychiatric hospitalization as the criterion variable and the caregiver needs domain of the Childhood

Severity of Psychiatric Illness (CSPI) scale as the primary predictor variable. Control variables included standard demographic variables (e.g., gender, race, age) and aspects of severity (e.g., risk behaviors, emotional and behavioral symptoms, functioning problems, juvenile justice risk, a need for child protective services, whether or not the screening is the child’s first screening in the time period).

Population Studied: The study sample (n =

14,127) included information on all screenings conducted by the SASS program between

December 1, 2005, and August 31, 2006, and was restricted to children and adolescents between the ages of 3 and 21 years at the time of screening.

Principle Findings: Results suggest that among children with a mental health crisis, those with caregiver needs were more likely to be stabilized in the community than those without caregiver needs [OR = 1.386, 95% CI = 1.274, 1.506]. Other significant predictors of community stabilization included whether the crisis was the child’s first crisis during the study time period [OR = 2.684,

95% CI = 2.439, 2.953].

Conclusions: These findings suggest that among children with a mental health crisis, the presence of caregiver needs increases a child’s odds of being stabilized in the community.


Understanding factors related to clinical decision making for children and adolescents with a mental health crisis is important to improving the ability of systems of care to offer appropriate treatments in the least restrictive setting.

Funding Source: Advanced Rehabilitation

Research Training, NIDRR

• The Importance of Psychosocial

Rehabilitation in Prevention of Developing

Chronicity in Mental Disorders: View Points of Iranian Mental Health Professionals

Zia Ghaemmagham, M.D., Mahshid Foroghan,

M.D., Ali-Reza Jazayeri, Ph.D.

Presented By: Zia Ghaemmagham, M.D.,

Assistant professor, Psychiatry, University of

Social welfare and Rehabilitation Sciences,

Koodakyar St. Daneshjoo Blvd, Evin, Tehran,

Iran, Phone: +98(21)22400036,

Fax: +98(21)22400110, Email: drzia2001@yahoo.com

Research Objective: The aim of this survey was studying of the importance and effect of psychosocial rehabilitation on preventing developing of chronicity in mental disorders from the view points of Iranian Mental Health

Professionals.

Study Design: This study is a part of more detailed cross- sectional and descriptive survey which included 10 items, 7th item was related to this study. The content validity and reliability of the main questionnaire was quite high (Alpha =

0.84, r11= 0.77) and Alpha coefficient for 7th item was 0.8. In this item professionals were asked to score four types of psychosocial rehabilitation

(medical, psychological; social and vocational) according to their importance and effects.

Questionnaires were completed by mental health professionals with at least 1 year of experience on

working with mentally ill patients, being familiar with classification of mental disorders (DSM-IV,

ICD-10). Total of 400 questionnaires were used, of which only 331 were complete. Data were analyzed using descriptive and inferential statistics, SPSS -10 was used.

Population Studied: Questionnaires were completed by mental health professionals with at least 1 year of experience on working with mentally ill patients, being familiar with classification of mental disorders (DSM-IV, ICD-

10).

Principle Findings: The disciplines of participants were: psychology (38.31%), psychiatry (25.32%), nursing (15.94%), general medicine (6.6%), social work (6.25%), occupational therapy (5.62%), and internal medicine (1.87%). Participants were from both sexes including 51.57% male. Findings showed that from the view points of Iranian mental health professionals the psychological component of psychosocial rehabilitation was the most important followed by social, medical and vocational rehabilitation. Differences between importance of psychological (p<0.01,

S= 0.01,df =7, x² =37.51), social rehabilitation

(p<0.01, S=0.0001, df= 7, x²= 29.97) and vocational rehabilitation (p<0.01) were significant, where medical rehabilitation was not significant (p<0.01).

Conclusions: Due to the role of vocational, social and medical components of psychosocial rehabilitation in integration of mentally ill patients in the community, revision of educational programs in related fields is a necessity for changing attitudes of professionals toward psychosocial rehabilitation.


Revising educational curriculum in different disciplines,providing financial and social support and establishment of vocational facilities and continuation of medical and rehabilitative measures for chronic mentally ill patients are the most needed in this context.

Funding Source: University of Welfare and

Rehabilitation Sciencesn

•

Carve-Outs, Referrals, and Mental Health in

Primary Care

Sherry Glied, Ph.D., David Brick, B.A., Michael

Sparer, Ph.D., Kelly Kelleher, M.D.

Presented By: Sherry Glied, Ph.D., Professor,

Health Policy and Management, Mailman School of Public Health, Columbia University, 600 West

168th Street, 6th Floor, New York, NY 10032,

Phone: 212-305-0299, Fax: 212-305-3405, Email: sag1@columbia.edu

Research Objective: Many children with mental health problems do not receive appropriate treatment. One strategy to narrow this gap is to increase treatment by primary care providers.

Some analysts have argued that policy decisions, including the use of carve-out plans and the availability of specialist referrals, may affect the ability of primary care providers to diagnose and treat mental health problems in children.

Study Design: We conduct a retrospective analysis of 2001 Medicaid claims (Medicaid

Analytic Extract data) from Massachusetts,

North Carolina, and New York. There is considerable variation between and among these states in the use of carves-out and the availability of mental health specialty providers.

Population Studied: Children aged 5-17, where the child is eligible for Medicaid for reasons other than disability.

Principle Findings: We find that rates of diagnosis and medication treatment in primary care are higher for children enrolled in carve-out plans than for children not enrolled in such plans, after controlling for characteristics of the primary health care plan. We find that primary care physicians and psychologists are complements -- increased availability of psychologists is correlated with a greater likelihood of mental health diagnosis and treatment in primary care -- but primary care physicians and psychiatrists are substitutes ---- areas with more psychiatrists tend to have lower rates of diagnosis and treatment in primary care.

Conclusions: There have been concerns that carve-outs reduce the propensity of primary care physicians to treat mental health problems, but we find no evidence of this pattern. Rather, we see some evidence suggesting that primary care physicians are more likely to provide mental health care (especially medications), in areas where psychiatrists are less available.


Medicaid program directors have often found mental health carve-outs to be a successful strategy for containing costs and increasing access. An important concern, however, has been that this form of mental health financing impedes diagnosis in primary care. Our results suggest that this concern may not be valid.

Funding Source: MacArthur Foundation

• The Liver Health Initiative: Promoting

Hepatitis Services in Substance Use

Disorders Treatment Clinics

Hildi Hagedorn, Ph.D., Nancy Rettmann, M.A.,

Eric Dieperink, M.D., Janet Durfee, N.P., Deb

Dingmann, R.N., Carl Isenhart, Psy.D.

Presented By: Hildi Hagedorn, Ph.D.,

Implementation Research Coordinator,

Psychiatry, VA Substance Use Disorders Quality

Enhancement Research Initiative, Minneapolis

VA Medical Center, One Veterans Drive (116A9),

Minneapolis, MN 55417, Phone: (612) 467-3875,

Email: hildi.hagedorn@va.gov

Research Objective: Integrating hepatitis prevention and referral services into substance use disorders (SUD) treatment programs provides a unique opportunity to target services to this high-risk group. The initial goal of the

Liver Health Initiative was to establish a pilot

Liver Health program in a VA SUD clinic which would: 1) improve screening for hepatitis A, B, and C, 2) provide comprehensive, structured patient education on liver health, 3) provide hepatitis A and B immunizations for patients lacking immunity, and 4) increase rates of successful referral to the hepatitis clinic for hepatitis C positive patients (Hagedorn, et al.,

Journal of Substance Abuse Treatment, in press).

Following successful establishment of the pilot program, a 2-day workshop designed to promote the implementation of hepatitis services in other

VA SUD clinics and increase collaborations between SUD providers and hepatitis C providers was developed and evaluated.

Study Design: The first day of the workshop was educational and focused on the risks for hepatitis in SUD patients, the goals of a Liver

Health Program, how to implement a Liver

Health Program, and techniques for hepatitis C providers to use in managing SUDs in their patients. During the second day, each team was assisted in developing an action plan including objective actions that would occur in the six months following the workshop. The workshop was followed by one, three and six month

"coaching calls" during which the teams' progress on their action steps was evaluated. All attending teams, plus seven teams that applied to attend but were not invited, completed surveys assessing current clinic practices regarding hepatitis services at baseline and during follow-up calls.

Population Studied: Teams consisting of a leader from the SUD clinic, an SUD clinical staff member with an interest in providing hepatitis services, and a hepatitis C provider were selected from 11 VA medical centers around the nation.

Seven teams that applied to attend the workshop but were not invited served as "controls".

Principle Findings: All attending clinics were able to report accomplishing at least one of their action goals. Examples of improvements reported include: 1) adding screening for hepatitis A and B to routine intake labs, 2) establishing a hepatitis A and B vaccination clinic, and 3) improving the quality of hepatitis education offered to patients by incorporating videos and slide shows provided as part of the workshop. In addition, SUD provider ratings of the level of collaboration with hepatitis C providers increased from 2.3 to 4.1 (0 = no collaboration, 5 = active collaboration). No corresponding increase in hepatitis related services or collaboration with hepatitis C providers was reported by the control SUD providers.

Conclusions: A 2-day workshop with follow-up coaching calls can successfully promote improvements in hepatitis services in SUD clinics and increase collaboration between SUD and hepatitis providers.


The goal of the Liver Health Initiative is to reduce the rates of new hepatitis infections through education and vaccination and to improve the identification and treatment of existing hepatitis infections through increased collaboration between SUD and hepatitis providers.

Funding Source: VA

• Association of Personal Characteristics

With Self-Identification of Depression

Jeffrey Harman, Ph.D., John Fortney, Ph.D., Kelly

Kelleher, M.D., M.P.H.

Presented By: Jeffrey Harman, Ph.D., Associate

Professor, Health Services Research,

Management, and Policy, University of Florida,

PO Box 10195, Gainesville, FL 32611-0195, Phone:

(352) 273-6060, Fax: (352) 273-6075, Email: jharman@ufl.edu

Research Objective: Although effective treatments for depression exist, non-treatment of depression is common. A significant facilitator to seeking treatment for depression is individuals’ willingness or ability to identify themselves as being depressed. If an individual does not identify the symptoms of depression or is unwilling to admit that they are suffering from depression, that individual is unlikely to seek help. The purpose of this study is to determine

personal characteristics associated with selfidentification of depression.

Study Design: Data from the 2004 Medical

Expenditure Panel Survey (MEPS) are used to assess personal characteristics associated with self-identification of depression after controlling for depressive symptoms as measured by the

PHQ-2, a two-item depression screener.

Although the MEPS is administered to respondents three times during a year, the PHQ-

2 is only administered once per year. Therefore, only self-reported conditions from the same interview where the PHQ-2 is administered are assessed. Individuals who are already receiving treatment for depression, defined as filling an antidepressant prescription or visiting a psychiatrist or psychologist, are dropped from the analysis. Weighted logistic regression is employed to identify respondent characteristics associated with self-reporting depression.

Respondent characteristics included in the analyses are gender, marital status, race/ethnicity, age, education, the presence of any functional limitation, the number of health conditions, and the number of primary care visits during the year. A dummy variable indicating a score on the PHQ-2 of 3 or more is used to control for depressive symptoms. All analyses are conducted using the survey procedures of Stata and use the provided weights to obtain nationally representative estimates and calculate standard errors that account for the complex sampling design of the

MEPS.

Population Studied: The Household

Component of the 2004 MEPS (N=34,403) is used. The MEPS is conducted annually by the

Agency for Healthcare Research and Quality. All adults who are not currently receiving treatment for depression are included in the analysis

(N=20,985).

Principle Findings: Overall, 9.9% of adults

(N=2,501) self-report depression and 9.2% of adults screen positive for depression (PHQ-2 >

2). However, of those adults who screened positive for depression, 67.3% did not self-report depression. Screening positive significantly increased the odds of self-report of depression

(OR=7.10, p<.001). Adults who were married

(OR=0.57, p<.001), African-American (OR=0.43, p=.049), or older than 65 (OR=0.51, p<.001) were less likely to self-report depression. The probability of self-reporting depression increased with the number of medical conditions reported

(OR=1.18, p<.001).

Conclusions: African-Americans, married persons, and older adults are significantly less likely to self-report depression, even after controlling for depressive symptoms, while gender, Latino ethnicity, education, and functional limitations appear to be unrelated to self-identification of depression.


Interventions intended to increase awareness of depression and its treatments, while important for all individuals, should be tailored to target the needs of older patients and African Americans.

Additionally, studies that rely on self-reports of depression to identify individuals with depression are likely not representative of all individuals with depression. It is important that this is taken into account when interpreting results from these studies.


Health

•

Responding to Depression among

Competing Demands: Clients’ Perceptions and Treatment Priorities

Leslie Hasche, M.S.W., Enola Proctor, Ph.D.,

Nancy Morrow-Howell, Ph.D., Luis E. Zayas,

Ph.D., Grace Snell, B.A., Michael Nickel, B.S.

Presented By: Leslie Hasche, M.S.W., NIMH pre-doctoral trainee, George Warren Brown

School of Social Work, Center for Mental Health

Services Research, 1 Brookings Drive, Campus

Box 1093, St. Louis, MO 63130, Phone: (314)935-

9796, Fax: (314)935-7508, Email: lhasche@wustl.edu

Research Objective: The President’s New

Freedom Commission Report on Mental Health

(2003) identifies public agencies whose clients have unmet mental health care needs, such as

CLTC, as potential sites for the integration of mental health care. However the extent to which behavioral health is a priority concern among clients in non-specialty settings remains unexplored. Given high levels of depression among older adults in community long-term care (CLTC), this project used an innovative methodology of assessing stakeholder preferences to inform the implementation of evidence-based depression treatments into CLTC service agencies. Specifically, it examines CLTC clients’ perceptions of depression and their priority for depression care among co-occurring social, medical, and functional problems.

Study Design: Methods employed standardized depression screening, semi-structured qualitative interviews which were audiorecorded and transcribed, free listing of problems, and qualitative and quantitative analysis of subjects’

preference rankings. Trained coders used NVivo for data management and codification. Freelisted problem statements were reduced to codes to develop a matrix, which was analyzed quantitatively using SAS. Researchers used a content-driven, iterative process to derive themes.

Population Studied: A homogeneous purposeful sample comprised 50 individuals, age

60 and above, all of whom were public CLTC clients who evidenced depression according to research protocol. The sample was low-income, predominantly female, dis-proportionately

African American.

Principle Findings: These public sector clients identified problems with physical health, functional impairment, family problems, housing, finances, and access to health care.

While all participants acknowledged depression, depression was ranked low among the cooccurring conditions. Only 7% identified depression as the most important problem;

47.6% identified depression as the problem lowest in importance. Study participants expressed preferences for informal and formal providers who would address their priority problems which co-occurred with depression.

Conclusions: Clients in public social services experience depression among a mixture of multiple psychosocial, physical health, and functional problems, and rank depression as lower in priority than these other problems.


These findings indicate that depression treatment should be linked to other services-----both conceptually and practically------in order to find receptivity among client who need depression care. Motivational interviewing, health education, and assessment of treatment priorities may be necessary in addressing depression outside of behavioral health care settings.


• Disparities in Mental Health Status among

Rural Children? Child and Family Findings for

Two States

Craig Anne Heflinger, Ph.D., Ana Maria Brannan,

Ph.D.

Presented By: Craig Anne Heflinger, Ph.D.,

Associate Professor, Human & Organizational

Development, Vanderbilt University, 230

Appleton Pl, Box 90 Peabody College, Nashville,

TN 37203, Phone: (615) 322-8275, Fax: (615) 322-

1141, Email: c.heflinger@vanderbilt.edu

Research Objective: To better understand healthcare disparities for rural children and adolescents by examining the extent to which differences exist in mental health status (and resulting mental health services need) between children living in rural and non-rural areas, and what explains those differences. A multi-level health services utilization/outcome framework is tested using multivariate modeling.

Study Design: In-depth interviews with family caregivers included assessment of child clinical status, family characteristics, caregiver well being, and reported barriers to care. First descriptive comparisons between rural children and families and their non-rural counterparts are examined, then multivariate models were used to explore the extent to which child mental health need and related family variables differed for rural children when controlling for child and family demographics. Comparisons include: mental health status (symptoms, psychosocial functioning), family characteristics, caregiver strain, and three types of reported barriers to care.

Population Studied: Stratified random statewide samples of Medicaid-enrolled children and adolescents and families in two southern states (n=1200). Weights controlling for age, race, gender, and past service use were used to provide representative statewide findings.

Principle Findings: Although bivariate differences between rural and non-rural youth were found in mental health status, no significant differences were found in the multivariate analyses with controls. Family income level was associated (negatively) with mental health status across all mental health variables in both states. Race by rural interactions were also found but differed by state. Several family-level variables were significantly different for rural children. Rural caregivers reported less caregiver strain and less satisfaction with family interactions. There were also significant differences in reported barriers to care. This finding held after controlling for child symptom severity and race.

Conclusions: Equivalent levels of child mental health status, with high levels of clinical symptoms and psychosocial impairment, were found for rural and non-rural children in two states, indicating similar high levels of mental health services need. Family factors shown in previous research to influence service use, however, differed for rural children.


Rural children and adolescents demonstrate high levels of mental health service need and need

access to care equivalent to urban youth.

Attention must be paid not only to community resources available to all, but in family factors that influence their decisions to seek care. The role of Medicaid as a ‘‘protective’’ factor in rural service access in these two states will also be discussed.


•

Factors Associated With Treatment

Adjustment for Depression in Primary Care

Rachel Henke, Ph.D., John Z. Ayanian, MD,

MPP, Thomas G. McGuire, Ph.D., Alan M.

Zaslavsky, Ph.D.

Presented By: Rachel Henke, Ph.D.,

Postdoctoral Fellow, Health Care Policy, Harvard

Medical School, 180 Longwood Avenue, Boston,

MA 02115, Phone: 617-432-3459, Email: mosher@hcp.med.harvard.edu

Research Objective: Many patients treated for depression in primary care do not improve after a first trial of medication or psychotherapy. For these individuals, depression treatment guidelines recommend adjusting the patient’s treatment. Little is known about how frequently patients receive these treatment adjustments and what factors influence adjustments.

Study Design: We characterize patterns of treatment adjustment in primary care, including the frequency of adjustment and its relation to the patient’s clinical condition using models for the probability of transition to a given treatment

‘‘state’’ conditional upon the current state of treatment. We explore the responsiveness of treatment decisions to the level of severity, changes in severity, treatment history, and patient and clinician characteristics.

Population Studied: We use survey data on

1,439 patients with major depression collected at six month intervals over a two year period.

Patient and clinician characteristics were collected at baseline and depression severity, changes in severity, treatment, and changes in treatment were measured at each interval.

Principle Findings: In our cohort, 59% of patients received some form of treatment adjustment. Individuals were more likely to receive an adjustment recommendation if they had severe depression symptoms (p<0.001).

After controlling for severity, individuals with persistent or worsening symptoms were no more likely to receive an adjustment recommendation than individuals whose symptoms partially or completely improved.

Individuals already receiving both antidepressant and psychotherapy were the least likely to receive adjustment recommendations (p<0.01).

Conclusions: While there is strong empirical evidence that patients with depression who do not improve after starting treatment should have their treatment adjusted, we find little support that clinicians follow this aspect of the guidelines. It may be challenging for clinicians to monitor changes in severity due to the lack of objective tests to quantify severity and suboptimal physician-patient communication.


Our findings raise concerns about the quality of care for patients who do not respond to initial treatment and suggest that quality improvement efforts should target treatment adjustment for patients with persistent or worsening symptoms.


•

Are Adolescents with Low SES More Likely to Have Mental Health Disorders as Adults?

Jennifer Humensky, M.P.P.

Presented By: Jennifer Humensky, M.P.P., PhD

Student, Harris School of Public Policy,

University of Chicago, 5242 S. Hyde Park

Boulevard, Apt 811, Chicago, IL 60615, Phone:

773-456-3480, Email: jhumensk@uchicago.edu

Research Objective: The relationship between

SES and mental health has been wellestablished: people with low SES are more prone to mental health problems. However, the longterm effect of living in poverty in childhood on adult mental health has not been welldocumented. The purpose of this study is to examine, in a nationally representative sample of

U.S. adolescents, whether low SES in adolescence is associated with increased risk of mental health disorders in adulthood, after accounting for SES in adulthood. The study also seeks to determine whether relative income in adolescence ---- that is, income relative to the median in the community - is associated with an increased risk of mental health disorders in early adulthood over and above the absolute level of income.

Study Design: Mental health disorders are measured by depressive symptoms (CES-D score) and substance abuse. SES in adolescence is measured by parents’ education, occupation status, household income and income differential. SES in adulthood is measured by educational attainment. The association between

SES and depression is measured via OLS while the association between SES and substance abuse is measures by count data models.

School-level fixed-effects are also examined to determine if unobserved school-level characteristics are driving these results.

Population Studied: Students interviewed in

Waves I and III of the National Longitudinal

Survey of Adolescent Health (AddHealth), a nationally representative survey of students in grades 7-12 at Wave I (1994-95). Wave III followup was conducted in 2001-02 when respondents were 18-26 years old.

Principle Findings: As expected, low SES in adulthood, as measured by education attainment, was associated with increased risk of both depression and substance use. However, the association with adolescent SES varied between the two disorders. Low SES in adolescence was associated with an increased risk of depression in young adulthood.

Specifically, low parental education and having household income less than 50% of the median income in the county were associated with significantly higher depression scores, after controlling for Wave III SES. However, the opposite was found for substance abuse. Higher

SES in adolescence was associated with greater substance abuse in adulthood. This result holds regardless of the measure of SES used ---- parents’ education, occupation, household income or income differential. These results were consistent in school fixed effects. However, due to missing observations, these results are applicable to a more affluent population than the population in general.

Conclusions: The effects of SES in adolescence continue into young adulthood. Adolescents who grow up poor continue to be at risk of depression, while adolescents who grow up wealthy continue to be at risk of substance abuse in early adulthood. Furthermore, relative income matters. Even after controlling for the level of income, being ‘‘poor’’ or ‘‘rich’’ in the community was associated with increased risk of depression and substance abuse, respectively, into young adulthood.


Although it is known that adolescents with low

SES are at risk for mental health problems, this study finds that wealthy adolescents are also at risk for substance abuse problems in adulthood.

This is a population that is frequently overlooked in public policy analyses. Furthermore, as the results from the relative income analyses show, even if an adolescent has a household income that would not generally be considered ‘‘poor’’ or

‘‘rich’’, he/she may be at risk if living in a community where he/she is advantaged or disadvantaged relative to peers.

Funding Source: AHRQ, T32

• Impact of Multiple Risk Factors on Health

Status among Chinese Americans

Dorothy Hung, Ph.D., M.A., M.P.H., Donna

Shelley, M.D., M.P.H., Marianne Fahs, Ph.D.

Presented By: Dorothy Hung, Ph.D., M.A.,

M.P.H., Research Scientist, Sociomedical

Sciences, Columbia University Mailman School of Public Health, 722 W. 168th Street, Suite 942,

New York, NY 10032, Phone: (212) 342-0154,

Email: dh2237@columbia.edu

Research Objective: Smoking, risky drinking, physical inactivity, and obesity are leading causes of death and disability, yet little is known about these highly related risks or their cumulative impact on health status particularly among minority populations. This study contributes to the understanding of health indicators among a rapidly growing but understudied minority group in the U.S. Research objectives include the following: (1) Describe the prevalence of risk factors and health status among Chinese

Americans (CAs); (2) Compare risk factors and health status to estimates and norms of the general U.S. population; (3) Construct a CA health risk profile that identifies both individually occurring and co-occurring risk factors, and compare these to the general U.S. population;

(4) Examine associations between health status and individual as well as multiple risk factors among CAs.

Study Design: This study used cross-sectional data from a representative probability sample of

CAs residing in two communities. Eligible households were obtained from the white pages, using a list of 867 unique spellings from 622 native surnames identified in consultation with

Chinese linguists. A stratified systematic sampling procedure was applied by zip code to all listed households, resulting in a sample frame of households representative of each community. Sample data were weighted to account for unequal probabilities of sample selection and nonresponse. Prevalence of behavioral risk factors, and health status as measured by the SF-12, were described and compared with general U.S. data. Multivariate regression analyses were used to estimate associations between health status and individual as well as multiple co-occurring risk factors.

Population Studied: Chinese American adults located in New York City.

Principle Findings: The prevalence of smoking and physical inactivity as both single and combined risk behaviors among CAs surpassed estimates among the general U.S. population

(p<0.001). These behaviors were also negatively associated with health status after controlling for related chronic conditions (smoking: b=-0.69, p<0.05; physical inactivity: b=-2.38, p<0.001).

One, two, three, and four co-occurring risks were progressively associated with 1.83, 2.86, 4.87, and 8.74 point decreases in physical health status, compared to zero risks (p<0.001).

Similar trends were observed in mental health status scores, up to two co-occurring risk factors

(b=-1.94, p<0.001 and b=-2.32, p<0.01).

Conclusions: Cigarette smoking and physical inactivity are common among Chinese

Americans, surpassing general U.S. estimates of these behaviors as both single and combined risk factors. This suggests that relative to other health issues, preventive efforts to encourage cessation and physical activity may be particularly effective strategies to promote health and well-being in this population. This study also finds a ‘‘dose-response’’ decrease in health status with each additional occurrence of smoking, physical inactivity, risky drinking, and obesity/overweight. This relationship persists when controlling for related chronic conditions and other sociodemographic characteristics.


This study emphasizes multiple behavioral risks and their cumulative impact on health status.

Addressing risk behaviors through an integrated rather than a singular approach may ultimately be a more effective and efficient way to improve health across populations.

Funding Source: NCI

• How Does Mental Health Differ between

Vietnam Era Veterans Who Served in Vietnam and Those Who Served Elsewhere?

Sarah Laditka, Ph.D., M.B.A., M.A., James N.

Laditka, D.A., Ph.D.

Presented By: Sarah Laditka, Ph.D., M.B.A.,

M.A., Associate Professor, Health Services Policy and Management, University of South Carolina,

800 Sumter Street, Columbia, SC 29208, Phone:

(803)777-1496, Fax: (803)777-1836, Email: sladitka@gwm.sc.edu

Research Objective: The 8.4 million Vietnam era veterans are the largest cohort of living U.S. veterans, constituting 32% of all living veterans.

Half are age 65 or over. Yet, relatively little is known about the long-term effects of military service in Vietnam on mental health, or on needs for mental health services. We used a nationally representative survey of veterans to examine measures of mental health well-being, to estimate the prevalence and treatment of diagnosed post-traumatic stress disorder

(PTSD), and to estimate use of other mental health services. Our research question was: drawing on life-course theory, among a cohort of

Vietnam era veterans, how does mental health, and use of mental health services, differ between those who served in Vietnam and those who served elsewhere?

Study Design: We used nationally representative survey data from the 2001 National Survey of

Veterans (NSV), conducted by the Veteran's

Administration (VA). We restricted the data to veterans of the Vietnam era. The exposure variable indicated whether the veteran served in

Vietnam or elsewhere. We examined: (1) measures of mental health well-being; (2) diagnosis and treatment of PTSD; (3) treatment for other mental health conditions; (4) VA psychiatric treatment; and (5) other psychiatric treatment. Analyses included bivariate comparisons and multiple logistic regression.

Multivariate models controlled for individual characteristics (age, gender, education, race/ethnicity, occupational status, physical health). All analyses were weighted for national representation.

Population Studied: Vietnam era veterans in the

2001 NSV (n=7,914): 3,937 served in Vietnam;

3,977 served elsewhere.

Principle Findings: In bivariate results, those who served in Vietnam were notably more likely to report feeling downhearted or blue (Odds

Ratio, OR 1.54), taking less care in daily activities due to emotional problems (OR 1.34), or being socially isolated for health reasons (OR 1.22) (all p<0.001). They were less likely to have lots of energy (OR 0.92), or to feel calm (OR 0.74)

(both p<0.001). The prevalence of diagnosed

PTSD was 18.5% for those serving in Vietnam,

4.8% for others (p<0.0001). Adjusted odds of being treated for PTSD were more than 6 times greater for those who served in Vietnam (OR,

6.13, p<0.0001). Those who served in Vietnam were also notably more likely to be treated for other mental health conditions (OR 1.66)

(p<.001), or to have psychiatric treatment at the

VA (OR 2.26) or elsewhere (OR 1.08) (both p<0.05).

Conclusions: Among Vietnam era veterans, those who served in Vietnam report lower mental health well-being, are at higher risk of reporting diagnosed PTSD and other mental

health conditions, and are more likely to report receiving treatment for mental health problems.


As Vietnam veterans age, it is likely that they will continue to need substantial mental health services. Policymakers and practitioners need to plan for services to address these needs.

•

Does Peer Support Affect Hospital

Recidivism Rates and Crisis Intervention

Episodes?

Glenn Landers, M.B.A., M.H.A., Mei Zhou, M.S.,

M.A.

Presented By: Glenn Landers, M.B.A., M.H.A.,

Senior Research Associate, Georgia Health Policy

Center, Georgia State University, 14 Marietta

Street, Suite 221, Atlanta, GA 30303, Phone: 404-

463-9562, Fax: 404-651-3147, Email: glanders@gsu.edu

Research Objective: Peer Support programs have gained popularity nationwide as tools to support community dwelling consumers of mental health services. The programs specifically train and support participants in using skills to inspire hope, to engage the adult mental health consumer in creating and achieving recovery/life goals, and to orient the mental health system toward recovery. As a byproduct of these goals, it is expected peer support programs reduce inpatient recidivism rates and crisis intervention episodes or facilitate the use of less expensive and intensive crisis stabilization episodes over more expensive inpatient treatment. For the first time, we measure whether or not peer support programs produce the desired effects.

Study Design: Retrospective cohort analysis of

Georgia administrative data (Medicaid claims,

Mental Health, Developmental, and Addictive

Disease (MHDDAD) Community Information

System Data, and MHDDAD Hospital

Information System Data).

Population Studied: Study Group: 1,910 clients with Community Mental Health Claims accessing Peer Support Services in CY2003.

Control Group: 3,820 clients with Community

Mental health Claims not accessing Peer

Support Services in 2003 and matched to the

Study Group on Gender, Race, Age Group,

Urban or Rural Residence, and three top

Principle Diagnoses (Schizophrenic Disorders

(64%), Affective Psychoses (23%), and All Other

(13%)) as listed on the patient’s first Medicaid claim in CY2003.

Principle Findings: 1. More than 80% of the

Study and Control Groups do not use either inpatient mental health or mental health crisis stabilization services during the 12-month observation period. There is no statistical difference between the Study and Control Group.

2. The Study Group accesses crisis stabilization services more (p<.01) and state mental health hospital stays less (p<.1) than the Control

Group. 3. The odds of being admitted to a state mental health inpatient hospital stay are reduced by 15 percent for clients with Peer Support. The odds of experiencing a crisis stabilization episode are increased by 33 percent for clients with Peer Support. 4. Average inpatient mental health costs are $2,000 less for the Study Group, though the difference is not significant. 5.

Average crisis stabilization costs for both groups are about equal with no significant difference. 6.

Average total Medicaid costs are significantly higher (p<.01) for the Study Group.

Conclusions: Peer Support appears to have the desired effect of reducing inpatient mental health stays while facilitating the use of less intensive and expensive crisis stabilization episodes.


The Centers for Medicare and Medicaid Services only recently began reimbursing for peer support services as a component of Medicaid supported mental health recovery. This study suggests peer support may improve quality of life by reducing inpatient mental health stays.

However, this improvement in quality of life comes with no significant overall cost savings for mental health services.

Funding Source: CMS

•

Psychotropic Medication Use among

Privately Insured Youths With Autism

Douglas Leslie, Ph.D., Andres Martin, M.D.

Presented By: Douglas Leslie, Ph.D., Associate

Professor, Psychiatry, Yale School of Medicine,

NEPEC/182, 950 Campbell Avenue, West Haven,

CT 06516, Phone: (203)932-5711 x4015, Fax:

(203)937-3433, Email: douglas.leslie@yale.edu

Research Objective: Very little is known about how individuals with autism are treated in realworld practice settings. The objective of this study is to determine what psychotropic medications are prescribed for privately-insured children with autism, and how patterns of medication use have changed over time.

Study Design: Retrospective analysis of the

MarketScan database, a national administrative

claims database of privately insured individuals in the US, for the years 2000 through 2004.

Population Studied: Privately insured youths aged 17 and under with a diagnosis of autism.

Principle Findings: We identified 4,057 unique individuals aged 17 and under who had a diagnosis of autism between 2000 and 2004.

Of these individuals, 50.1% had a prescription for a psychotropic medication per year on average. The most commonly prescribed class of psychotropic medication was antidepressants

(25.6% per year on average), followed by antipsychotics (20.2%), stimulants (19.8%), anticonvulsants (15.1%) and anxiolytic/sedative/hypnotics (11.4%). Of the individuals who received any psychotropic medications, over half (53.5%) received more than one class of drug. These medication patterns remained relatively stable over time.

Conclusions: Use of psychotropic medications in youths with autism is common, with antidepressants and antipsychotics accounting for almost half the agents prescribed.


Further research is necessary to evaluate the effectiveness of these medications for youths with autism. To the extent that these drugs are effective, efforts must be made to ensure adequate access to them.


Health

• Do Client Responses to TC Treatment

Predict Retention?

Wallace Mandell, Ph.D., M.P.H., Maria Orlando

Edelen, Ph.D., Suzanne Wenzel, Ph.D., James

Dahl, Ph.D., Patricia Ebener, B.S.

Presented By: Wallace Mandell, Ph.D., M.P.H.,

Senior Research Associate, Research, Phoenix

House Foundation, 164 W. 74th Street, New

York, NY 10023, Phone: (410) 955-3889, Fax:

(410) 614-8132, Email: wmandell@jhsph.edu

Research Objective: This study examined associations between responses to therapeutic community processes measured by the

Dimensions of Change Instrument (DCI) and length of stay in treatment.

Study Design: A 9-month sample of 519 adult entrants to six Phoenix House therapeutic communities was examined as three distinct groups. An ‘‘entrants group’’ who stayed in treatment for a minimum of 29 days, a ‘‘treated cohort’’ who remained in treatment for one month or more and a ‘‘follow-up cohort’’ interviewed at 3-months post-treatment.

Population Studied: A national sample of adult therapeutic community treatment clients.

Principle Findings: Clients were more likely to complete the first month of treatment if they responded more positively during the first week on Dimensions reflecting, perceiving residents as accepting ‘‘Community Responsibility’’, demonstrating ‘‘Resident Sharing, Support and

Enthusiasm’’, actively participating in ‘‘Group

Process’’, feeling ‘‘Clarity and Safety’’ in the program’s methods, and expressed a personal’’

Commitment to Abstinence’’. Higher scores at the 30th day on ‘‘Clarity and Safety’’ and

‘‘Resident Sharing, Support and Enthusiasm’’ predicted continuing in treatment for 3, 6 and 9 months. Multivariate analyses indicate that longer stays in treatment were associated with post treatment employment, AOD abstinence,

12-step meeting attendance, and having a 12-step sponsor. No Dimensions of Change score predicted post-treatment outcomes.

Conclusions: Longer stays in treatment are associated with post treatment client benefits, and use of the DCI instrument at baseline entry and 30 days can predict who will leave and those who stay in treatment. .


The Dimensions of Change instrument may be an aid to clinical focus on high risk clients in the future

Funding Source: Phoenix House Foundation

• Drug Court Innovations to Improve

Treatment of Addictions for Offenders

Douglas Marlowe, J.D., Ph.D., David Festinger,

Ph.D., West Huddleston, Mady Chalk, Ph.D.

Presented By: Douglas Marlowe, J.D., Ph.D.,

Director, Center on Law and Ethics, Treatment

Research Institute, 150 S. Independence Mall

West, Philadelphia, PA 19106, Phone: (215) 399-

0980 x107, Email: marlowe@tresearch.org

Research Objective: Scientifically evaluate the impact of judges in drug court programs during addictions treatment of offender populations.

Study Design: A group of studies replicated in 5 different drug courts. Random assignment of offenders to one or two conditions: 1) biweekly attendance at judicial status hearings regardless of treatment progress or 2) attendance on an asneeded basis, ie.g., when requrested by treatment counselors in response to serious or repeated infractions.

Population Studied: Adult offenders, rural/urban settings, high- and low-risk groups as defined by criminogenic risks and needs, in

treatment. "High-risk offenders" are those with antisocial personality disorders or those who have previously failed drug abuse treatment;

"low-risk offenders" performed equivalently when they were monitored by clinical case managers and not required to attend routine court hearings.

Principle Findings: Some categories of substance busing offenders are likely to perform poorly in diversion to treatment programs that downplay the role of judges; in one of the most dramatic findings, 80% of offenders in one high risk group successfully completed their drug court program which included treatment when frequent meetings with the judge were required compared to 20% successful completion rate whe clients saw judges only when treatment counselors requested it.

Conclusions: We now have compelling evidence that for a subset of offenders the judge is a key component of drug court, including treatment.

For low-risk clients, the data suggest it may be appropriate and cost effective to maintain relatively non-porous boundaried between treatment providers and criminal justice personnel.


The findings raise serious questions about whether high-risk offernders could reasona bly be expected to succeed in the type of low-intensity diversionary interventions exemplified in

Propositions 36 or 200.


• VA Treatment for New Episodes of

Depression: Does Dual-System Use Explain

Poor Performance?

John McCarthy, Ph.D., M.P.H., Kara Zivin

Bambauer, Ph.D., Karen Austin, M.P.H., Marcia

Valenstein, M.D., M.S.

Presented By: John McCarthy, Ph.D., M.P.H.,

Research Scientist, Serious Mental Illness

Treatment Research & Evaluation Center, US

Department of Veterans Affairs, HSR&D Field

Program / SMITREC, P.O. Box 130170, Ann

Arbor, MI 48113-0170, Phone: 734-769-7100, x6253, Fax: 734-761-2617, Email:

John.McCarthy2@va.gov

Research Objective: Treatment guidelines recommend that patients with new episodes of major depression receive at least 3 outpatient follow-up visits and continuous antidepressant therapy during the 12-week acute treatment phase. Both HEDIS (Health Plan Employer Data and Information Set) and VA (US Department of

Veterans Affairs) performance measures are based on these recommendations. We assessed

VA health system treatment for patients with new episodes of depression and, among patients aged 65 or older, we determined whether patients also received Medicare-funded treatment for depression. Substantial crosssystem use could explain poor VA performance, while potentially complicating assessments of

VA depression treatment quality.

Study Design: Using the VA’s National Registry for Depression, we identified all patients with new episodes of depression in the first quarter of fiscal year 2003. These patients had to have received a depression diagnosis and an antidepressant prescription up to 30 days before or 14 days after the diagnosis. Further, they could have no depression diagnoses in the prior

120 days, nor antidepressant fills in the 90 days before their antidepressant start. We assessed receipt of adequate VA follow-up (>3 visits in the

12 weeks following diagnosis) and antidepressant coverage (>12 of the 16 weeks following diagnosis). Among patients aged 65 or older, we examined outpatient follow-up using

VA data alone and when considering both VA and Medicare-funded depression treatment visits.

Population Studied: 12,076 VA patients had new episodes of depression in the first quarter of fiscal year 2003, of whom 29.5% were 65 or older.

Principle Findings: 16.3% of patients received guideline-concordant VA follow-up visits. 64.9% had adequate antidepressant coverage. 12.4% received sufficient VA care for both measures.

Among older patients (N=3567), only 333 (9.3%) received adequate VA outpatient contacts.

Overall, 268 patients (2.2% of 12,076) received

Medicare-funded depression-related visits during the acute treatment phase. 205 older patients

(5.7% of 3567) received such visits. When considering both VA and Medicare utilization,

395 older patients (11.1%) met treatment guidelines for outpatient follow-up.

Conclusions: Despite ongoing performance assessments, VA treatment for new episodes of depression remains poor. Among older patients, consideration of Medicare services use only modestly increases the percentage of patients receiving guideline-concordant followup, from 9.3% to 11.1%. Dual system use (VA-

Medicare) does not explain poor VA performance.


Research and service initiatives are urgently needed to improve treatment for new episodes

of depression. Medicare use neither substantially supplements VA depression treatment, nor does it complicate assessments of VA health system depression treatment quality.

Funding Source: VA

• Depression Diagnosis is Related to Number of Outpatient Visits in Diabetes and Non-

Diabetes Patients

Patrick O'Connor, M.D., M.P.H., A. Lauren Crain,

Ph.D., William A. Rush, Ph.D., Ann M. Hanson,

B.S., Lucy Rose Fischer, Ph.D., John C. Kluznik,

M.D.

Presented By: Patrick O'Connor, M.D., M.P.H.,

Senior Clinical Investigator, Research,

HealthPartners Research Foundation, PO Box

1524, MS 21111R, Minneapolis, MN 55440-1524,

Phone: (952)967-5034, Fax: (952)967-5022,

Email: patrick.j.oconnor@healthpartners.com

Research Objective: Compared rates of depression diagnosis in adults with and without diabetes, with careful control for number of primary care visits.

Study Design: Cohort study from 1997 to 2005 of diabetes patients with and without depression. Logistic regression was used to predict depression diagnosis in each diabetes cohort relative to matched non-diabetes controls

Population Studied: Adults with incident

(N=2,932) or prevalent (N=14,144) diabetes were matched to non-diabetes controls based on (i) age and gender, or (ii) age gender and number of outpatient visits.

Principle Findings: Prevalent diabetes patients with few primary care visits were significantly more likely (odds ratio = 1.46, 1.19-1.80) to have a new depression episode than control group (i)

, but this relationship diminished and then reversed as patients accrued more than 10 PC visits (odds ratio = 0.95, .77-1.17). Prevalent DM patients with few primary care visits were more likely (odds ratio = 1.32, 1.07-1.63) to have a new depression episode than those in control group

(ii), but this relationship diminished and reversed as patients accrued more than 4 PC visits (odds ratio = .99, .80-1.23). Similar results were observed in incident DM patients and their matched non-diabetes controls.

Conclusions: These results demonstrate little or no increase in risk of a new depression episode in incident or prevalent diabetes patients relative to those without diabetes after controlling for number of outpatient visits. Prevalent diabetes patients had less depression than age- gender- and visit-matched controls, when visits exceeded

6 visits a year.


Previous studies showing such an association may have inadequately adjusted for exposure to the medical care system. The strong link between number of outpatient visits and likelihood of depression raises questions about how depression is diagnosed and merits further investigation.

Funding Source: NIDDK/NIH

• Should Diabetes Accountability Measures be Adjusted for Mental Health Diagnoses?

The Case of Schizophrenia

Patrick O'Connor, M.D., M.P.H., John C. Kluznik,

M.D., A. Lauren Crain, Ph.D., William A. Rush,

Ph.D., Lucy Rose Fischer, Ph.D., Heidi L.

Ekstrom, M.A.





Phone: (952)967-5034, Fax: (952)967-5022,


Research Objective: We assessed the impact of schizophrenia diagnosis on diabetes care, in order to assess whether diabetes accountability measures may require adjustments for a schizophrenia diagnosis.

Study Design: Patients were categorized as having schizophrenia if they had one or more

ICD-9 codes for schizophrenia in a 24 month period. Multivariate linear regression models were used to compare glycated hemoglobin

(A1c) values in these two groups while adjusting for patient covariates including age, gender,

Charlson comorbidity scores, outpatient medical visits and likelihood of an A1c test.

Population Studied: We identified 399 adults with diabetes mellitus and schizophrenia diagnoses, and 13,745 adults with diabetes and no evidence of schizophrenia.

Principle Findings: Compared to diabetes patients without a schizophrenia diagnosis, those with schizophrenia diagnosis were significantly older (mean age 68.5 vs. 60.8 years, p <.0001), more likely to be female (54.9% vs.

47.9%, p<.006), had more medical comorbidity

(28.3% vs. 15.0% with a Charlson score = 1, p<.0001), and more outpatient medical visits

(8.6 vs. 6.8, p=.0002). Diabetes patients with a schizophrenia diagnosis also had lower rates of

A1c testing (48% vs. 71%, p<.0001). Among those with an A1c test, unadjusted mean A1c was

7.4% in schizophrenia and 7.7% in nonschizophrenia patients (p<.02). After adjustment {for age, gender, comorbidity score, and medical outpatient visits and test likelihood}, those with schizophrenia had significantly lower A1c levels than those without schizophrenia (p<.005).

Conclusions: Adults with diabetes and schizophrenia diagnosis had more medical visits and fewer A1c tests but no evidence of worse glycemic control than adults with diabetes and no schizophrenia diagnosis.


Occurrence of comorbid schizophrenia in adults with diabetes affects A1c test frequency, but not

A1c levels. Thus, different types of accountability measures may require different approaches to adjustment for mental health conditions.


•

Does Comorbid Bipolar Condition Affect

Diabetes Quality of Care Measures?


Ph.D., William A. Rush, Ph.D., Lucy Rose

Fischer, Ph.D., John C. Kluznik, M.D., Heidi L.

Ekstrom, M.A.





Phone: (952)967-5034, Fax: (952)967-5022,


Research Objective: To assess the impact of bipolar condition on diabetes care, and evaluate whether diabetes quality measures should adjust for this mental health condition.

Study Design: Patients were categorized as having bipolar if one or more ICD-9 diagnosis codes for bipolar condition existed in a 24 month period. We compared patterns of diabetes care in both groups, including frequency of glycated hemoglobin (A1c) testing, A1c values among those tested, and number of medical outpatient visits. Multivariate linear regression predicted

A1c values adjusting for patient covariates including age, gender, Charlson comorbidity score, number of primary care visits and likelihood of an A1c test.

Population Studied: We identified 142 adults with diabetes mellitus and bipolar condition and

14,002 adults with diabetes and no evidence of bipolar condition.

Principle Findings: Compared to diabetes patients without bipolar, those with bipolar were significantly younger (mean age 54.8 vs. 61.1 years, p<.0001), more likely to be female (66.2 % vs. 47.9 %, p<.0001), had similar medical comorbidity (19.7% vs. 15.3%, Charlson score =

1, p=.15), and more primary care visits (10.3 vs.

6.9, p<.0001). Those with bipolar had significantly lower rates of A1c testing (59.2% vs.

70.5 %, p=.003). Among those with an A1c test, unadjusted mean A1c was 7.4% in bipolar and

7.7% in non-bipolar patients (p=.11). After adjustment {age, gender, comorbidity score, number of visits and test likelihood}, those with bipolar had significantly better A1c levels than those without bipolar (p<.005).

Conclusions: Adults with diabetes and bipolar had more medical visits and fewer A1c tests.

Glycemic control was significantly better relative to adults with diabetes and no bipolar.


Occurrence of comorbid bipolar condition in adults with diabetes affects A1c test frequency, but not A1c levels. Thus, different types of accountability measures may require different approaches to adjustment for mental health conditions.


•

Pathways to Mental Health Care for

Children

Susan Pfefferle, Ph.D., Edward L. Spitznagel,

Ph.D.

Presented By: Susan Pfefferle, Ph.D., Post

Doctoral Fellow, George Warren Brown School of Social Work, Washington University in St

Louis, 1 Brookings Drive, Campus Box 1093, St

Louis, MO 63130, Phone: 314-935-6376, Fax: 314-

935-7508, Email: spfefferle@gwbmail.wustl.edu

Research Objective: It is well known that parental mental health impacts upon child mental well being. What is less known is what drives parents to seek treatment for child mental health problems. The objective of this study is to identify causal pathways of child mental health service use. Such information will be helpful to target resources and services for families.

Study Design: This study used data from the focal child file of the 2002 National Survey of

America's Families to explore the relationship between maternal mental health as measured by questions adapted from MHI-5 scale of the

Medical Outcomes Study and report of child mental health services use. Observations were limited to the most knowledgeable adults who were also the child’s mother. Path analyses were performed using SAS Proc CALIS.

Population Studied: A sample of 8072 mothers reporting on their 6-11 year old children from all

50 states with over sampling in 13 states.

Principle Findings: Poor maternal mental health was associated with increased parental aggravation which in turn was associated with increased use of child mental health visits.

Negative child behaviors as reported by the mother were also associated with increased maternal aggravation and increased service use.

All paths were significant at the .05 level of significance or below. The Chi Square for the lack of fit of the model was insignificant.

Conclusions: Parental perception of child behaviors drives treatment seeking, both directly and indirectly through parental aggravation.

Parental tolerance for child behaviors is influenced by her own mental health status. Our findings are consistent with other studies.


Parental report should not be the only method for identifying childhood mental disorders as parental perception of child behaviors is influenced by her own mental health.

Opportunities exist to identify and treat parental mental health problems when child behavioral concerns bring them into treatment.


• The Importance of Social Contact in

Fostering Job Satisfaction in Adults with

Developmental Disabilities Who Work in

Sheltered Employment.

Stacey Plichta, Sc.D., Paul Babcock, M.S.

Presented By: Stacey Plichta, Sc.D., Professor,

SCEH, ODU, 3134 Health Sciences Building,

Norfolk, VA 23529, Phone: (757) 683-4259, Email: splichta@odu.edu

Research Objective: This study examines the factors related to job satisfaction among adults with developmental disabilities who work at a sheltered employment site. Specifically, this study examines the influence of personal characteristics (sex, age, race, residence), job characteristics (learn new things, do different things, stay busy, important job, happy at work, enjoy work, happy with pay, like where I work, personal space, feel good at work) and workplace/social characteristics (people like me, treated well by supervisor, get along with supervisor, receives feedback from supervisor, supervisor availability, have friends at work, like people at work, able to chat with friends) on job satisfaction.

Study Design: A cross-sectional, mixed methods approach was employed; quantitative and qualitative data were collected simultaneously using a survey. The participants were given a four-page questionnaire to evaluate their satisfaction or dissatisfaction of their job on a 4point Likert Scale ranging from ‘‘strongly agree’’ to ‘‘strongly disagree’’ and open-ended questions. Face-to face interviews were used for the participants in the sheltered employment while the government contract self-administered or obtained family assistance.

Population Studied: : A total of 102 participants completed the surveys; 89 from sheltered employment using face-to-face interviews

(RR=57%) and 19 from government contract employees using self-administered surveys

(RR=12%). Demographic characteristics of the group are: 53% male, 56% African-American, and

75% age 18-50. Overall, 62% reside with family,

26% in group homes and 9% in their own apartment. A majority (60%) have been employed by the work-site for 10 years or more.

Principle Findings: A multiple linear regression model was constructed to examine predictors of job satisfaction. The overall model predicts a substantial percentage of satisfaction (R2 adj. =.

66, p<. 001). In this model, which controlled for personal, job, and workplace/social characteristics, the strongest predictor of satisfaction was getting feedback from a supervisor (adj. Beta .45, p<.01), followed by liking where they work (adj. Beta .32, p<.03) and feeling people at work like them (adj. Beta .20, p<.02). Three factors that approached significance were: doing different things at work, the importance of their job, how they are treated by their supervisor and their residence. No other factors even approached significance.

Conclusions: Similar to previous work, this study has identified that the place where the consumers work, being liked at work, and receiving feedback from the supervisor when they do a good job significantly influences overall satisfaction.


Similar to traditional employees, adults with developmental disabilities value social contact in the workplace; they desire feedback when they do a good job and they want a workplace that allows them to relate mutually with people who like them. They also may want work that they feel is important, and varied tasks as part of their job.

Therefore, creating an environment that promotes peer and supervisor interaction would greatly enhance consumer satisfaction. As suggested by previous studies, it is helpful for

employment programs to implement an ongoing assessment of their consumers’ view about their job.

•

Association Between Childhood Severity of

Psychiatric Illness and Psychiatric

Hospitalization

YongJoo Rhee, Dr.P.H., Neil Jordan, Ph.D., Gary

M. McClelland, Ph.D., John S. Lyons, Ph.D.

Presented By: YongJoo Rhee, Dr.P.H., Research

Assoicate, Psychiatry and Behavioral Science,

Northwestern University, 710 N. Lake Shore

Drive, Chicago, IL 60611, Phone: 312-503-1130,

Email: y-rhee@northwestern.edu

Research Objective: For children with a mental health crisis, there are two common treatment options. Psychiatric hospitalization is a restrictive and intensive treatment, while community-based treatment represents a less restrictive and expensive alternative. Illinois’

Screening, Assessment, and Supportive Service

(SASS) program, run by the Department of

Children and Family Services (DCFS), provides these services through regional agencies.

Clinicians and social workers are required to complete a primary assessment, the Childhood

Severity of Psychiatric Illness (CSPI) scale, to evaluate the severity of the youth’s mental crisis and to make their decision for treatment referral.

The objectives of this study are to assess the reliability of the CSPI and to test the association between CSPI domain scores and the likelihood of hospitalization.

Study Design: This retrospective cohort study compares the outcomes of a natural sample of youth whose mental health crises were treated either in the hospital or in the community through Illinois’ SASS program. SASS providers collected demographic data and completed mental health assessments for each child at the beginning and end of the SASS episode. The primary measure used was the CSPI. The children in the study sample were divided into three groups: community-stabilized children (i.e., those with no psychiatric hospitalization)

(n=212), children with one psychiatric hospitalization (n=456), and children with 2 or more hospitalizations (n=865).

Population Studied: Children and adolescents from 3 to 21 years old with a mental crisis that received SASS services for the first time during fiscal year 2005 and had valid CSPI scores are defined as this study sample (n=1,533). The records of this study sample were followed until

August 21, 2006 to observe their hospitalizations

Principle Findings: The inter-reliability scores (a score) of five domains in the Childhood Severity of Psychiatric Illness (CSPI) are: symptoms

(0.71), risk factors (0.45), functioning (0.60), comorbidity (0.44), and system factors (0.84). Due to non-normal data distributions, Kruskal Wallis tests were performed to compare the five CSPI domain scores across the three hospitalization groups. Children with higher domain scores (i.e., more severe) for symptoms, risk factors, functioning, and co-morbidity were significantly more likely to be hospitalized more than once (p

<.001). During the follow up period, children and adolescents who were referred to the SASS program more than once had significantly higher domain scores at the first SASS episode

(p<.001).

Conclusions: Children and adolescents hospitalized more than once had significantly higher CSPI scores at baseline, representing a higher severity of mental crisis. CSPI scores effectively predict the likelihood of repeat SASS program users at the initial SASS program entry point among children and adolescents with a mental health crisis.


The Childhood Severity of Psychiatric Illness

(CSPI) is a relatively new scale in this field but it is reliable enough to estimate the outcomes

(hospitalization) in this study. Field workers should be encouraged to utilize CSPI and should be required to get proper training and education in order to even more reliably administer the

CSPI.

•

Strategic Clustering and Product

Differentiation by Alcohol Vendors

David Ridley, Ph.D., Paul A. Zandbergen, Ph.D.

Presented By: David Ridley, Ph.D., Assistant

Professor, Health Sector Management, Duke

University, 1 Towerview Drive, Durham, NC

27708-0120, Phone: (919) 660-3784, Email: david.ridley@duke.edu

Research Objective: For decades the rationale for alcohol control policy has been the relationship between location of alcohol vendors and consumption. We examine location decisions of alcohol vendors.

Study Design: We compare clustering by on-site alcohol vendors (bars and restaurants) to off-site alcohol vendors (liquor and grocery stores). We use the difference in L-functions to estimate clustering.

Population Studied: We use precise location data from five cities for on-site alcohol vendors,

off-site alcohol vendors, and public elementary schools.

Principle Findings: Bars exhibit the highest degree of clustering, followed by restaurants that sell alcohol, liquor stores, and offsite vendors excluding liquor stores.

Conclusions: The results support the extensive theoretical literature on clustering which indicates that vendors cluster more in markets with more differentiated products. Furthermore, we demonstrate that in contrast to the existing empirical literature, the proper measurement of clustering requires a comparison of clustering in multiple industries.


Theory suggests that proximity of alcohol vendors tends to increase competition.

Competition in alcohol markets might not be socially desirable, however, if it takes the form of lower prices and more lenient carding.

Funding Source: NIAAA

• Parental Exceptions to Underage Drinking

Laws and Elevated Levels of Underage

Alcohol Consumption

Madeline Robertson, J.D., M.D., Ann F. Chou,

Ph.D., M.P.H., James Potts, M.P.H., David M.

Thompson, Ph.D.

Presented By: Madeline Robertson, J.D., M.D.,

Associate Professor, Health Administration and

Policy, University of Oklahoma, P.O. Box 26901,

Oklahoma City, OK 73190, Phone: (405) 271-2115 x37076, Fax: (405) 271-1868, Email: madelinerobertson@ouhsc.edu

Research Objective: State laws prohibiting underage possession and consumption of alcohol are of 3 types: those without exceptions; those with exceptions if a parent consents; and those with exceptions that apply at specified locations. The objective of this study was to determine whether states with laws containing parental exceptions were associated with higher levels of underage alcohol consumption, in contrast to consumption in states with laws not permitting exceptions.

Study Design: For this cross-sectional study, we computed descriptive statistics to examine the frequency distribution of dependent and independent variables. Univariate analyses were first conducted for variable selection. Finally, we employed a multivariate logistic regression model to estimate alcohol consumption as a function of the laws of the state in which the respondent resided.

Population Studied: We studied all minors ages

18 to 20,in all fifty states and the District of

Columbia, who responded to questions concerning their alcohol consumption in the

Behavioral Risk Factor Surveillance Survey,

BRFSS. We utilized the National Institute of

Alcohol Abuse and Alcoholism Alcohol Policy

Information System to categorize relevant possession and consumption laws into the three categories.

Principle Findings: The odds that a respondent age 18 to 20 reported any alcohol consumption in the previous 30 days is 1.19: 95%: 1.08 to 1.32 times higher for individuals from states with a parental exception, p>0.0005, as compared to individuals from states with no exceptions.

Conclusions: All states passed these prohibitions by 1986, pursuant to the National

Minimum Drinking Age Act of 1984. In the last twenty years, extensive research has established that laws and parental guidance independently reduce underage consumption of alcohol, yet 27 states retain the parental exceptions. In 2003, the Institute of Medicine, IOM, report on underage drinking concludes that after two decades it is critical for states to reexamine their underage drinking laws to close loopholes. This timely study supports the IOM recommendations, and highlights that all possession and consumption prohibitions are not equal as measured by their associations with underage alcohol consumption.


This study encourages state legislatures, policymakers and the general public to examine the text of their underage drinking laws and consider amendments to decrease underage drinking.

• Rewarding Physicians for High Quality

Depression Care

Sarah Scholle, Dr.P.H., M.P.H., Ann F. Chou,

Ph.D., Johann Channin, M.S.

Presented By: Sarah Scholle, Dr.P.H., M.P.H.,

Assistant VP of Research, Research, NCQA,

2000 L Street, NW Suite 500, Washington, DC

20036, Phone: 202-955-1726, Fax: 202-955-3599,

Email: scholle@ncqa.org

Research Objective: To test the feasibility and acceptability of methods for identifying high quality depression care by primary care providers that could be used as the basis of pay-forperformance rewards.

Study Design: An expert panel was convened to identify and prioritize quality measures for

evaluating depression in primary care. Eleven measures were selected for feasibility testing among patients with new episodes of depression, including initial assessment, followup and treatment. Detailed specifications and a data collection tool were developed to allow physicians (or their delegates) to abstract required information. Each physician submitted chart reviews for up to 35 patients. Audits at each site were conducted to evaluate the accuracy of self-report data. Qualitative interviews were conducted to assess the acceptability of the measures and their use as the basis of pay-for-performance rewards.

Population Studied: The measures were tested among 25 primary care physicians recruited through a primary care research network, an integrated delivery system, a network model health plan, and NCQA’s Diabetes Physician

Recognition Program. The practices differed in region, size, availability of behavioral health services on site, and the extent of electronic medical records use.

Principle Findings: A total of 535 patients were screened for measure eligibility based on age >

18 years, depression diagnosis, medications/symptoms or both. In the 3 sites, a range of 17 ---- 18 patients were identified per physician, with new depression episodes accounting for 40-90% of patients, which resulted in measures being applied against a total of 302 patients with a new episode of depression. The pilot study showed: (1) the use of standardized tools to assess depression is uncommon with the exception of the integrated delivery system; (2) the identification of patients with new episodes was time consuming and yield is low; and (3) the assessment of medication use was challenging due to the lack of documentation and some measures had very small denominator sizes. Onsite audit results generally agreed with physician self-report data.

In qualitative interviews, physicians were generally supportive of the quality measures with the exception of measures related to the intervals between diagnosis and early follow up visits and the completion of referral to behavioral health.

Conclusions: Findings from the feasibility test and interviews indicate efforts to improve depression care should focus on: improving systems for managing depression in primary care settings (including improving coordination with behavioral health care); encouraging the use and documentation of standardized assessment tools such as the PHQ-9 in administrative data; and refinement of quality measures that build on such assessments.


Physicians responded positively to improving quality of depression care and measurement efforts. However, they felt that financial incentives aimed at improving quality would be futile without significant improvement in the coordination of care between primary care and behavioral health and without changes in reimbursement systems to allow physicians to invest in staff and systems to support efforts to improve and to monitor the quality of depression care.

Funding Source: RWJF

•

The Availability of Mental Health Services and the Admission of the Seriously Mentally

Ill From the Emergency Department

Jay Shen, Ph.D., Jay J. Shen, Ph.D., Chris

Cochran, Ph.D.

Presented By: Jay Shen, Ph.D., Associate

Professor, Health Care Administration and

Policy, University of Nevada Las Vegas, 4505

Maryland Parkway, Box 453023, Las Vegas, NV

89154-3023, Phone: (702) 895-5830, Fax: (702)

895-5573, Email: jie.shen@unlv.edu

Research Objective: Seriously mentally ill (SMI) patients require long-term continuous care and the lack of mental health services in an area may result in patients utilizing acute care medical facilities. This study tested the substitute effect between the availability of mental health services and the general acute hospital admission through the emergency department (ED) for patients with SMI .

Study Design: The dependent variable was the hospital admission from the ED. The patient level data were merged with hospital-level (AHA) and county-level (ARF) data. Availability of mental health services was measured by an aggregated indicator developed by the Health

Resource and Service Administration (HRSA) to indicate if a county is a mental health shortage area (MHSA). It was also measured by the numbers of short-term and long-term psychiatric inpatient days per 100,000 population in a county. Patient socio-demographic characteristics and co-morbidities, as well as hospital characteristics, that might influence admission from the ED were taken into account in multivariate analyses.

Population Studied: 94,242 patients with SMI between 18 and 64 years old included in the

2002 State Inpatient Data (SID) of New York.

Principle Findings: Compared with patients living in non-shortage areas, patients living in

shortage areas were much more likely to be admitted from the ED (odds ratios (OR) [95% confidence interval (CI)], 2.14 [2.00, 2.27]).

Further, compared to patients living in areas with the number of long-term inpatient psychiatric days per 100,000 population in the bottom 50 percentile, patients living in the third quartile had comparable odds of being admitted from the ED (OR [CI], 1.06 [0.99, 1.12]), but patients living in the top quartile were less likely to be admitted through the ED (OR [CI], 0.62

[0.57, 0.64]). Compared to patients living in areas with the number of short-term inpatient psychiatric days per 100,000 population at the bottom 50 percentile, patients living in the third and fourth quartiles were less likely to be admitted through the ED (OR [CI], 0.77 [0.73,

0.82] for the third quartile and 0.64 [0.59, 0.68] for the fourth quartile).

Conclusions: A negative relationship between the availability of mental health services and acute hospital admissions through the emergency department was observed. Although

New York has one of the strongest public mental health programs in the nation, the lack of mental health services in some areas may have resulted in the SMIl receiving potentially inappropriate care in acute care hospitals.


Long-term continuous care for seriously mentally ill patients is mostly provided by public mental health programs. Reductions in public funding due to state and federal budget cuts in recent years has further contributed to an already insufficient level of resources and services targeted to the seriously mentally ill. This has resulted in greater numbers of the SMI receiving potentially inappropriate care in acute care hospitals. Strengthening the public mental health infrastructure is urgent. Bolstering these services would improve the care of the SMI, as well as help alleviate ED over-crowding in acute care hospitals.

• School Resources and Adolescent Mental

Health

Michele J. Siegel, Ph.D., Laurie J. Bauman, Ph.D.

Presented By: Michele J. Siegel, Ph.D., Assistant

Research Professor, Institute for Health, Rutgers,

The State University of New Jersey, 30 College

Avenue, New Brunswick, NJ 08901, Phone: (732)

932-6943, Fax: (732) 932-8592, Email: msiegel@ifh.rutgers.edu

Research Objective: Theories borrowed from neighborhood studies suggest that attending a school with limited resources, i.e., a chaotic school in an overcrowded building, using inexperienced teachers not permanently assigned to that school, may be related to adolescent mental health. The objective of this study is to test the hypothesis that attending a school with more resources is associated with better mental health.

Study Design: This was a cross-sectional study of the relationship between school institutional resources and mental health, among inner city youth attending public schools. Individual-level data on Bronx adolescents was collected by L.J.

Bauman for her intervention to reduce risk behaviors. Data included measures of adolescent psychological disturbance and the school attended. Psychological symptoms were measured by Achenbach’s Youth Self Report -

YSR, using normalized scores for total, internalizing and externalizing symptoms.

School names were linked to Annual School

Reports from the NYC Education Department.

School resource measures included: stability ---- percent of teachers permanently assigned to school, staff experience ---- percent of teachers teaching anywhere more than five years, and overcrowding ---- percent of building capacity utilized. Ordinary Least Squares regression models were used to test the relationship of the

YSR to school resources. Three models were estimated, examining the relationship of school attributes to total, internalizing and externalizing symptoms. Each was estimated for the total sample and by gender. Results were unaffected by controlling for individual-level variables correlated with school resources and mental health.

Population Studied: 750 adolescents age 14-17 living in the Bronx, NY, attending 92 NYC public schools.

Principle Findings: Using p-values less than .05, for the overall sample and for girls, percent of teachers permanently assigned to a school was associated with fewer externalizing symptoms; percent of teachers with over five years experience was associated with more externalizing symptoms. For the former, standardized betas were -.179 for the total sample and -.200 for girls. For the latter, standardized betas were .188 for the total sample and .218 for girls. Overcrowding was not associated with psychological symptoms. For boys, school resources were not associated with mental health.

Conclusions: Results indicate that, while school resources explain little of the total variation in adolescent mental health, they are associated

with externalizing symptoms for girls, but not boys. Since percent of teachers with more than five years experience is associated with worse mental health, it may operationalize burnout more than experience. The lack of association between school overcrowding and mental health is also of interest.


Results suggest that, at least among inner-city youth, a stable environment with teachers permanently assigned to a school reduces externalizing symptoms. Policy makers ought to be mindful of this, in light of current changes reverberating throughout NYC public schools.

Since having more teachers with over five years experience is associated with more externalizing symptoms, it may measure burnout rather than experience, perhaps reflecting that this is not a random sample of schools; it is a sample of schools attended by inner-city adolescents. The lack of association between overcrowding and symptoms suggests that the current focus on overcrowding, while important, may be somewhat misplaced.


•

Understanding the Effect of Substance

Abuse Treatment on Earnings

Angela Snyder, M.P.H., (Ph.D. expected May

2007)

Presented By: Angela Snyder, M.P.H., (Ph.D. expected May 2007), Senior Research Associate,

Georgia Health Policy Center, Georgia State

University, 14 Marietta Street Suite 221, Atlanta,

GA 30303, Phone: 404-651-5001, Email: angiesnyder@gsu.edu

Research Objective: To economically evaluate the state of Connecticut’s substance abuse treatment programs specifically to identify any cost offsets to treatment in the form of increased client productivity post-treatment.

Study Design: Quasi-experimental design comparing the post-treatment quarterly earnings of individuals undergoing outpatient treatment for substance abuse in Connecticut during State

Fiscal Year (SFY) 2001 with the earnings trajectories of demographically-matched controls representing the general population of

Connecticut. Generalized estimating equations

(GEE) were used to model earnings changes over time. The outcome modeled is the difference between earnings in each of the ten quarters post treatment and earnings recorded three quarters prior to treatment, when earnings peaked for both groups.

Population Studied: 8,424 clients aged 18-64 who received outpatient substance abuse treatment during SFY 2001 and had at least one quarter of earnings recorded during the study period (July 1998 to June 2003). The study group was obtained by matching administrative data from the Connecticut Department of Mental

Health and Addiction Services(DMHAS)

Substance Abuse Treatment Information System

(SATIS) with the Connecticut Department of

Labor (DOL) Unemployment Insurance Tax wage file. Three demographically-matched controls for every treatment client were selected from DOL’s unemployment claimant database.

The four demographic variables used to create the control group included the client’s gender, race/ethnicity, educational attainment, and age-grouped in 3 year increments.

Principle Findings: While both groups lose earnings in the post-treatment period related to the deteriorating economy, outpatient clients have better employment outcomes in the posttreatment period when earnings trajectories are compared. Estimates indicate that outpatient treatment clients make on average $78.89 dollars per quarter more after treatment than persons in the general population who also experienced a spell of unemployment.

Conclusions: Cost offsets to treatment reported as a benefit-to-cost ratio from the state’s perspective amount to about 2-3.5 % over two years when the benefit, measured as the increase in state income tax receipts, is compared to the state’s substance abuse treatment costs. While these returns are low, most of the productivity gains associated with treatment accrue to the drug or alcohol abuser themselves.


For taxpayers and policymakers responsible for the distribution of public funds, employment after substance abuse treatment represents a critical return on investment. This is one of the first studies to longitudinally compare the costs of treatment to the gains in worker productivity from the state’s perspective. While the income gains and taxes paid by those receiving treatment do not themselves offset the amount a state spends in substance abuse treatment; they are important to quantify as they help to rationalize treatment services into the future.

Funding Source: Substance Abuse and Mental

Health Services Administration

•

Documentation of Tobacco Use and

Cessation Counseling at Primary Care Visits:

The Impact of Medical Setting.

Nancy Sonnenfeld, Ph.D., Susan Schappert, M.A.

Presented By: Nancy Sonnenfeld, Ph.D., Public

Health Analyst, Division of Health Care

Statistics, NCHS, 3311 Toledo Road, Hyattsville,

MD 20782, Phone: 301-458-4156, Fax: 301-458-

4693, Email: nls2@cdc.gov

Research Objective: Tobacco use is responsible for approximately 400,000 premature deaths, 5.5 million years per life lost, and $92 billion in productivity losses each year. Clinical guidelines call for screening and documentation of tobacco use in all patients and counseling of patients who use tobacco during the routine course of ambulatory care. The frequency with which these services are delivered in physician offices have been well described, but less is known about their delivery in hospital outpatient departments (OPDs). OPDs are an important safety net setting, providing services to a disproportionate number of Medicaid enrolled and non-white patients. We examined (1) documentation of tobacco use and (2) tobacco counseling during primary care visits in OPDs compared with physician offices. Because OPDs and physician offices are very different, we used multivariable models to examine differences in these settings after adjusting for a variety of patient and provider characteristics.

Study Design: The National Ambulatory

Medical Care Survey (NAMCS) and National

Hospital Ambulatory Medical Care Survey

(NHAMCS) collect data from a nationally representative sample of visits to ambulatory medical care providers in the United States. The data abstracted from medical records for sampled visits include items on tobacco use and counseling services. If tobacco use was blank or marked "unknown", we assumed documentation had not occurred. Counseling was examined only when tobacco use was indicated. Analyses were restricted to visits to patients’ primary care providers. Independent variables included setting, patient age, gender, race, Hispanic ethnicity, expected source of payment, reason for visit (e.g., acute versus chronic), pregnancy, cardiovascular disease diagnosis, chronic obstructive pulmonary disease diagnosis, number of visits in past year, care by a mid-level provider, location within a metropolitan statistical area, and region.

Population Studied: We studied 50,345 visits to primary care providers made by adults 18 and older to physician offices and OPDs in 2001-

2004 in the United States. Office-based anesthesiologists, pathologists, and radiologists and federally employed physicians are excluded from NAMCS. OPDs associated with federal, military, and Veterans Affairs hospitals are excluded from NHAMCS.

Principle Findings: Documentation of tobacco use occurred at 72% of primary care visits to physician offices, but only 61% of primary care visits to OPDs (p < .0001). The adjusted difference in documentation was 11% (95% confidence interval: 5%, 16%). Expected source of payment was not associated with documentation. Counseling was indicated at

26% of primary care visits to physician offices and 24% of visits to OPDs. This difference was not statistically significant before or after adjusting for covariates.

Conclusions: Relative to physician offices, OPDs document tobacco use less frequently. This disparity remains after adjusting for a wide variety of measured characteristics. Counseling is infrequent in both settings.


Given that documentation serves as a mechanism for tobacco treatment and referral,

OPDs could do more to document tobacco use among their primary care patients.

Documentation may be especially important in

OPDs where many providers may share care for the same patient. Opportunities exist to expand counseling in both settings.

• Follow Up After Hospitalization for Mental

Illness in Medicaid-Eligible Adults

Bradley Stein, M.D., Ph.D., Jane N. Kogan, Ph.D.,

Mark J. Sorbero, M.S., Shari L. Hutchison, M.S.

Presented By: Bradley Stein, M.D., Ph.D., Senior

Director of Research, Evaluation, and Outcomes,

Outcomes, Community Care Behavioral Health,

112 Washington Place, Pittsburgh, PA 15219,

Phone: 412-454-8633, Fax: 412-454-2177, Email: steinbd@ccbh.com

Research Objective: Timely treatment following inpatient psychiatric discharge is an important component of continuity of care as it has been shown to diminish the risk of readmission. The present study describes follow up care after inpatient psychiatric discharge in Medicaideligible adults and examines factors that may influence timely follow up and ultimately readmission.

Study Design: The study is an analysis of administrative data from Community Care

Behavioral Health, the largest Medicaid managed behavioral health organization in a mid-Atlantic state.

Population Studied: We identified 6730 adults aged 18-64 with a psychiatric hospital discharge

in 2004-2005. Multiple logistic regression models were used to examine clinical and sociodemographic predictors of 7 and 30-day follow up. We then extended these models to include variables representing the inpatient mental health service provider and evaluated provider as a predictor of follow up.

Principle Findings: Fifty-four percent of the sample was female, 34% were African-American, and 26% had a co-occurring substance use disorder. Thirty percent of hospitalized adults had follow-up care within 7 days of discharge;

49% had follow-up care within 30 days. Among those with follow up within 30 days, 54% received outpatient services first, 20% a medication management visit, 12% partial hospital services, 9% outpatient substance abuse treatment, and 5% ACT. The greatest predictor of follow-up care within 7 days and 30 days was receiving clinical behavioral health services in the month prior to admission.

Individuals who had received case management services prior to admission were also more likely to have 7 and 30-day follow-up, as were individuals whose hospitalization was longer than 9 days. African-Americans, those discharged against medical advice, those with co-occurring substance use disorders, and individuals with SSIM Medicaid eligibility were significantly less likely than other individuals to have 7 or 30-day follow-up. Individuals living in rural areas and those involuntarily committed to the hospital were less likely than other individuals to have a follow-up visit within 7 days, but not at 30 days. In an examination of the relationship between inpatient provider and follow-up, controlling for socio-demographic and clinical characteristics, we found that the inpatient provider block was significantly associated with 7-day follow-up (Wald Chi2=8.61; df=1, p<0.01), but not with 30 day follow-up

(Wald Chi2=2.02; df=1, p=ns). There was over a

3-fold difference in the odds ratio for 7-day follow-up between the top performing psychiatric hospital (45%; OR 1.68, CI 1.22 to 2.33) and the lowest performing psychiatric hospital (23%; OR

0.47, CI 0.30 to 0.76).

Conclusions: We found that patient sociodemographic and clinical characteristics predict likelihood of timely follow-up post hospitalization. In addition, provider level variation emerged as an important predictive factor.


Efforts to improve follow up should target individuals at higher risk for readmission.

Provider level variation may be used to identify opportunities to improve the quality of continuity of care.

•

The Role of Veterans Service Organizations in the Mental Health Crisis Facing Veterans from Iraq and Afghanistan

Manan Trivedi, M.D., (M.P.P. candidate June

2007)

Presented By: Manan Trivedi, M.D., (M.P.P. candidate June 2007), Health Policy/Health

Services Research Fellow, Medicine, VA Greater

Los Angeles, 3845 York Boulevard, Los Angeles,

CA 90065, Phone: 949 306-7011, Email: manantrivedi@yahoo.com

Research Objective: U.S. military personnel serving in Iraq and Afghanistan have a very high exposure to combat. This places them at an increased risk of developing mental health disorders. Rates of behavioral health problems such as post traumatic stress disorder (PTSD), depression, and anxiety are very high among those who have served in either Iraq or

Afghanistan. However, for a variety of reasons, many veterans fail to seek treatment.

Veterans service organizations (VSOs) such as the American Legion and the Veterans of Foreign

Wars traditionally have had an important role in connecting newly discharged service members to needed healthcare, including care delivered by the VA healthcare system. They are also likely to have valuable insight on the barriers to and resources for improving access and care of mental health disorders for veterans.

OBJECTIVE 1) To learn which mental health care issues veterans’ service organizations regard as key for Operation Enduring Freedom/Operation

Iraqi Freedom (OEF/OIF) veterans; 2) to seek partnership solutions with organizations that are interested in collaboration; 3) to identify an initial set of barriers and resources for mental health care for these veterans.

Study Design: Key representatives of VSOs were interviewed in a semi-structured format. Over twenty VSOs representing all major and most mid-sized organizations were contacted from the

VA Directory of VSOs. Interviews focused on four different areas of interaction: internal VA issues, the relationship between VSOs and veterans, internal VSO workings, and the VA-

VSO relationship. The recorded interviews were analyzed to identify the key problems, their barriers and facilitators, the current practices, possible solutions and measurable outcomes.

Population Studied: Veterans service organizations that have an understanding of issues pertaining to OEF/OIF veterans.

Principle Findings: There were four key issues surrounding mental health care for OEF/OIF veterans that were identified as problems by most of the VSOs: oThe stigmatization of mental health problems in the active duty military and veteran populations oThe lack of adequate funding and manpower at VA hospital facilities to handle the large influx of mental health problems o The faulty transition process and transfer of information from the Department of

Defense (DOD) to the VA health care system oThe use of outdated outreach and education programs for a new generation of "information age" veterans who have different information sources and more modern networks of communication. Several partnership solutions were offered to address the key problems identified. Changing the culture of VSOs along with other military organizations to be more open, understanding and aware of mental health problems would be a first step in addressing the negative stigma that serves as a major barrier for veterans to seek to care. Assisting the VA with outreach programs that target a younger, more internet-friendly generation of veterans would aid education programs and increase awareness of possible mental health problems. And, encouraging the DOD to revamp the transition process from active-duty to veteran would increase the likelihood that new veterans get the appropriate care they need.

Conclusions: Several issues have been identified by VSOs as key in dealing with mental health issues facing OEF/OIF veterans. VSO can serve as strong partners with the VA to address these issues and improve the care and treatment of mental health problems among these veterans.


Policies in the VA health care system regarding mental health resources, the DOD transition process, and current outreach programs for

OEF/OIF veterans may have to be re-examined to better care for the looming mental health crisis facing our country’s newest veterans

Funding Source: VA

• Service and Cost Implications of Extending

Close Monitoring To Adult Patients Following

Antidepressant Initiation or Dose Change

Marcia Valenstein, M.D., M.S., Daniel Eisenberg,

Ph.D., John F. McCarthy, PhD, Ph.D., Karen

Austin, MPH 1, M.P.H., Dara Ganoczy, MPH,

M.P.H., Hyungjin Myra Kim, Ph.D.

Presented By: Marcia Valenstein, M.D., M.S.,

Research Scientist, U of Michigan Department of

Psychiatry, Dept Veterans Affairs HSR&D,

P.O.Box 130170, Ann Arbor, MI 48113-0170,

Phone: 734-769-7100, Email: marciav@umich.edu

Research Objective: Depressed patients may be at increased risk for suicide following antidepressant treatment initiation and dose change. The US Food and Drug Administration

(FDA) recommends ‘‘close monitoring’’ of all patients following antidepressant initiation or dose changes and specifies that youth should generally have 7 provider contacts in the 12 weeks following these events. These recommendations may be extended to young adults. We assessed whether periods following antidepressant initiation or change were accompanied by higher suicide risks for adults receiving depression treatment in VA settings.

We also examined the services and cost implications of extending FDA- described close monitoring to these adults.

Study Design: This is a retrospective cohort study examining antidepressant use, suicides and monitoring visits among randomly selected patients receiving depression treatment in

Department of Veterans Affairs facilities. The primary outcomes were suicide and monitoring rates following antidepressant initiation and dose change.

Population Studied: 100,000 patients receiving

VA depression treatment between 4/1/1999 and

9/30/2004.

Principle Findings: The suicide rate was

81.7/100,000 person-years over the entire study period. In the 12-week periods following the

197,443 observed antidepressant starts or dose changes, the suicide rate was 181.6/100,000 person-years. Patients completed an average of

2.4 monitoring visits during these 12-week periods. Depending upon whether incremental visits were brief telephone and in-person visits or reflected current treatment practices, increasing visits by almost three-fold to 7 in these 12-week periods would increase average costs by $284-

$464 per patient. For all VA patients

(N=887,859) treated for depression during the study period, costs would have increased by

$252-$412 million.

Conclusions: VA patients in depression treatment have high suicide rates that increase further following antidepressant initiation and dose changes. Such changes occur commonly in clinical settings. Providing close monitoring to

these patients would require substantial increases in visits and expenditures.


The observed increase in suicide risks following antidepressant initiation or dose change may be due to antidepressant exposure or to patients' symptoms that prompted these therapeutic changes. Regardless of etiology, closer clinical monitoring may be warranted for all patients during these periods. However, health care organizations will likely require solid evidence for monitoring's effectiveness in reducing suicide before making the large shifts in depression services that would be required for broad implementation.

• Patient-Based Measurement of PTSD and

Depression Following Traumatic Experiences:

Is There Evidence of Overlap and

Redundancy?

Anthony Waddimba, M.B., Ch.B., M.S., Susan

Eisen, Ph.D., Howard Cabral, Ph.D., M.P.H.,

Lewis Kazis, Sc.D.

Presented By: Anthony Waddimba, M.B., Ch.B.,

M.S., Health Services Research Fellow, Dept of

Health Policy & Management, Boston University

School of Public Health, 715 Albany Street, Talbot

3 West, Boston, MA 02118, Phone: 617-414-1362,

Fax: 617-638-5374, Email: waddimba@bu.edu

Research Objective: Posttraumatic Stress

Disorder (PTSD) afflicts 5-8% of the U.S. population, and 15% of veterans. PTSD is often comorbid with major depression among people with a traumatic experience, but the etiologic mechanism is unclear. We analyzed the overlap and redundancy between patient self-report measures of PTSD and depression to assess the plausibility of their being dimensions of the same mental illness construct.

Study Design: This was a cross-sectional analysis of baseline survey data from the longitudinal Veterans Health Study (VHS). We assessed the PTSD checklist (PCL) and Center for Epidemiologic Studies Depression (CESD) scale. We determined internal consistency reliability of each scale within the study sample using Cronbach’s alpha. Oblique-rotated factor analysis identified plausible CESD subscales. We examined redundancy and overlap between scales using canonical correlation, and multivariate regression controlling for potential confounders. Redundancy was the variability in each measure attributable to its counterpart.

Uniqueness was the variability in each scale not explained by the other score.

Population Studied: We sampled 2,159 military veterans who experienced trauma, out of 2,425 respondents to the VHS baseline selfadministered survey. Enrolment was at VA ambulatory clinics in Boston, Massachusetts.

Inclusion criteria were regular clinic attendance, adequate cognition, and literacy. Exclusion criteria were no telephone or mailing address, or no reported history of trauma.

Principle Findings: 66% of veterans with trauma experiences had been to war, and 51% had combat exposure. The median military service was 3 years. 29.5% were depressed

(CESD>16), 12.3% had PTSD, and 8.4% had comorbid PTSD/depression. The mean SF-36

MCS score was 50.2 (95%CI=39.6-57.5).

Cronbach’s alpha was 0.89 for CESD and 0.94 for PCL. Factor analysis yielded three CESD subscales: somatic symptom burden

(alpha=.82), negative affect (alpha=.78), and low positive affect (alpha=.75). Item-to-scale correlations were = 0.7. A joint scale of CESD factors and PTSD subscales (numbing, reexperiencing, hyper-activity) is internally consistent (alpha=0.91). Significant canonical correlations were 0.85 (F=339.33, p<.0001), and

0.12 (F=7.52, p<.0001). The first canonical variable pair explained 71.6% of the variability.

Canonical depression correlated highly with somatic burden (r=.96) and negativity (r=.80), while canonical posttraumatic stress correlated highly with all PTSD subscales (r = .97, .95 and

.90). Canonical PTSD correlated with somatic burden (r=.81) and negativity (r=.68) while canonical depression correlated with all three

PSTD subscales (r = .82, .80, and .76). Canonical depression explained 59% of standardized variance in CESD score and 98% in PCL.

Canonical PTSD explained 88% of standardized variance in PCL and 97% in CESD. After adjusting for covariates, CESD scores explained

76% of variability in PCL, and PCL explained

66% of variability in CESD scores.

Conclusions: 24% of the PCL and 33% of the

CESD capture dimensions unique to each respective scale. Significant overlap and redundancy exists between these measures.

Aspects of PTSD and depression following trauma constitute the same posttraumatic illness construct, rather than distinct entities.


Harmonization of care delivery and health policies is imperative, once these findings are confirmed in various at-risk populations using multiple PTSD and depression measures.

Funding Source: Veterans Health

Administration

• Comparing Patients with Combined Major

Mental Illness and HIV, Major Mental Illness

Without HIV, and HIV Without Major Mental

Illness

James Walkup, Ph.D., Scott Bilder, M.A., Stephen

Crystal, Ph.D.

Presented By: James Walkup, Ph.D., Associate

Professor, IHHCPAR, Rutgers University, 30

College Avenue, New Brunswick, NJ 08903,

Phone: 212/724-8362, Email: jaywalks@aol.com

Research Objective: To describe sociodemographic and clinical characteristics of

Medicaid patients who have HIV and a major mental illness (MMI), such as schizophrenia

(SZ), bipolar disorder (BD), or major depressive disorder (MD), comparing them to patients with an MMI but no-HIV, and to patients with no-

MMI/HIV patients.

Study Design: Retrospective, observational design using the Medicaid Analytic Extract files for 1999-2000 from California, Florida, New

Jersey, and New York.

Population Studied: Age >17 with at least one full year eligibility, no comprehensive HMO coverage, and no long term care days.

Classification used International Classification of

Disease 9 ---- Clinical Modification, requiring one inpatient or two outpatient claims for HIV (042-

044), SZ (295.x), BD (296.0-296.1, 296.4-296.8,

301.13) or MD (296.2, 296.3). Co-occurring conditions required at least one inpatient or outpatient claim.

Principle Findings: HIV diagnosis was more common among those with MD (4.03%), BD

(3.29%), or SZ (2.06%) than in the population with no MMI (1.36%). Race and age differences between patients with and without HIV followed a generally similar pattern in all groups. Among patients with HIV, there was a higher percentage of African Americans among those with MD

(33% vs. 15%), BD (31% vs. 13%), SZ (47% vs.

23%), and no MMI (43% vs. 19%). Patients with HIV were more likely to fall in the 35-44 age range, and, in both HIV and no-HIV groups, those with MMI were somewhat more likely to fall in this age range. Compared to no-HIV counterparts, women were less common among

MD/HIV (46% vs. 75%), BD/HIV (43% vs.

66%), and no MMI/HIV (41% vs. 74%) groups, but not SZ/HIV (45% vs. 42%). Across groups, patients with HIV were more likely to have claims indicative of drug abuse -- MD (35% vs.

10%), BD (40% vs. 16%), SZ (42% vs. 13%), and no MMI (21% vs. 2%). A similar pattern was found for alcohol abuse -- MD (13% vs. 4%), BD

(18% vs. 7%), SZ (19% vs. 5%), and no-MMI

(7% vs. 1%). Regardless of HIV status, each

MMI diagnosis was associated with increased likelihood of both drug and alcohol-related claims. Anxiety disorder rates were: HIV/MMI

(24%), MMI/no-HIV (17%), HIV/no-MMI (7%), and neither (3%). Personality disorder rates were: MMI/HIV (5%), MMI/no-HIV (3%), and

<1% in both no-MMI groups. Among patients with no-HIV, dual eligibility for both Medicaid and Medicare was much more common among those with an MMI (32% vs. 11%). Among patients with HIV, approximately one quarter were dually eligible, with or without MMI (25% vs. 26%).

Conclusions: Descriptions of patients with MMI and HIV reflect the intersection of these disorders, influenced by epidemiological, clinical, and utilization characteristics. The data point to possibly distinct subgroups within MMI/HIV, particularly related to substance abuse, while also underlining resemblances to MMI and HIV comparison groups.


Patient profiling may help with financing, training, organization, and integration of treatment programs, particularly for drug and alcohol treatment. Also important may be outreach programs sensitive to the ethnic and racial composition of this patient group.


• What Does Penetration Rate Measure?

Hui Zhang, Ph.D., Sheila Baler, Ph.D., Saumitra

SenGupta, Ph.D., Michael Reiter, Pharm.D., Bill

Ullom, Lisa Farrell, B.S.

Presented By: Hui Zhang, Ph.D., Reporting

Manager, California EQRO, APS Healthcare, Inc.,

560 J Street, Suite 390, Sacramento, CA 95814,

Phone: 9162662575, Fax: 9162662542, Email: hzhang@apshealthcare.com

Research Objective: Since the National

Association of State Mental Health Program

Directors (NASMHPD) introduced the penetration rate as an important performance measurement for access to mental health care services, penetration rate has been becoming widely used in studies of the mental health programs performance evaluation and comparison. However, there are still many unsolved and controversial issues related to the concept, measurement and application of penetration rate. This study aims to 1) determine what the penetration rate really measures; 2) examine the factors influencing penetration rate

and 3) explore the conditions under which penetration rate can be used to measure, evaluate and compare mental health program performance in access to services.

Study Design: First, penetration rate as defined by NASMHPD was examined and proved to be a product of mental illness prevalence rate and mental health service utilization rate. Some practical implications of the decomposition of penetration rate into prevalence and utilization rate are identified and discussed. Second, the mental health services penetration rates for 57

California county mental health programs

(MHPs) in 2005 were used as one of the county

MHP performance indicators. The unadjusted penetration rates and those adjusted by age, gender, race/ethnicity, eligibility categories were used to rank the 57 county MHPs. Third, multivariate regressions and non-parametric analyses were applied to examine the agreements of different rankings and the factors influencing penetration rates.

Population Studied: The study population is more than 6.8 million California Medicaid (Medi-

Cal) enrollees who were eligible for Short-Doyle

Medi-Cal (SD/MC) specialty mental health programs operated by the 57 California county

MHPs in 2005. The monthly Medi-Cal enrollment data and SD/MC claims data came from the California Department of Mental

Health.

Principle Findings: The analysis results show that 1) California county MHPs penetration rates, either unadjusted or adjusted, varied greatly across MHPs; 2) some category-specific penetration rates also had big variations; 3) race/ethnicity, eligibility categories, total service funds available for county MHPs, unit service intensity, MHP location and size, the proportions of county population under federal poverty level, and the proportions of county population eligible for Medi-Cal were found to be significant factors influencing county MHPs penetration rates.

Conclusions: Mental health services penetration rate is determined by both mental health prevalence rate in defined target population and mental health utilization rate by mental health clients. Mental health services penetration rate is influenced by demographic, social-economic, geographic and a number of other important factors.


Penetration rate is a complicated composite measure for access to mental health services.

Great cautions should be paid when using it to measure, evaluate and compare the performance of even within state mental health programs.

Prevalence-based penetration rate may be a more desirable measure for access to services.

•

A Rural-Urban Comparison of Mental

Health Service Use and Expenditures

Erika Ziller, M.S., Andrew F. Coburn, Ph.D.,

Nathaniel Anderson, M.P.H., Nan Solomons,

B.S.

Presented By: Erika Ziller, M.S., Research

Associate, Muskie School of Public Service,

University of Southern Maine, PO Box 9300,

Portland, ME 04104-9300, Phone: 207-775-4615,

Fax: 207-228-8138, Email: eziller@usm.maine.edu

Research Objective: This study uses the

Medical Expenditure Panel Survey (MEPS) to examine the financial burden that rural residents face in seeking mental health services, compared to urban residents. By examining the mental health service use patterns of rural and urban residents, and the sources of payment for these services, we identify potential problems of underinsurance for mental health services and access barriers that may ensue.

Study Design: We use a pooled sample of the

2001, 2002 and 2003 panels of the MEPS to identify individuals of all ages that received mental health services over the course of a year.

For the purposes of this study, mental health service use includes office-based counseling as well as prescriptions for psychotherapeutic medications (because of limited cases, in-patient psychiatric care is excluded). We compare expenditures for mental health services by payer, and in total, to determine whether or not there are rural-urban differences in out-of-pocket expenditures, and to test the relationship between the payer source(s) and likelihood of receiving psychotherapy in addition to medication. In addition, we compare a ratio of out-of-pocket costs to family income to measure the degree to which rural residents may be underinsured for mental health services.

Population Studied: A nationally representative sample of community-dwelling rural and urban residents of all ages, between 2001 and 2003.

Principle Findings: While rural residents are somewhat more likely to use mental health services than urban residents are (16.8% versus

14.0%), the patterns of service use differ. For example, while nearly all of those receiving any type of mental health treatment are prescribed psychotherapeutic medications (91.8%), the proportion is slightly higher for rural residents

(95.2% versus 90.9% for urban). Conversely,

27.6% of all urban residents using mental health services received office-based counseling, compared to only 17.8% of urban residents.

Regression analyses are in process to determine what factors predict the likelihood of receiving psychotherapy among mental health service users, and whether there are rural-urban differences in these factors. Total average expenditures for mental health services are lower among rural than urban residents ($587 versus

$722), as are total out-of-pocket costs ($193 versus $248). This appears to be explained, in part, by higher payments by Medicaid/SCHIP made on behalf of rural residents. Ongoing analyses will compare the experiences of the subpopulation of privately insured individuals, as well as a more nuanced breakdown of rural residency. As prior studies have found that underinsurance for medical care is a particular problem for rural residents that live in counties that are not adjacent to urban counties, we will explore whether or not this relationship holds true for mental health services. In addition, we will compare ratios of out-of-pocket expenditures to family incomes to determine if there is a significant rural-urban difference.

Conclusions: Preliminary data indicate that rural residents are more likely to use mental health services and that this service use is much less likely to include office-based psychotherapy. In general, rural residents have lower total costs for mental health services and, on the surface, have lower out-of-pocket costs as well. However, it is unclear whether or not this relationship will hold upon sub-analyses of the privately insured and more remotely located rural residents.

Additionally, the impact of these out-of-pocket costs on rural families remains an important question to be answered by this study.


Developing an understanding of how rural residents use mental health services, and how this use affects their financial well being, will provide policymakers with evidence that informs rural mental health policy interventions. For example, if many privately insured rural residents face high out-of-pocket costs for mental health services, policymakers may want to strengthen the rural mental health safety net (i.e. by providing subsidies to rural mental health professionals). Determining the factors that increase the odds that a rural resident taking psychotherapeutic medication will also receive office-based mental health treatment has important access and quality implications. If rural-urban disparities are linked primarily to individual and small group coverage, this may indicate a need to reform existing mental health parity laws.

Funding Source: HRSA

Child Health

•

Teen Use of a Patient Portal: A Qualitative

Study of Parent, Teen and Provider Attitudes

David Bergman, M.D., Nancy Brown, Ph.D.,

Sandra Wilson, Ph.D.

Presented By: David Bergman, M.D., Associate

Professor, Pediatrics, Stanford University School of Medicine, Suite 325; 750 Welch Road, Palo

Alto, CA 94304, Phone: (650) 450-0071, Fax:

(650) 325-9070, Email: david.bergman@stanford.edu

Research Objective: To assess the attitudes of teens, parents and providers toward the use of a patient portal for health care services.

Study Design: Teens(11th and 12th grades) and parents were randomly selected from clinician practices for 2 teen and 2 parent focus groups and 1 teen and 1 parent electronic bulletin board.

A volunteer sample was used for the provider group. Videotapes from the focus groups and transcripts from the bulletin boards were independently analyzed by 2 reviewers for significant themes which were then validated by

2 members of the research team.

Population Studied: 11th and 12th grade teens drawn from a multi-specialty medical clinic

Principle Findings: Eleven teens and 13 parents participated in the focus groups and 17 teens and 19 parents participated in the electronic bulletin boards. Significant themes included: 1) parents and teens had mixed feeling about teens taking control of their own health care. ) Both parents and teens were enthusiastic about the use of a patient portal to increase teen access to care, 3) both parents and teens liked being able to seek health information and make appointments. but both groups expressed concerns about secure messaging with teens worried about confidentiality and parents concerned about being out of the loop , 4) both parents and teens felt that teen use of a patient portal provided an opportunity to discuss and negotiate issues of confidentiality, parent notification and billing prior to use and 5) providers were concerned about medical liability, extra time burden and inappropriate use by teens

Conclusions: Our results showed that there was positive support for teen use of a patient portal

and that the use of a portal provided an important opportunity for teens and parents to negotiate issues of confidentiality and parent notification prior to implementation


Patient portal may provide an important avenue for increased access to health care for teens.

There are however serious concerns about confidentiality that must be address prior to implementation.

Funding Source: The Blue Shield Foundation of

California

• Iron Deficiency in Early Childhood: Risk

Factors and Racial/Ethnic Disparities

Jane M. Brotanek, M.D., M.P.H., Jacqueline

Gosz, M.S., Michael Weitzman, M.D., Glenn

Flores, M.D.

Presented By: Jane M. Brotanek, M.D., M.P.H.,

Assistant Professor, Pediatrics, Medical College of Wisconsin, 8701 Watertown Plank Road, MS

756, Milwaukee, WI 53226, Phone: (414) 456-

5778, Fax: (414) 456-6385, Email: jbrotane@mcw.edu

Research Objective: Iron deficiency (ID) affects

2.4 million US children, and childhood irondeficiency anemia is associated with behavioral and cognitive delays. Given the detrimental longterm effects and high prevalence of ID, its prevention in early childhood is an important public health issue. The objective of this study was to identify risk factors for ID among US children 1-3 years old.

Study Design: Analyses of NHANES IV (1999-

2002) were performed for a nationally representative sample of US children 1-3 years old. Iron status measures were transferrin saturation, free erythrocyte protoporphyrin, and serum ferritin. Independent variables included age, gender, race/ethnicity, poverty status, weight-for-height status, blood lead level, birthweight, interview language, daycare attendance, and food security. Bivariate and multivariate analyses were performed to identify factors associated with ID.

Population Studied: Nationally representative sample of US children 1-3 years old

Principle Findings: Among 1,641 toddlers, 400

(42%) were Latino, 271 (28%) white, and 239

(25%) African-American. The ID prevalence was

12% among Latinos vs. 6% in whites and 6% in

African-Americans (p<.04). ID prevalence was

20% among those with overweight, 8% for those at-risk for overweight, and 7% for normal-weight toddlers (p=.02). 14% of toddlers with parents interviewed in Spanish had ID vs. 7% of toddlers with parents interviewed in English (p=.007). 5% of toddlers in daycare and 10% of toddlers without daycare had ID (p=.02). Latino toddlers were significantly more likely than white/African-

American toddlers to be overweight (16% vs. 5% vs. 4%) and without daycare (70% vs. 50% vs.

43%). In multivariate analyses adjusting for variables significant in bivariate analyses

(race/ethnicity, interview language, weight-forheight status, and preschool/daycare attendance), overweight toddlers (OR, 3.5; 95%

CI, 1.1-10.6) and those without daycare (OR, 1.8;

95% CI, 1.01- 3.4) had higher odds of ID.

Conclusions: Toddlers who are overweight and not in daycare are at high risk of ID. Latino toddlers are more likely than white/African-

American toddlers to be overweight and not in daycare. The higher prevalence of these risk factors among Latino toddlers may account for their increased risk of ID.


Screening practices and nutritional counseling should be targeted at these high-risk groups.

Funding Source: Medical College of Wisconsin

•

Time To Revive Popeye: Secular Trends in the Prevalence of Iron Deficiency among US

Toddlers: 1976-2002

Jane M. Brotanek, M.D., M.P.H., Jacqueline

Gosz, M.S., Michael Weitzman, M.D., Glenn

Flores, M.D.

Presented By: Jane M. Brotanek, M.D., M.P.H.,

Assistant Professor, Pediatrics, Medical College of Wisconsin, 8701 Watertown Plank Road, MS

756, Milwaukee, WI 53226, Phone: (414) 456-

5778, Fax: (414) 456-6385, Email: jbrotane@mcw.edu

Research Objective: Iron deficiency (ID) and iron-deficiency anemia affect 2.4 million and

490,000 US children, respectively. Striking racial/ethnic disparities in ID prevalence have been documented for toddlers, but no studies have examined national secular trends in ID in toddlers. The objective of this study was to examine secular trends in ID among US children

1-3 years old.

Study Design: Time-trend analyses of NHANES

II-IV (1976-2002) were performed for a nationally representative sample of children 1-3 years old.

Iron status measures included transferrin saturation, free erythrocyte protoporphyrin, and serum ferritin. Chi-square tests were performed to evaluate changes in ID prevalence by race/ethnicity, weight-for-height status, and

poverty. Multivariate analyses were performed to adjust for NHANES survey wave, race/ethnicity, age, gender, birthweight, weight-for-height status, poverty, and blood lead level.

Principle Findings: Between 1976-2002, there was no change in the prevalence of ID (9%) in

US toddlers. ID prevalence remained unchanged in Latino (15%) and white (6%) toddlers but decreased from 15% to 6% among African-

American toddlers (p=.006). For all 3 survey waves, racial/ethnic disparities in ID persisted between Latino and white toddlers with a disparity ratio of at least 2 (p<.03). The ID prevalence remained high (20-25%) in overweight toddlers, significantly higher than in at-risk for overweight (11%) and normal-weight

(8%) toddlers (p<.03). ID prevalence decreased from 22% to 9% in toddlers in poor households

(p=.02), but remained unchanged in toddlers in households at/above the federal poverty threshold (7%). In multivariate analyses, Latino toddlers (OR, 2.2; 95% CI, 1.4-3.4) and overweight toddlers (OR, 3.0; 95% CI, 1.8-4.8) had higher odds of ID.

Conclusions: There has been no change in the prevalence of ID among US toddlers in the last

26 years. Racial/ethnic disparities in ID prevalence persist between Latino and white toddlers. The ID prevalence has remained consistently high in overweight toddlers, higher than in at-risk for overweight and normal-weight toddlers.


Efforts to reduce the prevalence of ID in infancy and early childhood are urgently needed and should target Latino and overweight toddlers.

Funding Source: Medical College of Wisconsin

• Quality of Primary Care and Subsequent

Pediatric Emergency Department Utilization

David Brousseau, M.D., M.S., Raymond G

Hoffmann, Ph.D., Ann B. Nattinger, M.D.,

M.P.H., Glenn Flores, M.D., Yinghua Zhang,

M.S.N., Marc H Gorelick, M.D., M.S.C.E.

Presented By: David Brousseau, M.D., M.S.,

Associate Professor, Pediatrics, Medical College of Wisconsin, 999 N 92nd Street, CCC 550,

Milwaukee, WI 53226, Phone: (414) 266-2625,

Fax: (414) 266-2635, Email: dbrousse@mcw.edu

Research Objective: to determine whether high quality parent-reported primary care is associated with decreased subsequent nonurgent pediatric ED utilization.

Study Design: Retrospective analysis of prospectively collected data from a cohort of children from the 2000-2001 and 2001-2002

Medical Expenditure Panel Survey. Baseline parent-reported quality of primary care for familycenteredness, timeliness, and realized access (a measure of the ability to receive necessary care/referrals) was assessed using composite scores from the Consumer Assessment of

Healthcare Providers and Systems survey. The primary outcomes were the numbers of subsequent nonurgent and urgent ED visits per child. Incidence rate ratios adjusted for demographic factors and health status were calculated using Poisson regression.

Population Studied: Nationally representative sample of children from the Medical Expenditure

Panel Survey

Principle Findings: Of 8,823 children included,

70% rated family-centeredness, 88% rated realized access, and 56% rated timeliness as high quality. High quality family-centeredness was associated with a 42% (95% CI: 15%-60%) reduction in nonurgent ED visits for publicly insured children and a 49% reduction (95% CI:

25%-65%) for children less than 3 years old.

Higher quality realized access was associated with a 44% (95% CI: 15%-64%) reduction in nonurgent ED visits for children 3-11 years old, and a 56% (95% CI: 29%-73%) reduction for children > 11 years old. Higher realized access was also associated with decreased nonurgent

ED visits for publicly and privately insured children, 37% (95% CI: 6%-58%) and 35% (95%

CI: 1%-57%) respectively. There were no significant associations between quality of care and urgent ED utilization.

Conclusions: Parent-reported high quality family-centeredness and a high level of realized access to primary care are associated with decreased subsequent nonurgent ED visits in children. Parent reports of healthcare quality in these domains provide important information on healthcare quality.


Assessment of parent-reported quality of care may aid in the identifiation of children at increased risk for nonurgent ED utilization.

Funding Source: AHRQ

• Effects of Antenatal Care Services on

Birthweight: Importance of Model

Specification and Empirical Procedure Used in Estimating the Marginal Productivity of

Health Inputs

Yusuf Celik, , Mustafa Younis, D.R.P.H., M.A.,

M.B.A.

Presented By: Yusuf Celik, Assoc.Professor,

School of Health Administration, Hacettepe

University, Ankara-Turkey, Ankara, Phone: (90)

312 - 311 5506, Email: younis99@gmail.com

Research Objective: This paper is an attempt to examine the effects of antenatal care (ANC) utilization on birthweight. Cost-effectiveness based health sector reform requires careful estimation of costs and productivity of health interventions as well as the substitution possibility among health inputs. If the parameters of production function are known, policy makers can estimate the health outcome effects of various input-mix.

Study Design: The analysis is based on the data collected from ever-married women by Turkey

Demographic and Health Survey 2004 (TDHS).

Two-stage least squares (TSLS) and ordinary least squares (OLS) estimation procedures are used in this paper to estimate the effect of health care input, namely antenatal care visits, on birthweight. Since the utilization of medical care itself may be dependent on women’s expectation about the pregnancy outcome, the parameters estimated through OLS may underestimate the true productivity of the input.

Population Studied: The analysis is based on the data collected from ever-married women by

Turkey Demographic and Health Survey 2004

(TDHS).

Principle Findings: The estimated functions indicate that antenatal care, woman’s health status, and birth order are significant determinants in birthweight. The TSLS estimate of marginal productivity of ANC visits was about four times the marginal productivity estimate in the OLS model.

Conclusions: The sensitivity of the parameter estimates to model specifications and empirical procedures followed demonstrates the importance of selecting the right model from both theoretical and empirical point of view.


The finding will assist policy makers in improving health care for infant and pergnant mothers in develping countries

• Is Medicaid Meeting the Mental Health

Needs of Children?

Kellie Cody, M.S.W., Ph.D. Student

Presented By: Kellie Cody, M.S.W., Ph.D.

Student, Ph.D. Student, Interdisciplinary Health

Studies, Western Michigan University, 1903 West

Mic higan Avenue, Kalamazoo, MI 49008,

Phone: (269) 731-2366, Fax: (269) 731-2366,

Email: k4cody@wmich.edu

Research Objective: To determine if Medicaid is meeting the mental health needs of children.

Study Design: Literature review

Population Studied: Children receiving mental health services

Principle Findings: Medicaid and State

Children’s Health Insurance Program (SCHIP) are primary sources of insurance for low-income children and private insurance is a primary source of insurance for the non-poor. However, children covered by private insurance have been declining and the number of children enrolled in public insurance is on the rise. The number of uninsured children is also at an all time high because enrollment in public insurance is not keeping pace with the decline in private insurance. Thousands of children who are eligible for public insurance are not enrolled for a variety of reasons and remain uninsured and the number of children will continue to rise because states do not have the funds to insure eligible children.

Conclusions: There have been several changes in public insurance since Medicaid was created in 1965. Currently Congress is considering the

Medi Kids Act to provide one source of public insurance to children. However, unless the barriers are not addressed many children will continue to lack health insurance and thus lack access to the mental health services they need.

States, like Michigan have identified insuring all children as a priority. This cannot occur without adequate funding and funding for programs like

SCHIP have declined. As the number of children covered under private insurance continues to decline, public insurance is the only safety net many children will have. Without insurance the fate of many children will be entry into foster care, the juvenile justice system or other public program at an additional cost to our citizens.

The current public insurance system for children, while serving millions of children is inadequate to meet the needs of the masses and millions of children remain uninsured.

Implications for Policy, Practice or Delivery: If children's mental health needs are to be met states will need to seek ways to insure children within the state. Outreach programs should be developed to enroll children who are eligible for public insurance. The eligibility requirements based on family income should be changed to ensure that the working poor who do not receive employer-sponsored insurance meet eligibility requirements.

• Disparities in Child and Adolescent Care in a Medicaid Managed Care Population

Mary Beth Conroy, M.P.H., Victoria Wagner,

M.S., Patrick Roohan, M.S

Presented By: Mary Beth Conroy, M.P.H., Unit

Director, Medicaid Encounter Data, Office of

Managed Care/BQMOR, NYS Department of

Health, Corning Tower Room 1938, Albany, NY

12237, Phone: (518)486-9012, Fax: (518)486-

6098, Email: mbm07@health.state.ny.us

Research Objective: This study evaluates the impact of race/ethnicity on the provision of primary and preventive care services, as measured by nine quality measures during the

2005 time period, to a large and diverse

Medicaid managed care child and adolescent population.

Study Design: Quality specifications are based on National Committee for Quality Assurance

Health Plan Employer Data and Information Set

(NCQA HEDIS) and state-specific quality measures. The nine quality measures studied include: Childhood Immunization, Lead Testing,

Well-Child Visits in the First Fifteen Months of

Life, Well-Child Visits in the Third, Fourth, Fifth and Sixth Year of Life, Adolescent Well-Care

Visits, Appropriate Treatment for People with

Asthma, Appropriate Treatment for Children with

Upper Respiratory Infection, Appropriate

Treatment for Children with Pharyngitis and

Annual Dental Visit. Bivariate and multivariate results are presented.

Population Studied: Children and adolescents enrolled in New York State’s Medicaid Managed

Care Program during 2005.

Principle Findings: Results indicate that race/ethnicity has a statistically significant effect on performance rates, even after controlling for the potential confounders of gender, Medicaid aid category, eligibility level (as a proxy for socioeconomic status) and geographic location.

Conclusions: In New York, collecting and monitoring care for Medicaid managed care enrollees began in 1994. Since that time, studying disparities has proven that they exist

(albeit decreasing), they are complex, and that disparities between African Americans and other racial/ethnic groups are durable.

Implications for Policy, Practice or Delivery: A commitment to measuring and monitoring disparities in Medicaid allows states the ability to focus attention on needed intervention strategies. Public-private health care collaboration between state officials, health plans and providers of service will expedite the identification of high need areas of service improvement and/or case management interventions. Further state-funded activities are necessary, including public reporting of health disparity findings and focused clinical studies addressing disparities in care for New York’s children.

Funding Source: NYS State

•

Free Drug Samples: Characteristics of

Pediatric Recipients

Sarah Cutrona, M.D., Steffie Woolhandler, M.D.,

M.P.H., David H. Bor, M.D., David Himmelstein,

M.D., William Shrank, M.D., M.S.H.S., Neal S.

LeLeiko, M.D., Ph.D.

Presented By: Sarah Cutrona, M.D.,

Internist/Clinical and Research Fellow in

Medicine, Medicine, Cambridge Health

Alliance/Harvard Medical School, 1493

Cambridge Street, Cambridge, MA 02139, Phone:

(617)665-1032, Fax: (617) 665-1671, Email: scutrona@hsph.harvard.edu

Research Objective: Free drug samples are frequently given to children, but little data is available on distribution patterns in the pediatric population. We sought to describe characteristics of free sample recipients and to determine whether samples are given primarily to poor and uninsured children.

Study Design: We analyzed data from the 2003

Medical Expenditure Panel Survey (MEPS), a nationally representative survey which includes questions on receipt of free drug samples. We performed bivariate and multivariate analyses to determine the odds of having received one or more free drug samples in 2003 and identified the most frequently reported sample medications.

Population Studied: We studied 11,699 U.S. residents under the age of 21.

Principle Findings: Six percent of children under 21 received at least one free drug sample in 2003. In bivariate analysis, the poorest children (those with family incomes <200% federal poverty level) were less likely to receive free samples than those with incomes > 400% of poverty level (4.9% vs. 7.8%; p<0.0001).

There was no statistically significant difference between receipt of samples among children with and without continuous health insurance in

2003. In multivariate analyses of sample receipt controlling for demographic factors, neither insurance status nor income predicted sample receipt. Children who were uninsured all or part of the year were no more likely to receive free

samples (Odds ratio [OR] 1.00; 95% Confidence

Interval [CI] 0.76 - 1.32) than those continuously insured; those with income < 200% of poverty were no more likely to receive free samples (OR

0.84, CI 0.63-1.13) than those with income >

400%. Variables that captured routine access to health care were associated with greater receipt of free sample in multivariate analyses.

Conclusions: Poor and uninsured children are not the main recipients of free drug samples.

Implications for Policy, Practice or Delivery: In the face of mounting data on safety and prescribing issues, the strongest argument in favor of free drug sample use has been that these samples provide pediatricians with the ability to give free medications to their neediest patients. Our study demonstrates that this is not the primary way free drug samples are being used. Free drug samples go primarily to those with better access to health care; their distribution does not substantially decrease inequalities in medication access.

Funding Source: National Research Service

Award

•

Family Structure and the (Under)Treatment of Childhood Asthma

Jose Escarce, M.D., Ph.D.

Presented By: Jose Escarce, M.D., Ph.D.,

Professor of Medicine, Medicine, UCLA School of Medicine, 911 Broxton Avenuw, Room 204,

Los Angeles, CA 90024, Phone: (310) 794-3842,

Email: escarce@rand.org

Research Objective: Family structure is associated with important cognitive and psychosocial outcomes in children and adolescents. However, few studies have assessed health care or health outcomes. To fill this gap, this study examines the effect of family structure on the treatment of childhood asthma and measures of asthma symptom control.

Study Design: We used data from the 1996-

2003 Medical Expenditure Panel Surveys (MEPS) and the 2003 National Survey of Children’s

Health (NSCH). MEPS uses a rotating panel design that follows subjects for two years and contains detailed information on health care use, sociodemographics, and health status. NSCH was a cross-sectional survey that elicited information on sociodemographics and, for asthmatics, measures of asthma symptoms.

Using MEPS, we estimated negative binomial regression models to assess the effects of singlemother families (vs. two-parent families) and number of other children in the family on asthmatic children’s number of office visits for asthma and prescriptions for inhaled bronchodilators, asthma controller medications

(inhaled steroids, leukotriene inhibitors, and cromolyn), and oral steroids. The models controlled for children’s age, sex, and health status; health insurance coverage; family income; and maternal age and education. Using NCSH, we estimated an ordinal logit model to assess the effects of family structure on health problems from asthma (mild, moderate, or severe) and a binary logit model for whether the child had an asthma attack in the last 12 months. The models controlled for sociodemographics and insurance.

Population Studied: Children and adolescents age 2 to 17 years who (or whose parents) reported that they had been diagnosed with asthma by a physician. (For MEPS, N=2400; for

NSCH, N=11,100.)

Principle Findings: Children with single mothers and children living with several other children received less intensive treatment for asthma, respectively, than children with two parents and children living with no other children. Specifically, the less intensively treated children received fewer prescriptions for all types of asthma medications (including controller medications) and fewer office visits for asthma.

However, children with single mothers had more severe health problems from asthma than children with two parents, and children living with three or more other children were more likely to have had an asthma attack than children living with no other children.

Conclusions: The findings of less intensive treatment but worse control of asthma suggest that children with single mothers and children with many siblings may be undertreated for their disease, with potential consequences for symptoms and quality of life. These results are consistent with studies showing deleterious effects of single parents and numerous siblings on cognitive and psychosocial outcomes.

Additional research about the impact of family structure on the health care of children is needed to understand in greater detail the mechanisms underlying these effects.


Health care providers should be aware of the risk for inadequate care among children living in certain types of families.


•

How Insurance Instability Impacts Children

Gerry Fairbrother, Ph.D., Paul Newacheck,

Dr.P.H., Amy Cassedy, Ph.D.

Presented By: Gerry Fairbrother, Ph.D.,

Professor, Clinical Effectiveness, Cincinnati

Children's Hospital Medical Center, 3333 Burnet

Avenue MLC 7014, Cincinnati, OH 45229-3039,

Phone: 513-636-0189, Fax: 513-636-0171, Email: gerry.fairbrother@cchmc.org

Research Objective: To examine the influence insurance continuity and gaps on access to and use of health care for children.

Study Design: This was a two-year longitudinal study of children with and without insurance coverage where gaps in coverage were calculated using monthly insurance coverage data. We used bivariate frequencies and multivariate logistic regression to determine the effect of gaps on outcomes (usual source of care; routine medical and dental visits; unmet medical and prescription needs; and satisfaction with care), controlling for race, age, language of interview, income, education and health status. Outcomes for children who were continuously covered were compared with those for children with single gaps, multiple gaps and no coverage during the two-year period.

Population Studied: We used a pooled sample from the Medical Expenditure Panel Survey

(Panel 5, 6, and 7) of 12,519 children between the age of 2 and 17.

Principle Findings: During the two-year period,

68% of the children in the survey were continuously covered, 22% had a single gap in coverage, 3% experienced multiple gaps, and 7% of children had no coverage during the two years. The average length of gaps for children in this study was 6.9 months (median 5 months).

In the multivariable analyses, children with multiple gaps reported most problems with access to care. For example, children with multiple gaps had 6.64 higher odds (p<0.0001) of not having a usual source of care compared to children continuously insured. The odds ratio for children with a single gap was 2.65

(p<0.0001), and 4.85 (p<0.0001) for children continuously uninsured. Patterns for utilization were similar, with children with gaps, especially multiple gaps having highest odds of not having a well care visit (multiple gap: OR=2.61, p<0.0001; single gap: OR=1.36, p=0.0006; continuously uninsured: OR=2.55, p<0.0001) and dental visit (multiple gap: 1.52, p<0.0001; single gap: NS; continuously uninsured:

OR=2.48;p<0.0001) in the past 12 months, compared to continuously insured children.

Conclusions: Having gaps, especially multiple gaps, in insurance coverage diminishes a child’s access to and use of the health care system.


Our study demonstrates that insurance gaps are more prevalent when longer time spans, such as the 2 year period used in this study, are considered. Hence, studies using shorter time frames understate the extent of insurance instability and the attendant access problems.


• Sick Leave and Health Service Utilization

Sherry Glied, Ph.D., Bisundev Mahato, B.A.


Health Policy and Management, Mailman SPH,

Columbia University, 600 West 168th Street,6th

Floor, New York, NY 10032, Phone: 212-305-

0299, Fax: 212-305-3405, Email: sag1@columbia.edu

Research Objective: Members of Congress, and several interest groups, have advocated requiring firms to provide workers with paid sick leave so as to improve health and health care access for workers and their children and keep sick children out of school. Nearly half of American workers currenlty lack paid sick leave. We study whether being allowed sick leave affects workers’ and their children’s preventive health care utilization, days worked, and days missed from school.

Study Design: We analyze Medical Expenditure

Panel Survey (MEPS) 2003 data using crosstabs, linear and logistic regressions, adjusting for the complex survey design of the MEPS.

Population Studied: We look at those workers who are employed full-time for the full-year, are

18-64 years old, are not self-employed, are not in the military, and are either full-year insured or full-year uninsured. We also study the subsample of this population where the worker has a child aged 6-17 in their household.

Principle Findings: Privately insured workers

(especially those who have employer sponsored insurance in their own name) are much more likely to be allowed sick leave than are the publicly insured or the uninsured. They are also more likely to have a usual source of care.

Controlling for health insurance, usual source of care, wage level, and other characteristics, the availability of sick leave is correlated with increases in the use of preventive services, including cholesterol, blood stool, sigmoid/colonoscopy check, dental check up, and flu shots. However, the availability of sick leave is not correlated with BMI.

Children of workers who have paid sick leave have similar use of health services as do children of workers without paid sick leave. Children of workers with paid sick leave, however, have more days missed from school.

Conclusions: Sick leave has a significant effect on the health status of workers, as well as on many kinds of preventive health care utilization.

Parents’ allowed sick leave also has important implications for the health and care of their children.


Policies that increase the number of workers receiving sick leave are likely to have a positive effect on preventive health care utilization, and to keep sick children out of school.

Funding Source: CWF

• State Policy Improvements that Support

Children's Development: Expereince from

Eight States

Neva Kaye, Jennifer May, M.P.H., Melinda

Abrams, M.S.

Presented By: Neva Kaye, Senior Program

Director, , National Academy for State Health

Policy, 50 Monument Sq, Suite 502, Portland,

ME 04101, Phone: (207) 874-6524, Fax: (207)

874-6527, Email: nkaye@nashp.org

Research Objective: NASHP has administered two consortia to help states improve policy and practice to better support children’s development. Consortia states (CA, IL, IA, MN,

NC, UT, VT, WA)improved the policies governing their Medicaid, MCH, early intervention, and mental health agencies. There is also evidence that, as called for by the AAP, more physicians are using developmental screening tools as part of well-child care. The objective was to produce an analysis of policy improvements made by the consortia states and identify the critical elements to successful policy improvement with the intent of providing a starting point for others seeking to improve policy to: 1. improve the identification of young children with or at risk for developmental delays and 2. improve families’ access to follow-up services.

Study Design: Authors initially identified the improvements made by the consortia states and critical elements in the improvement process based on state progress reports, site visits, and state presentation material. Authors developed a matrix displaying policy improvements by objective, area (coverage, reimbursement, and performance), and mechanism.

Consortia state staff reviewed initial and revised drafts of the matrix and critical process elements to ensure completeness and usefulness. Authors analyzed the matrix to identify trends and innovations.

Population Studied: Medicaid agencies in consortia states were the primary study population. Consortia states often found they needed to change the policies of other state agencies to support their efforts------these are also in the study population. Finally, the states examined the experiences of physicians as part of their processes.

Principle Findings: From the final report

(released 12/06) Seven of the eight consortia states reported improvements to policies defining program coverage (eligibility and benefits). All seven reported improvements to benefits and three reported improvements to eligibility. The most frequently reported improvement to benefit coverage was to clarify the state’s expectations to individual providers to encourage the use of developmental screening tools as part of an EPSDT screen. Five states reported one or more improvements to reimbursement policies. Three reported improvements that relate to clarifying that providers (including primary care clinicians) can bill for conducting a developmental screen with a screening instrument using CPT code 96110. Six states reported one or more policy improvements designed to enhance program performance, including performance measurement. The only policy improvements designed to improve the delivery of child development services that were reported by more than one state were based on two sets of federal regulations ---- Medicaid managed care and EPSDT. Factors associated with each state’s success were: a strategic plan; broad stakeholder participation; grounding proposed improvements in experience, and creating opportunity.

Conclusions: Consortia states changed statutes, contracts, provider manuals, and other documents that define state policies to improve the delivery of child development services. They also changed eligibility and claims processing systems to implement the policies described in the documents, and conducted quality improvement projects designed to assess performance and foster change.


Consortia state experience offers guidance and inspiration others can use to improve children’s care.

Funding Source: CWF

• Prevalence of Overweight among Children

With Chronic Conditions

Sue Kim, Ph.D., M.P.H., Sue E. Kim, Ph.D.,

MPH, Amy J. Houtrow, M.D., M.P.H., Paul

Newacheck, Dr.P.H.

Presented By: Sue Kim, Ph.D., M.P.H.,

Specialist, Medicine, University of California, San

Francisco, 3333 California Street, Suite 335, San

Francisco, CA 94143-0856, Phone: 415-502-4078,

Fax: 415-502-8291, Email: sue.kim@ucsf.edu

Research Objective: Many children suffer from a pediatric chronic condition; these children may also be predisposed to significant co-morbidities such as overweight. This study’s aim was to provide estimates of the prevalence of overweight among children and adolescents with various chronic conditions.

Study Design: Using the National Survey of

Children’s Health (NSCH), a nationally representative random-digit-dial sample of U.S. children from 2003-2004, we estimated the prevalence of overweight (defined as at or greater than 95th percentile of the sex-specific

BMI for age growth charts), by an array of pediatric chronic conditions. We adjusted for underlying demographic and socioeconomic factors (age, sex, race/ethnicity, family income, family structure, parental education, and region).

Population Studied: Our study included 46,707 children aged 10 to 17 years. We selected 10 to 17 year old children for our analyses because older children and adolescents have been shown to be at the greatest risk for developing adult obesity and related health consequences.

Principle Findings: The overall prevalence of overweight was 14.8% in children 10 to 17 years of age. The prevalence of overweight in children with chronic conditions was higher than that of their condition-free counterparts (17.3% v. 12.2%; p<0.01). The prevalence of overweight was 15.0%

(95% CI:13.8-16.2) for children with one identified chronic condition, 18.3% (95% CI:16.6-20.1) for children with two conditions, and 20.8% (95%

CI:19.1-22.7) for children with more than two conditions. Children with developmental

(19.8%; 95%CI:18.1-21.7) and behavioral/emotional conditions (19.4%;

95%CI:17.8-21.1) have a statistically significant higher prevalence of overweight than children with physical conditions (17.6%; 95%CI:16.6-

18.6). Differences in prevalence between children with and without chronic conditions were largely attenuated after adjusting for age, sex, race/ethnicity, family income, family structure, parental education, and region.

Conclusions: Among children 10 to 17 years old, the prevalence of overweight was higher for those with chronic conditions compared to those without any conditions. Much but not all of the differences in prevalence appear to be attributable to the underlying distribution of demographic and socioeconomic characteristics in the two groups.


While children’s chronic conditions may or may not be life threatening, development of comorbidities such as overweight and obesity may significantly impede their long term health and quality of life. Understanding of the comorbidities associated with pediatric chronic conditions may increase awareness about the challenges these children face in maintaining a healthy and active life style. Information on overweight prevalence may aid health maintenance and health promotion efforts to benefit chronically ill children.

• The Two Well Child Visits: Implications for

Health Services Research

Lawrence Kleinman, M.D., M.P.H.

Presented By: Lawrence Kleinman, M.D.,

M.P.H., Vice Chair for Research and Education,

Health Policy, Mount Sinai School of Medicine, 1

Gustav Levy Place, New York, NY 10029, Phone:

(212) 659-9556, Email: lawrence.kleinman@mountsinai.org

Research Objective: To study the implications of a subtle difference in the approach to specifying a well child visit (WCV) using administrative data. We discuss the implications for the design and interpretation of health services research.

Study Design: Cross sectional study of all visits captured during one year by the clinicallydetailed electronic medical record system of 6 affiliated pediatric practices in 2 counties in one middle Atlantic state. Findings were discussed with clinicians and office staff from one practice.

Population Studied: 11,196 children age 0 through 16 years with a CPT-4 (procedure, ) or

ICD-9 (diagnosis) code indicating that well child care was provided at one of the practices (17,445

WCV). Mean age of the children was 70.3 months, with a median of 59.0. 40% were black and 49% white. 48% were insured by Medicaid and 47% by commercial insurers.

Principle Findings: Virtually all visits noted by procedure to be a WCV also carried a diagnostic code for WCV. Only 70% of WCV with a diagnosis code also had a procedure code. WCV

with a procedure code were more likely to have a recorded height or length (95% v 77%, p<.0001), weight (96% v 91%, p=.002), and a greater percent had illness diagnosis as well (39% v

19%, p<.0001). No differences were found for urinalysis, vision screen, or tuberculin skin test.

Considering children over 2 years (the age at which the practices typically change to a standing height) and further adjusting for age, children without a procedure code indicating a

WCV were 9.3 times more likely not to have their height recorded (N=9657 visits). Discussion with staff concluded that the routine order of events: scheduling a block of time associated with a pre-specified procedure code; nurse and nurse's aid weighing, measuring; doctor or nurse practitioner visit with decisions about urinalysis, hearing and vision screening, and tuberculin screening, along with diagnostic coding, accounted for many of the findings. They noted the near universal practice of weighing children when they were seen accounted for the smaller differences in the proportion weighed, compared to measured. They further suggested that the patient families and the clinicians often negotiated to transform a visit that the practice had not anticipated as a WCV into one.

Conclusions: Subtle differences in the approach to identifying well child visits from administrative data will identify visits with systematic and meaningful differences in their content. Use of diagnostic codes will identify almost all such visits and will include visits lacking procedure codes that are less likely to include a recorded height and weight. The accurate interpretation of health services research findings may be nuanced and require involving practitioners with local knowledge. In this example, it appears that many children for whom the practice is not anticipating a health supervision visit actually receive one. When that happens, the quality of their care suffers: despite recommendations for universally measuring children at all well child visits and the presence of an obesity epidemic, many children are not having height data recorded when they receive their well child care.


This is a cautionary tale. If these findings are generalizable, then the practice of pediatrics needs to design systems that assure excellent quality well child care even when a WCV was not anticipated. Subtle and potentially unnoticed differences in specifications may be critical.

Studying such differences may offer insight into practice as they do here. We further illustrate how involving the subjects in the interpretation of results can be critical, even when staying within the community of medical practice. The accurate translation of research results into an understanding of practice is difficult, subtle, and critical. A beneficial transformation to evidencebased practice will require not only high standards for the collection of empirical data, but for its interpretation as well.

• Predictors of Pediatric Asthma

Hospitalizations

Alana Knudson, Ph.D., Ed.M., B.A., Kyle Muus,

Ph.D.

Presented By: Alana Knudson, Ph.D., Ed.M.,

B.A., Associate Director for Research, Center for

Rural Health, University of North Dakota, 501 N.

Columbia Rd, Stop 9037, Grand Forks, ND

58202-9037, Phone: (701)777-4205, Fax: (701)777-

6779, Email: aknudson@medicine.nodak.edu

Research Objective: Examine the incidence, patterns, and predictors of U.S. hospitalizations for asthma among children (i.e., aged 2 to 17).

Specifically, we examined the incidence rates for rural versus urban children and demographic/geographic factors which increase the likelihood of being hospitalized for this condition.

Study Design: Secondary analysis of HCUP hospital claims data.

Population Studied: Pedicatric hopsitalizations

2003 Healthcare Cost and Utilization Project

(HCUP) Nationwide Inpatient Sample data file.

Principle Findings: There were an estimated

118,869 hospitalizations for asthma among children in the U.S. in 2003. Of this number,

103,672 were incurred by urban-based children and 15,197 involved rural-based children. Per population, urban children had hospitalization rates that were substantially higher than for rural children (193.2 versus 137.4 per 100,000). Using logistic regression, urban children were 37.7% more likely than rural children to have a hospitalization resulting from asthma, after controlling for age, gender, race, and income level.

Conclusions: Children residing in urban areas were much more likely than their rural counterparts to have been hospitalized for asthma. Other factors that increased the likelihood of being hospitalized for this condition included being male, aged 2-6, African American race, and residing in lower income areas.


Implications for policy include ensuring that

Medicaid and SCHIP programs have adequate reimbursement for follow-up visits for children

and particularly, educating parents on asthma triggers. In addition, access to timely pharmacuetical refills are important to the continuity of their care. Practitioners may need to pay particular attend to the education they provide to low-income families to assure that the information about asthma management is clearly communicated and understood by the children's parens.

Funding Source: HRSA, ORHP

• Effects of a Community Agency Intervention on Care Management, Health Services Use and Quality of Life for Children with Asthma

Richard S. Kurz, Ph.D., Mary E. Homan, M.A.,

Kristin D. Wilson, M.H.A.

Presented By: Richard S. Kurz, Ph.D., Professor and Chair of the Department of Health

Management and Policy, Department of Health

Management and Policy, Saint Louis University

School of Public Health, 3545 Lafayette Avenue,

Saint Louis, MO 63104, Phone: 314.977.8111, Fax:

314.977.1674, Email: kurzrs@slu.edu

Research Objective: The study assesses the effects of a community agency intervention,

Asthma HELP, on asthmatic children’s process of care, health services use, and perceived quality of life.

Study Design: Annual cohorts of approximately

60 children at two sites of a community agency receive visits throughout the year. Information is gathered about their behavior at each visit by an asthma-educated social worker through a detailed checklist, and quality of life through an annual Juniper Survey. Two years of data have been collected. Dependent variables include: utilization of emergency departments, hospitalizations, and controller medications; provision and presence of an asthma action plan, provision and presence of a bed cover, and

Juniper Survey scores. The intervention, Asthma

HELP, provides families with support in the home setting regarding health care and asthma, environmental triggers, and suggestions for the prevention of asthma episodes, emergency department visits, and hospitalizations. Support is accomplished through home visits, advocacy, and related casework, but also through support groups and educational opportunities.

Population Studied: The population includes children in the midtown and northside St. Louis inner-city areas who have been diagnosed with asthma and whose parents sought assistance through the community agency.

Principle Findings: Statistically significant improvements occurred across visits at both sites in the provision and use of asthma action plans by children. Emergency department use and hospitalizations declined for children across visits at both sites for the total population and cohorts. The pattern of visits with regard to controller use and the presence and provision of bed covers differed between the two sites. Bed cover usage significantly increased at one site for the total population and cohorts.

Analysis of the Juniper Surveys is not completed at this time but will be complete for presentation. A complete third year of data and analysis will be available at the presentation.

Conclusions: The Asthma HELP intervention positively affected the process of care and use of services. The Asthma HELP intervention significantly impacted the process of care through the provision and use of asthma action plans for both sites, and the provision and use of bed covers at one site. Controller usage also increased across sites. The intervention produced appropriate declines in services usage, which may indicate reduced asthma morbidity for these children. Declines in use of both the emergency department and hospitals occurred at both sites but did not reach significance. It should be noted that non-significant effects often fell between a p-value of .05 and .10.


The Asthma HELP program demonstrates that an asthma management program can be integrated into the casework process of a community agency in which social workers have received asthma education. Such an integrated program can also decrease the use of emergency departments and hospitals, reducing the cost of care of clients and third party payers.

Funding Source: CDC

•

The Effect of Maternal Education on Child

Health and Health Care Use

Dean Lillard, Ph.D., Kosali Simon, Ph.D., Maki

Ueyama, B.A., Ning Zhang, B.A.

Presented By: Dean Lillard, Ph.D., Senior

Research Associate, UniversityDepartment of

Policy Analysis and Management, Cornell, MVR

Hall, Ithaca, NY 14853, Phone: 607-255-9290,

Fax: 607 255 4071, Email: drl3@cornell.edu

Research Objective: To examine the causal effect of mother’s high school education and college education on child health and health care use.

Study Design: We use an instrumental variables approach to overcome problems in attributing difference across education groups to the effect of education. Our instruments for mothers education predict educational attainment on two important margins - the completion of high school and attendance at and completion of college. On the first margin our instruments include state policies governing age of school entry and exit, high school graduation requirements. We leverage the school entry and exit policies by interacting each with a woman's exact date of birth. On the second margin our instruments include average distance to a 2- or

4-year college from a woman's place of residence and the average college tuition she faces for all colleges within 500 miles of her place of residence.

Population Studied: Children and mothers from the National Longitudinal Survey of Youth.

Specifically, the 1979-2002 waves of the NLSY79 and the 1986 -2002 waves of the NLSY79CY.

Principle Findings: We find that mothers who complete high school are more likely to report their child was ill enough to need a doctor, that their child was ill more times, and that their child was more likely to have fractured or dislocated a bone in the past 12 months that required medical attention or treatment. Across samples of mothers who dropped out of high school and who completed high school, we find no difference in the date of their children’s last routine health checkup, percentiles for weightfor-age, height-for-age, BMI-for-age, or in the probability of children at risk of overweight and of being overweight. When we examined the possible mechanisms, we found that mother’s high school education increases mother’s age at child’s birth, health insurance coverage and child care use. We also find suggestive evidence of a much more complex set of behaviors that are causally related to education (child care use, health insurance status, fertility decisions) and that likely affect child health.

Conclusions: This preliminary evidence suggests that although child health care use increases with education, much more work needs to be done before one can strongly conclude that child health does or does not systematically vary with differences in maternal education on the margin we study.


While there have been several studies of the link between maternal education and child health in developing countries, there is very little in the

US. Existing research only studies infant birth outcomes and offers conflicting evidence. Our paper will provide valuable evidence on the causal link between maternal education and child health and health care use. These are important non-market outcomes of education that should be considered in policies to publicly subsidize education.

• Child-Restraint-Use Rate in Taiwan and a

Methodological Comparison

Sue-Jen Lin, Ph.D.

Presented By: Sue-Jen Lin, Ph.D., assistant professor, Mass Communication, I-Shou

University, No.1, Sec. 1, Syuecheng Rd., Dashu

Township, Kaohsiung County, 840, Taiwan

Phone: 011886958035515, Fax: 01188676577277,

Email: suelin@isu.edu.tw

Research Objective: In Taiwan, an average of

3.8 children die each day from injuries sustained in motor-vehicle accidents -- the leading cause of death in children. According to U.S. National

Highway Traffic Safety Administration(NHTSA),

61 percent of the occupants killed in motorvehicle accidents used no restraints. Based on these grim statistics, the Ministry of

Transportation and Communications R.O.C., has mandated the use of safety restraints for children in 2004, specifying age- and weight-appropriate rules for children under 12, all in an effort to improve the safety of child passengers. It remains unclear how effective this newly enacted law will be in preventing transport-related injuries in children since no official studies have been conducted. The study was undertaken to determine the rate of child safety-restraint use, factors for use and nonuse, and a better method to measure the use.

Study Design: To evaluate the effectiveness of the newly enacted law and the current practice of restraint use in Taiwan, this study used a convenient sampling method to observe and record the use of safety restraints by the driver and any child passengers in the parking lots of several kindergartens in both Kaohsiung City and

Kaohsiung County. To compare the results of the observational study, questionnaires were sent to parents of randomly selected kindergarteners to obtain self-reported data on driver-restraint use and child-restraint use. A total of 477 and 512 responses were obtained from the mailed survey and the observational study respectively.

Population Studied: Drivers and child passengers in Kaohsiung City and Kaohsiung

County.

Principle Findings: The study shows that 39.8 percent of subjects self-reported child safetyrestraint use. This contrasts sharply with the observational study which saw only 9.2 percent of parents using safety restraints for their children. Similarly, the self-reported adult seatbelt use was 80.3 percent ---- far higher than the 49.0 percent we observed. The use of child safety-restraint is higher in Kaohsiung City than in Kaohsiung County. Factors that influence child safety-restraint use are driver’s gender, adult seatbelt use, number of children in the vehicle, and age of the children, but the age of drivers, gender of the children, the number of adult passengers in the car, driving distance from home to the destination are not influential factors.

Conclusions: The low child safety-restraint use rates obtained from both methods suggest the newly enacted law is ineffective in terms of increasing child safety-restraint use. Both adult- and child-restraint use are higher in cities than in rural areas. In addition, driver seatbelt use and gender, the number of child passengers in the car, and the age of child passengers are all strong predictors of child safety-restraint use.


The results demonstrate the need for public education campaigns to inform parents about child safety-restraint use, especially for parents in rural areas and those who are less likely to use car seats. In addition, an observational study is a better method to estimate the prevalence of car safety-restraint use than a mailed survey.

Funding Source: Bureau of Health Promotion,

Department of Health, R.O.C. (Taiwan)

•

CSHCN Access to a Medical Home:

Differences by Income Group

Kristine Lykens, Ph.D., Kristine Lykens, Ph.D.,

Sejong Bae, Ph.D., Karan Singh, Ph.D.

Presented By: Kristine Lykens, Ph.D., Assistant

Professor, Health Management and Policy,

University of North Texas Health Science Center

- School of Public Health, 3500 Camp Bowie

Blvd, Fort Worth, TX 76107, Phone: (817) 735-

2325, Fax: (817) 735-0446, Email: klykens@hsc.unt.edu

Research Objective: The objective of this research study was to identify factors that affect access to a medical home for children with special health care needs and to identify how these factors vary among different socioeconomic levels.

Study Design: Access to a medical home was derived using an algorithm combining five characteristics of a medical home established by the Maternal and Child Health Bureau of DHHS.

The analysis examined the relationships of demographic characteristics, geographical location of household, severity of condition, and social factors on access to a medical home.

Multiple logistic regression models were constructed for four SES levels defined by FPL: <

133%; 133-199%; 200-299%; = 300%.

Standardized regression coefficients for the independent variables were calculated to compare coefficients among SES strata.

Standard errors were adjusted to incorporate sample design characteristics.

Population Studied: Data were obtained from the National Survey of Children with Special

Health Care Needs, 2000 - 2002, available through the CDC. Approximately 750 CSHCN from each of the 50 states and the District of

Columbia were included. Survey data represented parent report responses for 38,866

CSHCN up to 17 years of age.

Principle Findings: Age, severity of condition, race, maternal education, insurance type / status, geographical location of the household, and language of the interview significantly predicted receiving comprehensive, coordinated care in a medical home for CSHCN in the <

133% of FPL stratum. Age, severity of condition, sex, race, relationship of the respondent to the

CSHCN, and the number of kids in the household significantly predicted receiving care in a medical home for CSHCN in the lowest stratum. Severity of condition, race, insurance type, relationship of the respondent to the

CSHCN, and the number of kids in the household significantly predicted receiving care in a medical home for CSHCN in the 200 - 299% of FPL stratum. Age, maternal education, insurance type / status, geographical location of the household, and number of adults in the household significantly predicted receiving care in a medical home for CSHCN in the highest stratum

Conclusions: Severity was significant in all SES strata. Demographic characteristics also varied among SES strata. Females were more likely than males to have received care in a medical home for the 133 - 199% of FPL stratum. Black

CSHCN were less likely than white CSHCN to have received care in a medical home for the <

133% and 200 - 299% of FPL strata. No differences were found between Hispanic and non-Hispanic CSHCN. The total number of kids

in the household had a significant impact in the two middle strata, but in reverse directions.

CSHCN with Medicaid and SCHIP were more likely to have received care in a medical home in the lowest SES stratum; however, CSHCN with

Medicaid were less likely in the highest SES stratum. This is reflected by the benefits offered to CSHCN through Medicaid and SCHIP.


Results indicate factors affecting CSHCN's access to a medical home differed among the four income groups. Therefore, policies and program design characteristics need to reflect the varying needs of children targeted by income.

•

An Assessment of Emergency Care for

Children in Nebraska

Michelle Mason, M.A., Michael Shambaugh-

Miller, Ph.D., Liyan Xu, M.S., Kelly Shaw-

Sutherland, B.S.

Presented By: Michelle Mason, M.A., Health

Data Analyst, Health Services Research and

Rural Health Policy, University of Nebraska

Medical Center, 984350 Nebraska Medical

Center, Omaha, NE 68198-4350, Phone:

(402)559-8406, Fax: (402)559-7259, Email: mmason@unmc.edu

Research Objective: To assess the extent to which structures and processes within Nebraska hospitals and emergency medical services (EMS) that provide emergency care to children are consistent with evidence-based guidelines

Study Design: We used the Dillman method to survey all Nebraska hospital emergency departments (EDs) that treat children, and all

EMS services in Nebraska. We developed two surveys (one for EDs and another for EMS services), using guidelines recommended by the

American Academy of Pediatrics, performance measures developed by HRSA for the Emergency

Medical Services for Children (EMSC) program, and recommendations from the National EMSC

Data Analysis Resource Center and the Nebraska

EMSC program.

Population Studied: We received completed surveys from 78% of 85 EDs contacted [50

Critical Access Hospitals (CAHs) with 25 or fewer beds, 2 small hospitals with 26 to 49 beds, and 14 larger hospitals with 94 or more beds] and 68% of 429 EMS services in Nebraska [13

First Responder services, 214 Basic services, and

49 Advanced services].

Principle Findings: In Nebraska children account for about one-fourth of all visits to EDs and about 10% of all EMS runs. Only 16% of

EMS services had all the essential pediatricspecific BLS equipment, and 18% of Advanced services had all the essential pediatric-specific

ALS equipment. Sixty-six percent of EDs had written care protocols addressing stabilization of critically ill or injured children, while 79% of EMS services utilize the NE State Model Protocol.

Only 20% of EMS services utilized on-line pediatric medical direction at the scene of an emergency. Less than half of EMS services required EMTs to have pediatric-specific training/education. ED providers were not likely to be required to obtain pediatric-specific CME.

Ninety-eight percent of EDs transferred children to other facilities for specialized care; over 60% had a written inter-facility transfer agreement that specified inter-facility communication (69%) and transfer of patient materials (65%). About one-third of EDs annually reviewed the frequency and outcomes of pediatric patients. Only two

EDs provided a child-life specialist.

Conclusions: Emergency health care providers in rural areas are most likely to lack the necessary experience and equipment for treating pediatric patients due to limited resources and the low volume of emergencies involving children. The majority of EMS services lack the essential equipment needed to treat children in the prehospital setting. Because CAHs are not likely to offer specialized pediatric care, they often transfer children to other facilities, increasing the need for written inter-facility agreements. Pediatric-specific education and increased resources would benefit both prehospital and in-hospital providers. More efforts must be made to standardize care through the use of written protocols and regular assessment of children’s outcomes in order to serve this population safely and effectively.


Policymakers in rural states must assess the infrastructure of emergency pediatric care with a goal of maximizing access to high-quality emergency care through coordination at the state and local level. This assessment must include the locations of facilities capable of treating children according to evidence-based guidelines. Integrated systems of emergency care for children are necessary in rural states, where EMS services licensed to provide only BLS treatment and CAHs serve significant proportions of the population.

Funding Source: Nebraska Health and Human

Services System, EMS Program

• Health Services Need and Access for

Children with Special Health Care Needs: The

Role of the Medical Home

Timothy McBride, Ph.D., Shirley L. Porterfield,

Ph.D.

Presented By: Timothy McBride, Ph.D.,

Professor, Health Management and Policy, Saint

Louis University, 3545 Lafayette Avenue, St.

Louis, MO 63104, Phone: 3149774094, Fax:

3149778150, Email: mcbridet@slu.edu

Research Objective: This project examines the association between aspects of the medical home concept, perceived necessity, and use of health care services among children with special health care needs (CSHCN). The role of health services for CSHCN, both in terms of what they need and what they use, is analyzed, contrasting needs specified by parents whose children have a medical home with those whose children do not, controlling for socioeconomic and demographic characteristics, insurance status, and type and severity of health condition. In addition, variations in utilization of health services by each aspect of the medical home concept are analyzed, paying particular attention to the interplay between health insurance coverage and medical home. We hypothesize that the existence of a medical home will improve the continuity and coordination of care, increasing both perceived necessity and utilization of health services.

Study Design: According to the American

Academy of Pediatrics, ‘‘desirable characteristics’’ of a medical home include a provider/place that is personal, accessible, comprehensive, family centered, coordinated, and culturally effective. Questions concerning each aspect of the medical home are individually compiled in a measure of medical home developed by Bethell et al. (Pediatrics 2004).

Descriptive analysis is used to examine the relationship between aspects of the medical home, type of health insurance coverage, family and child characteristics, expressed needs and access to health services, and reasons for delay in receiving services. Multivariate models are used to examine the relationship between aspects of the medical home measure, type of health insurance coverage, and the need for and access to specialized health services, controlling for family and child characteristics. Since utilization of health services is predicated on perceived need, the multivariate analysis is addressed through a two-stage model. Separate estimations are completed for medical care, dental care, and prescription drugs.

Population Studied: The project uses data drawn from the 2003 National Survey of

Children’s Health (NSCH) available through the

Centers for Disease Control, National Center for

Health Statistics. Nearly 18% of children in this study met criteria in the special health care needs screener, resulting in a sample of 18,578

CSHCN.

Principle Findings: The multivariate findings suggest that access is the key dimension of a medical home in both perceived need and use of medical services, followed by communication and coordination of care for need, and communication and comprehensive care for use.

Having a medical home is important overall in perceived need and use of dental care, but no particular dimensions of the medical home stand out. Comprehensive care is the key aspect of the medical home for perceived need and use of prescriptions drugs.

Conclusions: This study points to the importance of each aspect of a medical home for families who have children with special health care needs and provides a better understanding of the barriers experienced by parents in providing care for CSHCN.


The barriers faced by parents of CSHCN may be eased by implementation of the medical home model for special-needs children for public and private insurance programs, improving the continuity and coordination of care, and access to needed medical services.

•

Delivery of Asthma Education and Pediatric

Asthmatics: Is It Effective?

Jeannette Oshitoye, Ph.D., M.S.A.S., M.P.A.

Presented By: Jeannette Oshitoye, Ph.D.,

M.S.A.S., M.P.A., 2909 Buckner Boulevard,

Dallas, TX 75228, Phone: 214-676-3560, Email: oshitoye@msn.com

Research Objective: To determine whether asthmatic patients are receiving required educational information to self-manage their asthma as outlined in the National Asthma

Guidelines (NAGs). Cote et al. (2001) indicate that the single prescription of a self-action plan does not diminish asthma morbidity. When patients with asthma are not given sufficient information and reinforcement, they do not seem to have enough self-confidence to increase the dosage of inhaled corticosteroids according to asthma symptom severity or PEF. The NAGs

offer specific techniques that allow physicians to provide both information and reinforcement.

These strategies include the provision of understanding causes and triggers, proper metered dose inhaler and peak flow meter use, following written guidelines, keeping written diaries, and evaluating results of treatment. The guidelines specify that there should be a strong emphasis on education in patients at the time of diagnosis and as part of continuing care. The

NAGs list detailed strategies, including understanding causes and triggers, following written guidelines, keeping written diaries, and evaluating results of treatment, teaching of asthma self-management, basic facts about asthma, roles of medications, skills such as how to use their inhaler, spacer, holding chamber, and how to self-monitor. Most studies that have been completed to date have tried to determine the concordance between physician practice and the NAGs on the basis of pharmacological management. Fewer numbers have looked at whether physicians’ provision of asthma education is in concordance with the NAGs.

Finkelstein et al. (2000) found that only half of those pediatric and family physicians they surveyed reported providing written care plans.

Legorreta et al. (1998) found that only 26% of asthmatics reported having a peak flow meter.

Krishnan et al. (2001) found that fewer African

Americans than whites reported care consistent with recommendations for self-management education.

Study Design: This study is a retrospective study which analyzes data from the National

Asthma Survey. It uses a logit regression to predict the probability of a pediatric asthma patient receiving appropriate educational information as outlined in the NAGs.

Population Studied: U.S. asthmatics between the ages of 5-17 years old.

Principle Findings: The literature clearly documents that in the U.S., minority groups are least likely to receive treatment in accordance with established guidelines. Similar findings have been documented in relation to the provision of educational information that allows patient self-management. However, this study found that African Americans received similar information as their Caucasian counterparts.

Only those individuals who self-identified as

Latino were least likely to receive the required medications as outlined by the NAGs.

Conclusions: Those individuals who self-identify as Latino are least likely to receive the required medications as outlined by the NAGs. Thus, steps need to be taken to address this group, either through re-release of the NAGs or some other mechanism.


Given the increasing number of Latinos in the

U.S., if the delivery of information which it technically free does not meet the required levels in this population, the U.S health care system could experience increased cost outlays in the area of asthma as seen in the 80s and 90s.

• Making the Connection between School-

Based Health Programs and Academic

Achievement: Practical Experiences from the

Dallas Independent School District Youth and

Family Centers

Jeannette Oshitoye, Ph.D., M.S.A.S., M.P.A.

Presented By: Jeannette Oshitoye, Ph.D.,

M.S.A.S., M.P.A., Evaluator, Research and

Evaluation, Dallas Independent School District,

2909 S. Buckner Blvd, Dallas, TX 75228, Phone:

214-676-3560, Email: oshitoye@msn.com

Research Objective: School-based health centers (SBHCs) began emerging in the late

1960s in recognition of the increasing number of children who lacked access to health care.

Efforts to document the connection between school health programs and academic improvement have become more urgent due to the increasing accountability pressures placed on schools by the No Child Left Behind. Districts must now document improvements in school achievement for all their campuses, and because

SBHCs are part of the school system they are not exempt. The objective of this presentation is to illustrate how the Dallas Independent School

District (DISD) established SBHCs to deliver services to their most disadvantaged clientele.

And how the services provided by the centers have been successfully linked to academic achievement measures.

Study Design: Using data from the 30,747 students and their families served in 2004-2005 and 2005-2006 who received 75,207 services.

Promotion rates, Texas Assessment and

Knowledge and Skills (TAKS) the state mandated test which evaluates student learning based on the state-required curriculum and attendance rates. Clients seeking services were divided into four groups ---- low-frequency and high-frequency physical health clients, low-frequency and highfrequency behavioral health clients. Data were analyzed first by year, for each of the outcome variables using paired t-tests and chi-square analysis. Secondary analysis was conducted

using longitudinal data of those clients who had received services for more than one year.

Population Studied: The study populations consisted of DISD students (ages 4-21years old) and their parents who used the nine Youth and

Family Centers to receive physical health and behavioral health services in 2004-2005 and

2005-2006 school years.

Principle Findings: Initial analysis showed that students using the Youth and Family Centers for either physical or behavioral health services had lower rates in terms of promotion, attendance, and TAKS passing rates than students in the control group who did not use the Youth and

Family Centers. However, when comparisons were made between physical health and behavioral health cohorts and matched control groups results were favorable for the Youth and

Family Centers. In both years there was no difference in outcome measures for the treatment group and the control group. In fact, in 2005-2006 passing rates were higher for those students receiving behavioral health services from the Youth and Family Centers despite the increase morbidity burden.

Conclusions: The findings of this study show that the DISD’s Youth and Family Centers are having a positive effect on improving student achievement outcomes and have the ability to document these results. The method used to analyze the data is as important as providing services in a school-based health program.


Many SBHCs have closed due to funding shortages because of their inability to link academic achievement with the services provided. These centers are responsible for reducing the number of children who lack access to health care. Thus, as the numbers of children who are eligible for SCHIP are being reduced because of state funding constraints, it is important that the number of SBHCs, who can serve as a safety-net, continue to increase. This can only be accomplished if funding is constant.

• The Effect of a Novel Intervention for

Improving Healthcare Quality for Ill Children in Benin, West Africa

Dawn Osterholt, M.D., M.S.P.H., Faustin

Onikpo, M.D., M.P.H., Michael Deming, M.D.,

M.P.H., Marcel Lama, M.D., M.P.H., Alexander

Rowe, M.D., M.P.H.

Presented By: Dawn Osterholt, M.D., M.S.P.H.,

Research Fellow, General and Community

Pediatrics, Cincinnati Children's Hospital

Medical Center, 3333 Burnet Avenue - ML 7035,

Cincinnati, OH 45229, Phone: (513) 636-8954,

Fax: (513) 636-4402, Email: dawn.osterholt@cchmc.org

Research Objective: The Integrated

Management of Childhood Illness (IMCI) strategy has been shown to improve care for ill children in outpatient settings in developing countries. A central component of the strategy is a training course on IMCI clinical guidelines.

Although IMCI encourages efforts to strengthen healthcare systems, little guidance exists on what can be done in addition to training to improve health worker (HW) adherence to IMCI guidelines. Our objective was to evaluate a novel intervention to support HWs after IMCI training.

Study Design: We conducted a randomized controlled trial in Ouémé Department, Benin

(population ~1.2 million). In 1999, a health facility survey was undertaken to assess baseline healthcare quality before IMCI implementation.

Then, HWs began receiving either: 1) IMCI training plus specially designed IMCI posttraining supports (in a randomly selected group of 8 intervention districts), or 2) IMCI training plus ‘‘usual’’ follow-up (in 8 control districts).

Our post-training supports included: a patient register with IMCI-specific memory-aids, supportive supervision of HWs and supervisors, and non-financial incentives (certificate of merit presented at a ceremony). Follow-up surveys were conducted in 2001 and 2004. The outcome for this analysis was the percentage of children with clinical pneumonia who received life-saving treatment.

Population Studied: Ill children 2----59 months seen in public or licensed private outpatient health facilities in Ouémé Department, Benin.

Altogether, we observed 1041 consultations for new illness; 308 were for children with clinical pneumonia.

Principle Findings: Although appropriate pneumonia treatment increased in both intervention and control groups, from about 18% in 1999 to 46% in 2004, we found no significant difference in trends between groups from 1999----

2001 (p=0.51) or 1999----2004 (p=0.37). However,

IMCI training proceeded slowly (in 2001 and

2004, only 51% of children were treated by IMCItrained HWs), and poor quality care from non-

IMCI-trained HWs could have diluted the effect of the IMCI post-training supports. Post-hoc analyses revealed that HWs who received IMCI training and supports provided better care than

HWs who received IMCI training and usual follow-up, and both groups generally provided better care than non-IMCI-trained HWs. Results

of the pneumonia treatment outcome from

1999, 2001, and 2004 were: 8%, 76%, and 53%

(IMCI training + supports); 22%, 56%, and 48%

(IMCI training + usual follow-up); and 23%, 12%, and 35% (non-IMCI-trained HWs). Compared to

IMCI training plus usual follow-up, the effect of the IMCI post-training supports was statistically significant in 2001 (p=0.04), but only borderline significant in 2004 (p=0.09). Quality appeared to decrease among both groups of IMCI-trained

HWs from 2001 to 2004.

Conclusions: Although results of an intentionto-treat analysis of our IMCI post-training supports did not show benefit, low coverage of

IMCI training (and therefore the post-training supports) diluted improvements seen in both intervention and control groups. Analyses by exposure to IMCI training suggest that the posttraining supports added to gains in healthcare quality seen with IMCI-training alone.


Although IMCI training improved short-term quality of care, long-term improvements appear to require ongoing support. Wherever IMCI is implemented, a priority for supervisors and program managers should be to ensure that

IMCI-trained HWs perform consultations.

Funding Source: US Agency for International

Development

•

Preventive Care for Children: How Well Do

Medicaid and SCHIP Do?

Cynthia Perry, Ph.D., Genevieve M. Kenney,

Ph.D.

Presented By: Cynthia Perry, Ph.D., Research

Associate, Urban Institute, 2100 M Street NW,

Washington, DC 20037, Phone: 202-261-5905,

Fax: 202-223-1149, Email: cperry@ui.urban.org

Research Objective: In this paper, we examine receipt of clinician advice about health behaviors and injury prevention for low-income children.

We compare the care provided by these public insurance programs to the care children receive when they are uninsured and to that received by children with private coverage. We also compare the absolute levels of preventive care and clinician counseling received to the levels recommended by the American Academy of

Pediatricians.

Study Design: We estimate linear probability models where the key analytic variable of interest is the child’s insurance status over the past year.

The main outcome measures are whether the child (and parent) were advised about healthy eating, physical activity, the harmful effects of smoking in the home, proper safety restraints in a car, and use of a bicycle helmet when riding a bicycle. We also examine intermediate barriers to receiving clinician advice, including whether the child had any preventive care visits in the past year and whether the child had a usual source of care other than a hospital emergency room. We control for family and child characteristics, including measures of the child’s health status.

Population Studied: We use a sample of children living in families below 250% of the

Poverty Line in the Medical Expenditure Panel

Data 2001-2003 surveys.

Principle Findings: We find that children who are publicly insured are less likely than children who are privately insured and children who are uninsured to have gone without a preventive care visit in the past year, but that regardless of health insurance status, many children are going without preventive care. Even conditional on having had a preventive care visit, more than half of children do not receive clinician advice in the areas measured, and this is true even for the children who are most in need of the advice

(e.g., less than a third of overweight children who had a preventive care visit were advised about exercise).

Conclusions: SCHIP and Medicaid can provide a vehicle for improving the chances that uninsured children and their parents receive important advice about health behaviors and injury prevention, but more than half of insured children are not receiving this important advice from their clinician.


Steps should be taken to increase receipt of physician counseling for children during preventive care visits.


•

The Impact of a Medical Home on Mental

Health and Stress for Parents of Children with

Autism

Shirley Porterfield, Ph.D., Timothy D. McBride,

Ph.D.

Presented By: Shirley Porterfield, Ph.D.,

Associate Professor, Social Work, University of

Missouri-St. Louis, One University Boulevard,

Saint Louis, MO 63121, Phone: 314-516-4617, Fax:

314-516-5816, Email: porterfields@umsl.edu

Research Objective: Autism spectrum disorders

(ASD) affect an estimated 25-60 out of 10,000 children and have profound impacts on not only the medical care use of the child, but on the

mental health and stress of their parents. This study seeks to determine whether a medical home contributes to better parental mental health and lower parental aggravation for parents of children with ASD.

Study Design: The medical home is hypothesized to improve parental mental health and reduce parental stress by improving the access, coordination, continuity and quality of care. This study uses a measure of the medical home developed to capture the Academy of

Pediatrics definition for children with special health care needs (CSHCN). Multivariate analyses were performed on measures of parental stress (using the four-item Aggravation in Parenting Scale (APS)) and mental health of the caregiver parent (using a 5-point Likert scale). An OLS regression model is estimated for the first dependent variable; an ordered

Probit model for the second dependent variable.

Explanatory variables include whether the child has a medical home, aspects of the medical home, demographic, economic, insurance, and measures of the child’s medical conditions.

Population Studied: This study focuses on children with ASD, as identified by the 2003

National Survey of Children’s Health. The sample includes parent-reported data for 401 children with ASD, ages 6 to 17.

Principle Findings: Having a medical home for the child is significantly associated with lower parental aggravation and better parental mental health in multivariate analyses. While 90% of parents reported their child had a personal physician or nurse, only 31% met criteria for a

‘‘medical home’’ in each category applicable to their child. Older child age, two-parent family, higher parental education level, fewer child comorbid conditions, and better child health status are also associated with lower parental aggravation as measured by the APS. A significantly higher percentage of parents with

ASD children report mental and emotional health problems (26% of parents of children with ASD children report excellent mental and emotional health, as compared to 35% of parents without ASD children). APS scores are significantly worse for parents of children with

ASD (with 54% of parents with ASD children in the clinical range for this scale, as compared to only 15% of parents without ASD children).

Conclusions: Parent of children with ASD are more likely to report mental health problems and stress, but the existence of a medical home can help moderate the stress associated with parenting.


Caring for a child with disabilities is often costly both monetarily and psychologically. In addition to increased medical, schooling, and therapy costs, families with disabled children may have to reduce time in the labor market and cope with lower incomes in order to provide needed care, affecting their family’s economic stability and their access to health insurance. Maternal stress in particular is higher among mothers of children with developmental disabilities, particularly when child behavior is maladaptive. Research suggests that support mechanisms, such as might be offered by a medical home, can aid in improving parental, and particularly maternal, well-being.

• Decreased Use of the Pediatric Emergency

Department: Just a Phone Call Away

Andrew Racine, M.D., Ph.D., Elizabeth M.

Alderman, M.D., Jeffrey R. Avner, M.D.

Presented By: Andrew Racine, M.D., Ph.D.,

Director, Division of General Pediatrics,

Pediatrics, Albert Einstein College of Medicine /

Children's Hospital at Montefiore, 1621

Eastchester Road, Bronx, NY 10461, Phone: (718)

405-8092, Fax: (718) 405-8091, Email: aracine@montefiore.org

Research Objective: To test whether a follow-up phone call to counsel families about Pediatric emergency department ED use and primary care availability, made by the primary care practice within 72 hours of a Pediatric ED visit, would modify subsequent decisions to seek care in the

Pediatric ED.

Study Design: A longitudinal prospective intervention wherein subjects, who visited a

Pediatric ED from April-December 2005 and received their primary care at any of four pediatric practices associated with an urban academic medical center, were randomized to receive either routine recommendations to follow-up with their primary care practice or to receive an intervention consisting of a follow-up phone call from the primary care practice within

72 hours of the initial Pediatric ED visit. All subsequent visits to the primary care practice, to the Pediatric ED, to pediatric sub-specialists, or for inpatient hospitalization were recorded for each subject during a 300 day follow-up period.

Logistic and OLS regressions were used to estimate unadjusted and adjusted odds ratios and mean number of follow-up visits of various types.

Population Studied: 5,513 subjects aged 0 to 21 years of age who recorded 26,700 follow-up visits during the 300 day study period were tracked. Of the total sample, 34% were African

American, 56% Hispanic, 52% male, and 44% had publicly financed health insurance. The age distribution indicated that 15% were infants, 18% toddlers, 31% adolescents and the remainder school aged. The 50% randomized to the intervention group did not differ from the control subjects in the above parameters

Principle Findings: Compared to control subjects, intervention subjects had lower rates of follow-up Pediatric ED visits (OR 0.88; p<0.001), higher rates of pediatric sub-specialty visits (OR

1.11; p<0.001) and no difference in hospitalizations during the follow-up period.

During weekday office hours, intervention patients had fewer mean number of Pediatric ED visits (1.70 vs. 1.88; p<0.001); higher mean number of pediatric sub-specialty visits (4.8 vs.

3.5; p<0.001) and slightly more hospitalizations

(0.56 vs. 0.51; p<0.03). Mean number of followup primary care visits did not differ between the two groups.

Conclusions: The use of follow-up phone calls from the primary care office to counsel families regarding ED use and primary care availability is a useful tool that can successfully modify subsequent care seeking behavior in pediatric populations.


Follow-up phone calls after an initial emergency department visit represent low cost interventions requiring little modification of existing practice operations that have the potential to generate significant cost savings by modifying subsequent care seeking behavior during episodic illness in pediatric populations.

Funding Source: CWF

•

Why WIC Appears to Improve Birth

Outcomes: Evidence of Gestational Age Bias

Andrew D. Racine, M.D., Ph.D., Theodore J.

Joyce, Ph.D., Christina Yunzal-Butler, M.A.

Presented By: Andrew D. Racine, M.D., Ph.D.,

Director, Division of General Pediatrics,

Pediatrics, Albert Einstein College of Medicine /

Children's Hospital at Montefiore, 1621

Eastchester Road, Bronx, NY 10461, Phone: (718)

405-8092, Fax: (718) 405-8091, Email: aracine@montefiore.org

Research Objective: To estimate the effect of participation in the WIC program on birth outcomes, we compared, among singleton births, the mean birth weight (BW), percent of small for gestational age deliveries (SGA), rates of premature birth (PREM), and rates of low birth weight (LBW) of prenatal WIC enrollees by trimester of enrollment to that of post-natal WIC enrollees.

Study Design: A cross-sectional analysis of data from the Pregnancy Nutrition Surveillance

System was conducted on all singleton live births for which complete information was available. Multivariate OLS and marginal Probit regressions were used to estimate the effect of

WIC, by trimester of enrollment, on mean BW, percent SGA, percent PREM, and LBW rate adjusted for maternal demographics and other program participation characteristics.

Population Studied: All singleton deliveries among WIC participants in North Carolina for the years 1996-2003 (N=356,495). The sample was 45% white, 36% black, and 13% Hispanic;

9% of mothers were under 18 years of age, 53% were between 18 and 24; 26% of mothers had less than high school education.

Principle Findings: Compared to post-partum

WIC enrollees, prenatal participants had 87.2 gm higher mean BW (p<0.01), 0.9% lower percent of SGA deliveries (p<0.01), 3.9% lower rate of

PREM (p<0.01), and 3.2% lower LBW rates

(p<0.01). Compared to post-partum enrollees, adjusted WIC effects for first, second, and third trimester of enrollment respectively were BW increases of 69.6 gms, 75.0 gms, and 130.1 gms

(p<0.01 for all); SGA decreases of 1.3%, 0.7% and 0.5%, (p<0.01 for all); PREM decreases of

2.0%, 2.8%, and 5.5% (p<0.01 for all); and LBW rate decreases of 2.0%, 2.2%, and 4.2% (p<0.01 for all). Thus earlier WIC enrollment produced greater improvements in SGA but later WIC enrollment produced greater improvements in

PREM, BW, and LBW.

Conclusions: These findings suggest that inclusion of third trimester WIC enrollees in cross sectional analyses of WIC effects on birth outcomes introduces a gestational age bias that accounts for much of the program's observed effects on mean birth weight and on the probability of a premature or LBW delivery.


The overall impact of the WIC program on birth outcomes may have been overestimated in previous research. Further careful analysis that takes into account the timing of enrollment may help elucidate the true impact of this important public health initiative on birth weight and prematurity.

Funding Source: U.S.D.A.

• Children Emotional and Behavioral

Problems and Parental Work Decisions

Patrick Richard, M.A.

Presented By: Patrick Richard, M.A., Health

Policy & Management, Johns Hopkins

University, 624 North Broadway, Baltimore, MD

21212, Phone: (240)475-4386, Email: prichar2@jhsph.edu

Research Objective: This study investigated how children with emotional and behavioral problems influence the labor force participation of their single parents, particularly their mothers, compared to how having children with these problems influence the labor force participation their married and cohabitating parents.

Study Design: I used data from the 1997, 2002, and 2003 Panel Study of Income Dynamics

(PSID) core survey and the Child Development

Supplements (CDS I & II) for this analysis. I used several models including exogenous probit, bivariate probit, probit with instrumental variables, and linear probability specifications to account and test for the endogeneity of the child’s health and parental work decisions.

Population Studied: The present study estimated how the caregiver’s rating of the child's emotional and behavioral problems is a predictor of his or her parent’s ability to participate into the labor force. Therefore, the subjects for this analysis consisted of children aged from 3 to 18 years old and their parents.

Separate analyses were conducted by family structure including single, cohabitating and married households.

Principle Findings: Based on preliminary analyses, I found that children with emotional and behavioral health problems have a significant negative effect on parental work decisions, particularly their single mothers.

Conclusions: The results of this study might help policymakers and employers in implementing programs that address the needs of these families while rewarding work habits.

Implications for Policy, Practice or Delivery: It is essential for policymakers and researchers to understand these effects because of the role the parent’s income plays in shaping the child health, educational, and economic trajectories.

This study aims to provide policymakers, employers, and parents with a better understanding of the mechanisms through which the child’s mental illness influences the parent’s ability to work

Funding Source: NIMH, Health Economics

Training Grant

• Addressing Disparities in Maternal and

Child Health Through Interconceptional Care

Margo Rosenbach, Ph.D., Deborah Klein Walker,

Ed.D.

Presented By: Margo Rosenbach, Ph.D., Vice

President, , Mathematica Policy Research, Inc.,

955 Massachusetts Avenue, Suite 801,

Cambridge, MA 02139, Phone: 617-301-8967, Fax:

617-491-8044, Email: mrosenbach@mathematica-mpr.com

Research Objective: The interconceptional period is a critical time to address both medical and social issues that can increase the risk of infant mortality, and particularly those that contribute to disparities in infant mortality.

Interconceptional care services may prevent or treat complications from a recent pregnancy

(such as diabetes or hypertension), as well as reduce the risk of adverse outcomes in subsequent pregnancies (such as low birthweight and preterm delivery). This study describes the services provided by Healthy Start grantees to women and infants during the interconceptional period.

Study Design: This study is based on a national survey of Healthy Start program directors. The survey was conducted in 2004. The survey asked about the nine core components of

Healthy Start programs (including interconceptional care). Responses were submitted electronically. Of the 96 programs, 95 participated in the survey. This is the first national survey of the HRSA-funded Healthy

Start program and the first survey to examine the provision of interconceptional services to highrisk women and their infants.

Population Studied: The national Healthy Start program is comprised of 96 programs in highrisk communities with significant disparities in infant mortality. Program directors from 95 of the 96 programs responded to the survey.

Principle Findings: Most programs provided education about the importance of interconceptional care (98%), family planning counseling (97%), postpartum needs assessments (94%), and counseling about the use of folic acid (90%). Grantees were less likely to offer interconceptional services that addressed medical risk factors: hypertension follow-up

(74%), diabetes follow-up (73%), and obesity reduction (71%). Most grantees had procedures in place to track whether interconceptional care clients------both women and infants------received recommended care (such as a postpartum visit within six weeks or a newborn visit within one

month). The content of care varied according to the case management staffing arrangement.

Programs with lay/paraprofessional case management staff were significantly less likely than programs with other case management staffing arrangements (social work, nursing, multidisciplinary) to provide postpartum needs assessments, counseling about the use of folic acid, smoking cessation/reduction, and obesity reduction. In addition, they were less likely to provide follow-up services for these medical conditions.

Conclusions: Interconceptional care is an integral part of Healthy Start services. The grantees are providing a wide range of services to address women’s and infant’s health needs during the interconceptional period. Fewer grantees, however, addressed weoment’s medical risk factors. In addition, variation was observed by case management staffing arrangements. While lay/paraprofessional case managers are important to ensuring the cultural competence of Healthy Start programs, they are less likely to provide services that may address women’s health issues.


The interconceptional period provides an opportunity to address women’s acute and chronic medical issues (such as hypertension, diabetes, and obesity), as well as educate them about important practices that can improve the outcome of subsequent pregnancies (such as taking folic acid, quitting smoking, and maintaining at least two years between pregnancies). Variation across Healthy Start programs, especially by staffing arrangement, suggests the need for additional training and development of protocols about evidence-based interconceptional care practices.


•

Does Prenatal Care Improve Utilization of

Well-Baby Care?

Karen Sautter, M.P.H., Priscilla Canny, Ph.D.,

Amanda Learned, B.A., Mary Alice Lee, Ph.D.

Presented By: Karen Sautter, M.P.H., Project

Manager, Health Policy and Management,

Boston University School of Public Health, 715

Albany Street, T5-West, Boston, MA 02118,

Phone: (781) 424-1477, Fax: (617) 638-5374,

Email: ksautter@gmail.com

Research Objective: To determine the relationship between prenatal care and well-baby care for infants born to mothers in a Medicaid managed care program.

Study Design: This study used a cross-sectional retrospective cohort design with bivariate and multivariate analyses to determine whether an association exists between early and adequate prenatal care and receipt of well-baby care.

Potential confounding variables included in the analysis were maternal age, race/ethnicity, education, residence, primary language, managed care plan, and smoking, and birth plurality and birthweight. Birth data were matched with Medicaid managed care enrollment data to identify mothers who were enrolled in Connecticut’s Medicaid managed care program when they gave birth in 2003.

Maternal Medicaid managed care enrollment data were then linked with enrollment data for infants and their healthcare encounter records.

The analytic file was restricted to infants who were continuously enrolled for the first 15 months of life. The association between prenatal care utilization (early prenatal care, adequate prenatal care) and having had 6 recommended well-baby visits, adjusted for independent variables, was determined using logistic regression. Significant statistically relationships are reported at the p<0.05 level.

Population Studied: 7,054 infants born in 2003 to mothers in Medicaid managed care and subsequently enrolled for the first 15 months of life.

Principle Findings: Just over half (55%) of the infants received the 6 recommended well-baby visits in the first 15 months of life. Bivariate analysis revealed that infants whose mothers initiated early prenatal care (e.g., first trimester) were more likely to receive recommended wellbaby care. Similarly, infants with adequate prenatal care were more likely to receive recommended well-baby care. Factors also associated with increased risk for not having recommended well-baby care included younger maternal age, non-White non-Hispanic race/ethnicity, less than a high school education, urban residence, and switching managed care plan. After adjusting for these potential confounders, no statistically significant relationship between early prenatal care and wellbaby care was found (OR=1.06; 95% CI=0.91-

1.21). However, having had adequate prenatal care increased the odds of having recommended well-baby care in the multivariate model

(OR=1.36; 95% CI=1.21-1.53).

Conclusions: Prenatal care utilization measures can identify which infants are at risk for receiving less than recommended well care during the early months of life.


Prenatal case management can be reconceptualized as just the first step in a continuum of care coordination for new mothers and babies. Linking birth certificate data to

Medicaid administrative data is an effective tool for identifying risk factors for less-thanrecommended care.

Funding Source: Connecticut Department of

Social Services

• Factors Associated With Adolescents'

Mental Health Access and Patterns of

Utilization

Nancy Scotto Rosato, Ph.D., Judith Baer, Ph.D.

Presented By: Nancy Scotto Rosato, Ph.D.,

Senior Research Analyst, Center for State Health

Policy, Rutgers University, 55 Commercial

Avenue, New Brunswick, NJ 08901, Phone: (732)

932-4648, Fax: (732) 932-0069, Email: nscottorosato@ifh.rutgers.edu

Research Objective: Epidemiological studies have found a large gap between mental health need and actually obtaining services by children and adolescents. According to the 2001 Surgeon

General’s Report on children’s mental health,

20% of children needed mental health care but only a small percentage of these children were receiving appropriate care. These statistics are particularly disconcerting when expansions of federal programs such as systems of care were initiated to improve access and services to children. The question then remains about barriers to children and adolescents accessing services, especially continued services.

Basing the conceptual framework on the Helpseeking Decision-Making model and extending it to include outcomes in help seeking (i.e., continued or stopped), the present study addresses the following: oWhat individual and environmental factors influence youth’s mental health utilization? oGiven their entry into care, what service settings were utilized?

Study Design: The present study used an ex post facto design. Previously collected data from the National Longitudinal Study of Adolescent

Health (Add Health) was used to test the hypotheses. A latent class analysis was conducted to derive categories of symptomatology and several multivariate logistic regressions were performed to measure the factors that predicted one time care, continued care, and two service settings: schools and physician’s office. Although the Add Health includes information by several sources, the present study relied primarily on information from the youth’s in-home questionnaires from

Wave I and Wave II.

Population Studied: A nationally representative sample of youth between the ages of 11 and 21 were included in this study.

Principle Findings: From the latent class analysis, four classes of symptomatology emerged: internalizing symptoms, externalizing symptoms, a combination of both (i.e., most severe), and a normative class. These classes varied by race and ethnicity, gender, and age.

Youth in all three symptomatology classes were more likely to access and continue mental health care. Results from the multivariate logistic regressions examining one time care, continued care, and service setting showed that several individual and environmental level factors (i.e., parent characteristics, race/ethnicity, gender, and provider availability) were associated with mental health utilization. Furthermore, youth who accessed care were more likely to do so at school and a doctor’s office. African-American,

Hispanic, and poor youths were more likely to obtain care at school.

Conclusions: An apparent racial and ethnic disparity exists for youth most in need of mental health care, particularly in continuing care.

Additionally, minority youth were less likely to obtain care in specialty care settings such as a physician’s office.


There are several programmatic and policy implications. Minority youth in need of mental health care clearly need to be reached and this could be done through schools. Schools played a central role in obtaining mental health care for younger youth and this was particularly true for racial and ethnic minorities. However, since the question of whether schools are appropriate locations for mental health care is still debated, there is a need for policy changes that would ensure quality care and a standardization of services in school mental health clinics.

• Health Status and Health Care

Expenditures in a Nationally Representative

Sample: How Do Overweight and Healthy-

Weight Children Compare?

Asheley Cockrell Skinner, B.S., Michelle L. Mayer,

Ph.D., M.P.H., Kori Flower, M.D., M.S., M.P.H.,

Morris Weinberger, Ph.D.

Presented By: Asheley Cockrell Skinner, B.S.,

Health Policy and Administration, The University of North Carolina at Chapel Hill, CB 7411, Chapel

Hill, NC 27599, Phone: 336-392-5021, Email: asheley@unc.edu

Research Objective: Childhood overweight is an epidemic in the US. Overweight children are at increased risk for chronic disease, poorer health status as a child, and are more likely to be overweight or obese as an adult. To our knowledge, the prevalence of these conditions has not previously been established in a nationally representative sample. A more complete understanding of the effect of overweight on children’s health requires a nationally representative, population-based sample. Specifically, we examine whether, compared to healthy-weight children, overweight children have: 1) a higher prevalence of selected chronic conditions (hypertension, dysglycemia, and hyperlipidemia); 2) poorer health; and 3) greater health care expenditures.

Study Design: Cross-sectional study. Chronic conditions were measured as the prevalence of dyslipidemina, hyperglycemia, and hypertension; health was assessed as self-reported health status, school days missed due to illness or injury, and functional status; and health care expenditures. Using body mass index, we classified children as overweight (> 95th percentile), at risk for overweight (=85th - <95th percentiles), and healthy weight (=5th - <85th percentile); because children with a body mass index <5% may have underlying malnutrition and/or medical conditions, they were excluded from all analyses.

Population Studied: Children aged 6-17 participating in one of two nationally representative surveys of civilian, noninstitutionalized Americans: the 2001-2002

National Health and Nutrition Examination

Survey (NHANES) and the 2002 Medical

Expenditure Panel Survey (MEPS).

Principle Findings: Overweight children, compared to healthy-weight children, have significantly (p<0.05) increased risk for high total cholesterol (15.7% vs. 7.2%), high (11.4% vs.

7.7%) or borderline LDL cholesterol (20.2% vs.

12.5%), low HDL cholesterol (15.5% vs. 3.0%), high triglycerides (6.7% vs. 2.1%), high fasting glucose (2.9% vs. 0.0%), high glycohemoglobin

(3.7% vs. 0.5%), and high systolic blood pressure

(9.0% vs. 1.6%). Overweight children, compared to healthy-weight children, demonstrate significantly (p<0.01) lower prevalence of excellent health (NHANES, 36.5% vs. 53.3%;

MEPS, 42.8% vs. 55.6%). Compared to healthy weight children, overweight children are less likely to have any health care expenditure

(OR=0.7, p<0.01); this difference does not remain after adjusting for socioeconomic status

(aOR=0.9, p=ns).

Conclusions: Our data suggest that overweight children have more chronic conditions, poorer health, and greater health care expenditures than healthy weight children. Strategies must be developed to increase access to care and physician recognition of overweight and related chronic conditions.


To address the gap between the care needed to address chronic conditions and poor health, and the care overweight children actually receive, it may be beneficial to consider designating overweight children as CSHCN. Including overweight children under the umbrella of

CSHCN is one potential strategy for highlighting the chronic nature of overweight for clinicians, improving access to care, and enhancing health care resources available to overweight children.

Such strategies to address overweight during childhood are critical to prevent chronic conditions, improve health status, and reduce health care expenditures, both during childhood and into adulthood.


• Changes in Access to Primary Care for

Children in California: How Do the Most

Vulnerable Fare?

Gregory D. Stevens, Ph.D., M.H.S., Michael Seid,

Ph.D., Michael Cousineau, Dr.P.H., Kai-Ya Tsai,

M.S., Kyoko Rice, M.S.

Presented By: Gregory D. Stevens, Ph.D.,

M.H.S., Assistant Professor of Research,

University of Southern California Department of

Family Medicine, Center for Community Health

Studies, 1000 S. Fremont Avenue, Unit #80,

Alhambra, CA 91803, Phone: 626-457-4049, Fax:

626-457-5858, Email: gstevens@usc.edu

Research Objective: Recent trends in California, including rising poverty and immigration rates, and decreasing employer-sponsored insurance, may impact children’s access to needed primary care over time. This study examines population changes (2001 to 2003) in child access to care in

California, the contributions of changes in insurance coverage and other factors to changes in access, and variations in impact for more and less vulnerable children.

Study Design: Cross-sectional data on children from 2001 and 2003 are used to assess 1) population changes in risk factors for poor access to care (poverty status, uninsured status,

low parent education, non-English language), 2) changes in general health status and primary care access (physician and dental visits in the past year, regular source of care), and 3) the relationship between the them.

Population Studied: Children 0-19 years of age from the 2001 (n=19,771) and 2003 California

Health Interview Survey (n=13,544).

Principle Findings: Significant improvements were found in reports of excellent/very good health status (+6.3 percentage points for adolescents, CI: 2.3-10.3) and both physician visits (+1.5, CI: 0.1-3.0) and dental visits (+6.3, CI:

4.1-6.4) from 2001 to 2003. Among adolescents, significant decreases were found in having a regular source of care (-4.6, CI: 1.6-4.4) and in surety in accessing care (-5.6, CI: 2.1-9.2).

Contrary to our expectations, these changes in health status and primary care experience were unrelated to significant changes from employerbased insurance to public coverage, a decrease in the uninsured rate, or increases in the prevalence of non-English speaking families, or any other risk factors. This study further finds that higher risk children (i.e., those living in poverty, enrolled in Medicaid, etc.) were more likely to experience improvements in health status and primary care access, and were less likely to experience a decrease in having a regular source of care or surety in access.

Conclusions: This study suggests that some non-trivial improvements in children’s health status and access to care occurred in California between 2001 and 2003. These occurred despite a significant decline in private insurance coverage, but were surprisingly not explained by a concomitant increase in the public coverage rate or decrease in the uninsured rate.


Because the most vulnerable children (including those in poverty and those covered by Medicaid) fared particularly well with respect to changes in access during this period, this suggests that

California may be making important, and potentially replicable, strides in improving access to care for the most vulnerable children through mechanisms other than just increasing insurance coverage. New quality monitoring initiatives that were implemented for Medicaid enrollees in California between 2001 and 2003 may a potential factor, and deserve additional study.

Funding Source: California Program on Access to Care, University of California Office of the

President

• Quality Assessment in California's Child

Health Insurance Expansions

Gregory Stevens, Ph.D., M.H.S., Gregory D.

Stevens, Ph.D., M.H.S., Em Arpawong, M.P.H.,

Lori Miller Nascimento, M.P.H., Michael R.

Cousineau, Dr.P.H.

Presented By: Gregory Stevens, Ph.D., M.H.S.,

Assistant Professor of Research, University of

Southern California Keck School of Medicine,

Center for Community Health Studies, 1000 S.

Fremont Avenue, Unit #80, Alhambra, CA 91803,

Phone: 626-457-4049, Fax: 626-457-5858, Email: gstevens@usc.edu

Research Objective: Federal and state governments have restrictions that limit their ability to provide health insurance coverage to subgroups of uninsured children (including the undocumented). Consequently, an increasing number of California counties are forming children's health initiatives (CHIs) to expand coverage, usually via comprehensive health insurance products known as Healthy Kids programs. The study aimed to evaluate the quality of care provided to the nearly 90,000 children enrolled in these Healthy Kids programs.

Study Design: A set of ten well-validated quality indicators was selected for assessing the quality of care delivered to Healthy Kids enrollees.

These included preventive care visits on schedule, physician and dental visits, emergency room use, asthma medication use and others.

The health plans serving the CHIs were asked to provide detailed data for each of the indicators, including comparison data for their Medicaid and State Children's Health Insurance Program

(SCHIP) enrollees.

Population Studied: Eight CHIs (n=8), representing eleven of California’s largest counties, that were operational during all of 2005 were asked to provide the quality data. These data are compared across counties, and compared with Medicaid and SCHIP counterparts, as well as to state benchmarks.

Principle Findings: All CHIs responded, but with varying levels of data completeness due to differing abilities and resources to collect and report each indicator. For most indicators that were reported by CHIs, however, Healthy Kids scores were similar to Medicaid and SCHIP scores. For example, only two CHIs reported

Healthy Kids well adolescent visit rates that were less than the statewide Medicaid benchmark comparison of 37% (18% and 23%). The remaining responding CHIs reported well

adolescent visit rates equal to or greater than the statewide Medicaid rate.

Conclusions: While there were major variations in reporting data and quality, this initial study suggests that Healthy Kids programs are assuring access to care and quality for children at a level similar to that provided by Medicaid and SCHIP, despite serving a population of primarily undocumented immigrant children who have previously experienced substantial barriers to accessing health care.


County initiatives are helping to close the gap in health insurance coverage in California.

Assessing the quality outcomes of these programs is difficult given local operational variations. A coordinated evaluation at the State level may bring some standardization in the future and improve the state's ability to estimate the contribution of these programs to improved quality and health outcomes.

Funding Source: The California Endowment and

First 5 California

•

Effect of Recent State Policies

(SCHIP/Medicaid Expansions, Welfare

Reform and EITC) on Child Health and Health

Care Use

Maki Ueyama, B.A., Kosali Simon, Ph.D.

Presented By: Maki Ueyama, B.A., PhD candidate, Dept of Policy Analysis and Mngmt,

Cornell University, MVR Hall, Ithaca, NY 14850,

Phone: 607 255 7103, Fax: 607 255 4071, Email: mu24@cornell.edu

Research Objective: To examine the effect of state-level social assistance policies on child health and health care use. Specifically, we use the restricted-access version of 1990-2002

National Health Interview Survey to study the impact of SCHIP/Medicaid, welfare reform, and the Earned Income Tax Credit on children.

Study Design: To examine the impact of

Medicaid/SCHIP expansions on children, we use an instrumental variables approach, instrumenting for Medicaid participation and eligibility with an index of state Medicaid/SCHIP generosity created from Current Population

Survey (CPS) at the state/age/year level. We do this both at the child level as well as the family level, as making a larger fraction of the family eligible may have considerable spillovers. We first estimate the effect of any public health insurance eligibility on health insurance status to compare the effect with that reported in other data sets. We then estimate the effect of public health insurance participation (instrumented in the same manner described above) on children’s use of health care and health status (eg. a parental report of child’s health, whether the child has any limitation of activity, number of doctor visits in past 12 months, number of school days lost to illness in past 2 weeks and 12 months, and a dummy indicating whether the child needed prescription drugs but could not get them in past 12 months). To examine the effects of welfare reform, we use a treatment and control group approach to study the health and health care outcomes for children of single lowskilled mothers before and after welfare reform relative to children of married mothers. In the case of the EITC we take advantage of withinstate changes over time in the generosity of state

EITC supplements, as well as the fact that children in different families (married vs. single for example) are differentially affected by these supplements.

Population Studied: Low-income children

Principle Findings: Our preliminary analysis shows that public insurance eligibility increased for all children from 1997-2002; eligibility increased especially between 1998 and 1999 with the greatest increase for children ages 6-19. We also find a greater increase in public insurance among children living at 100-200% of the

Federal Poverty Line, particularly among older children.

Conclusions: This study adds to our understanding of the effects of important social assistance programs on children’s health. In particular, we examine both parents’ and children’s public health insurance eligibility and participation using more recent data, as well as focus on children’s health status and other health-related outcomes.


The U.S. has seen a slow improvement in child health over the past several decades (FIFCFS

2004). Although the health gap between low- and high-income children decreased slightly over the years, low-income children remain consistently and considerably less healthy compared to high-income children (FIFCFS

2004). In light of this, it is critical to understand how changes in social welfare policies during the

1990s may have influenced child health.

•

Strategies for Improving Access to

Comprehensive Obesity Prevention and

Treatment Services for Medicaid-Enrolled

Children

Sara Wilensky, J.D., M.P.P., Ramona Whittington,

Sara Rosenbaum, J.D.

Presented By: Sara Wilensky, J.D., M.P.P.,

Assistant Research Professor, Health Policy,

George Washington University, 2021 K Street,

NW - Suite 800, Washington DC, DC 20006,

Phone: (202) 530-2359, Email: wilensky@gwu.edu

Research Objective: This policy brief is a followup to our initial Robert Wood Johnson report that evaluated the role of public and private insurance in financing preventive care and treatment for at-risk and obese children. One of the key findings from that report was that

Medicaid’s existing Early and Periodic Screening

Diagnostic and Treatment (EPSDT) coverage standards provide for comprehensive, obesityrelated pediatric health care interventions. This report examines the extent to which state

Medicaid programs currently use EPSDT benefits to address and finance obesity-related services that advance best-practice standards in obesity prevention, treatment and management in children.

Study Design: We reviewed the current standard of care for childhood obesity prevention and treatment, payment policies and information provided by states Medicaid programs to providers about childhood obesity prevention and treatment (in both managed care and feefor-service settings), and medical procedure coding through CPT-4 and HCPCS coding systems.

Population Studied: Medicaid programs/Medicaid-enrolled children.

Principle Findings: 1. Existing state EPSDT coverage and payment policies suggest that state

EPSDT operational standards generally do not focus on obesity as a specific focus of pediatric intervention activities to be encouraged and supported. 2. A review of available Medicaid managed care contracts suggests that contractual requirements generally do not highlight obesity prevention and treatment strategies in reference to EPSDT standards or performance measurement requirements. 3.

Several states have taken important steps to use

EPSDT coverage standards to incentivize best practices among pediatric health professionals and providers. 4. A review of state EPSDT billing, coding, and payment practices underscores that existing billing codes permit coverage of all procedures and interventions essential to high quality obesity-prevention pediatric practice.

Conclusions: Medicaid is currently wellequipped to tackle the childhood obesity problem if states take advantage of the opportunities available to them. Our specific recommendations to state Medicaid programs include: 1. Clarify the application of obesity prevention and treatment guidelines as part of the EPSDT benefit for children and adolescents;

2. Clarify proper coding and payment procedures for obesity prevention and treatment services; 3.

Bundle obesity prevention and treatment services into a single package following a disease management model.


The significant and rising level of childhood obesity in this country gives rise to numerous negative consequences in terms of the health status of individuals and financial costs to individuals, government, providers and society as a whole. Medicaid providers frequently report barriers to receiving payment when treating children for obesity-related conditions. This report provides specific steps state Medicaid programs may take to alleviate this critical obstacle to preventing and treating childhood obesity.


• Does Public Insurance Provide Better

Financial Protection Against Rising Health

Care Costs for Families of Children with

Special Health Care Needs?

Hao Yu, Ph.D., Andrew Dick, Ph.D., Peter

Szilagyi, M.D., M.P.H.

Presented By: Hao Yu, Ph.D., Associate Health

Policy Researcher, RAND Corporation, 4570 Fifth

Avenue, Pittsburgh, PA 15213, Phone: (412)683-

2300 ext4460, Fax: (412)683-2800, Email: hao_yu@rand.org

Research Objective: 1) To examine how the growth of health care costs affected financial burden for families of children with special health care needs (CSHCN) between 2001 and

2004; and 2) To determine the extent to which health insurance coverage protected families of

CSHCN against financial burden.

Study Design: Data are from the national

Medical Expenditure Panel Survey (MEPS) 2001-

2004. The unit of analysis is the family. The main outcome is financial burden, defined as the proportion of family income spent on out-ofpocket (OOP) health care expenditures for all family members, including OOP costs and premiums. Family insurance coverage is classified as (1) all members publicly insured, (2) all members privately insured, (3) all members uninsured, (4) partial coverage, and (5) a mix of public and private with no uninsured periods.

In addition to bivariate analyses, we estimated two logistic regression models to determine the probability that a family’s financial burden exceeded 10% or 20% of family income.

Population Studied: 5,196 families of CSHCN.

Principle Findings: An upward trend in financial burden for families of CSHCN occurred and was associated with growth of economy-wide health care costs. A multivariate analysis indicated that, given the economy-wide increase in medical costs between 2001 and 2004, a family with

CSHCN was at increased risk in 2004 for having financial burden exceeding 10% of family income

(OR=1.39, P<0.01). Similar findings were noted for financial burden exceeding 20% of family income. Over 15% of families with public insurance spent >10% on financial burden, compared with 20% of families with private insurance. After controlling for covariates, publicly insured families of CSHCN had significantly lower likelihood of financial burden

>10% or 20% of family income than privately insured families.

Conclusions: Rising health care costs increased financial burden on families of CSHCN in 2001-

2004. Public insurance coverage provided better financial protection than private insurance against the rapidly rising health care costs for families of CSHCN.


Continuation of the broad benefits provided by public insurance programs is important to protect enrolled CSHCN and their families from the high costs of health care.

Caution should be exercised with policy recommendations to increase cost-sharing for the publicly insured families, which could leave those families at risk for high OOP costs, especially in the current period of rapid health care costs growth. Our results also support the concern that rising medical costs are reducing the protection afforded by private insurance coverage. The privately-insured families may be at increased risk for financial burden as employers would adjust to higher health care costs in the coming years by shifting more of the burden to their employees. Finally, our finding of the positive association between the growth in economy-wide health care costs and financial burden on families suggests that rising overall medical costs are reducing the protection afforded by insurance coverage, either private or public. Unless health care costs are controlled, financial protection from health insurance will likely continue to deteriorate for families of

CSHCN.

Funding Source: RAND Corporation

Comparative Effectiveness &

Technology Assessment

• Using New Modeling Approaches to

Casefinding: HIV in the VHA

Candice Bowman, Ph.D., R.N., Tamara

Slipchenko, Ph.D., Catherine Sugar, Ph.D.,

Yuexin Chen, M.S., Lisa Backus, M.D., Ph.D.,

Allen Gifford, M.D.

Presented By: Candice Bowman, Ph.D., R.N., investigator, Health Services Research &

Development, VA San Diego Healthcare System,

3350 La Jolla Village Drive (111N-1), San Diego,

CA 92161, Phone: (858)552-8585 x5967, Fax:

(858)552-4321, Email: candice.bowman@va.gov

Research Objective: There is an expanding interest in assembling system-wide disease registries with the increasing availability of electronic medical records. Such registries are useful tools for tracking quality, although generally dependent upon simple capture rules that use only disease-specific information, which may miss actual cases. Therefore, we sought to develop and test empirically-derived quantitative algorithms for identifying HIV-infected persons within the VHA system and compare performance to a reference model using only

HIV-specific ICD-9 codes.

Study Design: We built logistic regression (LR), decision tree (DT), and neural network (NN) models in SAS v.9.1.3 using 123 variables derived from several merged VHA databases as inputs.

Because an even sample of ‘‘gold standard’’ true positives (TPs) and true negatives (TNs) based on laboratory results was used in model development, we incorporated population priors and corresponding decision weights to achieve conforming population models. Error rates and

Receiver Operating Characteristic (ROC) curve indices were used for model comparisons.

Population Studied: 4.97 million VHA patients with at least one outpatient or inpatient encounter between 6-1-04 and 5-31-05.

Principle Findings: All of our models outperformed the reference model (RM).

Adjusted false negative (FN) and false positive

(FP) rates for each of our best models were (FN rate/FP rate, variables selected at p =0.5): Full

LR, 0.014/1.137, 22; Stepwise LR, 0.016/0.536, 21;

DT-Boosted, 0.012/1.167, 44; NN-3 neurons,

0.016/0.515, 24; NN-3 neurons, 0.13/0.987, 54; compared to RM, 0.022/0.086, 1. All ROC

indices for our models were significantly better than the RM at the 95% level. Examples of non-

HIV-specific variables selected by our models included age, race/ethnicity, marital status, service-connected disability, number of days hospitalized, number of primary care and social work visits, number of total and lipids lab tests, and blood pressure and liver co-morbidities.

Conclusions: We were able to demonstrate improved casefinding performance using sophisticated modeling methods compared to a simple reference model of HIV-specific diagnostic codes by using additional variables available in VHA data. The next step will be to score the entire cohort based on calculated probabilities to find cases with elevated probability of disease not identified by the reference model.


An improved HIV casefinding algorithm, in terms of accuracy and clinical policy priorities, may serve as a practical tool for improving a disease registry for HIV care management.

However, similar approaches can be used in developing other disease registries where clinical data are electronically available.

Funding Source: VA

• Cost Effectiveness of a Genetic Test for

Susceptibility to Lung Cancer

Paul Brown, Ph.D., Jane Willingale, MPH, Robert

Young, M.D.

Presented By: Paul Brown, Ph.D., Senior Health

Economist, School of Population Health,

University of Auckland, Private Bag 92019,

Auckland, 0005, New Zealand Phone: 64-9-373-

7599, Fax: 64-9-373-7503, Email: pm.brown@auckland.ac.nz

Research Objective: While annual CT screening has been shown to be effective in detecting early stage lung cancer in smokers over aged 55, the cost of offering CT screening has been seen as prohibitive. However, a genetic test has recently been developed that identifies individuals at low risk of developing lung cancer. This new technology might be used to identify smokers not at-risk of developing lung cancer, thereby reducing the number required to receive annual

CT screening. This paper examines whether using genetic tests in conjunction with CT screening for at-risk smokers is cost effective when compared with no CT screening or CT screening for all at-risk smokers.

Study Design: A Markov model was developed to assess the number of early stage lung cancers that would be detected and the associated costs under three scenarios: No CT screening for asymptomatic smokers, annual CT screening for smokers aged 55 and over, and CT screening for smokers aged 55 and over who are identified at risk by a genetic test. The outcome variables are early detection of lung cancer and life expectancy. The costs include the cost of the genetic test, the cost of annual CT screening, and the cost of treating early and late stage lung cancer. Data from published studies is used to populate the model.

Population Studied: All smokers aged 55 and over in the US assuming the introduction of an opportunistic screening programme. Disease occurrence in the cohort is projected over 25 years.

Principle Findings: Assuming that 30% of individuals receiving a genetic test are shown to be not susceptible to lung cancer and that 1% of those who test negative will develop lung cancer, then the use of the genetic test will be associated with a greater overall cost than with no testing, but will lead to more early detections and improved health outcomes. When compared with a screening program for all smokers over aged 55, the use of the genetic test will result in slightly more early stage lung cancers, but at a lower overall cost. The cost of the genetic test is expected to be offset within two years of introduction of the screening program for the cohort.

Conclusions: The use of genetic tests in conjunction with CT screening is cost effective when compared with no CT screening or CT screening for all smokers over age 55.


The results suggest that a genetic test might e a cost effective technology for identifying individuals at a higher risk of developing lung cancer. However, the implementation should be viewed with caution. It is unclear what the behavioural response to the genetic information will be from smokers and non-smokers. For instance, if a negative test results in increased smoking by individuals who test negative for a genetic predisposition to lung cancer, then it might lead to an increase in other negative health impacts from smoking (e.g., cardiovascular risk) that would outweigh any potential gains from screening. This highlights the importance of understanding the behavioural response to the genetic information before drawing conclusions regarding the overall impact.

• The Cascade Effect: A Potential Cause for the Rapid Increase in the Use of Coronary

Stents?

R. Adams Dudley, M.D., M.B.A., Rita F. Redberg,

M.D., M.Sc., R. Adams Dudley, M.D., M.B.A.

Presented By: R. Adams Dudley, M.D., M.B.A.,

Associate Professor of Medicine and Health

Policy, Institute of Health Policy Studies,

University of California, San Francisco, 3333

California Street, Suite 265, San Francisco, CA

94118, Phone: (415) 476-8617, Fax: (415) 476-

0705, Email: adams.dudley@ucsf.edu

Research Objective: Percutaneous coronary intervention (PCI, or coronary stenting) is performed in patients with asymptomatic coronary artery disease, despite evidence that such interventions offer no mortality benefit and may reduce quality of life. Physician judgment is a key input into the decision to perform PCI.

Our objective was to examine the beliefs, current practices, and decision making of primary care physicians and cardiologists in California with respect to the pathway to elective PCI.

Study Design: We conducted a qualitative study using six focus groups consisting of 38 primary care physicians and 20 interventional and noninterventional cardiologists from around the state of California. Participants discussed issues surrounding PCI using hypothetical case scenarios. Transcripts and observational notes were analyzed according to the principles of grounded theory.

Population Studied: Primary care physicians, interventional and non-interventional cardiologists.

Principle Findings: Both primary care physicians and cardiologists believed that once a patient had a high calcium score or a positive test for coronary artery disease, even if asymptomatic, the patient entered a clinical cascade that ultimately led to percutaneous coronary intervention if a lesion was found during catheterization. Reasons given for performing a cardiac catheterization and PCI as follow up to a positive non-invasive test in asymptomatic patients included relief of patient anxiety, physician's intolerance of uncertainty, fear of missing a lesion, anticipatory guilt if no intervention was done and a cardiac event subsequently occurred, and medicolegal liability of not pursuing further testing and treatment.

Primary care physicians also cited a lack of knowledge of the latest evidence for treatment and anxiety about positive test results as reasons for further diagnostic testing and referral, and did not participate in the decision making process after referral. Cardiologists believed that once a patient was referred to them, the patient and the referring physician expected further testing and intervention if an amenable coronary lesion was found. Cardiologists also believed

PCI benefited asymptomatic patients, despite acknowledging that the available evidence shows

PCI does not decrease risk of future myocardial infarction or death in such patients.

Conclusions: The widespread use of PCI in patients with asymptomatic coronary artery disease ---- despite evidence that such interventions offer no clinical benefit ---- appears to be the result of a cascade effect of positive initial imaging or stress testing leading to more testing and procedures. Emotional and psychological factors, along with beliefs about expectations from patients and other providers, greatly influence physician decision making.


These findings call into question the current paradigm of technology assessment and evidence dissemination driving changes in clinical processes.

Funding Source: Blue Shield Foundation of

California

• Comparative Effectiveness of Alternative

SSRI Treatments

Dominick Esposito, Ph.D., Peter Wahl, M.S.,

Gregory Daniel, Pharm.D., Michael A. Stoto,

Ph.D., M. Haim Erder, Ph.D., Thomas W.

Croghan, M.D.

Presented By: Dominick Esposito, Ph.D.,

Researcher, Mathematica Policy Research, PO

Box 2393, Princeton, NJ 08543, Phone: 609-799-

3535, Email: desposito@mathematica-mpr.com

Research Objective: Previous research has shown significant within class differences among antidepressant medications. The purpose of this project was to determine the effectiveness of the antidepressant escitalopram compared to generic antidepressants.

Study Design: We used propensity score weighted logistic regression to assess the effect of antidepressant choice on the likelihood of continuing initial antidepressant treatment after two and six months. We first modeled the propensity to initiate treatment with escitalopram based on demographic, diagnostic, insurance, and service use characteristics in the six months prior to treatment, and the results of this analysis were used to calculate weights for analysis of treatment continuation. The primary

outcome measure was receipt of two prescriptions of the index drug in the two months and four prescriptions in the six months following initiation of treatment. In addition to antidepressant choice, cost and service use characteristics during the treatment period were included as covariates.

Population Studied: The study population included 43,921 patients in six health plans across the US who initiated treatment with escitalopram or a generic SSRI (citalopram, fluoxetine, or paroxetine) between July 1, 2002 and July 1, 2005. To be included in the study, patients must have had at least one claim for a depressive disorder and to have initiated treatment following a period of at least six months during which there was no evidence of antidepressant treatment. Those with claims for bipolar disorder or treatment with antipsychotic medications were excluded from the analysis.

Principle Findings: Use of escitalopram was predicted by age between 36 and 64 years; costs of non-antidepressant psychotropic medications and receipt of specialty mental health care or anxiolytic medications in the 6 month preperiod; and a diagnosis of major depression.

Comorbid anxiety or obsessive-compulsive disorder and Medicare plan type predicted use of a generic antidepressant. Sex, diagnosis of dysthymia or comorbid panic disorder, chronic disease score, and plan type other than Medicare had no significant effect on antidepressant selection. After adjusting for the propensity to receive escitalopram, escitalopram users were 30 percent more likely to remain on treatment after

2 months (Odds Ratio=1.296, 95% Confidence

Interval 1.244-1.350) and 17 percent more likely to remain on treatment after 6 months (OR=1.165,

CI 1.100-1.234) compared to those initiating treatment on a generic antidepressant. Each dollar increase in antidepressant copayment was associated with a 2.4 percent reduction in continuation (OR=0.976, CI 0.974-0.979).

Receipt of any mental health care after initiating an antidepressant was associated with a 22 percent reduction in continuation (OR=0.780, CI

0.727-0.836).

Conclusions: After adjusting for selection effects, choice of escitalopram was associated with continuing treatment after 2 and 6 months, while higher copayments and mental health specialty care were associated with discontinuation.


Despite significant attention and advances in treatment, adherence to antidepressants remains poor. In this study, we found that selection of a branded antidepressant was associated with higher continuation rates while higher copayments were associated with lower continuation rates. These findings should be considered in formulary and reimbursement decisions for antidepressants.

Funding Source: Forest Laboratories

• Addressing Regression to the Mean in a

High-Cost Population: Toward an Accurate

Method for Determining Cost Outcomes in

Studies of Innovative Care Strategies in the

Chronically Ill Population

Joe Gifford, M.D., Al Lewis, J.D.

Presented By: Joe Gifford, M.D., Chief Medical

Officer, Health Services, Regence BlueShield,

1800 Ninth Avenue, Seattle, WA 98101, Phone:

(206) 332-5146, Fax: (206) 292-9935, Email: jgifford@regence.com

Research Objective: A variety of studies are currently underway to address the policy interest in improving care for the chronically ill by providing innovative models of care delivery.

From commercial disease management approaches to re-engineered clinical settings, from the use of new clinical information technologies to home monitoring devices, all these approaches need to demonstrate improved quality and lowered costs of care for their populations. Evaluating the cost behaviors of the treatment arm of these studies is difficult, as control groups are often not available and never precisely matched. Measurements of costs of care usually begin with the known costs of a baseline year followed by an evaluation of the observed costs during a treatment year.

Unfortunately these costs usually go down of their own accord, in a phenomenon commonly described as Regression to the Mean (RTM).

To assist cost-analysis of these studies, we undertook to precisely quantify the Regression to the Mean effect in two dimensions: according to clinical illness category (e.g. heart disease vs. asthma) and according to decile of illness burden (e.g. in the sickest 2% to the sickest 30% of a population). For the relevant clinical intervention studies, observed costs then can be compared to expected costs adjusted for

Regression-to-the-Mean on one of several tables of applicable RTM curves, as opposed to a comparison to historical costs adjusted only for inflation.

Study Design: Using a commercial grouping tool on a commercially insured population, we identified the most costly chronically ill patients

in 2004 and 2005. These patients were stratified by major disease state and by percentile of predicted costs. The actual costs of these patients as measured in the baseline identification years are then compared with their subsequent costs in the following years, 2005 and 2006 respectively.

Population Studied: A commercially insured

PPO population in Western Washington State of over 1 million individuals is the underlying population from which these chronically ill patients are studied.

Principle Findings: While the results of the analysis are not yet final due to required claims run-out for the study year 2006, preliminary estimates are that the Regression to the Mean effect is substantial, with a larger effect seen at the sicker end of the population. The effect is less prominent in illnesses which progress quickly over time, such as congestive heart failure, than it is in chronic illnesses with intermittent and/or unpredictable events, such as asthma and CAD.

Conclusions: Regression to the Mean is a real phenomenon and is a confounding factor when analyzing the cost-effectiveness of new ways of caring for the chronically ill. The sickest people identified at the end of year 1 will invariably have lower costs during year 2 without any intervention.


While it is tempting for promoters of new approaches to care to claim credit for lowered costs, we recommend use of our Regression to the Mean curves to compare observed experimental results with the expected costs of the null hypothesis rather than a simple inflationadjusted baseline. It is never acceptable in these studies to simply report observed costs during a treatment period with baseline year costs without an accounting of expected RTM effects.

Funding Source: Regence BlueShield

• Cardiac Stenting and Subsequent

Outcomes

Patricia Gladowski, R.N., M.S.N., JoAnn

Matthews, B.S., M.S.

Presented By: Patricia Gladowski, R.N., M.S.N.,

Medical Project Analyst, Healthcare Informatics,

Highmark BCBS, 120 Fifth Avenue, Suite P7205,

Pittsburgh, PA 15222-3099, Phone: 412-544-3195,

Fax: 412-544-0700, Email: patty.gladowski@highmark.com

Research Objective: One of the objectives of the study was to determine the number of individuals that had cardiac stenting in a population of 3.8 million members. After the initial stenting procedure, complicating factors such as re-stenting or the need for coronary artery bypass grafting (CABG) was evaluated in a follow-up period of up to two years. In addition, antiplatelet medications prescribed post-stenting and period of time an indivdual remained on a particular drug was evaluated and related to subsequent events.

Study Design: The study was designed to identify individuals who had an initial stenting procedure using claims data. A one year period prior to the stent was used to ensure that the individual did not have a stent or CABG for the one year prior to what is referred to as the "initial stent". After identifying this population, only individuals that were continuously enrolled for a period of from one to two years post-stenting were included. Individuals that required repeat stenting or CABG were identified and divided by timeframes. For individuals that had the drug benefit, antiplatelet medication prescripitions and days supplied for the drug were calculated.

This information was then reviewed to identify associations between lenth of time and type of drug administered and the need for repeat stenting and/or CABG.

Population Studied: The population consisted of all individuals who had a minimum of a one year period without a coronary artery procedure such as stenting or CABG, then identifying those that had an initial coronary artery stent placed.

Individuals who were continuously enrolled for a period ranging from one to two years were followed with information pulled on repeat stenting, CABG and overall procedures and costs. Individuals without a drug benefit were not excluded, but were listed in a separate file.

Principle Findings: Data is currently being reviewed on 57,290 members who had 85,928 admissions for stenting in a period of time from

2003 through 2005, with an average number of approximately 17,000 unique patients per year that had stents placed. The average number of catheterizations performed each year was approximately 40,000. An average number of approximately 7,000 CABGs were performed on an annual basis. Considering continuous enrollment and the drug benefit, these members are being followed using the criteria as listed to ensure adequate time for follow-up and a clean period of one year.

Conclusions: Preliminary results have shown that between 25 to 33 percent of members initially receiving cardiac stenting, require a repeat procedure within the year. This appears

to be increasing since stenting procedures have outpaced CABG in recent years.


There have been many concerns about cardiac stents and outcomes for patients. This study is very important in helping to identify factors that play a role in adverse outcomes, including type of antiplatelet medication prescribed and time on the drug ads it relates to adverse events.

Also, it is important to look at the change in outcomes over the years as stenting comprised approximately 2.2 times the number of CABG procedures in 2003 and increased to 3 times the number of CABG procedures in 2005.

•

Costs and Outcomes of Drug Eluting

Coronary Stents versus Bare Metal Stents

Peter Groeneveld, M.D., M.S., Mary Anne Matta,

M.S., Feifei Yang, M.S.

Presented By: Peter Groeneveld, M.D., M.S.,

Assistant Professor, Center for Health Equity

Research and Promotion, Philadelphia VA

Medical Center and the University of

Pennsylvania, 1229 Blockley Hall, 423 Guardian

Drive, Philadelphia, PA 19104-6021, Phone: (215)

898-2569, Fax: (215) 573-8778, Email: peter.groeneveld@va.gov

Research Objective: Since 2003, most percutaneous coronary interventions in the

United States have involved the use of drugeluting stents--DES, which have replaced less expensive bare metal stents--BMS--that had been in common clinical use prior to Food and Drug

Administration DES approval in April, 2003.

Clinical trials have demonstrated that DES confer no mortality benefit or reduction in clinical events other than decreasing the necessity for repeat revascularization procedures. The clinical and economic outcomes of drug eluting stents in routine clinical practice among the elderly are uncertain.

Study Design: Using Medicare hospital claims, we identified patients emergently or urgently hospitalized with acute coronary syndromes who had no prior percutaneous coronary intervention.

A propensity score logistic regression model including patient demographics, clinical diagnoses, and comorbidities was used to match patients receiving DES to similar patients receiving BMS during the 9 months immediately following FDA approval. A separate propensity score model was used to match DES patients to

BMS patients hospitalized during the 9 months immediately prior to FDA approval of DES.

Medicare enrollment data were used to ascertain subsequent mortality. Multivariable Cox proportional hazards models were fitted to the two independently matched cohorts of DES recipients and controls. Inpatient and outpatient claims were examined to quantify health care utilization costs during the year after stent receipt. A generalized linear model with a log link was fitted, with cost as the dependent variable, to ascertain the adjusted cost of DES receipt. Bootstrap replications generated a 95 percent probability interval for the cost of DES.

Population Studied: We used a 5 percent random sample of Medicare beneficiaries nationwide hospitalized with acute coronary syndromes from 2002-2003, encompassing the time immediately before and immediately after

FDA approval of DES in April, 2003.

Principle Findings: We identified 3,332 Medicare beneficiaries who received DES between April and December of 2003. Eighty-three percent of these patients were matchable to contemporaneous BMS controls, while 98 percent of the DES recipients were matchable to

BMS controls hospitalized in the preceding 9 months. DES patients had reduced mortality when compared to contemporaneous controls-hazard ratio 0.70, 95 percent CI 0.56----0.88, as well as compared to prior-year controls--hazard ratio 0.81, 95 percent CI 0.65----1.02. Drug-eluting stents averaged 1,361 dollars in additional costs--

95 percent probability interval 167 to 2,508 dollars--during the 12 months following percutaneous coronary intervention.

Conclusions: In this non-experimental setting, and in contrast to clinical trials, DES appeared to reduce mortality among patients with acute coronary syndromes when compared to BMS.

While these findings could have resulted from unmeasured comorbidity or from healthier patients being selected for DES, they were consistent across comparisons using two distinct control groups. The higher initial implantation costs of DES were not entirely offset by lower health care costs during the subsequent year.


Drug eluting stents have substantially increased the average cost of percutaneous coronary intervention, yet they appear to provide a significant survival benefit when used among the elderly.

Funding Source: Institute for Health

Technology Studies

• The Improving Efficiency Frontier of

Religious Not-for-Profit Hospitals

Jeffrey Harrison, Ph.D., M.B.A., M.H.A.,

Christopher Sexton, M.P.A.

Presented By: Jeffrey Harrison, Ph.D., M.B.A.,

M.H.A., Assistant Professor, Health

Administration Program, University of North

Florida, 4567 St. Johns Bluff Road, South,

Jacksonville, FL 32224-2673, Phone: (904) 620-

1440, Fax: (904) 620-1035, Email: jharriso@unf.edu

Research Objective: This research was published under the title ‘‘The Improving

Efficiency Frontier of Religious Not-for-Profit

Hospitals’’ in Hospital Topics. 84(1), 2-10,

Winter 2006. The objective of this study was to evaluate the efficiency of religious not-for-profit hospitals and allow for improved management of healthcare resources as well as to identify savings in U.S. healthcare expenditures. The study has managerial implications for religious not-for-profit hospital executives to improve organizational performance and from a policy perspective highlights the importance of developing industry benchmarks to improve performance.

Study Design: The study utilized a variable returns to scale input oriented data envelopment analysis (DEA) model to evaluate efficiency in religious not-for-profit hospitals. The data were drawn from the American Hospital Association

Annual Survey of Hospitals (AHA) for the years

1998 and 2001.

Population Studied: The study examined 480 religious not-for-profit hospitals in 1998 and 471 religious not-for-profit hospitals in 2001. The study utilized the input variables, operating expenses, hospital beds, full-time employees

(FTEs), and service complexity as well as output variables of admissions and outpatient visits.

Principle Findings: Results indicate overall efficiency in religious not-for-profit hospitals improved from 72% in 1998 to 74% in 2001. Not only is the efficiency frontier of religious not-forprofit hospitals improving over time but the number of religious not-for-profit hospitals operating on the efficiency frontier increased from 40 in 1998 to 47 in 2001. The study also provides insight on the level of inefficiency

(slack) for each variable over time.

Conclusions: This study demonstrates that the cost effectiveness of religious not-for-profit hospitals is increasing as they continue to operate in a more competitive environment. The study also identifies the efficiency frontier for religious not-for-profit hospitals which allows the benchmarking of individual organizations as a measure of comparative effectiveness. The growing volume of charity care places religious not-for-profit hospitals at an increasing risk for acquisition or closure. As a result, research using

DEA as a measure of comparative effectiveness has the potential to increase efficiency and improve the allocation of scarce healthcare resources.


These results have important managerial implications as the hospital industry faces a more competitive environment. Religious notfor-profit hospital managers who wish to improve efficiency are challenged to implement programs that can positively affect the hospital’s financial status. This study clearly demonstrates that the use of DEA to identify the efficiency frontier is an opportunity to improve religious not-for-profit hospital efficiency. Additionally, it’s clear that opportunities for improved utilization of hospital beds, operating expenses and fulltime employees currently exist in religious notfor-profit hospitals which are not operating on the efficiency frontier. Therefore, managers are encouraged to integrate hospital benchmarking programs in the strategic planning process to ensure operational efficiency and organizational profitability. From a policy perspective, the DEA model is an effective mechanism to evaluate multiple input and output variables to improve the allocation of healthcare resources. Successful management of these resources is critical to the improved well being of the US population and to ensuring the survival of individual religious notfor-profit hospitals.

• How to Maximize the Effectiveness of

Society of Thoracic Surgery (STS) Registry

Data by Building Complementary Research

Databases for Cardiac Surgery

Sharon Hunt, B.S., M.B.A., Lisa M Martin, M.A.,

Linda L Henry, Ph.D., Niv Ad, M.D.

Presented By: Sharon Hunt, B.S., M.B.A.,

Database Administrator, Cardiac Surgery

Research, Inova Heart and Vascular Institute,

3300 Gallows Road, Falls Church, VA 22042,

Phone: (703) 776-7070, Fax: (703) 776-7008,

Email: sharon.hunt@inova.com

Research Objective: To optimize clinical outcomes in cardiac surgery by utilizing registry and institutional data in complementary research databases.

Study Design: The excitement of collecting and utilizing data from a national registry may be diminished when questions asked about patients’ outcome can not be addressed due to the potential impact of recurring non-measured factors or events that were not considered initially and occur long after the initial data is collected. More often than not, national registry data can be difficult to modify and is global in design. Some national registries such as the

Society of Thoracic Surgery (STS) Registry are very sophisticated and provide much more detail about the patients’ clinical profile, type of surgical procedure and outcome. However, often the investigator requires more elaborate identification of risk factors or clinical characteristics that may impact desired outcomes which are not captured in the national registry. Specifically, detailed clinical data about subsets of patients or patient follow-up that would provide measurements of health related quality of life or long-term survival statistics are often not captured because patient follow-up was not part of the original design of the registry.

Unfortunately, the investigator is often forced to re-design his study, limit his analysis or drop his research endeavor altogether. In order to identify all potential risk factors, it became necessary to collect additional clinical data during the hospital stay that was beyond the scope of the national registry data. Also, deficient from the registry data was detailed clinical and Health Related

Quality of Life (HRQL) follow-up after 30 days discharge. At our facility, we have established a process where the STS Registry data for our institution is exported into detailed independent research databases. The research databases focus on detailed clinical characteristics, continuous clinical follow-up with multiple records, HRQL data, and mortality information based on the national death registry.

Population Studied: Since 2001 we have over

7,000 patients with cardiac surgery and 30 day follow-up data available for research stored in a comprehensive local database that is designed to export data to the STS national database and provide facility reporting for some outcomes analysis.

Principle Findings: With the use of a data management package like SAS (Statistical

Analysis System), national registry data is incorporated with the detailed research data into a comprehensive local research database without the burden of collecting redundant information.

In addition, the detailed research databases are structured so that redesign is easy, updates are manageable, data flow is streamlined and the research process is efficient. Finally, as our analysis identifies significant risk factors or outcomes, we can then incorporate these factors into the main registry database as needed.

Conclusions: National registry data provides a substantial base for complementing evolving research. However, the limitations of the registry data should not slow or impede the investigator from evaluating more detailed factors or longer follow-up.


By appropriate design and the use of data management software, the registry data can be successfully and effectively merged with local research data to optimize outcomes in the cardiac surgical patient.

• Modeling the Effects of Organizational

Innovations and Medical Technology

Adoption on Hospital Performance

Keon-Hyung Lee, Ph.D., Yasar Ozcan, Ph.D.

Presented By: Keon-Hyung Lee, Ph.D., Assistant

Professor, Department of Health Professions,

University of Central Florida, 4000 Central

Florida Boulevard, Orlando, FL 32816, Phone:

(407) 823-5481, Fax: (407) 823-6138, Email: keonlee@mail.ucf.edu

Research Objective: The purpose of this project is to investigate hospital’s operational performance in a changing environment. The contingency-organizational perspective is used to examine the mediating effect of organizational innovation and medical technology adoption on hospitals’ effectiveness and efficiency.

Study Design: This perspective outlines three components of a hospital system. The first component represents environmental or contextual variables that include institutional environment and organizational characteristics, directly affecting how hospitals are configured or adopt medical technologies, and indirectly affecting hospital performance. The second component comprises of organizational strategies and adoption of medical technologies

---- as the design factors that directly influence hospital performance. The third component is the operational performance of hospitals. By employing the structural equation modeling and the growth curve modeling methods, a multivariate model will be analyzed to detect the component effects on change trajectories of hospital performance.

Population Studied: All acute care hospitals in the State of Florida from 2001 to 2004.

Principle Findings: 1. Membership in an integrated health care delivery system increases hospital performance. 2. The level of medical technology adoption is positively associated with hospital performance. 3. Rural-urban differences in medical technology adoption are observed in hospital services.

Conclusions: Membership in an integrated health care delivery system and the medical technology adoption could enhance hospital performance.


Major inefficiencies exist in the availability of hospital services including high-tech services, the number of operating beds, the utilization of hospital staffing and operating expenses.

Membership in an integrated health care delivery system and the medical technology adoption could enhance hospital performance.

Funding Source: UCF

• Cost-Effectiveness of Aspirin Use among

Persons with Diabetes

Rui Li, Ph.D., Thomas J. Hoerger, Ph.D., Ping

Zhang, Ph.D.

Presented By: Rui Li, Ph.D., Prevention

Effectiveness Fellow, Division of Diabetes

Translation, Centers for Disease Control and

Prevention, 4770 Buford Hwy, NE, MS K-10,

Atlanta, GA 30341, Phone: (770)488-1070, Fax:

(770)488-1148, Email: Rli2@cdc.gov

Research Objective: Persons with diabetes have a two- to fourfold increase in the risk of dying from cardiovascular diseases (CVDs). The

American Diabetes Association recommended the use of aspirin for primary and secondary prevention of CVDs among persons with diabetes. The cost-effectiveness of aspirin use among persons with diabetes has not been evaluated. The objective of this study was to assess the cost-effectiveness of aspirin use for the prevention of CVDs among persons with newly diagnosed type 2 diabetes.

Study Design: We used a Markov simulation model to estimate progression of disease, longterm costs, benefits and side-effects of the intervention. The health benefits of aspirin included in the model were reduced risks of myocardial infarction (MI) and strokes. The side effects were increased risks of hemorrhagic strokes and gastrointestinal bleeding. Persons in the intervention group were treated with lowdose aspirin in addition to the usual diabetes care. Persons in the comparison group received just the usual diabetes care. The time horizon was lifetime. We took a health care system’s perspective. The health outcome measures were life-year gained (LYG) and quality-adjusted lifeyear (QALY) gained. Both the costs and health benefits were discounted at a 3% annual discount rate. Sensitivity analyses were performed by varying the effectiveness of aspirin to reduce risks of myocardial infarction, overall relative risk of strokes from aspirin, and the increased risk of aspirin-related gastrointestinal bleeding.

Population Studied: Persons with newly diagnosed diabetes aged 35 years and older in the US, including all races, both men and women.

Principle Findings: Based on the preliminary results, the estimated incremental costeffectiveness ratios of aspirin use were

$2,072/LYG and $5,758/QALY gained. The costeffectiveness of aspirin use was sensitive to changes in the risk reduction of MI and the excess risk of aspirin for gastrointestinal bleeding. The cost-effectiveness results were not sensitive to the overall relative risk of strokes from aspirin use. The cost-effectiveness ratios under all simulation scenarios were lower than

$4,000/LYG and $10,000/QALY gained.

Conclusions: Aspirin use was cost-effective in preventing CVDs among persons with newly diagnosed diabetes aged 35 years and older, compared to no aspirin use.

Implications for Policy, Practice or Delivery: In

2003, less than half of the persons with diabetes used aspirin. Considering the low costeffectiveness ratio of aspirin in preventing CVDs, payers and health providers should consider promoting use of aspirin for all persons with diabetes aged 35 and older.

• Quality-of-Life Weights for the U.S.

Population: Self-Reported Health Status and

Priority Health Conditions, by Demographic

Characteristics

John A. Nyman, Ph.D., Nathan A. Barleen, Ph.D. candidate, Bryan E. Dowd, Ph.D., Daniel W.

Russell, Ph.D., Stephen Joel Coons, Ph.D.,

Patrick W. Sullivan, Ph.D.

Presented By: John A. Nyman, Ph.D., Professor,

Health Policy and Management, University of

Minnesota, 420 Delaware St. SE, Box 729,

Minneapolis, MN 55455-0392, Phone: (612) 626-

4425, Fax: (612) 624-2196, Email: nyman001@umn.edu

Research Objective: Many of the large ongoing national surveys of the US population contain a

question that asks for the respondent’s selfreported health status: ‘‘excellent,’’ ‘‘very good,’’

‘‘good,’’ ‘‘fair’’ or ‘‘poor.’’ These surveys could be used to conduct cost-utility analyses of health care policies, treatments or other interventions if quality-of-life (QOL) weights for the self-reported health statuses were also available. The objective of this study was to produce nationally representative QOL weights for self-reported health status and for 10 priority health conditions, by a series of demographic variables.

Study Design: The Medical Expenditure Panel

Survey contains the questions from the EQ-5D health status measure. A recent study has calculated time-trade-off-derived QOL weights corresponding to the EQ-5D health states for a large US sample. We use these data to construct QOL weights for the five self-reported health status categories and 10 priority health conditions, by a series of demographic variables.

Population Studied: Medical Expenditure Panel

Survey participants from 2000 and 2002.

Principle Findings: Mean and median QOL weights were produced for self-reported health status, the 10 priority health conditions, and the demographic variables. We also report QOL weights for the self-reported health state and priority health conditions, by the demographic variables. Finally, ordinary least squares and

CLAD regression equations were used to estimate adjusted QOL weights for these variables.

Conclusions: By providing nationally representative QOL weights for self-reported health status and priority health conditions, by demographic variable, we have facilitated the use of large national surveys for conducting costutility analysis and increased their value to researchers and policy makers.


•

Wide Variation in Efficiency of Outpatient

Diabetes Care Across Medical Groups

Patrick O'Connor, M.D., M.P.H., Thomas J.

Flottemesch, Ph.D., Richard R. Paskach, M.A.,

Gary J. Kitching, B.S.





Phone: (952)967-5034, Fax: (952)967-5022,


Research Objective: This secondary analysis of a retrospectively constructed dataset has three objectives: 1) explore methods of measuring the efficiency of diabetes care across medical groups, 2) quantitate variation in the provision of diabetes care provided across MGs, and 3) estimate potential resource savings and quality gains from improving the provision of diabetes care at the MG level.

Study Design: Non-parametric Data

Envelopment Analysis (DEA) modeled the relationship between medical group resource utilization and quality of care. A medical group’s quality of care was defined as the proportion of patients achieving two or more evidence-based clinical goals. The resulting analysis: 1) quantified the relationship between resource utilization and quality, 2) ranked groups in terms of patient likelihood of achieving two or more clinical goals, and 3) identified performance benchmarks for poorly performing medical groups.

Population Studied: 2,511 adults with diabetes mellitus, insured by a single payer during 2003-

2004, and receiving care at one of 33 medical groups. Chart abstractions provided three evidenced-based clinical goals: A1c <8%,

BP<130/85, and LDL<130 mg/dl. Standard methods calculated resource utilization by converting all billing into resource value units

(RVUs) scaled by a single cost factor.

Principle Findings: Medical groups with fewer than 30 patients (n=5) were excluded. The remaining 28 medical groups averaged 109 patients (range: 174 to 38). Median per patient costs across medical groups was $19,045 with group-specific medians ranging from $8,822 to

$38,842. 73% of all patients (n=1,824) achieved two or more goals with group-specific percentages ranging from 57% to 82%. After controlling for age and comorbidities, three medical groups were identified as relatively efficient ‘‘benchmarks’’, four were classified as outliers, and twenty-one were found inefficient.

If inefficient medical groups performed at benchmark levels an estimated 35% decrease in resource use OR an 8% increase in patients achieving two or more evidence-based goals would be realized.

Conclusions: In terms of using medical resources to facilitate patients achieving evidence-based goals, there is considerable variation in the efficiency of diabetes care across medical groups. Techniques such as DEA can support efforts to identify best practices and guide interventions to improve the efficiency of diabetes care across medical groups.


Efficiency of chronic disease care at the level of medical groups can be measured using existing

health plan data. Improved efficiency in outpatient diabetes care would have substantial benefits for both patients and payers.

Funding Source: HealthPartners Research

Foundation

• Lung Cancer Screening for Academic

Medical Centers: Examining Downstream

Revenue Possibilities

Matthew Powondra, B.A.

Presented By: Matthew Powondra, B.A.,

Administrative Project Assistant, Health Systems

Management, Rush University Medical Center,

2437 W Walton #2F, Chicago, IL 60622, Phone:

(517) 282-4905, Email: matthew_powondra@rush.edu

Research Objective: The objectives of this study are to (1) determine the total downstream revenue associated with a lung cancer-screening program utilizing CT scans, (2) determine which type of patient contributes the greatest amount of downstream revenue, and (3) determine what the expected revenue is from an individual coming in for a screening.

Study Design: This study is a cross-sectional study.This study will use Rush University

Medical Center’s Tumor Registry, data warehouse and decision support system in order to create a database consisting of all patients who have been treated for lung cancer within the medical center. Each subject, defined by specific

ICD-9 codes will be tracked through the data warehouse and decision support system to determine the aggregated downstream revenue at the patient level. These figures will then have cancer detection probabilities (extrapolated from the recently released I-ELCAP study) applied to determine what the expected revenue is for each patient category.

Population Studied: This study uses identified and treated cases of lung cancer within Rush

University Medical Center between January 1st

2003-December 31st 2005. These cases of lung cancer are tracked through the system in order to determine actual and expected revenue.

Principle Findings: Have yet to recieve data for analysis. Will have analysis complete by March

2007.


This study will lend insight into the financial implications of a lung cancer screening program within an academic medical center. This understanding is very crucial in determining whether a lung cancer screening program utilizing CT scans is viable within an academic medical center. This understanding is important as lung cancer will continue to plague our society. This problem needs to be addressed, and this project begins to tackle this issue.

Funding Source: Health Systems Management-

Rush University

• Updating Estimates of Cost-Effectiveness and Survival: The Case of Imatinib vs

Interferon-alpha for Chronic Myeloid

Leukemia

Shelby D. Reed, Ph.D., Kevin J. Anstrom, Ph.D.,

Yanhong Li, M.S., Kevin A. Schulman, M.D.

Presented By: Shelby D. Reed, Ph.D., Assistant

Research Professor of Medicine, Duke Clinical

Research Institute, Duke University, PO Box

17969, Durham, NC 27715, Phone: 919-668-8101,

Fax: 919-668-7124, Email: shelby.reed@duke.edu

Research Objective: Most cost-effectiveness analyses require analysts to project costs and survival well beyond the period for which followup data are available. In many cases, particularly in oncology, investigators follow trial participants for an extended period to evaluate long-term survival. Our objective was to use 60-month survival data to update a previously conducted cost-effectiveness analysis of 19-month data from a clinical trial of imatinib vs interferonalpha for chronic-phase chronic myeloid leukemia.

Study Design: We used 60-month data from the

International Randomized Study of Interferonalpha vs STI571 (imatinib) for participants randomized to imatinib to calibrate the survival curves generated with the original costeffectiveness model. Due to the high rate of crossover among participants randomized to interferon-alpha, we relied on historical data to model survival estimates for those patients. We updated costs to 2006 values and applied two sets of costs to imatinib and interferon-alpha-average wholesale prices and wholesale acquisition costs.

Population Studied: 1106 participants in a randomized controlled trial of imatinib vs interferon-alpha in patients with chronic-phase chronic myeloid leukemia.

Principle Findings: Survival at 5 years for participants randomized to imatinib was better than predicted in the original model (89.4% vs

83.2%). After model calibration, we estimated remaining life expectancy with first-line imatinib to be 19.1 years, an increase of 3.8 years over the original model. Remaining quality-adjusted life-

years (QALYs) were estimated at 15.2, an increase of 3.1 QALYs. Estimates for interferonalpha remained at 9.1 years and 6.3 QALYs.

When we applied average wholesale prices to imatinib and interferon-alpha, incremental costeffectiveness ratios ranged from $51,800 to

$57,500 per QALY, depending on assumptions about the duration of treatment. When we applied wholesale acquisition costs, the incremental cost-effectiveness ratios ranged from $42,000 to $46,200 per QALY. The updated ratios using average wholesale prices were generally higher than the original estimate of $43,300 per QALY, and the updated ratios using wholesale acquisition costs were consistent with the original estimate. These results occurred despite the gain in QALYs because of higher acquisition costs of medications and the close tracking of increased survival and costs.

Conclusions: Although the analysis revealed that the original survival estimates were conservative, the updated findings were relatively consistent with or slightly higher than the original estimate of $43,300 per QALY, depending the on the costs assigned to the study medications. Even with 5 years of data, most of the expected survival benefit has yet to be observed, and this analysis should be updated again in the future.


For trials in which participants are followed beyond the main study period to assess longterm survival, economic evaluations conducted using short-term data should be systematically updated to compare projected survival to observed survival and to update estimates of cost-effectiveness. If cost-effectiveness was significantly overestimated or underestimated, policy recommendations or coverage decisions may need to be revised. Furthermore, if this practice uncovers a systematic bias in findings of cost-effectiveness, methodologists may be able identify modeling approaches associated with higher degrees of bias and to develop recommendations for improving the predictive validity of cost-effectiveness models.

Funding Source: Novartis Pharmaceuticals

Corporation

• A Cost-Utility Analysis of Photodynamic

Therapy (Foscan-PDT) Versus Standard

Treatment for Patients With Small Superficial

Tumors of the Oral Cavity and Oropharynx.

Valesca Retel, Msc, S.M.A.A. Evers, Ph.D., I.B.

Tan, M.D., Ph.D., M.P. Copper, M.D., Ph.D.,

M.A. Joore, Ph.D.

Presented By: Valesca Retel, Msc, PhD student,

Psychology and Social Research and

Epidemiology, Netherlands Cancer Institute-

Antoni van Leeuwenhoek hospital, Plesmanlaan

121, 1066 CX, Amsterdam, Netherlands, Phone:

0031205122318, Fax: 0031205122759, Email: v.retel@nki.nl

Research Objective: Background: Head and neck cancer poses a serious health risk, with the

American Cancer Society projecting that approximately 38.530 new cases of head and neck cancer were diagnosed in the United States, accounting for about 3% of adult malignancies in

2004. Cancer is the second cause of death in the

Netherlands. The incidence of small tumors of the head and neck (oral cavity and oropharynx) in the Netherlands is approximately 300. Next to curative treatment, quality-of-life is a very important aspect for these patients. Depending on the location and the treatment of the tumor, functions like eating, drinking and cosmetics of the face can be considerably reduced. The need to account for the cost of care is being imposed on clinicians by the corporate purchasers of health care. Foscan is an expensive photosensitizer, but results in a better quality-oflife than conventional treatments and has the advantage of the possibility to repeat the treatment. In October 2001, Foscan

(photosensitizing agent (a light-sensitive drug), which contains temoporfin and is used in photodynamic therapy) was approved in the

European Union. At the moment, there are negotiations about registration of Foscan in de

US. Hopper et al. (2004) has published the costeffectiveness of Foscan-PDT for palliative treatment of head and neck cancer (Hopper C,

Oral Oncology, 2004). The cost-effectiveness for curative treatment of early stage tumors of the head and neck is still unknown. A cost-utility analysis, as a part of Health Technology

Assessment, could be helpful to policy makers to decide whether the new technology should be implemented in regular clinical practice.

Objective: Cost-utility analysis of photodynamic therapy (Foscan-PDT) versus standard treatments (surgery or radiotherapy (RT)) for patients with T1N0 tumors of the oral cavity and oropharynx.

Study Design: Two Markov decision models were developed, Foscan-PDT versus radiotherapy in oropharyngeal cancer and Foscan-PDT versus surgery in oral cancer. Severity of illness was based on use of feeding substitutes per week

(UFS/week).

Several health states were distinguished in the models; from ‘no cancer’ to ‘death’, within between all treatment possibilities. Transition probabilities were calculated, based on empirical and secondary sources. Outcomes were expected total societal costs and expected

QALY´s. All costs were reported in year 2002-

2006 in euros. One-way sensitivity and probabilistic sensitivity analyses were performed.

Population Studied: Dutch patients with T1N0 superficial tumors of the oral cavity and oropharynx, no previous cancer in history.

Principle Findings: Foscan-PDT versus radiotherapy in early oropharyngeal cancer is dominant. Foscan-PDT versus surgical treatment of oral cancer is cost- effective with an ICER of

2874 costs/QALY.

Conclusions: Foscan-PDT is cost-effective compared to standard treatment modalities like surgery and radiotherapy for patients with small superficial tumors of the oral cavity and oropharynx.


This cost-utility analysis can be important for several providers of care with interest in head and neck oncology, like policy makers and health care insurers. Further research is recommended because of the promising results of Foscan-PDT, not only for head and neck tumors, but also for other, superficial tumors like specific skin tumors and gynecology tumors.

Consumer Decision-Making

•

Explaining Care-Seeking Behaviour: A Case

Study of Maternal Care in Pakistan

Raheelah Ahmad, M.Sc., Professor Rifat A Atun,

M.B.B.S., M.B.A., DIC, FFPH, FRCGP

Presented By: Raheelah Ahmad, M.Sc., Doctoral

Researcher, Centre for Health Management,

Imperial College, London, Exhibition Road,

London, SW7 2AZ, UK, Phone: +44 (0)20 7594

9217, Email: raheelah.ahmad@imperial.ac.uk

Research Objective: To use an inductive, interpretive paradigm of inquiry to investigate care seeking behaviours in the developing country context. In addition, to determine consumer perceptions of quality, how these are shaped, and the role of these perceptions in care seeking behaviour.

Study Design: The epistemological assumptions for this work,are broadly positioned within the constructivist paradigm of inquiry which is particularly useful for the understanding and reconstruction of meanings. Our research has used public and private health services for pregnant women as a tracer to explore and explain consumer decision making in urban- and rural-Pakistan. We use sensemaking as a lens to analyse users’ perceptions of quality and decision making processes, and the role of contextual factors in the construction of such perceptions. We used a longitudinal study design to follow health-seeking behaviour through a care cycle, at start and during pregnancy and after delivery, to observe the feedback loops created throughout this process, and to enhance the validity of data. We used twostage theoretical sampling with snowballing, informed by theoretical themes emerging form the literature and by pilot studies undertaken during the study, to select first a sample of healthcare facilities and second a sample of sixty women from a community. We followed these women through the duration of their pregnancy and after delivery. Dat was collected at threemonthly intervals using non-participant observation and in-depth interviews in Urdu.

Population Studied: Contemporary research highlights the importance of placing consumers at the centre of heath service delivery and regarding consumers as extended members of healthcare organizations. In the developing country context, the position of consumers requires special attention: as the majority of healthcare expenditure is out-of-pocket for private care; service quality is low; services, which are difficult to reach and unresponsive to users, are poorly regulated, while information on healthcare providers is lacking. Collectively these factors have contributed to the deterioration of health outcomes, particularly for women, the poor and the rural population. Pakistan presents an extreme case in such a context, where maternal mortality rates are estimated to be at least 350 per 100,000 live births, compared to 5-

10 in industrialised countries, and where 100 in every 1,000 die before the age of five . Pakistan, an Islamic State, is also an intrinsic case given its cultural complexities and diversity, and colonial past. Our research, therefore focuses on women living in urban and rural Pakistan.

Principle Findings: Early analysis reveals a diverse typology of the consumer, whose behaviour is influenced by socioeconomic, cultural and religious factors. We have mapped consumer care-seeking pathways to demonstrate that women access public, provider and traditional providers in parallel and seamlessly switch between and within these domains.

Conclusions: Perceptions of quality influence the decision to switch provider. While consumers identify interpersonal and technical dimensions of quality, their care-seeking behaviour is influenced by their perception of the technical dimension of quality. The research has identified multiple reference groups beyond the family, along with family consumption-related roles, and demonstrates that users’ behaviour is influenced to a great extent by these reference groups.


This research adds to the empirical and theoretical literature on health seeking behaviour,with implications for quality management programmes in developing countries. Interventions based on contextual evidence are important for addressing the huge disparities, between and within nations.

Funding Source: Centre for Health

Management, Imperial College, London

• Consumer Involvement in Developing

Health Care Policy: The Archimedes

Movement

James Bryan, M.P.A., Sherril B. Gelmon, Dr.P.H.,

John Kitzhaber, M.D., Elizabeth Baxter, M.P.H.,

Matthew Carlson, Ph.D., Bowen McBeath, Ph.D.

Presented By: James Bryan, M.P.A., Ph. D.

Student, Public Administration, Portland State

University, PO Box 751, Portland, OR 97207-0751,

Phone: 503-725-3044, Fax: 503-725-8250, Email: bryanj@pdx.edu

Research Objective: The Archimedes

Movement was organized in 2006 as a grassroots effort to develop legislation to provide universal health care coverage in Oregon. Using the internet and community meetings, this movement solicited citizen input to develop draft legislation for presentation to the Oregon

Legislature’s 2007 session. This research examines the effectiveness of community meetings, internet discussion forums, and blogs for obtaining consumer involvement in developing health care policy. We also describe differences in the input provided through each medium.

Study Design: Data come from three sources: community meetings, internet discussion forums, and blog entries. In community meetings, citizens were given a preliminary set of ten principles for designing a basic universal health care coverage system. Participants broke into small workgroups to discuss these principles and then reported their decisions about the principles back to the larger group.

Breakout session results were recorded and transcribed after the meetings. Consumer input was also solicited via internet discussion forums and blog entries. Internet discussion forums solicited input in four areas: eligibility, financing, benefits, and delivery. Blogs were used for input on virtually any topic related to health care.

Content analysis was performed on all three data sources to determine the type of consumer input provided through each medium, and the extent to which each form of input shaped the draft legislation.

Population Studied: Health care consumers, advocates, physicians, administrators, insurers,

Medicare beneficiaries and the general population participated in the community meetings.

Principle Findings: Through the consumer input process, six of the ten initial principles were incorporated with little change, and two of the principles were combined into one principle, all of which were incorporated into the model legislation. These seven principles describe how the future health system should operate. Two of the ten initial principles were refined and define eligibility, scope of coverage and financing issues in the model legislation. Five new principles included in the model legislation were developed during the consumer input process; two of these principles were addressed at every community meeting: the system should emphasize wellness programs and encourage personal responsibility.

Consumer input via unstructured blogs provided little consensus on principles that should be included in the model legislation. Structured discussion forums were more valuable than blogs in gathering citizen input, particularly in soliciting input on the topic of personal responsibility. The lack of data useful for input into the model legislation and submitted via the internet may be due a lower level of structure in the internet discussion forums and blog entries compared to the community meetings.

Conclusions: Structured community meetings appear to be the most successful method for obtaining useful consumer input. When the internet is used, structured discussion forums appear to be more successful than unstructured blogs, but the use of multiple methods does allow for consumers to contribute via their preferred medium.


Consumer input can be successfully obtained through structured community meetings and internet forums. These venues can offer

policymakers assistance for drafting health reform legislation.

•

The Relationship Between Health Care Use and Probability of Internet Access for Health

Care Information

William Cecil, M.B.A., John Barnes, M.A., M.B.A.,

Henry E. Wells, M.S.

Presented By: William Cecil, M.B.A., Director,

Health Policy Research, Health Policy Research,

BlueCross BlueShield of Tennessee, 801 Pine -

1E, Chattanooga, TN 37402, Phone: (423) 763-

3372, Fax: (423) 755-5100, Email: bill_cecil@bcbst.com

Research Objective: To identify the relationship between health care use, access distance and copay and accessing the internet for health care information.

Study Design: An observational study of commercially insured members using an internally developed survey tool. The survey was tested for reliability and validity using a pilot sample. Survey results were coded for use in a logistic regression to estimate the probablility of internet access to seek health information.

Control variables included age, gender, region of residence and diagnostic cost group.

Population Studied: The study population consisted of all commercial BCBST PPO members 18 years of age and older who lived in

Tennessee or one of the eight contiguous states and were effective at the time of the study.

Employer groups who have not given BCBST permission to survey their members were excluded. Stratified random sampling was used to draw a probability sample of 14,543 members.

Explicit strata were defined using seven levels of physician office visit co-pay ($5 or less, $10, $15,

$20, $25, $30, $35 or more) and five levels of diagnosis cost groups (DCG) risk (levels 1-5) resulting in 35 mutually exclusive strata.

Principle Findings: The probability of internet access to seek health information was lower with: higher office visit copay; more primary care physician visits; greater specialist physician office visit distance; higher branded prescription drug copay and more prescription drug use. Access of the internet was higher with: greater primary care physician office visit distance; more specialist physician office vists; higher generic prescription drug copay and greater non-preferred brand drug use.

Conclusions: The use of the internet to seek health care information is influenced by the type of health care used or being considered, out-ofpocket cost and access distance to the physicians office.


Understanding the factors that influence consumer use of internet to access health care information could add focus to information development and design.

• End-of-life Informal Care-Giving and

Decision-Making Experiences among Blacks

Norma Conner, Ph.D.

Presented By: Norma Conner, Ph.D., Professor,

College of Nursing, St. Petersburg College, P.O.

Box 13489, St. Petersburg, FL 33733, Phone: (727)

341-3685, Fax: (727) 341-3646, Email: conner.norma@spcollege.edu

Research Objective: To describe the various informal support relationships and care-giving and decision-making roles within those relationships, the dynamics of the caregiving/decision-making process, and beliefs and values about end-of-life care among Blacks who have experienced care-giving or health decisionmaking for a seriously ill loved one.

Study Design: This qualitative study used a focus group methodology. A total of 5, 90minute focus groups were held in two counties in south west Florida. Informed consent procedures were followed and participants completed a demographic data sheet. The sessions were tape-recorded. A previously pilot tested interview guide was used. Debriefing of the group took place after each session. Focus group sessions were transcribed verbatim, and data were organized into themes.

Population Studied: Study population criteria were Black men and women, age 18 or older,

English speaking, who have been care-givers or decision-makers of an adult loved one at the end-of-life. The 53 participants in this study included 7 Black men and 46 Black women with a mean age of 63 and an age range of 28 years to

88 years.

Principle Findings: Findings indicate that individuals assumed a care-giving/decisionmaking role most often for grandparents, parents, spouses and in-laws, and less frequently for siblings and friends. Patterns of decisionmaking with loved ones had often been previously established encompassing more than just health care. The dynamics if care including physical care and the care of business matters did not fall strictly along gender lines. Men often related experiences of providing physical care.

Areas of decision-making included nursing home

placement, place of care, advance directives, and life sustaining treatment options. Decision makers were often asked to make immediate decisions about life sustaining treatments for which they felt ill prepared. Decisions most often included home care rather than nursing home placement. Nursing home placement most often occurred for individuals with some form of dementia. Resource availability varied by locale, and often there was a lack of knowledge about potential resources, and out-of-pocket costs were often incurred. Prior knowledge of a loved one's wishes and those who had cared for their loved ones in a home setting most often expressed satisfaction with their decisions.

Conclusions: Findings from this study are consistent with the literature related to end of life care among Blacks. Findings also indicate the important role of the care-giver/decision-maker in determining end-of-life care among Blacks.

Findings also indicate the need for health professionals to work with communities to prepare individuals for the possibility of a caregiving or decision-making role.


Health Care providers need to work in coalitions with Black communities to increase awareness of available resources. The current hospital policies and procedures for establishing and upholding advance directives should be reviewed by a panel that includes individuals who have been decision makers for family members.

Funding Source: University of South Florida

Research Council and Division of Grants

•

Preferences for Colon Cancer Screening among Minorities: A Study Using Conjoint

Analysis

Sarah Hawley, Ph.D., M.P.H., Partha

Krishnamurthy, Ph.D., Maria Jibaja-Weiss, Ed.D.,

Natoshia Hebert, Sally Vernon, Ph.D., Robert

Volk, Ph.D.

Presented By: Sarah Hawley, Ph.D., M.P.H.,

Assistant Professor, Internal Medicine,

University of Michigan and Ann Arbor VAMC,

300 N. Ingalls, Room 7C27, Ann Arbor, MI

48109, Phone: 734-936-4747, Fax: 734-936-8944,

Email: sarahawl@med.umich.edu

Research Objective: To assess preferences for different colorectal cancer (CRC) screening test options and test attributes (e.g., test accuracy, frequency) among minority patients using conjoint analysis.

Study Design: The first phase of this study involved qualitative in-depth interviews to develop the tools to conduct a preference assessment using conjoint analysis. The second phase used these tools to assess preferences among 212 racially/ethnically diverse patients.

Population Studied: Phase I consisted of interviews with 22 African Americans, 26

Hispanics and 26 white primary care patients.

Phase II involved preference assessments with

61 AA, 73 Hispanic and 78 white primary care patients.

Principle Findings: Conjoint analysis found that the most valued CRC screening attributes across racial/ethnic groups were what the test involved and accuracy (35% and 24% importance values, respectively). The part-worth utilities showed that collecting stool was preferred to an invasive test with or without sedation, and to a CT-scan or Xray. Other part-worth utilities revealed preferences for attributes were as expected (e.g., more accurate preferred to less accurate). There was variation in valuation of test attributes with racial/ethnic minorities expressing greater preference for less invasive testing compared to whites(P<0.05). The test scenarios that received the highest ratings across groups were those for virtual colonoscopy and fecal DNA testing (mean on 0-10 scale: 8.8, 8.1, respectively).

Conclusions: These results confirmed there is variation in preferences for CRC screening.

Conjoint analysis determined that patients are willing to trade off certain test characteristics for others, and that new screening technologies rate highly among diverse primary care patients.


Conjoint analysis is a viable and valid method for eliciting preferences for CRC screening in a diverse patient population. Future interventions to increase screening adherence may be more effective if tailored to the underlying preferences of patients for different test characteristics.

Funding Source: NCI

• Qualitative Validation of A Segmentation

Screener Tool among Medicare Beneficiaries

Amy Heller, Ph.D., Sunyna S. Williams, Ph.D.

Presented By: Amy Heller, Ph.D., Social Science

Research Analyst, DCAHS/ POAG, CMS, 7500

Security Boulevard/Mail Stop: S1-15-03,

Woodlawn, MD 21244, Phone: 410-786-9234,

Email: amy.heller@cms.hhs.gov

Research Objective: To validate the findings of a quantitative segmentation analysis, which defined four distinct segments based on individual levels of health literacy and

motivation. The research question was: Does the segmentation screener tool and segmentation algorithm, which assigns individuals to their segment, correspond to skills and behaviors identified through focus group participation?

Study Design: This study used a qualitative nonexperimental design. Four focus groups were conducted in three cities for a total of twelve focus groups. The segments were identified as either possessing high and/or low scores on health literacy and health motivation producing a

2X2 matrix. A screener tool consisting of two questions was used to assign participants to their appropriate segment and determined participant’s group assignment. High scores on literacy and motivation were classified as Active consumers, low scores on literacy and motivation were classified as Passive consumers.

High literacy and low motivation were classified as Complacent consumers. Low literacy and high motivation were classified as Motivated consumers. The focus groups explored participant’s health care decision making processes by probing individual decisions about eating healthy diets, choosing a doctor and choosing a Medicare Prescription Drug Plan. The results of these groups were analyzed to verify that the self-described health behaviors corresponded to the cluster segment.

Population Studied: People with Medicare

Principle Findings: Eating Healthy: Participants who reported having health problems, such as high cholesterol or diabetes, relied on the advice of their healthcare providers regarding the types of food they should be eating. Only participants in the High Effort group reported seeking out dietary information beyond that given to them by their caregiver. Choosing a Doctor: The majority of Active, High Effort and Complacent participants relied on themselves to make healthcare decisions. The High Effort and

Complacent groups tended to rely on recommendations from their family and friends.

The Active group used the most information to make a health decision. The Complacent group relied the on referrals from their doctors, emergency rooms, and hospitals. Passive participants relied heavily on medical professionals. Choosing a Drug Plan: All participants thought the program was confusing and there were too many choices. Participants based their decision to enroll in varying degrees on advice from their pharmacists, the Social

Security Administration, and whether their previous drug coverage would be discontinued.

Knowledge about the new drug benefit varied across groups. Participants in the Active and

High Effort groups knew the most while participants in the Complacent and Passive groups were more confused and had difficulty choosing a drug plan.

Conclusions: The screener tool worked well in differentiating the Active and Passive groups and the High Effort group however the Complacent group had less distinct character. The

Segmentation Screener Tool is useful for helping identifying Medicare beneficiaries’ ability to comprehend and use health and Medicare program information.


With limited education and outreach funding, the Medicare program should consider using this tool to target to those beneficiaries most capable of increasing their ability to participate in health decisions by including motivational messages and tailored educational messages.

Funding Source: CMS

• Assessing Adolescent Caregiver's Decision-

Making Ability to Recognize Child Illness

Severity and Utilize Health Care Resources using the CROSS Scale

Christine Nelson, D.N.S., R.N.C., P.N.P.

Presented By: Christine Nelson, D.N.S., R.N.C.,

P.N.P., Research Assistant Professor, School of

Nursing, University at Buffalo, 11127 Alaura

Drive, Alden, NY 14004, Phone: (716)761-9957,

Fax: (716)829-2021, Email: cnelson2@buffalo.edu

Research Objective: Adolescents who are parents or caregivers to small children must learn to recognize symptoms of illness severity and make decisions regarding appropriate health care management that is safe and cost-effective.

This study identifies factors that influence this decision-making process, which can alert health care providers to a need for education in this high-risk population.

Study Design: Secondary analysis of demographic data (2005) used in a study to test the psychometrics of the Caregiver Recognition of Symptom Severity Scale (CROSS) was performed using ANOVA to evaluate group differences in scores on the CROSS scale related to age, school grade, ethnicity, type of residence, and child care experience (Nelson, 2005).

Participants determine how ill they think the child is (mild, moderate or severely ill) and the health care management needed (home care, office, emergency department).

Population Studied: An ethnically and socioeconomically diverse sample of 702 parenting

and non-parenting male and female adolescents,

13 to 19 years of age participated. These participants were recruited from 3 clinics at

Women and Children's Hospital of Buffalo and seven high schools, public and parochial, situated in urban, rural, and suburban Western

New York.

Principle Findings: No differences were found among mean scores on factors of age, school grade and residence (who they reside with) in illness recognition or management. Significant gender differences were present in ability to accurately identify severe illnesses but not in management. Childcare experience was a significant factor in moderate illness recognition and management of severe illnesses. Mean scores for teens with childcare experience were more predictive for appropriate management of all illness severities. Ethnicity was not a significant factor in illness recognition. There were significant differences in choices of appropriate management among white, black and Hispanics.

Conclusions: Groups at high risk for errors in illness identification and management can be targeted for additional childcare education and assistance by their providers. This situation is especially important for teen parents. The

CROSS scale can be easily used by health care clinicians in health education classes to evaluate the ability of adolescent parents and caregivers to recognize illness severity in small children and chose appropriate and cost-effective health care options before the need arises in their caregiving roles.


Health care consumers are required to make safe health care decisions that are considered appropriate and cost-effective. The CROSS scale is a psychometrically sound tool that provides data on factors that influence this decisionmaking process.

• Health Literacy as a Barrier to Managing

Hypertension Treatment among Patients in

Federally Qualified Health Centers

Chandra Y. Osborn, Ph.D., Stephen, D. Persell,

M.D., Michael S. Wolf, Ph.D., M.P.H.

Presented By: Chandra Y. Osborn, Ph.D., Health

Services Research Fellow, Institute for

Healthcare Studies, Northwestern University,

Feinberg School of Medicine, 676 N. St. Clair

Street,Suite 200, Chicago, IL 60640, Phone:

(312) 695-6956, Fax: (312) 695-4307, Email: cosborn@northwestern.edu

Research Objective: Hypertension is a major contributor to cardiovascular disease, stroke, and kidney disease. Multiple antihypertensive medications and dose changes are often required to achieve blood pressure control. The benefits of treatment rely heavily on a patient’s ability to properly manage his/her medication regimen. We examined the independent association of literacy and patients’ ability to correctly identify their medications in inner-city medical clinics.

Study Design: Patients with hypertension were recruited from two clinics in Grand Rapids,

Michigan. In-person interviews were used to both assess health literacy with the Short ----Test of Functional Health Literacy in Adults (S-

TOFHLA), and obtain self-reported information on the number and name of patients’ hypertensive medications. Current medications and most recent blood pressure were extracted from medical records. A physician identified and compared the antihypertensive medications in each medical record to that of patients’ selfreports. Discrepancies were identified, and patients were coded as reporting all, some, or no medications in common with their record; and being able to or unable to name their hypertensive medications.

Population Studied: Patients were ineligible if they did not speak English, or if the clinic nurse judged that they were too ill or cognitively impaired to participate. The rate of participation was 71%. Of those who participated (N = 119), average age was 55, 67% were female, 61% were

African American, 39% reported completing less than a high school education, and 31% were identified as having inadequate health literacy.

Principle Findings: Patients with inadequate literacy were more likely to be prescribed 2 or more antihypertensive medications than patients with adequate literacy (81% vs. 54%, p=0.004).

Only 23% of all patients could name 2 or more antihypertensive medications, whereas 40% named none correctly. Compared to patients with adequate literacy, patients with inadequate literacy were more likely to be unable to report any of their medications (60 % vs. 32 %; OR 3.2,

95% CI 1.4-7.1). This difference remained after adjusting for age and income (AOR 2.9, 95 % CI

1.3-6.7). Self-reported medications differed entirely from the medical record for 65% of patients with inadequate literacy and 38% with adequate literacy. Patients with inadequate literacy tended to be less likely to have blood pressure below 140/90 mm Hg compared to those with adequate literacy (60 % vs. 71%; p=0.096).

Conclusions: Nearly a third of patients had inadequate health literacy. These patients were taking more hypertensive medications, less able to identify their medications, and exhibiting a trend of higher blood pressure than patients with adequate health literacy.


Low health literacy may be an important risk factor for poor comprehension of health information, medication mismanagement, and chronic disease control. Strategies are needed to better educate low literacy patients about their medications. This might include improved packaging, labeling, and dispensing practices.

Funding Source: CDC

• A Comprehensive Intervention Plan to

Provide Medical and Psycho Social Supportive

Care to Breast Cancer Patients

Nancy Rodriguez, R.N., B.S.N., C.P.H.Q.,

P.A.H.M., Sandra White, M.D., FACR, M.B.A.

Presented By: Nancy Rodriguez, R.N., B.S.N.,

C.P.H.Q., P.A.H.M., Senior Clinical Quality

Compliance Administrator, Quality

Management, Blue Cross Blue Shield of Georgia,

3350 Peachtree Road, NE; MSC GAG006-0008,

Atlanta, GA 30326, Phone: (404) 848-2334, Fax:

(404) 842-8480, Email: nancy.rodriguez@bcbsga.com

Research Objective: Development of a comprehensive educational campaign for breast cancer care addressing identified barriers to quality breast cancer care and satisfying the

Priority Aims and Recommendations of the

Institute of Clinical Systems Improvement including encouraging multi disciplinary care using all appropriate treatment modalities, improving access to information regarding all appropriate local treatment options, and increasing the use of standardized educational materials and psycho social support for patients and their families.

Study Design: In 2004, Advisory Panels of physicians and laypersons identified barriers to care, and information needs of physicians and newly diagnosed breast cancer patients. A comprehensive educational program was developed, materials were written, and in 2005 materials were distributed via mail to all network primary care, OBGYN, general surgeon, and oncology specialist physicians, and to all

BCBSGA members with a medical claim diagnosis of breast cancer in 2004 and thereafter. Every educational packet included a feedback survey tool to assess the intended use of the item and its usefulness to the patient and physician.

Population Studied: Materials have been distributed to 5,277 individual physicians at 7,823 practice locations, and to 9,583 patients to date.

Over 14,000 component materials have been distributed on request to Georgia community leaders, breast cancer community advocates, and individuals with breast cancer, regardless of insurance coverage. 165 patients and 141 physicians returned the survey.

Principle Findings: All materials were rated for intended use and helpfulness on a scale of 1 to 5 with 5 being the most favorable score. The

General Treatment Guidelines for Physicians, rated average 4.46 is useful to facilitate patient discussions for non cancer specialists, and promotes guideline compliance for oncology specialists. The Patient Checklist, a decision support tool, rated 4.2 by physicians and 4.1 by patients, helped the patient and doctor talk to each other, understand and discuss treatment options and make treatment plans together.

Both patients and physicians recognized that the

Patient Education Booklet, rated average 4.56 helped the patient better understand breast cancer and how to cope with it, covered topics that were important to her, and was helpful. The

Resource List, rated average 4.42 helped the patient locate additional sources of support and more information.

Conclusions: A carefully developed portfolio of written material will assist patients and physicians in navigating through breast cancer episodes. Based on surveys returned, patients and physicians are highly satisfied with the program. All materials distributed were deemed suitable for patients, and physicians indicated they will use them in their practice. Patients are overwhelmingly positive in their feedback about the program, recognizing and valuing the support they received from their insurance company.

Implications for Policy, Practice or Delivery: It is possible to implement an effective educational program suitable to a diverse audience of professionals and laypersons. Optimal use of tools to support informed and shared decision making includes a distribution mechanism close to time of diagnosis, and availability to any physician discussing a new diagnosis and treatment options with the patient. Community partnerships and a variety of venues are valuable in disseminating information resources.

Funding Source: Quality Management

Department Operating Budget

• Consumer Perception of Self-Aid Materials in Over-The-Counter Nicotine Patch

Chih-wen Shi, M.D., M.S.H.S., Shu-Hong Zhu,

Ph.D., Sonia Jain, Ph.D., Lida Becerra, M.S.,

Theodore Ganiats, M.D.

Presented By: Chih-wen Shi, M.D., M.S.H.S.,

Assistant Adjunct Professor, Family and

Preventive Medicine, UC San Diego, 9500

Gilman Drive M/C-0807, La Jolla, CA 92093,

Phone: 6195435489, Fax: 6195435996, Email: cwshi@ucsd.edu

Research Objective: Over-the-counter (OTC) nicotine patch products contain self-aid materials as a surrogate for formal physician counseling. Yet little is known about whether consumers utilize these resources and what their perceptions are of these materials. We undertook a study to explore this issue.

Study Design: Adult consumers (N=155) of OTC nicotine patch from 30 retail pharmacies in San

Diego County were recruited to complete a selfadministered questionnaire two weeks after purchase. The questionnaire asked participants in an open-ended format whether they elected to use the enclosed CD-ROM, a self-aid tool, and the reasons behind their decision.

Immersion/crystallization methods were used to extract major themes. Logistic regression was performed to explore factors associated with CD-

ROM use.

Principle Findings: Of the 22% percent who used the CD-ROM, 26% stated that the material was helpful. Among the 78% who did not use the CD-ROM, most believed the material would not augment their knowledge or motivation for quitting. Other reasons for not viewing the CD-

ROM included having no time or seen similar materials in the past, lost or cannot find the CD-

ROM, and forgetting to use the material. Less utilization of CD-ROM was associated with individuals who live with multiple smokers, have poor self-rated health status, experience sideeffects with the patch, and believe the patch is inexpensive.

Conclusions: Although self-aid materials are included in each OTC nicotine patch package, few consumers utilize this resource. Even among those who did review the material, few found it helpful. The current material appears to lack application for smokers, especially those with impeding factors to quitting.


• Consumer Responses to Complexity Under

Medicare Part D

Denise Soffel, Ph.D., Aviva Goldstein, M.P.A.,

Swati Garg, M.P.H.

Presented By: Denise Soffel, Ph.D., Senior Policy

Analyst, Community Service Society, 105 East

22nd Street, New York, NY 10010, Phone: (212)

614-5308, Fax: (212) 614-9441, Email: dsoffel@cssny.org

Research Objective: What does the transition to

Medicare Part D as it was experienced by the dual-eligible population in New York City tell us about privatized health care and consumer choice.

Study Design: When Medicare Part D was implemented, the Community Service Society received funding to establish a monitoring collaborative to capture the experience of dualeligibles during program implementation. The

Collaborative included 7 agencies that served different segments of the dual-eligible population, including immigrants, people with disabilities, HIV, and mental illness. We conducted a focus group with 6 of the participating agencies. Three focus groups were with dual-eligible beneficiaries; three were with case workers that serve the Part D population.

Population Studied: Dual-eligibles who sought help in navigating their Part D drug benefit from one of six agencies providing client assistance in

New York City.

Principle Findings: The transition to Medicare

Part D shifts responsibility for navigating the system onto vulnerable consumers. For the system to work requires that a multitude of unrelated systems all work properly. When things go wrong, it is difficult to identify where the problem occurred, and how to resolve it.

The program is working in part because individuals craft temporary solutions to their problems, which include borrowing medication from a friend or relative, going to the emergency department for a short-term supply of medication, and relying on the kindness of local pharmacists to fill in when coverage cannot be established. Dual-eligible beneficiaries experience a significant amount of fear because they know that they don’t fully understand how the drug benefit works, and that something might go wrong at any time. For people who are poor and who rely on medication to maintain their health, this creates a profound sense of vulnerability. It also results in individuals going without medication, or in taking reduced doses

of medication, as a way of managing uncertainty about their drug coverage.

Conclusions: The confusion caused by Part D results in individuals cutbacks and self-dosage of prescribed medications, with potentially dangerous health consequences. Communitybased organizations, mental health providers, pharmacists, and physician offices play a large role in making Part D function. This role is unacknowledged, and unreimbursed. The quality of the information provided varies greatly; cases of pharmacists providing misinformation are extremely common. Reliance on this informal network also constrains their ability to provide the services they are actually supposed to be providing.


For many dual-eligible consumers the

‘‘consumer choice’’ provided through the Part D drug program is overwhelming and disempowering. Consumers recognize the serious consequences of making a poor choice.

Given the large number of options, and the high degree of confusion surrounding the choice, many consumers opt not to make a choice at all, but allow themselves to be auto-assigned into a plan. Highly vulnerable patients do not have the confidence or the ability to navigate the system themselves. Consumers turn to a variety of informal sources to help them navigate, not all of which are reliable.

Funding Source: United Hospital Fund; Altman

Foundation; New York Community Trust

• The Promotion and Sale of Nutrigenomic

Services On-Line

Rene Sterling, M.H.A.

Presented By: Rene Sterling, M.H.A., Pre-

Doctoral Fellow, University of North Carolina at

Chapel Hill, Cecil G. Sheps Center for Health

Services Research, 725 Martin Luther King Jr.

Blvd., Chapel Hill, NC 27599, Email: renesterling@verizon.net

Research Objective: To conduct a comprehensive search for and quantitative content analysis of commercial websites that sell or promote nutrigenomic services on-line.

Study Design: Nutrigenomic researchers hope to improve health outcomes through personalized nutrition. While nutrigenomics is a promising field, many experts consider the current sale and marketing of nutrigenomic services to be highly premature. Nutrigenomic services include genetic tests marketed to identify variants in several genes associated with diet-related, chronic health conditions that can have multiple causes. Some of these conditions include high blood pressure, osteoporosis, insulin sensitivity, or impaired ability to eliminate toxins from the body. Nutrigenomic services also include personalized supplement, diet, or lifestyle advice based on individual test results and other health information. The most extensive promotion of nutrigenomic services currently occurs on the Internet. What consumers read on commercial websites may be different from what they need to know before making a purchase. More information is needed about the on-line promotion and sale of these services to inform the development of genetic testing policy to protect consumer health and safety.

Population Studied: Publicly accessible commercial websites promoting or selling nutrigenomic services.

Principle Findings: October 2006, a comprehensive search for commercial websites promoting or selling nutrigenomic services was completed using 20 pilot-tested keywords and three popular search engines. Over 1800

Uniform Resource Locators (URLs) appearing in search results were reviewed yielding 55 relevant websites for quantitative content analysis. Most of the organizations hosting these websites were private practitioners, group practices, and laboratories. A minority of organizations displayed trademark symbols for their nutrigenomic tests. In addition to nutrigenomic services, these organizations promoted other health- (e.g., pharmacogenetic testing) and social-related (e.g., genealogy testing) genetic services. Several websites allowing consumers to purchase services on-line did not identify any requirements for consultation with a health or genetic expert. Furthermore, the majority of websites did not discuss the importance of consultation with a genetic expert regarding test results (excluding fine-print disclaimers). In addition, websites included limited to no information regarding the limitations of nutrigenomic tests, and risks associated with genetic testing. More detailed statistics will be provided during the presentation.

Conclusions: When searching the Internet for information regarding diet, health, and genetics, consumers are likely to encounter commercial websites for nutrigenomic services. Several of these websites will provide little to no information about the risks and limitations of testing while allowing consumers to purchase services independently on-line. Furthermore, the appearance of trademark symbols on several

nutrigenomic tests and the promotion of nutrigenomic services by a wide variety of organizations may suggest to the average consumer a sense of legitimacy that currently is unwarranted.


The commercialization of nutrigenomics is charging ahead of both scientific discovery and genetic testing policy. While researchers continue to explore relationships among diet, genes, and health, the federal government must consider how it will go about protecting consumers from fraud and harm given the extensive promotion and sale of nutrigenomic services. Findings from this study can help to support informed policy development.


• Likelihood of Using Published Quality

Information and Importance of Quality-based

Financial Incentives: Variation Related to

Patient Characteristics

Deborah Taira, Sc.D., Richard S. Chung, M.D.

Presented By: Deborah Taira, Sc.D., Research

Manager, Care Management, HMSA (BCBS of

Hawaii), 818 Keeaumoku Street, Honolulu, HI

96814, Phone: 8089485337, Fax: 808-952-7536,

Email: deb_taira@hmsa.com

Research Objective: To examine the relationship between patient characteristics and

(1) likelihood of using published quality information and (2) perceptions of the importance of quality-based financial incentives.

Study Design: 2004 member survey. Members were asked whether they would (1) look up this information; (2) discuss with their doctor; (3) use it to make decisions. They were also asked to rate the importance of quality-based financial incentives. Multivariable generalized linear models were used to estimate the relative risk of using published quality data and valuing qualitybased incentives.

Population Studied: Adult enrollees in a large health plan in Hawaii who responded to a member satisfaction survey (n=42,614).

Principle Findings: A total of 68% said they were ‘extremely’ or somewhat’ likely to look up quality information; 66% said they were

‘extremely’ or ‘somewhat’ likely to discuss it with their doctor; 77% said they were ‘extremely’ or

‘somewhat’ likely to use it to make a decision.

Approximately 57% said financial incentives for quality were ‘very important’; 32% said they were

‘somewhat important’; 7% said they were ‘not too important’; 5% said they were ‘not important at all.’ Older members were significantly less likely to say they would use published quality information but more likely to view financial incentives for quality as important. Members in

‘very good’ or ‘excellent’ health were significantly more likely to report they would use published quality data [RR 1.3 compared to members in poorer health 95%CI(1.3-1.3)] and to view financial incentives as important [RR 1.2 95%CI

(1.2-1.2)]. Compared to whites, Chinese [RR .88

95%CI(.82-.94)], Japanese [RR .87 95%CI(.83-

.90)], and Korean [RR .87 95%CI(.77-

.99)]members were significantly less likely than whites to use published quality information, but

Filipinos [RR 1.1 95%CI(1.1-1.2)]were more likely.

Moreover, compared to whites, Chinese [RR .91

95%CI(.87-.95)]were significantly less likely to view financial incentives as important, while

Filipinos [RR 1.1 95%CI(1.1-1.2)]were more likely.

Conclusions: There is large variation in patient perceptions of their likelihood of using published quality information and the importance of quality-based incentives, related to age, ethnicity and health status.


Efforts to facilitate consumer decision-making through published quality information may need special outreach to target older members, members in poorer health, and possibly members of specific ethnic groups.

•

Physician-Patient Relationship and

Consumer Satisfaction: The Impact of Patient

Information Search and Education

Yang Xie, Ph.D, M.P.H.

Presented By: Yang Xie, Ph.D, M.P.H., Assitant

Professor, Clinical and Administrative Pharmacy,

College of Pharmacy, University of Iowa, 115 S.

Grand Ave. S-513 Phar., Iowa City, IA 52242,

Phone: 3193358623, Fax: 3193535646, Email:

Yang.Xie@gmail.com

Research Objective: To understand the role of information and patients' propensity to use that information, on the physician-patient relationship: does more information lead to better outcome or not? To examine the interaction between patient's information search and their education attainment in affecting patient's trust towards their physicians. To examine how such effect is influenced by different health insurance plans.

Study Design: We propose a cross-sectional study design to evaluate the relationship between patient's information search from nonphysician resources and their trust in physicians.

We will identify how patient's education attainment interacts with the information search behavior in affecting the trust and thereby their satisfaction. We also test for the simultaneity between information search and patient trust.

Population Studied: The data for this study are mainly from the Community Tracking Study

(CTS) 2000-2001 Household Surveys. Sixty communities were randomly selected across the nation using stratified sampling with probability in proportion to population size to ensure representation of the U.S. population.

Principle Findings: Patients with at higher education and conducted no information search are the most trusting patients. Compared with the group with no college education and no information search, the high education/information search group leads to a

35% increase in their trust scores, the group with at least some college education and conducted information search leads to a 13% increase in their trust scores. Among the low education group, regardless of information search effort, no significant difference in their trust score.

Conclusions: Not only the level of information asymmetry between patient and physician affects the patient-physician interaction in clinical decision making, but also patients' education, which influence patient's ability and propensity to use the information, affects the patientphysician relationship.

Implications for Policy, Practice or Delivery: In the information era, patients have many more resources to access information on health and treatment, but their ability to accurately process and utilize that information is not homogeneous. But patients have started to take more active roles in clinical decision making.

Therefore, designing and providing accurate information that can help patients to make optimal treatment choice in practice has significant impact on improving quality of care.

Coverage & Access

•

Changes in Prescription Use and Out-of-

Pocket Costs among Medicare Eligible Adults,

2005-2006

G. Caleb Alexander, M.D., M.S., Anirban Basu,

Ph.D., James Zhang, Ph.D., Shawn Sun, Ph.D.,

Kwan Lee, Ph.D., David Meltzer, M.D., Ph.D.

Presented By: G. Caleb Alexander, M.D., M.S.,

Asst. Professor, Department of Medicine,

University of Chicago, Phone: 773 834 9177, Fax:

773 834 2238, Email: galexand@uchicago.edu

Research Objective: Few assessments of the

Medicare Part D Prescription Drug Benefit have been performed. We examined the impact of the drug benefit on drug utilization and out-ofpocket expenditures.

Study Design: We used pharmacy claims data from a large national pharmacy accounting for nearly 15% of the market share of prescription drugs to compare drug utilization and out-ofpocket expenditures of Medicare eligible seniors in 2005 to their outcomes in 2006. We used pharmacy customers aged 60-63 during the same period as a control group to capture non-

Medicare related trends in drug utilization and costs occurring during the study period.

Population Studied: The sample represented approximately 5.1 million unique Medicare beneficiaries aged 66-79 and 1.8 million unique subjects in the control group who filled and obtained at least one prescription in pre-benefit

2005 period.

Principle Findings: After adjusting for individual characteristics and socio-economic characteristics of subjects' zip code of residence, preliminary analyses suggest subjects' annual drug utilization increased by 5.5% (95% confidence interval [CI] 4.7%-6.2%) and subjects’ annual out-of-pocket expenditures decreased by

10.6% (CI 9.6%-11.9%) in 2006 as compared to

2005, net of non-Part D related effects. Dual eligible subjects had little to no increase in drug utilization. However, they had similar declines in out-of-pocket expenditures as the broader beneficiary population. Sensitivity analyses demonstrated that the measured impact was not due to trend differences among different age groups over the study period.

Conclusions: Modest increases in prescription drug utilization and decreases in out-of-pocket expenditures occurred for these Medicare seniors following the implementation of the

Medicare Part D Prescription Benefit.


Our results highlight that the impact of Part D should be considered not only among those who enrolled in the benefit, but among non-enrollees as well. Further work is needed to examine these patterns among other beneficiaries and to evaluate the impact of these changes on health outcomes. These analyses, in turn, will help discern the degree to which increased utilization reflects moral hazard vs. beneficial expansion of coverage.


• Characteristics of Patients Receiving

Pharmaceutical Samples and Association

Between Sample Use and Out-of-Pocket

Prescription Costs

G. Caleb Alexander, M.D., M.S., James Zhang,

Ph.D., Anirban Basu, Ph.D.

Presented By: G. Caleb Alexander, M.D., M.S.,

Asst. Professor, Medicine, University of Chicago,

Phone: 7738349177, Fax: 773 8342238, Email: galexand@uchicago.edu

Research Objective: Pharmaceutical samples are widely used for promotion and marketing, yet little is known about who receives samples or how their use is associated with patient’s out-ofpocket prescription costs. We sought to examine the characteristics of patients receiving samples and to describe the association between sample receipt and prescription costs.

Study Design: We divided the 2002-2003

Medical Expenditure Panel Survey (MEPS) into a baseline period (the first two interview rounds) and an analysis period (the remaining three rounds). We conducted logistic and generalized linear regression analysis of 5,881 individuals receiving no sample during the baseline period.

We defined our main outcome measures as: (1) sample receipt, (2) out-of-pocket prescription expenditures, and (3) total prescription expenditures.

Population Studied: MEPS is a nationally representative, panel-design, longitudinal study of the U.S. civilian, non-institutionalized population.

Principle Findings: On preliminary analyses, a total of 781 (14%) individuals received at least one pharmaceutical sample during the analysis period. On multivariate analyses sample receipt was greater among those who were younger and those not on Medicaid. In generalized linear regressions controlling for demographic characteristics and health care utilization, the

180-day out-of-pocket prescription expenditures were $178 (standard error [SE] $3.9) for those never receiving samples. Among those receiving samples, the corresponding out-of-pocket prescription expenditures were $166 (SE $8.9) for periods before sample receipt, $244 (SE

$9.2) for periods during sample receipt, and

$212 (SE $12.4) for periods following sample receipt. Results were similar when total prescription costs were examined. Analyses that:

(1) stratified by baseline health care utilization,

(2) stratified by sample use for acute vs. chronic conditions, and (3) compared the number of diagnoses during periods prior to, during, or subsequent to sample receipt suggested that the observed associations were less likely to be driven by greater unobserved illness among sample recipients.

Conclusions: Individuals receiving samples have higher prescription expenditures than their counterparts. These findings suggest that sample recipients remain disproportionately burdened by prescription costs even after sample receipt.


Extensive commentary and research both supports and argues against the routine use of samples in the office setting. Few of these studies have examined the association between sample use and out-of-pocket prescription costs.

Our results highlight the importance of designing sample policies to minimize burden of out-of-pocket costs while maximizing patient welfare.

• Impact of Medicaid Preferred Drug Lists on

Therapeutic Adherence

Kirsten Axelsen, M.S.

Presented By: Kirsten Axelsen, M.S., Director,

Economic and Policy Research, Pfizer, 235 E.

42nd Street 235-8-8, New York, NY 10017, Phone:

212-733-8321, Fax: 212-716-9261, Email: kirsten.axelsen@pfizer.com

Research Objective: To estimate rates of nonadherence for statins following implementation of a preferred drug list (PDL).

Study Design: In a retrospective cohort study, a difference-in-difference-in-difference approach was used to estimate the impact of a PDL on statin utilization in an Alabama Medicaid population. The PDL restricted access to certain branded medications and imposed a monthly prescription limit. The use of restricted drugs was compared with the use of unrestricted drugs in the months before and after the PDL in North

Carolina (where there were no such restrictions) and Alabama.

Population Studied: Pharmacy claims data for statins paid by Medicaid from 2001 to 2005 were used to examine the effect of the Alabama PDL implemented in 2004 and the comparator state

North Carolina.

Principle Findings: Following the PDL in

Alabama, Medicaid beneficiaries taking statins had an 82% higher relative odds of becoming non-adherent with statin therapy compared with

North Carolina and with pre-PDL Alabama [odds ratio (OR) 1.82, 95% CI 1.57, 2.11]. Furthermore, patients taking a restricted statin were more

likely to be non-adherent than unrestricted patients (OR 1.42, 95% CI 1.12, 1.80). In addition, among Medicaid beneficiaries taking a restricted statin, people aged 65 years or older were more likely to be non-adherent than their younger counterparts after the PDL (OR 1.33, 95% CI 1.02,

1.73). Fifty-one per cent of patients in the

Alabama sample were non-adherent with statin therapy after the PDL, compared with 39% before. Non-adherence was 36% in North

Carolina in both periods.

Conclusions: Non-adherence increased markedly after utilization management was implemented. Furthermore older patients and beneficiaries taking medications restricted by the policy were most affected.


The management of heart disease and high cholesterol are important challenges, especially for low-income patients. Policy makers should be aware that access restrictions can have adverse consequences for patient adherence with medications that reduce cholesterol, a risk factor for heart disease. Note: This paper has been published in PharmacoEconomics, Vol. 24,

Supplement 3 (pp. 65-78), 2006.

Funding Source: Pfizer

• To Identify the Public Health Consequences of Migration and Define the Ways to Decrease the Consequences

Baasai Bulganchimeg, M.H.A.

Presented By: Baasai Bulganchimeg, M.H.A.,

Senior officer, Policy and Planning, Ministry of

Health, Government building 8, Olympic street

2, Ulaanbaatar, MN, Phone: 976-99244670, Fax:

976-51-262013, Email: bulgaab@yahoo.com

Research Objective: To identify the public health consequences of migration and define the ways to decrease the consequences

Study Design: The research methods such as questionnaire, observation, group discussion, individual interview and morbidity survey from family doctors’ records were used for the survey.

Population Studied: Totally 1000 migrated families of Songinokhairkhan district,

Ulaanbaatar city has been selected in this research.

Principle Findings: Average age of the respondents is 39.13-13.16 and 9.7% of them are

16-24-year old, 60.8% of them 25-44-year old,

24.3% of them 45-64-year old, and 5.2% of them

65 and above. 70% of respondents are male and

30% are female.

Looking at the educational level 13.0% of the participants of the survey are highly educated,

18.6% have technical/vocational education,

57.4% have secondary education, 9.3% have primary education and 1.7% are noeducated.

Compared to the males, females are 2 times less married, 2 times more widowed, and 6.4 times more divorced. Average duration of living without registration after migration to

Ulaanbaatar for survey participants is 19.9 ? 16.4 months. Having access to public health services and primary health care regardless of where he or she lives is one of basic human rights in the country. Ensuring the accessibility and quality of primary care provided to the migrants is an important component of basic social services.

The survey findings show that 77.5% of respondents know where the family clinic is,

22.5% do not know, 71.3% are under regular health check up, and 28.7% are not checked up.

Availability of communication facilities for the migrants were as follows:o 29.5% of respondents are able to communicate by mobile phone o7.5% by telephone o4.5% by mobiphone in case of emergency and o58.5% are not able to make any contact. Almost 13.5% of the migrants live at a distance more than 3 km from the family clinics.

It means that primary health care may be difficult to access physically for those people.

Respondents thoughts about the difficulties with primary health care access are as follows: -46.2%

- have no difficulties -17.4% - no permanent address and no registration -8.5% - bad living conditions and no money -3.7% - no telephone, bad roads -2.3% - clinic is far -0.4% - staff attitude -6.8% - lack of awareness -1.2% - don’t know where to go. 32.7% of pregnant women were not covered with routine medical check up and they explained the reasons: o37.5% of them are not covered bacause they did not know the location of the family clinics o62.5% of them did not approach the family clinics although they knew the location. This shows a lack of care seeking behavior of migrated women and not enough IEC activities of the family clinics for the inhabitants. Compared to the city statistics

2002, home birth of migrant women is the concerning problem because it is 3 times higher than total city home birth (1.4 percent). 15.7% of children under 5 of the families who participated in this survey were malnurished. To compare it with the National Nutrition Survey findings that was conducted in 2000, this figure is 2.4 times higher. According to the health statistics in 2002, coverage of immunization of under 1-year children was 98 percent for BCG, 95.4 percent

for OPV, 95.2 percent for DPT, 95.2 percent for measles and 95.1 percent fot hepatitis B.

Survey findings show that 46.6% of families involved in this survey responded that they were fully covered with routine vaccination after coming to a new residence, 5.2% gets some of the vaccines they should be covered by, 26.4% are covered before coming, 6.9% are not covered at all. By age category of the respondents, high morbidity rate occurred among the infants

(18.9%), middle-aged people (17,7%), adolescents (13,9%) and schoolchildren (12,3%).

Comparing health seeking behaviour with sex, men tend to come more to family doctors and ambulance; and women tend to apply clinical hospitals, private clinics and familier doctors.

With higher education they tend to approach clinical hospitals and with less education they do not know whom to apply to. Average usage of clean water of the participants of the survey for family one week was 285.5?167.6 litre. Compared with average usage of water (200-250 litre per day) at the level of centralised water supply, average water usage of the migrants is very limited. 65.3% of the selected families have enough food for family members according to the observation on availability of food products at home and 34.7% of them do not enough food.

It means one out of three families does not have enough food at home. Only 37.5% of the families live with good hygiene. 62.7% of them have a sink. It means that one out of three families does not have a sink, but it is not clear whether they wash their hands or not and there is the risk of contracting infectious diseases. Also this conclusion is confirmed by the findings that only 30.6% of families have water tanks in hygienic conditions. 24.6% of the adult participants in this survey belonged to unemployed. 71.3 per cent of unemployed people are male, 28.8 per cent of them are female.

Conclusions: Internal migration of the population to Ulaanbaatar city from the countryside has become a newly emerging social and demographic problem in the country. The migrants tend to leave their soum and hometown because of loss of their animals due to natural disaster and look for better living opportunities in the city, but the most of them are vulnerable people such as elderly, unemployed, and female headed families. This creates needs and demand of the migrants for the provision of accessible basic social services.

- The migrants are more vulnerable in terms of lack of access to basic health services because there is no timely registration of most migrants with local government, and coverage of health insurance among the migrants is comparatively very low. Even those who are covered by health insurance do not pay the insurance fee. - Internal domestic migration has a serious consequence on accessibility and availability of basic health services in sub-urban areas of Ulaanbaatar city.

- Access of the migrants to information and education on health related issues are insufficient due to lack of communication facilities available to them and no specific programs based on that. - Provision of maternal and child health care with high quality for the migrants is vital due to domination of women and children among the migrated population.

Lack of maternal and childcare provided by the family doctors and lack of care seeking behavior of the migrants leads to high rate of child morbidity and poor antenatal care for the pregnant women. - Hygiene and sanitation levels of most migrants is very low due to poor environmental settlements such us toilet, sink, boreholes and hand washing facilities that are high risk factors for spreading infectious diseases among the migrants. - High morbidity rate among the migrants compared with permanent residents of Ulaanbaatar city may relate to their mobility, living conditions and lifestyles.

Implications for Policy, Practice or Delivery: -

There are urgent needs and demand of the migrants for the provision of accessible basic social services. - One problem is lack of infrastructure development in the area where they live. On the one hand these implications are related to lack of awareness of their duty in migration and health insurance as citizens indicated in the relevant laws and rules, on the other hand, caused by a lack of proactive health interventions taken by the family doctors. There is a need for targeted IEC campaign for the migrants on priority public health issues. -

Migrants tend to ignore the importance of health insurance for the individuals and do not follow other related laws and rules. - Hygiene and sanitation levels of most migrants requires the building of safe environment for them in order to prevent infectious diseases - Family doctors’ home visits should be effective and should have followed up actions. Family doctors also should be paid for services they provide for the uninsured.

Funding Source: WHO

• Examining the Health Insurance Premium

Gap Between Affordability and Current

Product Prices for Small Employers and Their

Employees: Findings from the Nebraska State

Planning Grant

Li-Wu Chen, Ph.D., Michelle Mason, M.A., Liyan

Xu, M.S., Michael Shambaugh-Miller, Ph.D.,

Keith Mueller, Ph.D., Fred Ullrich, B.A.

Presented By: Li-Wu Chen, Ph.D., Associate

Professor, Preventive and Societal Medicine,

University of Nebraska Medical Center, 984350

Nebraska Medical Center, Omaha, NE 68198-

4350, Phone: (402)559-5260, Fax: (402)559-7259,

Email: liwuchen@unmc.edu

Research Objective: This study examines the premium gap between self-reported affordability and the prices of health insurance products currently available for small employers and their employees. We also examine the relationship of plan design to affordability.

Study Design: We conducted a mail survey using a sample of 600 small businesses with 50 or fewer employees in 3 regions of Nebraska in

2006. The survey included questions related to employer-sponsored health insurance (e.g., offering status, premium amounts business and employees say they can afford (premium threshold)). In addition, scenario questions were developed to examine the employer’s likelihood of offering health insurance in response to variation in premium price, deductible, copayment, and coinsurance of an insurance package. The scenario questions were randomized into questionnaires and the collected information was analyzed using generalized estimating equation (GEE) modeling.

Population Studied: Of the 600 contacted businesses, 158 responded to the survey (26% response rate). About half (47%) of the responding businesses were located in a metropolitan area. Businesses reported a median of 6 employees, ranging from 1 to 40.

The median percentage of full-time employees was 75%. Businesses reported that most of their employees made between $15,000 and $30,000 a year.

Principle Findings: Sixty-one of the 158 responding businesses (39%) reported offering health insurance to their employees. Those not offering health insurance were more likely to be smaller firms, have a lower percentage of fulltime employees, have younger and lower-income employees, and have a higher employee turnover rate, as compared with the businesses that did offer health insurance (p<0.05 for all). In addition, the non-offering businesses reported a statistically significant lower premium threshold for their business and employees than the offering businesses (p<0.05). Approximately twothirds of non-offering businesses reported a monthly premium threshold of less than $100 for their business as well as for their employees.

However, the total monthly premium prices of current insurance products available in the market range from $250 to $300 for employeeonly coverage, according to a panel of Nebraska insurance company representatives. The GEE regression analysis based on scenario questions suggests that non-offering businesses are 3.38

(95% CI of odds ratio: 2.53, 7.57) times more likely to offer health insurance if the total monthly premium is reduced from $500 to $300, while the offering businesses are 72% (95% CI of odds ratio: 1.04, 2.85) more likely to offer health insurance under the same premium change. The offering businesses are also 48% more likely to offer health insurance if the coinsurance of an insurance package is reduced from 30% to 10% for employees (p < 0.1).

Conclusions: There is a gap -- at least $50 to

$100 for employee-only coverage and much higher for family coverage -- between the premium price most non-offering small businesses and their employees say they can afford and the insurance product prices currently available. Small businesses (especially the nonoffering businesses) respond significantly to the reduction of the premium gap when considering whether to offer health insurance to their employees.


Strategies can be developed to help close the premium gap measured in this paper.

Approaches can blend private sector actions

(e.g., lowering charges for patients insured by plans serving small employees, lowering administrative charges by insurance companies for plans covering employees in small firms) and public policy (e.g., reinsurance pool, subsidy of the premium including use of Medicaid resources for that purpose).

Funding Source: Nebraska State Planning Grant from HRSA

• Demography of Hospice Use in the United

States

Stephen Connor, Ph.D., Felix Elwert, M.A., Carol

Spence, R.N., M.A., Nicholas A Christakis, M.D.,

Ph.D.

Presented By: Stephen Connor, Ph.D., Vice

President, Research and International

Development, National Hospice & Palliative

Care Org, 1700 Diagonal Rd, Suite 625,

Alexandria, VA 22314, Phone: (703) 837-3149, Fax:

(703) 837-1233, Email: sconnor@nhpco.org

Research Objective: To examine the entire population of hospice users in the US in comparison to all who died in order to improve access to hospice through improved understanding of

Study Design: Complete CDC death certificate records and CMS 100% Standard Analytic File for hospice claims for 2002 were used to describe the whole population of hospice users and non-users in the United States.

The hospice utilization ratio (HUR) was used in this study. We defined the HURi of a specific group of decedents, i, as the fraction of decedents in that group who used professional,

Medicare-reimbursed hospice care at some point during the year before their death.

Population Studied: There were 1,811,720 persons aged 65 years and older who died in the

United States in 2002. In the same year, 518,078 unique individuals used hospice services under the Medicare program and likely died.

Principle Findings: The overall hospice utilization rate among elderly Americans in 2002 is estimated as 28.6%. Hospice utilization varied by cause of death, and was highest for individuals with malignancies (65%), kidney disease and nephritis (55%) and Alzheimer’s disease (41%). Hospice utilization was lowest for conditions leading to rapid or unexpected death such as accidents and suicide (0%), influenza and pneumonia (3%), and sepsis

(6%). Racial differences in hospice use are shown including black white differences.

Considerable geographic differences in hospice utilization existed with hospice use higher in the

South and the Southwest and lower in the

Midwest and the Northeast. State-specific usage rates range from 8% in Alaska to 49% in

Arizona.

Conclusions: Hospice use in the US has increased significantly but variations in hospice use are identified.


Our findings highlight opportunities for the hospice industry to provide more care, opportunities defined by diagnostic, racial, and geographic axes.

Funding Source: NHPCO

• Free Clinics: A Nationwide Survey

Julie Darnell, M.H.S.A., A.M.

Presented By: Julie Darnell, M.H.S.A., A.M.,

Doctoral Candidate, School of Social Service

Administration, The University of Chicago, 969

E. 60th Street, Chicago, IL 60637, Phone: 773-

263-0533, Email: j-darnell@uchicago.edu

Research Objective: Given our widespread attention to the rising number of uninsured persons and continued concern about the viability of the healthcare safety net, free clinics should be considered because they serve uninsured persons who are at greatest risk for adverse health outcomes. This research reports on the first nationwide comprehensive study of free clinics, and it describes the characteristics and distribution of the clinics in the United

States.

Study Design: A national mail survey (October

2005 ---- December 2006) of all known free clinics in the United States was completed, using a 70item, 12-page questionnaire designed to obtain information about the attributes of free clinics, the characteristics of patients, and the amount of scope of services, the number and type of staff and volunteers who deliver services, and future plans. Of 1,038 clinics that were determined eligible, 789 responded, yielding a response rate of 76%.

Population Studied: Free clinics are private nonprofit organizations providing healthcare services to uninsured individuals, staffed principally by volunteer licensed healthcare professionals but also utilizing paid staff. They charge no fees or nominal fees for services or may request donations.

Principle Findings: Having consulted more than three dozen sources to generate my sampling frame, I estimate that there are approximately 1,050 free clinics in the United

States. Free clinics exist in every state, although the number varies considerably from one clinic

(Alaska, Delaware, Hawaii, and Rhode Island) to

71 clinics (Texas). The number of free clinics per

100,000 residents ranges from .07 clinics (New

Jersey) to 1.64 clinics (Vermont). Free clinics are open 18 hours (mean) per week. Most provide some primary medical services on site, including medications (92%), physical exams (87%), health education (78%), chronic disease management (73%), and urgent care (67%). The total mean number of medical and dental visits per clinic per year is 3,489 with a mean operating budget of $290,790. Free clinics draw from a diverse portfolio of sources for financial support,

including individuals (91%), civic groups (67%), churches (66%), foundations (66%), and corporations (57%). Most free clinics (58%) report that they receive no revenues from government sources. Among clinics that accept government funding, the percentage of revenues from government sources accounts for less than

25%. While 50% of free clinic patients are white,

African Americans account for 21% and Latinos account for 25%. Free clinics have existed for several decades and a few for nearly a century; the mean age is 12 years (1994). Free clinics serve 1.9 million (mean) patients annually, of whom 92% are uninsured. By contrast, the federal $1.8 billion health center program serves

15 million patients, of whom 40 percent (six million) are uninsured.

Conclusions: Free clinics are important contributors to the healthcare safety net.

Operating with little or no government funding, free clinics target their resources to uninsured patients.


The very existence of free clinics suggests the limits of a safetynet buttressed by insurance and government. Our decisions to apportion limited public resources to safety net providers would be sounder if consideration were given to the full range of providers, including free clinics.


•

Is Private Health Insurance Leaving Low-

Income Children Behind?

Jennifer DeVoe, MD, DPhil, Lisa Krois, M.P.H.,

Tina Edlund, M.Sc., Jeanene Smith, M.D.,

M.P.H., Nichole E. Carlson, Ph.D.

Presented By: Jennifer DeVoe, MD, DPhil,

Assistant Professor, Family Medicine, Oregon

Health & Science University, 3181 Sam Jackson

Park Rd, mailcode FM, Portland, OR 97239,

Phone: 503-494-2826, Fax: 503-494-2746, Email: devoej@ohsu.edu

Research Objective: Despite expansions in public health insurance, millions of US children lack coverage. Oregon has a high rate of uninsured children compared to other states, and many Oregon children eligible for publiclyfunded health insurance remain uninsured. The percentage of uninsured children in Oregon rose from 10.1% in 2002 to 12.3% in 2004. Shortly after the Oregon Health Plan expanded eligibility for children and cut benefits for adults, this study was conducted to examine why children eligible for publicly-funded health insurance remain uninsured, with a specific focus on the associations between coverage for parents and children.

Study Design: This study was a cross-sectional analysis of statewide data. Primary predictor variables for the multivariable analysis were parental insurance type and status. Covariates included ethnicity, age, household income, and parental employment. The main outcome variable was children’s insurance status.

Population Studied: Random sample of families enrolled in Oregon's food stamp program with children presumed eligible for publicly-funded health insurance.

Principle Findings: Nearly 11% of children in the study population were uninsured. Over 80% of uninsured children had an uninsured parent, compared with only 25.5% of insured children

(p<0.0001). After adjusting for ethnicity, age, household income, and parental employment, children with an uninsured parent had a significantly lower likelihood of being insured

(OR 0.07, 95% CI 0.05, 0.10). Insured parents were less likely to have an insured child if the child was Hispanic, if the parent was employed, and/or if the household income was at the upper end of the income threshold (133-185% of the federal poverty level). Among these insured families, the children of parents with private insurance had a lower likelihood of having insurance coverage compared to children whose parents were covered by a publicly-funded program (OR 0.21, 95% CI 0.10, 0.47).

Conclusions: Among families enrolled in

Oregon's food stamp program in 2005, parental uninsurance was strongly associated with a lack of insurance coverage for children. Parents with private insurance coverage were less likely to have insured children, compared with families who had public coverage.


Current fiscal constraints have led many states to reduce the number of parents eligible for public health insurance, which may impact children's coverage. As parents lose insurance, children appear more likely to go without coverage as well. In addition, when low-income families succeed in finding employment with health insurance coverage, the private insurance may be leaving children behind. Findings from this study contributed to the Governor’s

‘‘Healthy Kids’’ initiative, which will be presented to Oregon’s state legislature this year. This initiative was designed to continue discussions about creating affordable health insurance options for vulnerable families. Some of the alternatives being proposed during this legislative session include expanding the public

subsidies to help parents afford private family coverage or creating a public insurance plan with graduated premium prices, depending on family income levels.


• The Public Costs of Uninsured Workers and

Their Dependents

Sherry Glied, Ph.D., Bisundev Mahato, B.A.


Health Policy and Management, Mailman SPH,

Columbia University, 600 West 168th Street,6th

Floor, New York, NY 10032, Phone: 212-305-

0299, Fax: 212-305-3405, Email: sag1@columbia.edu

Research Objective: Declines in private coverage, expansions in public programs, and a growing uninsured rate, have shifted the distribution of health care financing for full time workers and their families toward public sources.

Employees of small firms are much more likely than those in larger firms to lack an offer of coverage, and employees of these firms and their family members are more likely to be uninsured or to rely on public programs than are employees of larger firms. Recently, however, there has been an increase in the share of uninsured workers in larger firms. The growth of large ‘‘low benefit’’ firms has captured considerable public attention. In this article we estimate the extent of this problem and assess how it has changed over time, using the 1999 and 2003 MEPS.

Study Design: We use the Medical Expenditure

Panel Survey (MEPS) 2003 for our main analysis and make comparisons with the 1999 MEPS. We define a worker as someone who works full-time, is not self-employed, and earns at least $1 per hour in current dollars. When a family contains more than one worker, we assign the family members to the worker whose establishment size is largest. We divide workers into three groups--- those at small firms (establishments with 2-100 employees and only one location); those who work at multilocation firms

(establishments with 2-100 employees and multiple locations); and those who work at large firms (establishments with more than 100 employees).

Population Studied: Our principal interest in this analysis is the population of people who are full-year publicly insured or full-year uninsured.

Principle Findings: In 2003, the public cost burden associated with full-time workers and their family members amounted to $475 billion, an increase of $26.5 billion over 1999. About ½ of all workers without employer-sponsored insurance and about ½ of family members who are uninsured throughout the year work at large or multi-location firms. The share of all workers and family members enrolled in public health insurance programs who were associated with large or multi-location firms increased between

1999 and 2003. The public burden associated with workers and their family members increased by about 50% between 1999 and 2003, with a proportionate increase among workers and family members in large or multi-location firms.

Conclusions: Most of the increase in public cost associated with full-time workers and their family members has come about through a decline in the propensity of household members to hold coverage through a worker in the family. For workers in small enterprises, this decline has been associated with an increase in uncompensated care. For workers in multilocation establishments, and particularly those in larger establishments, much of the decline in private employer-sponsored coverage has been offset by an increase in public coverage.


Rising costs have made private health insurance less accessible for many workers. At the same time, expansions in public programs, especially for children, have offered a new source of needed coverage. As policymakers consider further reforms, our results suggest, they should favor plans that combine public program expansions with efforts to maintain or expand employerprovided coverage.

Funding Source: CWF

•

Using the Andersen and Aday Behavioral

Theory of Health Care Utilization to Model

Health Service Use among Adult Uninsured

Patients at a Community Health Center

Jewel Goodman, M.P.A., Ph.D.(c), Stacey B.

Plichta, Sc.D., Qi Harry Zhang, Ph.D., Barbara

Morrison-Rodriguez, Ph.D.

Presented By: Jewel Goodman, M.P.A., Ph.D.(c),

Full time graduate student, College of Health

Sciences, Old Dominion University, 304 Brook

Avenue, Suffolk, VA 23434, Phone: (757) 582-

3190, Fax: (757) 952-0184, Email: jgoodman@pich.org

Research Objective: This proposed dissertation will contribute to the lack of prescription medication access literature as it refers to improving access at the community level for uninsured adult patients who are managing

newly diagnosed chronic conditions with prescription therapy and are in receipt of care at a community health center. The purpose of this dissertation will be threefold: 1) to test the explanatory power of the Behavior Model of

Health Care Utilization for health service use among adult uninsured patients seeking care at an urban community health center; 2) to explore the context within which preventable health care utilization visits occurred during the follow-up period; and 3) to measure the relative contribution of an enabling factor of prescription medication access via the stop-gap program on health care utilization.

Study Design: This study is a longitudinal, observational design covering a period of 90 days. There exists no random assignment or random selection, all patients captured during the defined time period who meet the criteria of being a new patient have the potential to be participants and will be invited to participate.

The longitudinal, observational design has been selected for this study, as it is especially appropriate for addressing issues and supporting research methods that require more than the traditional cross-sectional approach and use of existing data; this design is particularly valuable when the focus is directly on change and the phenomena are themselves inherently longitudinal as with this study. This design requires a pretest and a posttest for the treated group and the comparison group. In this study, the treated group will be those patients who are eligible for stop-gap prescription medication and the comparison group will be those patients who are not eligible for stop-gap prescription medication.

Population Studied: The inclusion criteria for participation in this study includes the following: the participant must be at least aged 18 years; be categorized as either underinsured, uninsured or self-pay by the financial department personnel at the host community health center; be a new patient seeking care at the host CHC or not have been treated by the CHC within the past 12 months; and once the initial physician encounter is completed, a review of the medical record takes place for the additional inclusion criteria.

The patient then must receive a physiciandiagnosis of at least one of the five chronic disease states of asthma, diabetes, heart conditions, hypertension or hyperlipidemia and be in receipt of a prescription to treat, manage, lower, or control the chronic condition. Those patients found to meet all of the inclusion criteria will be invited to participate in the study.

Therefore, the pretest measure is categorization as underinsured, uninsured or self-pay.

Principle Findings: It is hypothesized that there will be a change in health utilization patterns and ultimately health outcomes among those patients who have access to the enhanced service-delivery model of stop-gap prescription medication access. Those patients who do not have access to stop-gap prescription medications will have more preventable health care visits than patients who have access to stop-gap prescription medications when controlling for such factors as age, ethnicity, social support system, attitudes about health and health care, past 12 months prescription access history, self-report disease state, and physician-diagnosed chronic condition. Those patients who do not have access to stop-gap prescription medications will be more likely to have either uncontrolled or a negative change in health outcomes as compared to patients who have access to stop-gap prescription medications when controlling for such factors as age, ethnicity, social support system, attitudes about health and health care, past 12 months prescription access history, self-report disease state, and physician-diagnosed chronic condition.

Conclusions: The data analysis and results are forthcoming as the data collection stage is in process; yet interpretations of the results should be conservative when they are available for several reasons. Participants are from one community health center system with locations in two Hampton Roads’ cities, therefore, group characteristics may not be representative of a larger national sample and thus the selectiontreatment interaction threat limits the generalizability of the study; patients may either consciously or unconsciously change their performance or responses so the experimenter effect should be considered; multiple treatment interference is yet another potential threat to external validity, as the sample of participants consists of new patients, who may or may not return for follow-up appointments; and lastly, reactive affects, as subjects have a tendency to change their behaviors when they are participating in a study. Unexpected events are likely to occur between the pre- and posttest, and may affect health care utilization behaviors and clinical outcomes; patients may incorporate substantial lifestyle modifications such as diet and exercise and may no longer be required to adhere to prescription regimens. Given these potential threats to external and internal validity, it is suggested that generalizations beyond this

study’s sample population be completed with caution.


This study proposes that a management program focusing on improved access to prescription medication is likely to show a decrease in preventable health service utilization visits as prescription needs are met. Although most efforts of change are met with the complexity of the overall process, this study proposes to show the benefit of implementation of an enhanced service delivery model for uninsured adult patients at a local community health center’s three clinical provider locations in real-time over a period of 90 days.

Funding Source: Old Dominion University's

Office of Graduate Studies and the Peninsula

Institute for Community Health

•

Access Through Community Health Centers or Coverage Through Medicaid: A

Geographical and Mathematical Analysis of the State of Georgia

Paul Griffin, Ph.D., Susan Griffin, Ph.D.,

Christina Scherrer, Ph.D., Julie Swann, Ph.D.

Presented By: Paul Griffin, Ph.D., Professor,

School of Industrial & Systems Engineering,

Georgia Institute of Technology, 755 Ferst Drive,

Atlanta, GA 30332, Phone: 404 894-2431, Fax:

404 894-2301, Email: pgriffin@isye.gatech.edu

Research Objective: The objective is to analyze the impact of expanding community health centers (CHCs) on primary care access and compare to increasing coverage through changing Medicaid, accounting for population needs, geographic differences, and physician supply.

Study Design: We developed an optimization model to locate CHCs and choose the level of medical services with the objective of increasing access to primary care. We estimated healthcare need and insurance coverage from NHANES and Census, and obtained CHC and Medicaid costs from HRSA and The Kaiser Family

Foundation reports. We compared the increase in primary care coverage from locating CHCs to increasing coverage for patients by raising

Medicaid eligibility.

Population Studied: Adults aged 18-65 in the state of Georgia.

Principle Findings: Doubling the current government CHC budget for Georgia from its

2002 level of $44M would increase uninsured persons served from 56,323 to 110,007 and persons with no previous form of primary care served from 68,998 to 130,799 at a annual cost per person of $820. Raising the Medicaid income limits for non-disabled, non-elderly adults from 33% to 100% of the federal poverty limit could increase participation from 203,771 to

566,159 persons (5.98% of which are estimated to have no primary source of care) at an annual cost of $2,655 per person. However, 40% of the counties in Georgia have no capacity for

Medicaid expansion.

Conclusions: Results suggest CHCs are effective for increasing persons with a primary source of care. However, either approach would require significant increases in government budget and medical personnel.

Implications for Policy, Practice or Delivery: If

CHC expansion is to continue in Georgia, it is important to consider it in the context of the system of provision.

Funding Source: National Science Foundation

• Threat of Medical Malpractice and Choice of Practice Location: The Case of Obstetrics and Gynecologists in the USA

Mahmud Khan, M.A., Ph.D., Shafin M. Khan,

B.Sc.

Presented By: Mahmud Khan, M.A., Ph.D.,

Professor, Health Systems Management, Tulane

University, 1440 Canal Street, #1440, New

Orleans, LA 70112, Phone: (504) 988-1979,

Email: Khan@tulane.edu

Research Objective: Malpractice threat is considered one of the most important reasons for physician relocation and pre-mature retirement, especially for high-risk specialties like

Obstetrics and Gynecology. The purpose of this study is to examine the effect of malpractice threat against OB/GYN on their choice of work location. The paper will address the following issues: (1) what should be the geographic distribution of OB/GYN if location decision is determined by the healthcare needs alone? (2)

How important is the malpractice threat in location decision of physicians?

Study Design: State level data on OB/GYN numbers, paid malpractice lawsuits, and other

State level characteristics are used in the analysis. Malpractice threat in a State is defined as the total number of paid claims over the previous three years per 1000 adult women in the State. Assume that the need for OB/GYN services in a State is given by Ni and there are P number of OB/GYN physicians in the country. If physician income depends on the healthcare need to physician ratio, a physician will locate in

State i if (Ni/(Pi+1))>(Nj/(Pj+1) for all j. Let the need-based physician distribution vector be [P*i].

Percent deviation of actual physician numbers from the need-based estimates are affected by a host of push and pull factors in physician location decision. The pull factors are: per capita income of the population, quality of life ranking of the state, degree of urbanization. The push factors are: the threat of malpractice, poverty rate, and percent of population uninsured. Both bivariate and multivariate analyses were conducted to identify important pull and push factors. For each of the years, need-based distribution was derived by writing and running a program written in Turbo C.

Population Studied: This is a cross-state analysis.Data were obtained from National

Practitioner Data Bank (NPDB), Department of

Census, Bureau of Labor Statistics, American

Medical Association, etc. State level information was collected for the years 1995, 2000 and 2004.

Principle Findings: Need for OB/GYN services for each of the States and Washington DC was calculated by taking a weighted average of number of births, normal and c-section deliveries and number of adult women in the State (costbased weights). Some States show presence of significantly higher number of physicians compared to the need-based numbers in all the three years (CT, DC, HI, MA, MD, NJ, NY). The number of OB/GYN physicians were significantly lower than expected in 11 (in 2004) to 16 (in

1995) States. In all the years, States with higher than expected number of physicians show higher per capita income, better quality of life, lower rate of poverty, higher penetration of HMOs, lower uninsurance rate and higher malpractice threat compared to the States with lower physician numbers. Regression model confirms that the effect of income per capita, percent of population in HMO plans, malpractice cases per

1000 women and poverty rate remains statistically significant in a multivariate analysis.

Conclusions: Income earning potential is the most important factor affecting physician location decision. 94% of the variations in inter-

State distribution of physicians is explained by the need for OB/GYN services. Income per capita of population and other demand affecting factors explain 70% of the remaining variations.

Empirical results are not consistent with the claim that physicians are being driven out of a

State due to high malpractice threat.


Physician numbers in a State is determined by demand and quality of life factors. Malpractice threats show no negative impact on physician location decision. Tort reforms to restrict malpractice lawsuits will not help improve

OB/GYN supply in a State.

•

The Impact of Health Insurance Coverage on Native American Elder Health:

Implications for Addressing the Health Care

Needs of Native American Elders

Alana Knudson, Ph.D., Ed.M., B.A., Kyle Muus,

Ph.D.

Presented By: Alana Knudson, Ph.D., Ed.M.,

B.A., Associate Director for Research, Center for

Rural Health, University of North Dakota, 501 N.

Columbia Rd, Stop 9037, Grand Forks, ND

58202-9037, Phone: (701)777-4205, Fax: (701)777-

6779, Email: aknudson@medicine.nodak.edu

Research Objective: The objective of this paper is to examine health insurance coverage among

American Indian and Alaska Native (AI/AN) elders, defined as 55 years or older by addressing the following:o to estimate the percentage of uninsured AI/AN elders;o to investigate what types of health insurance coverage AI/AN elders have, and,o to examine how different types of health insurance coverage and the lack of it impact access to health care services among

AI/AN elders.

Study Design: This study uses data from a national survey of elders, Identifying our Needs:

A Survey of Elders II, developed by the National

Resource Center on Native American Aging. The dataset, consisting of 8,305 Native elder respondents, was weighted to the respondent’s age- and gender-specific population from the

2000 census data for their respective Indian

Health Service areas. Three logit models were specified to evaluate the variables that predict health insurance coverage for this population.

Population Studied: American Indian/Alaska

Native elders (Native elders) are a small percentage of the U.S. elder population, thus their disparities are seldom identified in national studies.

Principle Findings: This study’s findings indicate that one out of four Native elders is uninsured. Young elders, 55 to 64 years of age, are most likely to be uninsured with one-third reporting having no insurance while 13% of adults 55 to 64 years of age in the U.S. general population report they are uninsured. Older

Native elders, 65 years and older, are also less likely to be insured; there is a 20-fold difference in the uninsured rate between Native elders 65 years of age and older and the U.S. general population (15% versus 0.7%). Further, the

result also indicates that uninsured Native elders are over twice as likely as insured Native elders to report that they have no regular provider (43% versus 20.4%), and one out of 10 Native elders report they were not able to get care when they needed it during the preceding 12 months.

Reasons cited for not getting health care when it was needed included long waiting times, transportation problems, and cost.

Conclusions: Our study provides evidence that the Native elders not only lack health insurance coverage, but for those who are uninsured, they also suffer from lack of access to health care.

Clearly, the intent of the Indian Health Services to provide health care services is not being met by meeting the needs of even the most fragile, uninsured Native elders.


The paucity of information pertaining to health insurance coverage, coupled with the misperception that Native American elders’ healthcare needs are fully addressed through the

Indian Health Service based on Federal treaty obligations, contributes to increasing unmet health care needs and health disparities.

It is essential to develop policies that address the financial, geographical, and cultural access to health care for them. To address the health care needs of the Native elders, a multi-faceted policy strategy is recommended to increase their health insurance coverage and reduce heatlh inequality, including recognizing that the trust relationship concerns of Native elders must be addressed as part of the enrollment process in private and public sponsored health insurance.

Funding Source: HRSA, ORHP

•

Challenges of Urban Safety Net Evaluation

Glenn Landers, M.B.A., M.H.A., Bernette

Sherman, M.P.A., Mei Zhou, M.S., M.A.




Street,Suite 221, Atlanta, GA 30303, Phone: 404-


Research Objective: Evaluate the supply of and demand for safety net health care services in seven metropolitan Atlanta counties and identify challenges and opportunities in data collection.

Study Design: Secondary analysis of individual characteristics, community level variables, and health care access and outcomes for seven counties. Primary data collection and analysis using survey, administrative, and interview data from 35 safety net organizations representing 101 servies delivery sites.

Population Studied: Safety net health care delivery sites in seven metropolitan Atlanta counties, defined as: oPublic hospitals that participate in the Disproportionate Share

Hospital program (DSH) oHospital-based clinics oFederally Qualified Health Centers (FQHC) oCommunity Health Centers (CHC) oIndependent clinics or Freestanding Primary

Care Clinic, including faith-based clinics oCounty health departments oCommunity Service Boards and affiliated mental health providers oNontraditional providers, including those that focus on specific diseases, conditions, or populations

Health care delivery sites were considered safety net providers if they serve individuals not covered by public or private insurance.

Principle Findings: The determination of the supply of and demand for health care safety net services at the community or regional level is challenged by: 1. Lack of common data definitions and reporting across service providers. 2. The potential shortcomings of selfreported data. 3. The lack of reliable estimates of the uninsured at the county or community level.

4. Administrative idiosyncrasies across service sites. 5. The time and effort involved in primary data collection. A qualitative study of community safety net providers can surface potential partnerships, collaborations, and joint ventures that might not otherwise be evident. Qualitative analysis across communities can also point to common needs (root causes) such as stable housing and employment opportunities not apparent in publicly available data sets.

Conclusions: In spite of the challenges encountered in measuring the supply of and demand for health care safety net services, the information gained from such an effort can contribute to a greater understanding of community-specific needs and opportunities.


Safety net providers are focused on their core business of health care delivery, not the accurate and reliable collection of administrative data that might be used to create system-wide efficiencies and promote collaborative partnerships. There are, however, important opportunities that might be exploited for safety net populations through the coordination and alignment of safety net services across providers within communities or regions. Such opportunities might include economies of scale or more efficient referral patterns. Toward the better coordination of safety net services, states have an interest in encouraging partnerships and promoting

efficiencies. Such partnerships and efficiencies can be promoted through the establishment of standardized data collection and reporting requirements that support reliable measurement of safety net service supply and demand. States might consider supporting sustainable safety net monitoring systems that enhance the capacity and efficiency of individual providers and that promote partnership and collaboration across communities.

Funding Source: The Community Foundation of

Greater Atlanta

• Can "Non-Emergency" Emergency

Department Visits Shed Light on Access to

Care?

Robert Lowe, M.D., M.P.H., Rongwei Fu, Ph.D.

Presented By: Robert Lowe, M.D., M.P.H.,

Associate Professor of Emergency Medicine,

Center for Policy and Research in Emergency

Medicine, Oregon Health & Science University,

3181 SW Sam Jackson Park Road, Mail Code

CR114, Portland, OR 97239, Phone: 503-494-7134,

Fax: 503-494-4640, Email: lowero@ohsu.edu

Research Objective: The "emergency department algorithm" (EDA) uses ED diagnosis to assign probabilities that an ED visit falls into each of 4 categories: non-emergency; primary care treatable emergency; preventable emergency; and non-preventable emergency.

Developers of this tool report that it can evaluate the medical safety net because patients with worse access to care will use EDs for less-urgent conditions, and it has been adopted widely by policy-makers. After the Oregon Health Plan

(OHP, Oregon’s expanded Medicaid program) underwent cutbacks that affected access to care in 2003, we tested the ability of the EDA to detect changes in ED use.

Study Design: This observational study used administrative data to compare all visits to 21

Oregon EDs during 2002 with all visits during

2004. For each payer category, mean probabilities that ED visits fell into each of the 4 categories were compared before versus after the

OHP cutbacks.

Population Studied: The ED visits in this dataset represented 55% of all ED visits statewide.

Principle Findings: The largest change in mean probabilities after the cutbacks was 2%.

Attempts to enhance the sensitivity of the EDA through other analytic strategies were unsuccessful. By contrast, ED visits by the uninsured increased from 6,441/month in 2002 to 8,754/month in 2004 and the proportion of uninsured visits leading to hospital admission rose by 51% (95% CI 46%, 57%).

Conclusions: The EDA was less useful in demonstrating changes in access to care than were other, simpler measures. Methodological concerns with the EDA that may account for this inability will be discussed.


Given the widespread adoption of the EDA among health policy researchers, we conclude that further refinement of the methodology is needed.


•

How Does Measures of Access to Care

Differ Between Rural and Urban Working-Age

Adults?

Ning Lu, Ph.D., M.P.H, Michael E. Samuels, Dr.

P.H., Elmer T. Whitler, M.A., M.P.A.

Presented By: Ning Lu, Ph.D., M.P.H, Associate

Professor, Public Health, Western Kentucky

University, 1 Big Red Way, Bowling Green, KY

42101, Phone: 270-745-5260, Fax: 270-745-4437,

Email: ning.lu@wku.edu

Research Objective: The purpose of this study is to examine the differences in access to care between rural and urban areas using four measures of access to care. 1) Health insurance status: measured by having or not having health insurance. 2) Usual source of care: measured by asking respondents if they had a personal or family doctor, or a nurse practitioner to rely on for medical care when needed. Respondents were classified as having a usual source of care if they reported ‘‘yes’’ and as without usual source of care if they reported ‘‘no’’. 3) Usual place to obtain care: respondents were asked to describe the type of place they usually go to when they have a health or medical problem. We grouped usual place of care into three classifications: private doctor’s office or clinic; a public clinic, free clinic, or community health center; and a hospital clinic or emergency room. 4) Timeliness of receiving care: respondents were asked how soon they could usually get in to see a doctor or a nurse practitioner when they felt sick and wanted to see one. We classified respondents as receiving care the same day or the following day; within the week; and longer than a week or see a doctor on call or go to ED.

Study Design: We conducted cross-sectional surveys of Kentucky household. Respondents were contacted using a modified, list-assisted

Waksberg Random-Digit Dialing method (RDD)

giving every household with a telephone an equal probability of being contacted. Interview calls were made from May 27, through September 12,

2005. Up to 15 attempts were made to each number in the sample. In addition, up to 10 scheduled call-backs were made to those were reached at an inconvenient time, and one refusal conversion was attempted. A total of 2,068 eligible individuals were used in this study. Both descriptive and inferential statistics were performed.

Population Studied: Study population is working-age adults 18 to 65 years of age in

Kentucky.

Principle Findings: We found no significant differences in overall health insurance status between rural and urban adults when demographic, socioeconomic factors and individual health status are considered.

However, rural adults are significantly more likely to report having usual source of care, and receiving care the same day or next day when needed, compared to their urban adults. Our analyses show that rural adults are more likely to use a public clinic, free clinic, community health center, a hospital clinic or emergency department for obtaining care than their urban counterparts.

Conclusions: We conclude that rural area adults are more likely to use public, free clinic and ED as their usual source of care and more likely to rely on receiving care at public or free clinic or

ED when they needed.


Although no significant differences in rural-urban overall rate of health insurance coverage, this does not automatically translate into an equal access to care between rural and urban workingage adults. Public and free clinic may have significantly increased the access to care for rural adults in Kentucky.

•

Distance Limits Initiation of Mental Health

Intensive Case Management Services among

High-Risk Patients with Serious Mental Illness

John McCarthy, Ph.D., M.P.H., Marcia

Valenstein, M.D., M.S., Stephanie Visnic, B.A.,

Frederic Blow, Ph.D., Lisa Dixon, M.D., Eric

Slade, Ph.D.

Presented By: John McCarthy, Ph.D., M.P.H.,

Research Investigator, Serious Mental Illness

Treatment Research & Evaluation Center, US

Department of Veterans Affairs, HSR&D Field

Program / SMITREC, P.O. Box 130170, Ann

Arbor, MI 48113-0170, Phone: 734-769-7100, x6253, Fax: 734-761-2617, Email:

John.McCarthy2@va.gov

Research Objective: In the Department of

Veterans Affairs (VA) health system, as the locus of psychiatric services has shifted from inpatient to outpatient settings, patients with serious mental illness (SMI) have become increasingly reliant on Mental Health Intensive Case

Management (MHICM) services. MHICM services are designed to support functional independence and community reintegration among patients with SMI who are at high risk for rehospitalization. Ensuring adequate and equitable access to MHICM care is a priority for the VA. We assess whether non-clinical factors, in particular geographic accessibility barriers, may limit eligible patients’ initiation of MHICM services.

Study Design: Using the VA’s National

Psychosis Registry, we identified all patients who in fiscal year 2003 (FY03) qualified for MHICM services (by having had >30 psychiatric days of stay or >=3 psychiatric stays); received diagnoses of schizophrenia, bipolar disorder, or other psychoses; and had received no MHICM services during FY03 or in the prior two years.

MHICM initiation was indicated by use of

MHICM services in FY04. In sensitivity analyses, we also examined sustained use (>=0.8 visits/week, prorated for time following initial use). Generalized Estimating Equations with a logistic link were used to adjust variance estimates for the clustering of patients within facilities. We assessed distance from the patient’s residence at the start of FY04 to the nearest MHICM team. Other covariates included age, gender, race/ethnicity, marital status, service connection, substance abuse, psychiatric inpatient days in FY03, presence of an on-site MHICM team in the last inpatient psychiatric stay of FY03, and number of available

MHICM slots at the nearest location.

Population Studied: 7047 patients qualified for

MHICM services in FY03, had diagnoses of SMI, and had not received MHICM services during

FY03 or in the prior two fiscal years.

Principle Findings: In FY04, 478 patients

(6.8%) received MHICM services, and 217 (3.1%) had sustained MHICM services use. Patients were significantly more likely to receive MHICM if they were younger (OR=1.10 per 5 years), female (OR=1.65), or unmarried (OR=1.37).

Those living farther from MHICM sites were less likely to receive services (OR=0.95 per 10 miles).

Similar results were observed for sustained use.

Patients who were homeless were less likely to have sustained use (OR=0.51).

Conclusions: Many eligible patients fail to receive MHICM services. Distance barriers limit

MHICM use.


Focused efforts are needed to improve initiation and delivery of MHICM services for eligible patients, particularly for those in remote locations.

Funding Source: VA

• Burden of Prescription Drug Expenditures among Veterans with Cardiovascular

Conditions

Pramod Meduru, M.D., M.P.H., Usha

Sambamoorthi, Ph.D.

Presented By: Pramod Meduru, M.D., M.P.H.,

Post-Doctoral Fellow, Center for Health Care

Knowledge Management, VA NJ Health Care

System, 385 Tremont Avenue, East Orange, NJ

07018, Phone: 732-735-6314, Fax: 973-395-7114,

Email: meduru@njneuromed.org

Research Objective: Over 71 million American adults, 34 percent, have one or more cardiovascular diseases with an estimated direct cost of over 257 billion dollars ---- 19 percent of which was primarily pharmaceutical costs.

However, the Veterans Health Administration,

VHA, has generous pharmacy benefits that may protect against high cost burden. Among veterans with diabetes, hypertension and heart disease, we compared the burden of pharmaceutical expenditures between veterans who used the VHA facility, VHA users, and veterans who did not, non-VHA users.

Study Design: This was a retrospective study on nationally representative data from MEPS years

2000-2003 analyzing total pharmaceutical expenditures, out-of-pocket pharmaceutical expenditures, and cost burden, i.e., percent of total pharmaceutical expenditures that were outof-pocket, on the individual veteran. T-tests and regressions were used to evaluate the relationships between pharmaceutical expenditures and VHA users and non-VHA users. Logarithmic transformation of expenditures was used to normalize the distribution. All analyses accounted for the complex survey design.

Population Studied: Veteran respondents aged

18 years and older with diabetes, hypertension or heart disease from the Medical Expenditure

Panel Survey, MEPS, years 2000-2003.

Principle Findings: Overall, 3,845 veterans from

MEPS reported having diabetes, heart disease or hypertension between 2000 and 2003. Of these,

2,364, 61 percent, were classified as VHA users.

Non-VHA users were significantly more likely to be married, employed, have private health insurance, be physically and mentally healthy, and have hypertension, and significantly less likely to have diabetes and heart disease compared to VHA users. The average total pharmaceutical expenditures was greater for

VHA users, 1,763 dollars compared to non-VHA users, 1,310 dollars, P<0.001. After controlling for demographic, socioeconomic and health status factors, the average out-of-pocket pharmaceutical expenditures was not different between the two groups. However, non-VHA users incurred higher out-of-pocket cost burden,

43 percent of total pharmaceutical expenditures, compared to VHA users, 39 percent, P<0.001. A major percentage of total pharmaceutical expenditures was for cardiovascular drugs, 59 percent for VHA users and 65 percent for non-

VHA users. The average pharmaceutical expenditures on cardiovascular drugs was greater for VHA users, 1,034 dollars compared to non-VHA users, 853 dollars, P<0.001. As with total pharmaceutical expenditures, non-VHA users incurred higher out-of-pocket cost burden for cardiovascular drugs, 44 percent, compared to VHA users, 39 percent, P<0.001. VHA and non-VHA users with all three conditions, diabetes, heart disease and hypertension, incurred the highest average expenditures for cardiovascular drugs - 2,296 and 2,026 dollars, respectively. VHA and non-VHA users with hypertension only had the lowest average expenditures on cardiovascular drugs - 640 and

652 dollars, respectively.

Conclusions: Despite greater total and cardiovascular pharmaceutical expenditures,

VHA users had lower cost burden compared to non-VHA users. Among both groups, those with multiple chronic conditions faced the highest cost burden.


As rates of employer-sponsored health insurance continue to fall, more veterans, especially those with multiple chronic conditions are expected to utilize the VHA for prescription drug coverage.

Although the economic cost to the VHA would be substantial, veterans who newly access the

VHA may reduce their individual cost burden.

Funding Source: VA

• The Effects of Office-Based Provider Visits on Emergency Room and Inpatient Care

Expenditures

Doug Melton, B.A., M.P.H.

Presented By: Doug Melton, B.A., M.P.H., P.O.

Box 1574, Pittsboro, NC 27312, Phone: (919) 260-

1568, Email: dougmelton04@yahoo.com

Research Objective: To examine the effects of office-based provider visits on the combined total of emergency room (ER) and inpatient care

(IP) expenditures, among adults (18 or more years of age). The study also investigates differences in ER/IP expenditures for African-

Americans with and without office-based visits.

Study Design: Ordinary Least Squares regression was used to conduct a multivariate analysis. The primary dependent variable was a construct of total emergency room and inpatient care related expenditures. The primary independent variable was the number of officebased provider visits.

Population Studied: The source of the dataset used for the analysis is the Household

Component of the 2003 Medical Expenditure

Panel Survey.

Principle Findings: The number of outpatient office-based visits are positively correlated with

ER and IP care expenditures (p<.001).

Specifically, each additional office-based visit is associated with an $89.80 increase in ER/IP expenditures, all variables being constant in the model.

Conclusions: Estimates indicate that the privately insured have higher ER and IP care expenditures than the uninsured. Subanalysis of

African American utilization of office-based services indicated that being African-American with or without office-based is not a significant predictor of ER and IP expenditures.


These finding suggests that prevention strategies aside from office-based visits, such as health education sessions, should be developed by decision-makers to decrease African Americans’

ER/IP expenditures. Insurance status results for the entire sample suggests that major payer organizations each year should consider financially planning for higher emergency room and inpatient hospital costs that are associated with the privately insured.In closing the gap in health disparities, we suggest that future research explore African-Americans use of physician-provided care to address barriers to care and associated medical expenditures.

• The Effect of Health Insurance on

Medication Use in Adults with Asthma

David Nau, Ph.D., Usha Mallya, Ph.D.

Presented By: David Nau, Ph.D., Associate

Professor, College of Pharmacy, University of

Kentucky, 725 Rose Street, Lexington, KY 40536-

0082, Phone: 859-257-4523, Fax: 859-257-6873,

Email: dnau2@email.uky.edu

Research Objective: To determine the effect of health insurance on the use of asthma medications among U.S. adults with asthma.

Study Design: A conceptual model, based upon the Andersen Behavioral Model for Health

Services Use, was developed to explain the medication use of persons with asthma. To test the model, data were analyzed from a cohort of adults with asthma who participated in the

Medical Expenditure Panel Survey (MEPS) during 2002-03. MEPS obtains data on health status, health insurance, access to care and health care utilization from a nationally representative sample of the U.S. civilian, noninstitutionalized, population. The asthma cohort was characterized by person’s predisposition

(age, gender, marital status, race), enabling resources (income, health insurance and prescription drug insurance), need for medications (health status, comorbidity) and the use of asthma medications. Multivariate regression models were then constructed to determine the effect of health insurance on asthma medication use while controlling for all predisposing, enabling and need variables.

Population Studied: Adults (age > 25 yrs) with asthma who participated in the MEPS household component (HC) in 2002 and 2003 (Panel 7).

The sample included 709 adults who answered affirmatively to the question ‘‘Have you ever been told by a doctor or other health professional that you have asthma?’’ in 2002, and who were inscope for the full two years of Panel 7.

Principle Findings: The vast majority of adult asthmatics had uninterrupted health insurance coverage (85.1%) in 2002-03, and 59.3% had uninterrupted prescription drug insurance. Only

8.6% of subjects had no health/drug insurance throughout the study period. Fifty-four percent of the asthma cohort indicated that they were currently using an asthma medication. Fifty percent of subjects indicated that they had used a preventive asthma medication at some point in the past, while only 34.9% indicated that they were currently using an inhaled steroid asthma medication. The multivariate regression models indicated that persons who did not possess

health insurance were less likely to have ever used a preventive asthma medication (OR =

0.26; 95% CI = 0.11 to 0.60) and were less likely to currently use any asthma medication (OR =

0.49; 95% CI = 0.24 to 0.99) than persons who possessed public or private health insurance.

Current use of inhaled steroids was not associated with insurance status, perhaps because of its overall low utilization.

Conclusions: During 2002 and 2003, the vast majority of adults with asthma possessed health insurance. However, only 50% of the asthma cohort indicated that they previously used any preventive medication for asthma, and only

34.9% of the subjects reported current use of an inhaled steroid medication for asthma. Persons who lacked health insurance were less likely to have ever used a preventive asthma medication, or to currently use any asthma medication.


Persons who lack health insurance are less likely to obtain medications for asthma. Expansion of health insurance coverage for persons with chronic diseases may be an important step in improving medication use.

•

Medical Care for Non-Resident Aliens: The

Case of Organ Transplantation

Jesse Schold, M.Stat, M.Ed, Herwig-Ulf Meier-

Kriesche, M.D., R. Paul Duncan, Ph.D., Alan I.

Reed, M.D.

Presented By: Jesse Schold, M.Stat, M.Ed,

Associate Instructor, Medicine and Health

Services Research, Management and Policy,

University of Florida, PO BOX 100224,

Gainesville, FL 32610-0224, Phone: (352) 392-

9331, Fax: (352) 392-3581, Email: scholjd@medicine.ufl.edu

Research Objective: Numerous processes

(sometimes referred to as globalization) have combined to create a circumstance in which patients receive medical care in nations other than their usual residence. Over the past two decades, the roles of nationality, citizenship, residency and related concepts have become dramatically more germane to many discussions of healthcare delivery. There is a paucity of research regarding these phenomena or populations involved. Our study sought to describe one subset of this population over a broad period with reference to the two most common forms of solid organ transplantation

(kidney and liver). Additionally, we sought to determine if there was any evidence of differential care for transplant candidates based on citizenship or residency status.

Study Design: A retrospective cohort study examining solitary kidney and liver transplant candidates and recipients from January 1st, 1988 to December 31st, 2005 in the US from a national registry with follow up until July 14th,

2006. In addition to descriptive analyses, we examined time to deceased donor transplant acquisition estimated by cumulative incidence and adjusted Cox proportional hazard models.

Population Studied: The study included solitary kidney and liver transplant candidates and recipients in the United States which are classified as either US citizens, resident aliens or non-resident aliens derived from mandatory data submission forms. There were 374,104 kidney and 134,860 liver candidates over the study period.

Principle Findings: There were 2724 (0.8%) solitary kidney and 2072 (1.5%) liver non-resident alien (NRA) candidate listings and 1615 kidney and 1296 liver transplant recipients. NRAs had high levels of self-pay (kidney 22%, liver 36%) and foreign sources (kidney 13%, liver 26%) of primary insurance coverage as compared to US citizens who cumulatively had less than 1% of these sources of payment. The number of kidney donations from NRAs exceeded the number of recipients, but the converse was true among liver transplants. In 2005, 79% of liver candidates arrived in the US within the same year as listing for transplant. Liver NRA candidates received transplants more rapidly than US citizens during pre- (AHR=1.2, 95% C.I. 1.1-1.3) and post-

(AHR=1.5, 95% C.I. 1.3-1.7) MELD eras in which a more objective prioritization on the waiting list was established. Among Liver NRA candidates, patients with self-pay insurance also received transplants most rapidly.

Conclusions: Both kidney and liver transplantation are low-incident, high-cost and life-saving medical interventions. In these contexts, NRAs in the US are a highly diverse cohort with potentially unique care needs and distinct treatment patterns. Further investigation into rapid transplant acquisition among NRA liver candidates is warranted.


Determining the appropriate allocation of scarce donor organs and health care services for the non-resident population is a challenging medical, ethical and economic predicament.

These issues are particularly salient in the field of transplantation in which a significant shortage of resources (and in particular donor organs) exists. Our study documents some of the

important existing data about this population to guide future policy development and medical care practice.

•

Physician Acceptance of TRICARE

Eric Schone, Ph.D., Richard Bannick, Ph.D.

Presented By: Eric Schone, Ph.D., Senior

Researcher, Mathematica Policy Research, 600

Maryland Avenue, SW, Washington, DC 20024,

Email: eschone@mathematica-mpr.com

Research Objective: Learn how physicians make decisions about the forms of public insurance they accept.

Study Design: An ongoing nationwide survey of a random sample of physicians and their office managers. The current wave includes questions about whether they accept TRICARE and

Medicare, the proportion of their patients who have TRICARE coverage and their reasons for nonacceptance.

Population Studied: Office based physicians in

20 states and selected additional health care markets.

Principle Findings: Of patients surveyed who accept new Medicare patients, approximately 88 percent reported they also accepted new

TRICARE patients, though reimbursement rates for the programs are generally the same.

Acceptance of new TRICARE patients is positively related to the proportion of TRICARE patients in the physician's panel. The positive relation weakens and eventually reverses as the proportion increases. Compared to variation in

Medicare acceptance, more variation in TRICARE acceptance occurs by individual physicians within a practice or organization.

Conclusions: TRICARE's particular characteristics lead to a substantial degree of specialization by physicians in treating TRICARE patients.


Special efforts may be needed to introduce

TRICARE in some market areas to overcome initial resistance. Efforts to inform physicians may reduce variation in physicians' knowledge of and awareness of the program.

Funding Source: Dept of Defense

• Place of Residence as a Determinant of

Access to Health Care Services in Canada.

Lyn Sibley, Ph.D.

Presented By: Lyn Sibley, Ph.D., Fellow, ,

Institute for Clinical Evaluative Sciences, 2075

Bayview Avenue - G1 06, Toronto ON, M4N

3M5, CA, Phone: 416-480-4055 x7846, Fax: 416-

480-6048, Email: lyn.sibley@ices.on.ca

Research Objective: The overarching goal of this research is to evaluate the determinants of access to health care services, particularly the role of place of residence at the levels of province, health region, and municipality.

Study Design: This is a cross-sectional study of the population of Canada using data from the

2003 Canadian Community Health Survey

(CCHS). Cohorts are compared in terms of their utilization of health care services and selfreported unmet need. Multilevel logistic regression models were constructed to predict access to health care services and to identify what proportion of the variation is associated with place of residence.

Population Studied: The CCHS is a national survey designed to gather health-related data at the health region level. The study sample

(N=119,104) includes all survey respondents aged 18 and older who resided in one of the ten provinces (territories were excluded). The sample is representative of 69.5% of the population of Canada.

Principle Findings: The results of this study show that place of residence has an effect independent of other determinants of access.

There is a great deal of variation by province, particularly in influenza vaccination rates and physician utilization. The municipality of residence is attributed with some level of variation in each of the outcomes, most marked being having a regular medical doctor.

In general the health region of residence contributes little to the observed variation in each outcome. In many cases it appears as though access to health care services is equitably distributed. The outcome showing the greatest degree of inequity is specialist physician utilization. Those aged 70 or older, with low levels of educational attainment, and in the lowest household income quartile were less likely to have seen a specialist physician even after accounting for need. Those living in urban centers, and the province of Quebec were more likely to have consulted a specialist physician and less likely to has see an family physician.

Inequalities were also observed in self-perceived unmet need where residents of the most rural communities were less likely to report having had unmet health care needs and those in younger age groups and with higher levels of education were more likely to report unmet health care needs.

Conclusions: These results are encouraging as they suggest that much of the observed variations in utilization are equitably distributed.

However some inequity was observed, the greatest degree of inequity is in utilization of specialist physician services. Further research is needed to asses what community level factors are associated with having a regular medical doctor. The observed differences in self-reported unmet need present interesting questions about expectations.


Universal health insurance coverage in Canada has eliminated many barriers to receiving appropriate, high quality health care, however geography remains as an important barrier to access. By identifying the levels of place of residence where inequities in access occur, this study highlights for policy makers the geographic level at which policies and strategies should be targeted.

Funding Source: CIHR Doctoral Award

• The Effects of Health Insurance Status on

Preventive Care for Adult Diabetics

Heidi Venegas-Rios, M.S., Kristine Lykens, Ph.D.,

Karan P. Singh, Ph.D.

Presented By: Heidi Venegas-Rios, M.S.,

Doctorate Student, Biostatistics, Univeristy of

North Texas -Health Science Center, Parque del

Monte MC-46, Trujillo Alto, PR 00976, Phone:

787-568-2061, Fax: 817-735-2314, Email: hvenegas@hsc.unt.edu

Research Objective: Recent reports show that the prevalence of diabetes has increased significantly in the US in the past few decades.

The present study determines how health care insurance impacts preventive care services utilization among diabetic patients using nationally representative data from the BRFSS.

Study Design: Data from the 2005 BRFSS was analyzed. The BRFSS is a cross-sectional telephone survey of the civilian, noninstitutionalized adult population over the age of

18 years. The survey selects state-specific probability samples of households using a multistage design to produce a nationally representative sample. Six self-reported measures of diabetes self-management and preventive care practices were analyzed.

Preventive care services utilization outcomes considered were: (1) last time a dilated eye exam was done, (2) at least one feet examination by a health professional during the previous 12 months, and (3) receipt of at least one HbA1c test during the previous 12 months. Diabetes self-management outcomes considered were: (1) how often are checks to blood glucose or sugar,

(2) how often are checks to feet for any sores or irritations, and (3) ever attending a diabetes education class.

Population Studied: All respondents reporting having diabetes as captured by the core question: ‘‘Have you ever been told by a doctor that you have diabetes?’’, and who were 64 years of age and younger were included in this study

(n=18,450).

Principle Findings: All measures of selfmanagement and preventive care practices were significantly associated to heath insurance coverage, except for the outcome relating to how often feet are checked for sores and/or irritations. Findings indicate that those with health insurance coverage, in general, had better overall diabetes management and access to preventive care practices. The uninsured were about 80% less likely to have seen a diabetes professional within the past year, and almost

60% less likely to have had either a dilated eye examination, or feet exam within the past year. In addition, the uninsured were less likely to have had an HbA1c test, to have participated in a diabetic education program, and to have monitored their blood glucose levels at least once a day. Insulin use was also a strong predictor for diabetic preventive care and selfmanagement practices even after controlling for health insurance coverage.

Conclusions: In this study, individuals without health insurance coverage were indeed less likely to have had the recommended annual dilated eye and feet examinations, HbA1c test, to have had participated in an educational program, and to monitor blood glucose levels on a daily basis, than those with health insurance coverage.

However, results showed that minority groups, specifically Blacks and Hispanics were more likely to report foot and/or eye examinations.

This study also found that Blacks were more likely than Whites to have had participated in diabetes educational programs.


The variations in preventive care and management practices found by this study underline the significance of finding ways to provide access to quality primary preventive care to the uninsured diabetic population. Access to simple, yet essential preventive services for the uninsured adult with diabetes could not only help improve management of their disease, but also avoid preventable, serious and costly complications.

• Perceived Access Barriers to Bonventional

Medicine and the Use of Complementary and

Alternative Medicine (CAM) in the United

States Adult Population

Tzy-Chyi Yu, M.H.A., Ph.D. candidate

Presented By: Tzy-Chyi Yu, M.H.A., Ph.D. candidate, Graduate research assistant, Health

Policy & Management, The University of

Minnesota, 609 Oak St SE Apt 3-7, Minneapolis,

MN 55414, Phone: (612)3792849, Email: yuxx0147@tc.umn.edu

Research Objective: Although plentiful studies have documented the relationship between dissatisfaction with conventional medicine and

CAM usage, little attention has been paid to the connection between perceived access barriers to conventional medicine and CAM usage. The purpose of this paper is to investigate whether perceived access barriers to conventional medicine are associated with CAM usage.

Study Design: This is a cross-sectional quantitative study using the 2002 National

Health Interview Survey (NHIS) (n=31,044). The dependent variable in this study is CAM usage.

As CAM approaches are not homogeneous,

CAM types will be categorized into alternative medical systems, mind----body interventions, biologically based therapies, manipulative and body-based methods, and energy therapies.

Conceding multidimensions of access barriers, perceived access barriers are grouped into distinct dimensions including accommodation, accessibility, and affordability. Besides perceived access barriers to conventional medicine, other independent variables include sex, age, race, education, health insurance, and income. We examine both the bivariate associations between

CAM and perceived access barriers to conventional medicine, and we use a recursive bivariate probit procedure to correct the associations for selection problems.

Population Studied: The target population for this analysis is noninstitutionalized U.S. residents aged 18 to 64.

Principle Findings: In bivariate analyses, overall, there are statistically significant differences at the

0.05 level between people who perceive access barriers to conventional medicine and use CAM.

Results from the recursive bivariate probit models indicated that about one-third of perceived access barriers to conventional medicine are statistically significantly negatively correlated with CAM usage at the 0.05 level.

Results from simple probit models showed that the other perceived access barriers to conventional medicine are statistically significant positively associated the use of CAM at the 0.05 level.

Conclusions: Ignoring the endogenous nature of perceived access barriers will bias estimate of the relationships between perceived access barriers to conventional medicine and CAM usage. People who perceived accommodation access barriers to conventional medicine are more likely to use all CAM except for manipulative and body-based methods.

However, the other results regarding accessibility and affordability access barriers and CAM usage are mixed.


Some people perceiving access barriers to conventional medicine use CAM as a coping strategy. However, some perceived access barriers to conventional medicine have more general impact on health care services utilization since they prevent people from using conventional medicine but they also keep people from using CAM. These access barriers should be addressed to ensure people have adequate access to health care services both conventional and alternative to improve their health.

Disparities

•

Preferred Drug Lists and Medicaid

Prescriptions

Tamer Abdelgawad, M.A., Economics, Lisa

Egbuonu-Davis, M.D., M.P.H., M.B.A.

Presented By: Tamer Abdelgawad, M.A.,

Economics, Senior Manager, Economic and

Policy Research, Pfizer Inc, 235 E 42nd St, New

York, NY 10017, Phone: (212) 733-0319, Email: tamer.abdelgawad@pfizer.com

Research Objective: When Medicaid Preferred

Drug Lists (PDLs) are implemented, they may impose indirect costs on prescribing physicians and Medicaid patients, leading to an unintended reduction in the number of Medicaid prescriptions filled. Our objective was to test the proposition that PDLs adversely affect the number of Medicaid prescriptions filled.

Study Design: The study was retrospective, and compared three 'test' states (Alabama, Texas, and Virginia) that implemented PDLs with restrictions on the prescription of statins with three control states (New Jersey, North Carolina, and Pennsylvania) that did not implement drug access restrictions. We conducted the analysis at the county level and used a differences-in-

differences approach that allowed for county and time-period fixed effects. We controlled for county-level socio-economic and population covariates.

Population Studied: Medicaid and non-

Medicaid patients filling statin prescriptions in the test and control states between April 2003 and March 2005.

Principle Findings: We found that PDLs adversely impact several measures of filled

Medicaid prescriptions in the 'test' states relative to the 'control' states. The estimates of the impacts were uniformly large and highly statistically significant.

Conclusions: The impact on Medicaid prescriptions in PDL states could be the result of a combination of reduced physician incentives to treat Medicaid patients, and the reduced persistence of Medicaid patients in obtaining prescriptions in the face of prior-authorization process delays. A limitation of our work is that our results cannot distinguish these two possible causes, but we view both potential explanations as adverse unintended effects of PDL implementation


There are possibly important unintended consequences to cost-focused health policy interventions.

Note: This paper has been published in

PharmacoEconomics 2006, Volume 24,

Supplement 3 (pp. 55-63)

Funding Source: Pfizer, Inc

• A Multilevel Controlled Intervention to

Increase Colorectal Cancer Screening among

Latino Immigrants

Abraham Aragones, M.D., Francesca M. Gany,

M.D., M.S., Nirav R. Shah, M.D., M.P.H., Mark

D. Schwartz, M.D.

Presented By: Abraham Aragones, M.D., Fellow,

Medicine and Public Health Research, Medicine,

New York University School of Medicine, 92 7th

Avenuw Apt 9, Brooklyn, NY 11217, Phone: 917-

912-8075, Email: aragoa01@med.nyu.edu

Research Objective: Latino immigrants have significantly lower rates of colorectal cancer

(CRC) screening compared to the general population. Low screening rates may be due to lack of physician recommendation, patient cultural barriers or poor patient CRC knowledge.

We examined the effectiveness of a multilevel intervention comprised of an educational CRC video and brochure for the patient and a paperbased reminder for the physician in increasing the rate of CRC screening among Latino immigrants at a primary care clinic in an urban hospital.

Study Design: All consenting physicians in the primary care clinic (N=64) were randomized to intervention or usual care. Consecutive Latino immigrant patients of participating physicians who were eligible for CRC screening were recruited to participate in the study and were assigned to the group to which their physician had been randomly assigned. Intervention patients were asked to watch a CRC educational video on a portable player in the waiting room before the visit with their physician took place.

Upon finishing the video, the patient was given a brochure with key information from the video and a paper reminder to show to his/her physician. Patients in the control group received usual care. The primary outcomes were: 1) guideline-concordant recommendation of any

CRC screening test and 2) patient adherence to physician recommendation for CRC screening.

To compare the rates of CRC screening between the intervention and the control group we used contingency table analysis and Chi-square tests.

We used logistic regression analysis to assess the effect of the intervention and recommendation for CRC screening, adjusting for intra-class correlations (physician effect) and other covariates.

Principle Findings: Interim analyses were conducted for the first 52 patients enrolled, (24 intervention and 28 control group). Mean participant age was 60 years, 59% were female,

58% had some high school or higher education,

48% were married, mean years since moving to the United States was 27 and 60% had health insurance at the time of recruitment, and no significant differences between intervention and control group patients were found. Overall rate of completed screening for CRC was 33.3% for the intervention group and 17.9% for the control group, p=0.16. Eight (33%) of the patients in the intervention group received a physician’s recommendation for CRC screening compared with ten (35%) of the patients in the control group, p>0.54. Among those who were recommended for CRC screening, all eight

(100%) in the intervention group adhered to their provider’s recommendation for CRC screening, versus five of ten (50%) of the patients in the control group, p<0.03.

Conclusions: Rates for CRC screening in both groups were low and consistent with previous studies. While the intervention had no effect thus far on physician recommendation rate, it was associated with increased patient adherence to

recommended CRC screening test. Although patient activation through education benefits patient adherence to CRC screening, the rate limiting factor appears to be physician recommendation.


Efforts should be focused on developing new strategies to increase referral for CRC screening.

Funding Source: CDC, Grant/Cooperative

Agreement Number T01 CD000146 from the

Centers for Disease Control and Prevention

• Life Course Socioeconomic Disparities and

Healthcare Utilization: Models for Causal

Inference

Onyebuchi Arah, M.D., Ph.D.

Presented By: Onyebuchi Arah, M.D., Ph.D.,

Visiting assistant professor, Department of

Epidemiology, UCLA School of Public Health,

650 Charles E. Young Drive So., Los Angeles, CA

90095-1772, Phone: 310-721-1895, Email: arah@ucla.edu

Research Objective: The health services research literature details that the socially disadvantaged, the sicker, minority ethnic groups, and women utilize more healthcare, even for similar health conditions and states. Comorbidity and other differentials have been given as possible explanations, but no research has looked thoroughly at possible life course socioeconomic disparities as an explanation for differential healthcare utilizations in adult life seen among the lower socioeconomic groups.

Life course health research investigates the complex links between lifetime exposures and adult health. This study illustrates the usefulness of the life course approach to both health services research by using advanced causal inference models, interdisciplinary knowledge, and theory to quantify the life course causal effects of socioeconomic position (SEP) and health on the likelihood of healthcare use in adulthood.

Study Design: We used data from a culturally homogeneous British birth cohort to examine the associations between lifetime SEP and healthcare utilization in adulthood, conditional on health status. Conditional and change multivariable logistic regressions and hierarchical growth models were used to tease out the possible effects of SEP at birth, and ages

7, 11, 16, 23 and 33 years on the likelihood and frequency of recent healthcare use at age 42. In ongoing analyses, we are using causal diagrams to summarize assumptions, identify key variables to be controlled to get unbiased effect estimates, and to communicate plausible causal mechanisms. We are also analyzing bias due to missing covariates, exposure missclassification, and unmeasured confounding.

Population Studied: More than 4,500 members of the 1958 National Child Development Study, all whom were born in one week in March 1958 in England, Wales, and Scotland.

Principle Findings: Conditioned on health status, smoking, body mass index, and other covariates, childhood socioeconomic positions from bith through age 23 were associated with increased use of healthcare at age 42 (odds ratios for the lowest SEP compared the highest

SEP ranging from 1.32, 95% CI: 1.07----1.62, for

SEP at birth to 1.55, 95% CI: 1.24----1.94, at age 23).

Disparities at age 33 made no additional contributions to the current SEP in determining healthcare use. In addition to the effects of current SEP, early socioeconomic changes before age 7 and from ages 16 to 23 contributed significantly to increased healthcare use in adult life.

Conclusions: This research demonstrates that critical and cumulative experiences of socioeconomic disparities over a lifetime shaped both health and healthcare use in adult life. This is the first study to place a life course perspective on healthcare use, and to use formal causal models for such analytical perspective.


More than on non-medical determinants of health, health policies tend to focus on healthcare issues, with the hope of maximizing healthcare effectiveness, efficiency, and equitability. For such policies to make meaningful contribution to health, they must take a life course approach to health, realizing that healthcare consumed in adult life reflects not just adult ill-health but also the cumulative health and non-health effects of socioeconomic disadvantages over the life course.

Funding Source: Rubicon fellowship (grant

825.06.026) from the Netherlands Organisation for Scientific Research

•

Diversity, Disease and Disparities in the

States

Dhananjaya Arekere, Ph.D., M.P.H. (05/07),

Woodrow Jones, Ph.D., M.P.H., Lee Green,

Ph.D., Criag Blakely, Ph.D., M.P.H., Brian Rivers,

Ph.D.

Presented By: Dhananjaya Arekere, Ph.D.,

M.P.H. (05/07), Interim Director and Visiting

Assistant Professor, Center for the Study of

Health Disparities, Texas A&M University, 4222

TAMU, 112 Harrington Tower, College Station,

TX 77843, Phone: 979-862-4403, Fax: 979-862-

3036, Email: arekere@tamu.edu

Research Objective: Examine relationship between health and population diversity at the state level

Study Design: Two types of analyses are undertaken. The link between two health indicators, Infant Mortality (individual health status indicator) and Physicians (per 1000 residents) (a sectoral health status indicator and access indicator at individual level) and population diversity, in the fifty U.S. states are examined. Second, the effects of six socioeconomic (SE) variables that are conventionally thought of influencing infant mortality and physician supply at the state level are investigated. In addition to examining the statistical significance using Pearson’s

Correlation Coefficient and simple, parsimonious linear regression models designed to test the explanatory power of diversity and the different

SE variables on infant mortality and physician supply, scatter plot are generated to depict the relationships as well as. Health Data is obtained from NCHS and population data from the U.S. Census Bureau.

Population Studied: State level population data by race and ethnicity.

Principle Findings: Results confirm general directional effects of diversity on infant mortality and physician supply. However, there is no indication of statistically meaningful relationship between diversity and the two dependent variables. Among the six different socioeconomic variables examined, per capita income and education level (proportion of population with more than B.S.) not only have the expected directional effects, but are also statistically significant. Other four variables examined, although in conformity with directional effects, offer insignificant information regarding the variation in the dependent variables across the

50 states.

Conclusions: Further research is needed to identify variables appropriate for usage at the ecological level to explain differentials in health status indicators between the 50 states. It appears that economic variables provide better explanations of differentials in health status between the states. The analysis should also be extended to other state level health indictors because the two dependent variables examined herein may merely be anomalies.


Policymakers should pay attention to state level health and socioeconomic variables and relationships to improve policymaking and outcomes. Considering population diversity alone in policymaking or practice does not appear to be supported by data analyzed here.

Because population diversity is concentrated at local levels, the unit of analysis is critical in research, and to policy and practice.

• People, Perceptions, and Problems in the

Healthcare System

Dhananjaya Arekere, Ph.D., M.P.H (5/07)

Presented By: Dhananjaya Arekere, Ph.D.,

M.P.H (5/07), Interim Director and Visiting

Assistant Professor, Center for the Study of

Health Disparities, Texas A&M University, 422

TAMU, 112 Harrington Tower, College Station,

TX 78743, Phone: 979-862-4403, Fax: 979-862-

3036, Email: arekere@tamu.edu

Research Objective: Examine factors underlying perceptions about the healthcare system.

Study Design: Data were derived from the 1999

Kaiser Family Foundation’s Survey on

Americans’ Perceptions of Racial Disparities in

Health Care. Multivariate analyses using logistic regression methods were carried out to detect independent effects of respondents’ race and ethnicity on perceptions about unfair treatment while controlling for confounding factors. The confounding factors considered were sociodemographic variables (age, gender and income), political party affiliation, health status and perceptions about affordability of health insurance. Results were compared to economic and structural inequities-based discrimination models using the same set of variables.

Respondents’ insurance status was included and the two models were re-estimated. In all four logistic regression models were estimated.

Population Studied: Data are obtained from a survey that was based on a national random sample of 3,884 telephone interviews with adults age 18 and over. The survey was designed and analyzed by researchers at the Foundation, and conducted by Princeton Survey Research

Associates between July 7 and September 19,

1999. The responses included 1,479 whites,

1,189 African Americans and 983 Latinos.

Telephone interviews were completed both in

English and Spanish based on the respondent’s preference.

Principle Findings: Racial and ethnic minorities are more likely than Whites to report race-based

discrimination in the health care system.

Females, Democrats, and younger respondents are also more likely to perceive higher levels of race-based discrimination than males,

Republicans and older respondents. In comparison, logistic regression results of economic and structural inequities-based discrimination changes the directional effect of age, race, and income variables. Also, respondents who cannot afford health insurance are more likely to report other forms of discrimination. Including insurance status in the models does not change the overall nature of the results in terms of directional or size of the effects.

Conclusions: Racial and ethnic minorities, females and Democrats are more likely to perceive race-based as compared to insurancebased discrimination in the healthcare system even when controlling for the distribution of respondents by insurance status and whether or not they can afford insurance. The results demonstrate race and ideology to play a greater role in perceptions about race-based health care disparities.


Researchers need to better understand the health care system in terms of general trust (or lack thereof) towards institutions in the

American society. Policymakers need to pay attention to the lack of trust among minorities towards public and private institutions. In practice, health care professionals and those who train them need to pay attention to differences in perceptions among different subpopulations to provide culturally competent or patient-centered care.

• Racial, Ethnic and Gender Differences in the Use of Cardiac Stents

Arlene Ash, Ph.D., Alice Jacobs, M.D., Jeanne

Speckman, M.Sc.

Presented By: Arlene Ash, Ph.D., Research

Professor, Boston University School of Medicine,

720 Harrison Avenue, Boston, MA 02118, Phone:

617-638-7518, Fax: 617-638-8026, Email: aash@bu.edu

Research Objective: Racial and ethnic minority men and women suffer higher mortality from coronary artery disease than white men. It is unknown if mortality differences reflect differences in disease or differences in treatment.

Evaluation and revascularization is the standard of care when feasible in Acute Coronary

Syndromes, especially for those at high risk. Our objective is to describe revascularization rates after Acute Coronary Syndromes by gender and race/ethnicity, adjusted for age, comorbidity,economic status and geographic variation.

Study Design: We conducted logistic regression analyses to assess stent use, compared with no cardiac intervention, or coronary bypass grafting.

Models controlled for demographics, comorbidities (using claims data of inpatient and outpatient visits) and small area geographic variation. Models were developed on three subsets: 1) all beneficiaries 2) those with a diagnosis of coronary artery disease in the previous year and, 3) those with an admission for acute coronary syndrome.

Population Studied: A random sample of

522,389 White, Black and Hispanic Medicare beneficiaries in 2001, aged 65+ with fee-forservice coverage, and without end stage renal disease. Blacks and Hispanics were oversampled to be able to study racial differences; of 22,903 acute coronary syndrome cases in the sample 34% were black, 25%

Hispanic. Results are reported with reweighting to reflect the Medicare population.

Principle Findings: In multivariate logistic regression adjusted for age, comorbidities, diabetes, prior MI or revascularization, CHF, peripheral arterial disease, RI, CVD, HTN and ecnomic status Black and Hispanic men and women had lower rates of cardiac stents compared with their white counterparts

(Hispanic men OR=0.56 (CI=0.53-0.56) and women 0.75 (0.71-0.80), Black men 0.48 (0.47-

0.50) and women 0.69 (0.67-0.71). White women (OR=0.67, CI=0.66-0.68) and Hispanic women (OR=0.74, CI=0.68-0.80), but not black women had lower rates than the corresponding men.

Conclusions: In the setting of Acute Coronary

Syndromes: women, Hispanics and Blacks are less likely to receive revascularization.

Differences in age, economic status and overall health only partially account for these differences in stent receipt.


These preliminary results suggest that stent placement, like other cardiac procedures, are affected by gender, race and ethnicity. Further analyses will determine if differences can be attributed to geographic variation. We will also consider the outcomes of stent placement among these groups, which could influence FDA recommendations for stent use.

Funding Source: Federal Drug Administration

(FDA)

• Disparities in the Quality of Hospital Care:

Assessment of the Relationships Between

Market Characteristics, Hospital

Characteristics, and Appropriate Processes of

Care

George Avery, Ph.D., M.P.A., Titilayo Okoror,

Ph.D., Bella Siangonya, B.S.

Presented By: George Avery, Ph.D., M.P.A.,

Assistant Professor of Public Health, Health and

Kinesiology, Purdue University, 800 West

Stadium Avenue, West Lafayette, IN 47907,

Phone: 765-496-3330, Fax: 765-496-1239, Email: gavery@purdue.edu

Research Objective: This project examines whether process-level measures of hospital care quality are related to the demographics of the market served by the hospital, controlling for organizational features of the hospital. In particular, the study examines how the racial/ethnic composition of a hospital market is related to the quality of care available.

Study Design: A social ecology model is constructed such that the quality of hospital care delivered is a function of organizational leadership and policies, complementary programs and infrastructure, and environmental factors related to market structure and market demographics. Quality of care is represented by the CMS/Hospital Quality Alliance Hospital

Compare measures for AMI, heart failure, pneumonia, and surgical infection prevention as reported for calendar year 2004. Independent variables were selected from the 2005 (FY2004)

AHA Annual Survey and the 2000 Census, matched to the hospital’s Health Service Area through the Dartmouth Atlas of Healthcare.

Least Squares Regression models were constructed using the White Robust Covariance

Matrix Correction to test relationships between model variables and care delivered.

Population Studied: The study population consisted of US hospitals voluntarily reporting

Hospital Compare data in 2004 that could be matched to relevant variables in the 2005 AHA

Annual Survey. Individual regression models were built from between 259-1255 hospitals.

Principle Findings: Findings indicated that in general, hospitals serving markets with larger proportions of African-Americans provided lower levels of appropriate care for AMI and pneumonia, markets with higher proportions of

Hispanics were associated with lower levels of care for all four conditions, and the proportion of

Pacific-islanders was associated with lower quality care for AMI, pneumonia, and surgical infection prevention. In contrast, higher proportions of multiracial residents were associated with better preventive care for surgical infections. Hospital size and the presence of an adult diagnostic catheterization laboratory were associated with better AMI care.

In terms of staffing, higher levels of nurse staffing were related to improved AMI and heart failure care, while an increased resident-to-bed ration is associated with lower levels of appropriate care for pneumonia.

Conclusions: Disparities between markets in the quality of hospital care delivered appear to be related to the racial and ethnic composition of the market, controlling for hospital factors.

Predictors of the delivery of appropriate care appear to differ based upon the measure and condition used.


Disparities in the quality of care may be related to market-level factors such as the ethnic or racial composition of the market, although the ecological nature of the study cautions against over-interpreting these results as indicating that disparities are caused by the demographics of the market. Further research controlling for patient, hospital, and market-level factors is necessary to establish why these disparities exist.

Furthermore, differences in predictors of quality caution against reliance on single conditions or measures for evaluating quality of care. Finally, several hospital-level predictors of the quality measures are identified.

Funding Source: Purdue College of Liberal Arts

•

Effects Of Medicaid Access Restrictions On

Statin Utilization For Patients Treated By

Physicians Practising In Poor And Minority

Neighborhoods

Kirsten Axelsen, M.S., Neal Masia, Ph.D.

Presented By: Kirsten Axelsen, M.S., Director,

Economic and Policy Research, Pfizer, 235 E.

42nd Street 235-8-8, New York, NY 10017, Phone:

212-733-8321, Fax: 212-716-9261, Email: kirsten.axelsen@pfizer.com

Research Objective: To explore whether

Medicaid preferred drug lists (PDL) impact the utilization of restricted statin medications for

Medicaid patients equally, or disproportionately impact patients treated by doctors prescribing in poor or minority neighborhoods.

Study Design: : A retrospective, regressionbased analysis, of a pharmacy claims database and census data of the prescriber’s zip-code.

Post policy changes in the proportion of statin

prescriptions filled for off-PDL medicines were examined in six states. Two non-PDL states were used as controls for underlying market dynamics. Demographics of physicians’ neighborhoods (poverty and ethnicity) were used to examine the variation in prescribing based on the characteristics of physicians’ areas of practice.

Population Studied: The analysis included pharmacy claims for statins filled by Medicaid beneficiaries in six states with PDLs (Alabama,

Florida, Georgia, Texas, Virginia, West Virginia) and two states without PDLs (New York, North

Carolina) from 2002 through 2005.

Principle Findings: The post-policy decline in the use of restricted prescriptions varied considerably, from Florida (-97%) to Texas (-

65%). There was a statistically significant positive association between the magnitude of decline and the share of impoverished households and the share of the minority population in Alabama, Florida and Texas.

Conclusions: The analysis indicates that there is considerable variation in the impact of a PDL by state, and in certain states by the degree of poverty or diversity in the neighborhood. This could imply due to the PDL, in poorer and more ethnically diverse neighborhoods, fewer patients receive the restricted medication by prior authorization, and more patients experience a disruption in their medication regimen and any resultant unintended consequences.


This is an area worthy of exploration, as the dual eligibles transition into Medicare part D and may experience changes in formulary. Certain beneficiaries may be more affected by formulary and access restrictions than others.

Note: This paper has been published in

PharmacoEconomics, Vol. 24, Supplement 3 (pp.

41-53), 2006.


• Citizenship Status and Limited English

Proficiency: Implications for Health and

Health Care Policy

Ann Bagchi, Ph.D.

Presented By: Ann Bagchi, Ph.D., Health

Researcher, Health, Mathematica Policy

Research, 600 Alexander Park, Princeton, NJ

08540, Phone: (609) 716-4554, Fax: (609) 799-

0005, Email: abagchi@mathematica-mpr.com

Research Objective: More than 8 million adult

U.S. citizens have limited English proficiency.

Citizenship status affects eligibility for many state and federal health benefits, but limited

English proficient (LEP) individuals often face significant barriers to health care access that undermine the quality of health care they receive.

This paper sought to compare demographic and health characteristics of citizens by English proficiency and explore the implications of these findings for health care policy.

Study Design: Using the 2000 Census, the study documents wide variation in the percentage of LEP citizens by state and compares the sociodemographic characteristics of LEP and non-LEP adults. Using the 2001

California Health Interview Survey (CHIS), it then compares health status and health care access by English proficiency among California residents who are U.S. citizens.

Population Studied: Adults age 18 or older who are either native born or naturalized U.S. citizens. LEP adults are those who speak English less than ‘‘very well.’’ Non-LEP adults either speak English at home or report speaking

English ‘‘very well.’’

Principle Findings: Nationally, 4.2% of U.S. citizens are LEP; the percentage is lowest in

West Virginia (0.6%) and highest in California and Hawaii (both at 10.2%). Nationwide, the majority of LEP citizens speak Spanish (56%, or more than 4.5 million people), followed in frequency by Chinese (5%), Vietnamese (4%) and French (3%). Forty-six percent of LEP citizens have less than a high school education

(compared with 17% among non-LEP citizens) and 19% have incomes at or below 100% of the federal poverty level (versus 13% among non-LEP adults). In 2001, 16% of California’s LEP citizens were uninsured all year, compared with only 6% of their English-fluent counterparts. Compared with non-LEP citizens, LEP citizens reported fewer visits to doctors or other health care providers in the prior year, despite the fact that they were more than twice as likely to rate their health as fair or poor. Non-LEP citizens were somewhat more likely than LEP citizens to report having needed help for emotional problems in the prior year (15% versus 13%) but were more than twice as likely to have visited a professional for emotional problems (9% versus 4%). LEP citizens were also less likely to have received recommended preventive services such as Pap tests, bone density exams, and tests for prostate cancer.

Conclusions: In most states, LEP citizens make up less than 10% of the total population but their absolute numbers are large in California

(more than 2 million) and Texas (more than 1 million). LEP citizens have higher poverty rates

and lower educational attainment than citizens reporting English fluency. They also appear to face significant barriers in access to health care; with lower insurance rates, fewer doctors’ visits, and lower use of preventive care.


LEP citizens are entitled to the same rights and services as their non-LEP counterparts, but this study documents substantial disparities in access to health care and in health status between these two groups. The states and the federal government should design interventions to reduce language-related barriers to health care access that contribute to these disparities.

•

Racial Disparities in the Elderly for Selected

Procedures: Was There a Decline Over Time?

Jayasree Basu, Ph.D., M.B.A.

Presented By: Jayasree Basu, Ph.D., M.B.A.,

Senior Economist, Center for Primary Care,

Prevention, and Clinical Partnerships, AHRQ,

540 Gaither Road, Rockville, MD 20850, Phone:

(301)427-1579, Fax: (301)427-1595, Email: jayasree.basu@ahrq.hhs.gov

Research Objective: Racial differences in health care utilization across a wide number of conditions and clinical settings have been widely documented. A more challenging task remains to examine whether disparities had lowered over time. There is evidence of racial/ethnic disparities in three procedures, two of which are cardiac (CABG and PTCA), while the third one is orthopedic (Joint Replacement). In addition to being ‘‘high-tech’’ and cost-intensive, these procedures also share a commonality as members of a group of admissions designated as referral-sensitive in previous research. Since minorities are more dependent on physician referrals, a study of racial disparities over time in these procedures would highlight significant aspects of referral patterns by providers and insurers. The objective of this study is to examine as well as compare the underlying racial and ethnic disparities in three procedures among the elderly over a time interval (1997-

2001) in which important changes in Medicare payment reforms have occurred that could affect access to care among the elderly. The study primarily departs from many other studies by using a multivariate design with individual data to make simultaneous comparisons of admission patterns between procedures with respect to a control group of admissions.

Study Design: Hospital discharge data for New

York and Pennsylvania from the Healthcare Cost and Utilization Project (HCUP-SID) of the

Agency for Healthcare Research and Quality is used. The study estimates mutinomial logit models for individual years (1997 and 2001) and pooled sample for both years, to compare each procedural admissions with a control group of admissions known as marker admissions. The multinomial logit models control for sociodemographic factors, clinical need, organizational factors, and insurance status, among the elderly.

Population Studied: The study focuses on elderly residents (age 65 and above) of two states: New York, and Pennsylvania, hospitalized in those states in 1997 and 2001.

Principle Findings: Compared to whites, African

Americans were 38 percent and 49 percent less likely to have received a PTCA and 36 percent and 52 percent less likely to have received a

CABG in 1997 and 2001, respectively. Hispanics were 31 percent less likely to have received a

PTCA in 2001, while not significantly differing from whites in 1997. ‘‘Other races’’ were 30 percent more likely that whites to have received

PTCA in 1997 and the difference became nonsignificant in 2001. Although racial disparities in utilization persist for all three procedures, the magnitude appears less for joint replacement and is not statistically significant. Other things remaining the same, the increasing racial/ethnic difference over time was not statistically significant in most cases.

Conclusions: The increasing racial/ethnic disparities in utilization of these procedures are of major concerns. Although the increase over time was not significant statistically for most procedures or racial groups, the results clearly indicate that the disparities have not narrowed despite numerous efforts to reduce them. Since the procedures studies are sensitive to physician referrals, a significant underlying factor could be differential referral patterns practiced by insurers across races. The lower racial/ethnic gaps in utilization of joint replacement relative to cardiac procedures could indicate a lower referral rates for cardiovascular surgeries in nonwhites.


The recommended action would be to reexamine provide practice patterns which particularly affect access to care among minorities.


•

Colorectal Cancer Testing in Socioeconomically Disadvantaged Hispanic and

African Americans Receiving Medical Care from Safety-net, Primary Care Settings

Mohsen Bazargan, Ph.D., Chizobam Ani, M.D.,

Shahrzad Bazargan-Hejazi, Ph.D., Roshan

Bastani,, Ph.D., Richard S. Baker, M.D.

Presented By: Mohsen Bazargan, Ph.D.,

Associate Professor, Family Medicine, Charles R.

Drew University of Medicine & Science, 2594

Industry Way, Lynwood, CA 90262, Phone: (310)

761-4722, Fax: (310) 631-1495, Email: mobazarg@cdrewu.edu

Research Objective: The aims of this study were threefold: 1) to examine correlates of colorectal cancer (CRC) testing in socio-economically disadvantaged Hispanic and African Americans receiving medical care from safety-net, primary care settings; 2) to examine the predictors of physician CRC testing recommendation in these individuals; and 3) to examine patients adherence to recommended CRC testing including knowledge, attitudes and beliefs.

Study Design: Cross-sectional survey of clinicbased sample.

Population Studied: A sample of 306 African-

American and Latino patients aged 50 years and older with no previous diagnosis of CRC were selected from a large urban safety net, outpatient primary care settings served by 33 family medicine physicians in the county of Los Angeles

Principle Findings: Our analyses indicated that

40% of participants aged 50 years and older had

CRC testing, using either sigmoidoscopy or colonoscopy in the previous 5 years. There was no significant difference in CRC testing rates between Hispanic and African American participants. Physician recommendation was among the most significant and substantial predictor of completing a recommended a CRC testing. Multivariate analysis showed that odds of CRC testing was higher in older participants with medical condition(s) associated with risk for

CRC. However, demographic characteristics

(excluding age), family risk for CRC, and participants’ knowledge or attitudes toward CRC testing were unrelated to completing a recommended CRC testing. Fifty-four percent of participants reported that their providers recommended CRC testing. Yet, 26% of those who had received provider recommendations for

CRC testing, never complete it. This data shows that ethnicity of participants, medical condition(s) associated with risk for CRC, attitudes toward CRC testing were significantly associated with adherence with CRC testing. In addition, multivariate analysis indicates that those who were older, had a recent fecal occult blood test (FOBT), those with medical condition(s) associated with risk for CRC, and those with other co-morbidities were more likely to receive a physician recommendation for sigmoidoscopy or colonoscopy.

Conclusions: Almost one half of disadvantaged

Hispanic and African American patients 50 years and older receiving medical cares at public safety-net, out-patient clinics have never received any recommendations for sigmoidoscopy and colonoscopy from their providers. Yet, one out of four patients who receive a recommendation for

CRC testing never completed the test. Family risk for CRC plays no role in influencing a physician recommendation or the completion of a recommended CRC test.


Interventions that address disparities in colorectal cancer incidence and prevalence in minority populations must consider the dual influence of physician recommendation and patient adherence, in safety-net primary care settings. Physician training should address also emphasize skills that allow for influencing patient adherence to recommended CRC screening tests.


• Experiences of Respect During Acute Care of Vaso-Occlusive Crisis among Adults with

Sickle Cell Disease

Mary Catherine Beach, M.D., M.P.H., Sophie

Lanzkron, M.D., Patrick Duggan, A.B., Carlton

Haywood, M.P.H., Neil R. Powe, M.D., M.P.H.,

M.B.A., Mary Catherine Beach, M.D., M.P.H.

Presented By: Mary Catherine Beach, M.D.,

M.P.H., Johns Hopkins University, 2024

EastMonument Street, Room 2-521, Baltimore,

MD 21287, Phone: 410-614-1134, Email: mcbeach@jhmi.edu

Research Objective: Adults with sickle cell disease (SCD) have reported adversarial relationships with health professionals anecdotally and in qualitative studies, but there are little quantitative data. We sought to examine experiences of respect among patients with SCD seeking acute care for vaso-occlusive crisis

(VOC), and to relate these experiences to patient reports of pain management quality.

Study Design: Cross-sectional. We interviewed patients upon discharge from the Emergency

Department (ED) at an urban academic medical center. We measured patient experience of respect using items from the Interpersonal

Processes of Care Instrument (responses summed to form a 'respect' scale from 0-100,

alpha 0.89), and asked patients to report on the quality of pain management. We then used chisquared tests and generalized estimating equations to account for multiple observations on individual patients in unadjusted and adjusted analyses controlling for potential confounders.

Population Studied: Adults with SCD and VOC.

Principle Findings: In 54 ED visits by 32 patients, patients generally reported low levels of respect and poor pain management. For example, a small proportion of patients reported

('all of the time') that doctors and nurses seemed to care about them as a person (19%), listened carefully to what they had to say (17%), and took their concerns seriously (13%). A substantial proportion reported ('all, 'most' or

'some of the time') that their doctors and nurses had a negative attitude towards them (63%), made them feel inferior (74%), made them feel as if they weren't welcome (65%) and behaved rudely towards them (50%). Patient experience of respect was not significantly related to patient age, sex, or employment status; however patients seen more frequently in the ED reported less respect (mean respect scores 74.1, 62.7, and

54.6 for patients seen <3 times/year, 3-10 times/year, and >10 times per year respectively, p=0.04). Compared to patients who reported timely receipt of medication, patients who reported delays in receipt had lower respect scores (mean 71.9 vs. 53.9, p<0.001). Similarly, compared to patients who reported changes in ineffective therapies, those who reported no change in ineffective medication had lower respect scores (65.6 vs. 53.7, p=0.04). There were no differences in patient experience of respect for patients who had or had not been offered alternative strategies (besides narcotics) to deal with pain. Results were not changed after controlling for the frequency of painful crisis and accounting for multiple observations on a single patient.

Conclusions: SCD patients with VOC generally reported low levels of respect and poor pain management; the more frequent contact they had with the ED, the less they felt respected.


Research is needed to determine the causes and consequences of, and to test interventions to improve, these poor experiences.

•

Racial Disparities in Methadone Treatment

Nancy Berkman, Ph.D., M.L.I.R., Wendee

Wechsberg, Ph.D., Mey Kuo, Ph.D.

Presented By: Nancy Berkman, Ph.D., M.L.I.R.,

Research Analyst, Division of Health Services and Social Policy Research, RTI International,

3040 Cornwallis Road, PO Box 12194, RTP, NC

27709-2194, Phone: (919) 541-8773, Fax: (919)

990-8454, Email: berkman@rti.org

Research Objective: Our research objective is to understand racial/ethnic differences in methadone treatment patient characteristics and outcomes and to explain how outcomes are affected by differences in programs attended by individuals in the three groups.

Study Design: We conducted our study using descriptive and hierarchical regression techniques. Site level data and site director, direct care staff and patient survey responses were obtained from a nationally representative cross section of methadone treatment programs

(N=144) in 2002.

Population Studied: White non-Hispanic

(N=3050), black non-Hispanic (N=1068) and

Hispanic (N=1371) methadone treatment patients.

Principle Findings: The three race/ethnicity groups differed by important individuals characteristics. Black patients were older than the other two groups but were least likely to have been in treatment for greater than two years or to have been in treatment before. Hispanic patients were younger and more likely to be male. Treatment programs attended by black and Hispanic patients tended to offer more support services on site and Hispanic patients were most likely to be attending programs offering special services for racial/ethnic minorities. White patients were more likely to be employed and receiving individual counseling.

Many patients attend programs where the majority of patients are of their same race/ethnicity group (76 percent of white, 44 percent of black and 42 percent of Hispanic patients). Based on results from hierarchical linear regression models, in the past three months, black patients were significantly more likely to have used heroin and cocaine. Hispanic patients were also more likely to have used cocaine. Heroin use and any needle use were more likely in treatment programs in which a majority of patients were Hispanic and in programs where none of the three groups was more than 50 percent of the patient population

(compared with majority white). Black and

Hispanic patients were less satisfied with treatment overall as were those attending notfor-profit versus for profit clinics.

Conclusions: Characteristics and treatment needs of white non-Hispanic, black non-Hispanic and Hispanic methadone patients tend to differ.

While the clinics attended by black and Hispanic patients offer more support and ancillary services, they are insufficient to meet the needs of these patients so that, even after controlling for differences in patient characteristics, outcomes were poorer.


Regulation of methadone treatment programs has recently changed to a system requiring all programs to be accredited. These new standards need to ensure that services offered by clinics are designed for the particular patient population being served and are available in sufficient quantities to reach all those who need them.


•

Are There Racial/Ethnic Disparities in

Screening Mammography Use, and What

Have Been the Trends in Disparities Over the

Past Decade?

Mythreyi Bhargavan, Ph.D., Criatian Meghea,

Ph.D., Jonathan H. Sunshine, Ph.D.

Presented By: Mythreyi Bhargavan, Ph.D.,

Director of Research, American College of

Radiology, 1891 Preston White Dr, Reston, VA

20191, Phone: (703) 715-4394, Fax: (703) 264-

2443, Email: mbhargavan@acr.org

Research Objective: (1) To measure trends in racial and ethnic disparities in mammography screening since 1996 and (2) to explore white-

Hispanic and white-Asian disparities, which have been little-studied, all (3) with appropriate controls for socio-economic characteristics.

Early detection by mammography screening made a sizeable contribution to the reduction in breast cancer mortality seen in recent years, but variations in mortality rates by race and ethnicity persist. The evidence regarding disparities in mammography use is mixed and confusing.

Recent studies found that survey self-reports show no black/white disparity in mammography use, but more reliable data on the same women

(namely, claims data or short-recall-period interviews about medical events) show substantial disparities.

Study Design: We use data from the Medical

Expenditure Panel Surveys (MEPS) for 1996-

2003, National Health Interview Survey (NHIS) for 1998 and 2000, Behavioral Risk Factor

Surveillance Survey (BRFSS) for 1996-2004, and claims data from a large national employer plan

(LNEP) for 1999-2003. The surveys are nationally representative and report individuals’ race/ethnicity and socio-economic characteristics in varying levels of detail. The claims data contain zip-code of residence; race/ethnicity and socio-economic characteristics of the zip-code are obtained from

Census data. From all three surveys, we use selfreports of having had a mammogram during the past two years. From MEPS, we also use a short-recall-period report of having had a medical event which included a mammogram.

From the LNEP data, we measure if there was a claim for a mammogram during a year. Logistic regression isolates the individual effects of race and other characteristics on use of mammography screening.

Population Studied: Women age 40 and older, because mammography guidelines recommend screening primarily for this population.

Principle Findings: Logistic regression of the self-reported use of mammography, with controls for time trend, demographic characteristics (such as age, marital status), socioeconomic characteristics (such as income, education), and health characteristics (such as self-reported health status), finds equal (MEPS) or higher (BRFSS, NHIS) odds of a black or

Hispanic women having a mammogram relative to white women (BRFSS odds ratios: Hispanicwhite=1.34, black-white=1.45, NHIS odds ratios:

Hispanic-white=1.32, black-white=1.23). Asian women have lower adjusted odds of having a mammogram than white women (Odds ratios:

MEPS: 0.44, BRFSS: 0.76, NHIS: not significant).

Corresponding comparisons of medical events that include mammography (MEPS) find lower odds of having a mammogram for all minorites relative to whites (odds ratios: Hispanicwhite=0.73, black-white=0.58, Asian-white=0.52); claims data find lower odds of having a mammogram for women in high-minority zipcodes relative to women in high-white zip-codes

(odds-ratios for 10% increase in the minority percent of population: Hispanic=0.95, black=0.98, Asian=0.91). The claims data and

MEPS event-recall data generally show no reduction in disparities over time.

Conclusions: Sound understanding requires using harder data than survey self-reports of having had a mammogram in the last two years.

Adjusting for socioeconomic characteristics is useful in clarifying findings.


Because the harder data show that, despite the publicity the general topic of disparities has received in recent years, there are large

disparities that are not declining, new efforts to eliminate disparities are necessary.

•

Health Disparities among Aged Hispanic

Medicare Beneficiaries: The Current

Perspective

Amanda Borsky, Ernest Moy, M.D., M.P.H.,

Presented By: Amanda Borsky, Center for

Quality Improvement and Patient Safety, Agency for Healthcare Research and Quality (AHRQ),

540 Gaither Road, Room 3212, Rockville, MD

20850, Phone: 301-427-1826, Fax: 301-427-1341,

Email: amanda.borsky@ahrq.hhs.gov

Research Objective: This study assessed the extent to which health disparities exist among aged Hispanic Medicare beneficiaries by race/ethnicity, socioeconomic status (SES), and geographic location in the United States.

Study Design: This study involved two research contracts that sought to improve the race/ethnicity and SES categorization of

Medicare beneficiaries. After assessing the current race/ethnicity data from the Medicare enrollment database (EDB), the first contract developed an algorithm using language preference, surname, and geographic location to improve race/ethnicity coding for Hispanics.

After validating the algorithm, it was applied to the entire 41.7 million Medicare beneficiaries.

The second contract created and validated a measure for SES. The top 10 metropolitan statistical areas (MSAs) with the largest number of Hispanics 65 years of age or older were also examined. Medicare administrative claims data

(2002) were used to measure the use of services for various cancer screenings and secondary prevention of diabetes complications.

Population Studied: The population studied is a probability sample of 1.96 million Medicare beneficiaries from the mid-2003 unloaded EDB.

The population includes: whites, African

Americans, Hispanics, Asian/Pacific Islanders, and American Indian/Alaskan Natives enrolled in fee-for-service Medicare.

Principle Findings: Improving the race/ethnicity and SES categorization of Medicare beneficiaries allowed for the assessment of health disparities between white and Hispanic Medicare beneficiaries. The percent of whites receiving cancer screenings and secondary prevention of diabetes complications were then used to compare the percent for Hispanics nationwide and in the top 10 MSAs for Hispanics. Key MSA findings include: in Miami, FL, Hispanics were half as likely to receive any type of colorectal screenings compared to whites (11 percent compared to 22 percent, respectively). In

Riverside, CA, Hispanic females were significantly less likely to receive a mammogram than white females (25 percent compared to 41 percent, respectively). In San Antonio, TX,

Hispanics diagnosed with diabetes were significantly less likely to receive an eye exam compared to whites (55 percent compared to 72 percent, respectively).

Conclusions: Racial/ethnic disparities among

Medicare beneficiaries should be negligible, as

Medicare eliminates insurance- and cost-related access barriers as explanations of health disparities. However, we found health disparities between white and Hispanic Medicare beneficiaries exist nationwide and in the 10

MSAs where the highest percentage of aged

Hispanics reside.


While other research examines disparities at the national and state levels, this research provides us with a better understanding of disparities faced by aged Hispanics in specific MSAs, which may help federal and state agencies target resources to specific areas more efficiently and allow localities to develop interventions that best meet the needs of their residents.

Funding Source: Centers for Medicare &

Medicaid Services (CMS) and AHRQ.

•

Is Assimilation Bad for Your Health? The

Association Between Acculturation Status and

Cardiovascular Disease (CVD) Risk Factors

Andrea Card, M.D., Olveen Carrasquillo, M.D.,

M.P.H.

Presented By: Andrea Card, M.D., PostDoctoral

Clinical Fellow, Division of General Medicine,

Columbia University, 622 West 168 Street, PH 9

East 105, New York, NY 10032, Phone: (212) 305-

6299, Fax: (212) 305-9349, Email: adc2121@columbia.edu

Research Objective: Latinos have lower cardiovascular disease (CVD) mortality rates that non-Hispanic whites. Several studies examining this "Latino Paradox" have also found that increasing acculturation is associated with an increased prevalence of CVD disease risk factors.However, most of these studies:a)do not use validated measures of acculturation, b)focus on disease prevalence (many using self-reported rather than physiologic measures), and c)do not control for important covariates. We examined the relationship between acculturation status and various CVD risk factors.

Study Design: We analyzed data from the 2003-

2004 National Health and Nutrition Examination

Survey. Our independent variable was acculturation status as measured using a modified version of the Marin acculturation scale. We categorized this variable into tertiles

(low, intermediate, and high). Our dependent variables were low density lipoprotein (LDL), systolic blood pressure (SBP), and hemoglobin

A1C (HbA1C). A priori, the following were selected as potential covariates: age, socioeconomic status (education and income), gender, and body mass index (BMI). We modeled age and BMI as continuous variables.

All the other variables were categorical. The Rsqueard for our models were 0.15 for LDl, 0.33 for SBP, and 0.13 for HbA1C. We used SUDAAN statistical software for the analysis. We present group means adjusted for the covariates listed above.

Population Studied: We analyzed data from the

2003-2004 national Health and Nutrition

Examination Survey. This nationally representative survey of the US population sampled 1,870 Hispanic adults.

Principle Findings: In bivariate analysis we found non-statistically significant (NS) trends for increasing acculturation to be associated with lower mean LDL, SBP, and HbA1C levels. In multivariate models, age and BMI emerged as the strongest predictors for all three outcomes

(except BMI and LDL). In all models, gender and socioeconomic status were also important covariates. Once adjusted for these baseline differences, we found increasing acculturation was signficantly associated with decreased mean

LDL levels. Mean LDL(mg/dL) +/- standrad error

(SE) by acculturation level: Low 121 +/- 2.9,

Intermediate 109 +/- 2.2, High 104 +/- 3.8; p<0/01, low versus high. SBP was not associated with acculturation. Mean

SBP(mmHg)+/- SE by acculturation level: Low

116+/- 1.1, Intermediate 119 +/- 1.4, High 118 +/-

1.1. We did, however, find a trend (NS) towards increased HbA1C among the highest acculturation. Mean HbA1C(%) +/- SE by acculturation level: Low 5.54 +/- 0.1, Intermediate

5.53 +/- 0.1, High 5.68 +/- 0.1.

Conclusions: Our unadjusted findings and most of our multivariate analysis refute the hypothesis that increasing acculturation is associated with poorer health status among Latinos.


The Latino paradox cannot be explained by the protective health effect of lower acculturation.


• Factors Associated with Informed Decision

Making Processes for Primary Breast Cancer

Treatment

Judy Chen, M.D., M.S.H.S., Jennifer Malin, M.D.,

Ph.D., Clifford Y Ko, M.D., May Lin Tao, M.D.,

M.S., Patricia A Ganz, M.D., Katherine L Kahn,

M.D.

Presented By: Judy Chen, M.D., M.S.H.S., NRSA

Fellow, Medicine, UCLA, 911 Broxton Avenue, 3rd floor, Los Angeles, CA 90024, Phone: (310) 209-

0850, Email: jychen@mednet.ucla.edu

Research Objective: To determine who had opportunities for informed decision making in their primary breast cancer treatment, we examined factors which predict self-reported physician-patient discussions of breast cancer treatment alternatives and outcomes.

Study Design: We conducted a secondary data analysis of the Los Angeles Women’s Study, a population-based study of women 50 years and older with breast cancer diagnosed from March through November of 2000. Our first dependent variable, physician-patient discussions of treatment alternatives

(lumpectomy plus radiation versus mastectomy), was dichotomous. Our second dependent variable, discussion of outcomes

(range 0 to 4), was constructed by tallying four items respondents discussed with their physicians prior to decision making about surgery: (1) the likelihood of breast cancer recurring over time, (2) how breast cancer might influence longevity, (3) the appearance of breast or chest wall after surgery, and (4) the possibility of arm swelling, pain, or difficulty with movement. We used multivariable logistic regression to estimate the impact of patient and hospital characteristics on the receipt of physician-patient discussions of treatment alternatives. We used ordered logistic regression to estimate the impact of the same factors on frequency of physician-patient discussion items.

Population Studied: Our cohort was composed of women with stage I or II breast cancer.

Women with scleroderma, prior history of chest wall irradiation, or no surgery for breast cancer were excluded from the analyses.

Principle Findings: Of 871 women, 56% reported having a discussion of treatment alternatives with their physicians. Regarding the frequency of outcome discussion items, 23% reported receiving no discussion of treatment outcome items, and 18% reported discussing all four outcome items. In adjusted analyses, advanced age and less education were

significantly associated with no discussion of treatment alternatives (OR 0.4, 95% CI 0.2----0.5 for age >= 70 compared to age 50-59; OR 0.6,

95% CI 0.4----0.9 for <= high school compared to college graduates) and less frequency of outcome item discussion (OR 0.4, 95% CI 0.3----

0.7 for age >= 70 compared to age 50-59; OR 0.5,

95% CI 0.4----0.9 for <= high school compared to college graduates). Women with annual income

< $20,000 were significantly less likely to receive discussions of treatment alternatives than women with annual income > $40,000 (OR 0.5,

95% CI 0.3----0.8). Income was not a significant predictor of frequency of discussion of treatment outcome items.

Conclusions: Women with advanced age, less education, and lower income were at higher risk of not being included in the informed decision making process regarding their breast cancer treatment.


Interventions to increase physician-patient discussion of treatment options and outcomes are particularly needed among older, less educated, or less affluent women with breast cancer.

Funding Source: NCI

• Differences in Subspecialty Co-

Management of Cardiovascular Disease by

Race, Ethnicity, Gender and Insurance Status

Nakela Cook, M.D., M.P.H., John Z. Ayanian,

M.D., M.P.P., LeRoi S. Hicks, M.D., M.P.H.

Presented By: Nakela Cook, M.D., M.P.H.,

Research Fellow, Department of Health Care

Policy, Harvard Medical School and

Massachusetts General Hospital, 180 Longwood

Avenue, Boston, MA 02115, Phone: (617)285-

6842, Fax: (617)432-3333, Email: ncook1@partners.org

Research Objective: To determine if, among a cohort of adult patients receiving primary care for coronary artery disease or congestive heart failure, the likelihood of being co-managed with a cardiologist differs according to patients’ race or ethnicity, gender, and insurance status and to examine if gender or racial and ethnic differences in access to cardiologist co-management is mediated by patient’s insurance status.

Study Design: In a retrospective cohort we assessed the likelihood of cardiologist comanagement in ambulatory care by patients’ demographic characteristics. Using multivariable logistic regression, we assessed whether gender, racial, and ethnic differences persisted after adjustment for other sociodemographic characteristics.

Population Studied: We examined electronic records of 26,151 adult patients between the ages of 21 and 85 with visit diagnostic codes of ischemic heart disease, coronary artery disease, cardiomyopathy, or heart failure receiving primary care in hospital or community-based practices affiliated with two academic hospitals in Massachusetts between January 1, 2000 and

December 31, 2005.

Principle Findings: In the study cohort, 56 percent of patients had an office visit with a cardiologist, 73 percent were White, 7 percent were Black, 7 percent were Hispanic, and 57 percent were men. In unadjusted analysis, women received significantly lower rates of consultation than men, 47 versus 64 percent, P value less than 0.0001. The uninsured were significantly less likely to receive consultation than the privately insured, 45 versus 53 percent,

P value less than 0.0001. Hispanic patients also received significantly lower rates of consultation than White patients, 52 versus 56 percent, P value equal to 0.0004. The consultation rate for

Black patients was 54 percent, P value equal to

0.0834 relative to Whites. After adjustment for patients’ race, ethnicity, sex, age, insurance status, and primary language, gender and insurance disparities persisted. However,

Hispanics had similar odds of receiving consultation as Whites after adjustment, adjusted odds ratio 0.9, 95 percent confidence interval 0.78 to 1.04.

Conclusions: For patients receiving primary care for major cardiac conditions, outpatient cardiology consultation occurred only 56 percent of the time and rates of referral differed significantly by patients’ race, gender, and insurance status. However, lower rates of consultation for Hispanic patients were primarily mediated by differences in insurance status, language, age, and gender.


Significant gaps in access to outpatient cardiology consultation exist based on patients’ ethnicity, gender, and insurance status.

Interventions targeted at eliminating disparity in consultation should focus on the impact of language and insurance among Hispanic patients, as co-management may improve cardiovascular outcomes in these populations.

Funding Source: AHRQ, National Research

Service Award (# 5 T32 HS000020-21) from the

Agency for Healthcare Research and Quality

• Immigrant Elder Participation in

Community Health Programs

Almas Dossa, M.P.H., M.S., P.T.

Presented By: Almas Dossa, M.P.H., M.S., P.T.,

Doctoral Candidate, The Heller School for Social

Policy and Management, Brandeis University,

Ms 035, 415 South Street, Waltham, MA 02454,

Phone: 617 566 1861,

Email: adossa@brandeis.edu

Research Objective: Strategies such as community health and fitness programs may prevent physical disability and maintain function thus reducing long-term care costs and improving elder quality of life. This study explored community stakeholders perspectives on issues that may impact elder participation in programs including: whether various stakeholders were congruent in elder health program decision-making for a specific senior center community; how various structures and processes such as recruitment, coordination, and communication were used by administrators to make program decisions; whether structures and processes differed for immigrants versus non-immigrants; participation issues including challenges, communication with stake-holders, program design, and differences in participation between immigrants and non-immigrants.

Study Design: Mixed methods approach using semi-structured interviews, field observations, and surveys.

Population Studied: 26 interviews with: senior center and Council on Aging leaders, collaborating organization leaders, health and fitness program leaders, immigrant outreach workers. 100 elder surveys (83 women,17 men,

60 non-immigrants,40 immigrants including 25

Russians, 5 Southeast Asians, and 10 ‘‘other’’).

Principle Findings: Qualitative findings showed that stakeholders collaborated with each other on program decision-making on an informal and formal basis. Senior center leaders encouraged elders to initiate programs, and elders were given opportunities to give program feedback and make suggestions. Immigrant participation was limited. Respondents perceived this to be due to unfamiliarity with group programs, different cultural backgrounds, lack of transportation, lack of marketing to immigrant organizations, and lack of program flyer translations. Another reason was a tendency to want to be with ‘‘their own kind’’ and participate in immigrant programs. For health education programs, language was perceived a major issue due to difficulty of gearing health issues to elders with different cultural backgrounds. Public housing elder participation, which included immigrants was limited. Immigrant outreach workers were only funded for a few hours per week. Bivariate analyses for immigrants vs. nonimmigrants and Russian immigrants versus US born elders showed that immigrants and

Russian born elders were significantly less likely than non-immigrants: to participate in programs; to say that the program leader spoke their language; to say that it was easy to find out about programs. Russian immigrants were significantly less likely than US born elders to find out about programs via the senior newsletter and via the local newspaper, and significantly more likely to go to health programs elsewhere. There were no significant differences between immigrants/ Russian born elders and non-immigrants for age, gender, education, race, and functional status, but significant differences existed for marital status where higher percentages of immigrants/Russian born elders were married.

Conclusions: Quantitative findings from elders supported qualitative findings received from key informants. Elder immigrants participated less than non immigrant in health and fitness programs at this specific senior center.

Participation appeared to be associated with marketing and language issues.


Policy makers need to consider increased funding for marketing, transportation, volunteer support, immigrant outreach worker support, increased immigrant program leaders, and program leader training in order to help immigrant elders maintain function and independence in the community.

Funding Source: The Charles H. Farnsworth

Trust

•

Impact of Treatment and Socioeconomic

Status on Racial Disparities in Survival among

Older Women with Breast Cancer

Xianglin Du, M.D., Ph.D., Shenying Fang, M.D.,

M.S., Tamra E. Meyer, M.P.H.

Presented By: Xianglin Du, M.D., Ph.D.,

Associate Professor, Division of Epidemiology,

University of Texas School of Public Health, 1200

Herman Pressler Dr, Houston, TX 77030, Phone:

(713) 500-9956, Fax: (713) 500-9264, Email:

Xianglin.L.Du@uth.tmc.edu

Research Objective: To determine the impact of treatment and socioeconomic status on

racial/ethnic disparities in survival among older women with breast cancer.

Study Design: This was a large retrospective cohort study with up to 11 years of follow-up in older women diagnosed with incident breast cancer between 1992 and 1999 in the 11 SEER

(Surveillance, Epidemiology and End Results) areas across the United States, identified from the SEER-Medicare linked data. These linked data not only provided reliable information on tumor stage and grade at diagnosis and longterm follow-up of the vital status, but also allowed the examination of various socioeconomic factors at the level of census tract. Three variables from the 1990 census were used to define socioeconomic status at the census tract level: a) percent of adults aged >=25 who had less than 12 years of education; b) percent of persons living below the poverty line; c) annual household income. In addition, comorbid conditions and chemotherapy could be identified from Medicare claims data. Other factors in the analysis included age at diagnosis, marital status, tumor stage, grade, size, hormone receptor status, year of diagnosis, and geographic area.

Population Studied: A cohort of 35,029 women with early-stage (stage I-IIIA) incident breast cancer at age 65 or older from 1992 to 1999 were identified with up to 11 years of follow-up in the

11 SEER areas (San Francisco/Oakland, Detroit,

Atlanta, Seattle, Los Angeles county, the San

Jose-Monterey area, and the states of

Connecticut, Iowa, New Mexico, Utah and

Hawaii). Of the 35,029 women, 30,484 were

Caucasians (non-Hispanic whites), 1,971 were

African Americans (non-Hispanic blacks), and

2,574 were other ethnicities. Cox proportional hazard regression analysis was performed to determine the risk of all-cause and breast cancerspecific mortality.

Principle Findings: African American women with breast cancer were more likely to live in the poorest quartiles of socioeconomic status than

Caucasians (73.7% versus 20.7%, P<0.001).

Those living in communities with the lowest socioeconomic status were 11% more likely to die than those in the highest (hazard ratio: 1.10,

95% Confidence Interval: 1.04-1.16). The risk of dying changed only slightly after controlling for race/ethnicity (1.11, 1.05-1.18). Compared to

Caucasian women with breast cancer, crude hazard ratios of all-cause and breast cancerspecific mortality were 1.35 (1.27-1.45) and 1.83

(1.56-2.16) for African Americans. After adjusting for treatment (surgery, radiation, and chemotherapy) and socioeconomic status, hazard ratio of all-cause mortality was no longer significant in African Americans (1.02, 0.84-1.10), whereas the risk of breast cancer-specific mortality was marginally higher in African

Americans (1.21, 1.01-1.46).

Conclusions: Racial disparities in survival between African American and Caucasian women with early-stage breast cancer were largely explained by their differences in treatment and socioeconomic status.


Since treatment and socioeconomic factors are modifiable, making efforts to eliminate racial disparities in health care and to minimize disparities in socioeconomic status may have important clinical and public health implications for reducing disparities in health outcomes.

Further studies would help to determine if this finding is similar for younger women with breast cancer.

Funding Source: NCI

• Frequency of Stress Testing Prior to Elective

Percutaneous Coronary Interventions in a

Medicare Population

R. Adams Dudley, M.D., M.B.A, R. Adams

Dudley, M.D., M.B.A., F. L. Lucas, Ph.D., David J.

Malenka, M.D., Rita F. Redberg, M.D., M.Sc.

Presented By: R. Adams Dudley, M.D., M.B.A,

Associate Professor of Medicine and Health

Policy, Institute of Health Policy Studies,

University of California, San Francisco, 3333


94118, Phone: (415) 476-8617, Fax: (415) 476-

0705, Email: adams.dudley@ucsf.edu

Research Objective: Current guidelines for percutaneous coronary intervention (PCI, or coronary stenting) suggest that documenting ischemia with noninvasive testing should be done to determine the need for elective PCI in patients with stable coronary artery disease, and that PCI performed without first documenting ischemia may involve clinical risk without any potential for benefit. Our objective was to determine the frequency of stress testing prior to elective PCI in an aged Medicare population.

Study Design: Using the Medicare Provider

Analysis, Physician/Supplier and Denominator

Files for a random 20% sample of Medicare beneficiaries, we calculated the proportion of patients who underwent stress testing in the 90 days prior to an elective PCI. We examined rates of stress testing by hospital referral region, age, sex, and race.

Population Studied: We took all patients 65 and older in a cohort of fee-for-service Medicare patients who had a PCI done in 2004. In order to define patients having an elective PCI, we excluded patients with emergent admissions, emergency room charges, transfer patients, and patients who had primary diagnoses of acute myocardial infarction or acute coronary syndrome. We also excluded patients with a history of prior PCI, coronary artery bypass grafting, valve surgery, acute myocardial infarction, or unstable angina within 1 year of the index procedure.

Principle Findings: In the 20% sample, we identified 22,750 patients who had elective PCI in

2004. Nationally, only 44.8% of patients underwent stress testing in the 90 days prior to

PCI. Proportions varied widely among hospital referral regions with at least 25 elective PCIs, from a high of 70.6% to a low of 19%

(interquartile range 50.9%, 39.3%). Rates of stress testing prior to PCI by age, sex, or race only varied by 1 or 2 percentage points, although due to sample size these differences were statistically significant.

Conclusions: In the majority of Medicare patients with stable coronary artery disease, stress testing to document ischemia is not being done prior to elective PCI. As the 2005

ACC/AHA/SCAI guidelines generally require documentation of ischemia prior to elective PCI, this finding suggests a lack of adherence to guidelines for PCI, meaning that interventions which are not useful or effective may be common in the Medicare population. The wide variation in geographic rates also suggests that factors other than national guidelines are influencing treatment of stable coronary artery disease.


Mechanisms other than guidelines may be necessary to ensure that physicians consistently evaluate the expected benefit of PCI prior to elective procedures.

Funding Source: Blue Shield Foundation of

California

•

Acculturation and Risk Factor Levels among

Hispanic Adults with Hypertension,

Hypercholesterolemia, or Diabetes: The

Multi-Ethnic Study of Atherosclerosis

Pracha Eamranond, M.D., Ana V Diez-Roux,

M.D., Ph.D., Namratha R Kandula, M.D.,

M.P.H., Walter Palmas, M.D., M.S., David S

Siscovick, M.D., M.P.H., Anna TR Legedza, Sc.D.

Presented By: Pracha Eamranond, M.D.,

Research Fellow, General Medicine and Primary

Care, Beth Israel Deaconess Medical Center,

1309 Beacon Street, Brookline, MA 02246,

Phone: 617-595-8908, Email: peamrano@bidmc.harvard.edu

Research Objective: Control of cardiovascular risk factors has been shown to be worse for

Hispanics than non-Hispanic whites. Although acculturation status may explain some variation in health outcomes, the association of acculturation and cardiovascular risk factor control among Hispanics has not been wellstudied. We investigated the association between acculturation and cardiovascular risk factor levels among Hispanic participants with hypertension, hyperlipidemia, or diabetes.

Study Design: Cross-sectional observational study. We used linear regression to examine the relationships between acculturation variables and cardiovascular risk factor levels, before and after adjustment for education, income, health insurance, physical activity, dietary factors, and

BMI. Measures of acculturation were language spoken at home and proportion of life spent in the U.S. Outcome measures included systolic blood pressure (mmHg), difference of measured

LDL-cholesterol and goal LDL-cholesterol

(mg/dL), and fasting blood glucose (mg/dL).

Population Studied: We studied 1492 Hispanic participants in the Multi-Ethnic Study of

Atherosclerosis (MESA), without clinical cardiovascular disease and with at least one of the following risk factors: hypertension, hyperlipidemia, or diabetes.

Principle Findings: Of 1492 Hispanic participants, the mean age was 63 with a female predominance (53%). 57% spoke Spanish at home and 71% were foreign-born. There were

580 Hispanics with hypertension, 539 with hyperlipidemia, and 248 with diabetes. After adjustment for age and sex, Spanish-speaking

Hispanics with cardiovascular risk factors had higher systolic blood pressure (4.7 + 1.8 mmHg, p=.01), LDL-cholesterol difference (7.9 + 3.4 mg/dL, p=.02), and fasting blood glucose (18.8 +

8.1 mg/dL, p=.02) compared to English-speaking

Hispanics. Additional adjustment for education attenuated most of the differences in blood pressure (1.7 + 2.0 mmHg, p=.38), whereas adjustment for lipid-lowering medication use attenuated nearly all of the differences in LDLcholesterol (2.8 + 3.4 mg/dL, p=.42). Differences in fasting glucose were attenuated by socioeconomic variables (10.2 + 9.5 mg/dL, p=.28) but were augmented after further

adjustment for dietary factors (21.0 + 9.1 mg/dL, p=.02). Similar associations were observed between proportion of life in the U.S. and risk factor levels. Physical activity and BMI did not have significant effects on these estimates.

Conclusions: Among those with cardiovascular risk factors, Hispanics with lower levels of acculturation based on language and proportion of life in the U.S. have worse control of cardiovascular risk factors.


Further preventive strategies that focus on

Hispanics with low levels of acculturation may improve cardiovascular risk factor control in this population.

Funding Source: National Research Service

Award

• Combating Cancer Disparities Through

Community Based Participatory Research

Keith Elder, Ph.D., M.P.H., M.P.A., Delores

Pluto, Ph.D., Deloris Williams, Ph.D., Delores

Scott, Leslie Cooper, Ph.D., M.P.H., James R.

Hebert, Sc.D.

Presented By: Keith Elder, Ph.D., M.P.H.,

M.P.A., Assistant Professor, Health Services

Policy and Management, University of South

Carolina School of Public Health, 800 Sumter

Street Room 116, Columbia, SC 29208, Phone:

803-777-5041, Fax: 803-777-1836, Email: kelder@gwm.sc.edu

Research Objective: Chronic diseases represent an important component of racial disparities in the United States. African Americans suffer a disproportionate burden from cancer. African

Americans have a higher mortality rate for prostate cancer (twice the rate of white men), colorectal cancer (30% higher), and breast cancer (37% greater). In South Carolina, the disparities are even greater. African Americans have a prostate cancer mortality rate 2.59 times that of white men, colorectal cancer mortality rates are 33% higher, and breast cancer mortality rates are 45% higher compared to whites.

Community-based participatory research represents an important approach for improving the health of underserved and disadvantaged communities. The overall goal of the NCIfunded South Carolina Cancer Disparities

Community Network is to develop and increase capacity to support community based-based participatory education, research, and training to reduce cancer health disparities among African

Americans in South Carolina and beyond, using the church as the centerpiece.

Study Design: This study used survey data collected from 19 churches throughout South

Carolina. We collected baseline data on attitudes, behaviors, and lifestyles related to cancer and health promoting behaviors. We also collected demographic information such health insurance status, obesity level, marital status, educational status, income level, employment status, gender, and age. All analyses were stratified by gender and region.

Population Studied: The study sample included women and men ages 18 years and over. The response rate for the first wave was 40%, i.e., 735 responses from the 1800 people who were mailed a survey.

Principle Findings: The majority of the women responders (60%) performed a breast self exam on a monthly basis; 79% of the women over 40 years of age had a mammogram in the last 2 years; 98% had a pap smear in the last 5 years; and 30% of those women 50 years of age and older have never had a colorectal cancer screening procedure. Most men over the age of

40 (91%) had a digital rectal exam within the last

5 years; 85% had a PSA within the last 5 years; over 30% of men 50 years and older had never had a colorectal cancer screening procedure.

Overall, 71% of those surveyed were overweight or obese; 56% do not exercise regularly; 87% ate less than 5 fruits and vegetables a day; 10% were regular smokers; 88% had some type of health insurance; and 7% were unemployed.

Conclusions: African-American men and women were likely to engage in cancer screening; however, they were not likely to engage in healthy behaviors that may decrease the likelihood of cancer.

Implications for Policy, Practice or Delivery: It appears that the majority of African Americans in

South Carolina are being screened for cancer.

The literature is replete with lifestyle and behavior being associated with cancer and cancer outcomes. The disconnect between screening behavior, lifestyle, and cancer statistics needs to be addressed in the African-American community in order to lessen the burden of cancer.

Funding Source: NCI

• Racial/Ethnic Differences in Adherence to

Hypertension Medication, Treatment

Intensification, and Blood Pressure Control in

Medicare Enrollees

Vicki Fung, Ph.D., Jie Huang, Ph.D., John Hsu,

M.D., M.B.A., M.S.C.E.

Presented By: Vicki Fung, Ph.D., Consulting

Data Analyst, Division of Research, Kaiser

Permanente, 2000 Broadway, 3rd Floor,

Oakland, CA 94612, Phone: 510-891-3527, Fax:

510-891-3606, Email: Vicki.Fung@kp.org

Research Objective: We examined racial/ethnic differences in hypertension (HTN) medication adherence, treatment, and blood pressure control.

Study Design: Using automated data from an integrated delivery system (IDS), we examined systolic blood pressure control in 2003

(SBP<140mmHg) among subjects receiving

HTN medication in 2002. We used medications dispensed in 2002 to define the prescribed regimen, and assessed adherence in the 90-days prior to SBP measurements in 2003 using the proportion of days covered (PDC>=80%).

Among subjects with elevated SBP on their initial

2003 measurement, we examined adherence and treatment intensification between an initial and subsequent measurement. We defined intensification as an increase in the number of prescribed drug classes, or the prescribed daily dose of individual drugs. Using logistic regression, we evaluated our outcomes across racial/ethnic groups. In all analyses, we adjusted for age, gender, neighborhood socioeconomic status, comorbidity, chronic conditions, drug cost-sharing, medical center, number of drugs in the regimen, and month.

Population Studied: All 78,157 subjects were continuously enrolled with Medicare, 65+ years old, in a hypertension registry, and had 1+ SBP measurement in 2003. On the first measurement, 38,095 had elevated SBPs and had 1+ additional measurement in 2003 more than 30-days later. Race/ethnicity information was available for 92% of all subjects: 9.0% were

Asian, 5.1% Black, 7.2% Hispanic, and 67.2%

White.

Principle Findings: Black subjects were most likely to have multi-drug regimens (60.8%) and elevated SBP on their first measurement

(50.0%), compared with other subjects. In multivariate analyses, greater adherence to the drug regimen was associated with better SBP control. After adjusting for covariates and adherence level, and compared with White subjects, Black subjects had higher odds of having an elevated initial SBP (OR=1.18, 95% CI:

1.10-1.26); Asians lower odds (OR=0.84, 95% CI:

0.80-0.89); and Hispanics similar odds

(OR=1.01, 95% CI: 0.95-1.07). Among patients with elevated SBP on the initial measurement,

54.6% had elevated SBP on a subsequent measurement (mean days between measurements=91). The percentage of adherent subjects increased by 3.3% (from 71.7% to

75.0%) between measurements and 24.6% experienced treatment intensification. Non-

White subjects were more likely to have intensification than Whites (e.g., OR=1.20, 95%

CI: 1.07-1.34 for Black subjects). Both greater adherence and intensification between measurements were associated with improvements in SBP level. After adjusting for individual characteristics, adherence, and treatment intensification, Black subjects remained more likely to have elevated SBPs, compared with Whites (OR=1.16, 95% CI: 1.06-

1.28).

Conclusions: Black patients were more likely to have elevated SBP at baseline and a subsequent measurement; they also were more likely to receive treatment intensification before the subsequent measurement. Differences in blood pressure control between Black and White patients persisted even after accounting for individual treatment regimens, adherence, and treatment intensification.


Differences in blood pressure outcomes across race/ethnicity persisted, even in an insured population receiving care within a single IDS, and after accounting for medication treatment and adherence. Additional work is needed to understand these outcome differences, and reasons for poor treatment adherence and low levels of intensification for all patients.

Funding Source: AHRQ, National Institute on

Aging

•

Income Disparity and Health: A multilevel

Analysis of the 2003 American Community

Survey

Tahany Gadalla, Ph.D., Esme Fuller-Thomson,

Ph.D.

Presented By: Tahany Gadalla, Ph.D., Assistant

Professor, Social Work, University of Toront, 246

Bloor Street West, Toronto, M5S 1A1, Phone:

(416) 946-0623, Fax: (416) 978-7072, Email: tahany.gadalla@utoronto.ca

Research Objective: This study aimed to:

(1) examine whether State-level income disparity had an independent effect on individual's limitations in activities of daily living (ADL) when controling for demographic and socio-economic characteristics such as age, gender, marital status, income, race and education, and

(2) to assess the roles played by these individuallevel characteristics and State-level income disparity in explaining the observed variation in

ADL rates across States.

Study Design: The study was based on secondary analyses of data collected in the 2003

American Community Survey (ACS). The ACS is a national survey of Americans 25 years and older with a 96.7% response rate. The sample used for this research included 645,835 participants. Respondents were defined as having a limitation in Activities of Daily Living if they had a physical, mental, or emotional condition lasting 6 months or more that made it difficult to ‘‘dress, bathe, or get around inside the home.’’ Income disparity for each state was measured using the Gini Coefficient for that state. The Gini coefficient is the most frequently used measure of income disparity within a community (Subramanian & Kawachi, 2004).

The multilevel modeling of individuals nested within state was achieved through the nonlinear logit link function within HLM5.02 software

(Raudenbush et al, 2000).

Population Studied: The sample used for this research included 645,835 Americans 25 years and older who participated in the 2003 American

Community Survey.

Principle Findings: States with higher income disparity have higher rates of limitations in ADL, even when individual level characteristics were controlled in the analysis. However, the magnitude of this relationship is quite modest; a

0.05 increase in the Gini coefficient increased the odds of ADL limitations by 11.2%, (OR = 1.11,

95% C.I. = 1.01, 1.22). ADL limitations have a substantially stronger relationship with individual poverty than with state-level income disparity.

Individuals living below the poverty line had approximately eight times higher odds of ADL limitations than those living above 500% of the poverty level.

Conclusions: State level income disparity was a significant, albeit modest, predictor of ADL limitations.


Interventions alleviating extreme poverty could have a positive effect on ADL limitation rates both directly and indirectly through improvements in state-level income disparity.

•

Diffusion of Alzheimer’s Disease Drugs among Medicare Beneficiaries: Disparities in

Treatment and Impact on Health Care

Expenditures

Chandrakala Ganesh, Ph.D. Candidate, Dennis G

Shea, Ph.D.

Presented By: Chandrakala Ganesh, Ph.D.

Candidate, , Health Policy and Administration,

Penn State University, 116 Henderson Building,

University Park, PA 16801, Phone: 585-414-1709,

Email: cxg913@psu.edu

Research Objective: This paper has two objectives: (1) to examine racial, geographic and socioeconomic disparities in the diffusion of drugs for Alzheimer’s disease; (2) to examine the trend and level of out-of-pocket costs and total health care costs of Alzheimer’s disease drugs

Study Design: The study design involves analysis on 11 years of data from the Medicare

Current Beneficiary Survey (1993-2003). The

2003 Area Resource File provides aggregate data on the health care system and socioeconomic and environmental characteristics. Disparities are measured implementing the Agency of

Healthcare Research and Quality and Institute of

Medicine definitions of disparities. Geographical

Information Systems (GIS) are used to map geographic disparities. Costs are estimated by a generalized linear model using gamma regression functions. Analyses are conducted on three samples: (i) beneficiaries with only a claims diagnosis of Alzheimer’s (ii) beneficiaries with a claims diagnosis or a survey report of

Alzheimer’s (iii) beneficiaries with a claims diagnosis of Alzheimer’s, survey report of

Alzheimer’s, or other dementia diagnosis. This categorization helps in determining how the results change based on varying sample definitions.

Population Studied: The sample includes community-dwelling Medicare beneficiaries who are enrolled in fee-for-service Medicare for each full calendar year. Only those beneficiaries who had a claims diagnosis and a completed survey are included to increase the validity of the measure and to avoid possible misclassification that might result from using claims data alone.

Beneficiaries who reside in nursing homes are excluded. In addition, select variables on health care systems from the 2003 Area Resource File are included.

Principle Findings: Findings indicate that overall Alzheimer’s drug use increased from 0.1 percent in 1993 to 32 percent in 2001. The percent of individuals, African-Americans and

Caucasians, diagnosed with Alzheimer’s has been fairly constant. The diffusion of Alzheimer’s drugs has been most rapid among beneficiaries who are white, live in urban areas, had higher education, with drug coverage compared to those who were black, in rural areas, with lower

education, or without drug coverage. In 2001, mean annual total drug and out-of-pocket expenditures of beneficiaries using Alzheimer’s drugs was $2317 and $850 respectively, versus

$819 and $318 in the year 1993.

Conclusions: Results suggest emerging disparities in the diffusion of Alzheimer’s drugs.

These drugs also have a significant impact on the health care costs for Medicare beneficiaries.


Drug treatments for Alzheimer’s provide a unique opportunity to study emerging disparities and the effects of new drug technology on costs.

The results highlight how individual characteristics, insurance, and health system factors impact disparities and costs as a new drug becomes available. Discussion highlights the implications of growing Alzheimer’s costs for

Medicare and the elderly and how policy-makers may be able to influence the development of fewer disparities as new drug technologies are introduced.


•

Race, Avoidance of Care, Illness

Perceptions and Patient Satisfaction

Lisa Gary, Ph.D., M.P.H., Jacqueline Wiltshire,

Ph.D., Keith Elder, Ph.D., Velma Roberts, Ph.D.

Presented By: Lisa Gary, Ph.D., M.P.H.,

Assistant Professor, Health Care Organization and Policy, University of Alabama at

Birmingham, 1530 Third Ave. South (RPHB 330),

Birmingham, AL 35294-0022, Phone: 205-975-

0506, Email: LGary@uab.edu

Research Objective: Studies show that racial minorities, specifically African Americans, have worse health outcomes than whites across a large array of indicators of mortality and morbidity. These differences are clearly in part due to lower rates of insurance coverage and lower socioeconomic status in minority communities. However, recent studies suggest that the racial differences in health outcomes are in part due to racial minorities receiving lower quality health care than their white counterparts

(Smedley, 2002).Previous literature has proposed that racial differences in illness perceptions and patient-driven delays in seeking care are potential contributors to racial health disparities. The purpose of this study was to determine whether minority patients had different underlying health beliefs regarding health care seeking and perceptions of illness, and to determine the effect of patient satisfaction on these beliefs.

Study Design: Data were drawn from the 2003

Household Component of the Community

Tracking Study, a nationally representative survey. Data (n=32,552)were analyzed using multiple logistic regression with adjustment for complex sampling design. The primary outcomes under study included beliefs regarding health care seeking (avoid going to the doctor) and regarding perceptions of illness (go to the doctor as soon as you feel bad).

Population Studied: The population studied was adults aged 18 and older.

Principle Findings: After adjusting for patient satisfaction, age, health status, poverty level, region, insurance type, ER use, sex and other covariates, African-Americans (AAs) and Latinos were more likely than whites to endorse the belief of seeking care as soon as they feel bad

(OR=2.06, OR=1.56, respectively). African

Americans were less likely than whites to state that they "will do just about anything to avoid going to the doctor", i.e.-delay care, (OR=0.64).

Interaction models with race and patient satisfaction were not significant. Interaction models with recent ER use and race showed a significant relationship between race, recent ER use and the health belief regarding illness perception.

Conclusions: The study found that AAs were more likely to not delay care compared to whites despite current propositions although this finding is influenced by ER. Results are also discussed in terms of how current health care experiences may influence the creation and updating of health beliefs about the health care system, the impact of patient satisfaction and the appropriate use of health care.

• Do Minority Patients Use Low Quality

Hospitals?

Darrell Gaskin, Ph.D., Christine Spencer, Sc.D.,

Patrick Richard, M.A., Gerard Anderson, Ph.D.,

Neil Powe, M.D., M.P.H., M.B.A., Thomas

LaVeist, Ph.D.

Presented By: Darrell Gaskin, Ph.D., Associate

Professor, African American Studies, University of Maryland, 2169 LeFrak Hall, College Park, MD

20742, Phone: (301) 405-1162, Fax: (301) 314-

9932, Email: dgaskin@aasp.umd.edu

Research Objective: This study examines whether minority patients compared to white patients disproportionately use low quality hospitals.

Study Design: We computed hospital level composite quality scores using the AHRQ

inpatient quality indicators (IQIs) and patient safety indicators (PSIs). We computed the average quality of hospital used by each race/ethnic group (whites, blacks, Hispanics and

Asians). Also, we identified hospitals ranked in bottom 20 percentile according to their composite quality scores. We computed the percentages of white, black, Hispanic and Asian discharges in these low performing hospitals.

Population Studied: We used 2001-2003 state inpatient discharge (SID) data from 11 states:

AZ, CO, FL, IA, MA, MD, MI, NC, NJ, NY, and

WI, and 2000-2002 SID data from PA. These states were selected because they report patients’ race and Hispanic origin, permit researchers to use the hospital identifiers, and collect all the data elements required to compute the AHRQ IQIs and PSIs.

Principle Findings: Asian and black patients were more likely to use hospitals with poorer composite quality scores than white and

Hispanic patients. All three minority groups were more likely to use hospitals in the bottom

20 percent of hospitals ranked according to their composite IQI and PSI scores.

Conclusions: Racial and ethnic disparities in hospital care are in part due to quality differences across hospitals.


Interventions designed to reduce disparities in quality of hospital care should focus on low quality hospitals that serve high percentages of minority patients.

Funding Source: CWF

•

Impact of Breast Radiotherapy Delay on

Health Outcomes in Early Breast Cancer

Heather Gold, Ph.D., Huong T. Do, M.A.

Presented By: Heather Gold, Ph.D., Assistant

Professor, Public Health, Weill-Cornell Medical

College, 411 E 69th St, New York, NY 10021,

Phone: 212-746-1245, Email: heg2001@med.cornell.edu

Research Objective: To understand the impact of timely radiotherapy on disease-free survival

(DFS) in early breast cancer patients ages 65 and above.

Study Design: Descriptive and proportional hazards analysis of longitudinal cohort diagnosed with Stage 1 breast cancer or ductal carcinoma in situ (DCIS). Covariates include age, race, poverty, marital status, comorbidity, rurality, radiation completion and delay, elapsed time since diagnosis, comedo necrosis histology

(DCIS only), and chemotherapy receipt (Stage 1 only). Subjects were censored at end of followup

(including enrolling in Medicare managed care from Medicare fee-for-service) or death.

Treatment delay is defined as radiotherapy beginning 8+ weeks post-surgery without chemotherapy or 4+ weeks after chemotherapy ends; other definitions also were explored.

Radiotherapy is considered complete if the patient received greater than 16/22 of expected treatments.

Population Studied: Women diagnosed from

1991-1999 in the linked SEER-Medicare database who underwent breast-conserving surgery and radiotherapy within 6 months of diagnosis.

Median followup varies from 4 years for DCIS

(n=1185) to 5 years for Stage 1 (n=7481), and ranges from 0-11 years.

Principle Findings: DFS is negatively associated with radiation delay (OR=1.24, p=0.003 for Stage

1; OR=1.40, p=0.054 for DCIS) and Klabunde’s inpatient comorbidity index (OR=1.32, p=0.004 for Stage 1; OR=1.66, p=0.065 for DCIS).

Additional analyses suggest that a longer delay of 12+ weeks post-surgery (16+ weeks postchemotherapy) further reduces DFS (OR=4.66, p<0.0001 for Stage 1; OR=12.4, p<0.0001 for

DCIS). Non-white women with Stage 1 disease are more likely to delay radiotherapy (p<0.0001), but are not more likely to have worse outcomes

(p>0.3).

Conclusions: Delayed initiation of radiation therapy is associated with decreased DFS following radiotherapy for early breast cancer and DCIS. Non-white race was associated with delay, but not reduced DFS.


Programs targeting referring physicians and patients should be developed to promote timely receipt of radiotherapy by early breast cancer patients, thereby reducing the risk of adverse health outcomes.

Funding Source: American Cancer Society

• Mortality Risk and Educational Attainment of Black and White Men

Guan Gong, Ph.D.

Presented By: Guan Gong, Ph.D., associate professor, Economics, Shanghai University of

Finance and Economics, 777 Guoding Road,

Shanghai, 200433, CN, Phone: 86-21-65903861,

Fax: 86-21-65903688, Email: ggong@mail.shufe.edu.cn

Research Objective: This paper investigates to what extent the differences in education between

black and white men can be explained by the differences in their mortality risks.

Study Design: A dynamic optimal stoppingpoint life cycle model is examined, in which group-level mortality risk plays an important role in determining individual-level mortality risk, health expenditure, and the amount of schooling. The model is calibrated to quantify the effect of mortality risks on schooling by taking the black and white male population as the respective reference groups for black men and white men.

Population Studied: We apply the model to study the impact of differential mortality risks on the educational attainment of black and white men. In particular, we consider an agent at the age of 16, having finished compulsory education, deciding (with his parents) how many additional years of schooling to obtain. The agent faces the probability of death in every period and maximizes the discounted value of the expected utility from consumption and leisure. We assume that a black man has the same utility, the same discount rate, the same return to education and the same living and working conditions as a white man. The only difference between a black man and a white man is the mortality risk of their reference groups. In this model, both the years of schooling and the life expectancy at the individual level are endogenously determined. The exogenous variable is the reference group’s mortality risk.

Principle Findings: We find that the impact of mortality risk on schooling explains more than two-thirds of the empirical education differences between black and white males. This conclusion is robust to a set of plausible parameter values.

Conclusions: Tremendous resources have been devoted to reduce the black-white gap. This paper investigates to what extent the difference in educational attainment between black and white men can be explained by the differences in their mortality risks. We develop a dynamic lifecycle model with optimal stopping-point in which group-level mortality risk plays an important role in determining individual-level health expenditure, mortality risk and amount of schooling. In the model, an agent’s mortality is a function of his own health expenditure and his reference group’s mortality risks. In such a framework, both the agent’s years of schooling and mortality risks are endogenous while the reference group’s mortality risks are exogenous.

We let the black male population be the reference group for a representative black male and let the white male population be the reference group for a representative white male.

The resulting years of schooling for black and white men are then compared with observed schooling for black and white men, respectively.

We calibrate the model by finding a set of baseline parameter values such that optimal schooling years match a large part of the observed years of schooling for both black men

(12.74 years) and white men (13.50 years). The optimal health expenditures are $1,584 per year for a black male and $1,802 per year for a white male. Blacks spend about 12% less in health expenditure than whites. We then conduct various sensitivity analyses by locally varying parameters. We find that although levels of schooling years are sensitive to various parameter values, the difference in schooling years between blacks and whites is relatively robust in various parameter values. We conclude that the mortality difference between blacks and whites is capable of explaining their difference in educational attainment.


Understanding why blacks have less education than whites has important policy implications. If education is the key reason for future wage differences, public policies designed to reduce the black-white wage gap should concentrate on helping blacks attain more education. If the higher mortality risk of blacks is a major cause of less education, then public policies should put more emphasis on improving access to health care and intervening in the composition of residential neighborhoods, such as making predominantly black neighborhoods safer (since part of the risk may result from living in highcrime neighborhoods).

Funding Source: National Institute of Health

• The Impact of Immunosuppressant Costs on New Kidney Transplant Recipients

Elisa Gordon, Ph.D., M.P.H., Thomas R.

Prohaska, Ph.D., Mary Gallant, Ph.D., M.P.H.,

Laura A. Siminoff, Ph.D., Peter J. Minich, M.D.,

Ph.D., Ashwini R. Sehgal, M.D.

Presented By: Elisa Gordon, Ph.D., M.P.H.,

Associate Professor of Medicine, Alden March

Bioethics Institute, Albany Medical Center, 47

New Scotland Avenue, MC 153, Albany, NY

12054, Phone: (518) 262-3700, Fax: (518) 262-

6856, Email: gordone1@mail.amc.edu

Research Objective: Kidney transplant recipients must take immunosuppressant medications for the life of the kidney graft.

Medicare covers 80% of immunosuppressant costs for 3 years post-transplant, while patients

cover the rest. After 3 years, patients receive no financial help. This may lead to difficulty obtaining medications thus jeopardizing kidney graft survival. This study examines new kidney recipients’ ability to afford these costs, and the financial impact of immunosuppression on their lives.

Study Design: Semi-structured interviews were conducted with kidney recipients (n=48) within 6 weeks post-transplant. Measures include the

Financial Distress Scale and Likert-scaled items measuring the impact of medication costs on their lives and the impact of the transplant on their ability to afford living expenses e.g., home, furniture, car, food, medical care, clothing, and leisure.

Population Studied: Kidney transplant recipients were eligible for inclusion in this study.

Principle Findings: Over a third (38%) experienced financial distress. Patients reporting greater financial distress were more likely to have incomes below $60,000 (p<.0005), and less education (r=.32; p<.05). Due to the transplant and related costs, patients report some or a great deal of difficulty in their ability to buy a home (41%), leisure activities (38%), and afford medical care (30%). Eight percent experienced difficulty paying for anti-rejection medications, while a third (30%) anticipates having financial difficulties within 6 months. Patients predicting greater difficulty earn less than $60,000

(p<.002; n=40) and have less education (r=-.32; p<.05). Regardless of financial hardship, all patients report making the purchase of immunosuppression or other transplant medications are a priority over daily necessities.

Patients use diverse strategies to cover out-ofpocket costs of immunosuppression and transplant medications, including, getting a job, borrowing money, using credit cards, using coupons, buying in bulk, paying bills late, and living without buying goods. Patients varied in their understanding of how long Medicare’s entitlement lasts, ranging from not at all knowing, to maintaining inaccurate estimates, to having accurate time frames.

Conclusions: Patients’ financial distress will likely worsen after Medicare’s entitlement ends, risking their ability to purchase immunosuppression. Sociodemographic disparities emerged in financial distress which may contribute to disparities in graft survival.

Future research should investigate how patients afford their transplant medications after

Medicare’s entitlement ends to reveal the shifting role of finances in relation to graft survival in the long term.


Given the adverse impact of these costs on patients’ lives, we advocate for modifying

Medicare’s entitlement policy so that patients are better able to obtain immunosuppression over their life and thus foster long-term graft survival.

Funding Source: NIDDK

• Transportation: A Hidden Barrier to Child

Health Access

Roy Grant, M.A., Jeffrey Muschell, M.E., M.P.H.,

Mark Burton, Ph.D.

Presented By: Roy Grant, M.A., Director of

Research, Policy, The Children's Health Fund,

215 West 125th Street, New York, NY 10027,

Phone: 212-535-9400, Fax: 212-535-7488, Email: rgrant@chfund.org

Research Objective: Most discussions of child access to healthcare focus on economic factors, specifically health insurance. Currently, 11.2% of children (more than 9 million) nationwide lack health insurance. The percentage of children without economic access to adequate healthcare is higher, with about twice as many having insurance for only part of the year. Still more children have inadequate insurance, with no coverage for routine and preventive healthcare.

Having insurance is not enough. Powerful noneconomic barriers to health access include cultural and language factors. Transportation is frequently overlooked as a barrier to healthcare.

A related problem is the extremely uneven distribution of health professionals throughout the country, with the lowest availability continuing to be in rural communities. The pediatrician-to-child ratio in cities is three times higher than in rural communities, and rural communities have benefited least from increases in pediatrician workforce. With fewer health professionals available, the distance patients must travel to get to the doctor increases. This study was intended to quantify the nature and extent of transportation barriers to child health access.

Study Design: The Children’s Health Fund developed a survey instrument with The Marist

College Institute for Public Opinion. The survey was administered to 1,819 adults, including 610 parents, during September 2006.

Population Studied: A representative sample of the adult U.S. population based on the 2002 update of the 2000 census.

Principle Findings: Overall, 39% of U.S. residents did not have public transportation in their community; 75% in rural communities lacked public transportation access. More than one-third, 35%, of parents had to travel ten or more miles to take their child to a doctor. Only

16% of parents reported transportation was a covered benefit in their child’s insurance plan.

Each year, 4% of children missed at least one healthcare appointment because of transportation barriers; only 48% of missed appointments were for routine or well child care.

Most of these children missed two or more health appointments during the year. One third of the children who missed appointments because of transportation barriers later required emergency room care for the same condition.

Especially affected by transportation barriers were low-income and African-American children, and those living in the south and central regions of the country.

Conclusions: Applied to the 2002 census update, approximately 3 million children missed at least one healthcare appointment each year because of transportation restrictions, with approximately one million pediatric emergency room visits associated with those missed appointments. Enhanced availability of nonemergency medical transportation would be a cost-effective way to improve child health status.


Using federal MEPS (2003) data, we estimate the representative cost per emergency room visit to be $750. This translates to $750 million in emergency room costs which are potentially preventable if transportation were available to facilitate timely access to care. These calculations do not include the potentially preventable cost of emergency transportation

(e.g., ambulance). Because low-income children are most affected, the greatest potential savings would be realized in public health insurance programs, Medicaid and SCHIP.

Funding Source: WKK, Federal Transit

Administration

•

A Comprehensive Strategy to Improve

Asthma Outcomes in the District of Columbia

Rhonique Harris, M.D., Lynn Seim, M.S., R.N.,

Michelle Montero, Roy Grant, M.A.

Presented By: Rhonique Harris, M.D., Medical

Director, Mobile Health Programs, Children's

National Medical Center, 1901 Mississippi

Avenue SE, #104, Washington, DC 20020,

Phone: 202-436-3060, Email:

RSHarris@cnmc.org

Research Objective: The pediatric asthma rate in the District of Columbia (‘‘DC’’; population

~550,000) is 11.8%, farhigher than the national rate of 7%. Between 1995 and 2002, 112 DC residents died of asthma; >10% of these fatalities were children. The highest asthma prevalence and mortality rates are in the poor and >90% African-American Anacostia community. The highest asthma hospitalization rates in DC are for children <5 years old and for

African-Americans. The pediatric emergency room (ER) visit rate for DC children <5 is more than four times the national rate. Anacostia has

DC’s highest hospitalization rate for ambulatory sensitive conditions. DC does not have legislation allowing children to carry and administer asthma and allergy medications in school. There are not enough school nurses or school-based health centers to deliver asthma care during the school day if needed. This initiative is intended to develop a comprehensive strategy to improve asthma outcomes especially for high-risk children in DC.

Study Design: The Children’s Health Fund’s

Childhood Asthma Initiative (CAI) has been implemented in the DC Children’s Health Project to deliver NHLBI guidelines-based asthma care to primary care patients in Anacostia, including health education, parent seminars, and dissemination of low literacy asthma management guides. CAI also trains medical students and residents on asthma management and education. Collaborating with the national

Capital Asthma Coalition and CDC/DC

Department of Health sponsored DC Control

Asthma Now (DC CAN) Program, CAI is helping develop a standardized Asthma Action Plan to be used by all medical providers and school nurses in DC. CAI is advocating for legislation to allow students to carry and use prescribed medications at school.

Population Studied: Poor and minority children with asthma.

Principle Findings: Decreased ER use and hospitalizations are noted through delivery of guidelines-based care. Program assessment found that 100% of medical students felt comfortable providing asthma education; 93% rated their comfort level treating asthma as 9 or

10 out of 10. The standardized Asthma Action

Plan is being piloted throughout DC Children’s

National Medical Center. Once implemented, it will serve as provider and parent authorization for nurse administration of asthma rescue medications at school, and authorization for selfadministration after legislation is passed. This is anticipated to reduce asthma ER visits and

missed school days, with significant healthcare savings and improved academic outcomes.

Conclusions: Reducing socioeconomic and race-ethnicity health disparities for children with asthma requires a comprehensive and coordinated approach. Our experience to date suggests that, in a small or medium-size city, it is possible to make changes to improve asthma outcomes for high-risk children.


Over time the standardized Asthma Action Plan will be adapted as a template in electronic health records and for on-line access. Electronically formatted Asthma Action Plans may be transmitted to and registered in an Asthma

Registry Data Base similar to citywide

Immunization Registries. Through the Asthma

Registry, every child’s Asthma Action Plan would become available in a HIPAA protected way to

ER doctors or providers other than the child’s primary care provider who see a child for an asthma exacerbation, ensuring continuity of care.

Funding Source: The Picower Foundation

•

A Randomized Controlled Trial of Nurse

Management versus Home Blood Pressure

Monitoring to Improve Control of

Hypertension in African American and

Hispanic Patients

Paul Hebert, Ph.D., Mary Ann McLaughlin, M.D.,

M.P.H., Jane E Sisk, Ph.D., Jodi Casabianca,

M.S., Leah Tuzzio, M.P.H., Velvie Pogue, M.D.

Presented By: Paul Hebert, Ph.D., Assistant

Professor, Health Policy, Department of Health

Policy, Mount Sinai School of Medicine, One

Gustave L Levy Place Box 1077, New York, NY

100296574, Phone: 2126599191, Fax:

2124232998, Email: paul.hebert@mssm.edu

Research Objective: To compare the effectiveness of nurse-based disease management, self management with a home blood pressure (BP) monitor, and usual care on reducing blood pressure for African American and Hispanic patients with uncontrolled hypertension.

Study Design: From November 2002 to

September 2006, we conducted a three-armed randomized controlled trial. Patients who had been treated for hypertension for at least 6 months were recruited from outpatient clinics in

Harlem and enrolled in the trial if their BP measured at recruitment was =10mm Hg over target systolic BP or =5 mm Hg over target diastolic BP. Patients were randomized to usual care, a nurse management group that received a home BP monitor plus a face-to-face counseling visit with a registered nurse and regularly scheduled telephone follow-up for 9 months, or a BP monitor group that received a home BP monitor and one-time instruction on its use. BP measurements were taken in-person at recruitment, 9 months, and 18 months. The primary outcome was change in BP from baseline to 9 months, which marked the termination of the nurse intervention.

Population Studied: African American and

Hispanic patients with uncontrolled hypertension who were treated for hypertension at outpatient clinics at one of the four hospitals and one community clinic serving East and

Central Harlem, New York City.

Principle Findings: 416 patients enrolled in the trial and were randomized to receive nurse management (n=120), a home BP monitor

(n=120), or usual care (n=176). The mean age was 60.8(±11.6); 59.3% were Non-Hispanic

Black, 36.6% Hispanic, and 4.1% were mixed

Black and Hispanic; 70.9% were female, 50% had diabetes, and 45.9% had inadequate health literacy. Mean BP at baseline was 153.3(±16.1) systolic / 86.4(±13.0) diastolic and did not differ by treatment arm.

At 9-months, the mean change in systolic BP was greater for patients in the nurse management group (-15.8; p=0.021) than the usual care group (-8.1). BP in the home BP monitor group (-13.1; p=0.687) also improved but was not significantly different from usual care. No statistically significant change in mean diastolic BP were found in the nurse (-10.6; p=0.459) or home BP monitor (-8.3; p=0.383) groups compared to usual care (-9.1).

By 18 months, BP in the nurse management and

BP monitor groups were no different from the usual care group. The mean BP change from baseline to 18-months in the usual care group (-

14.4 systolic, -8.4 diastolic), was not statistically different from that in the nurse group (-14.5 systolic, p=0.973; -8.7 diastolic p=0.851), or the

BP monitor group (-10.4 systolic, p=0.380; -8.2 diastolic, p=0.487).

Conclusions: Nurse management combined with home BP monitors resulted in lower systolic

BP for Black and Hispanic patients with uncontrolled hypertension. Self-management with home BP monitors alone was not effective.


Nurse management can effectively improve control of hypertension in urban minority communities. Why the benefits of nurse management over usual care were not sustained merits further exploration.

Funding Source: NIH National Center on

Minority Health and Health Disparities

•

Impact of Cultural Concordance in an

Asthma Medicaid Disease Management

Program

Keiko Higuchi, M.P.H., Pshyra Jones, M.P.H.,

CHES, Stella Schloss, R.N., M.H.A.

Presented By: Keiko Higuchi, M.P.H., Senior

Manager, Outcomes & Analytics, PHS Inc., 2400

Broadway, Suite 500, Santa Monica, CA 90404,

Phone: 310-586-2566, Fax: 310-586-2538, Email: keiko.higuchi@pfizer.com

Research Objective: In the U.S., health disparities in minority populations with asthma are widely recognized. African Americans are 3 times more likely to be hospitalized for asthma than their white counterparts (National Center for Health Statistics: National Hospital

Discharge Survey, 2001). Contributing to this widening gap in care are poor self-management skills and non-adherence to prescribed treatment. Many factors have been attributed to this disparity including patient-provider miscommunication and lack of cultural sensitivity. Molina Healthcare Inc., a national managed Medicaid provider with over 1 million members, developed a disease management

(DM) program, Breathe with Ease, to help manage its asthma population. Supported by

Pfizer Health Solutions' care management tools and services, the program is a comprehensive, nurse directed, and telephone-based asthma program. The Breathe with Ease program was culturally adapted for minority beneficiaries to reduce health disparities in order to improve asthma self-management and impact health care utilization. To accomplish this, Molina implemented a comprehensive cultural competency training program and a 24 hour nurse translation line. In addition, Project CARE

(Culturally Appropriate Resources for

Encounters) was developed to evaluate the impact of culturally appropriate asthma services using a cultural concordance approach by matching care managers and patients by culture.

Study Design: This was a descriptive study analyzing data 6 months pre and post asthma

DM program enrollment. Evaluation was based on administrative claims data from 1999 through

2006 and self-reported patient survey data between 2004 and 2006. Patients were randomized to care manager/patient cultural concordance intervention group or comparison group without care manager/patient cultural concordance.

Population Studied: This study evaluated

4,608participants age 2 to 65 years with severe asthma being actively managed. Disease stratification was based upon historical utilization and prescription.

Principle Findings: After 6 months, 76% of the patients in the intervention group experienced a reduction in asthma day time symptoms compared to 44% in the control group. The intervention group improved in selfmanagement practices (use of spacers and knowledge of peak flow meter use) compared to the control group. Intervention group members were more compliant in their medication regimen than the control group with 38% more believing medication helps their condition. Final clinical, utilization and financial results will be presented.

Conclusions: Results suggest that asthma disease management combined with cultural alignment positively affects asthma health outcomes. Concordant care appears to provide additional increased benefits in patient selfmanagement when combined with traditional asthma disease management and cultural competency training.


While these findings are preliminary, they may have several health practice implications. As the

U.S. becomes more diverse, providers need to respond to patients’ varied perspectives and behaviors. Minority populations have less access to care, use fewer health care resources, and are less satisfied with the care they receive. Adapting standard practice to address patients by becoming sensitized to specific cultural issues appears to be an effective strategy to improving health outcomes. Further research is needed to improve how providers communicate and work with diverse patient populations to improve health and reduce disparities.

• Disparities in Chronic Disease Management and Prevention

Karen Ho, M.H.S., Edward Kelley, Ph.D.

Presented By: Karen Ho, M.H.S., Health Science

Administrator, Center for Quality Improvement and Patient Safety, Agency for Healthcare

Research and Quality, 540 Gaither Road, Room

3202, Rockville, MD 20850, Phone: 301-427-1342,

Fax: 301-427-1341, Email: karen.ho@ahrq.hhs.gov

Research Objective: To examine changes over time in racial and ethnic disparities across a broad range of health care quality measures.

Study Design: Data come from the 2006

National Healthcare Disparities Report, which compiled national estimates on 211 measures of health care quality from 3 dozen data sources.

Measures cover the quality dimensions of effectiveness, safety, timeliness, and patient centeredness. Analyses focus on 22 selected core measures from the full measure set and comparisons of whites, blacks, Asians, American

Indians and Alaska Natives and Hispanics. For each core measure, disparities are measured in both absolute and relative terms. Disparities for a baseline year and for the most current year of data are compared to assess trends in disparities.

Population Studied: Most measures cover the civilian, non-institutionalized U.S. population.

Some measures are appropriate for specific groups defined by age and gender. Nursing home measures are specific to residents of these facilities.

Principle Findings: Disparities in health care remain prevalent in the U.S. For most core quality measures, blacks (73%), Hispanics

(77%), and poor people (71%) received worse quality care than their reference groups (whites and high income). For most measures for poor people (67%), disparities were increasing.

Disparities were prevalent in preventive care including colorectal cancer screening, counseling for obesity and pneumonia. Colorectal cancer screening rates were significantly lower for blacks and Asians compared with whites. Obese blacks were less likely to be told they were overweight by their doctor or other health care provider. The proportion of adults age 65 and over who ever had a pneumococcal vaccine was significantly lower among blacks and Asians compared with whites, and among the poor and less educated.

Disparities were increasing over time for chronic care including care for asthma and diabetes.

Blacks had 376% more pediatric asthma hospitalizations than whites in 2003. This was an increase of 25% compared to 2001. Poor people lacked recommended diabetes care 54% more often than people with high income in 2003. This was an increase of 9.5% compared to 2000.

Conclusions: Tracking disparities over time is important to identify groups and areas in greatest need of intervention. Findings from the

2006 National Healthcare Disparities Report show that there are increasing disparities over time for chronic disease management and disparities in preventive care for all priority populations. However, better and improving quality was also observed for at least 1 measure for every population.


The findings point to important opportunities missed to help Americans avoid disease, as well as opportunities to properly manage care for chronic diseases. Communities can use the findings from the annual National Healthcare

Disparities Report Communities as national benchmarks to help track their progress in decreasing disparities in these diseases including colorectal cancer, obesity, pneumonia, asthma, diabetes and others.

•

Socioeconomic Disparities in Inpatient

Cardiac Care

Mark Holmes, Ph.D., Maurico Cohen, M.D.,

Sandra Greene, Dr.P.H., Cam Patterson, M.D.,

Sid Smith, M.D., Tim Carey, M.D., M.P.H.

Presented By: Mark Holmes, Ph.D., Senior

Research Fellow, Sheps Center for Health

Services Research, University of North Carolina,

725 Martin Luther King Blvd CB 7590, Chapel

Hill, NC 27599-7590, Phone: (919)966-9694, Fax:

(919)966-1634, Email: mark_holmes@unc.edu

Research Objective: To investigate the effect of socioeconomic status on access to health care for acute myocradial infarction (AMI) patients.

Study Design: Retrospective cohort study design

Population Studied: Individuals diagnosed with

AMI admitted to North Carolina acute nonfederal hospitals 1997-2003

Principle Findings: We analyzed the difference in mortality, access to technology (diagnostic catheterization, percutaneous coronoary intervention [PCI], and coronary artery bypass graft [CABG]), and resource use (length of stay and total hospital charges) controlling for comorbidities, other patient factors, and hospital characteristics likely to affect resource use.

Patients from low income ZIP codes were generally less likely to receive high cost interventions (e.g. diagnostic cathetrization, PCI,

CABG; all p<.001) than patients from high income ZIP codes, but limiting the study sample to only those admitted to hospitals with the technology eliminated the disparity.

Conclusions: AMI patients from low income neighborhoods face barriers to accessing health care in the hospital setting, but this barrier is primarily due to difficulty accessing hospitals with the technology. Patients from high and low income neighborhoods admitted to the same

hospital have roughly the same access to high technology health care.


Policymakers should ensure that geographic access to high technology cardiac care is adequate to ensure that all AMI patients receive high quality health care.

•

An Investigation of Racial/Ethnic

Disparities in Service Use among Severely

Mentally Ill Homeless Adults, US 1994-1997

Marcela Horvitz-Lennon, M.D., M.P.H., thompson, wesley, Ph.D., sharon-lise normand,

Ph.D., richard frank, Ph.D.

Presented By: Marcela Horvitz-Lennon, M.D.,

M.P.H., assistant professor, psychiatry, university of pittsburgh medical school, 201 north craig Street,#250, pittsburgh, PA 15213,

Phone: (412) 383-5121, Email: mvh3@pitt.edu

Research Objective: Service use disparities have been widely documented in the general and mental health care of minorities. It is however unknown whether disparities also encumber the care of severely mentally ill and homeless

(SMIH) persons, a population so disadvantaged that the possibility of inequity within the group rings improbable. This study aimed to fill this knowledge gap using data previously collected by a large study of SMIH persons that included significant numbers of African-Americans and

Latinos.

Study Design: Baseline self-reports of utilization of a variety of services by an SMIH sample recruited for a demonstration study were used to assess for disparities in conditions of usual care.

We used the Institute of Medicine approach to evaluate disparities by estimating the effect of race/ethnicity on service utilization controlling only for clinical need differences between the groups. To account for the skewed utilization distribution within the sample, analyses were conducted with ordinal regressions but given logistic regressions yielded same results, we report the latter findings. Multiple imputations were used to account for missing data.

Population Studied: Adult participants in the

Access to Community Care and Effective

Services and Support (ACCESS) study. The

ACCESS study was a quasi-experimental demonstration conducted in nine states between

1994 and 1997.

Principle Findings: After excluding lowfrequency racial categories, the ACCESS sample

(n = 6,829) consisted of 50% African-American,

44% white, and 6% Latino persons enrolled as 4 distinct annual cohorts. Latinos more than

African-Americans and whites were highly concentrated in a few states (mainly CT, TX, and

WA). Unadjusted results suggested that relative to whites, Latinos used more substance userelated services, while African-Americans received more public supports. Of these, only the public support finding held up in the adjusted analyses (OR =1.55, 95% CI 1.33-1.80).

African-Americans also used more case management (OR =1.43, 95% CI 1.23-1.67) and substance use services (PO=1.64, 95% CI 1.11-

2.42). Latinos had lower odds of utilization of inpatient (psychiatric and medical), substance abuse, public support, and housing services and higher odds of vocational service use, yet neither of these achieved significance. Lack of power may have been a factor for some of these nonsignificant Latino vs. white comparisons. Odds of utilization of case management, a critical service given this population’s multiple health and social needs, were lower among people with higher clinical need. On the other hand, odds of utilization of psychiatric inpatient services did not vary according to clinical need.

Conclusions: Using a large and multiethnic sample, we found little evidence of inequity in service use and where it was present, the disparity favored African Americans. It is however noteworthy that despite this main finding, there is some indication that Latinos may indeed experience disparities, particularly in use of inpatient, substance abuse, and housing services. It is also worrisome that case management appears to be used less by those with the greatest need.


Clinical and policy implications of these results are discussed.


•

Horizontal Equity in HealthCare Utilization in Korea

Soonim Huh, Ph.D., Kim, Minah Kang, Ph.D.,

Shin, Hosung, Ph.D.

Presented By: Soonim Huh, Ph.D., Research

Fellow, Social Security Research, Korea Institute for Health and Social Affairs, San 42-14,

Bulgwang-dong, Eunpyeng-gu, Seoul, South

Korea 122-705, Phone: 82-2-380-8143, Email: hsoonim@hotmail.com

Research Objective: Recently in Korea, there have been numerous efforts to improve benefit coverage of the universal health insurance,

National Health Insurance (NHI). This study

described and compared the extent of income related horizontal inequalities in outpatient visits and tertiary inpatient stays among Korean adults and the elderly.

Study Design: We analyzed cross-sectional data from the 2005 Korean National Health and

Nutrition Examination Surveys, which provides comprehensive information including health status, health behavior, health care utilization, and nutrition as well as sociodemographic characteristics from nationally representative sample. Utilization was measured by the volume of outpatient visits and length of stay in the hospital. Visits to and stay at tertiary hospitals were used as an indicator of higher level services. To investigate the extent that ‘‘equal treatment for equal need’’ is maintained, we calculated an index of horizontal inequity (HI), which summarizes deviations in the extent to which health care is distributed according to need. Using negative binomial regression models to deal with substantial zero values of outcome variables, income related inequality in the utilization of health care was calculated after controlling for differences in need, as predicted by age, gender, self-rated health status, education, marital status and the number of chronic disease. Household income was converted to equivalence scale by adjusting for household size.

Population Studied: A stratified multistage probability sampling design was applied to the

South Korean population. Our final sample consisted of 23,616 adults including the enrollees of the NHI who age 20 and over. Adults aged 65 and older were separately analyzed, as we expected that the medical utilization pattern would be different from that of younger counterpart.

Principle Findings: Demands for medical services were predicted to be higher among the poor (pro-poor), indicating importance of controlling for the needs in calculating the concentration index of disparity. Despite the more outpatient visits among the poor, the level of utilization was below the extent of their medical needs. On the other hand, utilization in inpatient services remained pro-poor (the poor stayed longer in hospital than the rich) even after controlling for the medical needs. With regard to utilization of tertiary hospital services, results showed pro-rich tendency, but reasons for prorich horizontal inequalities were different between outpatient visits and tertiary inpatient stays. Rich people used more outpatient care than the poor, while poor people used inpatient services less than their needs. Overall, the extent of income related disparities in utilization of medical services among the elderly appeared to be slightly less than young adults.

Conclusions: Despite the recent government’s efforts, we found that there were income related disparities in utilization of medical services.

Findings indicate that financial burden for health care use may be barriers for the poor to meet their medical needs.


The primary policy option may be to provide more generous benefits of the NHI to relieve financial barrier to health care use.

•

The Influence of Patient Origin on Health

Care Use for Acute Myocardial Infarction at

Academic Medical Centers

Tricia Johnson, Ph.D, Lisa Aponte-Soto, M.H.A.,

Samuel Hohmann, Ph.D., Shital Shah, Ph.D.

Presented By: Tricia Johnson, Ph.D, Director,

Center for Health Management & Policy

Research, Health Systems Management, Rush

University, 1700 W Van Buren Street, Room

126B, Chicago, IL 60612-3244, Phone: (312) 942-

7107, Fax: (312) 942-4957, Email:

Tricia_J_Johnson@rush.edu

Research Objective: Academic medical centers serve as subspecialty referral hubs for large and often very heterogeneous geographic regions, drawing patients from both urban and rural areas. While prior research has shown that individuals in rural areas are in poorer health, are less likely to have health insurance coverage, and more likely to come from low income areas than their urban counterparts, the extent to which differences in subspecialty care use are due to differences in health insurance coverage versus other factors associated with patient geographic origin remains poorly understood. This study examined whether geographic region of patient origin was associated with hospital length of stay

(LOS), intensive care unit (ICU) LOS and hospital costs for patients with acute myocardial infarction (AMI) who were admitted to academic medical centers for care.

Study Design: This study was a retrospective cross-section analysis using data from the

University HealthSystem Consortium Clinical

Database. The main outcomes of interest included hospital LOS, ICU LOS, and total hospital costs. Patients were classified as residing in either a rural or urban area based on the zip code of their home residence. Random effects generalized linear models were used to estimate the relationships between geographic

origin and each of the health care outcomes. A two-part random effects generalized linear model was used to estimate the relationship between patient geographic origin and ICU length of stay, due to the substantial proportion of patients with no ICU stays. The random effects models were used to account for the clustering of discharges within academic medical centers.

Population Studied: This analysis included adults age 18 and older discharged from 16

Midwestern academic medical centers between

July 2004 and June 2005 with a principal diagnosis of AMI (ICD -9 diagnosis codes

410.x1). The sample included 5,249 discharges.

Principle Findings: After controlling for demographic characteristics and severity of illness, rural patients with AMI had 9% longer lengths of stay (0.50 days). There was no difference in the likelihood of being admitted to the ICU, but rural patients admitted to the ICU had 11% longer ICU stays (0.39 days). There was no difference in total hospital costs between the two groups.

Conclusions: While some of the differences in health care use were associated with differences in health insurance coverage, residing in a rural area was associated with longer hospital and ICU

LOS, even after controlling for severity of illness and demographic characteristics. Patient geographic origin was not associated with total hospital costs.


Academic medical centers should explore interventions to improve access to equitable care for patients residing in rural areas, such as innovative methods of communication, coordination with patients’ local health care providers, health care and health insurance literacy initiatives, and incentive programs for physicians to practice in rural communities.

Disentangling the effects of patient geographic origin from health insurance coverage is important in understanding the causes of health care disparities as well as designing successful interventions targeted at improving the quality of care provided to patients with AMI residing in rural areas.

• Influence of Language Barriers on Hospital

Outcomes for Ethnically Diverse Inpatient

Population

Sue Kim, Ph.D., M.P.H., Sue E. Kim, Ph.D.,

MPH, David Meltzer, M.D., Ph.D., Andrew

Auerbach, M.D., M.P.H.

Presented By: Sue Kim, Ph.D., M.P.H.,

Specialist, Medicine, University of California, San

Francisco, 3333 California Street, Suite 335, San

Francisco, CA 94143-0856, Phone: 415-502-4078,

Fax: 415-502-8291, Email: sue.kim@ucsf.edu

Research Objective: Our study's aim was to examine how patient's primary language influenced hospital cost, length of stay (LOS), and 30-day readmission risk.

Study Design: We conducted analyses on a merged database of administrative (collected as part of the Multicenter Hospitalist trial) and registration data for inpatient care. Data regarding patients’ self-report of primary language were obtained from the hospital registration database and recoded into several primary categories: 1) English 2) Asian

(composed of 12 separate languages), 3)

Russian, 4) Spanish, and 5) Other (composed of

10 separate categories). We performed logistic and linear models adjusting for patients’ age, gender, ethnicity, insurance status, admission to the ICU, a Charlson Comorbidity Index calculated using administrative data (CCI), admission diagnosis, and attending physician

(hospitalist/ non-hospitalist). These models were used first to understand differences between

English and non-English speakers (using an

English/Non-English predictor), then to understand associations between English speakers and all non-English language categories and our key outcomes. Finally, we also examined how ethnicity and primary language influenced each other and our primary outcomes.

Population Studied: We examined care of patients 18 years of age or older admitted to the

University of California San Francisco between

7/1/2001 and 6/30/2003. 7,360 patients were admitted during the study period. Patient mean age was 61 years (s.d. 20), and 51% were female.

The majority (5,968 (81%)) were English speakers; 693 (9%) spoke Asian languages, 290

(4%) Russian, 268 (4%) Spanish, and 123 (2%)

‘Other’. Forty-six percent were White, 18%

African American, 17% Asian, 7% Latino and 12%

Other ethnicity.

Principle Findings: In multivariable models using the English vs. non-English predictor variable, non-English speakers and English speakers had statistically similar LOS and cost; however, non-English speakers had a higher odds of readmission by 30 days (OR 1.3; 95% CI

1.0-1.6). In models employing a disaggregated non-English category variable, we again saw no significant differences between English and non-

English speakers in terms of LOS or cost.

However, compared to English speakers,

Spanish and Asian language speakers had

increased odds of being readmitted at 30 days

(OR 4.1; 95% CI 2.7-6.5 and OR 1.5; 95% CI 1.1-

2.0 respectively), while Russian speakers had a lower odds (OR 0.6; 95% CI 0.4-0.9). When comparing within ethnic groups, both Spanish speakers and Asian language speakers had increased odds of readmission at 30 days compared to their English speaking Latino or

Asian counterparts (Spanish speaking OR 7.0;

95% CI 3.0-16.0; Asian language OR 1.6; 95%CI

1.1-2.3).

Conclusions: A non-English primary language did not influence LOS or cost of hospitalization in our study, but was associated with higher risk for readmission among Latinos and Asians, and lower risk among Russian speakers - even after accounting for available socioeconomic variables, ethnicity and comorbidity.


These results suggest that post-discharge outcomes differ for distinct minority language groups, perhaps related to poor communication at the time of discharge, or variable access to home/social supports. Improved communication at discharge and particular attention to post-discharge care for non-English speaking patients may be necessary to reduce disparities in readmission risk.

• Factors Associated With Service Provision by Federally Qualified Health Centers

I-Heng Emma Lee, M.A., Andrea Radford, Dr.Ph.

Presented By: I-Heng Emma Lee, M.A., PhD student, Health Policy and Administration,

University of North Carolina at Chapel Hill,

Campus Box 7411, Chapel Hill, NC 27599-7411,

Phone: (443) 310 5049, Fax: (919) 966-6961,

Email: ihelee@email.unc.edu

Research Objective: To identify the extent to which the scopes of community health center primary care, OB/GYN, and dental services respectively reflect patient need, center capacity, and financial incentives.

Study Design: Data were from annual reports submitted by all federally funded health centers in the US from 1998- 2004, and Area Resource

Files. The unit of analysis was the health centeryear; n= 4,397 for 905 centers. We measured the scope of each service category as the number of types of services in that category. The range was

0-11 for primary care, 0-8 for OB/GYN, and 0-3 for dental services. Patient population attributes measured were the percentages female, elderly

(65 or above), nonwhite, needing interpretive services, migrant, and homeless. We measured center capacity through age (available only in terms of whether or not the facility was federally funded in 1996), number of encounters, net revenue per encounter, percent of medical staff who were physicians, and rurality. Incentives included were the percentage patients with private insurance and levels of federal and nonfederal grants. Mixed effects intercept-asoutcomes regression models accommodated clustering of years within centers. We set the threshold for statistical significance at alpha =

0.05.

Population Studied: US federally funded community health centers

Principle Findings: Health centers provided an increasing scope of primary care and dental services between 1998 and 2004, but a decreasing scope of OB/GYN services.

As expected, higher proportions of elderly patients and patients needing interpretors were each associated with greater ranges of all three types of services examined. The percentage of patients who were migrant farm workers was also positively associated with the scope of

OB/GYN services. Contrary to expectations, the percentage of patients who were homeless was negatively associated with the scopes of primary care and dental care. Also contrary to expectations, centers with higher proportions of nonwhite patients provided narrower scopes of all three types of services. Older and larger health centers provided greater scopes of services than did younger and smaller centers.

Net revenue per encounter and the percentage of clinicians who were doctors were unrelated to the scopes of all services. Rural centers provided a broader scope of primary care services and a narrower scope of OB/GYN services than centers in more urban areas. Centers with more privately insured patients provided a broader scope of primary care services but a narrower scope of dental services than other centers.

Conclusions: Decreasing numbers of OB/GYN services over time may be leading to inadequate access, especially in rural areas. Some indicators of patient vulnerability were positively associated with the scopes of services, as we had expected.

The negative associations between homeless and nonwhite patient proportions and service scopes, however, were concerning.


Rural, homeless, and nonwhite patients are especially reliant on community health centers.

Health centers serving these populations may need additional support to provide adequate scopes of services.

• Effect of Patient Disabilities on Imaging

Utilization

Rebecca S Lewis, M.P.H., Rebecca S. Lewis,

M.P.H.

Presented By: Rebecca S Lewis, M.P.H., researcher, Research Department, American

College of Radiology, 1891 Preston White Drive,

Reston, VA 20191, Phone: (703) 295-6771, Fax:

(703) 264-2443, Email: rlewis@acr.org

Research Objective: To examine the role of patient disabilities on the utilization of mammography in the United States.

Persons with disabilities are a large sector of the population that needs health care services.

According to the CDC, about 50 million people in the U.S. have a disability, such as physical limitations, mental disability, hearing loss, or vision loss. Health care facilities may be inaccessible to persons with disabilities or not have the appropriate equipment to serve persons with disabilities, or staff may not know how to assist a person with a disability. Persons with disabilities may be embarrassed to seek needed special assistance in obtaining health care services, such as transportation.

For imaging specifically, they may simply not be able to use the equipment; it might be physically difficult for persons with limited mobility (wheelchair bound for instance) to get into or be put into an MRI or CT machine, or access a mammography machine. Because of these additional barriers, persons with disabilities may not receive the care they need, may receive inadequate care, or may delay or forego medical attention in an emergency or acute situation.

Delay in or not receiving appropriate screening tests, such as mammography may lead to delays in diagnosis and treatment and less favorable outcomes/prognosis.

Study Design: We examine the extent to which presence of a disability explains/influence differences in imaging utilization, while controlling for individual and neighborhood socioeconomic (SES) and racial/ethnic characteristics. Using Medical Expenditure

Panel Survey (MEPS) data for years 1999-2004, we identify disabilities in patients using survey variables such as requiring ADL or physical functioning assistance, the use of assistive devices and/or hearing aid, blindness, deafness, and physical functioning, work, school, or cognitive limitations, and others. Further, we will use evidence of eligibility for Medicare under age 65 as evidence of being determined to be disabled. For women age 40 and older, we compare the probability of having a mammogram persons with disabilities and persons without. We use logistic regression to evaluate probability of imaging controlling for age, gender, SES (income, education, etc.).

Coefficients on the disability variables show which disabilities affect utilization and by how much.

Population Studied: Women age 40 and older in the U.S. non-institutionalized population as surveyed in the Medical Expenditure Panel

Survey (MEPS) from 1999-2004.


Our results will assist policy makers and payers in estimating the need for suitable equipment, and in designing effective practice guidelines to ensure equitable utilization for patients with disabilities.

•

Are Minority Patients More Likely to be

Initially Diagnosed of Hypertension During

Non-Office-Based Visits? Evidence from

Medical Expenditure Panel Survey 1996-2003

Chenghui Li, Ph.D.

Presented By: Chenghui Li, Ph.D., Assistant

Professor, College of Pharmacy, University of

Arkansas for Medical Sciences, 4301 West

Markham Road, Little Rock, AR 72205, Phone:

501-686-6298, Fax: 501-686-1168, Email:

Cli@uams.edu

Research Objective: Despite improvements in treatment of hypertension among minority patients, racial disparities in blood pressure (BP) control persistent over the years. This study focused on the initial diagnosis of hypertension and attempted to test the hypothesis that hypertension among minority patients is more likely to be first diagnosed during a non-officebased settings such as emergency rooms, which suggests elevated severity and may lead to conditions much harder to control after detection.

Study Design: Newly diagnosed hypertension patients were identified using Medical

Expenditure Panel Survey (MEPS). Data from

1996-2003 were pooled to increase sample size.

Hypertension was based on self-reported medical conditions with clinical classification of

‘‘essential hypertension’’ (CCCODEX= ‘‘098’’) or

‘‘hypertension with complications’’ (CCCODEX=

‘‘099’’) from the condition files. These conditions were then linked to medical events files. Patients were considered newly diagnosed if they reported their conditions to have started during the interview period and had linked

medical event records on the same dates.

Patients’ demographic characteristics (e.g. age, gender, poverty level and education attainment), health insurance status, medical care utilization

(type of events and prescription drugs) and concurrent medical conditions at these first events were compared among Hispanics, non-

Hispanic Blacks and Whites. In order to assess racial disparities in follow-up treatment, eligible patients were also required to remain in the survey for at least 6 months immediately after their initial diagnoses. Insurance coverage, medical care utilization and the type of prescription drugs during the follow-up period were then compared across the 3 racial/ethnic groups. To control for potential confounders, multivariate logistic regression methods were applied. All analyses were conducted using survey procedures in SAS 9.1 to take into account of the complex survey design.

Population Studied: Newly diagnosed hypertension patients from MEPS. The final data set had 572 patients, representing 5.9 million civilian non-institutionalized hypertension patients during years 1996-2003.

Principle Findings: More Hispanics (14%, 95%

CI=6-21%) and non-Hispanic Blacks (15%, 95%

CI=6-24%) were initially diagnosed during nonoffice-based visits, compared with Whites (8%,

95% CI: 6-11%). After adjusting for confounding factors (age, gender, family income, education, concurrent medical conditions and health insurance status), both Hispanics (OR=0.67,

95% CI=0.35-1.27) and non-Hispanic Blacks

(OR=0.56, 95% CI=0.25-1.21) had lower odds of being initially diagnosed during office-based visits compared to Whites, although neither estimates were statistically significant.

Hispanics and Blacks were also estimated to have lower odds of receiving follow-up officebased visits related to hypertension (Hispanic:

OR=0.83, 95% CI=0.45-1.52; Black: OR=0.59,

95% CI=0.37-0.94).

Conclusions: Racial disparities in the likelihood of initial diagnosis of hypertension during officebased visits were indicated but statistical significance was not found. However, non-

Hispanic Blacks were found to be significantly less likely to receive follow-up office-based visits for hypertension.


This study offers a potential explanation for persistent racial disparity in BP control that has not been examined previously. However, its small sample may have limited the power to achieve statistical significance. Larger nationally representative datasets with the capability to identify events of initial diagnosis of hypertension should be used to further test this hypothesis.

•

Adherence to Pap Test Guidelines among

Asian Females in California

Michael Lin, M.S.P.H., Ph.D., Joel Moskowitz,

Ph.D., Gene Kazinets, , Susan Ivey, M.D., Young

Bok Kim, Ph.D.

Presented By: Michael Lin, M.S.P.H., Ph.D.,

Assistant Professor, Health Policy and

Management, University of Pittsburgh, A649

Crabtree Hall, Pittsburgh, PA 15261, Phone: (412)

624-2743, Fax: (412) 624-3146, Email: linm@pitt.edu

Research Objective: This study assesses rates of compliance among Asian Pacific Islander

Americans (APIAs) with the US Preventive

Services Taskforce guidelines for periodic Pap screenings. The primary aim is to understand the extent and sources of variation among different

APIA ethnic groups. In order to explain variation in these rates, researchers employed the

Andersen Behavioral Model to ascertain which particular factors are most consistently related to the failure to receive the suggested periodic tests.

Study Design: This study uses the California

Health Interview Survey (CHIS) from 2001 and

2003. A random digit dialing survey approach was used to contact individuals living in

California for participation. To ensure adequate representation of certain ethnic groups, a surname based supplemental sample was contacted in each wave. A multi-stage sampling frame was employed to obtain a sample representative of the entire state.

Population Studied: Based on the sampling framework, CHIS provides information about the entire non-institutionalized civilian population living in California during 2001 and 2003. This particular study focuses only on APIA women between the ages of 18 and 65 years who have not had a hysterectomy. The final sample of

3,787 APIA women comprises a weighted sample of 2.41 million California women who self-identify as Chinese, Filipino, Japanese, Korean, South

Asian, or Vietnamese.

Principle Findings: Filipino women were the most likely to report adherence to the guidelines, with only 14% failing to receive the recommended screening. Korean and

Vietnamese women were the least likely to report adherence to the guidelines, with 34% of both groups failing to receive a Pap test in the past

three years. Twenty-four percent of Japanese women, 27% of South Asian women, and 30% of

Chinese women failed to receive the suggested periodic screening. In terms of statistically significant predictors of non-adherence to the guidelines, the needs measure used in this study, poor or fair self-rated health, is significant for only the Korean women. As for predisposing factors, being unmarried is associated consistently with failure to comply with the guidelines. Age is important for Chinese,

Japanese, Korean, and Vietnamese women.

Acculturation is assessed in two ways, time in the US and English proficiency: the former is associated with Pap screening among the

Chinese, Filipino, and Vietnamese women, while the latter is associated only among Japanese women. Educational attainment is associated with failure to have the recommended Pap screening among Chinese, Filipino, and Korean women. Among enabling factors, income is an important predictor only among Vietnamese women. Current insurance coverage and having a usual source of care appears to be associated with Pap screening among Chinese, Korean, and

South Asian women. Having a usual source of care is also an important correlate of Pap screening among Vietnamese women.

Conclusions: APIA ethnic groups face different challenges in receiving recommended Pap screens. Acculturation, education, insurance status, and income are not consistently related to compliance with guidelines. Programs that target unmarried women who lack a usual source of care may be most effective at increasing screening rates.


Policymakers and providers should consider different correlates of Pap testing among different APIA groups.

•

Influenza and Pneumococcal Vaccination

Coverage among American Indian/Alaska

Natives Aged 65+ Years

Megan C. Lindley, M.P.H., Amy V. Groom,

M.P.H., Pascale M. Wortley, M.D., M.P.H., Gary

L. Euler, Dr.P.H.

Presented By: Megan C. Lindley, M.P.H.,

Contractor, McKing Consulting, National

Immunization Program, Centers for Disease

Control & Prevention, 1600 Clifton Road, N.E.

MS E-52, Atlanta, GA 30333, Phone: 404-639-

8717, Fax: 404-639-8614, Email:

MLindley@cdc.gov

Research Objective: Estimate influenza and pneumococcal vaccination coverage among

American Indian/Alaska Native (AI/AN) older adults in the United States, and examine demographic and regional variations in coverage.

Study Design: Behavioral Risk Factor

Surveillance System (BRFSS) telephone survey data from 2003-2005 were pooled to create the sample. Demographics and vaccination coverage by race and region were compared using chisquare tests. Multivariable logistic regression was used to obtain predictive marginal coverage for each covariate of interest, including race, education, income, insurance status, age, region, telephone service interruption, and residence in an Indian Health Service (IHS) service county.

Population Studied: Non-Hispanic white

(n=180,064) and AI/AN (n=1,986) BRFSS respondents aged 65+ years with land-line telephone service.

Principle Findings: AI/AN respondents were younger, more likely to report having diabetes, less likely to report insurance coverage, and had lower income and education than whites.

Unadjusted vaccination coverage was far below the Healthy People 2010 goal of 90%, and varied by geographic region for influenza (whites:

63.0%-71.5%; AI/AN: 63.7%-77.6%) and pneumococcal vaccines (whites: 60.6%-69.6%;

AI/AN: 45.1%-70.6%). These regional differences were considerably reduced after multivariate adjustment. Residence in an IHS service county was not associated with higher influenza or pneumococcal vaccination coverage among

AI/AN. Adjusting for covariates, predictive marginal coverage between whites and AI/AN was not statistically different for influenza

(69.1% vs. 72.1%) or pneumococcal vaccines

(66.5% vs. 62.0%). In the adjusted analysis, having health insurance, more education, diabetes, asthma, and being older were associated with higher coverage for both vaccines. Use of pooled data and a relatively small sample of AI/AN respondents with landline telephone service may obscure true variations particularly in subgroup coverage, e.g. regional differences. Vaccination coverage may be substantially lower among persons without land-line telephones, although national coverage estimates from face-to-face interviews are comparable to telephone-based BRFSS estimates.

Conclusions: Nationally, older AI/AN adults do not appear to experience the disparities in recommended vaccination coverage observed among other racial/ethnic minorities. Regional

differences in coverage indicate a need to monitor vaccination coverage within geographically and culturally diverse segments of the AI/AN population, as wide variation in telephone service by tribe may mask substantial regional disparities among older AI/AN. The impact of IHS-funded programs in providing recommended vaccines to older AI/AN is unclear, as eligibility for IHS-funded services was measured by proxy (county of residence) and many AI/AN respondents in BRFSS may not be eligible for IHS-funded services.


Racial disparities in immunizations are welldocumented among black and Hispanic older adults. This analysis provides the first published estimate of vaccination coverage among a nationally-based sample of AI/AN adults. Larger samples of AI/AN respondents might permit calculation of valid single-year estimates or regional differences in coverage. These samples could be obtained by specifically oversampling

AI/AN respondents and by making special efforts to reach AI/AN with limited telephone coverage. Health services research incorporating specific questions about current and lifetime access to IHS-funded services and other public and private coverage would facilitate assessing the impact of these programs on AI/AN service utilization. Healthcare providers for AI/AN adults should implement strategies to increase coverage to HP2010 target levels.

Funding Source: CDC

• National Data on Rural Residents Who

Crossover to Urban Areas for Inpatient

Hospital Care

Jill A. Marsteller, Ph.D., M.P.P., Jill A. Marsteller,

Ph.D., M.P.P., Maria F. Owings, Ph.D.

Presented By: Jill A. Marsteller, Ph.D., M.P.P.,


Management, Bloomberg School of Public

Health, Johns Hopkins University, 624 N.

Broadway Street,Rm 433, Baltimore, MD 21205,

Phone: (410) 614-2602, Fax: (410) 955-6959,

Email: jmarstel@jhsph.edu

Research Objective: To examine the patient, hospital, and county characteristics associated with rural residents’ utilization of inpatient care in urban, rather than rural, hospitals.

Study Design: This study analyzed inpatient data from the National Hospital Discharge

Survey, NHDS, a nationally representative survey of US short-stay, nonfederal hospitals. NHDS data were merged with county data from the

Area Resource File, and with Medicare data on hospitals' case mix index. Patient, hospital, and county characteristics of crossovers and noncrossovers were compared. Patient characteristics studied included age, gender, source of payment, DRG-diagnosis related group-weight, Charlson-Deyo comorbidity index, and receipt of surgery; rural residents’ county characteristics included income, education, availability of health services, and percent commuting to urban areas for employment; hospital characteristics included ownership, teaching hospital status, and Medicare case mix index of hospitals. Sampled data were weighted to produce national estimates using multistage estimation procedures. Both descriptive analyses and multivariate analysis using logistic regression were conducted.

Population Studied: Included in this study were rural residents who were inpatients in 2003.

Crossovers were identified as rural patients who were hospitalized in an urban hospital, and noncrossovers were rural patients who remained in rural areas for their inpatient care.

Principle Findings: In 2003, 7.3 million rural residents were hospitalized. Over two-thirds of these, 4.9 million, went to rural hospitals for their inpatient care. The other 32 percent, 2.4 million, crossed over to urban hospitals for inpatient care. Several factors distinguished between crossovers and non-crossovers, controlling for other variables. Crossovers to urban hospitals were more likely to be younger, have a surgical DRG, a higher DRG weight, and to have a first-listed diagnosis of ischemic heart disease or mental illness. Patients who had emergency admissions and those with higher comorbidity scores were less likely to be crossovers. Crossovers were more likely to receive care in proprietary or government hospitals than in not-for-profit hospitals, and in hospitals with higher Medicare case mix index scores. Crossovers were also more likely to live in counties with a lower rate of hospital beds, but with a higher rate of physicians per population.

Conclusions: Most rural patients are hospitalized in rural hospitals. Those hospitalized in urban hospitals are younger, often require surgery and have more intensive resource needs, but are less likely to be emergent or have many comorbidities. Crossovers overwhelmingly go to hospitals with higher case mix indices, perhaps indicating more specialized services than patients have access to locally.


This research illustrates important differences in

patterns of inpatient care for rural residents, who often must travel for more advanced services.

Other research has documented disparities between rural and urban patients in access to technologically advanced medical and surgical inpatient care. The findings presented here will assist urban and rural hospitals as they develop collaborative arrangements to ensure efficient use of inpatient hospital resources.

Funding Source: CDC

• Racial, Age, and Gender Disparities in

Quality Outcomes from Ambulatory Surgical

Procedures

Nir Menachemi, Ph.D., M.P.H., Askar

Chukmaitov, M.D., Ph.D., L. Steven Brown, B.S.,

Charles Saunders, Ph.D., Robert G. Brooks,

M.D., M.B.A.

Presented By: Nir Menachemi, Ph.D., M.P.H.,

Assistant Professor, Division of Health Affairs,

Florida State University College of Medicine, 1115

West Call Street, Tallahassee, FL 32306, Phone:

(850) 644-2362, Fax: (850) 645-2859, Email: nir.menachemi@med.fsu.edu

Research Objective: Many studies have documented disparities in surgical outcomes in the inpatient setting but less is known about the ambulatory setting. The purpose of the current study is to explore if racial, age, and gender outcome disparities exist from ambulatory surgical procedures performed in Florida.

Study Design: Large-scale retrospective and longitudinal observational study. Logistic regression models, controlling for patient comorbidities, payer status, and other patient characteristics, were used to examine 7- and 30day mortality and 7- and 30-day unexpected hospitalization after ambulatory surgical procedure.

Population Studied: Patients receiving one of several common procedures in either a freestanding ambulatory surgical center or a hospital-based outpatient department in an 8 year period. Specific procedures examined included colonoscopy, cataract removal, upper gastrointestinal endoscopy, arthroscopy, and repair of inguinal hernia.

Principle Findings: Overall, 3,174,436 patients received one of the five procedures examined during the 1997-2004 study period. African-

American race was a significant predictor of either mortality or unexpected hospital admission in four of the five procedures examined, even after controlling for confounders.

For females, unexpected hospital admission was less likely to occur after all five procedures examined; mortality was less likely after four of the five procedures. Age was also found to be significantly related to both mortality and unexpected hospital admission for many procedures. This risk was as high as sixty-fold for 7-day mortality from an inguinal hernia procedure (p<.05), and sixteen-fold for 30-day mortality from upper gastrointestinal endoscopy

(p<.01).

Conclusions: Many of the racial and gender disparities documented in the inpatient surgical literature are observed in the ambulatory setting as well.


More research is needed to determine the source of the racial, gender, and age inequities that are observed in the current study.

Funding Source: Florida Agency for Health Care

Administration

• Digital Disparities and the Health Care

Internet: Race, Ethnicity, and Online

Information Searches in the United States

Edward Miller, Ph.D., M.P.A., Darrell M. West,

Ph.D., Melanie Wasserman, Ph.D.

Presented By: Edward Miller, Ph.D., M.P.A.,

Assistant Professor, Taubman Center for Public

Policy, Borwn University, 67 George Street,

Providence, RI 0212-1977, Phone: (401) 863-9311,

Email: edward_a_miller@brown.edu

Research Objective: Concomitant with growing recognition of racial and ethnic disparities in health care, there is growing appreciation of the digital divide, which may lead to inequities in the use of online health resources. Given the absence of studies examining the moderating influence of race and ethnicity on health Internet use, this article seeks to determine use of health websites by race and ethnicity------whether non-

Hispanic White, African American, Hispanic, or

Other, and to identify variation in characteristics associated with website use across each group examined.

Study Design: Cross-sectional analysis of responses to a November 2005 national survey.

In addition to reporting the extent of website usage stratified by race and ethnicity, we use ?2 and Fisher’s exact tests to examine bivariate associations between website usage and respondent characteristics. Logistic regression and multiple imputation of missing data were used to examine the correlates of usage in a multivariate context.

Population Studied: Data derive from 828 respondents to a November 2005 survey conducted nationally in the continental United

States.

Principle Findings: Results indicate that the percentage of respondents visiting health websites varied across racial and ethnic group, with the percentage of Whites using (33.7%) exceeding the percentage of African Americans

(31.0%) and Hispanics (20.4%). No African

American or Hispanic respondents aged 65 years or older reported going online. Although better educated respondents of all types were more likely to access health information, the relationship between education and website use was more than twice as strong for African

Americans and Hispanics. Better perceived health was associated with greater use of the health care internet among Hispanics and

Whites, and stronger health literacy was associated with greater use of the health care internet among Hispanics.

Conclusions: Given prevailing disparities and the growing importance of the Internet, it is imperative that a concerted effort be undertaken to close the digital divide in health care before it grows even bigger.


From a young age members of underprivileged groups need to be taught to be not only active participants in their own health but to use the

World Wide Wide as one tool toward achieving that goal.

• Folk Beliefs and Genetic Destiny: Differing

Causal Views of Colorectal Cancer among

Participants in a Genetic Epidemiology Study

Mairead Eastin Moloney, M.A., Gail Henderson,

Ph.D., Jada Bussey-Jones, M.D., Giselle Corbie-

Smith, M.D., M.S.

Presented By: Mairead Eastin Moloney, M.A.,

NRSA pre-doctoral fellow, Cecil G. Sheps Center for Health Services Research, UNC Chapel Hill,

108 windsor circle, Chapel hill, NC 27516, Phone:

(919) 260-1039, Email: moloney@email.unc.edu

Research Objective: With the completion of the human genome project the role of heredity in cancer is gaining lay and media attention.

Individuals are more likely to credit extrapersonal or environmental factors, including genes, with cancer causation. ‘‘Folk wisdom’’ beliefs deviate from accepted scientific models, tend to be fatalistic and are more likely to be articulated by those of low SES. Fatalistic causal beliefs may prompt poor health behaviors, leading to delayed medical attention, and increased morbidity and mortality. We sought to determine the range of lay causal models of colorectal cancer (CRC).

Study Design: We used qualitative methodology to determine causal models of CRC among

African Americans and whites, both with and without CRC. Project participants completed a phone survey covering a variety of topics, including perceived causes of CRC and their views on genetic research. All interviews were taped, transcribed and analyzed using Atlas software.

Population Studied: Learning about Cancer in

North Carolina (LeARN) is a mixed methods project comprised of African American and white

CRC cases and controls participating in the

North Carolina Colorectal Cancer Study. Cases had a diagnosis of invasive colorectal cancer; controls were drawn from DMV records and

Medicare beneficiary lists. From the larger

LeARN sample (n=725) a qualitative sub-sample was created (n=194) using all of the Black cases and controls (n=51 and n=46 respectively). White cases and controls were matched on case status, age, education and sex.

Principle Findings: Participants, across race and case status, were most likely to cite the following three causes of CRC: diet, heredity/genes and lifestyle/behavior (in that order). When asked about genetic research, several participants mentioned altering genes as an eventual means of improving health outcomes. A small portion (13%) of the sample reported ‘‘folk wisdom’’ beliefs that included: constipation, sexual promiscuity, being unclean, homosexual sex and the idea of cancer developing from unrelated illness. Only 3 of the

194 participants mentioned colorectal polyps as a cause of CRC. In comparison to previous research, respondents in this sample were much more likely to answer ‘‘I don’t know’’ (28%); this answer was more likely to occur among cases than controls (n=33 v. n=21) and seemed unrelated to race status.

Conclusions: Participants expressing ‘‘folk wisdom’’ beliefs were in the minority and tended to be of low SES. Lifestyle factors and diet were commonly cited along with heredity/genes as causes of CRC. These co-occurring variables are not necessarily disparate in terms of personal control; several participants implied plasticity within and control over heredity and genes particularly when considering the future of medical science. Based on these data, we hypothesize that lay beliefs are shifting from notions of external forces acting on the

individual toward greater emphasis on variables within individual control, including diet, lifestyle, health behaviors, and possibly even genetics.


Individuals may perceive increasing control over

CRC outcomes. Although encouraging news to many health professionals, some individuals still adhere to ‘‘folk’’ beliefs about CRC. Identifying these individuals for targeted education on risk reductive health behaviors and the importance of regular screening for CRC will be important.

Funding Source: NIH/Human Genome

Research Institute/ELSI

•

Feasibility of Using Personal Health

Records to Address Disparities in Health Care

Lorenzo Moreno, Ph.D., M.Sc., Ann Bagchi,

Ph.D., Raquel af Ursin, M.B.A., Stephanie

Peterson, M.P.P.

Presented By: Lorenzo Moreno, Ph.D., M.Sc.,

Senior Researcher, Health, Mathematica Policy

Research, Inc., 600 Alexander Park, Princeton,

NJ 08540, Phone: (609) 936-2766, Fax: (609)

799-0005, Email: lmoreno@mathematicampr.com

Research Objective: To inform policy discussion about the future direction of personal health records (PHRs)--electronic records of an individual’s health information that the individual manages and owns in a secure environment--in reducing health care disparities.

Widespread adoption of PHRs among underserved racial and ethnic minority groups can help alleviate health disparities by reducing medical errors and improving the adherence to treatments. Use of electronic resources is limited among low-income racial and ethnic groups and the elderly due to their lack of access to and comfort with computers and associated technology (the so-called digital divide). This divide is also heavily influenced by language use and health literacy. The study will address three questions: (1) How do members of underserved populations view the concept of PHRs? (2) What are the potential barriers to adopting PHRs among underserved populations? and (3) What factors must be taken into consideration when designing a PHR for underserved populations?

Study Design: Focus groups in federally designated, medically underserved areas in New

Jersey to be conducted in February 2007.

Systematic review of the most widely used PHRs in the market to assess whether they address the needs of underserved populations.

Population Studied: Adults between 30 and 79 years of age from the following racial/ethnic and language groups: (1) English-speaking non-

Latino African Americans, (2) English-speaking

Latinos, and (3) Spanish-speaking Latinos.

These groups have disproportionately higher barriers to health care and information than other minority populations and whites.

Principle Findings: If our hypotheses are confirmed, we expect little familiarity of focus group participants with the PHR concept. We also anticipate that focus group participants will:

(1) have limited trust of the security of electronically-housed data, (2) see limited value of PHRs, (3) dislike the idea of entering or updating information, and (4) dislike the idea of documenting sensitive information.

Furthermore, we expect that existing PHRs may not include functions that focus groups participants report as desirable.

Conclusions: If our hypotheses are confirmed, we expect that developers of existing or future

PHR systems may need to adapt their products to better serve the needs of underserved populations.


The research findings may elicit interest from the

Centers for Medicare & Medicaid Services

(CMS) if it decides to offer a PHR for Medicaid or low-income Medicare beneficiaries. In particular, CMS may be interested in assessing whether PHRs can be used as an intervention to reduce health care disparities among these populations, as recently proposed by Congress in the Better Health Information System Act (HR

4157).


• Racial and Ethnic Minority Primary Care

Providers: Improving Access and Patient-

Provider Communication

Ernest Moy, M.D., M.P.H., Sara Hogan

Presented By: Ernest Moy, M.D., M.P.H.,

Medical Officer, Center for Quality Improvement and Patient Safety, Agency for Healthcare

Research and Quality, 540 Gaither Road,

Rockville, MD 20850, Phone: (301)427-1329, Fax:

(301)427-1341, Email: ernest.moy@ahrq.hhs.gov

Research Objective: To examine the role of

Black, Asian, and Hispanic providers in the delivery of primary care to disadvantaged populations and to compare patient-provider communication by primary care provider race and ethnicity.

Study Design: Data come form the Medical

Expenditure Panel Survey, a nationally representative survey of the U.S. noninstitutionalized civilian population. In this survey, individuals who identify a usual primary care provider are asked to report the gender, race, and ethnicity of that provider. In this analysis, patients who report Non-Hispanic

White, Non-Hispanic Black, Non-Hispanic Asian, and Hispanic primary care providers are compared. Patient-provider communication is measured among individuals who visited their provider in the past year using standard CAHPS questions: how often their provider listened carefully, explained things, showed respect for what they had to say, and spent enough time with them.

Population Studied: U.S. noninstitutionalized civilian population age 18 to 64 with a usual primary care provider.

Principle Findings: Over half of Black, Asian, and Hispanic individuals identify a racial and ethnic minority provider as their usual source of primary care. Individuals who are uninsured, have family incomes below the poverty level, did not finish high school, and report poor health also disproportionately rely upon minority providers for primary care.

Patient-provider communication varies by primary care provider race and ethnicity.

Individuals with Asian primary care providers are less likely to report that their provider always listens carefully, explains things, and shows respect for what they have to say; this may be explained in part by the concentration of Asian patients, who report more communication problems overall, among Asian providers. Better communication was generally reported when patient and provider race and ethnicity matched; communication problems were more common among White patients with Black or Asian providers, Black patients with Hispanic providers, Asian patients with Asian providers, and Hispanic patients with White providers.

Conclusions: Racial and ethnic minority primary care providers play a significant role in ensuring health care access and delivery to disadvantaged populations; minority primary care physicians treat a disproportionately unhealthier, poorer, less educated and uninsured patient population.

In addition, patients with primary care providers of the same race and ethnicity may experience improved communication.


The results of this study have direct implications for graduate medical education and primary care provider training. Given worsened communication between patients and primary care providers of different race and ethnicity, systemic use of cultural competency training and patient-provider communication instruction may ameliorate communication problems. Language discordance and limited English proficiency status may also play roles in negatively influencing patient-provider communication.

Research and policy development should occur to establish uniform reimbursement mechanisms for primary care providers to provide language access services, and better serve limited English proficiency patient populations. Additionally, this study highlights the need for continued research regarding patient expectations of primary care providers, and how the length of time spent at a source of care and the site of care location may influence patient-provider communication outcomes.

•

Uncontrolled Diabetes Hospitalizations in the United States: A Rural/Urban Comparison

Kyle Muus, Ph.D., Alana Knudson, Ph.D., Steven

Lancette, M.S.

Presented By: Kyle Muus, Ph.D., Research

Associate, Center for Rural Health, University of

North Dakota, 501 N. Columbia Road, Box 9037,

Grand Forks, ND 58203, Phone: 701-777-3848,

Fax: 701-777-6779, Email: klmuus@medicine.nodak.edu

Research Objective: Examine the incidence, patterns, and predictors of U.S. hospitalizations for uncontrolled diabetes among adults (i.e., aged 18 and older). Specifically, we examined the incidence rates for rural versus urban residents and demographic/geographic factors which increase the likelihood of being hospitalized for this condition.

Study Design: Secondary analysis of hospital claims data.

Population Studied: 2003 Healthcare Cost and

Utilization Project (HCUP) Nationwide Inpatient

Sample data file.

Principle Findings: There were an estimated

53,442 hospitalizations for uncontrolled diabetes in the U.S. in 2003. Of this number, 40,557 were incurred by urban-based residents and 11,928 involved rural-based patients. Per population, rural residents had hospitalization rates that were substantially higher than for urban residents (32.6 versus 23.5 per 100,000 persons). Using logistic regression, we found that rural residents were 18% more likely than urban residents to have been hospitalized for

uncontrolled diabetes, after controlling for age, gender, and race.

Conclusions: Across all of AHRQ’s ambulatory care sensitive conditions, hospitalizations due to uncontrolled diabetes occurred infrequently in the United States. Persons residing in rural areas were much more likely than their urban counterparts to have been hospitalized for this condition. Other factors that increased the likelihood of being hospitalized for this condition included being male, middle-aged, non-White, and residing in lower income areas.


Hospitalization stays for uncontrolled diabetes, in many cases, can be avoided through regular checkups with a healthcare provider, compliance with health care providers’ prescribed care regimens, careful monitoring of one’s diabetes condition, getting sufficient exercise, and eating a healthy diet. The markedly high hospitalization rates for rural residents may be explained by a variety of factors, including decreased access to health care services, lower rates of health insurance, and higher rates of diabetes. Rural residents with diabetes, given their lower access to health care resources, need to pay particularly close attention to monitoring their disease, getting sufficient exercise, and eating a healthy diet.


•

Setting Priorities for Disparity-Reduction

Initiatives: Comparing Effects on Population

Health

David Nerenz, Ph.D., Keoki Williams, M.D.,

M.P.H., Jennifer Elston Lafata, Ph.D., Christina

Moon, M.H.S.A., Sandeep Vijan, M.D., M.S.

Presented By: David Nerenz, Ph.D., Acting

Director, Center for Health Services Research,

Center for Health Services Research, Henry Ford

Health System, 1 Ford Place (3A), Detroit, MI

48202, Phone: (313) 874-5454, Fax: (313) 874-

7137, Email: dnerenz1@hfhs.org

Research Objective: The objective of the study was to compare the health benefits (lives saved,

Quality-Adjusted Life Years (QALYs) gained, and days at work or school) that would follow from elimination of racial/ethnic disparities in several standard quality of care measures among members of managed care plans.

Study Design: The study involved the development of detailed Markov simulation models, using available published data to estimate model parameters. Basic parameters were the probability of transition of patients through defined health states over defined periods of time, and the utility associated with, or probability of employment or school attendance during, those states. For example, the asthma medications model had a basic structure of monthly cycles during which patients did or did not use controller medications, did or did not have exacerbations, did or did not require ED care or hospital admission, and did or did not miss work or school. The clinical domains studied were: breast cancer screening, diabetes management, use of controller medications for asthma, and use of beta blockers after myocardial infarction.

For purposes of comparison across clinical domains, QALY gains over a five-year period were used as the primary model end point.

Whenever possible, input parameters (e.g., distribution of stage of disease at diagnosis for women with breast cancer; monthly probability of exacerbations for children or adults with asthma) were specific to African American or

Hispanic patients. The elimination of disparity was simulated by changing a quality of care parameter in the models (e.g., percent of women aged 50-65 with a mammogram in the previous two years) from a level reported for a defined racial/ethnic minority group to a higher level reported for a reference population (usually, non-

Hispanic Whites).

Population Studied: Simulation models in most clinical areas were created separately for African

American and Hispanic patients. Age and other demographic criteria for each model were matched to the current corresponding HEDIS denominator population definitions.

Principle Findings: The most significant finding was a 20-fold variation in the QALY gains associated with eliminating disparities with the greatest health impact (blood pressure and lipid control among diabetics) and those with the smallest health impact (HbA1c control among diabetics, breast cancer screening). In absolute terms, the estimated QALY gains per 1,000 individuals in a health plan denominator population over five years ranged from 2 to 44 across specific HEDIS measures. Sensitivity analysis allowed for the identification of specific areas of disparity (e.g., blood pressure control, lipid control, HbA1c control) whose elimination would have greater vs. smaller health impact.

Conclusions: Elimination of racial/ethnic disparities in quality of care in different clinical domains reflected by specific HEDIS measures has markedly different estimated effects on health in the denominator population(s).


Decisions about allocation of resources to reduce or eliminate racial/ethnic disparities can be guided in part by estimates of health gains to be achieved in the affected population(s). More generally, quality improvement initiatives, public quality reporting initiatives, and pay-forperformance initiatives can be guided by similar calculations.

Funding Source: CWF

• Effects of Neighborhood Characteristics on

Timing and Use of Prenatal Care: The Case of

Milwaukee City, Wisconsin

Emmanuel Ngui, Dr.P.H., Jacqueline K Gosz,

M.S., Kathleen Blair, B.S.N., M.S.

Presented By: Emmanuel Ngui, Dr.P.H.,

Assistant Professor of Pediatrics and Population

Health, Department of Pediatrics, Medical

College of Wisconsin, 8701 Watertown Plank Rd,

Milwaukee, WI 53226, Phone: 414-456-4302, Fax:

414-456-6385, Email: engui@mcw.edu

Research Objective: Although neighborhoodlevel characteristics and prenatal care have been associated with birth outcomes, the association of neighborhood characteristics with timing and use of prenatal care is unclear. This study examines whether neighborhood characteristics are associated with late (3rd trimester) or no prenatal care among non-Hispanic black women and non-Hispanic white women.

Study Design: Analysis of over 50,600 City of

Milwaukee Health Department geocoded birth records for white and Black residents from 1999-

2004, merged with the US 2000 census tract data. The neighborhood environment was assessed using four indexes created from census tract level measures: neighborhood education, residential stability, neighborhood poverty, and neighborhood deprivation. Random effects multilevel regression models were estimated separately for black women (n=29,928) and white women (n=20,680) to examine the association of each of the four neighborhoodlevel measures with late or no prenatal care, controlling for four individual-level characteristics (maternal education, age, marital status, and prenatal smoking).

Population Studied: Mothers who gave birth in the city of Milwaukee, WI from 1999-2004.

Principle Findings: Black women were significantly more likely than white women to have late or no prenatal care (7% vs. 2%), and to live in neighborhoods with higher concentration of lower educational attainment, residential instability, poverty, and deprivation. The adjusted odds of late or no prenatal care were significantly higher for white women in neighborhoods with the lowest educational attainment (OR=2.4 [95%

CI;1.7-3.5]) and for black women in neighborhoods with the lowest (OR=1.9 [1.3-2.6]) and moderately-low (OR=1.5 [1.03-2.1]) educational attainment. White women residing in low and moderately-low residentially stable neighborhoods were twice as likely as those in the highest residentially stable neighborhoods to have late or no prenatal care (OR=2.1 [1.5-2.9]).

Compared with their counterparts in the least deprived neighborhoods, black women in the most deprived neighborhoods (OR=1.7 [1.1-2.4]) and white women in moderately-high (OR=1.7

[1.2-2.5]) and the most deprived neighborhoods

(OR=2.0 [1.4-3.1]) had twice the odds of late or no prenatal care. Compared to their counterparts residing in the least deprived neighborhoods, the odds of late or no prenatal care were significantly greater for black women in moderately-high

(OR=1.5 [1.2-2.0]) and the highest (OR=1.7 [1.3-

2.3]) deprived neighborhoods, and white women in moderately-low (OR=1.6 [1.2-2.1]), moderatelyhigh (OR=2.4 [1.7-3.2]), and the highest (OR=2.5

[1.7-3.6]) deprived neighborhoods. A gradient was observed, with black and white women in the more impoverished neighborhoods being at greater risk of obtaining late or no prenatal care than those in less impoverished neighborhoods.

Conclusions: Disadvantaged neighborhood conditions are associated with increased risk of obtaining late or no prenatal care among black and white women, independent of individuallevel risk factors. The risk of obtaining late or no prenatal care is higher for black and white women residing in more impoverished neighborhoods than those residing in less impoverished neighborhoods.


Improving neighborhood conditions can increase early access to and use of prenatal care among urban women, thereby reducing disparities in birth outcomes.

•

Racial/Ethnic Disparities in Bicycle Helmet

Use among Children With and Without

Special Health Care Needs: Effects of

Neighborhood Characteristics and State

Helmet Laws

Emmanuel Ngui, Dr.P.H.

Presented By: Emmanuel Ngui, Dr.P.H.,

Assistant Professor of Pediatrics and Population

Health, Department of Pediatrics, and

Department of Population Health, Medical

College of Wisconsin, 8701 Watertown Plank Rd.,

Milwaukee, WI 53226, Phone: 414 456-4302, Fax:

414 456-6385, Email: engui@mcw.edu

Research Objective: Bicycle related head injuries are a major cause of morbidity and mortality among children. Little, however, is known about racial and ethnic disparities in bicycle helmet use among children with

(CSHCN) and without special health care needs

(CWSHCN). This study examines whether there are racial/ethnic disparities in bicycle helmet use among CSHCN and CWSHCN, and the effects of neighborhood characteristics (perceived support and home safety) and state bike helmet laws on bicycle helmet use.

Study Design: Bivariate and multivariate analyses of data on 55,106 children, 6-17 years old. Multivariate analyses adjusted for child’s age, gender, health status, residence, maternal education, income, and availability of personal doctor/nurse.

Population Studied: Nationally representative sample of children < 18 years old, participating in the 2003 National Survey of Children's Health.

Principle Findings: About 55% of CSHCN

(n=7,109) and 52% of CWSHCN (n=24,976) always or usually used bicycle helmets when riding bicycles or scooters. Among CSHCN, black (OR=0.5 [0.4-0.7]), Hispanic (OR=0.6 [0.4-

0.8]), and American Indian (OR=0.3 [0.1-0.8]) children had significantly lower unadjusted odds of bicycle helmet use than white children. After adjustments, disparities in bicycle helmet use persisted for black (OR=0.5 [0.4-0.7]) and

Hispanic (OR=0.5 [0.4-0.8]) CSHCN. Among

CWSHCN, black (OR=0.4 [0.4-0.5]), Hispanic

(OR=0.7 [0.6-0.8]), and American Indian

(OR=0.6 [0.4-0.9]) children had significantly lower unadjusted odds of bicycle helmet use.

Asian CWSHCN had significantly higher adjusted odds of bicycle helmet use than white children (OR=2.5 [1.3-4.5]). Racial/ethnic disparities in bicycle helmet use persisted for black (OR=0.5 [0.4-0.5]) and Hispanic (OR=0.8

[0.7-0.9]) CWSHCN after adjustment. The odds of bicycle helmets use were three times higher for both CSHCN (OR=2.7 [2.2-3.3]) and

CWSHCN (OR=2.8 [2.6-3.2]) in states with statewide bicycle helmet laws, and 20% higher for both groups in states with some bicycle helmet laws compared to states with no bicycle helmet laws. Bicycle helmet use increased with increasing levels of home safety among

CWSHCN (OR=1.3 [1.1-1.4]) but not CSHCN.

CWSHCN residing in the least supportive neighborhoods were less likely than those in the most supportive neighborhoods to use bicycle helmets (OR=0.8 [0.7-0.9). Overall, bicycle helmet use was lower among older children, non-MSA residents, children without a personal doctor/nurse, those with parents who had not graduated from college, and those in household with income <300% federal poverty threshold.

Conclusions: Racial/ethnic disparities in bicycle helmet use exist for black and Hispanic CSHCN and CWSHCN and persist after adjustments. For both CSHCN and CWSHCN, state bicycle helmet laws are significantly associated with greater bicycle helmet use. Neighborhood support and home safety are associated with bicycle helmet use for CWSHCN but not CSHCN.


Policies that increase statewide bicycle helmet laws and interventions that promote bicycle helmet use among children, particularly black and Hispanic children, are likely to substantially increase the use of and reduce racial/ethnic disparities in bicycle helmet use.

• Non-Urgent Dental Condition Visits to

Emergency Departments and Physicians'

Offices

Christopher Okunseri, B.D.S., M.Sc.,

F.F.D.R.C.S.I., Sandy Tomany-Korman, M.S.,

Andrew Snyder, M.P.A., David Ebert, B.S., Glenn

Flores, M.D.

Presented By: Christopher Okunseri, B.D.S.,

M.Sc., F.F.D.R.C.S.I., Assistant Proffesor, Clinical

Services, Marquette University School of

Dentistry, 1081 West Wisconsin Avenue,

MIlwaukee, WI 53201, Phone: (414) 288-6524,

Fax: (414) 288-3586, Email: christopher.okunseri@mu.edu

Research Objective: To examine factors associated with ED/PO visits for NUDCs among

Medicaid-covered patients.

Study Design: Retrospective analysis of all

Wisconsin Medicaid dental claims for NUDCs from 2001-2003.

Population Studied: Dental Medicaid-covered patient in Wisconsin.

Principle Findings: Of the 986,392 Medicaid visits for NUDCs, 8% were to EDs/POs. A significantly greater risk of NUDC visits to

EDs/POs was found for adults (11% vs. 5% for children), females (9% vs 7% for males), and

Native Americans and African-Americans (12% and 11%, vs. 7% for whites), but not dental health professional shortage areas (DHPSAs).

NUDC visits to EDs/POs slightly increased over time (7.8% in 2001 vs. 8.3% in 2003). In

multivariate analyses, significantly greater odds of NUDC visits to EDs/POs were found for adults (OR, 2.43; 95% CI, 2.39-2.48), Native

Americans (OR, 1.95; 95% CI, 1.85-2.05), Latinos

(OR, 1.25; 95% CI, 1.21-1.29), other race/ethnicity

(OR, 1.52; 95% CI, 1.40-1.64), and females (OR,

1.06; 95% CI, 1.04-1.07), whereas reduced odds were noted for Asians/Pacific Islanders (OR,

0.50; 95% CI, 0.46-0.54).

Conclusions: Substantial racial/ethnic disparities in NUDC visits to EDs and POs exist for Native Americans, African-Americans, and

Latinos. Adults and females also have a higher risk of NUDC visits to EDs/POs.


Reductions in NUDC visits to EDs/POs and associated costs might be achieved by targeted education of at-risk populations and improved access to regular dental care for minority populations.

• Provider and Clinic Cultural Competence in a Primary Care Setting

Kathryn A. Paez, R.N., M.S.N., M.B.A., Jerilyn K.

Allen, Sc.D., R.N., F.A.A.N., Kathryn A. Carson,

Sc.M., Lisa A. Cooper, M.D., M.P.H.

Presented By: Kathryn A. Paez, R.N., M.S.N.,

M.B.A., doctoral candidate, School of Nursing,

Johns Hopkins University, 10211 Pembrooke

Green Place, Columbia, MD 21044, Phone: 410-

772-1367, Email: kpaez1@son.jhmi.edu

Research Objective: A multilevel approach that enhances the cultural competence (CC) of clinicians and the healthcare settings in which they work is speculated to be one solution to reducing racial/ethnic disparities in healthcare.

Study objectives were to measure the CC of clinics and providers; determine if there is a relationship between provider and clinic CC; and assess whether provider demographic characteristics were associated with provider CC.

Study Design: We conducted a cross-sectional survey of clinicians participating in two larger studies. The survey, administered via the

Internet, assessed clinic CC with questions about provider/staff diversity, clinic-sponsored diversity training, and the provision of culturally tailored patient education materials. Three components of provider CC were assessed: attitudes

(power/assimilation, motivation to learn), factbased knowledge, and self-reported behaviors/skills. Provider CC scores ranged from

1 to 5 (attitudes), 1 to 4 (behavior) and 0 to

100% (knowledge), with higher scores reflecting greater CC. We used linear regression to assess the associations of provider CC with provider demographics and clinic CC.

Population Studied: Forty-nine providers from

24 primary care clinics serving primarily black and white patient populations in Baltimore,

Maryland and Wilmington, Delaware.

Principle Findings: Study participants included

36 internists, 9 family practitioners, and 4 nurse practitioners. Providers tended to be experienced

(13.6 +7.6 mean years experience), female (61%) and racially diverse (24 white, 10 black, 15 other).

Clinic employees were diverse (nonwhite physicians, 52% +28.9; nonwhite staff, 69%

+29.2). Over half of providers reported that their clinics offered diversity training to physicians and staff (51%), and culturally tailored patient education materials (78%). Provider CC scores were: cultural motivation, 4.7 +0.4; power/assimilation, 3.3 +0.7; behavior, 2.8 +0.7; and knowledge, 79.9% +11.9. Providers with attitudes reflecting greater cultural motivation were more likely to work in clinics with a higher percent of nonwhite staff (p<.01), and those offering provider and staff diversity training

(p=.03) and culturally tailored patient education materials (p=.02). More culturally appropriate behavior was associated with a higher percent of nonwhite staff (p<.01), and culturally tailored patient education materials (p=.05). Clinicians who were women (p=.04), family physicians

(p=.04), politically liberal (p=<.01) or more confident in caring for the disadvantaged

(p=.04) had power/assimilation attitudes that reflected greater cultural understanding than their counterparts. Greater confidence in caring for minorities (p=.02) was inversely associated with knowledge scores.

Conclusions: There are at least three potential interpretations of these results. First, more culturally competent providers may be attracted to work in clinics with a higher level of CC.

Second, clinics that have adopted more culturally competent practices may influence providers to develop more culturally competent attitudes and behavior. Finally, providers could influence the

CC of the clinics where they practice by advocating for diversity training, workforce diversity and use of culturally-appropriate education materials. Any combination of these three conditions could exist within a given clinical setting; a randomized trial or longitudinal study might help to determine the temporal direction of these relationships.


Enhancing provider and clinic CC may be synergistic strategies for overcoming healthcare disparities.

Funding Source: Agency for Healthcare

Research and Quality; National Heart, Lung and

Blood Institute; National Institute of Nursing

Research; Fetzer Foundation

• Access To and Utilization of Health Care

Services among New Immigrants

Nina Parikh, Ph.D.,M.P.H.

Presented By: Nina Parikh, Ph.D.,M.P.H., Senior

Research Associate, Brookdale Center for

Healthy Aging and Longevity, Hunter College,

City University of New York, 425 East 25th Street,

13 Floor North, New York, NY 10010, Phone:

212.481.4807, Fax: 212.481.3791, Email: nparikh@hunter.cuny.edu

Research Objective: The racial and ethnic diversity of new immigrants to the U.S. presents significant cultural and economic challenges to the provision of health care in these populations.

Recent attention has focused on the growing disparities in access to and utilization of health care services, particularly among ethnic groups.

Yet, it is striking how little is known about these factors among diverse immigrant groups.

Furthermore, few studies explore the explanatory power of multilevel social and economic contextual variables as potential predictors of access to care. This deficit is particularly pertinent for models predicting health outcomes of immigrants, where omitted variables (e.g., prior experience in sending country, social networks) may result in biased estimates. The objective of this study is to assess the social, economic, and cultural factors that affect access to and utilization of health care among new immigrants.

Study Design: This study analyzed data from the New Immigrant Survey (NIS), a public-use database on new legal immigrants to the U.S. and their children that provides information about migration behaviors and the impacts of immigration. The basic design of the study calls for collecting data on representative samples of cohorts of new legal immigrants and following them over time. The sample is based on probability samples of electronic administrative records compiled by the U.S. government that employs a multistage geographic sampling design of the top 85 MSAs and all the top 38 counties in the U.S.

Population Studied: The study population consists of 8,573 adult immigrants admitted to legal permanent residence from Round 1 of the

2003 NIS.

Principle Findings: Preliminary findings suggest that significant differences by immigrant status, country of origin, and household composition exist in regard to health care visits. Newly arrived individuals to the U.S. compared with those who have adjusted status were less likely to have seen a health care provider in the past 12 months (37% vs. 41% p< 0.001). Furthermore, individuals born in Cuba, Haiti, and Vietnam compared with those born in Canada, Europe, and Jamaica (p< 0.001) were less likely to have seen a health care provider in the past 12 months. Finally, newly arrived immigrants who lived alone compared with those who lived with other were less likely to have had a health visit

(32% vs. 38%, p< 0.01). Additional results from logistic regression models will be presented that examine the relationship between individual- and contextual-level variables and the outcome variables of interest, including utilization patterns and access to care.

Conclusions: Significant disparities exist by immigration status and country of origin in regard to utilization of health care services when immigrants first arrive to this country. To advance our knowledge of the barriers that exist among newly arrived immigrants social factors, including household composition should be included in models predicting access to and use of health care services.


The results will advance our understanding of factors affecting immigrant health trajectories over time, and can inform the targeted development of culturally competent interventions designed to improve health outcomes among immigrants in the U.S.


• Association Between Language Proficiency and the Quality of Primary Care among A

National Sample of Insured Latinos

Jennifer Pippins, M.D., Margarita Alegria, Ph.D.,

Jennifer S. Haas, M.D., M.S.P.H.

Presented By: Jennifer Pippins, M.D., Research

Fellow in General Internal Medicine, Division of

General Medicine and Primary Care, Brigham and Women's Hospital, 1620 Tremont Street,

Floor 3, Boston, MA 02120-1613, Phone: (617)

894-0030, Fax: (617) 732-7072, Email: jpippins@partners.org

Research Objective: Latinos experience substantial barriers to primary care. Limited

English language proficiency may be a mechanism for deficiencies in the delivery of

primary care to this population, even for Latinos with health coverage. The objective of this study is to determine the relationship between English language proficiency and the experience of primary care reported by a diverse sample of

Latinos.

Study Design: Analysis of the National Latino and Asian American Study (NLAAS), a nationally representative household survey administered in

2002 - 2003. Four outcome measures were selected to address different aspects of the quality of primary care: 1) not having a regular source of care or lacking continuity of care; 2) difficulty getting an appointment over the phone,

3) long waits (> 1 hour) in the waiting room, and

4) difficulty getting information or advice by phone.

Population Studied: NLAAS is a nationally representative, cross-sectional household survey of 2,554 Latinos and 2,095 Asian Americans that uses a stratified area probability sample design.

Data were collected from 2002 to 2003, and

Latino participants were questioned in either

English or Spanish. The response rate for the

Latino sample was 75.5%. Because our interest was specifically in the experience of Latinos, we restricted our analysis to individuals who selfidentified as Latinos (n = 2,554). We asked only those subjects who reported a current source of insurance (n=1,792) survey questions addressing the quality of primary care.

Principle Findings: English language proficiency was associated with the experience of primary care for three of the four outcomes. Insured

Latinos with poor/fair English language proficiency were more likely than those with good/excellent proficiency to report not having a regular source of care or lacking continuity

(odds ratio {OR} 1.80, 95% 95% confidence interval {CI} 1.33----2.43), long waits in waiting room (OR 2.06, CI 1.44----2.96), and difficulty getting information/advice by phone (OR 1.69,

95% CI 1.23-----2.32). There were no differences reported by language proficiency in ability to get an appointment by phone.

Conclusions: Low English language proficiency is associated with worse reports of access and continuity in primary care.


As Latinos are the largest and fastest growing minority group in the US, these results suggest that interventions to address limited English proficiency may be important to reducing disparities in the quality of primary care.


• The Association of Access to Quality Care with Recovery of Injured Workers

Nadereh Pourat, Ph.D., Gerald Kominskj, Ph.D.,

Dylan Roby, Ph.D., Meghan Cameron, M.P.H.

Presented By: Nadereh Pourat, Ph.D., Senior

Research Scientist, UCLA Center for Health

Policy Research, 10960 Wilshire Boulevard, Suite

1550, Los Angeles, CA 90024, Phone: 310/794-

2201, Fax: 310/794-2686, Email: pourat@ucla.edu

Research Objective: To examine access to and quality of health care provided to injured workers and to assess the association of these factors with recovery. The California legislation passed significant Workers’ Compensation reform in

2003 and 2004 to address escalating premiums.

These reforms imposed stricter utilization review criteria based on mandatory adoption of evidence-based medial treatment guidelines, implemented explicit caps on some services, and introduced the use of specific medical provider networks. These mechanisms may have adversely impacted access to quality care for injured workers.

Study Design: A cross sectional random sample of injured workers were surveyed by phone from

May to October 2006. The survey topics included questions on the first visit, main provider, access to specialty and rehabilitative care, satisfaction with provider and care received, perceived quality of care, and outcomes such as recovery and return to work. Participants were offered a $15 gift card after completion of the 15 minute survey.

Population Studied: Injured workers with injuries between April 1 to June 30, 2005 were selected for survey participation. The final study sample included 1,001injured workers with an adjusted response rate of 35%.

Principle Findings: Most (61%) injured workers missed less than 3 days of work, while 24% were in treatment for more than 6 months. A small proportion had experienced access barriers such as traveling more than 15 miles (14%) or more than 30 minutes (8%) for their first visit. Access to specialty and rehabilitative care was generally available to those who needed such care. Most

(82%) were satisfied with their care and most

(83%) reported they were able to access quality of care. More than half of injured workers (55%) had not fully recovered from their injury, including 10% who reported no improvement.

Using logistic regression analysis, race, lower income, higher number of visits, longer time spent in treatment, and lower rates of

satisfaction with overall care received were all significantly associated with lower likelihood of full recovery.

Conclusions: Injured workers generally had access to care and most were satisfied with the care they had received. Full recovery was not as frequent as expected. However, lack of full recovery was associated with the longer treatment time and higher level of utilization, perhaps indicating a higher level of severity of injury for those not fully recovered. The association of race and income with full recovery may indicate disparities in health outcomes.


Implementation of significant Workers’

Compensation reforms in California does not appear to have adversely impacted access to care or quality of care received as perceived by injured workers, particularly when compared with data from other states and from earlier studies in

California. However, the health outcomes of medical care under this system can be further improved. Further research is needed to address the potential disparities in rates of full recovery among injured workers.

Funding Source: California Division of Workers'

Compensation

• Language Services in Hospitals: A Work in

Progress

Marsha Regenstein, Ph.D., M.C.P., Holly Mead,

Ph.D., Kathryn Muessig, B.A.

Presented By: Marsha Regenstein, Ph.D.,

M.C.P., Associate Research Professor, Health

Policy, George Washington University Medical

Center, 2121 K Street, NW, Suite 210,


Email: marshar@gwu.edu

Research Objective: Effective communication is an essential element of quality within the health care experience. Studies show that patients who need an interpreter but do not receive one are less likely to understand instructions for taking medications, less likely to receive information on medication side effects, and less likely to be satisfied with their care. Elements considered essential in the development of high-quality language services (LS) include the capability to identify and track limited English proficient (LEP) patients and the ability to provide competent and appropriately trained interpreters. This study examines the extent to which these practices are being realized by hospital LS programs. This study also identifies two additional components, organizational structure of LS and LS volume and utilization, that may present challenges for hospitals as they attempt to reduce barriers to care through the implementation of LS.

Study Design: Data on hospital-based language services programs were collected from responses to questions in proposals submitted by hospitals wishing to participate in a foundation-sponsored language services quality improvement initiative. Descriptive statistics were generated on primary language and collection of language data, LEP patient volume and use of services, staffing and training requirements and organizational structure of LS.

The relationship between LEP admissions and

LEP encounters was analyzed, adjusting for variations in overall patient volume.

Population Studied: Information from 71 acute care hospitals that submitted proposals to participate in a national initiative to improve LS was analyzed for this study. Proposals were received from hospitals in 26 states and the

District of Columbia. Participation was limited to non-federal, acute care hospitals with substantial

LEP patients, a minimum of 10,000 discharges, and in-person professional interpreters; 74.7% of hospitals were not-for-profit and 62.7% were mid-sized (300-699 beds). The majority (87.3%) served primarily urban markets.

Principle Findings: Ninety percent of hospitals systematically collect patients’ primary language.

Spanish is the most common language among

LEP patients at 93% of hospitals. We found no statistically significant correlation between estimated LEP admissions and LEP encounters

(r=.19, p=.15). LS programs provide services in multiple languages, with 46.4% providing inperson interpretation for at least six languages.

Eighty-four percent of hospitals required training for interpreters (median = 40 hours). LS have a designated department in 88.7% of hospitals but no clear organizational home.

Conclusions: Hospital-based LS programs are facing significant challenges in identifying patients with language needs, staffing and training a LS workforce, and creating an organizational identity within the hospital structure. The need for LS is not associated with utilization of LS, suggesting that LS are not reaching LEP patients.


Opportunities for quality are hindered by the structure and placement of LS programs within the hospital organization. Hospitals do not know where LS functions belong, signaling a concern in terms of organizational commitment,

opportunities to secure and manage resources, and requirements related to performance improvement. Identifying an appropriate organizational home for LS programs and creating uniform standards for workforce qualifications and operations could create an opportunity for establishing quality thresholds in the delivery of LS to LEP populations and embedding LS into the hospital’s quality framework.


• Language Barriers Pose a Risk for California

HMO Enrollees

Dylan Roby, Ph.D., Cori Reifman, M.P.H.,

Meghan E. Cameron, M.P.H., Dylan H. Roby,

Ph.D.

Presented By: Dylan Roby, Ph.D., Research

Scientist, Center for Health Policy Research,

UCLA, 10960 Wilshire Boulevard, Suite 1550, Los

Angeles, CA 90024, Phone: 310-794-3953, Fax:

310-794-2686, Email: droby@ucla.edu

Research Objective: To measure the potential need for language services in commercial plans,

Medi-Cal and Healthy Families, the California

Department of Managed Health Care has recently enacted requirements for HMOs to provide language and translation services for commercial members comparable to the services required for members enrolled in Medi-

Cal and Healthy Families. This study compares the percentages of HMO enrollees with limited

English proficiency enrolled in commercial and public HMOs, as well as within particular commercial health plans. The study also measures the percentages of enrollees that experienced difficulty understanding their health care provider, both by commercial and public

HMOs, and by individual commercial health plan.

Study Design: Data for this analysis came from the 2003 California Health Interview Survey

(CHIS). We used questions from the survey regarding language spoken at home, limited

English proficiency (LEP) and HMO enrollment and insurance status. CHIS is a random-digit dial (RDD) telephone survey of households drawn from every county in California, and is representative of the state's non-institutionalized population living in households.

Population Studied: Insured adults, aged 18-64 living in California during 2003.

Principle Findings: More than 1 million adult

HMO members in California with limited English proficiency are at risk for problems accessing health care services and receiving quality treatment. Previous studies have shown that the absence of language services restricts access and decreases the quality of health care for non-

English-speaking individuals. More than 300,000 commercial HMO members in California with limited English proficiency had trouble understanding their own doctors, and 5 percent of these were not able to find anyone to translate for them. Although the public Medi-Cal and

Healthy Families plans have a higher percentage of members with limited English proficiency than commercial plans (21.4 percent compared to 9.2 percent), commercial plans have far more of these members (800,000 compared to 151,000).

In addition, Medi-Cal and Healthy Families plans have done a better job of providing language services to their limited-English-proficient populations relative to commercial HMOs.

Conclusions: While Medi-Cal and Healthy

Families (SCHIP) HMO enrollees are provided with relatively high levels of translation and interpretation services, the commercial HMO enrollees in California with LEP were not provided with the same level of services. This study demonstrates the large number of people with commercial insurance enrolled in HMOs that still face potentially serious language barriers when trying to access medical care.


Recent statutory changes (2006) will require commercial HMOs in California to provide the same level of interpretation and translation services as their Medi-Cal and Healthy Families counterparts. This study supports the need for such regulatory changes in California to improve the level of services provided to commercial

HMO members.

Funding Source: California Office of the Patient

Advocate

•

Comparison of Staging, Treatment Patterns and Clinical Adherence to Established

Treatment Guidelines for Racially Diverse

New Episode Breast Cancer Patients

Louise J. Short, M.D., M.Sc., Monique

Boudreaux, Ph.D., Sandra White, M.D., M.B.A.,

Nancy Rodriguez, R.N., Maxine Fisher, Ph.D.,

Peter Wahl, M.L.S., M.S.








Research Objective: African American, AA, race has been associated with increased breast cancer mortality. Specific contributing factors to this relationship are unclear. To elucidate the relationship between race and breast cancer mortality, staging and treatment and physician adherence to Institute for Clinical Systems

Improvement, ICSI, guidelines were evaluated among a racially diverse population.

Study Design: Retrospective cohort analysis utilizing administrative claims data identifying

3,017 new episodes of breast cancer in a

Southeast US Health Plan during the study period, January 2000 to August 2005. Medical chart review was performed on 479 patients through December 2006. Data collection is ongoing.

Population Studied: Patients were identified by breast cancer claims, ICD9 174, 233.0, 238.3,

239.3. Index date was first breast cancer diagnosis within the study period. New episode patients had no cancer diagnosis for at least 180 days and no cancer treatment for at least 90 days prior to index date. Medical chart review captured diagnosis, race, stage at diagnosis, treatment received, and mortality. ICSI guidelines were used for comparison of treatment patterns. Nonparametric univariate tests and multivariate logistic regression modeling were used to evaluate the impact of race on staging and treatment patterns.

Principle Findings: Charts were abstracted for

385 Caucasian, CAU, and 94 AA women identified by claims. Mean ages were 52.3 and

48.0 years, respectively, p less than 0.01. In stage percentages, AAs, 0, 9.6, I, 26.6, II, 36.1, III, 13.8,

IV, 7.4 were diagnosed at later stages compared to CAUs, 0, 15.8, I, 41.0, II, 28.8, III, 8.0, IV, 2.9, p less than 0.001. Approximately twice as many

AAs, 6.4 percent, were identified from medical chart review with unknown stage at diagnosis as

CAUs, 3.6 percent, p less than 0.001. Although

75.7 percent of AAs compared to 61.3 percent of

CAUs received chemotherapy, p less than 0.05, significance of race on receiving chemotherapy was diminished in a multivariate analysis, p equal 0.22, by age at first treatment, p less than

0.001, and stage at diagnosis, p less than 0.001.

Although AAs were younger, the all cause mortality rate was doubled at 7.5 percent among

AAs and 3.6 percent in CAUs, p equal 0.059.

Among 85 patients with Stage IIa breast cancer, lumpectomy followed by radiation was used in

63.5 percent of all patients with no significant differences between races, indicating that 36.5 percent of patients did not receive ICSI recommended treatment.

Conclusions: Our results indicate that stage at diagnosis is a stronger driver for chemotherapy than race. Later stages of disease are found among younger AAs than CAUs. Further analyses of these data will include evaluation of planned dose intensity vs. delivered dose, evaluation of adherence to guidelines for all stages, and attempts to separate breast cancer from all cause mortality.


Diagnosis at later stages, despite treatment modalities, may largely impact the outcome of disease among AA women and may indicate more aggressive cancers. Greater adherence to guidelines and more minority patient education about screening may help to decrease mortality from breast cancer.

Funding Source: HealthCore, Inc.

• Do Geographic and Age Group Differences

Explain Racial/Ethnic Disparities in Quality of

Care and Health Care Utilization?

Ronica Rooks, Ph.D.

Presented By: Ronica Rooks, Ph.D., Assistant

Professor, Sociology, Kent State University, 329

Merrill Hall, Kent, OH 44242, Phone: (330) 672-

9809, Fax: (330) 672-4724, Email: rrooks@kent.edu

Research Objective: Little is known about regional associations between average family health care spending, quality of care (QC), and health care utilization (HCU) among non-elderly populations and whether these associations explain racial/ethnic disparities in QC and HCU.

While greater Medicare spending across U.S. regions is associated with greater HCU, it is not associated with improved QC, better health outcomes, and lower mortality (Fisher et al.

2003a, b; Fisher et al. 2000; Wennberg, Fisher, &

Skinner 2002). The literature on patients’ QC as an explanation for racial disparities in HCU suggest that Black adults versus other racial groups experience lower levels of patient trust in and satisfaction with physicians, other health care workers, hospitals, and health insurance plans (Boulware et al. 2003; Hunt et al. 2005;

O'Malley et al. 2004); lower perceptions of patient-centered care and doctors’ cultural competency in communication, less involvement in medical decision making, and lower feelings of control in their medical encounters (Blanchard and Lurie 2004; Johnson et al. 2004b); limited

health insurance (Hunt et al. 2005); and greater perceptions of racial, low socio-economic status

(SES), and gender discrimination in patientdoctor relationships (Bird and Bogart 2001;

Collins et al. 2002; Corbie-Smith et al. 2002;

Johnson et al. 2004a; LaVeist et al. 2000;

Napoles-Springer et al. 2005). These studies suggest negative perceptions and experiences with health care may intensify racial disparities in

HCU via fewer routine physicals and less preventive care (Blanchard and Lurie 2004).

This study addresses whether: 1) racial/ethnic disparities in QC are explained by age group; average family health care spending, racial/ethnic group compositions, and poverty index by metropolitan area; perceptions of health care burdens (i.e. difficulties paying medical bills and unmet need); health insurance type; having a managed care plan or not; and SES (i.e. education and family income), and 2) racial/ethnic disparities in HCU are explained by

QC and the prior variables.

Study Design: To test whether the prior variables mediate the relationship between race/ethnicity (NH White, NH Black, and

Hispanic) and QC (i.e. patient perceptions of trust and satisfaction with physician choice, visits, and health plan) as well as between race/ethnicity and HCU (i.e. number of hospital stays, emergency room visits, physician visits, and other health worker visits in the last 12 months), multivariate regressions are used in multi-level analyses with Hierarchical Linear

Modeling software, controlling for sex and household number of people.

Population Studied: The Community Tracking

Study Household Survey, 2003 is a national, cross-sectional study administered to households in 60 metropolitan and nonmetropolitan sites, randomly selected to be representative of the nation.

Conclusions: This research contributes to the

QC and HCU literature by examining racial disparities via: 1) age group comparisons to understand more about non-elderly populations, since we know more about racial disparities in older adults’ QC and HCU experiences based on available Medicare data (Bulatao and Anderson

2004); 2) regional health spending and sociodemographic comparisons to understand geographic differences as explanatory factors; and 3) perceptions of health care burdens as stressors and explanatory factors.


• Payer Type as Predictor of Hospitalization

Resulting from Ambulatory Surgery

Charles Saunders, Ph.D., Askar S. Chukmaitov,

M.D., Ph.D., Nir Menachemi, Ph.D., M.P.H.,

Steven Brown, B.S., Robert Brooks, M.D., M.B.A.

Presented By: Charles Saunders, Ph.D.,

Assistant Professor, College of Medicine - Div. of

Health Affairs, Florida State University, 1115 West

Call Street,Suite 3200-B, Tallahassee, FL 32306,

Phone: (850) 645-2516, Fax: (850) 645-2859,

Email: charles.saunders@med.fsu.edu

Research Objective: To examine the relationship between payer type and quality outcomes for ambulatory surgical procedures.

Study Design: Retrospective study of 7- and 30day unexpected hospital admissions after the following ambulatory surgical procedures: arthroscopic surgery, cataract removal, colonoscopy, upper gastrointestinal endoscopy, and inguinal hernia repair. Patients were risk adjusted for morbidity and demographic characteristics in multivariate logistic regressions which were estimated separately for each procedure.

Population Studied: Individuals age 18 years and older undergoing one of the five procedures in Florida over the period 1997-2004.

Principle Findings: After controlling for age, race and gender, type of insurance was a significant predictor of 7- and 30-day unexpected hospital admission in all of the procedures examined. Medicaid recipients were found to be significantly more likely to be hospitalized than individuals covered by Medicare or commercial insurers or even those self-paying for procedures. For example, compared to individuals with Medicaid coverage, adjusted odds ratios for 7-Day hospitalization after cataract removal were 0.534 (95% CI: 0.455-

0.626) for Medicare recipients, 0.538 (95% CI:

0.454-0.637) for commercially insured patients and 0.581 (95% CI: 0.443-0.761) for self-payers.

For 30-day hospitalization after colonoscopy, adjusted odds ratios for commercially insured were 0.490 (95% CI: 0.463-0.518), 0.505 (95%

CI: 0.476-0.535) for Medicare patients, and

0.708 (95% CI: 0.645-0.778) for self-payers.

Results for the other procedures were comparable.

Conclusions: Despite the low frequency of unexpected hospitalizations after ambulatory surgery, patient’s type of insurance is an independent predictor of poor outcomes with

Medicaid patients being significantly more likely to be hospitalized.


Studies of several inpatient procedures have

established lower quality outcomes for Medicaid recipients. The current research corroborates this finding for certain outpatient procedures and points to the need for more research to understand why Medicaid patients have poorer outcomes after adjusting for confounders.

Policymakers can use this developing body of work to determine if the particular set of

Medicaid benefits being offered is appropriate.

• Measure or Mismeasure? Racial and Ethnic

Disparities in Preventable Hospitalizations,

1993-1999

Barry Saver, M.D., M.P.H., Laura-Mae Baldwin,

M.D,. M.P.H., Pamela Green, Ph.D., Sharon

Dobie, M.D., Ching-Yun Wang, Ph.D.

Presented By: Barry Saver, M.D., M.P.H.,

Associate Professor, Family Medicine and

Community Health, University of Massachusetts

Medical School, 55 Lake Ave. North, A3-146,

Worcester, MA 01655, Phone: 508-856-3458, Fax:

508-856-1212, Email:

Barry.Saver@umassmed.edu

Research Objective: To study racial/ethnic variation and time trends in ‘‘preventable hospitalizations’’ (PHs) in the years following the

IOM report recommending their use as quality/access measures.

Study Design: Rolling cohort analysis using

Medicare claims data. We modeled annual risk of acute or chronic PH during 1993-1999 using the AHRQ Prevention Quality Indicators (PQIs) for non-Hispanic whites, blacks, Hispanics, and

Asians/Pacific Islanders, first with unadjusted logistic regression, then controlling for predisposing, enabling, and need factors to identify factors predicting admissions and influencing racial/ethnic disparities.

Population Studied: U.S. Medicare beneficiaries over 65 residing in SEER cancer registry areas.

Principle Findings: Hospitalizations for acute and chronic PQIs had different patterns, so were analyzed separately. We excluded angina hospitalizations from the chronic PQIs after finding large changes clearly due to coding and in-hospital treatment trends, not averted admissions. For chronic PQIs, before adjustment, there was no significant temporal trend for whites, while odds relative to whites in

1993 rose for minority groups: from 1.79 (1993) to 2.25 (1999) for blacks, 1.05-1.55 for Hispanics, and 0.49-0.88 for Asians. Relative to whites in

1993, adjusted analyses demonstrated a drop in the odds of chronic PQI admission among whites (to 0.83 in 1999), stable odds for blacks

(roughly 1.2), modest odds fluctuations for

Hispanics (between 0.9-1.1), and increasing odds for Asians (0.65-0.84). Overall, adjusted black-white and Hispanic-white gaps in risk of chronic PQI admissions increased over time.

Racial/ethnic differences were less notable for acute PQIs, especially in adjusted analyses.

Before adjustment, odds of acute PQI admissions rose for all groups relative to whites in 1993: to 1.34 for whites in 1999, from 1.31 to

1.78 for blacks, from 1.15 to 1.76 for Hispanics, and from 0.51 to 1.13 for Asians. Adjustment moderated but did not eliminate these trends: 1-

1.18 for whites, 1.02-1.18 for blacks, 1.18-1.29 for

Hispanics, and 0.62-1.06 for Asians.

Age, comorbidity, and number of outpatient visits in the previous year were the strongest predictors of acute and chronic PHs.

Adjustment for age, comorbidity, outpatient visits, and an ecological surrogate for educational attainment narrowed estimates of racial/ethnic disparities substantially. Age adjustment had a particularly notable effect in narrowing Hispanic-white disparities, reflecting

Hispanics’ substantially younger age distribution. Comorbidity adjustment had a marked effect in narrowing estimated black-white disparities, reflecting blacks’ higher comorbidity levels. For acute conditions, an ecological income surrogate narrowed disparities for blacks more than for Hispanics.

Conclusions: Chronic and acute PQIs behave differently and should not be grouped together.

In the Medicare population, ‘‘preventable hospitalizations’’ appear to strongly reflect the health status of individuals. Increasing adjusted black-white and Hispanic-white gaps in chronic

PQIs over time might suggest deterioration in access to or quality of ongoing health services among these populations. The rapid disappearance of previously favorable rates for

Asians is troubling and substantially unexplained by our data. Our findings indicate substantial caution should be used when using ‘‘preventable hospitalizations’’ as quality measures and raise questions as to their validity for this purpose.


Using ‘‘preventable hospitalizations’’ to monitor quality and population disparities requires individual-level data and careful analysis and interpretation.

Funding Source: NCI

•

Strategies of Medically Uninsured

Individuals to Access Care

Sarah Shoemaker, Ph.D., Pharm.D.

Presented By: Sarah Shoemaker, Ph.D.,

Pharm.D., Associate, Domestic Health Policy,

Abt Associates Inc., 55 Wheeler Street,

Cambridge, MA 02138, Phone: (617) 864-0849,

Fax: (617) 386-7638, Email: sarah_shoemaker@abtassoc.com

Research Objective: To understand the chronic illness and medication experience of medically uninsured individuals.

Study Design: This study was an interpretive phenomenological study guided by the methodological insights of Max van Manen. The methods included in-depth interviews and limited observation. A purposeful sampling strategy was used to identify adults (19-64 years old) with at least two chronic medical conditions

(self-identified) and prescribed or recommended a medication within the past two years. The participants were passively recruited from fliers posted in community centers, libraries, hospitals, community clinics, and local businesses.

Population Studied: Eleven adults aged 27-64 without medical insurance (public or private) for a period from one to twenty-seven years, with at least two self-identified chronic illnesses, and prescribed or recommended medications in the previous two years located in a a major metropolitan city in the Midwest.

Principle Findings: The principal findings specific to this presentation theme were as follows: Participants employed "creative solutions" to access care including the active following and multiple attempts to participate in clinical trials and studies in order to obtain primary care services, drug therapy, and diagnostic tests. Participants also volunteered at a local medical school as actors with various medical conditions to at least obtain free physicals. Participants also attended health fairs and medical education events to obtain information to serve as their own docto. One participant even disguised herself as a marathon runner to obtain a free orthopedic evaluation at pre-marathon clinic.

Conclusions: In the absence of medical insurance participants in this study sought unique venues and employed creative solutions to obtain medical evaluations, diagnostic tests, and primary care services at no charge.


These study findings have ethical implications for the recruitment of individuals for clinical trials and the participation of medically uninsured individuals in trials. This warrants further understanding of the insurance status of clinical trial subjects. These study findings also raise awareness about the state of access to medical services for the over 45 million uninsured individuals in the United States.

Funding Source: Wal-Mart donated gift cards for participants in the study

• The Role of Health Literacy in Child Asthma

Care

Laura Shone, Dr.P.H., M.S.W., Lee Sanders,

M.D., M.P.H., Kelly Conn, M.P.H., Reynaldo

Tajon, B.S., Jill Halterman, M.D., M.P.H.

Presented By: Laura Shone, Dr.P.H., M.S.W.,

Assistant Professor, Pediatrics, Univ Rochester

School of Medicine & Dentistry, 601 Elmwood

Avenue, Box 777, Rochester, NY 14642, Phone:

(585)273-4084, Fax: (585)756-4132, Email:

Laura_shone@urmc.rochester.edu

Research Objective: Rationale: Low health literacy (HL) limits health care access, use, and outcomes for 30-40% of US adults, and adverse effects have been documented for adults with chronic health problems such as asthma.

Childhood asthma morbidity continues to increase, and little is known about how parent

HL affects care for children with asthma.

Objective: Our objective was to examine associations between parent HL and health care access, use, and outcomes among urban children with asthma. Hypotheses: We hypothesized that low HL parents would report the following about the child: more worry and concern about the child's asthma; greater unmet health care need; and greater use of acute care relative to parents with adequate HL.

Study Design: Design: Parents of asthmatic children participated in in-home interviews at intake for an asthma management randomized clinical trial. Measures: All measures pertain to the year prior to interview. We used the Rapid

Estimate of Adult Literacy in Medicine (REALM) to measure parent HL and followed NHLBI criteria for child asthma severity. We used validated measures of health status, health care access, use, and outcomes. Analyses: We performed bivariate chi-square analyses and multivariate logistic regression to predict 1) low parent HL and 2) urgent care use. Multivariate models adjusted for respondent (parent) ethnicity, child age, child insurance status, asthma severity, degree of asthma control, child health status, parent worry, preventive medicine use, unmet health care need, and report of confidence or need for assistance in reading medical forms.

Population Studied: Parents of 220 school-age, urban, asthmatic children from unique families

(no sibling overlap) in Rochester, NY, participating in a randomized clinical trial for asthma management.

Principle Findings: Response rate was 72%; mean child age was 7.0 years; 22% had a

Hispanic parent, and 85% had public insurance.

Parents of 35% of study children had low HL. In multivariate analyses, low parent HL was independently associated with extreme parent worry (OR 2.3, CI 1.2-4.5), parent perception of poorer child health (OR 2.3, CI 1.1-4.7), needing help to read medical forms (OR 2.0, CI 1.02-3.8), public insurance (OR 3.3, CI 1.1-10.2), and

Hispanic ethnicity (OR 2.8, CI 1.4-6.0). Urgent care use was associated with reported unmet health care need (OR 3.0, CI 1.1-7.7) and parent worry (OR 2.1, CI 1.1-4.0) but was not independently associated with low parent HL.

Conclusions: Low HL parents worried more about the child, rated child health less favorably, and had problems reading medical forms.

Parent HL was not associated with asthma severity or urgent care use.


Interventions for low HL parents are needed to address parent knowledge and understanding of their child’s asthma. Further studies may help improve our understanding of pathways for parent HL effects on child asthma care and health outcomes.

Funding Source: NIH

• Racial and Ethnic Disparities in End-of-Life

Care among Patients with Advanced Cancer

Alexander Smith, M.D., M.S., Craig C. Earle,

M.D., Roger B. Davis, Sc.D., Ellen P. McCarthy,

Ph.D.

Presented By: Alexander Smith, M.D., M.S.,

Fellow, General Internal Medicine, General

Medicine and Primary Care, Beth Israel

Deaconess Medical Center, 1309 Beacon Street,

Brookline, MA 02446, Phone: 617-754-1422, Fax:

617-754-1440, Email: asmith7@bidmc.harvard.edu

Research Objective: Hospice improves care for patients at the end of life. We studied Medicare beneficiaries newly diagnosed with advancedstage cancer to determine whether rates of hospice enrollment, length of stay (LOS) in hospice, and hospitalization in the last month of life vary by patient race/ethnicity.

Study Design: We used linked Medicare claims to determine hospitalization, hospice enrollment and LOS of patients with newly diagnosed stage

IIIB/IV non-small cell lung (NSCLC) (n=29,456), extensive-stage small cell lung (n=5,984), and stage IV colorectal (n=11,136), female breast

(n=2,897), and prostate (n=10,204) cancer.

Using Cox proportional hazards regression, we compared rates of hospice enrollment and LOS by race/ethnicity for all cancers and for individual cancers. Models were adjusted for year and age at diagnosis, sex, marital status, foreign birthplace, SEER registry, median household income and metropolitan status of place of residence, insurance type, low income status, tumor grade, stage at diagnosis (NSCLC only), and hormone receptor status (breast cancer only). For hospice LOS, we further adjusted for illness duration. We explored the length of stay in the hospital in the last month of life and death in the hospital among decedents with fee for service insurance.

Population Studied: We analyzed data from

59,677 beneficiaries aged 65 and older diagnosed with cancer in the Surveillance, Epidemiology, and End Results (SEER) Program from 1992-

1999.

Principle Findings: Of 59,677 patients, 78.3% were non-Hispanic White, 10.1% non-Hispanic

Black, 6.7% Asian/Pacific Islander, and 4.9%

Hispanic. Compared to White patients, we found significantly lower rates of hospice use for Black

(adjusted hazard ratio [aHR] 0.91, 95% CI 0.86-

0.96) and Asian patients (aHR 0.72, 95% CI

0.67-0.78) but not for Hispanics (aHR 0.92, 95%

CI .92-1.06). On average, 10.6% of patients enrolled within 3 days of death, and these results did not differ by race/ethnicity. Overall, 46% of patients were hospitalized at least once in the last month of life. Compared to White patients, in the last month of life Blacks and Asians but not Hispanics were more likely to spend more than 14 days in the hospital (White 11%, Black

16%, Asian 13%, Hispanic 10%)) and die in the hospital (White 28%, Black 33%, Asian 31%,

Hispanic 26%). Results were similar across patients with different types of cancer.

Conclusions: Black and Asian patients with advanced cancer were substantially less likely to use hospice care than White patients, and more likely to spend a greater proportion of time in the hospital at the end-of-life and die in the hospital compared to whites. Rates of hospice use and hospitalization for Hispanics were similar to

Whites.


These findings raise concerns about the quality of end-of-life care for Black and Asian patients with advanced cancer.

• Exploration of Urban/Rural Differences in

Breast Cancer Treatment among Medicare

Beneficiaries

Melony Sorbero, Ph.D., M.S., M.P.H., Lisa R.

Shugarman, Ph.D., Haijun Tian, Ph.D., Steven

M. Asch, M.D., M.P.H., Arvind K. Jain, M.S., J.

Scott Ashwood, M.A.

Presented By: Melony Sorbero, Ph.D., M.S.,

M.P.H., Health Policy Researcher, , RAND

Corporation, 4570 Fifth Avenue, Pittsburgh, PA

15213, Phone: (412) 683-2300, Fax: (412) 683-

2800, Email: msorbero@rand.org

Research Objective: Rural areas experience challenges recruiting and retaining providers, and rural health care facilities may offer limited services. As a result, rural patients may have to travel farther and wait longer for care than urban patients. This study examines the relationship between rural residence and the timely receipt of breast cancer treatment.

Study Design: Secondary data analysis using

Surveillance, Epidemiology, and End Results

(SEER) data linked Medicare claims and the Area

Resource File. Rural-Urban Commuting Area

Codes were used to create 4 residence categories: urban, large rural city, small rural town, and isolated small rural town. Three measures of breast cancer treatment were examined: 1) receipt of breast conserving surgery within 6 weeks of diagnosis among women with

Stage I or II disease (timely receipt of BCS); 2) receipt of radiation therapy within 6 weeks of surgery or chemotherapy for women undergoing

BCS (timely receipt of radiation); and 3) receipt of chemotherapy within 7.5 weeks (median in our sample) of surgery by women who were candidates for chemotherapy (timely receipt of chemotherapy). Descriptive analyses and multivariate logistic regressions controlling for patient characteristics, tumor characteristics, socioeconomic characteristics, and provider supply were performed to examine relationships between rural residence and timely receipt of treatments.

Population Studied: Medicare beneficiaries age

65 and older residing in a SEER region at the time of their breast cancer diagnosis between

1995 and 1999 and followed until December

2003 (N=32,626).

Principle Findings: Bivariate analyses revealed that rural breast cancer patients were less likely to have timely receipt of BCS, (p<.01) and radiation therapy (p<.01). A non-linear relationship was observed in the timely receipt of chemotherapy (p<.01); breast cancer patients in large rural towns were more likely to have timely receipt of chemotherapy than other women

(p<.01). In multivariate analyses, rural residence was no longer associated with the timely receipt of BCS; living in a higher income area was positively associated with the timely receipt of

BCS, while increasing age was negatively associated. Living in a small or isolated rural area remained negatively associated with timely receipt of radiation in multivariate analyses; increasing age and being on Medicaid were also negatively associated, while living in wealthier areas and areas with a greater supply of radiation oncologists were positively associated with the timely receipt of radiation. In multivariate analyses, residence was no longer associated with the timely receipt of chemotherapy; increasing age, black race and being on Medicaid were negatively associated with timely receipt of chemotherapy, while the supply of hospitalbased oncologists was positively associated.

Conclusions: These findings indicate that geographic residence, socioeconomic factors as well as some measures of provider supply are associated with the timely receipt of breast cancer treatments.


Rural residents are at a disadvantage when it comes to the timely receipt of some breast cancer treatments. Health care planners and policymakers should consider whether cancer treatment is suitably accessible for rural patients.


•

Are There Racial/Ethnic Disparities in the

Access-Enabling Characteristics of

Mammography Facilities?

Jonathan Sunshine, Ph.D.

Presented By: Jonathan Sunshine, Ph.D., Senior

Director for Research, Research, American


Reston, VA 20191, Phone: 703-648-8924, Email: jsunshine@acr.org

Research Objective: To ascertain if mammography facilities located in high-minority areas have fewer access ‘‘enabling’’ characteristics------for example, have less convenient hours, do less to assure that patients return, perform less outreach in the community, and are less likely to accept charity patients.

Even adjusting for socio-economic and other factors, minority women are less likely to have a periodic screening mammogram than non-

Hispanic white women. If facilities in high-

minority locations typically have fewer of the

‘‘enabling characteristics’’ that facilitate access and use of services by their clientele, that could explain some of the difference. (In another study, we have investigated another possible explanation--that facilities simply fail to locate in high-minority neighborhoods.) Enabling characteristics of care providers are a major component of the standard (Andersen) conceptual framework used to study access to care. However, they have received remarkably little empirical study despite the existence of a large literature on access.

Study Design: We will conduct a stratified random sample telephone survey of mammography facilities, sampling approximately 2,000 from the FDA’s complete listing of U.S. mammography facilities. Office managers are the target respondents; when they cannot be reached, the survey will be addressed to front office staff who make appointments.

The survey will collect data on relevant enabling characteristics; these have been identified in the literature. In addition, the survey will collect data on general facility characteristics, such as whether the facility is academic or not. Data from the U.S. census wil be used to measure the racial/ethnic composition and demographic and socioeconomic characteristics of the location of the facility. Multiple regression analysis will be used to identify the effect of local racial/ethnic composition (and other factors) on enabling characteristics.

Population Studied: Sample of mammography faciities in the U.S.

Principle Findings: A pilot survey was conducted on 105 facilities. Descriptive statistics indicate that facilities in heavily-minority zip codes have, if anything, slightly more numerous enabling characteristics. In particular, they are far more likely to have non-white staff and staff members who speak languages other than

English. Also, they are somewhat more likely to accept charity patients (in heavily black and heavily Asian zip codes), and use posters and flyers for outreach (in heavily black and heavily

Hispanic zip codes). Evening and weekend hours are sparse in all settings. Almost no facilities make next year’s appointment when the patient is present for this year’s mammogram.

Very few facilities carry on outreach to primary care physicians. Only half or fewer of facilities in heavily minority zip codes participate in a CDC program that provides free mammograms for poor women. Our full-scale survey will show whether the pilot study’s findings are borne out in a multivariable model that, because of larger sample size, can include many neighborhood socioeconomic and demographic controls.

Conclusions: Apparently, facilities in highminority neighborhoods have more accessenabling characteristics than facilities elsewhere, but facilities in all types of settings tend to be seriously deficient in some such characteristics.


All facilities need to be educated and encouraged in better means of outreach and extended hours in order to achieve increased mammography use.

• Health, Utilization, and Healthcare

Expenditures of Adolescent Girls:

Socioeconomic Status and Disparities

Amy Taylor, Ph.D.

Presented By: Amy Taylor, Ph.D., Senior

Economist, , Agency for Healthcare Research and Quality, 540 Gaither Road, Rockville, MD

20850, Phone: 301-427-1660, Fax: 301-427-1276,

Email: ataylor@ahrq.gov

Research Objective: There have been very few studies reported in the literature that provide a comprehensive examination of adolescent girls’ health care use and expenditures in relation to their social, demographic and health characteristics. The aim of this research is to identify differences in teenage girls’ health status, health care utilization and expenditures across socioeconomic and racial/ethnic groups.

Given the increased attention to disparities in health care, these analyses will help inform policy makers about the intersection of a variety of characteristics, including gender, age, race/ethnicity, poverty status, and their impact on health care utilization and expenditures.

Study Design: Full year data from the 2003

Medical Expenditure Panel Survey are used in this study. The analysis will examine teenage girl’s health status, use of medical care, types of services used, and health care expenditures within subgroups of adolescent girls. The paper will present tables showing expenditures for different types of health services, including ambulatory care, inpatient stays, emergency room, dental care, and prescription drugs.

Bivariate analysis will be used to explore whether subpopulations of teenage girls have higher medical care use and expenditures within these categories. The proposed analyses will study how health care is financed and the financial burden of out-of-pocket medical care expenditures.

Population Studied: The nationally representative sample of adolescent girls, aged

12 ---- 17, found in the MEPS-Household sample,

2003.

Principle Findings: In 2003, more than 75 percent of teenage girls were in excellent or very good health, while only 3 percent were in fair or poor health. Girls from poor or near poor families were more likely than those from high income families to be in fair/poor health. Poor and near poor teenage girls were also more likely to be overweight than high income girls. A lower percentage of black and Hispanic teenage girls used any health services during the year than did their white counterparts. While 93 percent of white girls had at least one health care visit in 2003, only 74 percent of Hispanic and

Black girls did so. Girls who were uninsured all year were significantly less likely to use any health services than girls with either public or private insurance. The probability of having a hospital stay was 17 percent for girls in fair/poor health, while it was 5 percent or less for those with better health status. Mean health expenditure overall for adolescent girls were

$1482 in 2003. Third-party payers accounted for about 70 percent of mean medical care expenses; nearly 30 percent was paid out-ofpocket.

Conclusions: Preliminary results indicate that disparities are evident across several area, including health status, health care coverage, use of health care services, and out-of-pocket expenditures.


To improve the quality of care for all adolescent girls, it is important for policy makers to understand the factors that influence their utilization and expenditures for medical care.

Data collection, analysis and reporting by race, ethnicity, and primary language across federally supported health programs are essential to help identify, understand the causes of, monitor, and eventually eliminate disparities.


• Racial/Ethnic Differences in ADL Disability among Older Adults: The Case of Spanish

Speakers

Manasi Tirodkar, Ph.D., Jing Song, M.S.,

Rowland W. Chang, M.D., M.P.H., Dorothy D.

Dunlop, Ph.D., Huan J. Chang, M.D., M.P.H.

Presented By: Manasi Tirodkar, Ph.D., Postdoctoral Research Fellow, Institute for


676 N. St. Clair Street, Suite 200, Chicago, IL

60611, Phone: (312)695-6968, Fax: (312)695-

4307, Email: m-tirodkar@northwestern.edu

Research Objective: It has commonly been assumed that a detailed translation of a questionnaire into Spanish is sufficient to capture the meaning of the questions. Prior literature suggests that surveys translated into languages besides English may communicate and assess different concepts than those we assume they represent. Recent data suggest a difference in health status between those who answered questions in Spanish compared to those who answered them in English. We aimed to compare patterns of incident disability in

Spanish-speaking Hispanic adults compared to those of English-speaking Hispanics, African

Americans and Whites.

Study Design: Prospective cohort study with six years (1998-2004) of biennial follow-up based on a national probability sample. The main outcome measure was disability in activities of daily living

(ADL) tasks (walking, dressing, transferring, bathing, toileting, feeding).

Population Studied: 1998 Health and

Retirement Study sample aged 65 or older of

12,288 non-Hispanic whites, 1952 African

Americans, 575 Hispanics interviewed in Spanish

(Hispanic/Spanish), 518 Hispanics interviewed in English (Hispanic/English) free of disability at baseline.

Principle Findings: Although Hispanic/Spanish reported lower extremity dysfunction more frequently than other groups: (Hispanic/Spanish

27.53%, Hispanic/English 15.22%, African

American 17.65%, White 11.52%), they developed walking disability at disproportionately lower rates (Hispanic/Spanish 6.2%, Hispanic/English

13.02%, African American 12.36%, White 6.74%).

Across the six ADL tasks, the development of walking disability was reported most frequently among Hispanic/English, African American, and

White, but among Hispanic/Spanish walking was the fourth most frequently reported ADL task disability. In contrast, Hispanic/Spanish reported dressing as the most frequent ADL task disability.

Conclusions: The unique pattern of

Hispanic/Spanish responses suggests that the simple translation of health outcome measures into Spanish may not fully communicate and assess the underlying concepts of disability.

Implications for Policy, Practice or Delivery: :

In studies of health outcomes, aggregating all

Hispanics regardless of the interview language may be inappropriate. Future research on linguistic group differences in self-reported health outcomes is necessary to ensure that

health status measures will be appropriate for use in diverse racial and ethnic groups.

Funding Source: Other, NIH/National Institute for Arthritis and Musculoskeletal Diseases and

NIH/National Center for Medical Rehabilitation

Research

• Social Class, Body Size, and Breast Cancer

Incidence

Celeste Torio, Ph.D., M.P.H., Ann Carroll

Klassen, Ph.D., Benjamin Caballero, M.D., Ph.D.,

Frank Curriero, Ph.D.

Presented By: Celeste Torio, Ph.D., M.P.H.,

Health, Behavior, and Society, Johns Hopkins

University, 8500 New Hampshire Avenue, Apt.

326, Silver Spring, MD 20903, Phone: (650) 315-

5198, Email: ctorio@hotmail.com

Research Objective: To examine whether body size influences the rate of breast cancer incidence by social class among postmenopausal women.

Study Design: Prospective Cohort Study

Population Studied: 5,429 post-menopausal,

Caucasian women from Washington County,

Maryland.

Principle Findings: During a 16-year follow-up period, 264 incident breast cancer cases were identified. Using Cox proportional hazards modeling, this study found that increased education, BMI, and BMI change were associated with an increased risk of breast cancer incidence (HR=1.05, HR=1.03, and

HR=1.04, respectively; p<0.05). Using the random-effects Cox proportional hazards modeling, this study found that the interaction of education and BMI at age 21, area-level social class and BMI, and area-level social class and

BMI at age 21 were associated with a decreased risk of breast cancer (HR=0.98, HR=0.97, and

HR=0.96, respectively; p<0.05).

Conclusions: The analyses indicate that the relationship of social class and body size were primarily independent of each other, suggesting that the mechanisms through which women of greater body size increase their risk for breast cancer are similar across social class, and that risk associated with social class does not operate through body size. However, there is evidence that social class may, to some degree, moderate the influence of body size on breast cancer risk.


Because of the independent and shared effects of social class and body size on breast cancer incidence, these factors need to be considered in the development and implementation of targeted interventions to further promote behaviors found to reduce the risk and burden of breast cancer in the population.

•

Individual Risk Factors and Social Capital as Determinants of Racial Differences in

Diabetes and Hypertension Rates for

Residents of Memphis and Shelby County,

Tennessee

Shelley I. White-Means, Ph.D., Zhiyong Dong,

M.S., Genene D. Walker, M.P.H.

Presented By: Shelley I. White-Means, Ph.D.,

Professor, Vice-Chair, Pharmaceutical Sciences,

Division of Health Science Administration, The

University of Tennessee Health Science Center,

847 Monroe Avenue, Room 205N, Memphis, TN

38163, Phone: (901) 448-7666, Fax: (901) 448-

4731, Email: swhiteme@utmem.edu

Research Objective: To examine the roles of individual risk factors and social capital variables in accounting for racial differences in diabetes and hypertension rates for residents of Memphis and Shelby County, Tennessee, a location with some of the highest rates of diabetes, cardiovascular disease and stroke in the United

States.

Study Design: With the 2004-2005 BRFSS, we estimate logistic regression models examining how patient characteristics and social capital variables influence diabetes and hypertension rates in Memphis and Shelby County. The regressions include race dummy variables, and are stratified by race.

Population Studied: Residents of Memphis and

Shelby County, Tennessee.

Principle Findings: Both individual level and social capital variables significantly influenced diabetes and hypertension rates. Diabetes was more likely for those age 65 and older and overweight. The more parks in one's community, the lower the diabetes rates. For whites only, exercise reduces the likelihood of diabetes. Among blacks only, living in neighborhoods with average incomes above the poverty level decreases the likelihood of diabetes.

Both diabetes and hypertension present earlier in blacks, with higher rates for those aged 50-64 and 65+ older than for younger blacks. With higher percentages of blacks living in a neighborhood, lower probabilities of hypertension were found for whites only.

Overweight whites are more likely than whites who are underweight or normal weight to be hypertensive. In contrast, blacks who are normal weight are significantly less likely to have

hypertension than blacks who are over or underweight.

Conclusions: Individual characteristics alone do not completely explain diabetes and hypertension rates in a high risk area of the country. Living in poverty-ridden communities and lacking opportunities to exercise are also important. Moreover, it is important to assess diabetes and hypertension rates using data stratified by race because these data indicate that the experiences of the disease states vary by race.


The policy strategies that provide resolutions for addressing the exceptionally high rates of diabetes and hypertension among residents in

Memphis and Shelby County, Tennessee should not solely focus on access and financing of health care. Instead, these strategies should include urban policy initiatives and community infrastructure modifications in order to effectively mitigate the sustained disease rates in this community.

•

A Survey for Minority Population

Evacuation Prediction and Resource Planning,

Based on Katrina Evacuees Focus Groups

Sudha Xirasagar, M.B.B.S., Ph.D., Keith T. Elder,

Ph.D., M.P.A., M.P.H., Carleen H. Stoskopf,

Sc.D.

Presented By: Sudha Xirasagar, M.B.B.S., Ph.D.,

Assistant Professor, Health Services Policy and

Management, University of South Carolina,

School of Public Health, 800 Sumter Street,

Room 116, Columbia, SC 29208, Phone: (803)

576 6093, Fax: (803) 777 1836, Email: sxirasagar@sc.edu

Research Objective: a) To develop an empirically-derived survey to predict minority disaster evacuation response and resource planning needs, b) To examine the empirical support for each survey item in quantitative terms to assess it's suitability for local/state/national sample testing and refinement into a comprehensive community evacuation needs assessment tool for policy makers and emergency management agencies.

Study Design: Survey items were developed based on the content of focus group transcripts of a qualitative study, conducted within two months of Hurricane Katrina to understand the factors underlying massive non-evacuation of

African-Americans from New Orleans. A discussion guide based on a theoretical model adapted from the Health Belief Model was used.

The survey items were based on nodes and child nodes developed during content analysis of the transcripts using Nvivo. Two graduate students then independently scored the six focus group transcripts for frequency of recurrence of each question’s theme, to assess the weight of empirical evidence for each item. Each comment was scored for single or multiple questions as relevant.

Population Studied: Six focus groups of African

American evacuees to Columbia, South Carolina,

(total 52 participants, convenience sampling)

Principle Findings: The focus groups yielded qualitative evidence for a minority population’s disaster evacuation prediction model that adds race-based discrimination elements, both historic and disaster-concurrent, to the traditional conceptualizations of the Health

Belief Model. A 40-item draft questionnaire was developed to capture our model elements into an evacuation prediction and resource needs survey. During pilot scoring of the first transcript, additional predictive as well as resource planning details were revealed, which were formulated into additional items by consensus of the research team. The final survey is a 52-item questionnaire which needs to be systematically piloted among minorities and non-minority population of different ethnocultural contexts of the disaster prone areas of the US (south east, north east, Pacific south and northeast, etc). The survey and our qualitativelyderived minority evacuation response model have most elements of the prediction questions of Brodie et al (2006) survey of evacuees, plus additional elements based on our focus group content analysis. The survey questions and frequency of recurrence of each question’s theme in the focus group transcripts will be presented.

Conclusions: A 52-item survey will be presented, directly drawn from experiences of minority evacuees soon after a catastrophic hurricane that seriously tested many cryptic weak links including race-based discrimination, both historic and concurrent, in the disaster planning and evacuation process that impacted African

Americans’ evacuation in New Orleans. The survey items comprehensively capture the various dimensions impacting minority populations’ evacuation outcomes, including important weaknesses that came together in an unprecedented ‘‘perfect storm’’ combination during Hurricane Katrina, causing the massive non-evacuation of African Americans.


This qualitative research-driven draft survey

needs sample testing among minority and nonminority populations of different ethno-cultural contexts of the disaster prone areas of the US

(southeast, northeast, Pacific south and northeast, etc). This is essential to test its psychometric properties (and our minority evacuation response model), validate and refine it for generalized use by policy makers and emergency management agencies for minority evacuation prediction and resource planning.

Funding Source: University of South Carolina

Research Foundation

• Ohio's Ethnic/Cultural Health Disparities

Research Agenda

Betty Yung, Ph.D.

Presented By: Betty Yung, Ph.D., Professor,

School of Professional Psychology, Wright State

University, 9 N. Edwin Moses Boulevard,

Dayton, OH 45402, Phone: (937) 775-4327, Fax:

(937) 775-4323, Email: betty.yung@wright.edu

Research Objective: To develop audience knowledge of the process and outcomes of a project to develop a statewide ethnic/cultural health research agenda to address the persistent health disparities of ethnic/cultural minorities and other underserved populations in Ohio.

Study Design: The research agenda development included a review of Ohio health databases and studies of health issues affecting the state’s ethnic/cultural groups. It also involved a series of regional meetings to learn the perspectives of health professionals, academic researchers, staff of government agencies and community-based organizations, and representatives from ethnic communities across the state about the research needed to identify and address health disparities in Ohio more effectively.

Population Studied: African Americans,

Appalachians, Asian Americans, Amish, Latinos, and Native Americans

Principle Findings: The completed research agenda identified key knowledge gaps and research needs in the categories of: nature and scope of health disparities; contributors to health disparities; and prevention and intervention programs to reduce health disparities. It also produced sample research questions in each category and described community perspectives on the research process and dissemination of research findings to diverse audiences.

Conclusions: Current efforts to address health disparities at the state level are often fragmented and driven by the research interests of individual investigators, rather than by a consensus understanding of state-specific needs and knowledge gaps. A statewide health research agenda will serve as a tool to develop a more coherent program to address the access, quality, and outcomes of health care and health promotion programming for ethnic/cultural communities.


Ohio’s development of an ethnic/cultural health research agenda can serve as a model for other states to: (1) promote academic/community partnerships for health disparities research on identified needs; (2) encourage state, local, and private funders to include health needs of ethnic/cultural groups in their priorities; and (3) generate knowledge that will improve efforts to prevent, detect, and treat illnesses and injuries that threaten the health of the state’s most vulnerable populations.

Funding Source: Ohio Commission on Minority

Health

• Have Blacks and Whites Equally Benefited from Improvements in AMI Mortality?

Jingsan Zhu, M.B.A., Jingsan Zhu, M.B.A.,

Tamara Konetzka, Ph.D.

Presented By: Jingsan Zhu, M.B.A.,

Economic/Statistical Analyst, Medicine, Univ. of

Penn, 1225 Blockley Hall, 423 Guardian Drive,

Philadelphia, PA 19104, Phone: 215-573-9731, Fax:

215-573-8778, Email: jingsan@mail.med.upenn.edu

Research Objective: The objective of this study was to compare the degree to which mortality from acute myocardial infarction, or AMI, improved over time for whites and blacks in

California from 1983 to 2001, a period in which technological improvements led to substantial reductions in AMI mortality. We examined this separately for Medicare and non-Medicare patients.

Study Design: This is an observational study of in-hospital mortality within 30 days of admission for patients admitted to hospitals in California with a principal diagnosis of AMI. We used

OSHPD discharge data from 1983 - 2001, creating 3-year moving averages of mortality for each year to create more stable estimates ---- except for the two end years, where two adjacent years were pooled. Linear Probability models and logistic regressions were used separately to examine the probabilities of 30-day in-hospital death for blacks versus whites, adjusting for patient age, gender, type of AMI and

comorbidities. All analyses were done separately for Medicare and non-Medicare patients.

Population Studied: All 826,210 unique patients admitted to acute-care hospitals in California from 1983 to 2001 with a principal diagnosis of

AMI.

Principle Findings: Among Medicare patients, blacks had much lower mortality, 15.7 percent, than whites, 21.6 percent, in 1983. This difference persisted through 1986 and then gradually narrowed until 2001, as mortality for whites improved by more than 9 percentage points to

12.0 percent while for blacks it improved by only

4.6 percentage points to 11.1 percent. For non-

Medicare patients, mortality between blacks and whites generally differed by less than 2 percentage points per year throughout the time period. Adjusted results largely confirmed the above trends. For Medicare patients, blacks were likely to have much lower mortality than whites from 1983 -- 3.7 percentage points lower, OR

0.75, p-value less than 0.0001 -- through 1986 --

3.8 percentage points lower, OR 0.73, p-value less than 0.0001. The degree to which mortality was lower among blacks diminished in the following 15 years, with the probability of inhospital death for blacks only 1.0 percentage point lower than whites around 1993 -- OR 0.89 p-value 0.03 -- and not significantly different from 1994-2001 -- p-values larger than 0.34. In comparison, for non-Medicare patients, the probability of in-hospital death for blacks was largely similar to that of whites over time, with statistically significant lower mortality for blacks reported only in 1986 --1.2 percentage point lower, OR 0.84, p-value 0.014 -- and in 1992-1995

-- 0.8 to 1.0 percentage point lower, OR 0.81 to

0.86, p-values 0.01 to 0.05. These results on inhospital mortality did not appear to be biased by differential changes in length of stay, as length of stay for whites and blacks tracked closely from

1983-2001.

Conclusions: Black AMI patients under

Medicare experienced significantly lower mortality in the 1980s, an advantage that disappeared by 2001. Mortality rates for whites and blacks not covered by Medicare were generally statistically similar and improved at similar rates.


Lower or similar mortality for black AMI patients suggests that hospital care may not be the best target for disparity reduction efforts; however, the greater rate of improvement in mortality for white Medicare AMI patients is a concerning trend, suggesting that elderly whites are disproportionately benefiting from new lifesaving technologies.

Funding Source: VA HSR&D, Doris Duke

Charitable Foundation

Gender & Health

•

Lost in Translation: The Effect of Language

Proficiency and Education on Gender

Disparities in Immigrants’ Experience of

Communication Problems with Doctors

Onyebuchi Arah, M.D., Ph.D., Karina Schaake,

M.A., M.Sc., M. Philip Lindo, Ph.D.

Presented By: Onyebuchi Arah, M.D., Ph.D.,

Assistant Professor, Department of Social

Medicine, Academic Medical Center, University of Amsterdam, Meibergdreef 9, PO Box 22700,

Amsterdam, 1100 DE, Netherlands, Phone:

+31205664892, Fax: +31206972316, Email: o.a.arah@amc.uva.nl

Research Objective: There is evidence that, although women live longer, they are likely to have more health complaints, receive poorer quality healthcare, and have poorer healthcare outcomes than men. The literature has focused disproportionately on gender disparities in whites with little research documenting such disparities among minorities, despite the latter’s well-known risk of receiving poor quality healthcare. Beyond access issues, not receiving quality healthcare begins with having problems communicating with doctors. Language, cultural differences, and doctor gender concordance with doctor are some important determinants here.

Our study is the first to examine the contribution of Dutch language proficiency and education to gender disparities in whether immigrants have language problems communicating with doctors in the Netherlands.

Study Design: We used the Dutch database from the European project, ‘Life-courses and quality of life of immigrants in a world of limitations’ (LIMITS), a recent study on

European immigrants and ethnic minorities, with interviewer-assisted internationally standardized data collection ending in 2005. The binary outcome was defined as: never versus sometimes or always have language problems communicating with doctors. We fitted logistic regression models to see if there were any gender disparities in this outcome, with or without adjustments for Dutch language proficiency (that is, how well Dutch is spoken and understood) and pre- and post-migration

education. The main confounders included age, duration since immigration, ethnicity, income, and health status. The results were further replicated in probit models with the outcome measured in its original three-category format.

Population Studied: The study included six hundred adults, born in Turkey and Morocco, representing two of the largest migrant groups in the Netherlands, who had been living in the

Netherlands for at least 15 years, were at least 35 years old. The sample was 52% women.

Principle Findings: Women were always more likely to experience language problems communicating with doctors than were men: odds ratios (OR) ranged from 3.36, 95% CI:

2.39----4.472, in unadjusted models to 2.06, 95%

CI: 1.22----3.45, in fully adjusted models. The largest contributor to this disparity was the respondent’s Dutch language proficiency, accounting for 35% reduction in the odds ratios for gender disparity. Pre- and post-migration education reduced the gender disparity odds ratios by 16% and 3% respectively. Sensitivity analyses revealed that factors like selfidentification with the Dutch had no independent effects on having communication problems with doctors.

Conclusions: Minority women in Amsterdam disproportionately experience more language problems communicating with doctors than men do. This gender disparity is due to poorer command of the Dutch language, lower education, and the more recent immigration history, thus lesser integration, seen among vulnerable minority women. Gender itself remains an important drawback in communicating with doctors, probably due to socio-cultural and religious reasons.


Currently, there is very limited use of language translation services in Dutch healthcare, making it particularly difficult for minority women to get the best out of their encounters with doctors.

Policies must target language, socio-cultural, and education-related obstacles that drive gender disparities in healthcare in multicultural societies.

Funding Source: Netherlands Organisation for

Scientific Research and the Fifth European

Community Framework Programme

•

Gender and Race Disparities in On-Pump vs. Off-Pump CABS In-Hospital Mortality

Rates, 1998-2004: Do Women Do Better Off

Pump?

Edmund Becker, Ph.D.

Presented By: Edmund Becker, Ph.D., Professor,

HPM, Emory School of Public Health, 1518

Clifton Road, NE, Atlanta, GA 30322, Phone:

404-727-9969, Fax: 404-727-9198, Email: ebeck01@sph.emory.edu

Research Objective: Mortality results have repeatedly shown that women have poorer coronary artery bypass surgery (CABS) outcomes than men. However, with the advent and diffusion of off-pump CABS, some limited studies have suggested that women fair better off-pump than on pump. With more than

250,000 CABS a year and one-third of them being performed on women, we investigated whether women had better outcomes undergoing off-pump CABS than on-pump and the influence of race.

Study Design: We control for more than 60 covariates and evaluate CABS patient in-hospital mortality rate trends by gender and race. With inhospital mortality as the dependent variable, major variables controlled in the logistic regression model include: patient characteristics

(gender, six age categories, patient's race -

Caucasian, African American, and Asian, and insurance coverage - Medicare, Medicaid, private, self-pay, no charge, and other); risk factors and co-morbid conditions (smoker, history of tobacco use, COPD, S/P CABG, S/P

PTCA, insulin-dependent diabetes, non-insulin dependent diabetes, conduction disorders, intracranial hemorrhage, chronic renal failure, unspecified renal failure, cardiogenic shock, hypertension, acute MI, old MI, cardiomyopathy, congestive heart failure, peripheral vascular disease, unstable angina, acute liver necrosis, endocarditis, mitral valve disease, aortic valve disease, mitral and aortic valve disease, and chronic hepatitis); procedure characteristics

(number of vessels bypassed, diagnostic cath, intra-aortic balloon pump, and hypothermia use); medications (GP2B3A and thrombolytics); year dummies; and site characteristics (dummy variables for each of the sites performing CABS surgery with one site excluded). Procedures, complications, and co-morbid conditions were identified using ICD-9 codes.

Population Studied: A total of 1,561,463 inpatients whose primary procedure was a CABS graft during the years 1998 through 2004 in the

Healthcare Cost and Utilization Project (HCUP) national databases were analyzed.

Principle Findings: For the 7-year period, for all

CABS patients, unadjusted in-hospital mortality rates averaged 2.46% but had fallen 27.2% - from 2.98% in 1998 to 2.13% in 2004. Overall,

female in-hospital CABS mortality rates were significantly higher than male mortality rates for both on-pump and off-pump procedures.

Unadjusted results show that female off-pump patients had significantly higher in-hospital mortality rates than women undergoing onpump procedures (3.68% vs. 3.54%; p=0.001).

However, these findings were not consistent across racial and ethic groups. While multivariate results indicate that Caucasian,

Hispanic, and Asian women were consistent with the superiority of off-pump versus on-pump surgical techniques, African-Americans women had significantly better in-hospital mortality rates for CABS performed off-pump than on-pump.

Multivariate results also reveal that over each successive year of the study, in-hospital mortality rates have declined significantly for all races although they remain significantly higher for females than males in each year.

Conclusions: Looking at national results for the past seven years, the potential benefit of offpump CABS surgery for women appears to be greatest for African-American women. The analysis provides evidence that U.S. gender and race disparities in CABS in-hospital patient inhospital mortality appear to be declining and some of the underlying gender and race disparities are ameliorated when other patient comorbidities and risk factors are included.


The potential advantages of off-pump versus onpump CABS procedures as well as other major procedures and treatments need to be more fully explored across both gender and race.

•

Gender, Neighborhood Air Quality and

Allostatic Load

Chloe Bird, Ph.D., Jose J Escarce, M.D., Ph.D.,

Brian Finch, Ph.D., Ricardo Basurto, M.S., Nicole

Lurie, M.D., Teresa Seeman, Ph.D.

Presented By: Chloe Bird, Ph.D., Senior

Sociologist, Health Unit, RAND, 1776 Main

Street, PO Box 2138, Santa Monica, CA 90407,

Phone: 310 393 0411 x 6260, Fax: 310 260 8159,

Email: chloe@rand.org

Research Objective: We assessed the relationship between neighborhood characteristics and biological markers of stress, based on summary indices for cardiovascular, inflammatory and metabolic response, adjusting for individual characteristics.

Study Design: Using 3-level hierarchical regression, we analyzed National Health and

Nutritional Examination Survey III (NHANES) data, merged with tract-level Census data and data on air quality. Allostatic load was measured as a summary score (range 0-9) based on clinical cut points for 9 indicators from 3 systems: metabolic (total cholesterol, HDL cholesterol, glycosylated hemoglobin, waist/hip ratio), cardiac (systolic and diastolic blood pressure, pulse) and inflammatory (c-reactive protein, serum albumin). Air quality was measured by Ozone (O3) levels and PM10, a measure of airborne particulates less than 10 nanometers in size. Neighborhood socioeconomic status was based on an index of educational and economic measures for the census tract of residence.

Population Studied: The sample (n=11,783 from

65 counties and 1679 census tracts) was 48% male; 35% white, 29% black, 30% Hispanic, and

5% other. Age ranged from 19.5 to 90 (mean =

47); 56% were employed, 61% had at least a high school education. Mean family income/poverty ratio was 2.47.

Principle Findings: Across all models, individual-level socio-economic controls including lower education (p < .00001), lack of employment (p < .0001), being male (p < .001), and lower family income (p =.05) were independently associated with higher allostatic load, while Hispanic ethnicity (p < .001) was associated with lower allostatic load.

Unexpectedly, whereas elevations in inflammation were expected to be among the stronger effects of poorer air quality, no significant effects were found. Rather, residing in a census tract with a more air pollution

(measured by PM10) was associated with higher scores on metabolic response independent of individual characteristics for women (coefficient

= 0.0016, p = .004), but not men. These relationships remained significant after controlling for engaging in a sedentary lifestyle

(no moderate or vigorous physical activity reported in past month) and for an index of neighborhood level socioeconomic status.

Conclusions: Air pollution (PM10) was found to be associated with greater evidence of metabolic risk among women. Though unexpected, this finding merits further attention as effects of pollution resulting in elevations in metabolic function carry increased risks for major cardiovascular outcomes, including both morbidity and mortality. The question of why such effects are seen only among women is another important unanswered question.


This study is part of a larger effort aimed at assessing whether and how neighborhood

characteristics differentially affect men’s and women’s health and understanding whether and how changing neighborhood features, such as air quality, could improve health and reduce health disparities. The mechanisms through which these effects are produced need to be explored.

Funding Source: NIEHS

•

Perinatal Smoking Abstinence Advice from

Health Care Providers

Julie Boergers, Ph.D., Alessandra Kazura, M.D.,

Marcia VanVleet, M.D., Judith Owens, M.D.,

M.P.H.

Presented By: Julie Boergers, Ph.D., Assistant

Professor (Clinical), Bradley-Hasbro Children's

Research Center, Brown Medical School, 1

Hoppin Street, Suite 204, Providence, RI 02903,

Phone: (401) 444-8945, Fax: (404) 444-8742,

Email: julie_boergers@brown.edu

Research Objective: The majority of pregnant women who smoke quit during pregnancy.

However, over half resume smoking during the first several postpartum months. Providerdelivered smoking interventions have been integrated into national clinical practice guidelines for this population. Our aim was to explore demographic factors associated with receipt of perinatal smoking abstinence advice from health care providers, and to examine whether this advice was, in turn, related to postpartum smoking relapse. We hypothesized that sustained abstinence would be higher in those reporting advice from health care providers.

Study Design: Women who quit smoking during pregnancy were recruited during their maternity hospital stay, and enrolled in an observational study of relapse risk during the first four postpartum months. Self-report of smoking status was biochemically validated through a semi-quantitative saliva cotinine rapid immunoassay (NicAlert). As part of a larger assessment battery, women were asked about their receipt of advice from health care providers

(physicians, nurses, midwives, pediatricians, and dentists) regarding quitting smoking during pregnancy, and remaining abstinent during the postpartum period.

Population Studied: The sample comprised 80 postpartum ex-smokers, aged 18-38 (mean age

26.9 years) who completed baseline and 16 week postpartum assessments. The sample was predominantly Caucasian (82.5%). Most women were married (53.8%), reported a household income under $45,000 (57%), and had completed some college education (57.5%).

Principle Findings: Prenatal quit advice from any health care provider was reported by 61.3%; only 3.8% received quit assistance during pregnancy (such as nicotine replacement therapy). Heavier smokers were more likely to be advised to quit prenatally. Receipt of prenatal quit advice was not associated with demographic variables (age, race, marital status, income, educational level, or presence of other household smokers). Women reporting postpartum abstinence advice from health care professionals

(61.3%) had lower incomes and heavier rates of smoking prior to pregnancy than women who were not advised to remain abstinent. Women reporting any smoking at 4 months postpartum

(70%) were younger, had less education, and were more likely to be single than abstinent women. Smoking relapse was not associated with recall of prenatal or postpartum abstinence advice from health care providers.

Conclusions: Previous surveys of OB/GYNs indicate almost all report advising smoking abstinence. However, in this sample, relatively few patients recalled receiving smoking advice from health care providers perinatally, and even fewer recalled receiving assistance. This is of particular concern, given that ex-smokers are at high risk for relapse. Consistent with other studies, a high rate of postpartum relapse was observed in this sample. Surprisingly, recall of advice was not associated with a lower rate of smoking relapse. This finding deserves replication in a larger sample, with attention to the number and quality of health care provider messages received.


Smoking during the perinatal period is harmful to both maternal and infant health. Evidencebased clinical practice guidelines alone appear to be inadequate for tobacco control interventions among perinatal women. In particular, health care providers may need additional education and support to identify women at heightened risk, and to integrate smoking cessation and relapse prevention advice and assistance into routine medical care.


• Use of Obstetric Specialty Consults by High

Risk Pregnant Women with Medicaid

Coverage

Janet Bronstein, Ph.D., Songthip T

Ounpraseuth, Ph.D., Curtis Lowery, M.D.

Presented By: Janet Bronstein, Ph.D., professor,

Health Care Organization and Policy, UAB

School of Public Health, 1665 University

Boulevard, Birmingham, AL 35294, Phone: 205-

975-8962, Fax: 205-934-3347, Email: jbronste@uab.edu

Research Objective: To examine the risk profile of Medicaid covered pregnant women in

Arkansas and identify characteristics associated with the likelihood that those with high risk pregnancies receive a specialty maternal fetal medicine consult.

Study Design: Using both ICD9-CM codes and vital statistics indicators from a dataset of linked

Medicaid claims-birth certificate data for 2001-

2003 in Arkansas, women with medical, obstetric or a combination of medical and obstetric risks are identified. Billing provider numbers are used to identify visits to maternal fetal medicine

(MFM) specialists that occurred during the pregnancies, and demographic and care use factors are compared for women within risk categories who did and did not receive a consult.

This analysis represents baseline data that will be used to measure the impact of an intervention designed to increase use of specialty consults for high risk pregnant women in the state.

Population Studied: 38,200 women with completed pregnancies covered by Arkansas

Medicaid in 2001-2003.

Principle Findings: 34% of the population had a serious pregnancy risk, including 13% with a medical risk (including diabetes, cardiac conditions and hypertension), 15% with an obstetric risk (including pre-eclampsia, eclampsia, premature membrane rupture and suspected fetal abnormality) and 6% with a combination of these risks. An additional 5% of the population had a preterm birth without these identifiable risks. Overall, 33% of this high risk population had MFM consults, including 27% of those with medical risks, 36% of those with obstetric risks, 45% of those with both types of risks and 21% of women with preterm deliveries and no other identifiable risks. Across all risk categories, more Black women, fewer Hispanic women and more women using the Public

Health Department system for prenatal care had such consults. Among those with obstetric or combination obstetric and medical risks, older and better educated women were more likely to have MFM consults. Among those with medical risks, women starting prenatal care after the first trimester were more likely to have a consult.

Women who received MFM consults were more likely to deliver in tertiary care settings, although overall only 33% of high risk women delivered their babies in these settings. Women with obstetric complications who received MFM consults were somewhat less likely to deliver extremely low birth weight infants.

Conclusions: The Medicaid covered pregnant population includes many patients with a mix of medical and obstetric risks. Care system and personal characteristics influence whether these women receive specialty consults.


Recent decades have seen the breakdown of perinatal regionalization systems established in the 1970’s and 1980’s to ensure that women with high risk pregnancies are treated in specialty appropriate systems. This baseline data from

Arkansas demonstrates the need to renew such systems and identifies those women particularly vulnerable to lack of appropriate specialty care in the absence of an organized referral system.

Contemporary system can be designed to provide specialty consults for high risk women who can then potentially remain in their home primary care setting for maternity care.

Funding Source: UAMS and AR Medicaid

•

Primary Care Referral Practices and

Facilitation Activities of Family Planning

Providers

Holly Felix, Ph.D., M.P.A., Zoran Bursac, Ph.D.,

M. Kate Stewart, M.D., M.P.H., Jonet Bronstein,

Ph.D., Rusty Foushee, Ph.D., Joshua Klapow,

Ph.D.

Presented By: Holly Felix, Ph.D., M.P.A.,


Management, University of Arkansas for Medical

Sciences, 4301 West Markham Street, Slot 820,

Little Rock, AR 72205, Phone: 501, Fax: 526-5266,

Email: felixholly@uams.edu

Research Objective: Family planning providers’ ability to successfully refer their low income family planning clients for primary and specialty healthcare services, including early cancer and

HIV/STI treatment, is an important aspect of family planning service quality. However, organizational and financial challenges faced by these providers, and psychological, social and financial challenges faced by family planning clients affect the ability of providers to successfully make referrals and for clients to successfully complete referrals for non-family planning-related healthcare services. We embarked on a study to understand the referral practices of public and private family planning providers and referral keeping practices of their

low income family planning clients in two

Southern states. The study involves two phases:

This presentation will focus on the outcomes of the study’s first phase, which had the research objective of assessing providers’ referral practices (making referrals and engaging in activities to facilitate the referrals), their concerns about making referrals, and characteristics of their practices that might explain variation in referral practices.

Study Design: Data were collected through a mail survey. Data analyses included descriptive statistics, t-test for comparison of means, chi square for comparison of proportions and logistic regression for association between referrals and facilitation activities with availability of local resources.

Population Studied: All family planning providers (n=2281) in Arkansas and Alabama participating in Medicaid family planning demonstration waiver programs, with 20% responding.

Principle Findings: Private providers were more likely to treat conditions themselves rather than referring for treatment whereas public providers were more likely to refer than treat for most conditions. There was a significant difference between public and private providers in making referrals for most non-family planning-related medical conditions. In general, both private and public providers were likely to identify a client’s usual source of care and provide contact information and least likely to arrange transportation. However, there was a significant difference between private and public providers in their level of use of facilitation activities.

There was no relationship between availability of local resources and whether providers treated or referred their family planning client. For the majority of the ten non-family planning-related conditions asked about, providers were significantly more likely to engage in facilitation activities for referrals they made when local resources were available.

Conclusions: Providers, particularly private providers, report providing care themselves.

After referring, providers engage in a few referral facilitation activities most of the time.

Availability of local resources results in more facilitation activities but not necessarily in referrals. Availability of referral sources, lack of insurance, and difficulty reaching clients are top concerns for FP providers.

Implications for Policy, Practice or Delivery: oWhen local resources are available, providers work to get clients to the resources. Educating providers about the availability of local resources may improve access by increasing the likelihood providers engage in facilitation activities.

Funding Source: Office of Population Affairs,

USDHHS

• Gender, Eating Disorders and Substance

Abuse: A National Study

Tahany Gadalla, Ph.D., Niva Piran, Ph.D.


Professor, Social Work, University of Toront, 246

Bloor Street West, Toronto, Ontario, M5S 1A1,

CA, Phone: (416) 946-0623, Fax: (416) 978-7072,

Email: tahany.gadalla@utoronto.ca

Research Objective: To examine the comorbidity between risk of eating disorders and several measures of alcohol, cannabis and illicit drug abuse and dependence in a nationally representative sample of Canadian men and women.

Study Design: This research was based on secondary data analyses of data collected by

Statistics Canada in the 2002 Mental Health and

Well-Being cycle of the Canadian Community

Health Survey (Statistics Canada, 2002). Data were collected from 36,984 respondents in faceto-face interviews using a Computer Assisted

Personal Interviewing method. The Eating

Attitude Test (EAT-26) (Garner et al, 1982) was used to assess risk of eating disorders, and modules of the short form of the Composite

International Diagnostic Interview (CIDI-SF)

(Kessler et al, 1998) were used to assess alcohol and drug use, dependence and interference.

Pearson chi-square tests and Fisher’s exact test were used to test the association between risk of

ED and substance abuse and dependence.

Expected probabilities of random co-occurrence of ED and SUD were calculated and compared with observed probabilities.

Population Studied: The sample used for this research includes 36,984 Canadian men and women 15 years of age and over, who participated in the 2002 Canadian Community

Health Survey.

Principle Findings: In women, significant associations were found between risk of ED and alcohol dependence, alcohol interference, cannabis drug use, illicit drug use and lifetime use of cocaine/crack, amphetamine (speed),

MDMA (ecstasy), hallucinogens/PCP/LSD and heroin. In men, risk of ED was strongly associated with alcohol interference and lifetime use of amphetamine (speed) while marginally associated with alcohol dependence and lifetime use of MDMA (ecstasy). In addition, the

number of different illicit substance classes used was significantly related to the degree of disordered eating attitudes in women but not in men. The significant association between ED and alcohol interference was found in both women and men. The observed probability of co-occurrence of these two conditions was 4 times as high as the expected probability of their random co-occurrence.

Conclusions: Results suggest different patterns of associations between risk of eating disorders and substance use in women and men.


Findings of this study support the importance of developing different assessment instruments and treatment strategies for men and women that address the co-occurrence of eating disorders and specific substances that are more prevalent in each gender. Further, informed by varied etiological models explaining the association between disordered eating patterns and SUD, and considering the clinical presentation of women and men with cooccurring difficulties, clinicians may want to specifically address patterns of dietary restriction, the modulation of negative affect states, or patterns of discharge of tension states.

• Incidence, Prevalence, and Treatment for

Uterine Fibroids in Insured Women

Teresa B. Gibson, Ph.D., David W. Lee, Ph.D.,

Ronald J. Ozminkowski, Ph.D., Ginger Smith

Carls, M.A., Shaohung Wang, Ph.D., Elizabeth A.

Stewart, M.D.

Presented By: Teresa B. Gibson, Ph.D., Director,

Research, Thomson Medstat, 777 East

Eisenhower Parkway, 902R, Ann Arbor, MI

48108, Phone: (734) 913-3481, Fax: (734) 913-

3850, Email: teresa.gibson@thomson.com

Research Objective: To profile women treated for uterine fibroids who were covered by commercial insurance obtained from large, selfinsured employers in the United States.

Study Design: Data were obtained from the

MarketScan Commercial Claims and Encounters

(CCAE) insurance databases for 2000 ---- 2004.

ICD-9-CM codes on insurance claims were used to find women with uterine fibroids and associated comorbidities. CPT codes were used to profile medical and surgical interventions.

Population Studied: Women age 25 - 54 in private insurance plans

Principle Findings: The CCAE data contain information for 1,293,398 women ages 25 ---- 54.

The incidence and prevalence of treated fibroids were stable over time, at 8.9 to 9.2 cases/1,000 women and 10.0 to 10.3 cases/1,000 women, respectively. The average age of the fibroid patients was 43.4 years. Women with fibroids were more likely than other women to have comorbidities, including anemia and other pelvic disorders (20 vs 6 %, p< 0.05) as well as pain or other menstrual disorder (50% vs 8%, p < 0.05).

Treatment patterns were similar over time. In the most recent year (2004), 16.7% of the 13,263 women with fibroids received no treatment,

17.3% received surgical treatment only, 20.8% received non-surgical treatment only, and 45.2% received surgical and non-surgical treatment.

Conclusions: Uterine fibroids were treated in about 1% of reproductive age women annually.

Comorbid genital or menstrual conditions were common and much more prevalent for women who were treated for uterine fibroids. Surgery was the treatment of choice for many women.


Successful non-surgical interventions are needed.

Funding Source: GE Healthcare

•

Counseling Conundrums: A Qualitative

Study of Providers Serving Women at

Increased Risk of HIV Infection

Jillian T. Henderson, Ph.D., M.P.H., Tina Raine-

Bennett, M.D., M.P.H., Nancy Padian, Ph.D.,

Maya Blum, M.P.H., Cynthia C. Harper, Ph.D.

Presented By: Jillian T. Henderson, Ph.D.,

M.P.H., Asst. Professor, Obstetrics, Gynecology,

& Reproductive Sciences, University of

California, San Francisco, 3333 California Street,

Suite 335, San Francisco, CA 94143-0744, Phone:

(415) 502-8544, Fax: (415) 502-8479, Email: hendersonj@obgyn.ucsf.edu

Research Objective: Health care providers serving women at heightened risk of HIV infection face particular challenges in helping their patients to protect themselves from both unintended pregnancy and disease. This study examines the contraceptive counseling approaches and perspectives of health care providers serving women at increased risk of

HIV infection.

Study Design: In-depth interviews with 31 health care providers serving women at heightened risk of HIV were conducted in 2005. A structured topic guide was used to elicit provider perceptions of their influence on patients and the clinical judgments about patients that shape contraceptive and disease prevention counseling messages. Deductive and inductive thematic

codes were developed by the study team and applied to the interview transcripts using Atlas.ti software.

Population Studied: A sample of providers from

6 regions in the U.S., both urban and rural, serving communities with the highest rates of

HIV infection among women was purposively selected. Obstetrician/Gynecologists (Ob/Gyn),

Family Practice Physicians (FP), Certified Nurse

Midwives (CNM), and Nurse Practitioners (NP) providing family planning or STI/HIV services to women were eligible.

Principle Findings: Clinicians adapt their counseling messages to the risk behaviors and relationship contexts of individual patients. The majority of providers felt they exerted a strong influence on the contraceptive preferences of their patients (ex., "...I kind of steer people to something I think they're going to be able to use correctly and completely."). Others downplayed their influence citing peer influence and imperfect knowledge of the social context of patients' lives. Contraceptive counseling was influenced by the demographic and relationship characteristics of patients, with age and partnership status influencing the types of methods promoted and provider confidence that women would be able to enact their recommendations. In contrast, counseling messages for disease prevention were not easily tailored to women's specific circumstances due to the absence of an acceptable femalecontrolled method and the challenges of promoting condom use for pregnant women and women in longer term relationships. Although most providers reported counseling all of their patients about disease prevention, they expressed less confidence that female patients would be able to enact their recommendations.

Conclusions: Results showed the inherent difficulties of providing pregnancy and disease prevention counseling, as the most effective pregnancy prevention methods to not offer disease protection. This study reveals how providers navigate a conundrum in women's health care by developing counseling messages that weigh levels of pregnancy and disease risk and perceived patient capacities.


New technologies for STI prevention are needed.

In the meantime, further work should be undertaken to develop novel and effective counseling messages to encourage dual protection against unintended pregnancy and sexually transmitted infections, particularly for providers serving women at heightened risk of infection.

Funding Source: NICHD

• Women’s Perceived Control of Their Birth

Outcomes: Implications for the Use of

Preconception Care

Marianne Hillemeier, Ph.D., M.P.H., Gary A.

Chase, Ph.D., Dawn Misra, Ph.D., Anne-Marie

Dyer, M.S.

Presented By: Marianne Hillemeier, Ph.D.,

M.P.H., Assistant Professor, Health Policy and

Administration, Pennsylvania State University,

116 Henderson, University Park, PA 16802,

Phone: (814) 863-0873, Fax: (814) 863-2905,

Email: mmh18@psu.edu

Research Objective: To examine non-pregnant women’s beliefs about whether or not they can influence their future birth outcomes with respect to the baby’s health, as a function of prior pregnancy experiences, health status and stress levels, access to health care, and sociodemographics. Internal control of birth outcomes is expected to be a factor predisposing women to use of preconception care, which is currently recommended for all women of childbearing age by the Centers for Disease

Control and Prevention (2006).

Study Design: Cross-sectional random-digit dial telephone survey (n = 2,002) of women’s health, pregnancy experiences and outcomes, and health care patterns. Outcome variables are two measures of internal locus of control for birth outcomes related to the baby’s health: (1) a 4item Internal Control of Birth Outcomes Scale

(Cronbach’s alpha = 0.72), and (2) a single-item measure of Preconceptional Control (‘‘There are things I can do before I become pregnant to make sure my child is born healthy’’).

Population Studied: 614 non-pregnant women aged 18 ---- 45 residing in a 28-county region of

Central Pennsylvania who have current reproductive capacity and report that they are considering a future pregnancy. The sample includes both preconceptional (never pregnant) and interconceptional (previously pregnant) women.

Principle Findings: In bivariate analyses, both measures of internal control are significantly associated with actions consistent with preconception health ---- receiving pregnancy planning counseling from a health care professional in the past year and using a daily multivitamin with folic acid ---- suggesting construct validity of the measures. Multiple logistic regression analyses show that internal control of birth outcomes is positively associated

with older age (35 ---- 45 years vs. 18 - 34 years), higher education (some college or more), marital status (currently married or living with a partner), and higher self-rated overall health status. Race/ethnicity, employment status, and poverty status are not associated with locus of control. Pregnancy experiences, including having a prior preterm birth or a baby born with low birthweight or a birth defect and having a mother who experienced adverse birth outcomes, have no association with locus of control. Depressive symptoms and psychosocial stress are not associated with locus of control. Health care access, including having a regular health care provider and having continuous health insurance in the past year, has no association with locus of control.

Conclusions: Variables associated with internal locus of control of birth outcomes among women considering a future pregnancy are primarily sociodemographic, and prior pregnancy experiences and specific health risks do not appear to influence perceptions of internal control of birth outcomes.


Efforts to increase women’s internal control for birth outcomes and predispose them to use of preconception care should focus on women who are younger, have less education, are not married, and have poorer overall health.

Targeting only women with a prior adverse pregnancy outcome is not indicated by these findings, since level of internal control is independent of pregnancy outcome.

Funding Source: Pennsylvania Department of

Health

•

Predictors of Safer Sex Behaviors of a

Multiethnic Sample of Midlife and Older

Women

Robin J. Jacobs, Ph.D.

Presented By: Robin J. Jacobs, Ph.D., Visiting

Instructor, Social Work, Florida International

University, PO Box 25375, Tamarac, FL 33320,

Phone: 954-600-9022, Fax: 954-333-3818, Email: jacobsr@fiu.edu

Research Objective: Purpose: Research indicates there has been a significant increase in

HIV/AIDS transmission among women over 50.

A need exists to identify HIV risk and resiliency factors and the influences of individual, interpersonal and socio-environmental factors on the sexual behaviors of this understudied and vulnerable population. The purpose of this study was to determine the influence of self esteem, sensation seeking, self silencing, sexual assertiveness, and HIV-stigma on the safer sex behaviors of women aged 50 and older.

Study Design: Method: This study was guided by the theory of gender and power (TGP) and the ecological perspective, which emphasizes the importance of the complex inter-relatedness of factors affecting women’s health behaviors within individual, interpersonal, and socioenvironmental contexts. A community-based, ethnically diverse sample of 572 women age 50 to 93 (M = 63.6 years) completed a 128-item anonymous, self administered questionnaire.

Fifty-nine percent (n = 337) of the sample were non-Hispanic White, 22% (n = 126) were

Hispanic, 8.7% (n = 50) were African-American, and 4% (n = 23) were Caribbean Black.

Participants were recruited from various community sites throughout South Florida in the fall of 2005. This study used a cross-sectional, correlational research design. The data were analyzed using Pearson correlation coefficients and multiple regression analysis.

Population Studied: Midlife and older women

(Women over age 50)

Principle Findings: Results: Results from the regression analysis with the predictors (i.e., ethnicity, age, self esteem, sensation seeking, self silencing, sexual assertiveness, and HIV stigma) indicated the model significantly predicted safer sex behaviors (p < .001). Self silencing (ß =-.115, p < .05) and age (ß = .173, p <

.001) were significant predictors. This indicates that women who self silence more are less likely to engage in safer sex behaviors. Also, the greater the age of women, the more likely they are to engage in safer sex behaviors. Bivariate correlation indicated a significant correlation and

HIV-stigma (p < .05) with safer sex behaviors.

Although this model was statistically significant, its practical significance may be limited due to the low percentage of variability explained by age and self silencing (4.1%).

Conclusions: Discussion: An ecological framework for planning HIV/AIDS prevention strategies involves assisting clients with interpersonal processes combined with skills for active involvement in addressing socioenvironmental issues. Situations that may lead to differential responses to risk and the resiliency factors to HIV are discussed, and recommendations for socially meaningful strategies for women over 50 are presented.


Designing and implementing sound interventions specifically targeting midlife and older women should be an immediate priority for

researchers, health providers, social workers, and policy makers to reduce the number of new cases of HIV-infection among this at-risk population.

Funding Source: Florida International University

GSA

• Impact of Obstetric Unit Closures on Birth

Outcomes and Quality of Care

Jennifer Kolker, M.P.H., Suet Lim, Ph.D., Cynthia

Line, Ph.D., Katherine Maus, M.S.W.

Presented By: Jennifer Kolker, M.P.H., Assistant


Drexel University School of Public Health, Mail

Stop 660; 1505 Race Street, Philadelphia, PA

19102-1192, Phone: 215-762-8457, Email: jkolker@drexel.edu

Research Objective: Philadelphia’s health care delivery system has undergone significant change in recent years, with consolidation and closure of area hospitals and elimination of obstetric and neonatal intensive care units in existing hospitals. The objective of this study is to determine if the these closures have had a measurable impact on birth outcomes and provider practices for Philadelphia resident births and develop policy recommendations for moving forward.

Study Design: Secondary data analysis comparing 1997 distribution of births by hospital and birth outcomes to 2004 distribution and birth outcomes. Subsequent analysis to examine quality indicators including c-sections, length-ofstay, and provider practices in relation to patient volume.

Population Studied: All Philadelphia resident births 1997 and 2004.

Principle Findings: Despite significant churning in Philadelphia’s in obstetric services, there has not been a measurable negative impact of hospital system changes on birth outcomes for

Philadelphia resident births, nor does the geographic distribution of existing hospitals does not appear to create significant hardship for pregnant women with regard to travel time.

However, system changes have had a disproportionate impact on particular hospitals and ongoing research is needed to determine impacts on provider practices and quality of care for women delivering in Philadelphia.

Conclusions: Concerns over the impact of obstetric closures on birth outcomes may be unfounded. However, the impact of individual hospital or unit closures does impact the overall system of care and may impact provider practice or quality of care.

Implications for Policy, Practice or Delivery: In determining the adequacy of obstetric care in a given geographic area, it is necessary to look not only at individual hospitals but at the impact of volume and volume changes on the system overall. As the obstetric landscape changes nationally, focused planning on hospitals, hospital closures, and provider practices as related to patient volume is necessary to assure quality of care for pregnant women and their infants.

Funding Source: Local Health Department

•

Federal Healthcare for American Indian and

Alaska Native Women Veterans

Josea Kramer, Ph.D, Stella Sarkisyan, M.S.W.,

M.P.H., Judith Harker, Ph.D., Elizabeth Yano,

Ph.D., M.S.P.H., Donna Washington, M.D.,

M.P.H.

Presented By: Josea Kramer, Ph.D, Assistant

Director of Education, Geriatric Research,

Education and Clinical Center, Veterans Affairs,

16111 Plummer Street (11E), North Hills, CA

91343, Phone: (818)895-9311, Fax: (818)895-9519,

Email: Josea.Kramer@med.va.gov

Research Objective: This study describes characteristics and utilization patterns of

American Indian and Alaska Native- AIAN- women to contribute to interagency planning for resource coordination between the Veteran’s

Health Administration ----VHA-and Indian Health

Service ----IHS-, which have executed a

Memorandum of Understanding to share resources.

Study Design: We identified women in the first systematic study of use of VHA and or IHS by

AIAN veterans, conducting bivariate analysis of linked and merged centralized administrative data from VHA National Patient Care Database and IHS National Patient Information Reporting

System for FY02 and FY03.

Population Studied: Female IHS-enrollees who were eligible and accessed services in VHA and or IHS.

Principle Findings: AIAN women represented 9

Percent -n equals 5,856- of the total AIAN population identified ----n equals 64,746-, exceeding the expected rate. The population had a mean age of 44-plus or minus 3- years, more than 150,000 encounters and more than 1,600 hospital discharges. Like all VHA veterans, hypertension -28 Percent- and diabetes -23

Percent- were the most frequently diagnosed

outpatient diseases. Like other women veterans, rates for depression -24 Percent- and anxiety disorders -21 Percent- were higher than their male counterparts but substance abuse -8

Percent- and PTSD -5 Percent- were lower. Three user groups emerged: dual users -40 Percent-,

IHS-only users -36 Percent- and VHA-only users -

24 Percent-. Two-thirds of dual users were nonveterans who received care at the VHA mainly through sharing agreements -65 Percent- or as employees -21 Percent-. Types of care accessed varied by user group. VHA-only users were more likely to be treated for behavioral and mental health conditions -e.g., alcohol dependence, schizophrenia- than dual users or IHS-only users. Dual users were more likely to access diagnostic and mental health clinics in VHA and primary care in IHS. However, dual users were treated for some key conditions in both VHA and

IHS settings, including bipolar disorders, diabetes without complications, lung cancer, hip fracture and hypertension. AIAN women who received care in any VHA outpatient setting were as likely as other female veterans to be treated in a women’s clinic. Hospital discharges reflected organizational resources, with IHS-only users top discharge diagnosis related to pregnancy and child-birth.

Conclusions: AIAN women veterans have similar healthcare needs as other veterans. VHA is an important resource for providing mental health care and diagnostic services and IHS is an important resource for primary care and obstetrics. There is some overlap with dualusers.


VHA already provides care to about half the population of IHS-enrolled female veterans.

Expanding VHA care to other eligible female

AIAN veterans would not require new types of services. However, increasing the potential for dual use would require coordination of care as well as resources to avoid unnecessary duplication or fragmentation of care. At least ad hoc coordination of resources for dual users already occurs. Since the majority of these dual users are non-veterans, VHA planning should include the opportunity to expand beyond the basic mission of services to veterans to include revenue generating sharing agreements where capacity exists.

Funding Source: VA

•

Predictors of Breast Cancer Diagnostic

Delay among Low-Income Women in

California

Cynthia Mojica, Ph.D., M.P.H., Rose C. Maly,

M.D., M.S.H.S., Barbara Leake, Ph.D.

Presented By: Cynthia Mojica, Ph.D., M.P.H.,

Research Scientist, Department of Family

Medicine, University of California, Los Angeles,

10880 Wilshire Boulevard, Suite 1800, Los


310-794-6097, Email: cmojica@mednet.ucla.edu

Research Objective: The goal of the study was to identify predictors of diagnostic delay among women receiving breast cancer treatment through the Medi-Cal Breast and Cervical Cancer

Treatment Program (BCCTP). Diagnostic delay in breast cancer may adversely affect outcomes of care, such as survival, and has been associated with psychological distress.

Diagnostic delay was defined as 60 days or greater from the time the patient first became aware of her breast abnormality (by self, physician, or radiographic evaluation) to the date of biopsy or first surgical intervention (whichever came first).

Study Design: Approximately 1,500 enrolled in

BCCTP and who met the study eligibility criteria were asked to participate in the study. A total of

925 (61%) women were interviewed at 6-months post breast cancer diagnosis. Predictors of diagnostic delay were identified through logistic regression analyses of patient-reported data.

Population Studied: Women were of low socioeconomic status. Most women (65%) reported an annual income of <20K and 41% had less than a high school education. Women had a mean age of 51 years, with Latinas constituting 54% of the sample, followed by

Whites (32%), Asian/Pacific Islanders (7%),

African-Americans (6%), and other (2%). Breast abnormalities were mostly self-identified (67%), followed by radiographic identification (27%), and clinical breast exam (5%).

Principle Findings: Slightly over half the women experienced a two-month or greater delay from identification of the breast abnormality to first surgical intervention resulting in diagnosis.

Results suggest that predictors of diagnostic delay are dependent on method of abnormality identification. Among women who self-identified their abnormality, ethnicity (African-American), low self-efficacy in communicating with physicians, and a belief that a woman would die from breast cancer predicted a two-month or greater delay in diagnosis, controlling for other variables. Among women who had a radiographic or physician identified abnormality,

the only significant predictor of diagnostic delay was ethnicity (African-American).

Conclusions: Findings suggest racial/ethnic differences in diagnostic delay, even within a group of low-income women with breast cancer.

In addition, patient-physician communication and health beliefs contribute to delay among patients with self-identified abnormalities.


Study findings will be used to provide an empirical basis to design interventions to improve patient-physician communication and breast cancer outcomes in underserved women with breast cancer.

•

Predictors of Health Care seeking among

Women Harmed by IPV

Stacey Plichta, Sc.D., Sariyemon Tiraphat, M.S.

Presented By: Stacey Plichta, Sc.D., Full

Professor, Ph.D. program in Health Services

Research, Old Dominion University, 3134 Health

Sciences Building, Norfolk, VA 23462, Phone:

757-683-4259, Fax: 757-683-6333, Email: splichta@odu.edu

Research Objective: Victims of IPVAW seek out health care as often as other women. In fact, health care providers are often the first and sometimes the only source of help that IPVAW victims seek out. However, IPVAW victims do not usually disclose their experiences with violence unless they are asked. Thus, they are less likely to receive needed services, more likely to overuse services and more likely to report poor relationships with providers. While several studies have examined factors related to health care use and disclosure of IPVAW, few have employed a community-based sample. This study examines the factors related to seeking out medical care for health conditions related to

IPVAW in a community-based population of women who report lifetime IPVAW.

Study Design: This study was a cross-sectional, random-digit dial telephone survey of women in the Virginia Beach-Norfolk-Newport News

MSA(population 1.5 million). A 20 minute survey, largely based upon the BRFSS, asked women about IPVAW, health status, use of health services and patient-provider relationships.

Population Studied: Overall, 1,105 women responded to the survey. Of these, 204 (18.4%) reported lifetime IPVAW. These 204 women ethnically identifed as Caucasian (69%), African-

American (26.0%) or other (4.9%), had and average age of 47.4 and had a marital status of single (21%), married (48%), divorced/separated

(25%) or widowed (7%). The majority (70%) were employed and income ranged from less than $10,000/year to over $60,000/year.

Principle Findings: Overall, 66% of IPVAW victims never sought medical care for conditions associated with the violence, 11.8% sought care but did not tell the health care provider about the violence and 22% both sought care and disclosed the violence to the health care provider. There were no differences in overall health care utilization (outpatient, ED or preventative) between those who did and did not seek medical care for IPVAW related conditions.

A logistic regression model that controlled for sociodemographic characteristics, high use of services and access to care found that only older age and reporting good communication with their MD significanlty increased the odds of seeking medical care for IPVAW associated health care problems.

Conclusions: Good patient provider communication is critical to the care of IPVAW victims. Women may not even seek out care if they are not comfortable with their provider.


IPVAW victims will receive sub-optimal treatment if their health care providers are unaware of the violence. While numerous studies report that the majority of both health care providers and patients support screening for IPVAW in the clinical setting, few health care settings formally require this and the majority of health care providers do not inquire about

IPVAW. Health care settings need formal protocols in place to assist providers communicating openly about IPVAW with patients.

Funding Source: ODU internal grant

• Intimate Partner Violence Against Women and Unmet Needs for Care

Stacey Plichta, Sc.D.

Presented By: Stacey Plichta, Sc.D., Professor and Graduate Program Director, School of

Community and Environmental Health, Old

Dominion University, 3134 Health Sciences

Building, Norfolk, VA 23462, Phone: 757-683-

4259, Fax: 757-683-6333, Email: splichta@odu.edu

Research Objective: This study seeks to examine the relationship of experiencing intimate partner violence against women

(IPVAW) to having an unmet need for medical care in a community-based sample of women.

IPVAW victims may be more likely to have unmet needs for care than other women. This could stem from both a direct refusal to seek or accept care, and from the health care provider not detecting that the underlying problem is IPVAW.

Several clinic based studies and one national study found that IPVAW victims are more likely have had an unmet need for care in the past year. Few of these, however, employed community-based samples or multivariate methods that controlled for other factors related to having an unmet need for care such as insurance status, health status and income.

Study Design: This study was a cross-sectional, random-digit dial telephone survey of women in the Virginia Beach-Norfolk-Newport News

MSA(population 1.5 million). A 20 minute survey, largely based upon the BRFSS, asked women about IPVAW, health status, use of health services and patient-provider relationships.

Population Studied: The survey respondents were similar to women living in the MSA. The average age was 48 years(sd 16.1; range 18-99).

Ethnically, 70% were white, 25% African-

American and 5% other. 59% are married, 26% are single and 15% are divorced; overall, 35% have a household income of $40,000 or less.

The majority (85%) have a usual and non-public place to go for medical care and most(89%) are insured.

Principle Findings: Overall, 11% reported that they needed medical care in the past year but did not recieve it. Additionally, 22% report IPVAW victimization (physical or sexual) at least once in their lifetime. The average number of visits per year was 5.23 (sd 7.21) and this did not differ between IPVAW victims and other women. A logistic regression model was constructed to examine the predictors of unmet need for care.

The overall model had a Nagelkerke R-square of

.26 (p<.001). Significant predictors (at p<.05) of having an unmet need for care included: IPVAW victimization (OR 2.9), having poor communication with their MD (OR 5.33), being uninsured for at least part of the past year (OR

5.25), not having a usual place of care (OR 2.17), being in poor health (OR 2.35) and being of an ethnicity other than white or African-American

(OR 3.49). This model also controlled for marital status, recieving a diagnosis of anxiety or depression and income, but these factors were not significant.

Conclusions: This study provides evidence that

IPVAW victims frequently use in the health care system, but do not necessarily receive the services that they need. There are a number of factors related to having an unmet need for care and it appears that prior IPVAW victimization is one of them.


Efforts to engage the health care system in assisting IPVAW victims require a supportive policy base in both the public and private sectors. In particular, health care providers will need to ask women about experiences of violence to ensure that the women receive appropriate care and referrals. Until quite recently, virtually all peer-reviewed articles, policy statements and clinical guidelines were supportive of policies that encouraged health care providers to engage in IPVAW screening, treatment and referral activities. However, most health care systems still do not do so. Of concern is a recent decision by the U.S.

Preventative Task Force, which formally concluded that insufficient evidence exists to support routine screening in the primary care screening. This position may lead to further reductions in the level of care provided to IPVAW victims, as many primary care practitioners employ the U.S. Preventative Task Force guidelines in their practice.

• Exploring the Relationship Between

Prenatal Oral Health, Preconception Oral

Health, and Pregnancy Outcomes in

Minnesota

Sheila Riggs, D.D.S., D.M.Sc., Sheila Riggs,

D.D.S., D.M.Sc., Steve Springman, , Peilei Jiang,

Ph.D., Nancy Garrett, Ph.D., Eric Bargman, Ph.D.

Presented By: Sheila Riggs, D.D.S., D.M.Sc.,

President and CEO, Delta Dental of Minnesota,

3560 Delta Dental Drive, Eagan, MN 55122,

Phone: 651-994-5431, Email:

SRiggs@deltadentalmn.org

Research Objective: This study uses medical and dental claims data to examine prenatal and preconception oral health utilization, comparing women experiencing premature, low birthweight

(LBW), and normal deliveries. The following questions are examined: (1) Which indicators in dental claims data best identify poor oral health outcomes prior to delivery? (2) Do mothers experiencing premature or LBW deliveries have differences in oral health utilization? (3) Can dental claims data be used to identify women at increased risk for premature birth and LBW?

Study Design: A retrospective study was conducted using longitudinal data from medical and dental claims files. Maternity cases from the

BCBS-MN population were identified by date of

delivery during the period 2004-2005. Adverse outcomes within the population were identified through claims data, with a focus on premature and LBW deliveries. The files were matched with dental claims files from Delta Dental of MN.

The dental utilization patterns in the prenatal and preconception periods were analyzed comparing normal deliveries to LBW and premature deliveries. The analysis controls for demographic characteristics such as age, geographic region, and comorbid conditions.

Population Studied: The population in this analysis includes 12,236 commercially insured mothers who gave birth during the period 2004-

2005 and also received dental benefits through the Delta Dental (a business associate of BCBS-

MN). Among the initial population of 19,656 deliveries, more than 62% of the population matched to the dental files, with comparable rates of LBW and premature deliveries among the matched and non-matched populations.

Principle Findings: Preliminary analyses showed that in 7.6% of the cases, the mother experienced a preterm delivery, a number consistent with 2003 data from the Minnesota

Department of Public Health (Center for Health

Statistics). The oral health services of interest include treatment for periodontal disease and gingivitis, dental maintenance such as cleaning and x-rays, endodontic services (root canal), and emergency treatments. Variation in utilization of dental services in the prenatal and preconception period was observed within the population. We expect to confirm previous studies finding a relationship between oral health and preterm deliveries, and provide new information regarding the temporal nature of the relationship.

Conclusions: This study investigates the relationship between prenatal and preconception oral health and adverse outcomes in pregnancy.

The analysis evaluates variation in treatment patterns in order to identify vulnerable populations and gaps in care. While a number of studies have examined the relationship between oral health and pregnancy outcomes, this study is unique in that multiple years of dental data are available for a large population, permitting analysis of oral health services provided during both the prenatal and preconception period.

Implications for Policy, Practice or Delivery: In recent years a number of studies have demonstrated an association between periodontal disease and adverse medical conditions such as cardiovascular disease, diabetes, stroke, and pre-term birth. However treatment and payment for these conditions are provided by distinct and separate industries.

Efforts such as this initiative will allow payers to develop a more integrated system for the analysis of data, and ultimately, the delivery of care.

Funding Source: Delta Dental of Minnesota

• "You Have to Stop Using Before You Go to the Doctor:" Barriers to Prenatal Care for

Women Who Use Drugs During Pregnancy

Sarah C. Roberts, M.P.H.

Presented By: Sarah C. Roberts, M.P.H., DrPH student, DrPH Program, UC Berkeley School of

Public Health, 2737 Garber Street, Apt. 5,

Berkeley, CA 94705, Phone: 510-333-2746, Email: scmr@berkeley.edu

Research Objective: It is widely accepted that women who use illegal drugs during pregnancy are less likely to receive prenatal care than women who do not use drugs. Among women who use drugs, those who receive prenatal care generally have better birth outcomes. There is widespread speculation about causes of inadequate or no prenatal care for women who use drugs. However, there is limited empirical evidence about barriers to prenatal care for this population. This qualitative study elicited drugusing women’s perspectives on and experiences with prenatal care to identify what they see as barriers to prenatal care.

Study Design: 20 semi-structured individual interviews and two focus groups were conducted with women who use or used drugs and/or alcohol during pregnancy. Interviews addressed beliefs about and attitudes towards prenatal care, positive and negative experiences with prenatal care, reasons why women who use drugs and/or alcohol attend/avoid prenatal care, advice they would give to other women regarding prenatal care, and recommendations for improving prenatal care for women who use during pregnancy.

Population Studied: 38 women from a county in

Northern California who were either currently using or in recovery and were either pregnant or had a child 2 years old or younger at the time of the interview or focus group participated.

Methamphetamine was the most commonly used substance, but participants also used crack, marijuana, PCP, heroin, ecstasy, and alcohol.

Participants were recruited through a community-based substance abuse treatment program, WIC offices, and a county home visiting program.

Principle Findings: While women’s experiences differed, there were some major themes relating to the decisions to enter and continue attending prenatal care. Themes include: wanting to have a healthy baby, readiness to reduce and/or stop drug use, and concern about doctors reporting them to Child Protective Services (CPS). Some women went to the doctor while using drugs because they were concerned about the health of their fetus. However, many women believed they had to stop using drugs before they went to the doctor because stopping use would clear women’s heads so that their ‘‘right mind’’ as opposed to their ‘‘addict mind’’ would allow them to take steps for both their own health and the health of their baby. More significantly, many believed that if they went to the doctor while using, doctors would find out and report them to CPS, who would then take their children away.

Conclusions: For women who are interested in having a healthy baby and are interested in reducing and/or stopping their drug use, the fear of being reported to CPS is an additional barrier to prenatal care.


Regardless of intent on the part of health care providers and policy-makers, fear of being reported to CPS shapes many women’s decisions regarding prenatal care. By not correcting the perception that doctors always report drug use to CPS, providers and policy makers are complicit with using this threat, and may, in fact, contribute to the ‘‘flight from care’’ and perhaps lead to poorer birth outcomes in this population.

Funding Source: March of Dimes

• The Lived Experience of HIV and Pregnancy:

Women’s Voices

Lorraine Sanders, D.N.Sc.

Presented By: Lorraine Sanders, D.N.Sc.,

Assistant Professor, Nursing, Adelphi University,

Alumnae Hall 205, Garden City, NY 11530,

Phone: 516-877-4532, Email: sanders@adelphi.edu

Research Objective: The purpose of this study is to explore the lived experience of living with

HIV as a woman, choosing to bear a child after diagnosis with HIV, the decision-making process, and the emotional/psychological aspects of being HIV positive and pregnant.

Study Design: This phenomenological study was conducted using in depth semi- structured interviews.

Population Studied: Women who reported being HIV positive and were currently pregnant, in the decision making process about achieving a pregnancy, or who had delivered a baby after diagnosis with HIV (n=11).

Principle Findings: Themes of extreme emotional distress after HIV diagnosis, negative reaction by health care professionals in relation to pregnancy, difficulty developing trusting relationships with health care providers, sense of maternal role attainment as a chance to do good, being normal, having hope for a positive future.

Conclusions: The experience of pregnancy for a woman with HIV is one fraught with isolation, anxiety, and distrust but it is also one of hope for the normalcy that motherhood may bring.


Program design with an emphasis on nonjudgmental professional support and education are essential to support pregnant women with

HIV. Further research is needed to determine best practice for care delivery as women with

HIV enter the health care system especially for perinatal services. Further studies to determine safe methods for women with HIV to achieve pregnancy are needed.

Funding Source: Adelphi University development grant

•

Drug or Biologic Exposure During

Pregnancy: An Update on Pregnancy Exposure

Registries

Pellavi Sharma, M.P.H., Ameeta Parekh, Ph.D.,

Beth Duvall-Miller, B.S., Connie O'Leary,

Kathleen Uhl, M.D.

Presented By: Pellavi Sharma, M.P.H., ORISE

Research Fellow, Office of Women's Health,

Food and Drug Administration, 5600 Fishers

Lane, Rockville, MD 20857, Phone: 301-827-1936,

Fax: 301-827-0926, Email: pellavi.sharma@fda.hhs.gov

Research Objective: With approximately 50 percent of pregnancies unplanned in the United

States, many women find themselves unwittingly exposing their fetus to medication and possibly affecting its health. In 2002, lack of data regarding drug effects on the health of a fetus prompted the Food and Drug Administration

(FDA) to issue a guidance regarding the merits and design of a pregnancy exposure registry.

The guidance defines a pregnancy exposure registry as a prospective observational study that collects health information on the woman and her fetus throughout the pregnancy, while both

are exposed to a drug or biologic product (e.g. vaccine). The current research was undertaken to collect information obtained on pregnancy exposure registries since the issuance of the guidance and to enable its public access.

Study Design: Pregnancy exposure registries are conducted by pharmaceutical manufacturers and other researchers. Women may enroll themselves or register through their health care providers. Enrollment into a registry requires that fetal health be unknown to reduce bias. Some studies also continue into the first year or more of the baby’s life, to determine if adverse effects develop later. Internal Food and Drug

Administration Center for Drug Evaluation and

Research (CDER) and the Center for Biologic

Evaluation and Research (CBER) databases were searched for products that required a pregnancy exposure registry. FDA’s Office of Women’s

Health (OWH) created a web listing of pregnancy exposure registries to provide information about specific studies underway and to potentially facilitate patient enrollment. This listing was updated after the current research.

Population Studied: CDER and CBER databases on postmarketing studies for specific drugs or biologics were followed in pregnancy exposure registries.

Principle Findings: A total of 41 products were identified with pregnancy registries; 17 were previously listed. One product had been withdrawn from the market and one product was released from the requirement. The 17 previously listed registries were contacted for updated information. Through multiple mechanisms the remaining 22 registries were researched. Nine out of the 22 registries had unobtainable information, four registries no longer enrolling were removed and 13 new registries were added. All the registries reported in the current update were from a postmarketing commitment or Phase 4 study.

Conclusions: The FDA pregnancy exposure registry guidance recommends methodologies to collect information on medical products likely to be used by women of childbearing potential. The need for a pregnancy exposure registry increases when there is potential for harm due to in utero exposure. It is important for this useful information to be disseminated to patients and health care providers in a centralized manner.

This research updates the centralized web listing.

Currently the OWH web listing contains information on about 32 pregnancy exposure registries; six specific to a medical condition and

26 specific to a medical product.


The OWH web listing will serve as a resource for pregnant women and their clinicians using medical products. By acknowledging that many pregnant women will take and developing fetuses will be exposed to medical products during their pregnancy, the FDA has encouraged more research and discussion in this area.

•

Gender Differences in Health-Related

Quality of Life for Veterans with Serious

Mental Illness

Carrie Farmer Teh, Ph.D., Amy M. Kilbourne,

Ph.D., Deborah Welsh, M.P.H., Frederic C. Blow,

Ph.D.

Presented By: Carrie Farmer Teh, Ph.D., NIMH

Postdoctoral Fellow, Western Psychiatric

Institute and Clinic, University of Pittsburgh, 3811

O'Hara Street, Pittsburgh, PA 15213, Phone: (412)

383-5139, Fax: (412) 383-5412, Email: tehc@upmc.edu

Research Objective: The prevalence of serious mental illness (SMI) is similar for women and men, though the symptoms, course, and treatment response can differ greatly. Although recent studies have suggested that health-related quality of life (HRQOL) is impaired in people with SMI diagnoses, little is known about whether HRQOL differs between women and men with SMI. The objective of this study was to assess gender differences on several HRQOL measures in a large sample of U.S. veterans with

SMI.

Study Design: Using linear and logistic multiple regression, we analyzed data from the Large

Health Survey of Veterans (LHSV), which was mailed to a national random sample of veterans in 1999. HRQOL was measured using the MOS

SF-36 (mental component scale, physical component scale, global health status, limitations in activities of daily living (ADL), and pain) and by questions assessing selfperceptions of health status. All analyses adjusted for age, education, employment status, social support, comorbid medical conditions, body mass index, smoking, alcohol consumption, exposure to toxins, exercise, health services use, and recent hospitalizations.

Population Studied: Our analyses included

30,937 veterans with an SMI diagnosis

(schizophrenia, schizoaffective disorder, or bipolar disorder) who completed the LHSV in FY

1999. The sample was 7% female, 73% white, and 86% unemployed. The mean age was 55.5

(SD=12.6); 83% had at least a high school education and 37% were married.

Principle Findings: Compared to male respondents, female veterans with SMI were more likely to report that they were limited ‘‘a lot’’ in vigorous activities (OR 1.36, CI 1.11-1.67), climbing several flights of stairs (OR 1.39, CI

1.19-1.62) and one flight (OR 1.21, CI 1.06-1.38), and walking more than a mile (OR 1.21, CI 1.04-

1.40). However, female respondents were less likely to report that they were limited ‘‘a lot’’ in moderate activities (OR 0.86, CI 0.75-0.99) and bathing or dressing themselves (OR 0.83, CI

0.72-0.96). Women were more likely to have positive views of their health; they were less likely to respond ‘‘false’’ to the statement ‘‘I am as healthy as anybody I know’’ (OR 0.73, CI 0.62-

0.86) and more likely to respond ‘‘false’’ to the statement ‘‘I expect my health to get worse’’ (OR

1.75, CI 1.47-2.07). There were no significant gender differences on the other HRQOL measures assessed.

Conclusions: Women and men with SMI differ on several aspects of HRQOL. Women with SMI are more impaired than men on activities of daily living related to physical activity, but are less impaired than men on more moderate activities.

In addition, women with SMI have better selfperceived health than men.


For researchers and clinicians interested in improving the quality of life for people with SMI, these findings suggest the need for a customized treatment approach for this population, especially as the number of women using VA services increases. For example, women with

SMI may need interventions and services that help to enhance their mobility, while men may need services to help with personal care.

Funding Source: VA

•

Breast Cancer Detection in a Low Income

Population. What are the Determinants of

Detection?

Amardeep Thind, M.D., Ph.D., Rose Maly, M.D.,

M.S.P.H., Allison Diamant, M.D., M.S.P.H.,

Lalima Hoq, M.D., M.P.H.

Presented By: Amardeep Thind, M.D., Ph.D.,

Assistant Professor, Department of Family

Medicine, University of Western Ontario, 245 -

100 Collip Circle, London, On, N6G 4X8,

England, Phone: 519-858-5028, Fax: 519-858-5029,

Email: athind2@uwo.ca

Research Objective: There are only two studies in the literature that examine methods by which breast cancers are detected, and none have focused on a low income population. We analyzed the determinants of breast cancer detection methods in a statewide cohort of low income women in California.

Study Design: Prospective cohort analysis. A statewide cohort of 932 women with breast cancer receiving treatment under the California

Breast and Cervical Cancer Treatment Program

(BCCTP) was assembled in 2003 ---- 2004.

Women were interviewed 6 months after definitive diagnosis.

Population Studied: Low income women with breast cancer in California, receiving treatment through the California BCCTP (n=932). The outcome modeled was medical vs. self detection of breast cancer. A 2 level multilevel logistic regression analysis was conducted, with county of residence being a Level 2 random intercept.

Principle Findings: Only 31% (n=298) of the lesions were detected medically (26% (n=250) by screening mammography, and 5% (n=48) by clinical breast exam). The majority (69%; n=633) were detected by the patient themselves (patient or partner felt lump, abnormal sensations etc.).

In the multilevel analyses, there was no significant variation at the county level. Among the Level 1 predictors, increasing age and having a regular source of care were statistically significant predictors of medical detection of breast cancer.

Conclusions: Even in a low income population, having a regular source of care is a strong determinant of medical detection of breast cancer.


Our analysis underscores the importance of having a regular source of care for low income populations. As states attempt to reform their health care finance and delivery systems, every effort should be made to ensure that vulnerable populations have a regular source of care.


• Self-Reported Memory Loss among Elderly

Male Veterans: Attributes & Timely Diagnoses

Iris Wei, Mark Kunik, M.D., M.P.H., Jessica

Davila, Ph.D., Robert Morgan, Ph.D.

Presented By: Iris Wei, 2002 Holcombe

Boulevard, Houston, TX 77030, Phone: (713)

794-8648, Email: iiwei@bcm.tmc.edu

Research Objective: Memory loss is the hallmark symptom of dementia, a disease that results in loss of independence and quality of life and extreme healthcare burdens. Previous

studies have had conflicting findings in associating self-reported memory loss with subsequent diagnosis of dementia. To understand the magnitude of the memory loss problem that affects our aging veteran population we assessed the prevalence of selfreported memory loss among elderly male veterans, and the related attributes to this condition and to the confirmation of having dementia.

Study Design: Health information was obtained by a mail survey (response rate=52%). Among the respondents, 1,279 (60%) were VA users and

843 (40%) were non-users (no VA use in prior 3 years). Specifically, we asked a Yes/No question:

‘‘Do you currently have memory problems that interfere with your daily activities?’’ Stepwise logistic regressions were used to model the relationship between self-reported memory loss and risk factors. Significance levels were at p<=0.05. Additionally, VA national patient care databases were used to screen the dementia diagnostic codes (defined according to the VA

Dementia Registry) for VA users.

Population Studied: Medicare-enrolled male veterans aged >=65 who resided in six large U.S. metropolitan areas in six states (CA, CO, FL, IL,

NY, and TX) in 2002.

Principle Findings: A total of 373 veteran elders

(73% were VA-users) reported having memory loss with strikingly high prevalence of 23% and

13% among VA-using and non-using veterans, respectively. Although the age (65-75 vs. >75 years) between the two veteran groups was not statistically different, the VA-users had more arthritis, cardiovascular conditions, depression, diabetes, chronic low back pain, gastric/peptic ulcers, and prostate disease. They were also more likely to have less education (<=high school) and income (<=20,000), and higher service-connected disabilities (>=50%).

However, the VA non-users had more polypharmacy (>2 prescriptions). Controlling for socio-demographic and co-morbid conditions, we found that current depression status had the strongest association with self-reported memory loss (OR=9.0, 95%CI=6.2-13.1). Additionally, with increasing gradient, household income

<=20,000, daily use of three or more prescription drugs, unfavorable health status

(Fair/Poor/Very Poor vs. Excellent/Very

Good/Good), age >75 years, 50% or more service connected disabilities, history of stroke, and gastric/peptic ulcers were all independently associated with increased likelihood of reporting memory loss (OR ranges 1.4-2.2). By screening the VA national patient care databases, we found confirmation diagnoses for 1 in 5 of the VA users who reported having memory loss. Multivariable analysis identified that self-reported memory loss was most strongly correlated with having a dementia diagnosis (OR=3.7, 95%CI=2.2-6.5), followed by depression (OR=2.2, 95%CI=1.2-3.9) and income <=20,000 (OR=1.9, 95%CI=1.1-3.1).

Interestingly, having arthritis was correlated with not having a dementia diagnosis (OR=0.5,

95%CI=0.3-0.8).

Conclusions: Our findings suggest that selfreported memory loss should be recognized as a potential early sign of dementia or associated depression.


We propose early screening/detection for memory loss of elderly veterans who come to the

VA for health care; thus allowing intervention to be instigated for improving their quality of life and delaying onset of dementia.

Funding Source: VA

Health Care Markets &

Financing

• Health Cost Analysis and Economic Impact on the Medicaid Managed Care as a Result of

Strengthening Cost Contaiment and

Utilization Control Measures on the State

Medicaid Non-Medically Needy Population in

Puerto Rico

Angela Avila, M.B.A., Hector I. Garcia

Maldonado, M.P.H.

Presented By: Angela Avila, M.B.A., Data

Analysis Administrator, Planning and Clinical

Affairs, Puerto Rico Health Insurance

Administration, P.O. Box 195665, San Juan,

Puerto Rico 00919-5661, Phone: 787-474-3300,

Fax: 787-474-3346, Email: aavila@ases.gobierno.pr

Research Objective: To provide a healthcare cost analysis and containment measures for utilization control mechanisms implemented on the MMC plan responding to financial challenges and cutbacks in the Commonwealth of Puerto Rico budget constraints.

Study Design: Healthcare cost analysis were performed based on MMC plan claims and encounters databases as well as utilization and costs trends on actuarial basis. MedInsight

Software was used to develop the healthcare cost analysis based on underwriting and actuarial assumptions. In addition, a budgetary analysis

was conducted to project income and expenditures from the MMC plan.

Population Studied: State Medicaid population consists of nearly half million enrollees for which

Medicaid federal cost sharing policies are not applicable, while Federal Medicaid and SCHIP population is around one million enrollees.

Principle Findings: Healthcare cost analysis showed an increased trend of 8% of the health costs on an annual basis. MMC plan costs increased by 21% from fiscal year 2005 to 2006.

Projected income was $1.4 billion dollars and expenditures by $1.7 billion. The analysis displayed a $314 million dollars deficit for fiscal year 2007. Identified savings were $52 million dollars, which considered prescription drug benefit rebates, Medicare-Medicaid Capitated

Wraparound Integrated Model cutbacks from

$77.00 premium to $26.00 for $85 million reduction, administrative expenses negotiation with the Managed Care Organizations (MCO) by two to four million dollars, Integrated Regional

Service Model implementation on a certain geographic area on the Island with $14 million dollars savings. Cost containment measures include, but were not limited to, increase on the

Medicaid cost sharing for the state population rather than federal ones, limitation of services and benefits on the MMC coverage, and determining a basic benefit package for the state population.

Conclusions: The Government, through the

State and Federal regulation, oversees the benefits and costs applicable to the state lowincome population. It may impose a responsibility on the Medicaid enrollee in order to achieve utilization of the MMC plan emergency room services, inpatient and prescription drug benefits. In addition, the

Government expects to increase awareness in the state low-income population to access preventive services rather than procuring clinical attention.


This analysis impulse changes in the provission of health services and the method of financial and risk arrangements for Medicaid purposes concerning the Statehold income population, regardless of eligibility.

Funding Source: CWF

•

Analyzing Health Care Cost Data in the

Presence of Heterogeneous Patients:

Wouldn't Three Pieces Be Better than One?

James F. Burgess, Jr., Ph.D., Chuan Zhou, Ph.D.,

Paul A. Fishman, Ph.D., Li Wang, M.S., Kevin L.

Sloan, M.D.

Presented By: James F. Burgess, Jr., Ph.D.,

Associate Professor, Department of Health

Policy and Management, Boston University

School of Public Health, 715 Albany Street, T3W,

Boston, MA 02118-2526, Phone: (617) 414-1424,

Fax: (617) 638-5374, Email: jfburges@bu.edu

Research Objective: Accurate estimation and prediction of health care costs play crucial roles in health policymaking. Previous attempts to address the issues raised by heterogeneous patients have not balanced "simplicity and transparency" and "statistical soundness and unbiasedness" in the implicit loss function for choosing methods. Many methods have been proposed; however, sophisticated methods, requiring a high level of statistical knowledge, are not easily interpretable or understood by managers, and also fail to predict costs accurately across the continuum of heterogeneity in severity of illness. And less sophisticated methods tend to be biased and/or perform very poorly in particular regions of the cost distribution. Our objective is to develop a balanced approach to solving the cost estimation problem employing simple generally understood ordinary least squares (OLS) methods in a new way.

Study Design: Case mix diagnostic and demographic information generally employed for risk adjustment first can classify individual patients into spending type groups, then predict health care costs using a separate OLS regression in each group. This is a special case of sub-classification models in statistics, but computationally much simpler to implement than other such models. We compare six models to our proposed three piece OLS model.

We compare OLS and no intercept OLS to four more complex models: log gaussian and log gamma General Linear Models, and two log retransformation models (Duan correction and

Zhou correction) using residual mean square error (RMSE) for overall evaluation, mean absolute prediction error (MAPE) for observation by observation evaluation, and predictive ratios by deciles for evaluation across the distribution of costs.

Population Studied: We employ a 50/50 split sample validation on the population of 3,744,264

FY2001 users of the Department of Veterans

Affairs (VA) health care system.

Principle Findings: OLS models, including the three piece model, have a mean predicted that is closest to the observed mean, and so do best using the RMSE criterion. The log gaussian

model comes closest to these among more complicated models. The three piece model does even better on the MAPE criterion (e.g.

$2785 vs. $3312 for the OLS), but for predictive ratio results, the 10th decile estimated most accurately using OLS alone and the three piece model does worse in that decile. However, a well known problem with the OLS method also is overprediction in the 7th-9th deciles. The three piece model does much better there. The more complex models each have their biases in particular deciles. The log gaussian model dramatically overpredicts most of the lower deciles and underpredicts the 10th decile. The other complicated methods overpredict the 10th decile by ratios exceeding 2.0, though they do better in other deciles than the log gaussian model.

Conclusions: The approach we proposed performs much better on all of the evaluation criteria than other statistical approaches. We have taken a simple approach to subclassification, as opposed to more complex methods previously suggested (i.e. mixture models) to achieve better cost estimation performance.


The three piece OLS method tested achieves the balance between ‘‘simplicity and transparency" and "statistical soundness and unbiasedness" that policymakers can use to better explain costs.

Funding Source: VA

• The Association of Incentives and

Performance with Hospital Closure: A Study of Distress, Recovery and Failure

Dana Forgione, Ph.D., M.S.A., M.B.A., B.B.A.,

Kathryn J. Jervis, Ph.D., Mustafa (Mike) Z.

Younis, Ph.D., Dana A. Forgione, Ph.D., M.S.A.,

M.B.A., B.B.A.

Presented By: Dana Forgione, Ph.D., M.S.A.,

M.B.A., B.B.A., Janey S. Briscoe Endowed Chair in the Business of Health, College of Business,

University of Texas at San Antonio, 18610

Surreywood, San Antonio, TX 78258-4480,

Phone: (210) 458-6319, Fax: (810) 815-5378,

Email: dana.forgione@utsa.edu

Research Objective: The purpose of this study is to examine the association of economic incentives and both financial and nonfinancial performance measures, with hospital financial distress, and either recovery or subsequent closure.

Study Design: Based on expectations formed from an adaptation of the economic Agency theory, we perform a multiple discriminant analysis on data taken from Medicare Hospital

Cost Reports. Based on the analysis, we develop a predictive model to classify hospitals into three groups: financially not-distressed, distressed and recovered, or distressed and closed. We then evaluate the classification efficacy of our model in comparison with the sample proportions as the next-best naive model.

Population Studied: We study a sample of 749 acute care hospitals throughout the US for the years 1997----1999 including those that were financially not-distressed, distressed and recovered, or distressed and closed, as defined by the DHHS Office of Inspector General.

Principle Findings: Consistent with our research expectations, we find that a hospital’s form of ownership control, debt burden, asset investment and occupancy rate are all strongly associated with the hospital’s financial distress, recovery or closure. Contrary to expectations, while the Medicare & Medicaid proportion and profitability are important factors, we find that they do not have strong discriminatory power for our sample with respect to financial distress.

Our model yields a collective 96.3% improvement in classification efficacy over the next-best naïve model, with strongest improvement in classifying the closed hospitals

(52.9% improvement) and recovered hospitals

(42.1% improvement), respectively.

Conclusions: Our model demonstrates strong classification accuracy, with highly significant discriminant functions in each year. In general our research hypotheses are supported, and our results demonstrate that a hospital’s form of ownership control is associated with its financial distress, recovery or closure. As expected, the debt burden, asset investment and occupancy rate are very strongly associated with hospital distress, recovery or closure. While Medicare &

Medicaid policies and hospital profitability are important, our results indicate that their effects are not differential enough across our sample hospitals to be a strong discriminator of financial distress.


The results of our study provide information useful for evidence-based healthcare policy makers with respect to understanding the distribution of cost, quality and access to care, by improving our understanding of the economic factors associated with hospital distress, and recovery or closure. Healthcare policy makers must be especially cognizant of changes in funding that impinge on a hospitals ability to service its debt, exacerbate declining occupancy,

or encourage over-capacity investment in assets.

Our results also provide information useful for the advancement of hospital management decision making with respect to navigating areas of performance that are associated with financial failure or recovery in an era of continuing cost containment pressures. As important as profitability and the Medicare & Medicaid proportion are, our results indicate that when it comes to financial distress and risk of failure, hospital managers will need to focus their priorities on scrutinizing their debt financing and asset investment practices, especially in the light of any adverse trends in occupancy rates.

• Financial Impact of Niche Hospitals on

General Hospitals

Gilbert Gimm, Ph.D., Deborah Chollet, Ph.D.,

Cheryl Fahlman, Ph.D., Su Liu, Ph.D., Allison

Liebhaber, B.A.

Presented By: Gilbert Gimm, Ph.D., Health


Maryland Avenue, SW; Suite 550, Washington,

DC 20024, Phone: (202)264-3460, Fax: (202)554-

7552, Email: ggimm@mathematica-mpr.com

Research Objective: This study examined the status and financial performance of niche and general hospitals in Texas between 2000 and

2004, and used multivariate analysis to estimate the impact of niche hospitals on the financial performance of general hospitals.

Study Design: We used ordinary least squared regression analysis to examine American

Hospital Association survey data on general and niche hospitals in Texas from 2000 to 2004. For general hospitals, we analyzed: (1) operating margin, (2) total margin, and (3) the amount of uncompensated care as a percent of revenues.

Niche hospitals were identified using criteria from the Texas state legislature and Center for

Medicare and Medicaid Studies. Markets were defined as health service areas (HSAs) in which niche hospitals were present or absent. Our key explanatory variable was the percent of admissions to niche hospitals within an HSA.

Control variables in the analysis included facility characteristics, HSA demographic characteristics, and market characteristics.

Population Studied: All general and niche hospitals in Texas in continuous operation for an entire year and that responded to the AHA survey. The final sample for the multivariate analysis (n=1,698) excluded psychiatric, rehabilitation, long-term care facilities and other facilities with incomplete or missing financial data between 2000 and 2004. The unit of observation was the individual hospital-year.

Principle Findings: In 2004, niche hospitals reported a higher average percentage of privatepay patients (54 versus 31 percent) than general hospitals and fewer Medicaid patients (3 versus

19 percent). Also, niche hospitals provided little uncompensated care (1.4 percent) compared with general hospitals (10.2 percent). Operating and total margins of niche hospitals were higher than that of general hospitals. Controlling for other factors that influence hospital margins and uncompensated care, there was no significant evidence that the presence of a niche hospital had an adverse impact on the financial performance of general hospitals in the same market area between 2000 and 2004. The most important predictor of the financial performance of general hospitals was for-profit tax status.

Conclusions: We did not find evidence that niche hospitals had an adverse impact on the financial performance of general hospitals between 2000 and 2004. Instead, for-profit tax status accounted for most of the explained variation in general hospital operating margins.

However, niche hospitals reported a much greater proportion of private-pay patients and provided relatively little uncompensated care compared with general hospitals.


These findings suggest that niche hospitals did not have an adverse impact on general hospitals during this period. However, this result does not imply that long-term effects or impacts at the local level will be neutral. The significant gap in the amount of uncompensated care provided by niche hospitals suggests that state policymakers should monitor the growth of niche hospitals and consider the role of transfer payments to general hospitals in support of the uninsured.

• Which Hospitals Give Discounts? The Role of Institutional and Environmental Factors

Amir Khaliq, Ph.D., Stephen L. Walston, Ph.D.

Presented By: Amir Khaliq, Ph.D., Associate

Professor, Health Administration and Policy,

University of Oklahoma Health Sciences Center,

College of Public Health, 801 NE 13th Street,

College of Health Building, Room 345, Oklahoma

City, OK 73104-5072, Phone: 405-271-2115 x37073,

Fax: 405-271-1868, Email: amirkhaliq@ouhsc.edu

Research Objective: To understand the role of institutional and environmental characteristics as predictors of hospitals' discounting behavior

Study Design: Test of 8 different hypotheses through linear regression analysis of American

Hospital Association Annual Survey data on hospital characteristics and Centers for Medicare and Medicaid Services (CMS) financial data for the same hospitals for the years 2000-2003.

Population Studied: All 1354 community general hospitals in fifteen states (representing a 27% sample of all medical/surgical hospitals in the dataset) included in the American Hospital

Association Annual Survey for the year 2000.

Principle Findings: The number of beds set-up and staffed, membership in a multi-hospital system, location in a Metropolitan Statistical

Area (MSA), affiliation with a medical school, total number of Medicare inpatient days, and mean net income for the four year period were positively associated (p<0.001) with the total amount of discounts provided by the hospital in the years 2000-2003 while total number of

Medicaid inpatient days and Herfindahl Index

(representing market share for hospital admissions in the geographic market) were negatively linked with the amount of discounts.

Altogether, the model explained 61% of the variation in discounts provided by hospitals in the fifteen states.

Conclusions: Discounts can be viewed as a strategy on the part of the hospital to succeed in a competitive market. The study demonstrates that the factors associated with the extent to which this strategy is adopted by a given hospital are largely a function of the environment in which the hospital operates.


Understanding the factors that influence hospitals' discounting behavior is important for third-party payers to exercise leverage in price negotiations.

• The Differences in Certificate of Need

Regulatory Processes that Influence Cost,

Quality, and Access

Glenn Landers, M.B.A., M.H.A., Bernette

Sherman, M.P.A., Patricia Ketshce, Ph.D.,

William Custer, Ph.D., Karen Minyard, Ph.D.




Street,Suite 221, Atlanta, GA 30002, Phone: 404-


Research Objective: Most studies that examine the effect of Certificate of Need on health care delivery assume little variation in the process of implementing these laws. We examine variations in the implementation of CON that affect the cost of market entry.

Study Design: Information on CON regulation was collected from Florida, Georgia, Iowa,

Maine, Massachusetts, Oregon, Washington,

West Virginia, and Wisconsin. Publicly available information was supplemented with in-depth interviews for all states except West Virginia.

Wisconsin’s CON program, although listed as active, has not been active for fifteen years.

Population Studied: Nine states with varying degrees of CON regulation.

Principle Findings: The states vary in fees, administrative requirements, reviewability, appeals, and administrative complexity.

Pre-application Process: All states will pre-review a project to determine reviewability, but Florida and Georgia are the only states requiring a Letter of Non-reviewability or Exemption for certain proposals, and Georgia is the only state that charges a fee for determination of reviewability.

A Letter of Intent for the state’s regular review process is required by six of the eight active CON programs. The ability of an applicant to review the rules and standards for CON is assessed as a measure of the complexity of the CON process. Six of the eight states provide information related to rules and/or standards on their web pages. Every state except Maine publishes at least some criteria for completing a needs assessment online. Maine requires that applicants receive technical assistance from

CON staff. Review Process: A more competitive application process creates an entry barrier and additional costs. Only Iowa does not conduct competitive, joined, or batched reviews for any proposal. Application hearings add to the rigor of CON programs by allowing external parties into the decision-making process. Only two states build pre-decision hearings into the standard process, while the others only hold predecision hearings upon request. The time from submission of a Letter of Intent to application approval or denial (except in cases of expedited or emergency determinations) ranges from three months to one year. Most states indicate that applicants, competitors, and taxpayers may appeal decisions, but West Virginia statutes indicate that any person may request a reconsideration of a decision. Appeals can lengthen the review process from between one month to two years. No state assesses appellants for appealing a decision. Each party

bears its own costs associated with preparing an appeal.

Conclusions: There is considerable variation in the process of CON regulation which is likely to affect the impact of CON regulation on the health care delivery system.


Policy makers and researchers should be cognizant of the fact that merely enacting CON laws might not in and of itself achieve the intended policy goal. Rather, the processes by which CON regulations are implemented and the scope and rigor with which they are implemented also have influences on health care delivery cost, quality, and access. Comparative analyses of the effect of CON should include consideration of the rigor of the processes in place.

Funding Source: Georgia Department of

Community Health

• Effect of Physician Financial Self-Interest on

Utilization of Diagnostic Imaging in the

Medicare Population: Further Results

Rebecca S. Lewis, M.P.H., Rebecca S. Lewis,

M.P.H., Jonathan H. Sunshine, Ph.D.

Presented By: Rebecca S. Lewis, M.P.H., researcher, Department of Research, American


Reston, VA 20191, Phone: (703) 295-6771, Fax:

(703) 264-2443, Email: rlewis@acr.org

Research Objective: Diagnostic imaging constitutes the fastest growing major component of Medicare costs, growing at a rate of 10% annually between 1999 and 2003, and

16% between 2004 and 2005 as reported by

MedPAC in its June 2006 data book. The objective of this study is to examine the effect of physician financial self-interest on Medicare imaging use, while controlling for beneficiaries’ demographic and clinical characteristics.

Study Design: Treating physicians are classified into four categories: (i) self-referrer if the treating physician performs imaging procedures on any patients, (ii) radiologist-referrer if the treating physician always refers imaging to a radiologist,

(iii) same-specialty referrer if the physician is not a self-referrer but sometimes refers patients to another physician of the same specialty as himself or herself, and (iv) others. Physicians are classified into these categories separately for each imaging modality (for example, MRI, CT, ultrasound). Self-referrers are regarded as financially-self-interested; radiologist referrers as not; same-specialty referrers are probably referring to physicians within their own group and thus potentially financially self-interested.

For 12 varied medical conditions, including chest pain, digestive tract cancers, and respiratory ailments, we compare the rate of imaging utilization (or imaging ordering) of physicians in each of these categories, while controlling for patient characteristics (age, gender, race, comorbidities, total Medicare costs in the preceding year, and whether the patient has state buy-in for Medicare), characteristics of the state and county of residence, and specialty of the treating physician. (Differences among specialties may reflect differences in patient severity or in specialties’ practice patterns.)

Outcomes of interest are (a) whether a patient receives an imaging procedure and, if so, (b) number of images and (c) imaging dollars per patient. We use the Medicare 5% Limited Data

Set claims files. All statistical analyses use standard techniques, such as logistic regression for outcome (a) and linear or log-linear regression for outcomes (b and c).

Population Studied: 5% sample of Medicare beneficiaries for 2002-2004.

Principle Findings: 2004 data for the 25 medical condition/imaging modality combinations we study show that, taking account of all the controls, self-referrers average 2.5 times the utilization of radiologist referrers. The selfreferrers’ utilization exceeds than that of radiologist-referrers by 40% or more for all except one of the 25 combinations. When there is imaging, the number of images per patient generally does not differ.

Conclusions: When financial self-interest exists, physicians order more images.

Preliminary 2002-2003 results are consistent with findings for 2004. Ongoing analysis of same-specialty referrers will yield findings on these physicians.


Much of the recent growth in healthcare expenditures may be explained by technological progress in medicine, i.e., medicine’s ability to do more for each patient now than it could several years ago. However, this growth and levels of utilization have been found to be highly variable across geographical areas, subpopulations, and physicians. Identifying the part of variability that can be attributed to physician financial self-interest will assist payers and policy makers in designing optimal initiatives to help ensure physicians utilize diagnostic imaging appropriately.

• The Effect of Price Control Policy on

Pharmaceutical Expenditure - Evidence from

Taiwan

Shuen-Zen Liu, Ph.D., Chi-Liang Chen, Ph.D. candidate

Presented By: Shuen-Zen Liu, Ph.D., Professor,

Department of Accounting, College of

Management, National Taiwan University, No. 1,

Sec. 4, Roosevelt Road, Taipei, 10617 Taiwan,

Taipei, 10617, TW, Phone: +886-2-3366-1122,

Fax: +886-2-2363-8038, Email: sliu@management.ntu.edu.tw

Research Objective: The objective of this study is to explore whether Taiwan’s drug price control policy has been substantially helpful in controlling the price level of drugs consumed in

Taiwan’s national health insurance program

(NHIP), and to curb the growth of drug expenditure.

Study Design: We investigated the difference in the average daily expense of a drug treating hypertension between a period before a drug price control policy and a corresponding period after the policy. There have been three major regulatory actions of drug price control taken by the NHIP. For each price control action by the

NHIP, we conducted such a before-after investigation. We applied the random-effects linear model to estimate coefficients in our empirical specification, and let hospitals be the units of observation.

Population Studied: In this study, the target cohort for investigating the consequence of a drug price control action was a group of elderly

Taiwanese aged 65 or older and already having hypertension before the starting day of the drug price control policy. The sample for our analysis is a national representative cohort and there are

8,858 patients and 75,120 outpatient visits.

Principle Findings: We found that Taiwan’s first two actions of drug price control were generally ineffective for reducing the price level of drugs consumed by Taiwanese elderly people, but the effect of price control policy did get stronger from the first to the third action, and this phenomenon was associated with the magnitudes of price reduction for the three actions.

Conclusions: Our results indicate that drug price control policy is not necessarily effective for controlling the price level of prescription drugs.

It appears that the extent of price reduction and the possibility for physicians to change the items of drugs for their prescriptions play influencing roles in determining the effects of drug price control policy. To effectively respond to changes in the prescribing behaviors of physicians and hospitals, the government had better generate information showing changes in drug prescribing patterns in a timely manner. One way is to periodically build health accounts that can show the items of drugs consumed, and investigate changes in drug prescription patterns for all pharmacology types. Information from such an investigation will be helpful for formulating policies and regulations to control inappropriate behavioral changes in drug prescription.


Our findings show that policy makers should carefully examine physicians’ opportunities to change prescriptions when designing this type of policy. Our investigation contributes to better predicting and monitoring the effects of drug price control policies in Taiwan and elsewhere.

• The Increasing Cost of Maintaining

Emergency Department On-Call Coverage

Kenneth John McConnell, Ph.D., Raymond Lee,

M.D., Craig Newgard, M.D., M.P.H.

Presented By: Kenneth John McConnell, Ph.D.,

Asst. Prof, Emergency Medicine, Oregon Health

& Science University, 3181 SW Sam Jackson Park

Rd. Mail Code CR-114, Portland, OR 97239,

Phone: (503) 494-1989, Fax: (503) 494-4640,

Email: mcconnjo@ohsu.edu

Research Objective: A recent change in the way that the Centers for Medicare and Medicaid

(CMS) interprets the Emergency Medical

Treatment and Active Labor Act (EMTALA) appears to have increased hospitals’ difficulties in maintaining emergency department on-call coverage. In efforts to maintain emergency department on-call coverage, hospitals have resorted to paying specialists stipends to take call. Anecdotal evidence suggests that specialists’ demands for stipends to take call are on the rise. Such changes may erode hospital operating margins and affect the ways in which hospitals provide services. The objective of this study was to assess changes in on-call related costs and service delivery in Oregon hospitals, using 2 years of survey data.

Study Design: This was a longitudinal, standardized survey of CEOs from all hospitals with emergency departments in Oregon (N =

56). The first wave was conducted in the summer of 2005; a follow-up survey was conducted in summer 2006.

Population Studied: 56 Oregon hospitals with emergency departments.

Principle Findings: 42 out of 56 hospitals provided completed surveys for 2005 and 2006, representing a 75% response rate. Among the 20 hospitals (49%) who paid stipends to at least one specialty in 2006, 18 (90%) of them had increased their total stipend payments since

2005. Among these hospitals, total annual payments averaged $898,000 per hospital, representing a 42% increase between 2005 and

2006. Increases in total stipend payments were driven primarily by increases in the magnitude and prevalence of stipends for general surgeons and orthopedic surgeons. Moreover, 22 hospitals (52%) indicated that they had lost 24-7 coverage for at least one specialty in 2006. Of these hospitals, 14 (64%) noted that they managed these shortages by transferring to other facilities on an ad-hoc basis, without formal pre-arrangements for such transfers. 6 of

25 trauma centers (24%) noted that their trauma designation had been affected in 2005 or 2006 because of difficulties in maintaining on-call coverage.

Conclusions: The cost of maintaining on-call coverage is increasing in Oregon, raising concerns about hospital financing and a degradation of the trauma system. Importantly, there has not been a systematic response to oncall shortages, with patient transfers primarily managed in an ad hoc, case-by-case basis.


Hospitals and physicians are redefining their responsibilities to the financial, regulatory, and patient care components of emergency on-call coverage. In Oregon, the delivery of emergency care has changed dramatically over the last 2 years. However, despite evidence of problems in

Oregon, the problem may be substantially worse in other states. Without explicit policies to improve call coverage, policy-makers must monitor the viability of trauma systems and the implications for patient outcomes.

Funding Source: Emergency Medicine Fund

•

Health Plan Investments in Diabetes Care

Saved Money and Improved Quality

Patrick O'Connor, M.D., M.P.H., George J.

Isham, M.D., David Cutler, Ph.D., Nancy Dean

Beaulieu, Ph.D., Katherine E. Ho, Ph.D., Andrew

F. Nelson, M.P.H.





Phone: (952)967-5034, Fax: (952)967-5022,


Research Objective: Diabetes is a common and very costly chronic disease. There is broad-based agreement on how to manage diabetes, yet less than 40% of adults with diabetes achieve guideline-recommended goals of medical care.

Study Design: We investigate the reasons for this phenomenon by examining the business case for improved diabetes care from the perspective of a single health plan

(HealthPartners of Minnesota). The potential benefits accruing to a health plan from a diabetes care improvement program delivered through existing primary care clinics include medical care cost savings and higher premiums.

The potential costs to the health plan derive from diabetes care improvement program costs and adverse selection.

Population Studied: All adults with diabetes who were insured at a single health plan for at least one year between 1994 and 2004.

Principle Findings: We find that medical group implementation of a low-cost, integrated, primary care clinic-based diabetes care improvement program coincided with large health improvements for adults with diabetes.

Substantial and sustained improvements were noted in glycated hemoglobin levels, cholesterol levels, amputation rates, and heart attack rates in adults with diabetes during the 10-year study period. For example, the glycated hemoglobin

(A1c) median value improved from 8.7% in 1994 to 6.8% in 2004, while the amputation rate decreased from 10.7 to 4.5 amputations per 1000 adults with diabetes per year from 1994 to 2004.

For a defined population of diabetes patients, cumulative discounted per patient program costs totaled $233 over 10 years, while cumulative discounted per patient net savings to the health plan were $5,345. Medical care cost savings over several years were small in the closed panel medical group but moderate for the health plan overall. We find evidence that adverse selection and the timing of cost and benefits worsen the health plan business case.

In addition, the payment systems, from purchaser to health plan and health plan to provider, are very weakly connected to the quality of diabetes care, further weakening the business case for both health plans and for medical groups. Finally, overlapping provider networks create a public goods externality that limits the health plan’s ability to privately capture the benefits from its investments.

Conclusions: During the 10-year study period, quality of diabetes care improved significantly.

Son of this improvement may have been attributable to health plan investments intended to improve diabetes care, but many other factors were also involved. The improved care appeared to be related to lower than expected rates of resource use by diabetes patients during the study period.

Implications for Policy, Practice or Delivery: It is clear that improved diabetes care affords economic benefits to health plans as well as valuable quality of life benefits to adults with diabetes. Improving the business case for better diabetes care at the medical group level may further accelerate diabetes care improvement.


Foundation

•

Physician Participation in the California

Workers' Compensation System

Dylan Roby, Ph.D., Nadereh Pourat, Ph.D., Dylan

H. Roby, Ph.D., Meghan E. Cameron, M.P.H.

Presented By: Dylan Roby, Ph.D., Research

Scientist, Center for Health Policy Research,

UCLA, 10960 Wilshire Boulevard, Suite 1550, Los


310-794-2686, Email: droby@ucla.edu

Research Objective: To assess the impact of reforms on provider participation in the

California Workers' Compensation system. In

2003 and 2004, significant reforms to the system resulted in the mandatory adoption of clinical guidelines by providers, decreased choice of certain providers, and reduced payments to providers. This study examines provider’s responses on how these changes affected their participation in the system.

Study Design: A stratified random sample of

1,077 physician providers was surveyed. These providers were asked questions about their practices, their workers' compensation patient caseloads, levels of reimbursement for services, and barriers to access, quality, and participation in the system before and after the reforms.

Population Studied: Providers included those defined as physicians by the California Labor

Code, including Medical Doctors, Doctors of

Osteopathy, Clinical Psychologists, Podiatrists,

Acupuncturists, and Chiropractors Dentists and optometrists who are also defined as providers under the Labor Code, were not included due to their very low volume of workers’ compensation care.

Principle Findings: The majority of providers believed injured workers did not have adequate access to quality care and even more believed that access had declined since the 2004 workers' compensation (WC) reforms. These unfavorable perceptions were particularly prevalent among chiropractors and acupuncturists, compared to

Medical Doctors and Osteopaths (MD/DO), podiatrists, and clinical psychologists. Among

MD/DO specialties, orthopedic surgeons also perceived a lack of access to quality care and a decline in access since 2004. More than onethird of providers report they plan to quit WC entirely (14%) or to reduce their WC volume in the future (21%). Providers most often reported that improvements in the authorization/UR process (25%) and in the fee schedule (24%) would help them to continue treating WC patients.

The majority of providers (54%) who reported being paid more than 15% below the fee schedule reported they are planning to decrease their WC volume or quit WC care entirely. In comparison, only 29% of providers paid at the fee schedule and 37% of providers paid from 1% to 15% below the fee schedule had similar plans to decrease volume or to quit the system.

Conclusions: Despite physician dissatisfaction with elements of WC reform, the majority of physicians continue to participate in the workers’ compensation system in California. However, some declines are noted among certain types of providers mostly due to more stringent utilization review, implementation of specific guidelines, and changes in the payment levels.


Streamlining the authorization/UR process to improve access to care for injured workers and increases in the fee schedule or limits on the discounts below the fee schedule imposed by insurers may be warranted to ensure continued broad provider participation in the WC system.

However, it is not clear whether these policy enhancements would prevent further exodus of physicians in response to such policy changes.

Further research is needed to establish trends in injured worker access and provider participation since the 2004 reforms.

Funding Source: California Division of Workers'

Compensation

•

National Health Expenditures by Medical

Condition, Annual Estimates: 1996 - 2004

Charles Roehrig, Ph.D., George Miller, Ph.D.,

Craig Lake, M.A.

Presented By: Charles Roehrig, Ph.D., Vice

President, Health Solutions Division, Altarum

Institute, PO Box 134001, Ann Arbor, MI 48113-

4001, Phone: (734) 302-4646, Fax: (734) 302-

4991, Email: charles.roehrig@altarum.org

Research Objective: While the official US

National Health Expenditure Accounts (NHEA) routinely track personal health expenditures according to type of service (hospital, physician, etc.) and source of funds (private insurance,

Medicare, etc.), there is no regular reporting of spending by medical condition. Yet such information is critical to a more complete understanding of what lies behind the increase in expenditures, what we are getting in return, and where we should focus efforts to improve health and healthcare in the United States. This paper seeks to fill this information gap by providing annual NHEA-consistent estimates of personal health expenditures by medical condition for the years 1996 through 2004.

Study Design: We decomposed NHEA personal health expenditures (PHE) for each year into cells defined by service type and population segment (e.g., hospital services delivered to the civilian non-institutional population). For each cell and year, we used national data from sources such as the Medical Expenditure Panel

Survey (MEPS) and the National Nursing Home

Survey (NNHS) to estimate how that cell’s PHE were distributed across medical conditions. We then summed results across all service types and population segments to produce PHE by medical condition for each year. We employed the Clinical Classification System developed by the Agency for Healthcare Research and Quality for our medical condition definitions. We compared our results for 1997 to published estimates for that year and explained the differences in terms of factors such as the population covered and elimination of double counting.

Population Studied: The population included in this study consists of all individuals who generated personal health expenditures in the

US between 1996 and 2004. Population segments include civilian non-institutional, nursing home residents, other institutionalized populations, and active duty military. Most previous studies of spending by medical condition have focused solely upon the civilian non-institutional population.

Principle Findings: This study provides, for the first time, annual estimates of NHEA personal health expenditures by medical condition. In

2004, the top three conditions in terms of expenditures were mental disorders, heart disease, and trauma.

Conclusions: Studies that focus solely on the civilian non-institutional population understate the share of health expenditures for mental disorders. Our findings also suggest that trends in disease prevalence are an important determinant of expenditure growth rates for particular medical conditions and should be a key consideration in assessing the value of such expenditures.


Understanding the time history of national personal health expenditures by medical condition is important to identifying effective and financially sustainable ways to improve health and healthcare in the coming years.

While further research is warranted, our first look emphasizes the importance of preventive measures such as addressing the problem of obesity. Effective control of those chronic conditions that lead to other conditions is another important form of prevention. As with all health expenditures, it will be important to study the relative value of alternative approaches to prevention.

Funding Source: Pharmaceutical Research and

Manufacturers of America

• Explaining Cost Inefficiency of AMI

Treatment among VA and German Hospitals

Jonas Schreyoegg, Ph.D., M.A., Tom Stargardt,

M.A., Oliver Tiemann, M.A.

Presented By: Jonas Schreyoegg, Ph.D., M.A.,

Commonwealth Fund Harkness Fellow, Center for Health Policy, Stanford University, 117 Encina

Commons, Stanford, CA 94305-6019, Phone: 650

736 0405, Fax: 650 723 1919, Email: jonass@stanford.edu

Research Objective: The objective is to explain cost inefficiency of AMI treatment among VA and German hospitals.

Study Design: The study follows a four-level approach including explanatory variables for patient characteristics/co-morbidities, treatment characteristics (e.g. procedures and OR days) and hospital characteristics. As a fourth level the regulatory environment is considered in a qualitative way. Total costs per case were taken as a dependent variable. Hierarchical linear regression (HLR) with hospital characteristics as second hierarchy was performed to explain cost inefficiency. Exogenous Switching Regression

(ESR) was applied to explain differences in cost efficiency between VA and German hospitals.

Population Studied: The study includes data from 31 VA hospitals with n=1200 AMI cases and

17 hospitals from Germany with n=420 AMI cases. All selected hospitals are general acute care hospitals and apply step-down-accounting.

Principle Findings: Results of HLR show that treatment characteristics and hospital characteristics explained large parts of cost inefficiencies while patient characteristics played a minor role. Risk-adjusted mean costs for AMI treatment are higher for VA hospitals than for

German hospitals. This is mainly due to higher wages for medical staff, higher overheads and more intense use of medical technologies in VA hospitals. Results from ESR suggest that hospital characteristics are more important for

VA hospitals to explain cost inefficiencies than for German hospitals.

Conclusions: The results suggest that cost efficiency is rather determined by hospital managers and physicians than by patient characteristics. Although VA hospitals generate savings by purchasing supplies centrally, they are still less cost efficient than German hospitals.


The results suggest VA hospitals should make use of physician profiling to reduce potential overuse of technologies. Next to other criteria hospital characteristics should be taken into consideration when choice of hospitals is possible in case of elective procedures.

Funding Source: CWF

• Consumer Opinions and Attitudes Toward

Corporate Advertising in the Pharmaceutical

Industry

Mansi Shah-Patel, Ph.D., John P. Bentley, Ph.D.,

M.S., M.B.A., B.S.Ph., David J. McCaffrey, Ph.D.,

M.S., B.S.Ph., Alicia Bouldin, Ph.D., M.S.,

B.S.Ph., B.A., Victoria Bush, Ph.D.

Presented By: Mansi Shah-Patel, Ph.D.,

Graduate Student, Pharmacy Administration,

University of Mississippi, Faser Hall, Room 211,

University, MS 38677, Phone: (662) 513 6237,

Fax: (662) 915 5102, Email: mshah@olemiss.edu

Research Objective: Although a recent increase in corporate advertising by healthcare organizations has been observed, there is little information available to suggest whether such promotional campaigns are effective. The pharmaceutical industry rarely has been studied in the context of its reputation among end consumers (i.e., patients). The objective of this study is to assess experimentally the impact of pharmaceutical corporate advertisements on attitudes toward the pharmaceutical industry

(PhAtt) and the advertised company (CAtt), intentions to trust the industry (PhTrust) and the company (CTrust), and intentions to watch a similar advertisement in the future (WatchAd).

Brown’s (1998) conceptual framework was employed along with attribution theory in order to explain the hypothesized relationships.

Study Design: The study employed a pre-testpost-test, matched sample, experimental design.

The study sample was divided randomly into three groups. One group was exposed to a goodwill corporate advertisement (promoting a prescription discount program) and the second group was exposed to a name identity corporate advertisement (promoting the company’s research activities and investments). Both advertisements promoted the same company.

The third group, a control group, was not exposed to any advertisement. A researcher - administered survey was used for data collection.

Population Studied: The study population comprised of non-teaching staff at a public university.

Principle Findings: Subjects’ CAtt scores were significantly (p<0.05) more positive, and they scored higher on WatchAd, if they viewed either of the two advertisement types, as compared to subjects not exposed to any advertisement.

Subjects exposed to the goodwill advertisement reported significantly higher likelihood to trust the pharmaceutical industry and the advertised company than the no advertisement group.

However, there were no significant differences in

CAtt scores or WatchAd scores between subjects that saw the goodwill advertisement versus subjects that saw the name-identity advertisement. Subjects’ attributions of the pharmaceutical company’s reasons for running the advertisement (causal attributions) were related to PhAtt and CAtt (p<0.05). Regardless of their prior attitude toward the industry, subjects who viewed the goodwill advertisement tended to attribute more public-serving motives to the company for airing the advertisement.

However, for subjects who viewed the name identity advertisement, those reporting more positive prior attitudes toward the industry attributed more public-serving motives; whereas company-serving motives were attributed by those with more negative prior attitudes toward the industry.

Conclusions: Corporate advertisement on television not only positively influences consumers’ opinions of the advertised company,

but also makes it more likely that they will pay attention to similar advertisements in the future.

Regardless of prior attitude toward the industry, consumers attribute goodwill advertising to more public-serving motives of the industry.

This was not the case for name-identity advertisement.


Certain types of corporate advertising can serve a dual purpose of not only promoting the advertising entity but by also informing the public about various resources (other than their primary product) they provide for improving public health and access to care. In addition, such advertising may help the public to understand industry policies and practices, and to be less skeptical and more accepting of the benefits that the industry is capable of providing, hence increasing utilization of such resources.

•

The Effect of Certificate of Need

Regulations on the Availability and Use of

Cancer Resections

Marah Short, M.A., Thomas Aloia, M.D., Vivian

Ho, Ph.D.

Presented By: Marah Short, M.A., Research

Analyst, Baker Institute for Public Policy - MS 40,

Rice University, 6100 Main Street, Houston, TX

77005, Phone: (713)348-4374, Fax: (713)348-5278,

Email: mnshort@rice.edu

Research Objective: Several states use

Certificate of Need (CON) regulations to control the growth of acute care services, but previous studies have not considered the possible association between these restrictions and cancer care. We compare states with and without CON regulations for acute care in terms of access to and utilization of six cancer operations.

Study Design: We obtained Medicare data for beneficiaries age 65 and over who had received one of six different cancer operations during the years 1989 through 2002. We obtained incidence rates by state and year for each cancer site associated with these procedures. We compared the number of hospitals performing each operation per 100 cancer incidents, the number of procedures performed per 100 incidents, and average hospital volume, among states with and without CON regulations and for states that discontinued CON during the sample period.

Population Studied: Medicare beneficiaries age

65 and over who had received a colon resection, rectal resection, lobectomy, pneumonectomy, esophagectomy, or Whipple procedure for an associated cancer diagnosis during the years

1989 through 2002.

Principle Findings: The number of hospitals per

100 incidents was significantly lower in CON versus non-CON states for four of the six procedures (e.g. 3.107 vs. 5.065 for colon resection p=0.001; 6.969 vs. 8.758 for rectal resection p=0.002; 0.900 vs. 1.114 for lobectomy p=0.005; 2.411 vs. 4.407 for esophagectomy p=0.001 in 2002). There was no significant difference between states with and without CON in the number of procedures per 100 incidents for any of the six operations. Hospital volume was significantly higher in CON versus non-CON states for four of the six procedures (e.g. 17.251 vs. 11.343 for colon resection p=0.000; 5.421 vs.

4.204 for rectal resection p=0.000; 8.618 vs.

6.845 for lobectomy p=0.001; 1.932 vs. 1.676 for pneumonectomy p=0.089 in 2002). There was no systematic change in the number of hospitals or operations per 100 incidents for the states that discontinued CON.

Conclusions: States with acute care CON tended to have more facilities performing cancer resections per cancer patient, but overall utilization of cancer procedures was similar in

CON and non-CON states. Correspondingly, average hospital procedure volume for four of the six cancer operations was higher in CON states.


Past studies have documented an association between higher hospital procedure volume and lower mortality rates for the cancer operations we studied. Therefore, acute care CON regulations may be associated with lower mortality rates for several cancer operations.

However, a lower supply of hospitals per 100 incidents in CON states along with the same number of procedures per 100 incidents as in non-CON states may enable CON states to charge higher prices for cancer surgery. The costs and the benefits of acute care CON for cancer patients should be carefully weighed and explored in further detail.


• The Price Effect of Hospital Closures

Vivian Wu, Ph.D.

Presented By: Vivian Wu, Ph.D., Assistant

Professor, School of Policy Planning and

Development, University of Southern California,

650 Childs Way, RGL 305, Los Angeles, CA

90089-0626, Phone: 213-740-6526, Fax: 213-740-

1801, Email: vivianwu@usc.edu

Research Objective: To examine the potential price effect of hospital closure ---- whether hospital closures occurred in the 1990s allowed their surviving competitors to raise prices?

Study Design: This paper utilizes modified rival analysis to examine such price effect for urban acute general hospitals that exited the market between 1993 and 1998. I categorize the competitors into different rival groups by distance, and examine whether a closure has differential impact on these groups.

Population Studied: All the competitors of a studied hospital closure (i.e., all acute general hospitals located within the same market) in the

US.

Principle Findings: I find some support for a small price increase among competitors located nearest to the closed hospitals (less than 5 miles). However, this is only a one-time price effect. There is no additional price hike within three years following a closure.

Conclusions: This research finds limited price effect in the remaining market as a result of the closures occurred between 1993 and 1998. The overall results are consistent with the explanations that hospital closures are facilitated to consolidate excess capacity, perhaps due to increased competition and demand contraction.

The market power implication on the remaining market is limited.


Hospital closures appear to be different from other forms of consolidation, such as mergers and system formations, in that it does not affect dramatically the market power of resulting players. Hospitals may have consolidated excess capacity to reflect the reduced demand for inpatient services in the 1990s. This would imply some efficiency gains. However, it also implies that hospitals may have to invest and build more capacity in the case of demand expansion in the future.


• Health Care Safety Net Providers Face

Significant Challenges

Obaid Zaman, M.P.P., Ellen Lukens, M.P.H.,

Linda Cummings, Ph.D.

Presented By: Obaid Zaman, M.P.P., Senior

Research Analyst, Research, National

Association of Public Hosptials and Health

Systems (NAPH), 1301 Pennsylvania Avenue,

NW, Suite 950, Washington, DC 20004, Phone:

(202) 585-0108, Fax: (202) 585-0101, Email: ozaman@naph.org

Research Objective: The purpose of this paper is to observe the financial and utilization trends that are occurring at the safety net hospitals that make up the membership of the National

Association of Public Hospitals and Health

Systems, also known as NAPH. Where appropriate, comparisons will be made with U.S. hospitals nationally over the same period of time.

Study Design: The data is drawn from the

NAPH Annual Hospital Characteristics Survey of members. The analysis is done on a on a matched set of hospitals that completed the survey each year from 1998 to 2004.

Comparison data for U.S. hospitals nationally are drawn from the American Hospital Association

Annual Survey of Hospitals.

Population Studied: The 59 member hospitals of NAPH that completed the Annual Hospital

Characteristics Survey each year from 1998 to

2004 make up the population studied in this paper.

Principle Findings: In 2004, the average margin for NAPH members was 1.2 percent- 4 percentage points lower than the average margin of 5.2 percent for all hospitals in the U.S.

Margins for NAPH hospitals and other hospitals nationally were 2.0 percent and 5.8 percent respectively in 1998.

Between 1998 and 2004, NAPH members experienced a 45 percent increase in average expenses for resident salaries and benefits, more than twice the rate of inflation over the same period of time. NAPH members also saw a 79 percent increase in the average cost of medical and surgical supplies since 1998, rising from

$14.3 million on average to $24.8 million.

NAPH members represented 2 percent of the nation’s acute care hospitals in 2004, and delivered 25 percent of the uncompensated care provided by U.S. hospitals that year. For hospitals nationally, 5.6 percent of costs were uncompensated compared to 21 percent of public hospital costs.

The average number of outpatient visits for an

NAPH member hospital exceeded 400,000 in

2004, a 23 percent increase over just six years earlier. The average NAPH member provides three times the volume of these ambulatory care visits as other acute care hospitals.

Conclusions: Public hospitals often experience small or negative financial margins. These scarce resources are often needed to support the special services that are necessary to maintain nation’s health care safety net. This scarcity of funding makes it more difficult for public

hospitals, compared to other hospitals, to absorb the rapid increase in health care costs.

High rates of uninsurance cause those without health coverage to seek care at public hospitals, resulting in high levels of uncompensated care costs for these safety net providers. The large volume of ambulatory care NAPH members provide is poorly reimbursed, if it is reimbursed at all. This is due to reimbursement rates for outpatient services generally being lower than reimbursement rates for inpatient services, as well as a substantial amount of this care being provided to the uninsured.


All of these challenges represent significant stresses to public hospitals and the health care safety net. Without government support through

Medicaid and state and local government subsidies, the care provided to our most vulnerable citizens would be compromised.

•

Information Technology Outsourcing in

U.S. Health Care Delivery Systems

Mark Diana, Ph.D.

Presented By: Mark Diana, Ph.D., Instructor,

Health Administration, Virginia Commonwealth

University, 1008 East Clay Street, Richmond, VA

23298-0203, Phone: (804) 828-5400, Fax: (804)

828-1894, Email: mldiana@vcu.edu

Research Objective: Health care delivery systems face substantial pressures to adopt information technology (IT) to address growing concerns and accountability for quality of care and patient safety. Systems also face high levels of competition, particularly in service offerings, exemplified by the growth of specialty hospitals.

IT investments are costly, complex decisions that compete with other demands for capital. This combination of pressures may lead management to consider outsourcing as a means of achieving enhanced IT capabilities. The purpose of this study was to explore the factors associated with outsourcing of information systems (IS), and if there is a difference in IS sourcing based on the strategic value of the outsourced functions.

Study Design: In this study, IS sourcing behavior was conceptualized as a case of vertical integration The theoretical framework is based upon a synthesis of strategic management theory (SMT) and transaction cost economics

(TCE) as they apply to vertical integration in the health care sector. The conceptual model proposed that sourcing behavior would be determined by asset specificity, uncertainty, the interaction of asset specificity and uncertainty, bargaining power, corporate strategy needs, and the strategic value of the IS functions outsourced. Analysis was conducted using a twostage negative binomial regression model to correct for suspected endogeneity. Tests of joint restrictions using the group of variables derived from TCE and SMT, respectively, were done with the dependent variable divided between strategic and non-strategic IS functions (the division was done based on a model of Core IS Capabilities developed as a model for a high-performance IS function).

Population Studied: The final sample consisted of 1,365 health care delivery systems and 3,452 hospitals. Data were from the American Hospital

Association (AHA), the Area Resource File

(ARF), the Health Information Management

Systems Society (HIMSS) Analytics database, and the Centers for Medicare and Medicaid

Services (CMS) hospital cost reports for 2003.

Principle Findings: There was a positive relationship between bargaining power and outsourcing, as hypothesized. There was a negative relationship between both asset specificity and corporate strategy needs and outsourcing, which is in the opposite direction than hypothesized. Non-profit systems were less likely to outsource, also opposite than hypothesized. Neither TCE nor SMT predicted outsourcing better.

Conclusions: These results do not support the application of TCE to this problem, and there is weak support for SMT. The findings do suggest that health care delivery system managers are likely not considering significant factors when making sourcing decisions, including the relative strategic value of the functions they are outsourcing. It is consistent with previous literature to suspect that investment cost alone may be driving the outsourcing decision and preventing more strategic considerations.


Health care managers should consider operational and strategic implications to sourcing decisions------it is not all about cost-----and should examine how other industries have handled IS sourcing decisions. Policymakers should recognize that cost likely represents a significant barrier to the IS adoption they are advocating and consider policy to alleviate this concern.

•

Barriers and Strategies: Implementing HIT for Quality Improvement in Rural Hospitals

Janine Edwards, Ph.D., JungEun Kang, M.A.,

Percy Galimbertti, M.D., Ph.D., Kathleen

Mechler, M.S.

Presented By: Janine Edwards, Ph.D., Research

Professor, Rural & Community Health Institute,

Texas A&M University system Health Science

Center, 3833 texas Avenue, Bryan, TX 77802,

Phone: (979-862-5003, Fax: (979)862-5015,

Email: edwards@tamhsc.edu

Research Objective: 1. Identify and describe characteristics of rural hospital culture that form barriers to implementing Health Information

Technology. 2. Describe strategies for successfully implementing HIT in rural hospitals to improve quality.

Study Design: A retrospective qualitative study and a quantitative study were conducted during the second year of a three year projet to develop and implement HIT. The qualitative study consisted of semi-structured interviews of key project personnel. The interview data were audio-taped, transcriberd, verified by interviewee, entered into Ehtnograph software, coded for themes and analyed for themes and subthemes by two independent researchers. The quantitative study was an electronic survey of 53 rural hospitals engaged in the HIT project. The survey consisted of eleven questions regarding the difficulties and assistance provided by the project staff for implementing technology to analyze and use patient data as quality indicators. Nine of the eleven questions were answered on a quantitaitive scale; two questions required comments. The quantitative answers were analyzed using SPSS; the comments were analyzed using traditional sorting methods.

Population Studied: The population for the qualitative study consisted of five key project staff members. The quantitative study surveyed

53 rural hospitals. Two persons serving the functions of administration and IT from each of the 53 hospitals were queried and responded,providing triangulation of responses.

The 53 hospitals were stratified and results analyzed into three subgroups: 1. hospitals receiving the educaton course during the project;

2. hospitals not receiving the education course;

3. hospitals that withdrew from being considered for the education course.

Principle Findings: Eleven characterists of the culture of rural hospitals are described. Many are barriers, such as time lapses; unique problems of patient safety, e.g.,familarity, lack of confidentialy, maintenance of competence, night coverage; variance in size, role structure, and knowledge of patient data. Description of strategies that staff members used to overcome the barriers include gaining trust, maximizing efficiency in using very limited resources, developing innovative software, providing hardware, adjusting expectations, approximating rural language, and providing extra training.

The overall response rate for the survey was 57%.

Surprisingly, only 43% of the rural hospitals reported having difficulty in implementation, mainly with data corrections and manipulation.

Other difficulties include lack of time, personnel,training, and hardware, issues with vendors that managed other hospital data. Fiftythree percent had requested assistance from staff. Mid-way through the project, 53% were using COGNOS to analyze patient data and make reports. Education and training were the main resources needed to implement HIT.

Conclusions: Rural hospitals demonstrate wide variation in size, resources, and capacity to implement HIT. barriers such as lack of personnel and expertise, time lapses, unique problems of patient safety present significant difficulties to analyzing and utilizing patient data.

Successful strategies include gaining trust, maximizing efficiency, approximating rural language. The survey results indicate partial success mid-way through the project.


Federal policy makers need awareness that implementing HIT in rural hospitals will require more years and a greater than average proportion of resources.


• Adoption of Clinical IT in US Hospitals:

Organizational and Market Factors

Katya Fonkych, Ph.D., Glenn Melnick, Ph.D.

Presented By: Katya Fonkych, Ph.D., postdoctoral fellow, Health Policy, USC, 1951 22nd

Street, Apt. 5, Santa Monica, CA 90404, Phone:

310-460-8673, Email: fonkych@rand.org

Research Objective: This study seeks to investigate the characteristics of hospitals and hospital systems that affect their propensity to adopt clinical information technologies, such as inpatient EMR, CPOE and PACS systems. The analysis focuses on the role of provider characteristics and market factors, such as structure of hospital system, capitation and competition in the process of health IT adoption.

Study Design: The paper includes a theoretical framework that describes hospital’s motivations to upgrade their clinical IT system, and links those motivations and barriers to the provider characteristics. The unique feature of this study is that its major dependent variable represents an overall level of clinical IT system

sophistication, as it is constructed from adoption pattern of many inter-related clinical IT applications. A multivariate cross-sectional regression analysis is employed to estinate marihnal effects of organizational and market factors responsible for adoption behavior by means of logit, OLS and ordered logit regressions.

Population Studied: The unit of analysis is a non-federal acute-care hospital in the US and a hospital system that this hospital belongs to.

The data on clinial adoption in 2004 come from the survey of health IT adoption in US hospitals and hospital systems from Healthcare

Information and Management Systems Society

(HIMSS) database. The sample covers those hospitals that are larger than 100 beds or belong to a multi-hospital system.

Principle Findings: Depending on the interest of the panel organizers, my presentation could emphasize any subset of the following empirical findings: 1)Hospitals that care for larger fraction of Medicare, Medicaid or indigent patients are less likely to adopt clinical HIT systems.

2)Capitation payment method has positive effect on EMR adoption, as it best allows hospitals to appropriate the benefits of efficiency improvement due to HIT. 3)Competition has positive effect on adoption of some clinical HIT systems but not the others. 4)Network externalities may allow local multi-provider organizations to enjoy benefits from organized exchange of clinical information. Local multihospital systems are more likely to adopt EMR than either independent hospitals or geographically dispersed systems. Similarly, hospitals linked to local ambulatory offices from the same maternal system are more likely to acquire EMR system.

Conclusions: Adoption of clinical IT is governed by a complex set of organizational and market factors, which in addition to hospital size and profit status include its payer mix, reimbursement methods, market structure and network externalities. The conclusions call for greater CMS involvement and reimbursement models that would reward higher quality and efficiency achieved through clinical health information technology.


The study identifies the areas where public policies are most necessary and suggest incentives and strategies to stimulate HIT adoption by healthcare providers. The empirical results are useful to understand market incentives and to suggest policies that could be considered to stimulate adoption, and identify groups of providers that are potential targets for such policies.

Health Information

Technology

•

The Effect of IT Capital on Hospital

Efficiency

Michael Housman, B.A., Kinga Z. Elo, Ph.D.,

Lorin M. Hitt, Ph.D., Nicolas Beard, M.D.

Presented By: Michael Housman, B.A., Ph.D.

Student, Health Care Systems Department,

University of Pennsylvania, 3641 Locust Walk,

Philadelphia, PA 19104-6218, Phone: (215) 681-

6955, Fax: (215) 573-7278, Email: housman@wharton.upenn.edu

Research Objective: Health information technology (IT) is widely thought to improve healthcare quality and productivity, and reduce costs. However, supporting empirical evidence is limited. This study aims to corroborate observational evidence through a cost function estimation to examine relationships between IT capital stock and cost efficiency in US hospitals.

Study Design: Most studies have utilized crosssectional analyses or small samples of convenience; instead, we analyze 1999 to 2004 data from multiple sources (HIMSS Analytics,

American Hospital Association, and Medicare

Cost Reports) describing the implementation status of 40 software applications in US hospitals. Consistent with prior work on hospital efficiency, we utilize a translog cost function system (the primal and the factor share equations) to calculate the marginal product of various factor inputs in hospitals (capital, labor, materials) as well as IT capital. By estimating the model with seemingly unrelated regression

(SUR) and adding terms to allow for nonlinear relationships between IT capital and hospital efficiency, we examine whether the marginal benefits of IT capital depend on level of investment.

Population Studied: Our panel dataset includes a majority of all US acute care hospitals. We exclude government hospitals, psychiatric hospitals, and long term care hospitals.

Principle Findings: The impact of IT capital on hospital productivity follows a non-linear pattern, suggesting that a certain amount of IT investment is necessary before hospitals gain efficiency benefits. We also find that non-profit hospitals appear less efficient than for-profit hospitals in terms of their IT usage, reaching the

‘‘tipping point’’ at higher levels of IT capital. We

also find that significant differences exist in the

‘‘cost-reducing effects’’ of applications.

Administrative applications show efficiency gains, even at relatively low levels of IT capital investment, with a higher marginal gain in forprofit hospitals. Clinical applications show no efficiency gains in non-profit hospitals but do appear to improve efficiency in for-profit hospitals. We also examined the impact of applications across different time horizons.

Clinical applications demonstrate efficiency gains in non-profit hospitals over time. In for-profit hospitals, clinical applications also yield both short- and long-term gains. Administrative IT applications show an efficiency effect in the short- and long-term within for-profit and nonprofit hospitals.

Conclusions: Higher levels of in IT capital are associated with reduced short-term operating costs in acute care hospitals, after a threshold level of investment has been reached. Nonprofit hospitals reach this tipping point at higher levels of IT investment than for-profit hospitals.

Administrative applications appear to yield greater efficiency gains than clinical applications but the benefits of all software applications increase within longer time horizons.


From the perspective of individual hospitals contemplating whether to invest more in information systems, this research tends to corroborate the investment as being worthwhile.

We believe that initial increases in IT capital may entail significant ‘start-up’ expenses (networking infrastructure, recruitment of IT staff) which increase costs prior to the efficiency gains that IT applications might provide.

Funding Source: PricewaterhouseCoopers

• Group Process in Prioritization of Clinical

Decision Support

Donald Levick, M.D., M.B.A., Karen Craig, B.S.,

M.B.A., M.Ed.

Presented By: Donald Levick, M.D., M.B.A.,

Physician Liaison Information Services,

Information Services, Lehigh Valley Hospital,

1245 S. Cedar Crest Boulevard, Suite 100,

Allentown, PA 18103, Phone: (610)402-1426, Fax:

(610)402-1408, Email: donald.levick@lvh.com

Research Objective: To evaluate the use of a multi-disciplinary group in the understanding and prioritization of the use of point-of-care clinical decision support in a CPOE system.

Study Design: Implementation of clinical technology usually follows several phases. After initial implementation and acceptance, there is usually an effort to leverage the technology. With clinical information systems, the use of clinical decision support is an area that can greatly impact quality of care and patient safety. Lehigh

Valley Hospital, an 800 bed academic community hospital in Pennsylvania, has implemented an electronic clinical information system throughout its three campuses. A multidisciplinary committee was organized to evaluate and prioritize potential point-of-care clinical decision support efforts. To aid in the prioritization of these efforts, an on-line survey was performed. The study investigated the awareness, use and utility of point-of-care clinical decision support efforts. The study results were collated and fed back to the multi-disciplinary group to guide further development of the clinical decision support system.

Population Studied: The population chosen for the study included the majority of clinical users of the system. An invitation to participate in the online survey was sent to approximately 1,500 personnel of the Lehigh Valley Hospital. This included the active medical staff (approximately

1,000), members of the nursing administrative staff, the research staff, and the allied health professions staff.

Principle Findings: The response rate to the survey was approximately 20%. This included more than 100 physicians/providers. Survey results were quite revealing and provided very useful guidance to the multi-disciplinary group.

Although it is widely reported in the literature that clinicians ignore many point-of-care alerts, the survey revealed that most clinicians at LVH read and react to these alerts. The findings were shared with the multidisciplinary group and continue to be used to guide their activities.

Group process and dialogue are effective tools for prioritization of resource allocation.

Conclusions: Although real-time clinical decision support is in its infancy, it is becoming a critical success factor as implementation of clinical information systems evolve. Determining the most appropriate sources of decision feedback is important for acceptance and use.

Feedback from users (through surveys and group discussion) is essential to determine the best use of limited resources to enhance the systems in place. Balance between utility and efficiency is a critical factor for success.


Real time clinical decision support, if implemented appropriately, can have dramatic impact on quality of care and patient safety. Pay for Performance and other quality based

initiatives will accelerate the need for development of decision support. The development of clinical decision support systems requires ongoing feedback from endusers who are actually impacted by the systems and tools. Bottom-up development, through surveys, group process and continuous feedback are all potential tools that can aid in this process.

Healthcare organizations should plan and budget for these efforts with any implementation of clinical information systems.

Funding Source: NLM IAIMS Grant

• Characteristics Associated with Use of

Public and Private Websites as Sources of

Health Care Information: Results from a

National Survey

Edward Miller, Ph.D., M.P.A., Darrell M. West,

Ph.D.



Policy, Brown University, 67 George Street, Box

1977, Providence, RI 02912-1977, Phone: (401)

863-9311, Email: edward_a_miller@brown.edu

Research Objective: We sought to determine the frequency with which Americans access health information from governmental (public sector) and non-governmental (private sector) websites, and to identify similarities and differences characteristics associated with use of each type.

Study Design: Cross-sectional analyses of responses to a November 2005 national survey.

In addition to forms of health communication, we asked about age, gender, race, income, education, insurance, lifestyle, residence, satisfaction, literacy, and health. We report the extent of website usage stratified by sponsorship type------public and private. We also use ?2 tests to examine bivariate associations. Logistic regression and multiple imputation of missing data were used to examine the correlates of usage in a multivariate context.

Population Studied: Data derive from 928 respondents to a November 2005 national survey.

Principle Findings: More than twice as many respondents visited private websites (29.6%) than public websites (13.2%). However, just

23.6% and 18.9% of private and public websites visitors, respectively, reported doing so once a month or more. Both public and private website visitors were more likely to be better educated respondents (Odds Ratio [OR]=0.83, OR=1.57) reporting greater concerns about health care access (OR=1.28, OR=1.20) than non-visitors.

Younger individuals (OR=0.83) living in urban areas (OR=1.59) with stronger health literacy

(OR=1.24) and reporting greater concerns about health care affordability (OR=1.59) were more likely to visit privately-sponsored websites but not publicly-sponsored ones.

Conclusions: Relatively low utilization of both public and private websites necessitate a concerted effort to improve the quality, accessibility, and relevance of Internet health information.


Efforts to close the digital divide must recognize differences in user characteristics across governmental and non-governmental website providers.

• Variation in Diabetes Quality of Care Across

Clinics: An Assessment Using Electronic

Medial Record Data

Patrick O'Connor, M.D., M.P.H., Stephen E.

Asche, M.A., Bruce Hamory, M.D.





Phone: (952)967-5034, Fax: (952)967-5022,


Research Objective: We used data passively transferred from EMR databases to assess patterns of diabetes care and quality in a large number of primary care clinics, to determine the feasibility, accuracy, and possible uses of such profiling activities.

Study Design: Data extracted and analyzed included confirmation of a diabetes diagnosis, dates and values of blood pressure (BP), glycated hemoglobin (A1c) and low-density lipoprotein (LDL) tests, selected other laboratory tests, gender, age in years, selected medications, primary care physician code, and clinic code.

Population Studied: We identified 66 clinics in two large care systems that used Epic Electronic

Medical Records (EMR), and collaborated with programmers at Epic (Madison, WI) to develop programs to extract clinical data that can be used to assess patterns of diabetes care and quality in primary care settings.

Principle Findings: Checks of data accuracy at both medical groups detected some programming errors, most of which were related

to identification of medications, that were iteratively corrected before finalizing the analytic data set. There was statistically and clinically significant variation in patterns of diabetes care and in measures of diabetes quality of care across primary care clinics. The proportion of patients who simultaneously met evidence-based goals of A1c < 7%, SBP < 130 mm Hg, and LDL <

100 mg/dl ranged from a low of 3.6% to a high of 32.5% across clinics, with a median clinic value of 13.4% in one medical group and 17.9% in the other medical group. Patterns of use of insulin, metformin, thiazolidenediones,

ACE/ARBs, statins, and other recommended medications also varied substantially.

Conclusions: There is wide variation in diabetes care quality across clinics and physicians, and efforts to understand the dynamics of this variation are likely to lead to identification and implementation of clinical care systems that may broadly improve care.


EMR-derived data may be used to passively monitor quality of diabetes care at the level of medical groups, clinics, and physicians. These electronic data are demonstrably accurate, permit adjustment for patient factors, and are inexpensive to obtain and analyze. This source of information has the potential to accelerate efforts to improve care delivered for diabetes, hypertension, heart disease, and other conditions in clinics that use EMRs.


Foundation

•

Define ROI in Healthcare: an IT perspective

Ebrahim Randeree, M.B.A., Ph.D., Darrell Burke,

Ph.D.

Presented By: Ebrahim Randeree, M.B.A., Ph.D.,

Assistant Professor, College of Information,

Florida State University, 234 Louis Shores

Building, Tallahassee, FL 32306-2100, Phone:

850 645 5674, Fax: 850 644 9763, Email: eranderee@ci.fsu.edu

Research Objective: In recent years, government entities have pushed the use of IT in healthcare as the solution to rising costs, increased errors, and quality concerns. As the role of IT and information based initiatives grows, the returns generated by the leap to computerized records and enterprise networks may not be so obvious. It is necessary for IT initiatives to objectively (and with evidence) demonstrate the benefits accrued to the stakeholders (physicians, insurers, employers, patients, etc.). The complexity of demonstrating

ROI must exits on both a macro and micro level and the results should be generalizable to encourage further expenditures.

Study Design: The measurement of ROI is complicated by the reimbursement system design, constant financial pressures, and the institutionalized environment that permeates healthcare. Review of the literature with propositions for how to define ROI within a healthcare settings

Population Studied: Hospitals

Principle Findings: Ongoing Review - initial data breaks ROI into financial measures, quality outcomes, and externalities

Conclusions: Our review presents a review of previous methods and a categorization of ROI for different stakeholders.


This research seeks to answer the question: what are the measured returns on IT investments ---- in financial savings, in improved quality, in satisfied patients, in improved efficiency, etc. Results can be reflective of the different stakeholder views in relation to expenditures, benefits, economic impact, social benefits, and public good. Beyond the anecdotal evidence for ROI in healthcare, the need for effective measures and evidence based outcomes is needed.

•

Improving Clinical Practices through Online

Education

Chris Sciamanna, M.D., M.P.H., Christopher N.

Sciamanna, M.D., M.P.H., Michael Feldman,

M.D., David B. Nash, M.D., M.B.A.

Presented By: Chris Sciamanna, M.D., M.P.H.,

Director, Division of General Internal Medicine,

Penn State Milton S. Hershey Medical Center,

Penn State College of Medicine, Division of

General Internal Medicine, HU15, 500 University

Drive, P.O. Box 850, Hershey, PA 17033, Email: cns10@psu.edu

Research Objective: To examine the potential for two online continuing medical education seminars (Type 2 Diabetes and Systolic Heart

Failure) to improve the quality of care provided by physicians.

Study Design: Physicians who chose to participate were randomly assigned through a computer generated program to either a Type 2

Diabetes or SHF seminar (64 and 49, respectively). Following the seminar, physicians were presented with four clinical vignettes and asked to describe what tests, treatments, prescriptions, advice, counseling, or referrals,

they would recommend for the patients within each vignette.

Population Studied: 113 primary care physicians from PA, NJ, DE, and MD were identified through a national medical association membership list and recruited via a broadcast email.

Principle Findings: Physicians who viewed the

SHF seminar were significantly more likely to recommend guideline-consistent care (measure

LV function, start Coumadin, and start a Beta blocker) to patients in the SHF vignettes compared to the control group. Physicians who viewed the Diabetes seminar were significantly more likely to order an eye exam for Diabetes patients (63%) compared to physicians in the control group (27%); however, they were no more likely to correctly manage meds, or offer smoking cessation counseling.

Conclusions: These results provide partial evidence of the effectiveness of online CME programs to improve physician clinical practices.


Evaluation of additional seminars is recommended in order to gain a fuller understanding of the potential impact of these seminars in promoting the application of evidence-based clinical guidelines.

Funding Source: Graduate Education

Foundation

•

Exploration and Exploitation of Health IT systems: Impact on Financial Performance of

Hospitals

Monika Setia, M.A., Vallabh Sambamurthy,

Ph.D., Ranjani Krishnan, Ph.D.

Presented By: Monika Setia, M.A., Ph.D.

Candidate & Graduate Assistant, Health Policy &


116 North Henderson, University Park, PA 16802,

Phone: 517-643-0975, Email: mzs187@psu.edu

Research Objective: The information technology (IT) systems have become pervasive in the modern day hospitals as they are implemented to enhance financial performance.

However, these new-age IT systems are assimilated into the organizational work over time and eventually the learning effects help realize the impact of these IT applications. Our research studies the two categories of IT systems adopted by the hospitals ---- administrative and clinical applications. The hospital’s breadth and depth of these applications is explored in this study using the exploration and exploitation framework by March (1991). The increasing returns to simultaneous exploration and exploitation are proposed using the Milgrom and

Roberts (1990, 1995) complementarities framework.

Study Design: The data for the research is collected from the HIMSS AnalyticsTM Database and annual hospital financial data from the

Healthcare Quality and Analysis Division,

California Office of Statewide Health Planning and Development. The analytical sample consists of cross sectional data on IT systems implementation collected from 292 hospitals in the state of California. The financial performance is measured as net income per patient for the hospital. The breadth (exploration) and depth

(exploitation) of information technologies is measured as the number and years of experience of the firm with these information technologies respectively. The complementarities are measured as the joint interaction of the breadth and depth, and the interaction is calculated for both the business and clinical applications.

These variables are regressed on the net income per patient after controlling for the size, type, and ownership of the hospitals, proportion of

Medicare and Medicaid revenues, and assets per patient.

Principle Findings: The findings of the study suggest contrasting differences across the types of IT applications. In the case of administrative

IT systems experience has a direct impact on financial performance. The joint effect of number and experience of the administrative technologies was not found to be significant. For the clinical IT systems in the absence of adequate breadth the direct impact of experience is negative. However, in interaction with the breadth of clinical technologies implemented at the hospital, the experience with clinical applications has a positive impact on financial performance of the hospitals. The number of technologies itself does not have any impact in the case of either business or clinical technologies.

Conclusions: The results empirically demonstrate the dynamics in assimilation of IT with differential performance effects for different types of technologies. The business technologies are found to require enhanced experience of the hospital to realize their financial impacts.

However, for clinical technologies the impact alludes to the presence of an ecosystem where not only just the experience but the number of such technologies is requisite for realizing the financial impacts of these technologies. The long experience restricted to only a very limited number of clinical technologies leads to a narrow

learning and hence inhibits the impact of these technologies on the firms’ performance. Overall this research has addressed the critical question for the effective use of IT systems in hospitals and would lead to better realization of value from hospitals’ IT investments.

• Health IT

Carlos Torres, M.I.S., Darrell Burke, Ph.D.

Presented By: Carlos Torres, M.I.S., Student,

LIS, Florida State University, Tallahassee, FL,

Phone: 850-519-1519, Email: cisfast@comcast.net

Research Objective: The research objective is to discuss the development and integration of technology that has take place in health care for recent years. This paper examines at how current technologies have been adopted to health care organizations across the US. Some of the technologies include the use of bar codes, computer aide decisions, EMR, and pharmacy medical dispensing machines.

Study Design: This paper is based on literature reviews and current research on organizations that are using the technologies. These technologies are adopted for various reasons.

Most important reasons include the reduction of the cost of health care and the improvement of the services provided to patients by health care organizations.

Population Studied: Any health care organization that has implemented the use of the technology discussed above.

Principle Findings: If successfully implemented, the use of the health care technologies can reduce the cost of health care and provide physicians with greater efficiency to the services they provide. Furthermore, patient satisfaction has been found across most of the literature reviewed.

Conclusions: Based on the preliminary research findings, there are many benefits associated with the use of technology at the health care setting.

Much research still lies ahead to discover the implications associated with the use of computers in the health care field.


The use of technology offers many benefits to the health care community. Although technology is a relatively good alternative, much research lies ahead to discuss possible implications associated with the use of technology in the health care field.

• Tele-Health: Bringing Care to the Home

Carlos Torres, M.I.S., Darrell Burke, Ph.D.,

Ebrahim Randeree, Ph.D.

Presented By: Carlos Torres, M.I.S., Student,

Florida State University, Tallahassee, FL, Phone:

850-519-1519, Email: cisfast@comcast.net

Research Objective: Web portals enable patients to stay informed about all their health information and any treatment options. This access enables patients to keep up with all their health history without reliance on their health care providers. While the benefits to web portals are numerous, current systems are limited in their functionality. Specifically, interactions between web portals and external monitoring devices are nonexistent. This research highlights the potential of a fully-functional web portal.

Study Design: This paper will examine some of the current health web portals available today and new ideas on how to better make use of the technology available today. Making use of the current technology and adding more functionality will enable greater efficiency to the use of TeleHealth.

Population Studied: This paper examines current health care organizations that use web portals to provide patients with health information.

Principle Findings: If the integration of the technology is successfully implemented, patients can greatly benefit from the use of the technology. Nevertheless, currently there are many limitations that the web portals currently face. Therefore, by improving the functionality, web portals can offer patients with greater flexibility and more efficiency when they use this technology.

Conclusions: The integration of other technologies offer patients more tools that they can use at the comfort of their home. Therefore, patients do not have to leave the comfort of their home when communicating with their physicians, thus at the same time reducing the cost of health care.


With the integration of other technologies,

TeleHealth via web portals can be a powerful tool for communicating health information. The advantages are far greater than can be anticipated. Therefore, the integration of health care technologies will provide patients and physicians an efficient portal of communication.

• Improving Integrated Care for CP-Children

Willem Van Harten, M.D., Ph.D., Jitske Gulmans,

M.Sc., Miriam Vollenbroek-Hutten, Ph.D., Lisette van Gemert-Pijnen, Ph.D. of the site. -Parents were outspoken positive, providers were often not convinced of the added value, although they appreciated the higher degree of parent information.

Presented By: Willem Van Harten, M.D., Ph.D.,

Prof. Quality Management of Health Care

Technology, School of Management and

Governance, University of Twente, P.O. Box 217,

Enschede, 7500 AE, Netherlands, Phone: 0031

Conclusions: The sequential mixed method design proved feasible to identify communication flaws in the integrated care setting of CP-patients in various care regions.

Parents and providers identified communication gaps that were tackled through a secured 20 512 2860, Fax: 0031 20 6691449, Email: w.h.vanharten@utwente.nl

Research Objective: 1.Identifying improvement possibilities in integrated care for children with

Cerebral Palsy (CP) 2.Design & pilot-testing of a interactive IT-helpdesk. The 6-months pilot of the web-based communication system proved that its use was feasible, both technically and by content. Parents were satisfied in using the application, whereas professionals did experience less added value of using the system.

Implications for Policy, Practice or Delivery: secured web-based communication system for parent-professional and inter-professional communication, an interactive ‘CP-Helpdesk’.

Study Design: 1. Evaluation of quality of communication in integrated care setting of CP-

Mixed research methods are valuable for identifying coordination/communication flaws in complex integrated care settings. -Securedpatients in three different care regions in the

Netherlands using a sequential mixed method design: -quality questionnaire for parents of CPpatients in the age of 4-8 years; -critical incidence helpdesk systems can be of use to provide patients with relevant provider info concerning their condition and improves information exchange between providers across institutes. interviews with subset of parents; -focusgroup sessions with involved professionals (1 session/ •

Incorporating Item Banks into Clinical region). 2.Design and 6-months pilot-testing of Trials: Investigator Perceptions the system; Evaluation of proof of principle Kevin P Weinfurt, Ph.D., Carrie B Dombeck, through questionnaire at baseline (t0) and after M.A., Esi Morgan DeWitt, M.D., M.S.C.E., Larry

6-months use of the system (t1). W Diener, M.L.S., M.B.A., Kevin A Schulman,

Population Studied: 1.Parents of 197 CPM.D., Kevin P Weinfurt, Ph.D. patients completed the quality questionnaire, of which a subset of 20 parents was interviewed; In Presented By: Kevin P Weinfurt, Ph.D., total 28 professionals participated in the Associate Professor, Psychiatry and Behavioral focusgroup sessions (max 10/ session); 2.A total Sciences, Duke University Medical School, PO of 30 parents and 120 professionals participated Box 17969, Durham, NC 27715, Phone: (919) in the pilot-testing and completed baseline 668-8019, Fax: (919) 668-7124, Email: questionnaire; response to t1 questionnaire was kevin.weinfurt@duke.edu respectively 87% (n=26 parents) and 88 % (105 professionals). Research Objective: The use of patient-reported

Principle Findings: -Using the definition of the outcomes (PROs) to evaluate the experiences of

IOM concerning patient-centeredness and the patients in clinical trials is increasing, but dimensions described in the AIMQ (Assessment assessment of PROs often suffers from several of Information Quality) various gaps in problems including long and burdensome coordination and communication were measures, significant floor and ceiling effects, identified. -The majority of parents felt to be and a lack of standardization that makes it indirect messengers in the interprofessional difficult to compare or combine scores across communication across institutions. -Based on different studies. Item response theory (IRT) critical incident interviews and focusgroup sessions priority was given to the improvement provider system produced the most intense use offers the promise of more sensitive and efficient measurement of PROs, and the NIH has made a of communication from patients perspective. A secured web-based system for selected and

Showed -The region with the more complex large investment toward creating banks of items based on IRT through the Patient-Reported parallel questioning of providers, provider interaction and coordinated responding was

Outcomes Measurement Information System

(PROMIS) network. However, the process of selecting and using PRO measures from these new IRT-item banks is very different from current methods of using PRO measures. Our objective

was to evaluate a brief tutorial on IRT-item banks and anticipate barriers to the adoption of IRTitem banks into clinical trials.

Study Design: We conducted semi-structured telephone or in-person interviews with authors of clinical trials, aiming for 10 interviews in each of

4 target areas: cardiovascular outcomes, oncology outcomes, pediatric populations, and mixed outcomes. Participants were identified through literature search and recruited via email, with one follow-up message emailed to nonresponders. Recruitment was not dependent on experience with PROs. Interviews were digitallyrecorded and lasted 30 minutes. Participants received $200. Two coders independently characterized interview content using a hierarchical coding scheme. Discrepancies were resolved through discussion. The 6-slide tutorial on IRT-item banks described common problems with current PRO instruments, the process for developing item banks used by the PROMIS network, and the novel products from IRT-item banks including customized short forms and computerized adaptive tests.

Population Studied: Lead authors who published results from clinical trials in the

Journal of the American Medical Association, the

New England Journal of Medicine, or other top clinical journals from July 2005-May 2006

(N=42, 39% response rate).

Principle Findings: Most (90%) investigators had previous experience using PROs in clinical trials. After the tutorial, most (93%) understood the novel products from an IRT-item bank, and most (90%) thought an item bank would definitely or potentially be useful to them for their trials. However, investigators mentioned a number of potential barriers to adoption including economic or logistic restraints, concerns about whether an item bank is better than current practices, concerns about how to convince study personnel or statisticians to use item banks, and the lack of availability of items banks validated in specific disease populations.

Conclusions: A brief tutorial is sufficient to interest clinical investigators in the improved

PRO measurement that IRT-item banks offer.

Some potential barriers to investigators adopting

IRT-item banks can be addressed through education (e.g., how an item bank is better), but others will require additional work on the part of bank developers (e.g., item banks validated in specific disease populations).


Use of IRT-item banks could be advantageous to health assessment but, as with any new technology, success is not guaranteed. By anticipating barriers to the adoption of IRT-item banks in clinical trials, developers can aim to address these barriers before widespread adoption is expected.

Funding Source: National Institutes of Health

• The Impact of Health Information

Technology on Academic and Private

Physicians and Administrators

John Windle, M.D., Roslyn Fraser-Maginn, M.A.

Presented By: John Windle, M.D., Professor,

Internal Medicine, UNMC, 982265 Nebraska

Medical Center, Omaha, NE 68198-2265, Phone:

402-559-9268, Fax: 402-559-8355, Email: jrwindle@unmc.edu

Research Objective: To evaluate the similarities and differences in the perceptions of academic and private physicians and administrators on the impact of health information technology (HIT) in the health care setting.

Study Design: Focus groups were conducted with physicians and administrators associated with either the University of Nebraska Medical

Center (academic) or its affiliated private hospital, the Nebraska Medical Center (private practice). All physicians worked in the same health care environment including use of the same electronic medical record. Participants were asked open-ended questions related to their use and expectations for HIT. This included their perceptions and attitudes related to patient care, education, and clinical research and outcomes. Interviews took place between

August and November, 2006. Focus group interviews lasted from 1 to 3 hours and averaged

3 to 4 participants per group. Group proceedings were audio-recorded and transcribed. Data elements were systematically coded and analyzed based on frequency, convergence and intensity using NVivo v7.0 software. Sampling continued until saturation was achieved. Investigators (LG and JW) independently reviewed transcripts and identified themes unique and similar across all groups.

Themes were verified by a third investigator (RF).

Using an iterative process, themes were revised until consensus was achieved.

Population Studied: A convenience sample of participants was obtained based on recommendations of the study’s steering committee. The study population (n=74) was divided into four categories: 1) Academic

Physicians, (n=38), 2) Private Physicians, (n=14),

3) Academic Administrators, (n=12) and 4)

Private Administrators, (n=10).

Principle Findings: Six themes were identified: patient care, physician workflow, care team interactions, outcomes and clinical research, the learning environment and impact on institutional culture. Academic Physicians frequently stated that HIT had a negative impact on patient care, physician workflow and communications citing more time in front of the computer at the expense of patient and team interactions. They were more positive about the impact of HIT on learning, outcomes and research. Private Physicians perceived HIT to have a very negative impact on the three clinical domains citing the steep learning curve, data silos and interference with workflow. Both physician groups believed HIT had a negative impact on the institutional culture. Both desired an intuitive interface that facilitates their efficiency, patient interactions and teamwork.

Academic and Private Administrators were neutral to positive in all themes (including institutional culture) related to HIT and most frequently cited improved patient care and data for outcomes and research.

Conclusions: Academic and Private Physicians both express serious concerns about the impact of health information technology as currently envisioned on patient care, physician workflow and team communications. Perhaps most disturbing is the discordant perception of the impact of HIT on the institutional culture between physicians and administrators.


Both academic and private physicians have strong negative opinions about the impact of

HIT implementation plans on clinical care.

These results are fundamentally at odds with administrators who believe they are adapting to national trends. This study helps explain the resistance to HIT adoption by the physician community.

Funding Source: National Library of Medicine

Implementation of Research

•

Multiple Approaches To Increasing

Pediatrician Survey Response Rates

Gretchen Caspary, Ph.D., Karen O'Connor,

Sanford Sharp

Presented By: Gretchen Caspary, Ph.D., Senior

Research Associate, Division of Health Services

Research, American Academy of Pediatrics, 141

Northwest Point Boulevard, Elk Grove Village, IL

60007, Phone: 847-434-7946, Fax: 847-434-4996,

Email: gcaspary@aap.org

Research Objective: Physician survey response rates have declined in recent years. The objective of these four studies was to determine the most effective methods for increasing survey response rates among pediatricians.

Study Design: A randomized, experimental design was incorporated into four existing AAP member mailed surveys. In study 1, we offered a modest financial incentive ($1 to group 1, N=533;

$2 to group 2, N=533; $0 to group 3, N=532) on the first mailing (Periodic Survey (PS) 1998). In study 2, we sent survey materials by certified mail to 382 non-respondents with office addresses (vs. first class mail to 422 with home addresses) in the fourth mailing (PS 2000).

Study 3 examined the effects of survey length on response rates; two surveys were compared to see if shorter length would produce a higher RR.

Group 1 was 8 pages in length (N=1,651) and group 2 was 4 pages (N=853) (PS 2005). In study 4, group 1 (N=500) received surveys sent by U.S. Mail, and if they did not respond within 2 weeks, they then received an email offering them the option to complete the survey online (for a total of up to 8 contacts), while the control group

(group 2, N=500) received only (up to 4) surveys sent by U.S. Mail (Graduating Resident Survey

2006).

Population Studied: Pediatricians were the focus of all four studies. Studies 1, 2 and 3 each included randomly selected non-retired members of the American Academy of

Pediatrics; all surveys were sent by U.S. mail.

Study 4 was sent to randomly selected graduating categorical pediatric residents.

Principle Findings: 1) Response rate (RR): 83% for the $2 group, 81% for the $1, and 74% for the control (83% v 74%, p<.01; 81% v 74% p<.05).

The difference in response is primarily the result of the first mailing (55% ($2) v 35% ($0), p<.001;

47% ($1) v 35% ($0), p<.05). 2) RR among the certified mail group was 12% vs. 5% response among the first class mail group (p<.001). No difference in response between the groups in prior and subsequent mailings. Higher overall

RR from the office group (70% v 64%, p<.05). 3)

Survey length had no effect on RR in this study.

Group 1: RR=48.4%; group 2: RR=48.1%

(p=.876). 4) RR for the mail/online group was significantly higher than for mail-only (66%,

59%, p=.026). There was no difference in the percent of mailed responses between the two groups (58%, 59%, p=.848).

Conclusions: In the face of universally declining survey response rates, the continued ability to collect valid research information from

pediatricians will require creative modifications to traditional survey methods. These studies suggest three methods for effectively increasing response rates, but additional research is needed to test and further refine these methods individually and/or in combination.


These studies suggest that modifications in traditional methodologies that show appreciation for the physician’s time, convey the importance of the study, and offer the physician more than one way to respond can increase response rates.

•

After the Crash: A Research-Based Theatre

Approach for Knowledge Translation in

Traumatic Brain Injury

Julie Gilbert, M.Sc., Ph.D., Angela Colantonio,

Ph.D., Pia Kontos, Ph.D., Kate Rossiter, Julia

Gray, B.F.A., Michelle Keightley, Ph.D.

Presented By: Julie Gilbert, M.Sc., Ph.D., 200

Front Street West, Suite 2501, Toronto, Ontario,

M5V 3M1, Canada, Phone: (416) 205-1443, Fax:

(416) 205-1440,

Email: jagilbert@changefoundation.com

Research Objective: Traumatic brain injury

(TBI) is under-recognized as a public health concern; brain injuries may result in a variety of long-term cognitive, emotional or behavioural challenges for the survivor. Presently, there is a gap in the transfer of TBI research from the sources of knowledge creation to the health care providers who might use such research findings.

This project was designed to address this gap by testing theatre as a creative method of knowledge translation and an educational tool for caregivers of TBI survivors.

Study Design: Primary data were collected from a series of focus groups held with TBI survivors, family members, and professional caregivers who practice in the field of TBI. The data from the transcript analysis of these focus groups were used as the basis for creating the ‘After the

Crash’ script and performance. Two types of transcript analysis were employed: 1) a conventional qualitative coding of the data, resulting in a number of key themes around which the play was based and 2) a ‘narrative’ or

‘dramatic’ coding of the transcript, whereby the dramaturg/research analyst highlighted passages that might inform a significant monologue, character, scene, or plot idea. The playwright/director led a professional cast through improvisation and early script development exercises to build a dramatic plotline and script. The draft script was critiqued by the team’s investigators as well as an invited audience of TBI survivors, informal caregivers and health care professionals, many of whom participated in the focus group discussion upon which the script was based. The feedback was incorporated into the final draft of the script.

Following each of four performances of the play, discussions were held and an evaluation questionnaire was distributed to assess the play in terms of its impact and aesthetic qualities.

Population Studied: Audiences have included: university students and faculty; health care professionals in TBI and rehabilitation; and a wide variety of other stakeholders in the brain injury community. Although the intervention was targeted for persons with minimal experience with TBI, many persons with experience were drawn to the performances

(mean: 6 years).

Principle Findings: Responses from the postperformance evaluation supported the effectiveness of drama as a knowledge translation strategy. There were significant negative correlations between years of experience with TBI and scoring of knowledge gained (Spearman correlation, p < 0.0001) and the play imparted new knowledge, or reinforced existing knowledge among experienced practitioners. Qualitative responses provided by audience members reflected many of the themes and findings from the original focus groups.

Conclusions: These findings provide support for the effectiveness of theatre as a means of communicating research findings, especially when those findings are emotional, psychological or humanistic in nature. Such messages are difficult to capture through traditional methods of knowledge translation yet vital for best practices in medicine and caregiving. This project was a unique synthesis of the disciplines of health psychology, health services research and theatre.


Theatre offers an effective method of knowledge translation and has the potential to support and improve practice among TBI health care providers. Findings from this project also highlight the efficacy of theatre to reaffirm and fortify positive care-giving skills.

Funding Source: Canadian Institute for Health

Research, The Change Foundation, University of

Toronto Health Care Technology and Place, the

Ontario Rehabilitation Research Network, the

Toronto Rehabilitation Institute, the Ontario

Work Study Program and a grant by the Ont

• Analyses of Knowledge Translation

Theories/Frameworks

Ian Graham, Ph.D., Jacqueline Tetroe, M.A.,

Nicole Robinson, B.A.

Presented By: Ian Graham, Ph.D., Vice

President, Knowledge Translation, Canadian

Institutes of Health Research, 160 Elgin, 9th

Floor Address Locator 4809A, Ottawa, K1A

0W9, Canada Phone: 613 954-2856, Fax: 613 957-

6141, Email: igraham@cihr-irsc.gc.ca

Research Objective: The purpose of the research was to conduct a focused search for conceptual models, frameworks, and grand theories of knowledge transfer (planned change); to undertake a theory analysis of the identified models/theories to determine their strengths and limitations and to determine similarities and differences between them; to determine the extent to which each theory has been used and/or tested and the contexts and populations in which it has been used and/or tested; and to produce a users-guide to the theories (theories catalogue, synthesis of theory analysis)

Study Design: We conducted a focused literature search of: health sciences, social sciences, management, education literature

(over 4,000 hits); internet, hand searching of the journals Science Communication; Knowledge,

Technology and Policy. We developed inclusion criteria to identify planned action theories and then extracted data from each theory as we determined the origins; examined the meaning; judged the logical consistency; defined the degree of generalizability and parsimony and testability. We conducted an analysis of the concepts found in each theory and used that to develop a set of action categories that form the phases of planned action.

Principle Findings: We identified 31 planned action theories that formed the basis of our analyses. The phases of planned action include:

Identify the problem; Identify the need for change; identify change agents; identify target audience; assess barriers; review evidence/literature or develop innovation; tailor/develop intervention; link(age); implement; evaluate (includes pilot testing, developing an evaluation plan as well as evaluating the process and outcomes); maintain change and disseminate. We created an Access Database containing an inventory of planned change models, frameworks/grand theories and a KT

Theories User’s Guide which synthesizes all the planned change models/theories; identifies common elements of each and provides information on their use.

Conclusions: There is an interesting contradiction in implementation research. While many implementation trials are uninformed by theory, at the same time, there would appear to be an alarming number of theories/models extant in the peer reviewed literature. We identified relevant theories and ‘‘unpacked’’ their concepts in order to find the commonalities between them as well as to identify the full range of components thought to be important for successful implementation.


Practitioners interested in implementing change in their setting can view our database to get an overview of theories, find one that suits their purpose, discover the common components of planned action theories and be enabled to use theory to guide their future implementation endeavours.

Funding Source: Canadian Institutes of Health

Research

• Identification, Concept and Bibliometric

Analyses of Knowledge Translation

Theories/Frameworks

Ian Graham, Ph.D., Jacqueline Tetroe, M.A.,

Nicole Robinson, B.A.

Presented By: Ian Graham, Ph.D., Vice

President, Knowledge Translation, Canadian

Institutes of Health Research, 160 Elgin Street,

Ottawa, K1A 0W9, Canada, Phone: (613) 954-

2856, Fax: (613) 957-6141, Email: igraham@cihrirsc.gc.ca

Research Objective: There is an interesting contradiction in implementation research. While many implementation trials are uninformed by theory, at the same time, there would appear to be an alarming number of theories extant in the peer reviewed literature. We were interested in identifying relevant theories and ‘‘unpacking’’ their concepts so as to be able to find the commonalities between them as well as to identify the full range of components thought to be important for successful implementation.

The purpose of the research was to conduct a focused search for conceptual models, frameworks, and grand theories of knowledge transfer (planned change); to undertake a theory analysis of the identified models/theories to determine their strengths and limitations and to determine similarities and differences between them; to determine the extent to which each theory has been used and/or tested and the

contexts and populations in which it has been used and/or tested; and to produce a usersguide to the theories (theories catalogue, synthesis of theory analysis)

Study Design: We conducted a focused literature search of: health sciences, social sciences, management, education literature

(over 4,000 hits); internet, hand searching of the journals Science Communication; Knowledge,

Technology and Policy. We developed inclusion criteria to identify planned action theories and then extracted data from each theory as we determined the origins; examined the meaning; judged the logical consistency; defined the degree of generalizability and parsimony and testability. We conducted an analysis of the concepts found in each theory and used that to develop a set of action categories that form the phases of planned action.

Principle Findings: We identified 31 planned action theories that formed the basis of our analyses. The phases of planned action include:

Identify the problem; Identify the need for change; identify change agents; identify target audience; assess barriers; review evidence/literature or develop innovation; tailor/develop intervention; link(age); implement; evaluate (includes pilot testing, developing an evaluation plan as well as evaluating the process and outcomes); maintain change and disseminate. We created an Access Database containing an inventory of planned change models, frameworks/grand theories and a KT

Theories User’s Guide which synthesizes all the planned change models/theories; identifies common elements of each and provides information on their use.


Practitioners interested in implementing change in their setting can view our database to get an overview of theories, find one that suits their purpose, discover the common components of planned action theories and be enabled to use theory to guide their future implementation endeavours.

Funding Source: CIHR

•

Implications for Evidence-based Practice

Implementation for Working Conditions among Nursing

Ronda Hughes, Ph.D., M.H.S., R.N., Bonnie

Jennings, D.N.Sc., R.N., F.A.A.N.

Presented By: Ronda Hughes, Ph.D., M.H.S.,

R.N., Senior Health Scientist Administrator,

Center for Primary Care, Prevention & Clinical

Partnerships, Agency for Healthcare Research &

Quality, 540 Gaither Road, Rockville, MD 20850,

Phone: (301) 427-1578, Fax: (301) 427-1595, Email:

Ronda.Hughes@ahrq.hhs.gov

Research Objective: Implementing evidencebased safety practices in health care settings is difficult and requires strategies that address the complexity of care, experience and training of individual clinicians, senior leadership, and a changing organizational culture. The working conditions within organizations have been found to be directly related to the quality and safety of patient care. Our aim was to systematically review the literature that might inform quality improvement and patient safety strategies for nursing across organizational settings.

Study Design: A systematic review of the literature was conducted on evidence-based practice strategies and quality improvement strategies related to working conditions.

Inclusion criteria included: English language; literature primarily reflecting practice in Great

Britain, Canada, and Australia; publication period from 1990 to 2006; and adult human subjects.

Articles were selected using pre-determined criteria to inform the scope of working conditions for nurses.

Population Studied: Sources for our review primarily included MEDLINE and CINAHL databases, using the following terms of: working conditions, work environment, work design, organizational climate, culture of safety, leadership, restructuring, mergers, staffing, stress, burnout, turbulence, workload, quality improvement, and patient safety. Our exclusions included articles associated with specific populations (e.g., low income), not directly associated with health care providers, or containing brief descriptions lacking essential details.

Principle Findings: From 28,692 total citations, we identified 1,863 potentially relevant articles,

498 of which ultimately met inclusion/exclusion criteria. We identified three themes for specification of evidence-based practice implications: (1) decreasing the impact of hazards to both staff and patients, (2) effective change strategies supporting a culture of safety, and (3) practice implications of effective working conditions. Some lessons from other disciplines have been effectively adapted to health care settings. The quality of the evidence varies in level of study design.

Conclusions: In general, the typical working conditions of nurses across organizational setting are characterized by serious threats to the quality of care and patient safety. Despite

targeted funding to develop the knowledge base of patient safety, significant gaps and the sparse empirical evidence have substantial implications for health care delivery. The working conditions literature does not support clear, simple strategies for improving conditions that will ultimately improve patient care and outcomes.

What is apparent is the need for effective leadership, organizational support for improvements, greater resources for clinicians, and increased nurse staffing.


Health care leaders, clinicians, and researchers need to work together to purposefully incorporate quality improvement and effective patient safety strategies into daily practice. Our review identified several practice implications for health care leaders and managers as well as those providing patient care. Existing evidence warrants implementation in the current the work environment. Research is needed to characterize the implications of working conditions on the unit level in hospitals, effective collaboration and team processes, and the effective interaction of clinicians and management during health system and care delivery change.

Funding Source: AHRQ, RWJF

• An Iterative Research/Policy Approach to

State and Local Community Health Insurance

Innovation

Karen Minyard, Ph.D., Patricia Ketsche, Ph.D.

Presented By: Karen Minyard, Ph.D.,

Director/Associate Research Professor, Georgia

Health Policy Center, Georgia State University, 14

Marietta Street, Atlanta, GA 30303, Phone:

(404)651-0168, Fax: (404)651-3147, Email: kminyard@gsu.edu

Research Objective: To learn how an iterative research/policy process can guide state and local innovations to decrease the incidence of uninsurance.

Study Design: An iterative process of research, education, policy design, and pilot studies has been used to build broad public understanding, the issues surrounding and the potential solutions to the growing lack of health insurance.

Population Studied: A variety of studies of the state’s population, employers, and stakeholders have been part of the five year study process: a state specific household survey regarding health and insurance (2002); annual analysis of the

CPS; two employer surveys (2002, 2004); focus groups with employers to understand barriers to offering insurance (2002, 2005); focus groups with various socioeconomic clusters to understand values related to health insurance

(2002, 2005); key stakeholders interviews to understand the policy environment (2002); a priority setting process with community leaders, county commissioners, and state legislators

(2004); economic modeling to measure the impact of various policy options (2005); thirty one-hour modules conducted with local business and government leaders to measure the preference for various uninsured policy options before and after education and discussion

(2006). The findings are continuously shared with community collaboratives in four pilot sites

(urban, suburban, and rural locations) to facilitate the design of local policy for the uninsured (2004-present).

Principle Findings: The findings from this research include: knowledge about health insurance trends and attitudes from the individual, employer, and state perspectives and understanding of the process of community based participatory policy design. Findings about health insurance are consistent with national findings (growing numbers of uninsured, erosion of ESI, high cost of coverage, administrative complexity for small firms). Local government and business leaders favor modest changes to the insurance market (distribution methods, increased competition, mandated benefit and minimum coverage changes) and tax incentives for employers and individuals.

Findings related to policy design include: an iterative process of research, education, and policy design facilitates public understanding of a complicated policy issue like health insurance; time, a combination of broad and tailored research, and exposure to best practices can accelerate the development of local innovation; and exposure to education and discussion impacts the views of local leaders on preferred policy options. Local collaboratives use the information to create momentum in reorganizing local provider resources as leverage to create low cost coverage for low wage workers. Such efforts are enhanced through cross community collaboration and generate interest throughout the state in duplication and broader state level reforms.

Conclusions: An iterative research/policy/education process that includes the translation of broad research and the implementation of specific research to support local policy making is helpful, especially when issues are complex and multidimensional. This approach recognizes both the evolution of knowledge and the messiness of state and local

processes. In the absence of broad national or state reform, local communities are not impotent with respect to the uninsured.


Many important health policy decisions regarding health insurance are being made at the state and local levels. The development of a research/policy process that informs, supports, and accelerates state and local decision making can result in more relevant, replicable state/local innovation.

Funding Source: Health Resources and Services

Administration, Georgia Department of

Community Health, Healthcare Georgia

Foundation

•

Crafting Health Education for State

Legislators

Karen Minyard, Ph.D., Mary Ann Phillips,

M.P.H., Glenn Landers, M.B.A., M.H.A.

Presented By: Karen Minyard, Ph.D.,

Director/Associate Research Professor, Georgia

Health Policy Center, Georgia State University, 14

Marietta Street, Atlanta, GA 30303, Phone:

(404)651-0168, Fax: (404)651-3147, Email: kminyard@gsu.edu

Research Objective: To determine the most effective strategies for building broad health knowledge and whole system decision making among state legislators.

Study Design: An iterative case study design has been used to understand each phase of the process: origination of the concept; endorsement of the concept by funder and key stakeholders; design of the education component; and delivery of the content.

Literature review, identification of best practices, and interviews with national and state experts as well as key state legislators provided the basis for the structured interview process. Key principles of systems change, whole system thinking, and community based participatory research were incorporated into the process.

Population Studied: State legislators, state government administrators, and key private sector stakeholders.

Principle Findings: Mind-set change among legislators is a multi-year, multi-faceted process, especially when dealing with a part-time legislature. Private stakeholder, legislative and government administrator buy-in and investment are fundamental keys to success.

Legislative leadership involvement in the endorsement, design, and delivery of the education components provides a firm foundation for the process. One size does not fit all when it comes to building health knowledge among legislators. Legislators categorize themselves into four clusters. The ‘‘basic group’’ includes novices just beginning to learn about health and health financing and struggling with acronyms and terms. The ‘‘intermediate group’’ desires in-depth knowledge about specific topics.

The ‘‘advanced group’’ seeks to understand how the system fits together, how issues impact each other, and what other states are doing. Those in the ‘‘leadership group’’ seek higher-level knowledge so that they recognize the implications of policy and resource decisions.

The most effective way to introduce a systemic approach to health policy is to begin with the issues currently being debated even though these issues may not seem to have significant potential for positive impact. As one legislator said, ‘‘meet us where we are and help us to think systematically about the specific issue confronting us’’. Involving legislators as advisors for each group’s learning and using legislators (and other private and government leaders) in the design of each educational product ensures that the process is relevant to the target population.

Conclusions: The iterative case study approach for both research and delivery is an effective way to accelerate both learning and teaching.

Principles from community-based participatory research are applicable in developing a legislative education process that seeks a fundamental modification in the approach to health policy.


Many of the most important health policy decisions are made at the state level. States are laboratories for innovation in health policy. State legislators often make policy decisions on individual health and health financing issues using a siloed approach. Building capacity at the state legislative level for a systems approach to health policy and financing creates opportunity for sustainable, relevant innovation and buy-in.

Funding Source: Woodruff Foundation

• Health Care Delivery System

Transformation Model: Depiction and

Application

Patricia Parkerton, Ph.D., M.P.H.

Presented By: Patricia Parkerton, Ph.D., M.P.H.,

Assistant Professor, Health Services, UCLA SPH,

Box 951772, Los Angeles, CA 90095, Phone: 310-

825-2926, Email: parkert@ucla.edu

Research Objective: The need to increase the effectiveness of health care delivery consistent

with evidence and with a reduction in variance is widely accepted. Yet, our mechanisms to seed change and transform care are primitive. We are not clear which interventions are effective or what provider/organization/team/system structures are likely to yield the best results.

Systematic study of effective implementation is needed for which a coordinating framework is absent.

Study Design: Review of the literature on models of care yields limited choices. However, development of a consistent model of influences upon patient outcomes would enable the field to isolate factors, test common hypotheses, and achieve greater understanding of organizational readiness to change, essential practice team supports, and necessary process evolution. To specify this framework, building upon 20 years of management experience and the published literature, evaluation was conducted in 3 different environments using both quantitative and qualitative techniques.

Population Studied: The framework evolved during assessment of change in three studies of delivery system organizations------diverse hospitals, California physician organizations, and federal ambulatory care facilities. These organizations included: 15 geographically and structurally diverse hospitals participating in

Phase II of the RWJF funded IHI Collaborative,

Transforming Care at the Bedside; 17 California physician organizations randomly selected to participate in a Quality Improvement intervention funded by the National Cancer

Institute to increase colorectal cancer screening; and 125 Veterans Administration ambulatory facilities linking a primary care structure survey and colorectal cancer screening rates.

Principle Findings: Elements of practice or team structure in any clinical environment influence the adoption of new care processes which in-turn influence patient outcomes-----consistent with Donabedian’s Model. Practice elements can be arrayed along continua as: autonomous, focused, integrated, and secure.

Care processes are categorized as efficient, patient centered, reliable, or staff engaged------in keeping with a balanced scorecard. Each of these categories are defined and measures suggested.

The introduction of an intervener attempting to stimulate improvement will be more or less effective depending on each of these elements of practice structure and care process. Aspects of the clients served, environment, clinicians, and organization are necessary control variables.

Conclusions: A pictorial model can be valuable in designing an intervention and assessing its completion. Unexplained variation in results can be followed up with directed studies. Common nomenclature will support complementary research as we strive to better understand clinical organizations and their transformation.


Policy makers, healthcare administrators, intervention implementers, and organization researchers interested in improving the effectiveness and stability of clinical services should focus on processes and resources that enhance the capacity of clinician teams to provide evidence-based services.

Funding Source: RWJF, California

HealthcareFoundation, VA HSR&D

•

Translation of Secondary Research to

Incubate Primary Research

MaryAnn Phillips, M.P.H., Karen Minyard, Ph.D.

Presented By: MaryAnn Phillips, M.P.H., Senior

Research Associate, Georgia Health Policy


Street, Suite 221, Atlanta, GA 30303, Phone:

(404) 651-1643, Fax: (404) 651-3147, Email: mphillips2@gsu.edu

Research Objective: To provide evidence-based research about childhood obesity to Georgia’s philanthropic community so that it will be translated into philanthropic policy formulation and resource allocation.

Study Design: The Philanthropic Collaborative for a Healthy Georgia brings Georgia’s grantmakers together to respond to healthrelated challenges facing Georgia. The

Collaborative launched a research initiative to study childhood obesity. The Health Policy

Center’s multi-pronged study design translated academic literature into user-friendly information; invited state and national experts to present best practice information to philanthropists; commissioned four papers from national experts to identify and recommend evidence-based practices focused on funding opportunities for foundations; prepared a brief targeted to foundations on preventing overweight children; and sponsored a symposium bringing together national and state foundations to discuss options for Georgia grantmakers.

Population Studied: Trustees and staff of family, corporate and community foundations in

Georgia

Principle Findings: The Collaborative determined that, before any policy related to childhood obesity could be implemented in

Georgia, a baseline assessment must be

conducted. The philanthropic community and the State formed a public/private partnership to fund the Georgia Youth Fitness Assessment

(GYFA). The Assessment utilizes the

FITNESSGRAM which applies criterionreferenced standards to evaluate physical fitness performance. About 5,000 students in grades 5 and 7 had their BMI measured and engaged in five physical fitness tests to assess aerobic capacity and muscular strength, endurance, and flexibility. Students completed a standardized questionnaire about physical activities, and each participating school provided information about its physical activity and nutrition policies.

Conclusions: Translating secondary research on childhood obesity and presenting findings to the

Collaborative resulted in funded primary research that will inform future state and national policy and program efforts.

Just as national philanthropy makes evidencebased investments to inform national and state policy, Georgia’s philanthropic community came together to examine the academic literature, understand the scale and scope of the problem, learn about best practices, and identify opportunities to inform Georgia policy and fund their local grantmaking activities. By studying issues associated with childhood obesity and best practices for addressing those issues, the

Collaborative determined that Georgia needed evidence-based information about the physical fitness of its 5th and 7th grade students.


Through this $700,000 investment, the philanthropic community will provide information about policy options and opportunities for foundations and state agencies to support and fund successful programs statewide and/or specific to their own communities. The GYFA will provide critical information for developing a statewide agenda and action plan to enhance physical fitness and promote physical activity among young people.

Results can be used by: the state to implement evidence-based physical education policies; schools to re-assess and modify physical education programs; students to plan personal fitness programs; parents to understand their children’s fitness levels; and community leaders to design opportunities to increase physical activity outside school. This investment to link research to local philanthropic policy and resource allocation serves as a catalyst toward the design and implementation of policies and programs to enable Georgia’s children to be more active and avoid the consequences of obesity.

• Development of a Rural Typology GIS for

Policy Makers

Michael Shambaugh-Miller, Ph.D., Keith Mueller,

Ph.D., Rebecca Slifkin, PhD., A. Clinton

MacKinney, M.D., Timothy McBride, Ph.D., Andy

Coburn, Ph.D.

Presented By: Michael Shambaugh-Miller,

Ph.D., Assistant Professor, Health Services

Research and Rural Health Policy, University of

Nebraska Medical Center, 984350 Nebraska

Medical Center, Omaha, NE 68198-4350, Phone:

402-559-7858, Fax: 402-559-7259, Email: mdmiller@unmc.edu

Research Objective: To better understand the spatial aspects of the various definitions of rural and frontier a GIS was created so as to aid researchers and policy makers in addressing the impacts of the choice of rural definitions upon

Federal policy.

Study Design: Using ArcGIS 9.1 data gathered from a series of Federal programs were manipulated to create the spatial files necessarty to populate a GIS which allows the user to compare the spatial, demographic and financial impacts of the spatial definition of various federal programs definition's of rural.

Population Studied: United States

Principle Findings: Rural, including components within rural (remote, frontier, nonadjacent to urban) can be defined using one of several ways of thinking about geography: zip codes areas, counties, census tracts, population density, distance. Most geography used to define rural do not have common boundaries.

Seemingly small differences in the definition of rural can produce dramatically different results in terms of who is affected by the policy. The application of definitions will sometimes drift from intent of authors because target populations were not carefully specified or because what seemed to be a reasonable definition in concept changes because the geography used in data construction is not the same as the geography in available data.

Oftentimes a definition will produce consequences not anticipated by the authors because potential implications were not considered during the development or selection of the definition.

Conclusions: There is no single, universal way to define rural. The definition that one selects will affect the way in which Federal legislation works.


The definition of rural used should be driven by the objective you want to achieve to insure that the intended people, places and providers receive the desired benefits.

Funding Source: RUPRI

• Why Are Clinical Practice Guidelines Not

Effective in Ontario?

Moriah Shamian-Ellen, M.B.A., Ph.D., Dr. Ross

Baker, Ph.D., Dr. Adalstein Brown, Ph.D.

Presented By: Moriah Shamian-Ellen, M.B.A.,

Ph.D., Student, instructor, Health Policy,

Management, and Evaluation, University of

Toronto, 57 Glen Park Avenue, Toronto, M6B

2C1, Canada, Phone: 416-256-4450, Email: moriah.ellen@gmail.com

Research Objective: Previous research has demonstrated that clinical practice guideline

(CPG) usage is not related to hospital length of stay (LOS) in Ontario, which is in stark contrast to a systematic review that found a strong relationship between CPGs and LOS (Shamian-

Ellen M., Brown, AD, Leatt, P, 2006, Shamian-

Ellen M., Brown, AD, Cockerill R, 2006) . The purpose of this research was to explore the development, implementation, and evaluation process of clinical practice guidelines (CPGs) in acute care hospitals and to determine why CPG usage does not influence LOS in Ontario hospitals. Shamian-Ellen M., Brown, AD,

Cockerill R, (2006), ‘‘Examining the Relationship

Between Clinical Practice Guidelines and Length of Stay Through a Secondary Data Analysis’’, work in progress. Shamian-Ellen M., Brown, AD,

Leatt, P, (2006), ‘‘Can Clinical Practice

Guidelines really Influence Hospital Length of

Stay? A Systematic Review’’, Submitted for publication to the Joint Commission Journal on

Quality and Patient Safety

Study Design: Semi-structured qualitative interviews were conducted. Interview questions were based on the AGREE tool used to rate

CPGs, and a thorough list of exploratory questions developed based on the review of the literature and a discussion with experts in the field. The individuals interviewed dealt with one or all of the following responsibilities: developing, implementing, monitoring, updating, or evaluating CPGs.

Population Studied: Acute care hospitals in

Ontario, Canada.

Principle Findings: Nine semi-structured interviews were conducted and three different hospital types (small, community, and teaching) were represented. Hospitals were at varying stages of CPG implementation. The interviewees stated that hospitals predominantly use pre-existing CPGs and include multidisciplinary teams in the development of

CPGs. CPGs are implemented for a variety of reasons i.e. political or organizational. Barriers to implementation were discussed such as lack of resources and clinician resistance. Tailoring pre-existing CPGs to the specific organizational setting was viewed as extremely labour intensive and the proper supports were not in place to ensure success. Lack of organizational support, financial resources, and tools, were cited as the largest barriers for implementation. Perceptions of the effectiveness of CPG on a variety of outcomes are reviewed.

Conclusions: The interviews explained some of the possible factors why CPGs are not realizing their full potential in Ontario hospitals such as poor compliance rates and resistance from health care providers. The CPG itself is not perceived by the interviewees to be the reason why CPGs are not effective, mostly because they are evidence based, well developed PGs adopted from outside organizations. The barriers are perceived to be at the organizational level i.e. not enough resources and support, and individual level i.e. clinician resistance.


There is a lot of pressure in health care for institutions to develop and implement CPGs.

Millions, if not billions, of dollars are being spent on developing evidence-based CPGs. However, policy makers need to start spending more funds and providing more assistance to health care managers and employees required to implement such a considerable change to the way health care is being delivered, Policy makers need to provide health care staff with the tools they need to succeed in CPG implementation, such as training, organizational analysis, and implementation.

Funding Source: Canadian Institutes for Health

Research: Doctoral Research Award

•

Translating Research Into Practice: The

National Nursing Practice Network

Marita Titler, Ph.D., R.N., F.A.A.N.

Presented By: Marita Titler, Ph.D., R.N.,

F.A.A.N., Director, Research, Quality &

Outcomes Management, Department of

Nursing Services & Patient Care, University of

Iowa Hospitals and Clinics, 200 Hawkins Drive,

#T-100 GH, Iowa City, IA 52242-1009, Phone:

(319) 353-6995, Fax: (319) 353-8669, Email: marita-titler@uiowa.edu

Research Objective: In order to close the existing gap between discovery and the use of knowledge, concentrated efforts must focus on methods to speed translation of research findings into practice. Development and dissemination of evidence-based practice guidelines are important first steps, but with out active translation efforts, they do little to promote knowledge uptake by direct care providers. The National Nursing Practice

Network (NNPN) represents a commitment to the promotion and implementation of evidencebased practices through a collaborative model designed to promote shared learning and participation.

Study Design: Based on social network theory and results of needs assessments, the University of Iowa College of Nursing and the University of

Iowa Hospitals and Clinics Department of

Nursing Services and Patient Care facilitates translation of research by means of: (1) fostering exceptional health care outcomes of individuals, groups and communities receiving nursing care in a variety of health care environments; (2) advancing professional practice through application of evidence in care delivery; (3) supporting on-going nursing leadership development for evidence-based practice; and

(4) increasing understanding of the mechanisms and strategies that foster the use of evidence by those delivering health care services.

Population Studied: The newly formed NNPN is a network of 44 acute care hospitals through which data, information, knowledge, practices and behaviors flow. The presence of networks can provide health care organizations with access to resources, information, opportunities for learning and knowledge transfer, and legitimacy and credibility with internal and external stakeholders. Most of these acute care hospitals are affiliated with skilled, long-term care facilities, ambulatory services and primary care sites.

Principle Findings: Outcomes of this network will include the identification of a battery of instruments for measuring organizational context variables that may influence implementation and sustainability of evidencebased practice in a variety of health care organizations.

Conclusions: Needs assessments found high priority given to: (1) training in evidence-based practice (EBP); (2) networking opportunities; and

(3) cataloging resources including EBP toolkits, models for promoting EBP, and targeted educational opportunities. Participants in this initiative of translational research, NNPN hospitals. Subsequent participation in this initiative will assess their ability to expand evidence-based practices and their linkage with patient outcomes.


The NNPN offers promising potential for contributing to the evidence base for translational research and a good mediator for the transition to EBP. It remains to be seen how the NNPN increases the utilization of EBP across settings and provides linkages and integration with EBP across clinician type.

•

How To Test Composite Non-Null

Hypotheses

Peter Veazie, Ph.D., M.S.

Presented By: Peter Veazie, Ph.D., M.S.,

Assistant Professor, Community and Preventive

Medicine, University of Rochester, 601 Elmwood


(585)273-5464, Email: peter_veazie@urmc.rochester.edu

Research Objective: To present the Extended

Conjunction Set rule for testing composite nonnull hypotheses. This is a new rule providing a means of testing that implies a single non-null alternative as opposed to the commonly used joint test that implies numerous alternatives.

Study Design: Logical analysis is used to determine the testing rule. Examples are based on Monte Carlo and Bootstrapping techniques in conjunction with standard regression models and tests.

Population Studied: Simulated data and data from the Chronic Illness and Caregiving survey conducted in the year 2000 from March 17th through November 22nd by Harris Interactive

Inc. are used to provide examples for implementation of the presented testing rule.

Principle Findings: The proposed Extended

Conjunction Set rule is easily applied and has an upper bound to the type 1 error rate of the desired significance level. Power or sample size calculations can be easily implemented via

Monte Carlo simulations.

Conclusions: Rejection of the typical joint test of

N hypotheses implies 2N?1 possible alternatives; for example, rejecting a joint test of three hypotheses implies seven possible alternative cases. However, researchers are typically interested in only one. This paper presents the

Extended Conjunction Set rule as a remedy that implies the single alternative of interest. Use of

this rule will allow researchers to infer an explicit composite non-null hypothesis.


Health services research and policy analysis depend on appropriate methods for drawing inferences from data. It is often the case that policy viability depends upon the claim that multiple quantities are simultaneously non-zero.

This paper presents a means for researchers and analysts to achieve greater confidence in such claims.

•

Least Squared Simulated Errors: An

Estimator For Models With Unspecified

Regression Function






585-273-5464, Email: peter_veazie@urmc.rochester

Research Objective: Estimation by minimizing the sum of squared residuals is a common method for parameters of regression functions; however, regression functions are not always known or of interest. Maximizing the likelihood function is an alternative if a distribution can be properly specified. However, cases can arise in which a regression function is not specified, no additional moment conditions are indicated, and we have a distribution for the random quantities, but maximum likelihood estimation is difficult to implement. This paper presents the Least

Squared Simulated Errors estimator for such cases.

Study Design: The conditions for consistency and asymptotic normality are given by mathematical analysis. Finite sample properties are investigated via Monte Carlo experiments on two examples: one example allows direct comparison with a gold standard estimator; another example is sufficiently complex to preclude other methods of estimation.

Population Studied: Monte Carlo simulation experiments are used to investigate small sample properties of the estimator.

Principle Findings: The estimator is consistent and asymptotically normal under fairly general conditions. The finite sample properties are model dependent; convergence toward zero bias and normality can be fairly rapid even for complex models. Resampling techniques can be used to estimate standard errors when normality is not well approximated for small samples.

Conclusions: The Least Squared Simulated

Errors estimator is a viable alternative when other methods are inapplicable. There are limitations, however: First, the asymptotic properties dependent on the the unspecified regression function meeting the usual Nonlinear

Least Squares regularity conditions. Second, convergence to normality of some parameters

(particularly the variance parameters) can be slower than others, but it is clear that convergence toward normality is being achieved.

However, even with a reasonably normal parameter distribution, the Type I error rates associated with standard tests can be inaccurate, suggesting the standard errors for the parameters may not have converged to a sufficiently small bias. Third, as with nonlinear optimization in general, it may be difficult to numerically locate the global minimum for a given dataset. Finally, like MLE, LSSE estimation can be sensitive to the assumed distribution for the random quantities. As with nonlinear estimators in general, it is prudent to engage a

Monte Carlo investigation of the finite sample properties of a model prior to its estimation on real data to determine whether resampling techniques should be used instead of asymptotic statistics such as the Wald statistic. Moreover,

Monte Carlo investigation of any given model can be used to judge bias in a particular finite sample of interest.


Health services research and policy analysis can depend on appropriate estimates of structural parameters, but common estimation techniques are not universally applicable to general structural model specifications. The LSSE estimator extends the set of models that can be estimated, thereby providing more appropriate estimates as the basis for policy analysis and decisions.

• Behavioral Risk Factor Surveillance System:

An Important Database for Public Health

Research and Practice

Guijing Wang, Ph.D., Robert Spengler, Sc.D.

Presented By: Guijing Wang, Ph.D., Health scientist, Office of Public Health Research,

Centers for Disease Contro and Prevention, 1600

Clifton Road, Atlanta, GA 30333, Phone: (404)

649-4666, Email: gbw9@cdc.gov

Research Objective: Background & Objectives:

The Behavioral Risk Factor Surveillance System

(BRFSS) has become a major public database for research and development in health promotion.

However, the contributions of the BRFSS to research in public health areas have not been systematically evaluated. This study attempts to evaluate such contributions, in order to provide valuable information to researchers and public health officials for further developing this database and enhancing its use for research and public health practice assessment and enhancement.

Study Design: Methods: Many personal health behaviors such as smoking, drinking, poor eating habits, and physical inactivity have been linked to major chronic diseases such as cardiovascular disease, diabetes, and cancers. Public health practices can be assessed and enhanced using population screening prevalence rates for common cancers and other diseases. To have a better understanding of these behaviors and practices, the Centers for Disease Control and

Prevention (CDC) has collaborated with State health department and the District of Columbia to collect population-based state-specific prevalence data, the BRFSS, since 1981. This project analyzed the literature outputs (scientific publications in PubMed database, excluding comments and letters) which analyzed the

BRFSS data during 1982 to 2005. First, we conduct a trend analysis of number of publications to show the overall impact of the

BRFSS on public health literature. Then, we analyzed publications in specific journals-

MMWR (a CDC publication) and additional 4 major journals in public health [JAMA, American

Journal of Public Health (AJPH), American

Journal of Preventive Medicine (AJPM), and

Preventive Medicine (PM)]. We further investigate the literature by major diseases, risk factors, health practices, and population groups.

The diseases are cardiovascular disease, hypertension, diabetes, cancers, and breast cancer. The risk factors include smoking, physical inactivity, overweight/obesity, and diet/nutrition. The special populations are women, African American, Hispanics, Native

American, and Asian and Pacific Islanders.

Population Studied: Scientific Literature.

Principle Findings: Results: The BRFSS has been used for 1,362 scientific publications during

1982-2005 (56 paper/year, min 1 and max 145), increased from one paper/year in 1982 to 123 paper/year in 2005. MMWR published 220 articles (16%). AJPH, AJPM, JAMA, and PM published 89, 74, 57, and 48 papers, respectively.

Since 1985, JAMA published at least one paper per year, with the highest number of 7 papers published in 1991. The numbers of publications on cardiovascular disease, hypertension, diabetes, cancer, and breast cancer are 59, 97,

114, 184, and 76 papers, respectively. There are

347, 253, 168, 161, and 140 papers analyzing smoking, inactivity, overweight/obesity, drinking, and diet/nutrition, respectively. Studies on women, African American, Hispanics, Native

Americans, and Asian/Pacific Islanders are 100,

109, 67, 41, and 28, respectively.

Conclusions: Conclusion: These results suggest that the BRFSS has become a major public database for prevention research. Because of the availability of the BRFSS, the knowledge base on health risk factors has been greatly expanded for researchers and public health officials.


The BRFSS has made a significant impact on supporting public health research and practices.

Best use of the data by health services researchers and practioners will benefit the nation's health.

Innovations in International

Health

•

Web-Based Decision Support System (DSS)

Based on the Fundamental Principles of

Indian Traditional Medical System of

Ayurveda Deploying Data Mining Techniques

Medha Dhurandhar, Ph. D. M.A. B.A. (Hons)

Presented By: Medha Dhurandhar, Ph. D. M.A.

B.A. (Hons), Head, High Performance Business

& R&D Computing, Centre for Development of

Advanced Computing, Pune University Campus,

Pune, 411007, India, Phone: (20) 25704222, Fax:

(20) 25694004, Email: medha@cdac.in

Research Objective: To Design, develop

Traditional Medicine based DSS for clinicians with end-to-end solutions for Constitution

Assessment, Diet & Lifestyle Advice, Disease

Diagnostics & Treatment, Patient Information

Management System; To Develop tools with

Data Mining techniques for pattern recognition, trend/predictive analyses to help clinicians generate evidence base for efficacy, safety of use of Traditional Medical system for preventive/curative health care management

Study Design: Strategy and Policy Planning for expectation management and conflict resolution;

Multi-tier team structure formed for validation, beta-testing; Close interaction with end-users for

Requirement Elicitation, Analysis, Definition of

Deliverables; Project Plan with specific milestones, deliverables, schedules, work breakdown structure; Knowledge Repository with a computational engine built with interactive, multi-dimensional databases; Rigorous fieldtrials for ensuring authenticity, quality, user friendliness

Population Studied: System was made available to clinicians/hospitals for clinical practice.

Applications like Constitution

(Physiological/Anatomical/Psychological)

Assessment, Disease Diagnostics & Treatment were used on healthy people and patients to validate the system-detected results with the physician's assessment. 11 hospitals/research institutes and 56 clinicians participated in the multi-centric field trials. Patients with clear diagnosis were selected from both genders, different age groups, in-patients/out-patients departments.

Principle Findings: In 85.11% cases, clinician detected Constitution matched with the system's result. Regarding Disease Diagnostics application, in 88.17 % cases results matched. In

11.83% cases exact match was not found, but in

8.81% of these system's & physician's diagnosis was very close. In 3.02% cases match was not found. Further analysis showed that when a patient suffered from multiple diseases the physician finalized on one disease and gave treatment. Here exact match was difficult. In

10.57% cases, system gave more precise diagnosis. In many conditions when a patient suffered from multiple diseases the system was useful in providing insight. In 7.88% cases the clinician did not give Ayurvedic diagnosis of some contemporary disease. Here system gave a list of probable diagnosis.

Conclusions: According to the WHO report, there is renewed interest in the use of traditional medicine globally. In India, 65% of the population in rural areas uses Ayurveda for their primary health care needs. In developed countries the population that has used complementary & alternative medicines at least once ranges from 42% to 70%. By exploiting the best of Man & Machine, deployment of IT can provide clinicians/researchers with accurate, timely, comprehensive data; improve accuracy in practice/research; generate standardized clinical data; and create evidence-base for safe and effective use of such Medical systems by recording Adverse Drug Effects.

Implications for Policy, Practice or Delivery: In health care resources need to be effectively and optimally utilized. Adoption of IT can improve operational efficiency, customer service, productivity and profitability. With holistic view of data and availability of effective tools for trend/predictive analyses IT can help policy planners with proactive strategies and rapid decision-making. Network connectivity among clinicians/hospitals can boost collaborative research for disease surveillance, prediction of probable outbreaks. Availability of web-based tools can contribute to improved health care planning, services and utilization. They can provide the most effective ways to organize, manage and deliver high quality care; reduce medical errors; and improve patient safety.

Funding Source: Ministry of Communications &

Information Technology

• Using AHRQ Prevention Quality Indicators to Compare Healthcare Delivery in Russia and the USA

Samuel Hohmann, Ph.D., Sofia Medvedev,

Ph.D., Slava Plavinski, M.D., Ph.D., Olga

Kuznetsova, M.D., Ph.D.

Presented By: Samuel Hohmann, Ph.D., Senior

Research Specialist, Information Architecture,

University HealthSystem Consortium, 2001

Spring Road, Suite 700, Oak Brook, IL 60523,

Phone: (630) 954-1740, Email: hohmann@uhc.edu

Research Objective: Compare incidence of hospitalizations related to AHRQ prevention quality indicators in Russia and the USA

Study Design: Retrospective cross-sectional analysis of hospital discharges. AHRQ prevention quality indicator definitions were used to count the discharges in the population at risk. Population based rates were generated and compared.

Population Studied: Adults hospitalized in a

Russian community of 10,000 residents and in 4 regions of the US (northeast, midwest, south, and west) using 2003 National Hospital

Discharge Survey data.

Principle Findings: There were similarities in hospitalization rates for some indicators, for example, hospitalization rates for diabetes short- and long-term complications were about the same for the Russian community and the 4 US regions. For other indicators, there was wide variation among the Russian community and US regional hospitalization rates. For example, the hospitalization rate for COPD in the Russian community was midway between rates of three

US regions with higher rates and the west region of the US that had a lower rate. A similar pattern was true for asthma hospitalizations, the US

west region having the lowest rate. In the case of hospitalizations for perforated appendix, the

US hospitalization rate was substantially higher

(three times higher) than the Russian rate.

Conclusions: There are similarities and differences in hospitalization rates for ambulatory sensitive conditions in different parts of the world as illustrated in the comparisons of a Russian community and 4 geographic regions of the US. Given the availability of hospital discharge patient origin and population data, much can be learned about current management of these conditions from population based comparisons as meausred by the AHRQ preventive quality indicators.


Sharing data can be an important step in designing population based health care quality improvement strategies. Gathering and analyzing additional hospitalization data on ambulatory sensitive conditions should help public health planners gain insight into health needs of communities in both Russia and the

US.

Funding Source: MAPO and UHC

•

Evaluation of a Prevention Program in the

Republic of Srpska/Bosnia and Herzegovina

Embry Howell, M.S.P.H., Ph.D., Radovan Rodic,

M.Sc., Verica Krajnovic, B. Sc.

Presented By: Embry Howell, M.S.P.H., Ph.D.,

Principal Research Associate, Health Policy

Center, Urban Institute, 2100 M Street, N.W.,


Email: ehowell@ui.urban.org

Research Objective: To evaluate a new prevention program in the Republic of

Srpska/Bosnia and Herzegovina. The program includes outreach to inform citizens of the program as well as increased capacity in the

‘‘Dom Zdravljas (DZ)’’ (health centers) to provide screening and treatment for diabetes, hypertension, high cholesterol, heart disease, and cancer.

Study Design: In fall, 2005 we conducted an evaluation of the program. The evaluation used key informant interviews (to evaluate program implementation) and a survey of citizens to assess their knowledge of and use of the new prevention program.

Population Studied: Twenty-five key informants-

-the Assistant Minister of Health, officials in the health insurance fund, and directors of the Dom

Zdravljas--were interviewed. In additoin, 1004 citizens were randomly selected and interviewed in person by a local survey organization.

Principle Findings: The capacity within the DZs was poor, except in one exemplary center with strong leadership and effective outreach. Fewer than one-third of citizens reported that they had heard of the program, and less than a third were registered with a family doctor (the main point of continuous primary care in the RS). While theoretically all citizens are entitled to preventive services, the DZs are reimbursed only for the services provided to insured people. Only 75% are insured, causing severe financial strains on the health centers. Few centers had the personnel and equipment to implement the preventive screening needed for the program to succeed.

Conclusions: In Eastern Europe, as in many other parts of the world, non-communicable diseases cause a majority of mortality and morbidity. In Bosnia and Herzegovina the public health system has suffered from lack of resources after the fall of communism and the civil war in the early 1990s. This has hampered the implementation of a new program of preventive care in the Republic of Srpska.

Implications for Policy, Practice or Delivery: In the near term, the scope of the prevention program should be limited to only the most costeffective screening procedures. Revenues to fund the program should be raised both by reallocating some health insurance funds and by increasing taxes on alcohol and tobacco.

Reimbursement to doctors for preventive care should be raised.

Funding Source: USAID

•

Understanding and Improving Tuberculosis

Patients' Compliance in South Korea

Chun-Bae Kim, M.D., Ph.D., Seung-Kyu Park,

M.D., Heon Choe, Ph.D., Byoung-Ju Kim, M.D.,

Sook-Jung Hyun, M.P.H., Min Kyung Kim,

M.P.H.

Presented By: Chun-Bae Kim, M.D., Ph.D.,

Associate Professor, Dept. of Preventive

Medicine, Yonsei University Wonju College of

Medicine, 162 Ilsan-dong, Wonju City Kangwon-

Do 220-701, South Korea, Phone: 82-33-741-0344,

Fax: 82-33-747-0409, Email: kimcb@wonju.yonsei.ac.kr

Research Objective: There is increasing concern in many countries about the problem of drugresistant tuberculosis. The National Masan

Tuberculosis Hospital (NMTH) in Korea estimated the incidence of multidrug-resistant

tuberculosis (MDR-TB) about 6.7% in 2003.

Because of low success rate of chemotherapy, high mortality, high social and economic burden, and high default rate of these diseases, this hospital has firstly adopted the directly observed therapy (DOT) program regarding to the recommendation of WHO as the intervention for improving their patients' compliance since 2004.

Therefore, the purpose of this study was to investigate the cause of bad adherence of tuberculosis patients and to develop the management for improving patients' compliance.

Study Design: We developed two kinds of questionnaire (for tuberculosis patient and medical record) by systematic review of related literatures as well as professional consults. The cross-sectional study was implemented for determining the causal factors in patients' compliance by the health belief model, etc..

Population Studied: TB patients who had been admitted or visited the OPD in the NMTH from

March to June 2006, were randomly selected in this study. We classified all patients into three groups regard to their objective compliance score through the evaluation of clinical and selfreported informations. These data were analyzed by desciptive analysis, X2-test, and hierarchical multiple regression using SPSS 10.0.

Principle Findings: A total of 307 tuberculosis patients (response rate 95.6%) were participated. Among them, inpatients and outpatients were 196 and 111, respectively.

According to the classification of respondents, the poor compliance group, good compliance group, and unknown compliance group were

44.1%, 37.8%, and 18.1%, respectively. As the results of hierarchical multiple regression analysis, among five regression models the magnititude of the variance of full model (Model

V) that is explained by the causal factors of patients' compliance was significantly larger than four reduced model. In this model, age and hospital satisfaction including DOT program

(positive), family history, treatment period, and drug event history (negative) were statistically significant variables.

Conclusions: This evidence suggests that the TB management of this hospital may be helpful for improving their patients' compliance, especially when patients are older.


Therefore, our Korean government have to adopt some interventions (including the hospital-based

DOT or public-private mix DOT, etc.) for improving the tuberculosis patients' compliance and to re-allocate the budget through amendment of the National Tuberculosis

Control Program goals its own priorities in the near future.

Funding Source: The 2005 Health Promotion

Fund, Ministry of Health & Welfare, Republic of

Korea

• Where Is The Key? Unlocking the Door to

Health Services Rationing in Europe, North

America and Oceania

Janne Nikkinen, M.Th.

Presented By: Janne Nikkinen, M.Th.,

Researcher, Dpt of Systematic Theology, Center for Social Ethics, Univ. Helsinki, PO Box 33

(Aleksanterinkatu 7), Helsinki U, 00014, Finland,

Phone: +358-9-19123022, Fax: +358-9-19123033,

Email: Janne.Nikkinen@Helsinki.Fi

Research Objective: The share of tax revenue devoted to public health services provision has soared globally. Medicaid is currently the second largest program in the US state budgets and growing. In many countries health policy makers search efficient rationing of health services, wishing to set ‘fair’ limits to care. This study is a doctoral research work from the area of social ethics comparing certain Medicaid rationing proposals and experiments with approaches advanced in Europe (Finland) and Oceania (New

Zealand). The goal was to identify the ideological and non-scientific components, which may hinder the research progress in this field. This is relevant for the international discussion about finding the ways for cost-containment in public health services.

Study Design: The study was conducted by analyzing systematically the academic literature and publications commenting Medicaid rationing experiment in Oregon (OHP), rationing proposals advanced in Tennessee

(TennCare) and wider country-level public rationing experiments of Finland and New

Zealand. The study included also several on-site research visits and interviews with the persons involved in the R & D of these rationing schemes.

Principle Findings: The users of publicly funded health services are often the ones in greatest need, i.e. the poor and underprivileged, having only limited opportunities for trusteeship within a democratic society. Without adequate evaluation of foreign models before implementation, service rationing is inadequately planned and adopted, affecting the most vulnerable population groups. For example, in

March 2005 Finland set timeframes for access to

non-urgent health care based on New Zealand’s rationing model and booking system, in order to increase equity in health services delivery. The number of patients waiting for elective surgery went down rapidly, mainly due to overtime working and outsourcing patients to private sector. However, this reallocation of public resources did not work in favor of certain disadvantaged patient groups, such as mental health patients and substance abusers. Their capability in demanding additional resources is limited when compared the ones with somatic diseases, and point calculations are difficult due to complex medical histories with overlapping diagnoses these patients often may have.

Conclusions: Although the health systems are different ---- the US having private, New Zealand public-private-mix and Finland public ---- similarities are found in the rationing discussion as well as in publications regarding the subject.

One of these is a supposed gap between needs and resources leading inevitably for rationing care that is accepted almost as an axiomatic fact.

This ‘‘gap-need’’-claim goes often in tandem with the claim of ‘‘infinite demand for zero-priced health services’’, which finds little evidential support. The rationing research consists more of assertion and political analysis, but less empirical work, which is somewhat unsatisfactory state of affairs.


Results show that certain problematic ideological factors, political viewpoints and non-scientific aspirations have shaped the rationing research.

Without proper evaluation of what kind of social goals are being advanced through different health policy actions, seemingly good and rational intentions of policymakers may result to undesirable consequences for some patient groups. These findings should be taken into account when considering the public health services rationing in the future.

Funding Source: Alfred Kordelin Foundation

• The Effect of Supplemental Private Health

Insurance on Health Care Purchases, Health and Welfare in Brazil

John Nyman, Ph.D., Nathan A. Barleen, Ph.D. candidate

Presented By: John Nyman, Ph.D., Professor,

School of Public Health, University of

Minnesota, 420 Delaware Street, SE, Box 729,

Minneapolis, MN 55455-0392, Phone: (612) 626-

4425, Fax: (612) 624-2196, Email: nyman001@umn.edu

Research Objective: The goal of health insurance programs in developing countries is often to allow citizens to gain access to additional health care, but according to conventional theory, this additional care----the moral hazard----is welfare decreasing. This paper uses data from the Living Standard

Measurement Study (LSMS) Survey for Brazil, collected by the World Bank during 1996-7, to estimate the net welfare gain that is generated by the additional care that is in turn purchased because of having private health insurance.

Study Design: The paper uses logit regression analysis to show that those with private health insurance purchase more health care. Separate analyses are reported for those with an acute disease, a chronic disease, and for all respondents. Having established that those with insurance purchase more health care, a probit regression analysis is used to determine the effect of health insurance on health, as measured by changes in the probability of falling into the self-reported health status categories of excellent, very good, good, fair, and poor. We find that those with health insurance are more likely to categorize themselves as excellent, very good, or good, and less likely to categorize themselves as fair or poor.

Population Studied: For a sample of Brazilian households, the welfare gain is determined by associating health-related quality of life scores with the various self-reported health states, and determining the increase in the average quality of life score that is generated by the change in the probabilities of a respondent classifying himself or herself in the various states that is caused by having private insurance. The change in health related quality of life score is then compared to the private insurance premium, a conservative, upper bound estimate of the cost of the moral hazard.

Principle Findings: We find that the cost of generating these additional quality-of-life gains appears to be consistent with incremental costutility ratios that would be deemed welfare increasing for new medical technologies.

Sensitivity analysis is performed with regard to estimates of the cost of private insurance in

Brazil, of various estimates of the health-related quality of life of self-reported health status, and of the value of a quality adjusted life year in

Brazil, in order to determine the robustness of the results.

Conclusions: The results generally suggest that private insurance in Brazil is welfare increasing.

• The Global Health Challenge of Dengue:

Cost of Illness Across Eight Endemic

Countries

Donald Shepard, Ph.D., Jose A. Suaya, M.D.,

Ph.D., M.B.A., M.P.H.

Presented By: Donald Shepard, Ph.D.,

Professor, Heller School, Brandeis Univesity, MS

035, Waltham, MA 02454-9110, Phone: 781-736-

3975, Fax: 888-429-2672, Email:

Shepard@Brandeis.edu

Research Objective: Annually, over 2 billion people living in tropical and sub-tropical regions of the world and 120 million travelers visiting those regions are at risk of contracting dengue.

Dengue fever is a major public health problem, with an estimated 50 and 100 million cases occurring annually. Vaccine manufacturers and government agencies are developing vaccines against this disease. Data on the cost of dengue are needed to inform current decisions around development and future decisions on vaccine purchase and use. This study seeks to quantify the economic burden of dengue with a particular focus on the costs per case and its distribution of burden among payers.

Study Design: Employing a cost of illness framework, this multi-country study uses a common protocol across eight dengue-endemic countries--three in Southeast Asia (Cambodia,

Malaysia, and Thailand) and five in Central and

South America (Brazil, El Salvador, Guatemala,

Panama, and Venezuela). Their 2005 per capita income ranged from $380 (Cambodia) to $4960

(Malaysia). Each site identified treated dengue cases through selected health facilities (hospital, clinic, national laboratory, or public insurance system). The researchers interviewed each patient or guardian (if the patient was a child) once or twice during and after the illness to ascertain the services received, out-of-pocket spending, travel expense, and time lost due to travel, illness, treatment and caring for a family member. We converted all costs to 2005 international dollars using purchasing power parities. Because a vaccine would likely provide protection over much of an individual’s period of risk, we also expressed costs per newborn.

Population Studied: The study involves 1711 patients with clinical diagnosis of dengue, of whom 49% were hospitalized and 51% were treated as outpatients. The patients generally live in urban areas (81%), are female (55%), and had their diagnosis confirmed by laboratory tests

(84% of those tested). Treatment sites range from clinics to provincial and referral hospitals, both public and private.

Principle Findings: The average costs per case were: $613 for ambulatory cases in the Americas, and $1883 and $2002 for hospitalized cases in the Americas and Asia, respectively. The public sector financed 41%, 74%, and 69% of those costs, respectively. Most of the remaining costs were borne by households. Average household funding for each hospitalized case was equivalent to 1.5 to 1.6 months of food spending in the Americas and Asia, respectively. The annual cost of illness just for reported hospitalized cases in these eight countries is

$1.0 billion in aggregate, equivalent to $2.95 per capita or $142 per newborn. Due to underreporting and our exclusion of fatal cases, actual costs are many times higher.

Conclusions: Despite government-supported medical care, dengue imposed a substantial economic burden on households in these eight countries in addition to its cost to the public sector. The cost per newborn suggests that over time, routine vaccination of birth cohorts could yield substantial economic savings in dengue endemic countries.


Providing the chances of success are reasonable, continued development of a dengue vaccine is a promising investment.

Funding Source: Pediatric Dengue Vaccine

Initiative

• Determinants of delivery location in India:

Analyses of the Second National Family

Health Survey

Amardeep Thind, M.D., Ph.D., Fred Hagigi,

M.P.H., Dr.P.H.

Presented By: Amardeep Thind, M.D., Ph.D.,

Assistant Professor, Department of Family

Medicine, University of Western Ontario, 245 -

100 Collip Circle, London, On, N6G 4X8,

Canada, Phone: 519-858-5028, Fax: 519-858-5029,

Email: athind2@uwo.ca

Research Objective: A major objective of India's

National Population Policy is to decrease the maternal mortality rate below 300 per 100,000 live births by 2010, by encouraging more institutional deliveries. We assessed the determinants of using a private facility, public facility or delivery at home in a nationally representative sample of 28,860 deliveries in

1998-99.

Study Design: A cross sectional analysis of

28,860 deliveries from the Second National

Family Health Survey. We used the Andersen

Behavioral Model as the conceptual framework.

The outcome modeled was delivery in a public facility, private facility or at home. After adjusting for the multistage survey design, a multinomial logistic regression analysis was conducted to assess the relationship between predisposing, enabling and need variables to the outcome.

Population Studied: The Second National

Family Health Survey is a house-to-house interview survey conducted in 1998-99 across of

India. It interviewed a nationally representative sample of approximately 91,000 ever married women between the age of 15 - 49 yrs. The unit of analysis in our study was an ever-married female in this age group, who had had a livebirth in the past three years (n=28,860).

Principle Findings: Nearly 2/3rds (65%) of the deliveries were at home, with 19% being in a public facility, and 16% in a private facility.

Higher birth order, younger age, lower maternal and paternal education, Hindu religion, lower socioeconomic status, lower media exposure, fewer antenatal care visits, rural location and presence of anaemia were associated with higher odds of home delivery compared to public facility. The same variables, plus negative past history of still births, were associated with higher odds of home delivery compared to private facility. Higher maternal and paternal education,

Muslim religion, higher socio-economic status, father as the health care decision maker, number of antenatal visits, and absence of anaemia were associated with higher odds of private facility use compared to public facility.

Conclusions: The majority of deliveries in India still occur at homes. Maternal education, paternal education, religion, socio-economic status, number of antenatal care visits and presence/absence of anaemia were statistically significant determinants across all three choice sets.


India contributes nearly a quarter of the worldwide burden of maternal mortality.

Reducing this is a high priority for the government, and one approach being adopted is to increase institutional deliveries. Our analysis suggests that in order to increase deliveries in public or private facilities, the government not only has to focus on the traditional factors of education and socio-economic status, but also has to consider the impact of birth order, religion, antenatal visits, and the anaemic status of pregnant women in its policy framework.

• Using the Ideation Framework to Predict

Contraceptive Practice: An Empirical

Assessment from an Information-Education-

Communication Campaign in Armenia

Michael Thompson, M.S., Dr.P.H., Tsovinar

Harutyunyan, M.P.H.

Presented By: Michael Thompson, M.S.,

Dr.P.H., Assistant Professor, Health Behavior &

Administration, University of North Carolina at

Charlotte, 9201 University City Boulevard,

Charlotte, NC 28223-0001, Phone: (704) 687-

8980, Fax: (704) 687-6122, Email: methomp1@uncc.edu

Research Objective: Data from a panel evaluation (n=1080) of a six-month family planning information-education-communication campaign in Armenia were used to test a model of ideation related to modern contraceptive use proposed by DL Kincaid. Components of ideation, intention, and use of modern contraception were measured before and after the six month campaign in order to test both prospective (predictive) and retrospective

(evaluative) formulations of the theoretical model of ideation.

Study Design: Panel (pre-post) evaluation

(n=1080) of a six-month family planning information-education-communication campaign were used to test the models. Logistic and linear regression techniques were used to assess the models.

Population Studied: The panel consisted of

1080 married women aged 18-35 who had lived with their husband in the past 30 days. Women were selected from 4 or Armenia’s Marzes using cluster sampling techniques where probability was proportional to sample size.

Principle Findings: Elements of the ideation construct were significantly higher among adopters and those continuing to use modern contraceptive methods. Adoption and maintenance of modern contraceptive use were associated with increased levels of exposure to campaign messages. Changes in ideation were positively correlated with changes in behavior.

In sum, the data supported the models of ideation, intention, and use of modern contraceptives described by Kincaid.

Conclusions: Such a model can improve estimates of program impact from contemplation to action, which is missed by measures capturing only behavior or stated intent at follow-up, and can expand our understanding of the determinants of best practices.


This approach should be applicable to any area of behavior change.

Funding Source: USAID

• Accreditation and Benchmarking in

European Cancer Institutes

Willem Van Harten, M.D., Ph.D., Mahasti

Saghatchian, M.D., Ph.D., Renée Otter, M.D.,

Dominique de Valeriola, M.D., Ulrik Ringborg,

M.D., Ph.D., Wineke van Lent, M.Sc.

Presented By: Willem Van Harten, M.D., Ph.D.,

Member Executive Board of Directors,

Organisation & Management, The Netherlands

Cancer Institute, Plesmanlaan 121, Amsterdam,

1066CX, Netherlands, Phone: 0031 20 5122860,

Fax: 0031 20 6691449, Email: w.v.harten@nki.nl

Research Objective: As no method of accreditation of Cancer Institutes existed on

European level that was appropriate as a bases for quality improvement and benchmarking, the

Organisation of European Cancer Institutes

(OECI) decided to start a pilot with accreditation and benchmarking. The objective was to design a quantitative and qualitative questionnaire as first step in the accreditation procedure that was to be used on EU-level and to experiment with benchmarking methods using those data.

Study Design: A quality framework was drafted based on Canadian, Dutch and French existing standards. The self evaluation manual was based on these and contained 120 subjects such as prevention, screening multidisciplinary care, logistics, outcome, survivorship care and research. The quantitative questionnaire (320 items) includes exhausted data mainly on structure and process items. The questionnaires were piloted in 4 centers in Sweden, the

Netherlands, Belgium and France.

Benchmarking pilots were performed on the total functioning of 3 comprehensive cancer centers and on Ambulatory Treatment units for chemotherapy of 3 other centers (the latter involving a comprehensive cancer centre in the

US).

Population Studied: Four Comprehensive

Cancer Centers (CCC) in different EU countries.

In one of the benchmarking studies a major US

CCC was involved.

Principle Findings: In 2006 a pilot of self evaluation was performed that provides comparable quantitative and qualitative information on the participating centers.

The self evaluation list contained 120 items arranged according to (Plan) Do Check Act scoring domains. This was incorporated in a software version that can be demonstrated during the session. Benchmarking on institutional level provided feasible; performance and efficiency differences were identified and can be presented. Focusing on unit or treatment group level a pilot benchmarking involving focused Ambulatory Treatment Centers for chemotherapy produced interesting differences in productivity per staff, IT use and patient orientation.

Conclusions: - The pilot of accreditation questionnaires proved that a feasible system was drafted; especially the software incorporating the

PDCA-cycle proved accessible for users.

- Benchmarking of cancer centers using quantitative data related to accreditation is feasible, especially when focusing on unit or treatment level.

Implications for Policy, Practice or Delivery: -

In 2007 a next phase of development in OECI accreditation will start with auditor training and pilot site visits using the self assessment data.

- Benchmarking studies of organisation and performance of research units and radiotherapy departments of EU Comprehensive Cancer

Centers will take place in 2007.

• Lessons Learned from Evaluating USAID-

Funded Public Health Initiatives

Bill Ward, B.A., M.A., M.P.H., Dr.PH.

Presented By: Bill Ward, B.A., M.A., M.P.H.,

Dr.PH., , Department of Health Policy and

Management, U of South Florida College of

Public Health, 1102 W Horatio St, Tampa, FL ,

Phone: 813-205-6269, Fax: 813-254-7813, Email: wward@hsc.usf.edu

Research Objective: The USAID-funded public health projects being examined all had strengths and weaknesses and the evaluations carried out of them also had strengths and weaknesses.

This review looks at ways to make the process more meaningful for the American Taxpayer while providing suggestions to USAID and host nations on how to make it more useful.

Study Design: This is a participant observer

Case Study Approach looking at 5 USAID-funded international public health projects

Population Studied: The 5 projects are:

1)International Centre for Diarrhoeal Disease

Research ---- Bangladesh Extended MCH and

Family Planning Programme; 2)Regional

Economic Development Services Office for East and Southern Africa (USAID/REDSO/ESA)

Public Health and Nutrition [PHN] Program;

3)Guinea Oral Rehydration Therapy Program;

4)Haiti AOPS Primary Health Care Program;

5)Danfa Rural Health and Family Planning

Project ---- Ghana

Principle Findings: In the REDSO/PHN project, there was very little communication between the

USAID regional office and the bilateral offices in the various East and Southern African countries where USAID was working. In the Guinea Oral

Rehydration Therapy Program the mid project evaluation went ahead even when the project had not moved to the field. In the Haiti AOPS

Primary Health Care Program, the review of the project showed that the project was being implemented effectively and that the local voluntary agency was well staffed for the task even though USAID was against it. In the Danfa

Rural Health and Family Planning Project ----

Ghana, although well implemented, some of the objectives were unrealistic and the demographic demands consumed many of the research resources.

Conclusions: Conclusions included: a number of evaluations were done to meet Congressional mid project evaluation requirements. I was told, on several occasions, of the evaluation outcome expected. There is no indication that USAID has a system for review of midterm evaluations from the field. in a way that would guarantee that findings and recommendations would be reviewed for possible implementation. The

LogFrame and Performance Monitoring Plan tools used by USAID result in formative rather than summative evaluations.


Implications include: Regional offices should either have planning authority over local incountry USAID offices or should work only with the countries where USAID has not permanent presence. USAID needs to have a well-vetted unit of competent evaluators that are not selected simply because they are available.

• Traditional Chinese Medicine in China and in the U.S.

Judy Xu, Ph.D.

Presented By: Judy Xu, Ph.D., Asistant

Professor, School of Management, New York

Institute of Technology, 16 West 61 St, Room

813, New York, NY 10023, Phone: 908-707-4649,

Email: jxu05@nyit.edu

Research Objective: The study examines the roles and values of traditional Chinese medicine

(TCM) in Chinese and the US health care systems from different perspectives, including historical, economic, and political perspectives.

Study Design: Literature review and comparative analysis based on public available data in both China and the US.

Principle Findings: TCM is one of the two mainstream medical practices in China.

However, TCM hospitals/clinics only represent less than 5% of the Chinese medical institutions.

Less than 6% of the health professionals are

TCM practitioners. Furthermore, most of these

TCM practitioners practice ‘‘westernized TCM’’ rather than ‘‘real TCM’’ due to the current medical education and professional regulation systems in China. In the US, TCM is regarded as a type of complementary and alternative medicine (CAM). However, more and more physicians and insurers as well as patients are getting interest in TCM. The government has also invested more on its research and regulations (e.g. acupuncture practice and herbal treatments). Similar to their counterparts in

China, however, very few TCM practitioners really understand TCM and practice it.

Conclusions: Both lacks of resources and knowledge on TCM prevent TCM from contributing to both countries’ health care. The different roles and fates of TCM in China and in the US reflect challenges in improving TCM since it requires health care professionals, researchers and policy makers to be both openminded and knowledgeable on different philosophies, methodologies, and medical sciences. To address these issues, the study provides a few policy recommendations on health care financing, efficiency and equity.


The future of TCM is critical in developing health care systems to meet the health needs as population aging and more and more people having chronic illness in both countries.

Long-Term Care

•

Using Data from Multiple Sources for

Multidimensional Assessment of Nursing

Home Quality

Evgeniya (Jenya) Antonova, M.S., David R.

Zimmerman, Ph.D.

Presented By: Evgeniya (Jenya) Antonova, M.S.,

1147 WARF Building, 610 Walnunt Street,

Madison, WI 53705, Phone: (608) 263-7455, Fax:

(608) 263-4523, Email: jenya@chsra.wisc.edu

Research Objective: BACKGROUND: It is a commonly accepted fact that nursing home

(NH) care is a multidimensional construct. Data on nursing home quality can be obtained from national federally required data sets such as the

MDS (Minimum Data Set) and the OSCAR

(Online Survey, Certification Reporting) systems and privately collected data sources e.g., customer satisfaction surveys. The data in each data set reflect NH care quality from different viewpoints and are complimentary to each other.

Use of data from a single data source will capture only a narrow group of NH care quality dimensions. There is a need for a methodological framework for combining data from multiple sources for multidimensional NH care quality assessment. RESEARCH

OBJECTIVE: The purpose of this study was to: a) review existing metrics of NH care quality from multiple data sources; b) classify the metrics into a single multidimensional system based on the

Donabedian’s Structure-Process-Outcome (SPO) model; c) identify the lack of metrics of the structure, process, and outcomes in each domain of the multidimensional system.

Study Design: DATA: The sources of metrics were the following datasets: the MDS, which is the basis for calculation of Quality Indicators and

Quality Measures (QI/QMs); the OSCAR system, which contains information of annual nursing home surveys, customer complaints and complaint investigation surveys, and NH staffing. Finally, three customer satisfaction surveys instruments provided metrics on NH customer satisfaction. METHODS: A two-lateral approach was utilized to develop metrics’ classification. First, metrics from each data source were classified into domains, which were further clustered into larger groups. Second, the metrics were classified based on Donabedian’s

SPO paradigm.

Principle Findings: The NH care quality metrics were clustered into 25 domains within three major groups: Clinical Care, Quality of Life, and

Organization of Care Delivery. Clinical care group consisted of 11 domains and included metrics from the MDS and OSCAR systems.

Organization of Care Delivery group included 9 domains consisting of metrics primarily from the

OSCAR system with some metrics from the

MDS. The Quality of Life domain consisted of 5 domains including metrics from the OSCAR and customer satisfaction surveys. The NH care quality domains were most frequently represented by process measures, followed by structure and outcome metrics. Outcome metrics mostly represented Clinical Care group; fewer outcome metrics were included into the

Quality of Life and Organization of Care Delivery group of domains.

Conclusions: Development of outcome metrics is needed to assess NH care quality.


This study has linked multiple NH care quality data sources in a single multidimensional model of NH care quality and developed a methodological framework for utilizing data from multiple sources for nursing home quality assessment.

• Variations in Antipsychotic Therapy and

Short-Term Mortality Across Long-Term Care

Homes

Susan Bronskill, Ph.D., Paula A. Rochon, M.D.,

M.P.H., Sudeep S. Gill, M.D., M.Sc., Feng Qiu,

M.Sc., Therese A. Stukel, Ph.D.

Presented By: Susan Bronskill, Ph.D., Scientist, ,

Institute for Clinical Evaluative Sciences, 2075

Bayview Avenue, G106, Toronto, Ontario, M4N

3M5, Canada, Phone: (416) 480-4055, ext 3873,

Fax: (416) 480-6048, Email: susan.bronskill@ices.on.ca

Research Objective: Recent studies have demonstrated increased short-term mortality among older adults with dementia who are prescribed antipsychotic drug therapy. Despite these findings, use of antipsychotics remains common in long-term care homes. In order to explore the real-world implications of variations in antipsychotic dispensing across long-term care homes, we assessed whether homes with higher rates of dispensing had higher rates of mortality among their residents.

Study Design: Retrospective cohort study using health care administrative databases. Long-term care homes were grouped according to intensity of antipsychotic dispensing to their residents as high (rate =20%) or low (rate <20%). Propensity score matching was used to adjust for baseline differences in resident health status between the two groups.

Population Studied: Older adults with no history of psychoses who were newly admitted to long-term care homes in Ontario, Canada between April 1, 2000, and March 31, 2004.

Principle Findings: In total, 19,184 propensitymatched pairs of residents were identified from high and low antipsychotic dispensing facilities with similar resident characteristics. Absolute baseline differences in 30- and 120-day mortality between facilities dispensing higher vs lower rates of antipsychotics were 0.7% and 1.7%

respectively. Mortality was greater in the higher intensity facilities (hazard ratio 1.16, confidence interval 1.08 to 1.26 at 30 days; hazard ratio 1.13, confidence interval 1.08 to 1.19 at 120 days).

Conclusions: Residents newly admitted to LTC homes with higher antipsychotic dispensing rates had increased risk of short-term mortality.


From a health policy perspective, this finding suggests that long-term care homes have an important role to play in ensuring quality of care for their residents and need to continue to be encouraged to reduce inappropriate use of antipsychotic drug therapies among their residents.


Research

• Timing of Referral to Hospice: Interaction of Race with Having a Hospital Referral

Source

Kyusuk Chung, Ph.D., Linda F. Samson, Ph.D.

Presented By: Kyusuk Chung, Ph.D., Associate

Professor, Health Administration, Governors

State University, 1 University Parkway, University

Park, IL 60466, Phone: 708 534 4047, Fax: 708

534 8041, Email: k-chung@govst.edu

Research Objective: Hospitals have motivations to transfer dying patients occupying beds for more than reimbursable lengths of stay to postacute settings including hospice programs. We examined racial differences in the timing of referral to hospice by hospitals by examining the duration of patient survival after enrollment in hospice care.

Study Design: Independent and interactive effects of race and hospital referral on survival after hospice enrollment were modeled using

Cox proportional model and adjusting for patients’ clinical attributes (primary diagnoses at admission and functional status), demographic attributes (age, gender, and caregiver type and availability) and other factors (setting of care, and discharge year).

Population Studied: Data were obtained from the National Center for Health Statistics’

National Home and Hospice Care Surveys

(NHHCS) for 3,215 hospice patients aged 65 and older discharged between 1998 and 2000.

Principle Findings: About one in four patients were referred to hospice by hospitals. If the source of referral was a hospital and the subject was white, while holding all other variables constant, the rate of death increased by 12.5%.

On the other hand, if the source of referral was a hospital and the subject was nonwhite, the rate of death decreased by 26.4%. If the race was nonwhite and the source of referral was not a hospital, the rate of death increased by 11.4%.

Conclusions: Consistent with previous research, having a hospital referral source was associated with shorter stay after enrollment. However, such an overall finding may be driven by white elders accounting for almost 90% of all hospice users. For minority elders, having a hospital referral source meant longer stay, suggesting that they were referred earlier than their white counterparts. However, when nonwhite elders were referred by sources other than hospitals, they were referred later than their white counterparts.


Our finding may be explained in the context of previous findings in racial disparity in access to health care and use of medical technology in general. However, even if referral to hospice is occurring earlier in minority elders for reasons that are possibly inappropriate, this might not actually be harming such patients, when there is consensus that hospice referral is occurring too late for patients in general. On the other hand, the cause of nonwhite elders having other referral sources being referred later than whites, unlike nonwhite elders having a hospital referral source, may deserve further research.

Funding Source: National Center on Minority

Health and Health Disparities

• Health Care Coverage Strategies for the LTC

Direct Service Workforce

Steve Edelstein, J.D., Steve Edelstein, J.D.

Presented By: Steve Edelstein, J.D., National

Policy Director, Policy Services, Paraprofessional

Healthcare Institute, 349 East 149th Street, 10th

Floor, Bronx, NY 10451, Phone: 718-402-7413,

Email: edelstein@paraprofessional.org

Research Objective: The purpose of this study was to examine the design and impact of health care interventions implemented by the CMS

Direct Service Workforce Demonstration grantees. Grantees used different strategies to offer coverage, including subsidizing employerbased insurance, discounts and tax-free savings accounts, and conducting outreach to employers and workers about the availability of state-funded insurance programs. Because these interventions are ongoing, this report provides a preliminary analysis of advantages and disadvantages of the interventions chosen and the grantees’ experiences implementing them.

Study Design: Researchers conducted document reviews and interviews with the grant administrators, participating employers and workers to create case studies on grant projects in Maine, New Mexico, North Carolina and

Washington and gain an understanding of the interventions used and the successes and challenges the grantees experienced in designing and implementing them.

Population Studied: The interventions target the direct service workforce -- home care aides, personal care assistants, Direct Support

Professionals -- who serve older adults and individuals with disabilities in home- and community-based settings.

Principle Findings: This study found that expanding coverage to the direct service workforce is costly and complex. The grantees struggled to balance the cost of the interventions, affordability for workers, the potential for sustainability, and the level of coverage for participants. Yet, with varied success, the interventions are helping workers meet their health care needs, improving job satisfaction and providing new incentives for jobseekers to consider direct care work. Preliminary results indicate that the interventions can be associated with dramatic decreases in turnover

(in North Carolina), and with increased interest in direct service jobs (in Washington).

The grantees faced major barriers in providing coverage to this population, including the cost of coverage and some unique characteristics of this workforce including the workers’ low wages, parttime status and instability of hours, high turnover, high medical risk, and non-traditional work sites.

Conclusions: While there is no single formula for designing health coverage policies for this workforce, it is possible to generalize key principles necessary for success in any environment : oAccessible to all direct service workers regardless of hours worked; oAffordable for workers and employers; oComprehensive, with a full range of benefits to protect older workers and those with chronic health conditions; oEasy to understand and enroll in; oSustainable over time.


The grantees’ efforts will be refined and improved upon and perhaps inspire others to explore similar strategies. More importantly, they draw attention to the need for policymakers to view this health care crisis as a systemic issue that individual employers are ill-equipped to solve on their own. Addressing this issue will require broader policy changes to support the cost of covering this workforce. This demonstration illustrates the need for further research to explore: oHow to build the cost of health care coverage into Medicaid reimbursement methodologies. oHow to redesign delivery systems to enable workers to achieve full-time work. oHow to design statesubsidized health insurance programs that will meet the needs of the direct service workforce.

Funding Source: CMS

• Usefulness of the Nursing Home Quality

Measures and Quality Indicators for

Assessing Skilled Nursing Facility

Rehabilitation Outcomes

Patricia Findley, Dr.P.H., M.S.W., L.C.S.W., Rita

Bode, Ph.D.

Presented By: Patricia Findley, Dr.P.H., M.S.W.,

L.C.S.W., Assistant Research Professor, School of

Social Work, Rutgers University, 536 George

Street, New Brunswick, NJ 08901, Phone: 732-

932-8003 x21, Fax: 973-395-7114, Email: pfindley@rci.rutgers.edu

Research Objective: To examine the usefulness of the nursing home quality indicators and nursing home quality measures for differentiating among providers from a rehabilitation outcomes perspective.

Study Design: Retrospective

Population Studied: Skilled Nursing Facilities

(SNFs)within the US

Principle Findings: No quality measures correlated with any rehabilitation outcomes.

Residualized FIM motor gain did not correlate with any quality indicators or quality measures.

Only 1 quality indicator------prevalence of daily use of restraints (QI 22)------correlated with the rehabilitation indicator community discharge percentage. The third rehabilitation indicator, prepared to manage care at discharge, correlated

(negatively) only with QI 18 incidence of decrease in range of motion. Among the rehabilitation outcomes, residualized FIM motor gain correlated significantly with both community discharge percentage and prepared to manage care at discharge.

Conclusions: Patients and referrers choosing

SNF-based medical rehabilitation need tools that differentiate among prospective providers from a rehabilitation outcomes perspective. Data in this study indicate that nursing home quality indicators and quality measures are inadequate for this purpose.


SNFs that offer postacute rehabilitation must accept the responsibility, as inpatient rehabilitation facilities do, to measure rehabilitation results and use them to inform consumers and referrers and drive internal quality improvement. Comprehensive, ongoing cost-effectiveness comparisons between postacute rehabilitation settings will be impossible without SNF rehabilitation outcomes.

Funding Source: NICHD

• A Report On: the Program of

Reconstruction and Organizing Psychiatric

Service Delivery to the Chronically Mentally Ill

Patients in Iran

Zia Ghaemmagham, M.D., Mahshid Foroghan,

M.D.

Presented By: Zia Ghaemmagham, M.D.,

Assistant Professor, Psychiatry, University of

Social Welfare & Rehabilitation, University of

Welfare and Rehabilitation Sciences Koodakyar

St. Daneshjoo Boulevard, Evin, Tehran - Iran

Post code :19834, Tehran, Iran, Phone:

+98(21)22400036, Fax: +98(21)22400110, Email: drzia2001@yahoo.com

Research Objective: The needs of chronic psychiatric patients especially those who are suffering from schizophrenia differs from acute ones. They need vast variety of services including crisis intervention facilities, out and in -patient services, rehabilitative measures, and many kinds of biopsychosocial supports.

Study Design: In 1999, Ministry of Health

(MOH) ordered Welfare Organization to prepare a project for reconstruction psychiatric service delivery to chronic patients. The author and his colleagues prepared the first draft of the project in the same year. The project was reviewed and criticized by a panel of mental health experts, then revised and finalized in the year 2000.In the same year, the Law of Third Social, Economical and Cultural Development Program of the

I.R.Iran was legislated and this program became a part of ACT 192 Section 5, part A of that law. In

May 2000 the Cabinet mandated the implementation of the program.

Population Studied: target population included patients with schizophrenia and homeless chronically mentally ill patients which estimated

300 persons in 1 million of population.

Principle Findings: during 5 years of implementation of program using DSM -IV criteria 42000 patients were identified 90% suffering from shizophrenia.85% of patients were living with their families..

Conclusions: Although the legalizing and implementation of previously mentioned project is a progress, still there are a lot of things that should be done. Those include : providing continuous, comprehensive services, providing psychiatric beds in general hospitals, qualitative promotion of services, moving toward omission of all discriminations about psychiatric patients,allocating enough budget for mental health programs and legislation of mental health ACT.


According to this law Welfare Organization is responsible to take all measures for settlement of abandoned patients and betterment of their conditions. This organization has to provide support for patients who live with their families, establish needed services including crisis intervention, outreach programs, out-patient rehabilitative facilities, vocational services, halfway houses, home visits and finally psychiatric beds for , intermediate and long term care. Due to this law Welfare Organization has to follow regulations of referral system and all other sections including MOH and related sectors have been obliged to cooperate with. In this program private section was involved and supported financially. In the first year of implementation of this program allocated budget was nearly to 20 billion RLS, increased each year and now it has reached to 115 billion

RLS. By now 16000 people are under coverage including, 10000 at their homes (receiving allowance),2000 in out patient rehabilitative services and nearly 4000 are receiving long -term residential care.

Funding Source: Welfare Organization

• The Direct Service Workforce

Demonstration: Promising Practices in

Marketing, Recruitment and Selection

Interventions

Amy Hewitt, M.S.W., Ph.D., Sheryl Larson, Ph.D.

Presented By: Amy Hewitt, M.S.W., Ph.D.,

Training and Project Director, , University of

Minnesota Research and Training Center on

Community Living, 204 Pattee Hall, 150 Pillsbury

Drive S.E., Minneapolis, MN 55455, Phone: 612-

625-1098, Email: carrie.blakeway@lewin.com

Research Objective: To identify promising practices in improving the direct service workforce through enhanced marketing, recruitment, and selection that emerged from

the CMS Direct Service Workforce

Demonstration projects.

Study Design: This report focused on the CMS

DSW grantees that implemented interventions related to marketing, recruitment and selections and includes discussion of projects in Arkansas,

Delaware, Indiana, Kentucky, Virginia and

Washington. Researchers conducted document reviews and in-depth interviews with the grant administrators, participating employers and workers to gain an explicit understanding of the interventions used by the grantees and the successes and challenges they experienced in designing and implementing their interventions.

Population Studied: Each of the grantees included in this study implemented workforce interventions targeting the direct service workforce, which includes home health aids, direct care workers, Direct Support

Professionals, and other paraprofessionals who serve older adults and individuals with disabilities in home and community based settings.

Principle Findings: The DSW grantees used many promising strategies to improve their recruitment and retention outcomes. Among those techniques are the following: oComputer

Based Registration and Referral ---- registering applicants into a computer database and matching these individuals to people or organizations who are looking for DSWs based on location, skills, interests, or other characteristics. oMarketing campaigns ---- a comprehensive and intentional advertising campaign to let the public know about the role of

DSWs. oRealistic job previews ---- providing applicants with specific, realistic, and consistent information about the job of direct support before a decision to accept employment is made. oExpanded list of recruitment sources ---- purposefully reaching out and using recruitment sources that have not been used by the organization in the past. oStructured interviewing ---- asking the same questions to all applicants that are designed to elicit responses that demonstrate skill and competence, and then scoring responses based on pre-established criteria. oExpanded orientation or mentoring of new employees ---- providing expanded access to orientation or mentoring experiences designed to help new employees feel welcomed in the new organization.

Conclusions: The CMS funded Direct Service

Workforce demonstrations have yielded many promising practices in the area marketing, recruitment, and selection of DSWs. Many of these interventions were based on wellresearched and established practices, and they could be replicated and used by long term care organizations across the United States.


The direct service workforce crisis requires intensive, focused, immediate, comprehensive interventions, many of which require additional investment in the long term care industry.

Involvement of all stakeholders is essential so that the promise of keeping individuals with disabilities and the elderly in their communities can be kept. The resources available through the grant have provided the opportunity to develop and implement these important interventions.

However, all the grantees have expressed concern for how they will sustain activities beyond the funding period. Long term sustainability will require partnership between providers, state agencies, and community stakeholders. It will be essential to focus attention on the ability of these grantees and others who seek to replicate these interventions to sustain these activities in the long term.

• Determinants of Remaining in the

Community Post-Discharge: Results From

New Jersey’s Nursing Home Transition

Program

Sandra Howell, Ph.D., Mina Silberberg, Ph.D.,

Winifred V Quinn, Ph.D., Judith A Lucas, R.N.,

Ed.D.

Presented By: Sandra Howell, Ph.D., Asst. Res.

Prof/ Sr. Policy Analyst, Center for State Health

Policy, Rutgers University, 55 Commercial Ave.

3rd Floor, New Brunswick, NJ 08901, Phone:

(732)932-4657, Fax: (732) 932-0069, Email: showell@ifh.rutgers.edu

Research Objective: Although nursing home transition programs (NHT) such as New Jersey’s assist nursing home (NH) residents in the transition process, there are concerns about what happens to these older adults once they reenter the community as well as questions about what factors predict their ability to remain in these settings. To assist states with their NHT programs, we determine what risk factors are associated with participants’ long-term readmission to a NH within a year after discharge.

Study Design: This study used a structured telephone interview to survey all persons transitioning through NJ’s NHT program. We used Andersen’s behavioral model to select predictors (predisposing, enabling, and need characteristics) of long-term nursing home

(LTNH) readmission, and Cox proportional hazards regressions to examine the relative risk of experiencing LTNH.

Population Studied: We interviewed 628 persons transitioning through the program and obtained state administrative data for all 1354 nursing home residents discharged during 2000.

Principle Findings: Overall, 72.6% of the 1354 individuals remained in the community, with

8.6% readmitted to nursing home for > 90 days, and 18.8% dying during the year. Cox regression analysis was used to consider the relative risk of experiencing a LTNH readmission versus remaining in the community for the entire oneyear observation period or dying during this period. Females had about half the risk of males to have a LTNH readmission. Those who were living alone were also at less risk of a LTNH readmission than those who lived with others.

Individuals who were married had a 22% less risk of a LT NH readmission. In terms of health beliefs such as eating a healthy diet, taking a vitamin, and exercising daily, those who said they did two of these three behaviors had about half the risk of having a LTNH stay than those who did 0-1 of these health behaviors. Those satisfied with their living setting were also at a significantly less risk (14 to 32%) of having a

LTNH readmission those who were dissatisfied with their living situation. Neither enabling factors, inability to use transportation and receiving formal help with ADLs were significant in the survival model. Most of the need factors were also not significant. Having a fall during the 8-10 week following their original NH discharge, however, was significant. Specifically, those who had fall had almost twice the risk

(1.86) as those who did not have a fall during this period. Overall, the model was significant with a Chi-Square of 59.59 (d.f.=14).


State policy makers, discharge care planners, and caregivers could use these results to determine the risk factors they consider when assessing potential NH transition participation, and to explore if discharge is a realistic goal. This study also illustrates the limits of formulaic approaches to assessing candidates for discharge. Findings can be used to assess clients’ risks and connect them with what risk specific services such as fall prevention programs should be made available to help people remain continuously in the community.


• Mandates Matter: Florida Nursing Home

Provider Response to Financial Incentives to

Increase Nurse Staffing

Kathryn Hyer, Ph.D., M.P.P., Christopher

Johnson, Ph.D., Robert Weech-Maldonado,

Ph.D., M.B.A., Jeffrey Harman, Ph.D., Mishu

Popa, M.S.G.

Presented By: Kathryn Hyer, Ph.D., M.P.P.,

Associate Professor, School of Aging Studies,

University of South Florida, 13301 Bruce B.

Downs Boulevard, Tampa, FL 33647, Phone: 813-

974-3232, Fax: 813-974-5788, Email: khyer@cas.usf.edu

Research Objective: Florida’s State Legislature provided $40 million (annualized) in the

Medicaid Direct Care Staffing Adjustment

(DCSA) as an add-on to the patient care component of the Medicaid per diem rate in nursing homes. The financial incentives allowed providers freedom in spending money as long as total resources for direct care staffing increased over baseline. This pre- post- study assesses how the nurse staffing incentives beginning in April

2000 (compared to 1999) were used by nursing homes to increase hours per resident day, increase wages of current staff or to change use of agency staff. We examine impact for the RN,

LPN and CNA staffing levels, and analyze if the incentive resulted in sustained higher staffing levels. The impact of nurse staffing change on quality is measured by deficiencies and quality measures.

Study Design: The data comes from Florida

State reports, Medicare and Medicaid Cost

Reports, Minimum Data Set (MDS), the On-line

Survey Certification of Automated Records

(OSCAR) file, and the Area Resource File (ARF) for the period of 1999-2001. Facilities were categorized into quartiles (N=145) receiving most incentive money and least incentive money. The dependent variable, quality of care is measured by deficiencies, chronic (ADL improvement, fractures, pain, pressure sores), and post-acute outcomes (pain, walk improvement, pressure sores). Independent variables consist of structure (staffing ratios), process (restraints and catheters), and control variables (ownership/chain affiliation, Herfindahl index, payer mix, case mix, and size). Quality indicators were calculated for the six month period immediately preceding implementation and for six months following the incentive. A loglinear multivariate regression model assessed the impact of incentive payments on quality indicators

Population Studied: Medicaid and medicare nursing homes in Florida from 1999-2002. The analysis of 595 Florida homes certified as

Medicaid homes that participated in the financial incentive programs.

Principle Findings: When offered incentives, providers in top quartile of incentives responded differentially from providers in lowest quartile.

Quartile receiving the most money ($68,117) increased total nurse staffing from 1.77 hours per resident day to 2.08 hours per resident day, wages stayed stable and use of agency increased.

Facilities receiving least money ($34,163) decreased from 2.54 to 2.33 hours per resident day, increased wages for paraprofessionals and decreased use of agency. The lowest staffed highest Medicaid facilities increased RN, LPN and CNA staffing but higher staffed homes decreased highest skill nurses and substituted lower cost nurses. Difference in difference results indicate pressure sore quality measures were significant.

Conclusions: Providing incentives results in absolute dollar increases allocated to direct care staff but skill mix decreases and total hours per resident day may not increase. Difference in differences shows mixed quality outcomes and suggests threshold needs to be reached before quality differences can be seen.


Legislatures wanting increased direct care staffing per resident need mandates. Providers, when given choice respond differentially but substitute lower skilled workers for higher skilled workers and increase wages for current workers.

The implications of skill mix on quality outcomes are uncertain, especially since staffing per resident day remain below CMS preferred levels.

Funding Source: CWF, Administration on Aging

• Advertising Activity in the Nursing Home

Sector: Does Market Competition Matter?

Bita Kash, Ph.D., M.B.A.

Presented By: Bita Kash, Ph.D., M.B.A.,


Management, Texas A&M University Health

Science Center, TAMU 1266, College Station, TX

77843, Phone: (979)458-0652, Fax: (979)458-

0656, Email: bakash@srph.tamhsc.edu

Research Objective: The objective of this study was to examine the effect of market competition on advertising activity in nursing homes. We first tested the association between level of competition and the likelihood to use advertising and the level of advertising activity. Secondly, we identified other factors associated with advertising activity.

Study Design: Pair-wise correlations between advertising expense, level of market concentration using the Hirschfeld-Herfindahl index (HHI), operating profit margin, occupancy rate, outcome quality, and other market and organizational factors were examined. Next, two dummy variables for advertising activity based on two spending cut-off points were developed.

Two logistic regression models were developed to predict the odds of engaging in advertising activities. Finally, the association between the level of spending on advertising and market competition was evaluated in three regression models using total advertising expenses and two advertising expense ratios as dependent variables.

Population Studied: The Medicaid Cost Report for non-hospital based nursing facilities in Texas, facility level resident characteristics from the

Minimum Data Set (MDS), the Texas Quality

Reporting System (QRS), and the Area Resource

File (ARF) were merged for the year 2003. Data merging and cleaning resulted in the elimination of only 199 out of 1,017 observations.

Principle Findings: Total advertising expenses in Texas nursing homes ranged from $0 to

$165,000 a year ---- this translates to a maximum of 22 percent of total net revenues and 26 percent of total operating costs allocated to advertising. Advertising expenses were positively correlated with market competition (measured by HHI), facility size, occupancy rate, Medicare census, and more urban locations in the bivariate analysis. The odds of spending more than

$1,550 a year on advertising (higher spending than the bottom 25th percentile) was significantly increased by facility size, occupancy rates and urban location. Higher total advertising expenditures were associated with larger facilities, higher occupancy, high Medicare census, and urban location. Advertising expense ratio, as a percentage of total net revenues, was associated primarily with lower operating profit margin, high Medicare census and urban location. Facilities budgeted more dollars toward advertising (advertising expenses as a percentage of total operating costs) if located in more urban areas with higher proportions of

Medicare residents.

Conclusions: Advertising expenses and budgets in nursing homes are not dependent on level of market competition. Generally, larger nursing homes with higher occupancy rates and larger

Medicare resident percentages which are located in more urban areas spend more money on

advertising. Therefore advertising activity in nursing homes seems to be more resource dependent than market driven.


Environmental scanning and competitive analysis should be drivers for marketing activity, including advertising. Results from this study indicate that nursing home administrators do not take factors related to market competition into account when budgeting for advertising expenses. Better marketing and planning practices in nursing homes could reduce unnecessary advertising costs in facilities located in less competitive markets. Facilities could also improve profitability and employee retention by investing in client and employee relationship management instead of excessive spending on advertising.


•

Nursing Home Strategic Groups and

Quality

Michael Lin, M.S.P.H., Ph.D., Joan R. Bloom,

Ph.D., Stephen Shortell, Ph.D., M.P.H., Charlene

Harrington, Ph.D., Martin Kitchener, Ph.D., Mark van der Laan, Ph.D.






Research Objective: First, this study forms strategic groups to characterize all nursing homes along key structural and operational dimensions. Second, to assess the utility of this classification system this research examines nursing home quality both within and across strategic groups.

Study Design: This study employs data from the

Online Survey, Certification and Reporting

System (OSCAR) and Area Resource Files (ARF) to delineate each nursing home. Applying cluster analytic techniques to classify nursing homes into strategic groups, this study evaluates the utility of strategic management theory in understanding organizational performance. This study tests the association between select organizational and environmental characteristics and the receipt of quality-related survey deficiencies using stratified logistic regression analyses.

Population Studied: All Medicare and/or

Medicaid-certified freestanding nursing homes that were in operation during 2003 were included in this analysis. This sample is more expansive and recent than previously-published research. More than fifteen thousand (n=15,006) nursing facilities were in operation from January

1, 2003 to September 1, 2004. Using a two-stage cluster analysis, 96.5% of these facilities were classified into nine different strategic groups.

Principle Findings: The strategic groups identified include: a High Quality Medicare and

Private Pay group (2.0% of sample); a Low-

Skilled High-Medicaid group (1.4%); a Middle-ofthe-Road group (36.7%); a High Supervision and

Low Quality of Care group (3.7%); a Small Urban

Custodial Care group (2.3%); a Large, High

Occupancy group (6.0%); a Specialized Care group (7.0%); a Low Supervision and Low Case

Mix group (35.6%); and a Small Town group

(1.7%). Comparison of these groups using both process and outcomes-based performance measures (e.g., restraints, pressure ulcers, contractures, and survey deficiencies) suggests that these classes are linked to quality. Logistic regression analyses were conducted within individual nursing home strategic groups to evaluate the organizational characteristics associated with receiving a quality-of-care or quality-of-life-related survey deficiency. The results suggest that nurse staffing levels, competition, Medicaid payment rates, and ownership are not uniformly associated with these facility outcomes across different strategic groups. For instance, within certain strategic groups increased competition is correlated with improved quality, while in others, increased competition is associated with a greater likelihood of quality-related problems.

Conclusions: While previous strategic groups research on US nursing homes isolated seven different classes of nursing homes, this study identified nine different classes of individual nursing facilities. This difference may be attributable to an expanded sample that includes all fifty states, a revised set of clustering measures, alterations in the clustering analyses, or simply, increased diversification in the field of nursing homes over time. Examining relationships among nursing home structure, operations, environment, and outcomes within strategic groups, we find systematic differences across groups.


Attention to strategic groups may enable policymakers to better understand the challenges of providing high quality care and ensuring high quality of life in nursing homes. In particular, policy changes may variably impact different strategic groups, suggesting that policy makers

should deliberate legislation in light of such heterogeneity. Based on the regression analyses, mandated nurse staffing levels, increased competition, and higher Medicaid payment levels may not improve quality across all types of nursing facilities.

• Cost and Profit Analysis for Renal Clinics in

Taiwan

Shuen-Zen Liu, Ph.D., Chia-Ching Cho, Ph.D. candidate, James Romeis, Ph.D.

Presented By: Shuen-Zen Liu, Ph.D., Professor,

Accounting, National Taiwan University, Room

1009, Building II, College of Management,

National Taiwan University, No. 1, Sec. 4,

Roosevelt Rd. Taipei 10617, Taiwan, Taipei,

10617, TW, Phone: 886-2-33661122, Fax: 886-2-

23638038, Email: sliu@management.ntu.edu.tw

Research Objective: The objective of this study is to analyze cost structure and financial information using administrative data obtained from one of the largest renal clinic chains in

Taiwan. The analysis helps better understand how sound health policy on End-Stage Renal

Disease can be implemented while maintaining profitability for health providers.

Study Design: Linear regression analysis is employed to examine factors that influence variable costs (i.e., cost drivers) in our study.

Four different types of cost drivers are examined: patient characteristics, medical treatments, clinic properties, and medical quality. Furthermore, we examine the relationship between costs and profits of the sample clinics and simulate financial consequences resulting from changes in operating environments.

Population Studied: The data used in the study is obtained from internal administrative sources of a large renal clinic chain. The company is the leading provider of dialysis and related services in Asia. It owns or operates about sixty dialysis facilities across Asia, treating nearly four thousand patients. In the regression analysis, there are 1,134 observations of dialysis treatments drawn from 15 dialysis facilities in

Taiwan. These data are from May, 2005; they are the most reliable data source available.

Principle Findings: In general, we find that variable costs of dialysis are influenced by various medical and non-medical factors. Two findings are of particular interests. First, we find that dialysis quality is positively related to variable costs, implying that it takes more resources to maintain medical quality. Second, the ownership structure matters. Specifically, the percentage of clinic ownership held by the company is positively associated with dialytic variable costs. That is, the less physicians own their clinics, they have less incentives to control costs. Furthermore, we find that it takes at least

44 patients for a clinic (15 hospital beds) to be profitable.

Conclusions: Our analysis indicates that dialytic costs are driven by four kinds of cost drivers.

Therefore, patients are not the same financially for renal clinics under the fixed payment system in Taiwan. In addition, the cost structure (high fixed costs) of renal clinics makes them vulnerable to an increase in variable dialytic costs and a cut in reimbursement rates.


The Bureau of National Health Insurance

(BNHI) in Taiwan has set a fixed payment rate for hemodialysis procedures per patient visit.

Our results suggest that BNHI might consider patient profiles and include other risk factors to develop different reimbursement rates. In addition, the positive association between the percentage of ownership held by the company and variable costs implies that dialysis service providers need to develop better performance evaluation schemes to motivate doctors to control costs.

• Voices From the Front: Recruitment and

Retention of Direct Care Workers in Long

Term Care

Clare Luz, Ph.D., Clare C. Luz, Ph.D.

Presented By: Clare Luz, Ph.D., Health Services

Research Division, Director, Office of Research,

Michigan State University, College of Human

Medicine, A209 East Fee Hall, East Lansing, MI

48824, Phone: (517) 432-2208, Email: luz@msu.edu

Research Objective: This research examined factors associated with entry and turnover among direct care workers within long term care settings, particularly nursing homes and home health agencies.

Study Design: The study involved 1,109 direct care workers in Michigan who completed an anonymous mail survey.

Population Studied: The population sample was based on both a random selection of workers from the state nurse’s aide registry and a convenience sample of direct care workers in home health settings. The sample included workers who were currently working in direct care, had already left the field, and who were considering leaving.

Principle Findings: Workers intentionally chose direct care work based on altruistic and vocational interests. The strongest predictors for leaving direct care work were lack of control, respect, household income, and wages. Nursing home workers were more likely to leave direct care work due to wages and lack of respect from supervisors, despite receiving higher wages compared to home health workers. Home health workers were more apt to leave due to lack of control over the job and reduced household income. Seventy three percent of the total sample reported overall job satisfaction yet nearly half (47%) of current workers reported that they were considering leaving their job within the next 6 months.

Conclusions: Wages are important but not the only predictive factor in turnover. Dedicated direct care workers with a desire to work in longterm care and specialized skills are driven from the field because of work conditions in addition to wages. Job turnover may be reduced by resolving concerns related to need for greater control over work conditions and respect from supervisors.


Recruitment and retention strategies need to include a culture change that provides direct care workers with more control over their work conditions and higher respect for their vocational interest and skills. This should be emphasized in management and supervisory training and practices. In addition, strategies need to be tailored to specific long-term care settings. For example, nursing home workers may need reduced caseloads whereas home care workers may need increased, dependable hours.

Funding Source: Michigan Department of

Community Health

• Nursing Home Resident and Facility

Characteristics Associated with Influenza

Vaccination, National Nursing Home Survey,

1995-2004

Jill Marsteller, Ph.D., M.P.P., Ronald Tiggle,

Ph.D., Barbara Bardenheier, M.P.H., M.A.,

Abigail Shefer, M.D.

Presented By: Jill Marsteller, Ph.D., M.P.P.,


Management, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Room 433,

Baltimore, MD 21205, Phone: 410-614-2602, Fax:

410-955-6959, Email: jmarstel@jhsph.edu

Research Objective: New data from the

National Nursing Home Survey, 2004, indicate that influenza immunization coverage among the elderly in long term care facilities declined as compared to 1999, despite heightened policy interest in improving influenza coverage over those years. 2004 was a shortage year for influenza vaccine, and this may provide a partial explanation for lower coverage rates. This work examines the change in influenza immunization coverage rates and considers resident and facility covariates of influenza immunization between

1995 and 2004.

Study Design: This study used bivariate and multinomial logistic regression analysis of merged data from the 1995, 1997, 1999 and

2004 National Nursing Home Survey resident and facility files. The dependent measure for influenza immunization was whether or not the resident had had a flu shot during the past 12 months. The measure was analyzed using three response categories: ‘‘yes’’, ‘‘no’’, or ‘‘unknown.’’

Population Studied: The study population comprised 34,095 randomly selected current residents aged 65 and over. Approximately 7,400 residents were sampled from roughly 1,400 facilities in each of the first three years, and

12,000 in 2004.

Principle Findings: Among the nursing home population aged 65 and over, bivariate analyses of the immunization trend indicated that influenza immunization increased significantly from 1995 to 1999. However, the percent who received influenza immunization fell significantly from 66.4% in 1999 to 63.7% in 2004, a difference equal to 38,797 fewer influenza immunizations nationally. The upward trend in coverage was no longer significant when 2004 was included. Multivariate regression using all survey years indicated that, controlling for other associations, greater length of time since admission and having a pneumococcal immunization were the strongest covariates of influenza immunization. Among significant interactions with year, in 2004, residents who had been in the facility a year or longer were no more likely than their newly admitted peers to have been immunized, a reversal of the pattern in other years.

Conclusions: Influenza immunizations among the elderly in nursing homes dropped between

1999 and 2004. Although nursing home residents were identified as a priority group for immunization, the 2004 influenza season was marked by a severe vaccine shortage. Reported estimates of success in covering vulnerable populations in this shortage year were based on the non-institutionalized population. Logically, residents who have been in the nursing home for

at least a year have the best chance to be immunized, given that they were in the facility during an influenza season, and the facility has had ample time to immunize them. Analyses of interaction between length of time since admission and year, however, indicate that in

2004 this advantage did not exist, supporting the hypothesis that the vaccine shortage played a part in the decreased influenza immunization rate in nursing homes in 2004 relative to 1999.


These results can inform policy and practice regarding the allocation of vaccine in shortage years, the importance of avoiding shortages, and practices within nursing homes to achieve higher immunization rates.

Funding Source: CDC

• Mental Illness and Use of Home Care

Nationally in the Department of Veterans

Affairs

Edward Miller, Ph.D., M.P.A., Robert Rosenheck,

M.D.



Policy, Brown University, 67 George Street, Box

1977, Providence, RI 02912-1977, Phone: (401)

863-9311, Email: edward_a_miller@brown.edu

Research Objective: To determine whether patients with mental health diagnoses in the

Department of Veterans Affairs (VA) are more likely to utilize home-based primary care

(HBPC), and to identify sociodemographic, utilization, and clinical characteristics associated with HBPC admission.

Study Design: Patients receiving treatment in the VA system nationally during FY2003 and having no evidence of home care utilization during FY2002 were followed through FY2005 using administrative claims data. Cox proportional hazard models were developed to identify correlates of HBPC use among VA patients, including analyses stratified by age.

Population Studied: 4,411,677 VA patients with no prior use of HBPC

Principle Findings: Of 4,411,677 VA patients with no prior use of HBPC, 24.2% received a mental health diagnosis, of whom 1.5% were eventually admitted to HBPC. Two in 5 new

HBPC admissions (38.6%) were diagnosed with at least one mental illness. Patients diagnosed with dementia were 66 percent more likely to be admitted. Patients diagnosed with nonschizophrenia psychoses (hazard ratio

[HR]=1.30), miscellaneous affective disorders

(HR=1.22), and schizophrenia (HR=1.21) had the next highest probabilities. Risk of admission was highest for those with 3+ outpatient medical visits (HR=2.61), followed by those with any inpatient medical/surgical days (HR=1.79) or outpatient mental health visits (HR=1.30). Elderly patients with any inpatient mental health days were less likely to be admitted, younger patients with nursing home use, community residential care, and mental health intensive care management were more likely.

Conclusions: Given that mental illness contributes independently to the likelihood of home care admission, it is critical that providers assess home care applicants for mental illness and develop the skills and resources necessary to meet the psychiatric care needs of those who eventually enroll.

Implications for Policy, Practice or Delivery: A policy question that deserves further consideration is whether mentally ill long-term care patients should be cared for exclusively within the confines of formal home care services, or whether they should receive general medical services through Assertive Community

Treatment style teams that specialize in care for individuals with severe mental illness, specifically.

Funding Source: VA

•

Medicaid Long Term Care Home and

Community Based Services: Trends in

Programs and Policies During the Fiscal

Crisis

Terence Ng, M.A., Terence Ng, M.A., Charlene

Harrington, Ph.D.

Presented By: Terence Ng, M.A., Research

Associate, Social and Behavioral Sciences,

University of California San Francisco, 3333

California Street, San Francisco, CA 94118,

Phone: 415 502 6330, Email: terence.ng@ucsf.edu

Research Objective: In response to consumer demand and the Supreme Court decision in the

Olmstead case, states have unevenly expanded combinations of three Medicaid home and community based services (HCBS) : home health, state plan personal care services (PCS), and 1915(c) waivers. By 2003, the federal-state

Medicaid program paid for 40 percent of the nation’s estimated $151 billion total long-term care (LTC) expenditures while institutional care

(e.g., nursing homes) consumed 67 percent of those expenditures. With 43 states reporting budget deficits in 2003, the Deficit Reduction Act

(2005) reflects growing concern about Medicaid

HCBS and the need for information on program and policy trends.

Study Design: This paper draws from a unique national dataset to present the latest trends in participants, expenditures and policies for the three Medicaid HCBS programs.

Population Studied: State Data on CMS Form

372 reports from 1999-2003 are studied

Principle Findings: While data for 2003 show a steady increase in participants and expenditures, these growth rates have slowed since 2001.

Findings from the survey of policies such on the programs in 2005 show that states are increasing the number of waiting lists for waiver services even as the number of available ‘‘slots’’ increases. Cost caps such as service and cost limits are also used in almost half the state plan personal care programs and almost a third of home health programs.

Conclusions: States are responding to fiscal deficit by shifting participants and expenditures to less costly propgrams and by restricting growth though cost control policies such as waiting lists.


The DRA of 2005 might exercebate movement towards restricting eligibility for persons most in need of services and states have to navigate their way between needs of their most needy populace and fiscal constraints

Funding Source: NIDRR

• Voting with Your Feet When You are Flat on

Your Back: The Current and Future Role of the Internet in Selecting a Nursing Home

Lisa R. Shugarman, Ph.D., Julie A. Brown, B.A.

Presented By: Lisa R. Shugarman, Ph.D., Health

Policy Researcher, , RAND Corporation, 1776

Main Street, PO Box 2138, Santa Monica, CA

90407-2138, Phone: 310-393-0411, x.7701, Fax:

310-260-8161, Email:

Lisa_Shugarman@rand.org

Research Objective: In November 2001, CMS implemented the Nursing Home Quality

Initiative, which promoted consumers’ use of nursing home (NH) quality measures through the publication of facility-level quality measures on the Nursing Home Compare website.

However, little is known about the utility of such information for consumers. The purpose of this study was to examine how consumers select a

NH; explore if and how existing information resources are used during selection; and identify information gaps.

Study Design: We conducted focus groups with consumers and information intermediaries to elicit participants’ views and experiences related to NH selection. The formulation of focus group questions was guided by a conceptual framework that assumes that the strategies consumers employ in choosing NHs depend on a variety of personal and contextual characteristics.

Population Studied: Focus groups were conducted in four geographically dispersed states (CA, IA, FL, and VA) with discharged short-stay nursing home residents, family members of current residents, hospital discharge planners, and community-based case managers.

Principle Findings: Consumers reported using some of the written resources (e.g., lists of facilities) provided by information intermediaries, which were often supplemented with information they identified on their own.

Few consumers mentioned using the Internet, and those who did, used it to develop lists of local facilities for their consideration.

Additional findings on resources include:

1)Primary source of information for short-stay residents was the list of facilities provided by information intermediaries; 2)A secondary but important source of information was prior personal experience and word of mouth; 3) Visits to facilities were a key step in decisionmaking; 4)

Short timeframe for decision-making limited the types of information consumers could access, particularly on the Internet; 5) Few consumers were aware of the Medicare.gov site or Nursing

Home Compare; and 6) Consumers voiced the need for report cards for each NH to facilitate comparisons, for access to consumer experiences with specific facilities, and for materials for non-English speakers. The primary factors in NH selection were location, the perception of caring staff (most often assessed by a visit to a facility), cost, cleanliness, and recommendations from friends/family.

Conclusions: Consumers did not use the multitude of Internet-based resources available to them to select a NH and perceived that the information they needed was not available to them when they needed it. Consumers were less concerned with the clinical, more technical factors that influence quality of care than with

QoL factors. Consumers based decisions on information often not available in Internet-based resources. Both consumers and information intermediaries found that many of the available

Internet resources were not ‘‘user-friendly,’’ and the lack of sites in languages other than English is a barrier to Internet use.


Our findings suggest that CMS and others who have developed Internet resources to communicate quality information about NHs to consumers will need to examine ways to combine objective and subjective quality information and to consider a more diversified approach to consumer education to increase the accessibility of information, physically and linguistically.

Funding Source: DHHS Office of the Assistant

Secretary for Planning and Evaluation

•

Understanding Variation in Personal

Assistance Use: The Impact of State

Attributes Affecting Provision of Home and

Community-Based Services

Jennifer Sullivan, Ph.D.

Presented By: Jennifer Sullivan, Ph.D., Research

Health Scientist, COLMR, VA Boston Healthcare

System, 150 Huntington Ave (152M), Boston, MA

02130, Phone: 857-364-5298, Fax: 857-364-438,

Email: jennifer.sullivan@va.gov

Research Objective: Because there is no integrated federal policy on long term care, home and community-based services fall under the domain of state-level policy. State oversight of the Medicaid HCBS program has led to variation in both access to programs and quality of services across states. Unmet personal assistance needs could result for older disabled people in states that do not consider HCBS funding a top priority. This study investigates factors that influence individual-level use of personal assistance services, or PAS, focusing on interstate variations in Medicaid HCBS resources and other macro-level state policy factors impacting the generosity of PAS funding.

Study Design: This cross-sectional study is nonexperimental quantitative research using secondary data. Individual-level data are from the

1999 National Long-Term Care Study. Publicly available state-level data included Medicaid

HCBS funding and summary variables measuring political culture and state expenditures. Multilevel non-linear hierarchal modeling was performed using HLM6.

Population Studied: This study is based on a subset of 5,147 community-dwelling NLTCS participants. The sample was restricted to respondents having Medicare coverage and with at least 1 ADL or IADL. The study sample consists of 3,014 respondents, 77 percent of whom used some type of PAS.

Principle Findings: At the individual-level, variables in this study played a significant role in

PAS utilization. In comparison to the no PAS use reference category, older adults using formal PAS only, both formal and informal PAS together, or informal PAS only were older, male, had three or more functional limitations, and had higher odds of having three or more medical or chronic conditions. The relationships of other individual-level characteristics varied depending on type of PAS use. In comparison to those who were unmarried, married persons used more informal care and both formal and informal services together. Formal care users had higher odds of being unmarried in comparison to respondents using no PAS at all. Elders living alone had lower odds of informal PAS only and use of both PAS types together. The SES index was lower for those using formal care versus no

PAS care at all. State-level predictors are examined by looking at whether there are random-effects in the model and examining significant fixed effects for state-level variables.

In comparison to no PAS use, overall variance at the state level was 6 percent for formal care only and 3 percent for both formal and informal service types used together. HCBS expenditures per capita were significantly related to use of formal care only and use of both formal and informal care together in comparison to those using no PAS at all. Other state-level factors hypothesized to have an effect on PAS use had no significant effect in the model.


This study has shown that there are interstate variations in HCBS funding leading to different patterns of utilization of PAS. The issues surrounding access and funding of providing care are important to grapple with given the impending demographic wave of aging person.

•

Trajectories of Depressive Symptoms among Women Caring for Their Husbands with Dementia

Donald Taylor, Ph.D., M.P.A., Michael Ezell,

Ph.D., Maggie Kuchibhatla, Ph.D., Truls Østbye,

M.D., Ph.D., Elizabeth Clipp, Ph.D.

Presented By: Donald Taylor, Ph.D., M.P.A.,

Assistant Professor, Public Policy, Duke

University, 112 Rubenstein Hall, Box 90253, NC

27708, Phone: (919) 613-9357, Fax: (919) 684-

6246, Email: detaylor@duke.edu

Research Objective: To identify the number of distinct sub-groups of depressive symptoms

(identified by their unique trajectories) that exist

within a large national sample of wives caring for their husbands with dementia, and the nature of those trajectories.

Study Design: Longitudinal survey with up to 4 observations per spousal dyad. We used Latent

Class Trajectory Analysis to identify the number of trajectories of depressive symptoms

(measured by the Center for Epidemiologic

Studies-Depression [CESD]) that were present in the data.

Population Studied: 1,595 wives who were caring for their husband who suffered from dementia and who responded to the National

Longitudinal Caregiver Survey (NLCS) in 1999; subjects in this national sample were the caregivers of Veterans identified as having dementia in the VA health system, and were surveyed annually through 2002.

Principle Findings: Four distinct trajectories of caregiver depressive symptoms were identified, providing evidence that a population-averaging approach substantially over- or under-estimates levels of informal caregiver depressive symptoms for many caregivers. Two trajectories, each representing roughly one-third of the sample were labeled High (mean CESD 6.6/20) and Very High (mean CESD 11.4/20). A third trajectory (Low) had low levels of depressive symptoms (mean CESD 3.3/20) and included about 22% of the wife caregivers. The remaining

14% of the sample had negligible levels of depressive symptoms and was labeled very low

(mean CESD 1.0/20). A population averaging method that fit one overall population trajectory had mean CESD of 6.6. Trajetories were identified while controlling for duration of caregiving, and age and disability of the care recipient. We investigated how the caregivers in the distinct trajectories differed based on observed variables and found that subjective measures of high burden (desire for more help and life satisfaction) were highly correlated with membership in the Very High and High depressive symptom trajectories.

Conclusions: Latent trajectory analysis identifies important depressive symptomatology subgroups of wife caregivers that are masked by commonly-used population-averaging methods.


Caregiving is a public health issue, and our analyses show that around one-third of wife caregivers do not suffer a great deal of harm as measured by CESD, while two-thirds have higher levels of symptoms. Simple subjective measures of burden may be useful for screening in primary care in order to identify subgroups of caregivers who are at high risk of harm.

Funding Source: National Institute of Nursing

Research (NINR)

•

Estimating Caregiving Transitions among

Elderly Couples

Donald H. Taylor, Jr., Ph.D., Truls Ostbye, M.D.,

Ph.D., Elizabeth Clipp, Ph.D.

Presented By: Donald H. Taylor, Jr., Ph.D.,

Assistant Professor, Public Policy, Duke

University, 112 Rubenstein Hall, Box 90253,

Durham, NC 27708, Phone: (919) 613-9357, Fax:

(919) 684-6246, Email: detaylor@duke.edu

Research Objective: To identify the transitions into and between caregiving states for both members of elderly couples.

Study Design: Longitudinal follow up design of couples living in the community in 1993, who were interviewed in 1995, 1998, 2000 and 2002.

Caregiving states include not caregiving, various caregiving arrangements, nursing home placement and death.

Population Studied: 1,967 couples who responded to the AHEAD cohort of the Health and Retirement Study in 1993; each couple had at least one member who was age 70 or older in

1993. In addition, each couple had at least 1 member with a limitation in at least 1 Activity of

Daily Living at some point during the study.

Principle Findings: Over the study period, 37% of females and 31% of males who were alive at the end of the study in 2002 provided care for their spouse at some point during the study.

The likelihood of caregiving increased when follow up was shorter due to one or both spouses dying during the study period. Around one-fith of women and 15% of men provided care at each wave. Approximately 2% of couples engaged in simultaneous caregiving whereby they each provided care for the other; this group was among the most disabled and apparently vulnerable in the study. The most common transition observed was continuation in the 'not caregiving' state. 80% of spouses not providing care at one wave continued to not do so at the next. Around 9% of persons not receiving care died by the next wave. However, once caregiving was initiated, the likelihood of death at the next wave ranged from 29 to 65 percent, and was typically the most common transition from a given caregiving state. There are examples of persons receiving care at one wave but not at the next wave, so numerous distinct transitions were observed.

Conclusions: Estimating the prevalence of spousal caregiving differs substantially according

to how long couples are followed up. Stability in the same caregiving state is common, but there are many types of transitions with many different implications for couples.


Spousal caregiving is best understood as a public health issue. Detailed assessment of the types of transitions into and between caregiving states are needed to help couples, their families and providers better prepare elderly persons for their potential caregiving career. Simultaneous caregiving couples appear to be particularly vulnerable to harm due to caregiving, and more work is needed to better understand and identify such couples.


Research (NINR)

• Daily Care Teams in Nursing Homes: What is the Evidence from New York State?

Helena Temkin-Greener, Ph.D., M.P.H., Shubing

Cai, M.D., M.S., Pluma Kluess, M.S., Paul Katz,

M.D., Dana B. Mukamel, Ph.D.

Presented By: Helena Temkin-Greener, Ph.D.,

M.P.H., Associate Professor, Community and

Preventive Medicine, University of Rochester

School of Medicine, 601 Elmwood Avenue, Box

644, Rochester, NY 14642, Phone: 585-275-8713,

Fax: 585-461-4532, Email: Helena_Temkin-

Greener@urmc.rochester.edu

Research Objective: Most healthcare organizations report having teams. Nursing homes (NH) are no exception, particularly since the MDS credentialing process mandates interdisciplinary teams. However, little is known about presence/absence of everyday practice teams in NHs. We assess perceptions of teamwork among NH managers and validate them by examining their association with facility attributes hypothesized to relate to teams.

Study Design: A mail survey of administrators

(ADM) and directors of nursing (DON) was conducted in New York. In the survey, we posited three ways of organizing the daily work of direct care staff: 1) formal teams with defined membership and process; 2) self-managing teams, 3) no teams. Other survey items addressed: perceived importance of teamwork to various aspects of NH operations; nurse aides’ participation on other teams (e.g. QI); presence of team policies/protocols; management style

(autocratic, custodial, supportive or collegial), managers’ job characteristics and tenure, and other facility characteristics (from OSCAR database). We estimated multinomial logistic regression models with random effects to assess the association between team type (dependent variable) and facility characteristics.

Population Studied: 188 NHs agreed to participate and complete the ADM and the DON surveys (n=376). A total of 338 surveys were received (response rate=89.9%); 166 from

ADMs and 172 from DONs.

Principle Findings: Respondents characterized everyday work practice as: formal teams - 35.2%, self-managing teams - 39.6%, and no teams -

25.2%. We find several statistically significant parameter estimates for the presence of formal and self-managing teams (no team=reference variable). Formal (OR=3.396) and self-managing

(OR=2.547) teams are more likely in facilities characterized by collegial management style.

Formal teams are more likely when management views teamwork as very important for staff turnover/retention (OR=3.053). When written team policies and protocols are present, formal

(OR=9.910) and self-managed (OR=2.984) teams are more likely. Homes are more likely to report formal teams when LPN (OR=3.900) and

CNA (OR=3.148) hours per resident per day are higher.

Conclusions: Almost 75% of managers reported formal or self-managed teams in the provision of daily care. Their observations are validated by strong associations with other facility attributes expected when teams are present, such as collegial environment and presence of teamspecific protocols. Furthermore, we find an association between formal teams and higher direct care staffing per resident. We also find an association between the presence of formal teams and managements’ views that teams are important to staff turnover/retention. When both the presence of teams and of policies/protocols pertaining to team training and practice are counted, only 34% of the facilities qualify as having direct care teams.


The relatively high prevalence of teams (34% to

75%) found in this study is based on managers’ reports and may be overly optimistic. Further empirical assessment by direct care staff is needed. Teamwork is not an automatic consequence of co-locating workers, and is more likely in homes that are proactive in developing and sustaining team practice.

Funding Source: NIA

•

Association of Geographic Regions with

High Rate of Health Care Transitions among

Decedents with Incident Insertion of Feeding

Tubes among Persons with Advanced

Cognitive Impairment

Joan Teno, M.D., M.S., Ramona Rhodes, M.D.,

M.P.H., Susan Mitchell, M.D., M.P.H., Elliott

Fisher, M.D., M.P.H., Syvia Kuo, Ph.D., Jon

Skinner, Ph.D.

Presented By: Joan Teno, M.D., M.S., Professor of Community Health and Medicine, , Brown

Medical School, 65 Ferry Lane, Barrington, RI

02806, Phone: 401-863-9627, Email: joan_teno@browne.du

Research Objective: Multiple transitions of frail, older persons have been associated with increased risk of medical errors. Previous research has documented a ten fold variation across states in the prevalence of feeding tube use in NH despite evidence suggesting a limited role in persons with advanced dementia. We examined geographic variation in the rate of health care transititions among decedents with a nursing home stay and its association with the incident insertion of feeding tubes among persons with advanced cognitive impairment.

Study Design: Secondary analysis of Medicare

Claims Data and the Minimum Data Set for all of the US. Measures included: Health care transitions per Medicare beneficiary over the age of 65 in the last six months of life and incidence of insertion of feeding tubes among nursing home residents with Cognitive Performance

Scale score of 4 and higher indicating advanced cognitive impairment.

Population Studied: Nursing home residents with advanced cognitive impairment

Principle Findings: Hospital Referral Regions

(HRR) varied in the rate of health care transitions in the last six months of life from 192 per 100 decedents (HRR city= Salem, OR) to 509 per 100 decedents (HRR city = Monroe, LA) while nine month incident feeding tube insertion varied between 0 per 1000 nursing home residents (found in 57 HRRs and for six out of eight HRRs in Iowa) to 179/1000 (Alexandria,

LA). HRR with higher transition rates in the last six months of life had a higher incidence of feeding tube insertion (Spearman correlation=

0.63). Nearly two-thirds of the feeding tubes were inserted during an acute care hospital stay.

Over one-half (51%) died within one year following feeding tube insertion with the median time to death being 42.5 days.

Conclusions: Conclusions: Rates of transitions varied by more then 2 fold across USA and this variation was associated a higher incident rate of feeding tube insertions among persons with advanced cognitive impairment.


Future research is needed to understand the role of health care transitions and insertion of feeding tube insertion, especially the role of patient preferences and whether avoidable transitions result in information discontinuity about how best to feed persons with advance dementia.

Potential interventions include enhancing advance care planning, improved care continuity, changes in state policy to avoid hospitalizations for acute illnesses that can be safely managed in the nursing home, and education of health care providers and families about the limited role of feeding tubes in persons with advanced dementia.

Funding Source: NIA

•

The Extended Care Career Ladder Initiative:

Results from a Qualitative Program

Evaluation

Michelle Washko, Ph.D., Robyn Stone, Dr.P.H.,

Alison Gottlieb, Ph.D., Kathy Wilson, M.S.,

M.B.A., Lauren Harris-Kojetin, Ph.D., Frank Caro,

Ph.D.

Presented By: Michelle Washko, Ph.D., Senior

Research Associate, Institute for the Future of

Aging Services, 2519 Connecticut Avenue,


Fax: 202-783-4266, Email: mwashko@aahsa.org

Research Objective: The Extended Care Career

Ladder Initiative (ECCLI) is one of

Massachusetts’ first state efforts to address the issue of frontline workforce quality improvement in the long-term care field. ECCLI attempts to effect workforce change through multiple years of funding and diverse interventions. These interventions usually involve the establishment of ‘‘career ladders’’ and clinical training--that often are linked to wage increases and new job titles--and as a variety of other educational opportunities (e.g. soft skills, adult basic education). A qualitative evaluation of ECCLI was conducted for the Commonwealth

Corporation (CommCorp) by the Institute for the

Future of Aging Services and the Gerontology

Institute at the University of Massachusetts

Boston. The ‘‘natural laboratories’’ of the nursing homes and home health care agencies involved in ECCLI allowed researchers to assess whether the programs created with the ECCLI funding produced changes in workplace practices and care outcomes.

Study Design: A mixed-method, qualitative research design was used to conduct the evaluation. Data collection activities included: site visits, interviews with key upper-level staff, residents/clients, family members, and external stakeholders, and focus groups with frontline caregivers and their supervisors.

Population Studied: The frontline workforce in long term care

Principle Findings: In terms of findings, the most successful ECCLI activities were the development of frontline worker career ladders, and addressing Adult Basic Education and

‘‘English as a Second Language’’ (ESL) needs.

The most evident change in organizational structure was the incorporation of direct care staff into care planning and decision-making.

Sustaining educational opportunities for staff when ECCLI funds are no longer available appeared to be especially challenging.

Conclusions: Overall, for the organizations who actively used the ECCLI funding to invest in their direct care workforce, positive effects were seen amongst employees, including greater satisfaction with work environments as well as improved communication and new job skills.

However, though the findings indicated these positive quality improvements in the workforce, there was no evidence that they translated into improved quality of care or life for the residents/clients.


Low retention, high turnover, and vacancies pose significant challenges among paraprofessional jobs in the long-term care (LTC) field. These negative trends can affect the quality of care for

LTC clients and residents. There is increasing evidence of the link between a quality workforce and quality outcomes, in the form of good resident care. The positive effects found in this evaluation illustrated that ECCLI is successful in developing job skills, soft skills, and influencing improved communication. This implies that investment of state funds in LTC workforce development (via the ECCLI program) resulted in the creation of a better quality workforce.

Funding Source: The Commonwealth

Corporation/Massachusetts State Legislature

• Cross-Validation of Aggregate Nursing

Home Quality Measurements Based on State

Surveillance and Self-reported Data

Ning Zhang, M.D., Ph.D., M.P.H., Thomas Wan,

Ph.D., Lynn Unruh, Ph.D., R.N., Seungchun

Paek, M.S.

Presented By: Ning Zhang, M.D., Ph.D., M.P.H.,

Assistant Professor, Health Administration,

University of Central Florida, 3280 Progress

Drive, Orlando, FL 32826, Phone: 407-823-3344,

Fax: 407-823-0744, Email: nizhang@mail.ucf.edu

Research Objective: Minimum Dataset (MDS) represents the largest resident-level nursing home self-reported administrative data while

Online Survey, Certification, and Reporting

(OSCAR) annual survey represents the largest state surveillance system on nursing home deficiencies. Their comparative validity and reliability have not been completely evaluated since they have been used for assessing quality of care. The objective of this study is to conduct the validity and reliability assessment of quality measurements developed based on MDS and

OSCAR data.

Study Design: The CMS Nursing Home

Compare quality measurement is the most widely used aggregate quality measurements based on the MDS data; a forty-indicator quality measurement developed by Dr. Harrington and colleagues (UCSF) represents the most comprehensive quality measurement based on the OSCAR data. We used generic structure equation models to examine the concurrent, discriminate, and construct validity and reliability of the two quality measurements. Both concurrent and cross-lagged correlation relationships were explored in the model. To further strengthen the accuracy of the analyses, we retrieved eleven identical pairs of quality measurements from MDS and OSCAR databases and conducted spearman correlations between each pair. Four years (1999-2002) of national MDS and OSCAR data were merged as the analytical dataset.

Population Studied: All US nursing homes certified by Medicare and Medicaid were included. A total of 63,742 nursing home observations and 57,210,853 resident records were involved in the analysis after data cleaning.

Principle Findings: The preliminary results of the structure equation modeling indicated that both MDS-based and OSCAR-based quality measurements showed sound construct validity and reliability over years. However, the relationships between them were relatively weak although statistical significances were observed.

The correlation analyses on the identical pairs of quality measurements also suggested weak relationships between variables.

Conclusions: CMS Nursing Home Compare quality measurement and Dr. Harrington’s

quality measurement are both valid and reliable.

These two quality measurements may represent different aspects of nursing home quality.


Cross-validation of the MDS and OSCAR-based quality measurements is of great importance to inform long-term-care researchers of the variations in quality measures and to guide the state and federal governments to develop effective resident-centered quality improvement system. The MDS-based quality measurements reflect more of clinical outcomes and OSCARbased quality measurements reflect more of managerial or process quality. The adequacy of pay-for-performance system should rely on the development of comprehensive and validated indicators. Given the current data collection schema, a valid quality measurement should build on both state surveillance and self-reported administrative data.

Funding Source: CMS

• Nursing Home Financial Distress and

Quality of Care: A longitudinal Study

Mei Zhao, Ph.D., Oetjen, Reid M, Ph.D., Nolin,

JoAnn, J.D.

Presented By: Mei Zhao, Ph.D., Assistant

Professor, Public Health, University of North


Jacksonville, FL 32224, Phone: (904)620-1444,

Fax: (904)620-1035, Email: mzhao@unf.edu

Research Objective: The nursing home industry in Florida was confronted with intense financial pressure during the last several years, resulting in a considerable number of nursing homes that were in financial distress. In particular, studies found that more than 40% of nursing homes had negative total margins. At the same time, the United States Government Accounting Office

(GAO) raised concern about a substantial number of residents receiving substandard care in nursing homes. Earlier research suggests that nursing home financial condition may have an impact on resident quality of care, but these studies typically only used one or two measures as their quality indicators. The objective of the current study is to examine what differences exist in the quality of care between financially weak

(distressed) and strong (non-distressed) nursing homes using multiple quality measures.

Study Design: A panel study design is applied to data from 2003-2005 to compare nursing home’s quality with consecutive negative total margin over three years with those with positive total margin. The prevalence of three specific deficiency citations (restraint use, pressure ulcers, catheter use) and the total deficiency citations are used to represent quality of care in nursing facilities. To date, descriptive analysis and t-tests have been conducted to examine the difference between these two groups.

Population Studied: All Florida nursing homes in operation between 2003 and 2005 that participated in the Online Survey Certification

And Reporting (OSCAR) data. This totaled around 1,500 facilities.

Principle Findings: Overall, we found that distressed facilities consistently had significantly higher prevalence of total deficiency citations in each study year. In addition, the prevalence of

Physical restraints, Pressure sores, and Catheter use are higher in distressed facilities, though the difference is not statistically significant. Finally,

Nursing home deficiencies have increased since

2003.

Conclusions: The findings of this study are consistent with existing literature that suggests nursing home quality of care is related to nursing home financial condition. Facilities with better financial performance have higher quality of care than those in poorer financial condition.


Public policies implemented in the last several years were intended to reduce costs without compromising quality of nursing home care.

However, these policies created considerable financial pressure on nursing homes. Our analysis indicates that these polices may have had unintended negative effects on nursing home quality of care. Nursing facilities experiencing financial distress may have fewer resources to invest in the quality of their services, which in turn affected resident outcomes.

Funding Source: Brooks College of Health

Fundation

•

The Impact of Litigation on the Financial

Performance of the Florida Nursing Home

Industry

Mei Zhao, Ph.D., Oetjen, Reid M, Ph.D., Nolin,

JoAnn, J.D.

Presented By: Mei Zhao, Ph.D., Assistant

Professor, Public Health, University of North


Jacksonville, FL 32224, Phone: (904)620-1444,

Fax: (904)620-1035, Email: mzhao@unf.edu

Research Objective: Litigation activity against nursing home providers for negligent care and abuse increased dramatically in the last decade

in Florida. During this period, losses in the nursing home market rose significantly, including significant increases in both the frequency of liability claims and in the size of damages awarded. In 2002, Florida’s nursing homes collectively confronted $1 billion in lawsuits from claims totaling four times the number of claims in all other states. Earlier reports suggest that nursing home litigation costs may have a big impact on nursing home financial performance, but no studies systematically examined this effect. The objective of the current study is to examine the magnitude and implications of malpractice paid-losses on the industry’s profitability.

Study Design: A panel study design was applied to data from 2001-2005 to compare financial performance of nursing homes with malpractice paid-losses to those without malpractice paidlosses. Total margins and operating margins are used to represent financial performance in nursing facilities. To date, descriptive analysis and t-tests have been conducted to examine the difference between these two groups.

Population Studied: This study focuses on the effect of malpractice paid-losses on financial performance of Florida nursing homes for the five-year period from 2001 to 2005. The primary data sources for this study are financial and operating data drawn from the Medicare cost report data files. The final sample included 2,674 facilities. Of those firms, 291 had malpractice paid-losses, 2,383 had no malpractice paid-losses during this time period.

Principle Findings: Overall, we found that total margins for both groups improved between 2001 and 2005; however, the group without malpractice paid-losses had consistently higher median total margins than the group with paidlosses in each study year. In addition, the median total margins were negative for the group with malpractice paid-losses for the period

2001 to 2003, while the group without paidlosses had no negative total margins over this five year period. Finally, there was an increasing trend of malpractice paid-losses during this period. In 2001, it was estimated that

$11.65/patient day was paid for the malpractice.

This number increased to $14.27/patient day in

2005, a 22.5% increase.

Conclusions: The findings of this study are consistent with existing literature that suggests nursing home financial performance is related to nursing home malpractice paid-losses. Facilities without malpractice paid-losses had better financial performance than those with malpractice paid-losses. The cost of malpractice has been increasing during the last five years.


With the increasing cost of malpractice, many of the national nursing home chains operating in

Florida may leave the market to minimize their liability exposure. Many nursing homes continue to operate without the protection of liability insurance and have to pay the losses by themselves. In the long run, this will have a significant influence on the profitability of this industry and may in turn affect the access and quality of nursing home services for the elderly in

Florida.

Funding Source: Brooks College of Health

Fundation

• The Impact of Case Mix Reimbursement on

Administrative Nurse Staffing Levels in

Nursing Homes

Jacqueline Zinn, M.B.A., Ph.D., Vincent Mor,

Ph.D., Zhanlian Feng, Ph.D., David Grabowski,

Ph.D., Orna Intrator, Ph.D.

Presented By: Jacqueline Zinn, M.B.A., Ph.D.,

Professor, Risk, Insurance and Healthcare

Management, Temple University, 413 Ritter

Annex, Philadelphia, PA 19119, Phone: (215) 848-

0796, Fax: (215) 204-4712, Email: jacqueline.zinn@temple.edu

Research Objective: To determine if the implementation of case mix reimbursement for both Medicare and Medicaid increased the administrative burden on nursing homes, as evidenced by an increase in the level of nursing staff engaged in administrative functions, and if facilities are responding by shifting nursing resources away from clinical services.

Study Design: The dependent variable in these facility-level analyses is the natural log of total administrative nursing hours per resident day.

We employed a facility fixed-effects model to examine the effects of the implementation of

Medicaid case mix reimbursement and Medicare

PPS on changes in administrative nurse staffing levels over an eight year period, controlling for calendar year time trend and other relevant facility and market characteristics that could influence the level of administrative nurse staffing. We tested for a ‘‘dosage effect’’ by interacting the proportion of Medicaid residents in the facility with introduction of Medicaid case mix reimbursement and the proportion of

Medicare residents with implementation of

Medicare PPS. We estimated a pooled model using the full sample and separate models

stratified by for-profit status, chain affiliation and bed size.

Population Studied: An OSCAR data file containing all urban, freestanding

Medicare/Medicaid certified nursing homes in the 48 contiguous U.S. states, between the years

1997 to 2004 (n=68,600 surveys from 9,817 facilities) merged with data on state Medicaid payment policies and the Area Resource File for the same period.

Principle Findings: While the introduction of both Medicare and Medicaid case mix reimbursement significantly increased the level of administrative nurse staffing, a ‘‘dosage effect’’ was observed only in the case of

Medicaid. The level of administrative nurse staffing increases with the level of direct care nurse staffing, suggesting the absence of a substitution effect. Case mix reimbursement is associated with increased administrative staffing only in for-profit and chain affiliated facilities.

Medium sized, but not larger, facilities were significantly more likely to increase administrative staffing after case mix reimbursement introduction.

Conclusions: While prior studies found that nursing home case mix reimbursement resulted in a decrease in direct care professional staff, ours is the first to demonstrate an accompanying increase in administrative nurse staffing. However, the administrative burden posed by the introduction of case mix reimbursement does not appear to be associated with a decline in direct care hours. The effect of

PPS introduction on administrative nurse staffing was not conditioned on the proportion of Medicare residents in the facility. Thus, the administrative burden posed by PPS may represent a relatively fixed cost that does not vary across the typical volume ranges. The administrative burden imposed by Medicaid case mix reimbursement is more likely to vary proportionately to volume.


Our results suggest there may be a disproportionate administrative burden imposed by case mix in high Medicaid volume facilities.

As the Center for Medicare and Medicaid

Services (CMS) prepares to launch a revised

MDS 3.0, better understanding of how the current system has already influenced staffing allocation decisions could provide insights informing its development.

Funding Source: NIA

Management &

Organization

•

The Use of Hospitalists and Resource

Utilization

James Bramble, Ph.D., James M. Puhl, Pharm.D.

Presented By: James Bramble, Ph.D., Associate

Professor, Creighton Health Services Research

Program, Creighton University Medical Center,

School of Pharmacy and Health Professions,

2500 California Plaza, Omaha, NE 68117, Phone:

(402)280-4129, Fax: (402)280-4809, Email: jbramble@creighton.edu

Research Objective: The hospitalist is a relatively new face in the inpatient care setting where their main focus is the care of hospitalized patients. The advantages of this method of patient care can include improved continuity, physicians who are more familiar with treating specific conditions, and physicians more experienced with hospital-based technologies for diagnoses and treatment. Various studies have shown that hospitalists used in patient care reduce costs and shorten hospital stays. While most studies have examined this relationship on a hospital case basis, the current study attempts to examine this relationship using large administrative databases. Specifically, we hypothesize that the presence of hospitalists will reduce patient length of stay (LOS) and costs.

Study Design: We conducted a quasiexperimental cross-sectional study using administrative data to examine the proposed hypothesis. The dependent variables include cost and length of stay per patient. We derived cost estimates using the 2004 HCUP cost-to-charge ratio files. The independent variable of interest was the hospitalists. The data could not identify if a hospitalist cared for the patient, but measured the presence of a hospitalist at the hospital. Additionally, data on the number of fulltime equivalents and the employment arrangement of hospitalists (e.g., hospital employed, independent group hospitalist, etc.) is considered. Controlling for patient, hospital, and market characteristics, we used hierarchal linear modeling to examine the relationship between the presence of a hospitalist and cost, as well as,

LOS.

Population Studied: The sample for this study included patients over the age of 18 with diagnoses of COPD, pneumonia, or heart failure as indicated by their DRG at discharge. These three diagnoses represent common conditions

treated by hospitalists as reported in previous studies. Patient characteristics from the 2004

HCUP National Inpatient Sample were merged with hospital data from the American Hospital

Association and the Centers for Medicare and

Medicaid Services, as well as, market data from the Area Resource File.

Principle Findings: For COPD patients treated in hospitals where hospitalists were present, or not, the mean LOS was 4.65 compared to 4.78 while costs were $5,386 and $5,522, respectively.

While this difference is not significant, the difference in LOS and cost for pneumonia and heart failure patients was significant (p < 0.05).

Specifically, pneumonia patients receiving care in hospitals where hospitalists are present had a

LOS of 5.29 compared to 5.59 and hospital costs of $6,300 compared to $6,930. The LOS for heart failure patients in hospitals utilizing hospitalists was 4.88 compared to 5.08 with costs of $6,310 compared to $6,717.

Conclusions: While the limitations of the data do not allow linking the care of the patient directly to the hospitalist physician, as done in hospital case-based studies, this study demonstrates that hospitals that use hospitalist have significantly lower cost and LOS for pneumonia, and heart failure patients.


Hospitals are continually looking for ways to use resources more efficiently. This research provides additional evidence for the use of hospitalists to care for specific acute care patients. This evidence along with evidence regarding quality and safety would suggest a better structure and process of providing care.

Funding Source: Health Futures Foundation

• The Economic Impact of an Inpatient

Palliative Care Consultation Program at a San

Francisco Bay Area Hospital

Elizabeth Ciemins, Ph.D., M.P.H., Linda Blum,

R.N., M.S., G.N.P., Marsha Nunley, M.D.,

Andrew Lasher, M.D., Jeff Newman, M.D.,

M.P.H.

Presented By: Elizabeth Ciemins, Ph.D., M.P.H.,

Health Services Researcher, Institute for

Research and Education, Sutter Health, 345


94104, Phone: 415 296-1805, Fax: 415 296-1844,

Email: CieminE@sutterhealth.org

Research Objective: The objective of this study was to evaluate the economic impact of the inpatient palliative care consultation service

(PCS) at a large private, not-for-profit, academic medical center in San Francisco, California.

Mean daily total costs and charges were evaluated for palliative care patients pre- and post-consultation. Palliative care patients were then matched with diagnostically similar patients, and total costs were compared between groups.

Study Design: A two-part approach was employed in this study. First, an interrupted time-series design was utilized to analyze the pre- post-PCS data over a 60-day hospitalization period. Second, a retrospective matched cohort design was used to compare PCS patients with non-PCS patients. Hospital administrative claims and financial data were utilized in order to compare daily costs and charges of the days prior to consultation to those post-consultation.

The matched cohort study of costs was conducted by matching palliative care patients on medical diagnoses, illness severity, and mortality risk to a Usual Care group who did not receive palliative care services.

Population Studied: All patients receiving an inpatient palliative care consultation at the

California Pacific Medical Center between 2004 and 2006 were enrolled in the study.

Principle Findings: There were 288 patients available for the pre/post-palliative care consultation analysis. Patients with zero costs or with less than one day in the pre- and postintervention period were excluded. Mean daily costs were reduced 80% from pre- to postconsultation period, a significant (p<.01) decrease in costs observed one day postconsultation and sustained through the study period. Findings cannot be attributed to trends, seasonality, other cycles, or the tendency of to remain elevated or depressed after high or low values in the series. In the second economic analysis, there were 140 cases matched to 3314 control patients. The greatest daily cost differences were observed for patients receiving radiotherapy with a 50% daily cost difference between cases and controls. A 20-40% cost difference was observed for nine more APR

DRGs.

Conclusions: The use of a palliative care consultation service for medically complex terminally ill patients may significantly lower costs. Further observational studies are warranted using larger samples, and intervention studies should be considered. These results may support more appropriate reimbursement policy from Medicare and other payers.


These findings provide evidence potentially supporting new reimbursement policies from

Medicare and other sources for end-of-life care services. They also suggest a culture change among the medical community from aggressive treatment therapies to a more symptom-focused patient-centered approach.

Funding Source: The Metta Fund

• Development and Testing of an Information

Structure for Quality and Safety Rounds

Akinluwa Demehin, M.P.H., George Reardon,

M.B.A., Daniel R Kerls, M.B.A., OTR/L, Katie

Farraher, B.A.

Presented By: Akinluwa Demehin, M.P.H.,

Administrative Fellow, Administration,

Massachusetts General Hospital, 55 Fruit St,

Boston, MA 02114, Phone: 617-726-4954, Fax:

617-726-6989, Email: ademehin@partners.org

Research Objective: Since 2003, The

Massachusetts General Hospital (MGH) has employed a tiered, interdisciplinary model of environmental scanning ‘‘rounds’’ to collect data on the quality of care and environmental conditions on inpatient units and procedural areas. Each set of rounds has a slightly different focus, involves clinicians, non-clinical staff and representatives from multiple departments, and addresses a broad array of issues. While the rounds have been effective at broadly engaging multiple departments in identifying quality and environmental issues, the data collected during the rounds were not systematically sorted and trended. Moreover, hospital leadership desired a better understanding of the findings from rounds in their patient care areas. Thus, the objective of this work was to develop an integrated model for sorting, trending and communicating data from environmental scanning rounds. This model would need to be reconcilable with the reporting categories of the

MGH’s parent health system, vetted through the literature, flexible enough to meet evolving data collection and reporting needs, and meaningful

(i.e.-- minimizes the number of issues classified as ‘‘other.’’)

Study Design: The project team employed a qualitative approach to select a framework for organizing the data. Several different data classification systems were identified, including

1) a framework from a sister institution, 2) the

MGH’s electronic incident report system, and 3) the MGH’s patient advocacy database.

Ultimately, a framework using a combination of the Joint Commission for the Accreditation of

Healthcare Organization’s ‘‘priority focus areas’’

(PFAs) and the Institute of Medicine’s six aims of healthcare was used to organize and report data from rounds.

Population Studied: The MGH was the site of the study. The MGH is a 902-bed academic medical center with over 48,000 inpatient visits per year. There are over 500 environmental scanning rounds each year at the MGH across approximately 47 patient care units.

Principle Findings: Using a common framework for two different sets of rounds has allowed the

MGH to aggregate data and identify overall trends much more readily than before. The rounds identified hospital-wide problems such as hallway clutter and safety issues with needle boxes. Building-specific issues also emerged

(e.g. elevator access), as did population-based concerns (e.g. bariatric equipment). Issues that arise in multiple forums have taken on a higher institutional priority.

Conclusions: Using a combination of JCAHO

PFAs and IOM’s six pillars provides a robust framework for organizing data from environmental scanning rounds. The dual framework allows for the simultaneous identification of regulatory and quality improvement issues. In addition, hospital leadership has commented that they feel much better informed about and engaged with the findings from rounds.


The original environmental scanning round framework was informed by research on high reliability organizations (HROs). HROs utilize dynamic, proactive processes that look for latent failures and near misses, react quickly and flexibly to problems, and involve experts to identify potential and actual patient safety problems. The classification and reporting framework of this study has enhanced the

MGH’s ability to use information from its high reliability processes.

•

A Qualitative Study of Nurses' and

Physicians' Perceptions of the Nurse

Physician Work Relationship

Karen Dunn Lopez, R.N., M.P.H.

Presented By: Karen Dunn Lopez, R.N., M.P.H.,

PhD Candidate, College of Nursing, The

University of Iowa, 131 E Maple Street, Hinsdale,

IL 60521, Phone: 630 204 1134, Email: kdlop1@comcast.net

Research Objective: The objective of this research was to gain a deeper understanding of perceptions, beliefs and attitudes of nursephysician work relationships from both nurse

and physician perspectives. The existing literature suggests that nurse-physician work relationships affect both patient and nurse outcomes. Significantly, less is known about the physicians’ perspectives of the nurse-physician work relationship that may affect physician outcomes and patient outcomes. Several studies have found disparate perceptions between nurses and physicians regarding their perception of the nurse-physician work relationship. This consistent finding highlights the inadequacy of relying only on nurses’ perceptions to develop interventions to improve nurse-physician work relationship and underscores the need to include physician perceptions to guide development of these interventions.

Study Design: A qualitative interview study was conducted using both purposive and theoretical sampling strategies. Sampling continued until information redundancy was achieved.

Systematic analysis of verbatim interview narrative data using directed content analysis procedures. Coding was conducted iteratively by the two authors from each profession. Each researcher coded the interview transcripts independently with an initial coding schema, developed from existing literature. Text that did not fit into the initial schema was given new codes by each researcher. Researchers reviewed transcript coding weekly, and updated the coding schema if needed. Discrepancies were counted; decision trails audited and discussed to reach agreement between the researchers.

Population Studied: The sample population included nurses and physicians from an academic medical center in a large Midwestern city. The physician population included attending physicians of the Section of General

Internal Medicine. The nurse sample included staff nurses from two general medicine units.

Principle Findings: Preliminary findings indicate that organizational culture, racial disparity between the professions and familiarity play a role for both professions. For physicians, the amount of annual time spent as inpatient attending, hospitalist subspecialty and house staff trust in the nurses play a major role in nurse physician work relationships. Nursing educational background was not viewed to be an important determinant of the relationship.

Contrary to previous research, gender and age were not found to be important predictors of the relationship.

Conclusions: The recent development of the hospitalist specialty in medicine may likely promote a more positive view of nurse physician work relationships primarily through increasing each professions exposure, and hence familiarity, with each other. The role of racial disparity between the professions, present in this institution, has not previously been reported.


Given the realities that not all in-patient physicians will be hospitalists in the future, interventions to promote familiarity with nurses may be beneficial for physicians who spend less time on inpatient rotations. Although, recent attention has been paid on racial disparities in patient health outcomes, there has been little or no attention on work relationship problems caused by racial disparities between professions.

In organizations where there is racial disparity between professional groups that work interdependently, additional efforts are likely needed to promote positive work relationships.

•

Clinic-level Process of Care for Depression in Primary Care Settings

Jacqueline Fickel, Ph.D., Elizabeth Yano, Ph.D.,

Louise Parker, Ph.D., Lisa V. Rubenstein, M.D.,

M.S.P.H.

Presented By: Jacqueline Fickel, Ph.D., Associate

Investigator, VA GLA Health Services Research &

Dev., Center for the Study of Healthcare Provider

Behavior, 16111 Plummer Street (152), North

Hills, CA 91343-2036, Phone: (818) 891-7711, x

5482, Fax: (818)895-5838, Email: jacqueline.fickel2@med.va.gov

Research Objective: New models of primary care management of depression require active collaboration between mental health and primary care providers in the areas of screening, assessment, patient self-management support, triage, and follow-up. In each of these areas, the steps in the process of care can be influenced by the way care is organized at the local clinic level.

However, there is little documentation of the clinic-level organization of the care process. This study assesses the usual processes for depression management in 10 primary care clinics in order to better understand how to improve concordance with care guidelines, and for tailoring of quality improvement activities.

Study Design: We use a qualitative case comparison method to describe common patterns and variations in the process of depression care in 10 outpatient primary care clinics in the Veterans Health system. Data come from two sources: data on organizational structures from administrative sources, and qualitative descriptions of care processes from

key informant interviews with clinical leaders from each clinic.

Population Studied: We interviewed 10 primary care and 12 mental health clinical leaders in depth about the usual depression detection and management practices at their primary care clinics. Clinics were distributed among three service networks in five states. They were small to medium in size, were both hospital- and community-based, and were located in both metropolitan and rural areas. Based on organizational structures, these clinics were generally typical of VA primary care clinics nationwide.

Principle Findings: Leaders at all 10 sites described generally similar steps in their clinics’ overall processes for identifying and managing depression. In the typical clinic, routine screening occurred at least annually, primary care providers diagnosed depression informally, made locus of care and treatment planning decisions based upon individual provider comfort level and patient severity, offered pharmacological treatment to those patients treated in primary care, and sought informal consultation from mental health providers as needed. The usual steps conformed in part to those of relevant clinical practice guidelines, although they differed in the areas of more informal clinical assessment and diagnosis, more informal treatment planning, and greater limitations in treatment options, treatment monitoring, and collaboration. Moreover, the usual practices varied among clinics on several key points, including rarely diagnosing in primary care, not treating in primary care, or having minimal procedures in place for urgent mental health requests. These variations were spread across different clinics, creating a good deal of individuality among sites in the specifics of the care process.

Conclusions: The variation among local clinics suggests that local context is a key factor in terms of assessing usual care. Variations in the degree to which care conforms to care models and practice guidelines indicates specific needs for targeted quality improvement activities in certain clinics.


These gaps between usual care and guideline recommendations have implications for implementing quality improvement models. In particular, different gaps at individual clinics suggests the importance of tailoring interventions to specific local needs, e.g. improving diagnosis techniques, treatment planning and options, treatment monitoring, or collaboration between providers.

Funding Source: VA

•

A Taxonomy of American Health Care

Regulation: Industry Oversight as an

Assortment of Public-Private Partnerships

Robert Field, J.D., M.P.H., Ph.D.

Presented By: Robert Field, J.D., M.P.H., Ph.D.,

Associate Professor and Chair, Department of

Health Policy and Public Health, University of the Sciences in Philadelphia, 600 South 43rd

Street, Philadelphia, PA 19104, Phone: 215-596-

7618, Fax: 215-596-7614, Email: r.field@usip.edu

Research Objective: To describe and classify regulatory models that are distinctive to

American health care and their relevance to efforts at reform in specfic areas.

Study Design: Comprehensive overall survey of all major areas of health care regulation from historical, policy, and structural perspectives.

Principle Findings: The structure of American health care regulation represents anything but a simple set of government command and control mandates. Every major sphere of regulation implements a complex collaboration between federal, state and private authorities. They can be seen as reflecting three distinct paradigms.

The first gives states primary authority, at least nominally, subject to significant federal restrictions, with the enforcement of major technical issues left to private professional and industry organizations. Examples include many of the earliest regulatory programs, including those that oversee professionals, institutions, private insurance, public health, and Medicaid.

The second invests primary authority at the federal level but with substantial private input.

Examples include the regulation of clinical research, prescription drug marketing, and

Medicare. The third is of particular interest because of its distinctiveness to the United

States. It creates a federal bureaucratic structure that encourages and guides, but does not direct, private sector innovation. Examples include the regulation of tax-exempt business status, the funding of biomedical research, and some aspects of the oversight of new drug development.

Conclusions: A taxonomy according to these paradigms helps to illuminate the underlying mechanics at work and to highlight the publicprivate collaboration that characterizes the overall process. The role of government in

American health care regulation is, in many

respects, more that of a partner with industry than of an adversary. The effect has nurtured, as well as restricted, the country’s health care enterprise. In fact, much of the industry would not exist in its present robust form were it not for regulatory initiatives such as Medicare, NIH, physician licensure, and the drug approval process.


While deficiencies in many specific areas of regulation certainly abound, efforts at reform should take care to respect the underlying publicprivate balance.

•

Assessing Employee Attitudes towards

Organizational Change in Substance Abuse

Treatment Agencies

James H Ford II, Ph.D.

Presented By: James H Ford II, Ph.D., Assistant

Scientist, NIATx, University of Wisconsin, 610

Walnut Street, Madison, WI 53726, Phone: 608-

262-4748, Email: jayford@chsra.wisc.edu

Research Objective: The processes of introducing change provide organizations with unique opportunities to influence employee commitment to and behavior towards the change. This research evaluates the relationships of employee perceptions about the change process, quality of information received about the change and change participation on their psychosocial reactions to change. In turn, it examines how those reactions, coping and change self-efficacy; influence employee commitment to organizational change and how that commitment shapes their behavior (i.e., actions) towards the change

Study Design: The research tested a modified application of the Employee Commitment to

Change model (ECC) by incorporating specific change related behaviors and employee psychosocial reactions to change; examining the influence of participate and information about the change process on self-efficacy and coping; and addressing the influence of employee commitment to change on behavior towards the change.

Population Studied: The data was analyzed as part of an organizational assessment survey administered to 520 employees of substance abuse treatment agencies who were members of the Network for the Improvement of Addiction

Treatment.

Principle Findings: A test of the overall model found significant benefits from opportunities to participate in the change process and employees’ coping skills in their ability to lead change and react to change within the organization. Other factors include employee’s with an affective commitment to change and the quality of the change information. These factors significantly explained 43.9% of the variance in an employees’ behavior towards change in their organization. Specific findings were that employees exhibiting a pure affective commitment has a significant association with a championing behavior towards change. An employee’s ability to cope with organizational change and their change self-efficacy were significant predictors of commitment to change.

Employees with a high change self-efficacy or who cope with change through leadership were more likely to exhibit affective commitment to change. Those employees who reacted to change or had a low change self-efficacy demonstrated a higher continuance commitment to change.

Conclusions: Results suggest that organizations, which provide quality information about the change and opportunities to participate in the change process, are more likely to significantly impact employee behavior towards organizational change. In fact, employees’ perceptions about the change process represent a more powerful set of predictors of an employee’s behavior towards organizational change than the employee’s psychosocial reactions to change or their commitment towards the organizational change.


The process of organizational change constitutes a stressful event in the lives of employees, often characterized by feelings of uncertainty. Findings from this research suggest that organizations are in a position to help their employees adjust to the process of change and thus influence their behavior towards change. Given the current environment of change, especially in addiction treatment, systems need to be developed that would help build employee commitment to organizational change.


•

Understanding Patterns of Military

Treatment Facility and Civilian Provider

Utilization among TRICARE Beneficiaries

Teresa Gibson, Ph.D., Christiine Vogeli, Ph.D.,

Julia Hidalgo, Sc.D., Alexandra Shields, Ph.D.,

William D. Marder, Ph.D., Thomas V. Williams,

Ph.D.

Presented By: Teresa Gibson, Ph.D., Director,

Research Division, Thomson Medstat, 777 E.

Eisenhower Parkway, Ann Arbor, MI 48108,

Phone: 734.913.3481, Fax: 734.913.3850, Email: teresa.gibson@thomson.com

Research Objective: The military health system is a provider and purchaser of health care services for current and former members of the armed services and their dependents in the US through the TRICARE program. Among

TRICARE beneficiaries, we examined patterns of purchased care (civilian) provider utilization relative to direct care (Military Treatment Facility,

MTF) utilization and characterized the patients and types of care most likely to ‘‘migrate’’ to purchased care providers.

Study Design: We analyzed the utilization patterns for each TRICARE beneficiary.

Consistent with the IOM adaptation of the

Andersen-Aday framework of access to care in medicine we examined the structural (e.g., provider supply in the geographic area, MTF characteristics), financial (e.g., type of coverage, type of eligibility), and personal (e.g, sociodemographic, illness severity) characteristics of persons who received direct care only, purchased care only or a combination of direct and purchased care. TRICARE administrative data (inpatient, outpatient, enrollment/eligibility and prescription drug) were employed to analyze utilization patterns.

Population Studied: 7.2 million non-elderly

TRICARE beneficiaries residing in the US in

Fiscal Year (FY) 2005 who were enrolled in

TRICARE Prime or were eligible to use TRICARE

Standard or Extra benefits. Medical care expenditures for this population totaled $14.2 billion dollars in FY2005.

Principle Findings: Patients with chronic illness or a larger co-morbidity burden were most likely to use a combination of direct and purchased care services. Beneficiaries using a combination of purchased care and direct care (1.8 million) were older (average age 33 years), female (56%), and half were active duty and dependents (50%).

They had the highest average medical expenditures and were not likely to have moved in the past year (14%). Beneficiaries using direct

(military) health care only (2.2 million) were young (average age 27 years), male (66%), and active duty military or their dependents (67%).

Over one quarter moved in the past year (26%).

Beneficiaries using purchased (civilian) health care only (1.4 million) were older (average age 31 years), female (58%), and retirees or their dependents (58%). The remaining 1.7 million beneficiaries did not use TRICARE in FY2005.

Geographic proximity played a large role in the utilization patterns, with those beneficiaries residing closest to inpatient and outpatient military providers using the largest amounts of direct care. Results of multivariate models help to identify major factors associated with migration and its impact on expenditures.

Conclusions: Patients with the greatest medical need are the most likely to receive care from a combination of military and civilian providers.


Further examination of the coordination of care between the military health system and civilian providers should occur. Mechanisms to share information across the military health and civilian systems should be implemented.

Civilian and military providers of care should be aware that the patients most likely to utilize services in the purchased care and military health systems are also most likely to have conditions that require frequent monitoring over time.

Funding Source: DoD - Center for Health Care

Management Studies, TMA

• QI and Research: Clarity and Structure in an

Academic Medical Center

Margaret Holm, Masters Health Services

Administration, Maurie Markman, M.D., Alma

Rodriguez, M.D., Mano Selvan, Ph.D.

Presented By: Margaret Holm, Masters Health

Services Administration, Executive Director,

Clinical Effectiveness, University of Texas M.D.

Anderson Cancer Center, 1100 Holcombe

Boulevard Unit 129, Houston, TX 77030, Phone:

713.745.5066, Email: mjholm@mdanderson.org

Research Objective: Quality improvement, QI, initiatives require standard processes and ethical oversight, just as research. In this paper we distinguish between QI and research, describe the standards we will use to review QI, the importance of ethical review, and the development of an infrastructure that we will use to implement and supervise QI.

Study Design: We reviewed the literature and conducted interviews with Institutional Review

Board chairs, clinical, research, ethical, and QI leaders at M.D. Anderson and other agencies, associations, and health care organizations.

Principle Findings: Because of the increasing significance of QI initiatives in patient care delivery and more recently reimbursement, there needs to be a clear definition of QI to identify and recognize this type of work. The wide belief that all publications must be reviewed by the

Institutional Review Board before submission to

a journal slowed or stopped QI initiatives within our institution. Enhancing our organizational infrastructure to oversee QI initiatives will ensure ethical oversight for these activities.

Conclusions: National forces are pushing health care organizations to change rapidly to improve quality and patient safety. Because of these national forces QI initiatives are becoming more important. Hospitals and health care systems should enhance or develop organizational infrastructures to support the supervision and ethical review of QI initiatives. Ethical considerations for research are based on patient autonomy and for QI, beneficence towards the patient. The debate regarding QI and research should not be based solely on the issue of publication. It is important for the outcome of

QI initiatives to be shared through publication.

The work associated with QI initiatives should be rewarded through merit increases and promotions.


Several recommendations were identified including, establishing national forums to debate issues surrounding the ethical oversight of QI activities and provide recommendations to appropriate national organizations and agencies and fund and track demonstration projects by national agencies, provide a working definition of

QI at a national level.

•

Reducing Controlled Substances Abuse

Through PolyPharmacy Intervention

Amanda Honish, M.S., Avery Ashby, M.S.,

Michael White, Pharm.D., Jacqueline Flowers,

R.N., Soyal Momin, M.S., M.B.A.

Presented By: Amanda Honish, M.S.,

Biostatistical Research Analyst, Health Services

Research, BlueCross BlueShield of Tennessee,

801 Pine St, Chattanooga, TN 37402, Phone: 423-

535-7984, Fax: 423-785-8083, Email:

Amanda_Honish@BCBST.com

Research Objective: The primary objective of the PolyPharmacy program is to decrease controlled substance abuse in commercial members by informing providers about their patients who inappropriately access emergency rooms, have multiple prescribing providers and use multiple pharmacies to fill controlled substance prescriptions.

Study Design: Medical and pharmacy claims data are used to identify members who, within a three month period, filled 10 or more controlled substances and met one or more of the following: were prescribed controlled substances by three or more physicians, filled controlled substance prescriptions at five or more pharmacies, or visited the ER three or more times. Controlled substances are identified as being in DEA Class II through Class IV. A team of nurses reviews a member’s medical claims history to determine if controlled substance prescriptions are appropriate. Cases are then referred to a pharmacy consultant who determines the member’s primary physician and sends a letter describing the patient’s last three months of controlled substance utilization as well as Care Coordination Programs available to members. Successful outcomes of the program include a reduction in the count and supply days of controlled substance prescriptions, a reduction in ER visits, pharmacies, and physicians prescribing controlled substances as well as a decrease in the total healthcare costs for members.

Population Studied: Data included in the evaluation were for members who were continuously enrolled for six months prior to and six months after beginning the program.

Additionally, only cases that were opened for at least 90 days were considered. There were 1,251 cases opened between October 2003 and

January 2006. Of these, 278 members met the inclusion criteria.

Principle Findings: A pre-post methodology was used to examine medical and pharmaceutical claims. For each member, data were gathered using claims history six months prior to and six months after beginning the program. All prepost comparisons were made using the

Wilcoxon Signed-Rank nonparametric test with a

.05 significance level. ER visits were reduced from 436 visits to 391 visits (-10.32%). The number of physicians prescribing controlled substances was reduced from 1,104 to 1,001 (-

9.33%). The number of pharmacies used to fill controlled substance prescriptions was reduced from 808 to 727 (-10.02%). The number of dispensed controlled substances was reduced from 4,653 to 4,010 (-13.82%), and supply days were reduced from 89,477 to 79,900 (-10.70%).

There was also a reduction in total healthcare costs from $1,248 PMPM to $1,204 PMPM (-

3.53%). With the exception of ER visits and healthcare costs, results from the Wilcoxon

Signed-Rank test show a significant difference before and after beginning the program.

Conclusions: Results of this study indicate that communication with physicians about

PolyPharmacy issues can reduce controlled substance abuse.


Inappropriate use of controlled substances is not only associated with adverse drug events, but it also increases the cost of healthcare. With the current fragmentation of medical and pharmacy data, many physicians are unaware of their patients’ total utilization. The Polypharmacy program, then, combines this information enabling physicians to provide safe and quality healthcare by managing their patients’ controlled substance use more effectively.

Funding Source: BlueCross BlueShield of

Tennessee

•

Increasing Health Care Efficiency by

Physician and Patient Empowerment: First

Results From a Large-Scale Behavioral

Change Project in Germany

Katharina Janus, Ph.D., Lawrence D. Brown,

Ph.D., Mario Weiss, M.D., M.B.A.

Presented By: Katharina Janus, Ph.D., Visiting


Management, Columbia University, 600 West

168th Street, 6th Floor, New York, NY 10032,

Phone: (212) 342-4521, Fax: (212) 305-3925,

Email: kj2186@columbia.edu

Research Objective: To assess the impact of behavioral change methods on the efficiency of medical therapies in a large outpatient setting.

Study Design: Evaluations are based on primary and secondary data. Long-term analysis of secondary data from medical records regarding drug utilization, hospitalization and other indicators is used to assess the achieved change in efficiency over an eight year period. Primary data is collected from patients and physicians through questionnaires that are developed using the scientific framework of cognitive behavioral psychology. The questionnaires are selfadministered and measure several dimensions of beliefs and attitudes; other behavioral-related confounding factors; and socio-demographic questions. Data collection is in progress and this paper presents first year results.

Behavioral change methods consist of a mix of individualized information and narratives

(stories with examples), depending on the target issues and the psychosocial context.

Communication with physicians and patients is coordinated in order to avoid conflict in the doctor-patient relationship. Communication channels include a mix of classical tools such as dialogue marketing, face-to-face interaction and public relations. In addition, artificial intelligence based knowledge management tools are provided via the internet.

Population Studied: 8500 physicians (primary care physicians and specialists) covering the outpatient care of 6.1 million patients in the region of Hesse/Germany.

Principle Findings: Secondary data analysis shows potential savings of 70 million euro/year

(91 million US $) in addition to quality and compliance problems (60% non-adherence to therapies in particular with respect to chronic diseases). Primary data revealed a very high degree of insecurity and mistrust among patients especially regarding drugs prescribed.

Physicians express strong frustration about bureaucracy and their decreasing influence on care processes. First interventions show that independent information is appreciated very much by patients. As a consequence, they become more active challenging physicians on their existing therapies. Although physicians complain about an increased workload due to reconsideration of existing therapies, they seem to adapt them more to individual patients’ needs and state-of-the art medicine. In addition a growing number of physicians is challenging the existing information paradigms of the pharmaceutical industry and is demanding better information on the efficiency of therapies.

Conclusions: This project shows that standard operating procedures and guidelines are not the only way to increase efficiency. Empowering physicians and patients seems to be even more promising. Individualized care that is based on objective information is not only beneficial for the patient, but also more satisfying for physicians. As this project questions established belief models on medical therapy, doctor-patient relationship and information management it is creating strong reactions among health care stakeholders.


The current trend in health care management in

Germany depends heavily on guidelines, regulations and restrictions. Besides these wellproven methods to increase efficiency this project shows an alternative approach that does not try to restrict and guide, but rather focuses on empowerment and self responsibility to increase health care efficiency. As this project is challenging existing models of management and thinking it is stimulating the public discussion

on fundamental questions of health care delivery in Germany.

Funding Source: German sickness funds

•

Using Health Risk Assessments to

Influence the Structure of Health Plan

Benefits

Rhonda Jaster, M.P.H., Paula Card-Higginson,

B.A., ELS, Kevin W. Ryan, J.D., M.A., George

Platt, Joseph W. Thompson, M.D., M.P.H.

Presented By: Rhonda Jaster, M.P.H., CDC

Prevention Specialist, Arkansas Center for Health

Improvement, 1401 West Capitol Avenue, Suite

300, Victory Building, Little Rock, AR 72201,

Phone: 501-526-2244, Fax: 501-526-2252, Email: rkjaster@uams.edu

Research Objective: Personal behaviors strongly influence healthcare use and ultimately cost. To enhance organization and management of a selffunded statewide health plan, we implemented a health-risk assessment (HRA) tool to identify risk behaviors. Responses were correlated with medical and pharmacy costs. On the basis of members’ self-reported health risks and associated aggregate costs, preventive health programming was adopted by the plan and implemented.

Study Design: Plan members voluntarily completed an HRA by telephone or Internet during the annual open enrollment for health benefits. Health risks were identified (physical inactivity, obesity, tobacco use), then matched to individual-level medical and pharmacy claims.

Confidentiality of individual information was maintained. Participants received premium discounts for completing the HRA and for maintaining healthy lifestyles.

Population Studied: The HRA response rate was 54% (46,637 of 87,065) of eligible adult, fulltime employees/spouses covered by the

Arkansas State and Public School Employee

Health Plan. HRA responses were confidentially matched to personal medical and pharmacy claim records to calculate aggregate effects of risk behaviors.

Principle Findings: Risks that in the aggregate correlated with high healthcare costs were communicated to the plan’s governing board.

HRA results showed a large portion of respondents self-identifying with health risks of tobacco use, body mass index over 30, or less than 3 days of physical activity/week. Hence they encountered higher healthcare costs than members who self-reported as not having these risks. The board then adopted a strategy incorporating disease prevention and wellness benefits into a plan that was formerly focused on disease treatment. Wellness programs were recommended to affect behaviors with the greatest impact on plan cost. As the first prong of its strategy, the board approved coverage of evidence-based clinical preventive services for enrollees to increase awareness of health risks among plan members. Second, they implemented a tobacco-use cessation program that included trained behavior health coaches; education by telephone, Internet, and mail; and covered nicotine replacement therapy. Finally, to address the cost differential of high BMI and physical inactivity compared with no risks

($1,183/person/year higher for risk group), the board approved a three-tiered obesitymanagement strategy for members------a sequential strategy of nutrition/weight management, intensive medical care, and bariatric surgery.

Conclusions: Members reporting health risk behaviors incur higher healthcare costs than members without those risks. Importantly, health plan design can be developed to incentivize risk management by enrollees.

Wellness programming and health promotion efforts that influence positive behaviors will be essential in improving personal health and therefore decreasing overall health plan costs.

Preventive wellness programs are presently being implemented to increase awareness, educate enrollees, and control costs. Wellness programs currently offered will be evaluated after

3 years to determine if a return on investment was achieved.


Use of an HRA catalyzed a healthcare plan to incorporate a strategy of awareness, support, and engagement to influence behaviors and inform plan management and benefit design.

(Note: These findings and conclusions have not been formally disseminated by the CDC and should not be construed to represent any agency determination or policy.)

Funding Source: State of Arkansas Employee

Benefits Division

• Perceptions of Hospital CEOs About the

Effects of CEO Turnover

Amir Khaliq, Ph.D., David M. Thompson, Ph.D.,

Stephen L. Walston, Ph.D.






City, OK 73104-5072, Phone: 405-271-2115

Extension 37073, Fax: 405-271-1868, Email: amirkhaliq@ouhsc.edu

Research Objective: To explore the perceptions and understanding of hospital CEOs regarding the circumstances and impact of CEO turnover on non-federal general surgical/medical hospitals in the U.S.

Study Design: A 2004 mail-out nationwide survey of 805 hospital CEOs through a structured pre-tested questionnaire with 22 single- or multi-item close-ended questions and three open-eneded questions.

Population Studied: Hospital CEOs in 2004 at non-federal general surgical/medical hospitals in the U.S.

Principle Findings: About two-thirds of the

CEOs indicated that their departure from the previous hospital was voluntary while almost half of the respondents indicated that their predecessor's departure was involuntary! From

21% to 50% of the CEOs indicated that their competitors attempted to take advantage of the turnover situation by aggressively marketing in the respondent's geographic market, by opening new clinics, and by recruiting physicians and key employees of the target hospital. One-third to nearly half of the respondents indicated that many important activities were halted or postponed after the CEO turnover while cost cutting activities and service closure were initiated in many instances. A vast majority of the CEOs indicated that their departure had a negative impact on financial performance, quality of care, employee morale, medical satff relations, hospital culture, and community relations. Conversely, a number of respondents

(48% - 71%) also indicated that their predecessor's departure had a positive impact on all of these variables at the respondent's current hospital.

Conclusions: Voluntary or involuntary CEO turnover, a common occurence in U.S. hospitals, has considerable negative impact on organizational culture, environment, and performance. Perceptions of CEOs are colored in this regard and empirical evidence is needed to fully understand the impact of CEO turnover.


Careful assessment of the circumstances and impact of CEO turnover can help devise strategies to reduce the frequency and negative impact of these events. Investment in succession planning can go a longway in minimizing the disruption and uncertainty resulting from unplanned turnovers.

Funding Source: The American College of

Healthcare Executives

• Incoming or Outgoing Hospital CEOs:

What Kind of Help Do They Want

Amir Khaliq, Ph.D., Stephen L. Walston, Ph.D.,

David M. Thompson, Ph.D.






City, OK 73104-5072, Phone: 405-271-2115

Extension 37073, Fax: 405-271-1868, Email: amirkhaliq@ouhsc.edu

Research Objective: To ascertain the assistance needs of incoming and outgoing hospital CEOs to facilitate the transition process and minimize potential organizational instability or uncertainty resulting from CEO turnover.

Study Design: A nationwide random mail-based survey of 2118 hospital CEOs. In response to three open-ended questions, the respondents provided suggestions, ideas and recommendations regarding things that matter most to incoming and outgoing CEOs.

Population Studied: Current CEOs at 805 nonfederal general surgical and medical short-stay hospitals.

Principle Findings: Suggestions for help for departing CEOs reflect outgoing CEOs' concerns regarding job placement, career planning, severance package, succession planning and financial planning. These concerns are more pronounced when CEOs leave involuntarily.

Continuing health insurance coverage was also high on the list of concerns under involuntary departure scenario. The need for hospital boards to appoint an interim CEO was frequently expressed in the context of involuntary CEO departure. The respondent felt that incoming

CEOs could be helped through a structured orientation, establishing a network of peers and support personnel, the availability of previous strategic plans and opportunities for consulting with the previous CEO.

Conclusions: The transition period is challengin for all involved. Depending upon the circumstances of change the incoming and departing CEOs can use assistance in a variety of ways to ease the transition process. Meaningful and concrete help from various sources can be critical in making a smooth transition. Help is

not only necessary ot reduce stress but essential to establish the ligitimacy of the newly hired

CEO. Limitations of the study include the fact that the observations made in the study are based on the personal opinion of current hospital CEOs without any assertions about the cost-effectiveness and practicality of various recommendations.


Hospital boards must carefully put in place mechanisms and protocols to assist the departing and incoming CEOs to make the transition process relatively less disruptive and pain free.

•

The Role of Social Networking in

Organizations Aspiring for High Quality

Risette Zoe LeVan, M.Sc., Carol VanDeusen

Lukas, Ed.D.

Presented By: Risette Zoe LeVan, M.Sc.,

Research Analyst, VA Center for Organization,

Leadership and Management Research, Veterans

Health Administration, and Boston University,

150 S Huntington Avenue (152-M), Boston, MA

02130, Phone: (857)364-4896, Fax: (857)364-

4438, Email: zoe.levan@med.va.gov

Research Objective: Increasingly, the Malcolm

Baldrige National Quality Program criteria are viewed as standards to which quality health care organizations aspire. Visionary leadership is a

Baldrige core value. It is widely recognized that leaders of healthcare organizations exert strong influence on their organizations’ performance.

However, the dynamics of that influence are not fully understood. One promising model for understanding is social network theory, which posits that inter-organizational networking is beneficial because it builds relationships that lead to useful alliances and exposes leaders to innovative practices and technologies. Our hypothesis, tested in the Department of Veterans

Affairs (VA), is that medical centers in which leaders are active in social networks outside their facility are more likely to use the Baldrige criteria to guide their organizations than medical centers with leaders with fewer outside contacts.

Study Design: We conducted secondary analyses of variables from the 2005 Inventory of

VHA Organizational Characteristics, the 2006

VA All-Employee Survey, and VA administrative databases. Medical centers were the unit of analysis. Social networking (SN) was operationally defined as number of regional committees in which hospital top leadership

(director, COS, nurse executive, associate director) reported participating during the previous year. A summary SN score was created for the whole leadership team in each facility. To identify level of Baldrige participation, each facility was assigned to one of three self-reported categories: 1) applied for the Baldrige award; 2) adopted Baldrige criteria as an operating philosophy but did not submit application; 3) no

Baldrige participation. To control for other organizational variables potentially associated with Baldrige participation, we included four indicators: employee distress (summary score for turnover, EEO complaints and sick rate); employee civility, focus on customer service, and management for achievement. We used ANOVA to test variation in SN between Baldrige groups and two binary logistic regression models to predict levels of Baldrige participation.

Population Studied: 136 VA medical centers.

Principle Findings: The findings basically support our hypothesis. SN was significantly correlated with Baldrige participation (r=0.3, p<.01). ANOVA showed significant differences in SN scores across the three Baldrige groupings

(R2=.08, p<.05). In the first logit model (to predict any Baldrige participation versus no partipation - categories 1 & 2 v 3), SN was significant (b=.07; p<.05). However, in the second logit model (to predict application versus adoption of philosophy only ---- 1 v 2), SN was not significant. Organizational control indicators were not significant in either model.

Conclusions: We found evidence that active social networking among top leadership is associated with the adoption of Baldrige principles, suggesting that social networking is beneficial to the hospital as well as to its leaders individually. While the analyses do not demonstrate a causal relationship, the persistence of the association when controlling for other organizational factors suggests a real relationship that merits further investigation.

The study opens avenues for promising research on the dynamics and impact of this association.


Understanding the aspects of leadership behavior that are associated with higher organizational performance will provide tools for improving the management of health care systems and the quality of care.

Funding Source: VA

•

Nursing Home Chains: Scale,

Standardization, and Quality

Michael Lin, M.S.P.H., Ph.D., Joan R. Bloom,

Ph.D., Stephen Shortell, M.P.H., Ph.D., Charlene

Harrington, Ph.D., Martin Kitchener, Ph.D., Mark van der Laan, Ph.D.






Research Objective: The primary aim of this study is to describe the nursing home chains operating across the US. More specifically, these nursing home chains are characterized by ownership, size, location, geographic dispersion, and standardization of operations. The second aim of this study is to compare non-profit and for-profit nursing home chains.

Study Design: This study utilizes the Online

Survey, Certification and Reporting System

(OSCAR) database and a chain-linked cross-walk file from the Center for Medicare and Medicaid

Services (CMS) to create a profile of nursing home chains. To compare non-profit to for-profit nursing home chains, t-tests statistics are calculated to test the equality of means for size, dispersion, and staffing.

Population Studied: All Medicare and/or

Medicaid-Certified nursing homes that were in operation during 2003 are included in this analysis. In order to ensure that all nursing homes from a chain are counted, the sampling frame is extended into 2004 to include facilities that were not surveyed during the 2003 calendar year. Nursing home chains are identified using

OSCAR’s designation of a multi-facility organization. However, because some nursing homes belong to a multi-facility organization in which there is only one nursing home in the company portfolio, we distinguish these chain facilities as single-home holding companies.

Principle Findings: There are 1,663 different nursing home chains if we include single-home holding companies. However, using a stricter definition based on a literal requirement of owning more than one nursing home, there are

852 different nursing home chains. Focusing on this latter definition of nursing home chains, the vast majority are owned by for-profit companies

(n=598, 70.2%). Non-profit companies account for 29.5% (n=251), and government-owned chains account for less than one percent (0.4%, n=3). On average, for-profit chains are larger than non-profit (9.8 vs. 5.3 homes/chain, p<0.001), and are somewhat more geographically dispersed (2.0 vs. 1.7 states/chain, p<0.05). More than eighteen percent of for-profit chains own ten or more nursing homes, while only 8.8% of non-profit chains own ten or more homes. For-profit chains are more likely than non-profit chains to provide care to Medicaid residents, while nonprofit chains are more likely than for-profit chains to provide care to private pay residents.

Non profit chains have higher RN and CNA staffing levels than for-profit chains.

Conclusions: Nursing home chains exhibit wide variability in their size, geographic dispersion, and extent of operational standardization. While the vast majority of nursing home chains are owned by for-profit companies, size and staffing levels appear to be the major difference in these chains. With respect to standardization, the variability in organizational configuration is greater within than between ownership types.

This suggests that chain ownership may not be a particularly sensitive measure of quality.


The profit status of a nursing home chain is not a very sensitive proxy measure of quality using a structure, process, and outcome approach.

While chain nursing homes are different than independent facilities on these measures, the chain approach to health care delivery may not be that different between ownership types.

Funding Source: N/A

• Organizational Performances of

Partnerships: National Empirical Analysis of

Partner Coordination and Integration

Blossom Lin, Ph.D.

Presented By: Blossom Lin, Ph.D., Assistant professor, Health Service Management, China

Medical University, 91 Hsueh Shih Rd.,

Taichung, 404, TW Phone: 886-922709359, Fax:

886-4-22076923, Email: yenju1115@hotmail.com

Research Objective: Taiwan’s primary community care network (PCCN) demonstration project, funded by the Bureau of National Health

Insurance on March 2003, was established to manage the health care of Taiwan’s rapidly aging population and discourage hospital shopping behavior. Between 2003 to 2005, 268 PCCNs were established. This study was aimed to empirically verify the theoretical thinking between the integration mechanisms and performance of primary community care networks (PCCNs).

Study Design: This was a cross-sectional mailed survey study. The structured questionnaire was designed to understand the partnership integration, in terms of governance, clinical, marketing, financial, and information integration.

Perceived performance and willingness to stay within the same network in the future were

measured as the outcome indicators of PCCNs.

The multivariate statistical approach of structural equation modeling (SEM), also known as LInear

Structural RELationships (LISREL) or covariance structural model, was performed to examine the causal relationships in this study.

Population Studied: To portrait the integration involvement and performance in individual

PCCNs, we sent questionnaires to individual members (clinic members and hospital members) to catch the data. One hundred and eighty-one PCCNs responded in this study (with

67.54% response rate).

Principle Findings: It found that a network’s efforts in integration mechanisms were positively related to its perceived performance and willingness to stay within the same network in the future.

Conclusions: The lack of an operational definition and information about systemwide integration has deterred the understanding of the organizational dynamics in a (virtual) integrated health system (or network), i.e., a

PCCN in this study. This study used the operational definition of integration mechanisms and outcomes to explore in depth the network dynamics. Such an empirical examination of individual PCCNs can offer new insights for improving network organizational structure, design, and performance.


To achieve the purposes and benefits of the partnership in PCCNs, in addition to the official regulations proposed by BNHI, it was really recommended that the network partners could rethink and apply the internal governance and management activities to make their network processes more smooth and efficient.

Funding Source: Taiwan National Science

Council

•

Innovations in Mental Health Services

Implementation: A Report on State-Level Data

From the U.S. Evidence-Based Practices

Project

Jennifer L. Magnabosco, Ph.D.

Presented By: Jennifer L. Magnabosco, Ph.D.,

Associate Director & Senior Research Associate,

The Leavey Center for the Study of Los Angeles,

516 San Vicente Boulevard, #304, Santa Monica,

CA 90402, Phone: 310-948-1758, Email: jlmagnabosco@mindspring.com

Research Objective: The Evidence-Based

Practices (EBP) Project has been investigating the implementation of evidence-based mental health practices (Assertive Community

Treatment, Family Psychoeducation, Integrated

Dual Diagnosis Treatment, Illness Management and Recovery, and Supported Employment)in state public mental health systems in the United

States since 2001. To date, Project findings have yielded valuable insights into implementation strategy characteristics and effectiveness. This paper reports results of an effort to identify and classify state-level implementation activities and strategies employed across eight states participating in the Project.

Study Design: Content analysis and Greenhalgh et al's (2004) definition of innovation were used to identify and classify state-level activities employed during three phases of EBP implementation: Pre-Implementation, Initial

Implementation and Sustainability Planning.

Activities were coded from site visit reports created from documents and notes from key informant interviews conducted during two periods, Fall 2002-Spring 2003, and Spring

2004. Frequency counts and rank-order analyses were used to examine patterns of implementation activities and strategies employed across the three phases of implementation.

Population Studied: State public mental health authorities.

Principle Findings: One hundred and six discreet implementation activities and strategies were identified as innovative and were classified into five categories: 1) state infrastructure building and commitment; 2) stakeholder relationship building and communications; 3) financing; 4) continuous quality management; and 5) service delivery practices and training.

Implementation activities from different categories were employed at different phases of implementation.

Conclusions: Insights into effective strategies for implementation EBPS in mental health and other health sectors require qualitative and quantitative research that seeks to: a) empirically test the effects of tools and methods used to implement EBPs, and b) establish a stronger evidence-base from which to plan, implement and sustain such efforts.


This paper offers a classification scheme and list of innovative activities and strategies. The classification scheme offers potential value for future studies that seek to assess the effects of various implementation processes, and helps establish widely accepted standards and criteria that can be used to assess the value of innovative activities and strategies.

Funding Source: John D. and Catherine T.

MacArthur Foundation Network on Mental

Health Policy Research

•

Potentially Inappropriate Variations in

Discretionary Surgical Procedure Rates in the

Military Health System

Nancy McCall, Sc.D., Arlene Ash, Ph.D., Thomas

Williams, Ph.D., Jenn Fonda, M.A., Lori Kaler,

M.D., Genevieve Cromwell, B.A.

Presented By: Nancy McCall, Sc.D., Chief

Scientist, Division of Health Services and Social

Policy Research, RTI International, 701 13th

Street NW, Washington, DC 20005, Phone: 202-

728-1968, Fax: 202-974-7855, Email: nmccall@rti.org

Research Objective: Decades of research indicates that health care is delivered in unexpectedly different ways among patients who may have similar clinical needs. There are poor implications for quality medical management of these patients, given the possibility for both over- and under-use of required medical services. The purpose of this study is to rigorously measure variations, across enrollment military treatment facilities (MTFs), in the use of selected medical treatment procedures and organizational factors associated with potentially inappropriate variations. We seek to understand variation in the rates of procedures at the level of the enrollment MTF, and to identify organizational factors of MTFs where the observed number of procedures deviates substantially from what is expected.

Study Design: We studied 1.36 million beneficiaries who were continuously enrolled in

TRICARE Prime for all 12 months in fiscal year

2001, assigned to a military PCM, and enrolled for at least the first month of FY2002. We matched study subjects to information on their demographic characteristics and use of medical services, both inside and outside the assigned

MTF, for FY 2002. We also identified key organizational factors of MTFs including: service, percent of outsourcing, level of disease burden among its enrollees. We use multivariable regression to study variations in the rates of five procedures: (1) coronary artery bypass graft

(CABG); (2) percutaneous transluminal coronary angioplasty (PTCA) with or without a stent; (3) knee arthroscopy; and (4) open and (5) laparoscopic cholecystectomy. We construct zscores to examine standardized differences between observed and expected numbers of procedures at the MTF level. The variation examined is a residual, after controlling for multiple factors, such as age and disease burden, that might appropriately influence procedure rates.

Population Studied: From the 1.36 million

Prime enrollees, we created three disease-based subpopulations to identify Prime beneficiaries

‘‘at risk’’ for our study procedures: a heart disease subset containing 18,148 beneficiaries with coronary artery disease (CAD); a gall bladder disease subset containing 10,119 enrollees ‘‘at risk’’ for a cholecystectomy; and a joint disease subset containing 96,056 enrollees

‘‘at risk’’ for a knee arthroscopy.

Principle Findings: We found little unexplained variation in the rate of the less discretionary procedures (i.e., CABG, PTCA, and open and laparoscopic cholecystectomy). There was considerably more unexplained variation in the rate of knee arthroscopy, a far more discretionary procedure. A key organizational factor, percent of cases outsourced to other treatment facilities, was found to be correlated with unexplained variation.

Conclusions: This study developed a costeffective, systematic method, using military administrative data, to establish that the majority of variation in rates of procedures for less discretionary procedures is explained by disease burden of its enrollees. A finding not often observed in civilian health care systems. The study also identified the need to more closely examine outlier MTFs in the rate of knee arthroscopy to determine the specific military health system factors leading to the unexplained variation.


The techniques used in this study could be easily replicated for other procedures to provide senior

TRICARE leadership with an effective tool to manage the military health system.

Funding Source: TRICARE Management

Activities

• Variations in Hospital Administrative Costs

Niccie McKay, Ph.D., Annesha White, Pharm.D.,

Christy Harris Lemak, Ph.D.

Presented By: Niccie McKay, Ph.D., Associate


Management & Policy, University of Florida, PO

Box 100195, Gainesville, FL 32610-0195, Phone:

(352) 273-6076, Fax: (352) 273-6075, Email: nmckay@phhp.ufl.edu

Research Objective: Many would agree that the fragmented U.S. health system suffers from

excessive bureaucracy, resulting in corresponding administrative costs that are too high. In spite of the widespread agreement that they are a problem, however, administrative costs have received relatively little attention in the literature. The primary objective of this study is to examine the relationship between administrative costs and various hospital characteristics.

Study Design: The study focuses on administrative costs for hospitals, the predominant type of healthcare provider, over the period 2000-2004. The analysis examines the relationship between two measures of administrative costs (as a percentage of total costs and per adjusted admission) and the following hospital characteristics: urban/rural location; teaching status; ownership type; size; and payer mix.

Population Studied: Short-term, acute-care hospitals in Florida over the period 2000-2004.

The state of Florida requires all hospitals to submit annual reports containing detailed financial and utilization data; in addition to information on hospital characteristics, the reports include operating expenses for a total of

90 cost centers. Administrative costs were calculated based on 12 cost centers that were identified as being clearly and predominantly administrative in nature (e.g., hospital administration and patient accounting). The resulting measure of administrative costs is quite conservative. For example, although some of the coronary care unit costs undoubtedly represent time spent on paperwork and other types of administrative activities, none of those expenditures were classified as administrative costs.

Principle Findings: In 2001 hospitals in the sample incurred an average of $23 million in administrative costs, accounting for slightly more than 22% of total costs and approximately

$1,200 per adjusted admission. Also in 2001: administrative costs accounted for a lower percentage of total costs but were higher per adjusted admission in urban hospitals than in rural hospitals; teaching hospitals had administrative costs that accounted for a lower percentage of total costs but were higher per adjusted admission than non-teaching hospitals; administrative costs as a percentage of total costs were highest for for-profit ownership and lowest for not-for-profit, with government falling in the middle; as bed size increased, administrative costs as a percentage of total costs declined, while administrative costs per adjusted admission increased. Data for the period 2000-2004 will be analyzed to determine if these preliminary findings continue to hold over the five-year period.

Conclusions: Hospital administrative costs are substantial, but vary considerably across hospitals. In particular, for-profit hospitals appear to have administrative costs that are a higher percentage of total costs than government and not-for-profit hospitals, and administrative costs as a percentage of total costs tend to decline as bed size increases.


Results of the study have important implications for policy makers searching for ways to control administrative costs. Although a certain level of administrative cost is necessary for hospitals to provide safe, effective, high-quality care, the observed variations among hospitals suggest that improvements based on ‘‘high-performing’’ hospitals have the potential to substantially reduce unnecessary administrative costs.

• Best Predictors of Hospital Performance

Mark Meterko, Ph.D., Hai Lin, M.D., M.P.H.,

Martin Charns, D.B.A.

Presented By: Mark Meterko, Ph.D., Manager,

Methodology & Survey Unit, VA Medical Center

(152M), Center for Organization, Leadership &

Management Research (COLMR), 150 South

Huntington Avenue, Boston, MA 02130, Phone:

(857)364-4608, Fax: (857)364-6104, Email: mark.meterko@med.va.gov

Research Objective: The goal of this study was to identify organizational characteristics that predict hospital performance, and secondarily to examine the degree of within-hospital consistency across different performance domains.

Study Design: We did secondary analysis of data from four independent sources within the

Veterans Health Administration (VHA): surveys of employees, inpatients, and outpatients, and administrative data. From the employee survey we computed 11 multi-item scales representing three broad domains: individual job satisfaction, workgroup conditions, and organization culture.

From VA administrative data we obtained measures of overall facility complexity, number of satellite outpatient clinics, and geographic region. These 14 variables served as the predictors of performance. From the inpatient survey we obtained 10 multi-item scale scores representing specific domains of care including access, staff courtesy, coordination of care, and physical comfort. The outpatient survey

provided scores representing 11 similar domains.

VA administrative databases were used to obtain an index of employee distress based on EEO complaint rates, turnover rates, and sick-leave rates. The employee distress index, along with composite inpatient and outpatient satisfaction indices, served as the outcome measures in the present study. Separate prediction models were created for each of the three outcomes. The

‘‘MaxR’’ option in SAS was used to build the models in a step-wise manner; a comparison of the value of Mallow’s C(P) statistic to the number of variables in the prediction equation at each step was used to determine when the value of adding predictors became marginal.

Population Studied: The employee survey was administered anonymously to all VHA employees during spring 2004; 110,490 (52%) responded. Both patient surveys were conducted by mail and involved monthly random samples of service users selected from the period corresponding to the employee survey.

Overall response rates were 56% among inpatients (n=29,657) and 70% among outpatients (n=74,667). Aggregate scores were computed for 130 medical care delivery sites.

Principle Findings: We observed a noteworthy independence of performance across the three outcome dimensions. For example, only 41% of the facilities were at the same performance quartile with regard to both inpatient and outpatient satisfaction. For inpatient satisfaction and employee distress the percent of quartile agreement was about 37%. Civility and/or intrinsic job satisfaction were the best single predictors of all three outcomes, accounting for about 21% of the variance in each case. Being located in the south had moderately strong negative association with performance on the two patient satisfaction outcomes. No consistent pattern was observed for the other predictors.

Conclusions: Contrary to common perceptions, facility performance is not often consistent across different domains. Facilities can be in the most favorable quartile on one dimension such as inpatient satisfaction, but in the lowest quartile on another dimension such as outpatient satisfaction. Secondly, the most robust predictors of performance were not

‘‘hard’’ facility characteristics such as complexity, but measures of ‘‘soft’’ characteristics associated with climate and culture, such as civility.


Managers and researchers should give increased attention to the ‘‘soft’’ organizational characteristics. Researchers should not assume that the ‘‘hard’’ characteristics are sufficient controls for organizational context. Further, they should not assume that performance in one domain can be generalized to level of performance in other domains.

Funding Source: VA

• The Influence of Professional and Physical

Isolation on Registered Nurse Practice in

Rural Hospitals

Robin Newhouse, Ph.D., Laura Morlock, Ph.D.,

Peter Pronovost, M.D., Ph.D., Vince Tola, B.A.,

Presented By: Robin Newhouse, Ph.D.,

Assistant Professor/Nurse Researcher, School of

Nursing/ Nursing Administration, Johns

Hopkins University/ Hospital, 525 North Wolfe

Street, Room 446, Baltimore, MD 21205, Phone:

410-955-7527, Fax: 410-955-7463, Email: rnewhou1@son.jhmi.edu

Research Objective: Rural hospital nursing is central to the provision of quality care for hospitalized patients. The challenges of promoting professional nursing practice may be intensified by the professional and physical isolation of rural settings. This study describes the influence of rural hospital isolation

(professional and physical) on problems encountered in enabling evidence-based practice, maintaining competency of staff, fostering ongoing continuing education, and basic staff nurse education while controlling for hospital type (rural or critical access hospital).

Study Design: A mail or phone survey of rural hospital nurse executives was completed using the Rural Hospital Nurse Executive Survey

(NES). The NES consists of 104 continuous and categorical items. Continuous items are rated on a four point scale. The NES is based on qualitative research and has demonstrated adequate estimates of reliability and validity. The isolation scale consists of four items that convey the perception of influence of professional and physical isolation on nursing and patient outcomes.

Population Studied: A national sample of 274 rural hospital nurse executives completed the survey with a response rate of 40 % (274/688) representing 182 rural and 92 critical access hospitals.

Principle Findings: Over one-third of rural hospital nurse executives perceive that physical isolation (35%) and professional isolation (35%) affect the nurse work environment. A majority of respondents state that enabling evidence-based

practice (70%), maintaining staff competency

(59%), fostering continuing education (55%), and basic staff nurse education (59%) are moderate or big problems. Cronbach’s alpha for the isolation scale was acceptable (a =.85). For rural hospital nurse executives, isolation explains

15% of the variance in enabling evidence-based practice (b=.132, p<.000), 11% of the variance in fostering ongoing continuing education (b=.123, p<.000), 8% of the variance in problems encountered related to basic staff nurse education (b=.113, p<.000), and 6% of the variance in maintaining basic staff competencies

(b=.089, p<.000).

Conclusions: Professional and physical isolation of rural hospitals affect the ability of rural nurse executives to enhance professional nursing practice. To promote nurse-sensitive quality of care, rural nurse executives will need to mediate the effect of physical and professional isolation while implementing evidence-based practices, providing continuing education, promoting higher levels of basic nurse education and building staff competencies.


Policy makers, professional organizations, quality organizations, universities, colleges and health care administrators need to create linkages to promote and enhance professional practice in rural hospitals. Innovative strategies should be identified, funded and implemented to foster these linkages to promote nursing quality, particularly in remote settings.


•

Modes of Specialist Employment: Their

Nature and the Effect on the Quality of

Working Life

Nurit Nirel, M.A., Arie Shirom, Prof.

Presented By: Nurit Nirel, M.A., Senior

Researcher, Smokler Center for Health Policy

Research, Myers-JDC-Brookdale Institute, JDC

Hill, POB 3886, Jerusalem, 91037, Israel, Phone:

(972)-2-6557420, Fax: (972)-2-5612391, Email: nuritn@jdc.org.il

Research Objective: The locus of secondary medical care is changing. Services that used to be provided solely in hospitals are now available in ambulatory settings. Furthermore, the competition among the four main Israeli HMOs has spurred the development of communitybased specialty medicine in Israel. Consequently, many specialists, in addition to their primary fulltime job, hold part-time jobs, mostly in community care. The study objectives were to explore (a) the extent of specialists' employment in multiple organizational settings and their modes of employment in each setting and (b) the relationship between a specialist's number of jobs and his or her perceived overload, burnout, and job satisfaction.

Study Design: A cross-sectional mail survey among a random sample of physicians in six areas of specialization that represent the provision of secondary-specialist care in ambulatory settings, either in hospital outpatient clinics or in the community.

Population Studied: A sample of 50% of all specialists, under age 65, in each of the following specialties: ophthalmology, dermatology, otolaryngology, gynecology, cardiology, and general surgery. The sample was selected from two sources: the health plan service-listings books and the Ministry of Health's Data File for

Certified Physicians. 890 physicians responded to the questionnaire (response rate: 63%).

Principle Findings: Most (84%) specialists worked in more than one organizational setting and more than 40% of them worked in three or more settings. Nearly all of them (98%) worked for public health institutions in their primary job.

In their secondary job too, most specialists provided services in a publicly financed setting.

About 42% of the physicians who held a third job were engaged in private practice. The average number of weekly work hours of practice

(including on-call hours) was 48 hours in the primary job and 63 hours in all jobs. Without oncall hours, the average number of weekly work hours was 52. Number of jobs held and weekly work hours were independently correlated with job overload and burnout. Physicians who worked at more than one job or more hours were more likely to report being overloaded and feel burned-out. Number of jobs was negatively correlated with job satisfaction. Physicians with four or more jobs were less likely to be satisfied than physicians with one job. Age, selfemployment under contract, and having completed one's medical education in the former Soviet Union were negatively correlated with job overload and burnout. Age, selfemployment under contract, and holding an academic post were positively correlated with job satisfaction.

Conclusions: The high proportion of specialists who hold multiple jobs suggests that provision of secondary care in Israel is based on

"additional work" of physicians. Multiple-job holding and hours of work reduce specialists' quality of work life.


One way of improving the situation is for policymakers in the health system to consider options, which would reduce, or limit, the numbers of jobs specialists hold by, for example, employing specialists in a combined hospital/community-clinic positions, in order to improve the quality of work of the physicians.

Funding Source: The Israel National Institute for Health Policy and Health Service Research

• Do the Emergency Medical Services in

Israel Need More Paramedics? An

Examination of Supply and Demand

Nirel Nurit, M.A., Rachel Goldwag, M.A., Zvi

Feigenberg, M.D., David Abadi, B.A., Pinchas

Halpern, M.D.

Presented By: Nirel Nurit, M.A., Senior

Researcher, Smokler Center for Health Policy

Research, Myers-JDC-Brookdale Institute, JDC

Hill, POB 3886, Jerusalem, 91037, Israel, Phone:

(972)-2-6557420, Fax: (972)-2-5612391, Email: nuritn@jdc.org.il

Research Objective: To examine the present and projected supply and demand for paramedics in the civilian market, the balance between supply and demand, and how this affects the planning of the paramedic civilian workforce.

Study Design: To examine supply we conducted a telephone survey of graduates of paramedic training programs between November 2005 and

February 2006, using a structured questionnaire.

To estimate the potential future workforce, we examined administrative data about training. To examine demand we interviewed key figures in the emergency medical services (EMS) system.

Supply was assessed by the annual number of graduates of paramedic training programs, the duration of stay in the profession and the likelihood of staying in the profession. We then computed the balance between the supply and demand forecast for each demand scenario in terms of manpower positions.

Population Studied: 1. A sample of 50% of the graduates of paramedic training programs, excluding conscripted soldiers, altogether 509 subjects (response rate ---- 88%). 2. Twenty key figures in the EMS system.

Principle Findings: Sixty four percent of the certified paramedics in Israel are active in the civilian labor market. The rate of leaving the profession is approximately 18% over a five-year period, with no significant difference between one year and another. Newcomers to the profession have a 96% likelihood of remaining in it after one year; 79% after five years; and 68% after ten years. With regard to the likelihood of remaining in the profession, the rates differ for men and women and according the type of training program. The likelihood of continuing to work as a paramedic is greater for people with children, those with a higher education, and older members of the profession. Study results show that if the demand does not change beyond the natural annual increase of two advanced life support (ALS) ambulances (which are staffed by paramedics), there may be a surplus of 180 paramedics by 2010. Increased demand outside the EMS labor market may temporarily absorb this surplus, but it will reappear by 2015 or 2020. Conversely, upgrading all ambulances to ALS vehicles will result in a shortage of 400----900 paramedics by 2010

(depending on the number of paramedics per vehicle) if the number of paramedics trained annually is not increased.

Conclusions: These findings indicate the feasibility and applicability of an evidence-based projection of the size of the paramedics' workforce according to different demand scenarios.


The study results may serve as a basis for a longterm planning process for training, recruitment, and employmnt of paramedics according to policy decisions regarding demand. The findings, also may serve as an example for workforce planning for other health professions.

Funding Source: The Israeli National Institute for Health Policy and Health Services Research

•

A Systematic Review Of The Potential Cost

Savings Of Asthma Disease Management

Programs

Ronald J. Ozminkowski, Ph.D., Greg Lenhart,

M.S., Ronald J. Ozminkowski, Ph.D., Shaohung

Wang, Ph.D., Rosanna Coffey, Ph.D., Dwight

McNeil, Ph.D.

Presented By: Ronald J. Ozminkowski, Ph.D.,

Director, Health & Productivity Research, ,

Thomson Medstat, 777 East Eisenhower

Parkway, 903R, Ann Arbor, MI 48108, Phone:

(734) 913-3255, Fax: (734) 913-3850, Email: ron.ozminkowski@thomson.com

Research Objective: To provide guidance on what to expect from asthma disease management. We evaluated the effect of asthma disease management programs on:

1. Emergency Department (ED) Visits, 2.

Hospital Admissions, 3. Outpatient Visits, 4.

Medication Costs, 5. Ancillary Service Costs, 6.

Missed Work Days due to Asthma-related

Care Giving Responsibilities, 7. Missed Work or

School Days Due to Asthma.

Study Design: Meta-analysis of studies reporting the impact of asthma disease management programs, for those outcomes.

Multiple regression was used to control for differences in study design, sample size, type of asthma, type of insurance coverage, and patient age group.

Population Studied: The ‘‘population’’ consists of relevant research studies, but ultimately we are interested in the impact of disease management on patients with asthma who are covered under private sector and state Medicaid plans, and by plans offered to state employees.

Principle Findings: The impact of asthma disease management varied substantially according to the design of the studies.

Controlled trials were less favorable to asthma disease management, but percentage reductions in the outcomes listed above were still significant and large. Savings in work-related productivity were often larger than savings in health care utilization.

Conclusions: Asthma disease management may lead to substantial reductions in the need for inpatient care and emergency room services.

Productivity-related savings may also be substantial. These savings seem more likely for patients with persistent asthma.


Providers and health plan administrators should consider developing or adopting disease management programs, for patients with persistent asthma. Productivity endpoints may be just as relevant when considering the potential utility of these programs.


•

Selling Them The Rope: Prevalence Of For-

Profit Health Care Corporate Directors among

Academic Medical Leaders

Roy Poses, M.D., Wally R Smith, M.D., Robert S

Crausman, M.D., Russell Maulitz, M.D.

Presented By: Roy Poses, M.D., President, ,

Foundation for Integrity and Responsibility in

Medicine, 16 Cutler Street, Suite 104, Warren, RI

02885, Phone: (401) 245-9521, Email: rposes@firmfound.org

Research Objective: There is increasing concern about conflicts of interest (COI) affecting health care, particularly physicians´ acceptance of small gifts and meals from company sales representatives. There are moves afoot to ban such COI. Recent anecdotes suggest that academic medical leaders may have more intense conflicts, however, which are rarely discussed. In particular, these leaders may also serve on boards of directors of for-profit health care corporations, and thus may have fiduciary duties to companies with which their academic institutions may do business. The purpose of this study was to estimate the prevalence of directors of for-profit health care corporations in the leadership of academic medicine.

Study Design: This was a cross-sectional prevalence study.

Population Studied: Our population of companies were those considered ‘‘pure’’ health care companies among the Standard & Poors

(S&P) 1500. Thus, these were the largest such companies whose stock was publicly traded in the US. All publicly traded companies are required to make public the membership of their boards of directors. We scrutinized biographies of all companies´ board members publicly available as of the end of 2005 in the companies´ proxy statements, annual reports or web-sites .

We tabulated all directors who also held positions at or were leaders of US medical schools.

Principle Findings: In 2005, there were 164 US health care companies in the 2005 S&P 1500, and 125 US medical schools. We identified 198 people who served on the companies´ boards of directors who had faculty or leadership positions at these medical schools. Of the 125 medical schools, 65 schools had at least one faculty member and/or leader who also served on a health care corporation´s board of directors.

15 schools had more than five, and 4 had more than 10 such individuals. Of the 125 schools, 7 reported to university presidents who were also directors of health care corporations, and 11 schools reported to vice-presidents for health affairs who were also such corporate directors.

Four schools were lead by deans who were also health care corporate directors, and 10 schools had academic medical center CEOs who were such directors. 22 schools had at least one top leader who was also a director of a health care corporation. 36 schools reported to university boards of trustees which each included at least one director of a health care corporation, and 12 schools´ own boards of trustees included at least one such director.

Conclusions: We found that more than one-half of US medical schools had a leader or faculty member who also was a director of a major US for-profit publicly traded ‘‘pure’’ health care

corporation, more than one-sixth of schools had a top leader who was also such a director, and more than one-fifth reported to boards of trustees which included such directors. Our data only gives lower-bound estimates of the number of medical schools influenced or lead by people who also have fiduciary duties to health care corporations that may conflict with their academic leadership obligations. Severe conflicts of interest may be more prevalent in US academic medicine than was heretofore appreciated.


Disclosure policies for conflicts of interest affecting academic medicine must be revisited, and consideration given to banning the most severe forms of conflicts.

• Under the Influence: Patient Advocacy and

Disease Priorities at the NIH and FDA

Nicole Quon

Presented By: Nicole Quon, Acting Assistant

Professor, School of Public and Environmental

Affairs, Indiana University, 1315 E. Tenth Street,

Bloomington, IN 47405, Phone: 812-855-0563,

Fax: 812-855-7802, Email: ncquon@indiana.edu

Research Objective: Scientific agencies such as the National Institutes of Health (NIH) and the

Food and Drug Administration (FDA) have historically relied on scientists and based decisions on scientific evidence, which suggests that these agencies are less likely to be influenced by politics that are shaped by values.

But elected officials and the public have been demanding more input into priority setting at these agencies. Disease advocates have been pressuring the NIH and the FDA to allocate more resources for their causes, but as agencies with public health missions, the NIH and the

FDA consider disease burden and scientific factors as well. The public health missions differ between the two agencies, however, which may lead them to have different responses to this outside pressure. This study examines whether measures related to advocacy, politics, public attention, and public health needs are related to the speed of FDA drug approval decisions and research funding in the NIH intramural program and NIH extramural program.

Study Design: The analysis focuses on four key disease categories: cancer, mental health,

HIV/AIDS, and global health. The health agenda for these disease categories was determined by examining materials from disease advocacy groups. Relevant NIH research grants were identified through keyword searches of the

CRISP database available online while data on new drug approvals came from the Tufts Center for the Study of Drug Development. Independent measures on disease advocacy, Congressional oversight, leadership in Congress, media attention, scientific journal attention, agency characteristics, and public health burden were also collected from public sources.

Population Studied: NIH grants and FDA new drug approvals for 4 disease categories from the early 1970s to the present.

Principle Findings: The agency programs seemed to have varying responses to similar outside pressure. The NIH intramural program seemed able to set its priorities with little regard to outside pressure while the NIH extramural program was influenced by factors in every category. The FDA showed some resistant to political pressure but seemed very responsive to public health needs.

Conclusions: Measures of patient advocacy are associated with increases in NIH research funding and faster FDA drug review times. Both agencies responded to requests to establish formal communication channels with the advocacy community.


The NIH and the FDA are not insulated from political pressure, despite the underlying preferences of these agencies to rely on scientific evidence and expertise. Patient advocates and their allies in Congress seem to be effective in influencing key NIH and FDA decisions.

Funding Source: National Science Foundation

•

Measuring and Explaining the Managerial

Efficiency of Private Medical Clinics in

Bangladesh: An Exploratory Study

Mohammad Rahman, Ph.D.

Presented By: Mohammad Rahman, Ph.D.,

Asst. Professor, Health Science, California State

Universitiy, Fresno, 2345 East San Ramon

Avenue M/S MH30, Fresno, CA 93740, Phone:

559-278-4222, Email: mrahman@csufresno.edu

Research Objective: Based on the extended

Pareto-Koopmans definition of efficiency and

Leibenstein’s X-inefficiency theory, this study examined what organizational, clinicalmanagement and environmental factors lead to inefficiency at the medical clinics. This study aimed to: 1) assess the status of the health care services provided by these medical clinics in terms of their technical efficiency; 2) explore the potential cost-savings by eliminating inefficiency;

and 3) examine what factors contributed to the inefficiencies.

Study Design: The Banker-Charnes-Cooper DEA model, which measures technical efficiency, was used under the assumption that the clinics may not be operating at the optimal scale level. After the efficiency measures were determined through the DEA model, the efficiency scores were regressed on some explanatory variables to test hypotheses using Tobit analysis.

Population Studied: 202 out of 670 medical clinics, located nationwide were randomly selected for the study. The data was obtained from the Survey of Private Medical Clinics in

Bangladesh, a study undertaken by the Ministry of Health and Family Welfare. The Banker

Charnes and Cooper model, which measures technical efficiency, was used under the assumption that the clinics may not be operating at the optimal scale level. After the efficiency measures were determined through the DEA model, the efficiency scores were regressed on some explanatory variables to test hypotheses using Tobit analysis.

Principle Findings: Regression analyses identified a number of variables that were associated with efficiency of the medical clinics.

The research revealed that: 1) clinics located in rural areas, accredited by the health directorate and managed by professionals (rather than doctors themselves) were likely to be more efficient; 2) older clinics, possibly entangled with bureaucracy, tended to be less efficient which supported the ‘structural inertia’ theory of

Hannan and Freeman (1984); 3) clinics can improve their efficiency by employing more nurses in the clinics; 4) market competition can drive efficient performance in medical clinics; 5) a positive relationship between efficiency and profitability, suggesting that clinics could increase their profitability by being more efficient.

Conclusions: There is considerable inefficiency in the way medical clinics in the private sector in

Bangladesh currently operate. The clinics should institutionalize professional management practices and undergo external maintenance and management review to revamp their productive competency. There is urgent need for health care management and nurse training be promoted and institutionalized to ensure more effective and quality health care service delivery. The growth of new clinics can be directed to remote areas to promote more competition and increase access. More extensive data management is suggested so that monitoring of health services and quality is made possible and more in depth research on efficiency can be undertaken for optimal resource utilization.


The successful application of DEA in this study demonstrates that researchers and policy-makers will find DEA a useful method to measure efficiency of health care providers in the context of a developing country where pure price and wage data can be quite challenging to obtain because of market imperfections. The study provides a relevant and useful framework to regulate a sprawling private healthcare sector to reduce waste in a resource-constrained country like Bangladesh.

• Moving Patient Safety Improvement

Practices to the Next Level: Closing the

Organizational Learning Loop

Peter E. Rivard, Ph.D., Victoria A. Parker, D.B.A.,

Amy K. Rosen, Ph.D.

Presented By: Peter E. Rivard, Ph.D.,

Postdoctoral Fellow, Center for Organization,

Leadership and Management Research, VA

Boston Healthcare System (152M), 150 South

Huntington Avenue, Boston, MA 02130, Phone:

(857) 364-5691, Fax: (857) 364-6140, Email: rivardp@bu.edu

Research Objective: The Veterans Health

Administration (VA) is recognized for its initiatives to improve patient safety. Many such initiatives follow the quality-improvement organizational learning model: planning and implementation of safety improvements is driven by collection and analysis of data from within the organization. Examples include adverse event reporting, Root Cause Analyses

(RCA) and Healthcare Failure Mode Effects

Analyses (HFMEA). The purpose of this study was to identify variation in implementation of patient safety improvement practices between facilities with higher and lower patient safety performance.

Study Design: Our research entailed exploratory case studies of four VA acute care hospitals. The sites were selected for their (a) high and low performance on a proxy for patient safety outcomes, and (b) geographic diversity. Safety performance was approximated by the AHRQ

Patient Safety Indicators (PSIs), which use administrative data to identify potentially preventable adverse events in acute inpatient care. A subset of PSIs was applied to Fiscal Year

2001-2004 VA discharge data to generate a composite ranking of facilities. At the selected sites, data on safety improvement structures and practices were obtained through face-to-face semi-structured interviews conducted in 2005 with executives, managers, and others involved in patient safety improvement. Interviewers and interviewees were blinded as to facility safety performance on the PSIs. Data analysis explored facility-level variation in implementation of patient safety improvement. Interview transcripts were coded for both a priori constructs and emergent themes.

Population Studied: VA facilities that provide acute inpatient care.

Principle Findings: The two facilities with patient safety performance that was either better overall or more improved 2001-2004 showed evidence of organizational structures for patient safety learning and improvement that were more comprehensive on two dimensions: (1) Projectlevel evaluation: more follow-up assessment of specific patient safety interventions through monitoring of implementation success and measurement of changes in process and outcomes; (2) Program-level evaluation: more

(a) executive-level assessment of the overall effectiveness of the patient safety program and

(b) attention to integration across various patient safety initiatives. Our study describes these evaluation practices and presents exemplars.

Conclusions: While organizational safety learning practices such as RCAs and HFMEAs help to elevate organizational response to safety problems from first-order ‘‘quick fixes’’ and workarounds to more effective second-order system improvement, this study suggests that higher-performing facilities then progress to a higher order of organizational learning, where they systematically assess the effectiveness and efficiency of their interventions. This is consistent with findings from implementation research: organizations with systems to monitor implementation of innovations and evaluate their impact are more likely to assimilate and sustain the innovation.


Further research should test the propositions generated by this study, i.e., that a next level of patient safety improvement, after implementation of focused system improvement practices such as event reporting and RCA, consists of systematic assessment of the effectiveness of these interventions, along with steps to prioritize, coordinate and integrate safety improvement initiatives across the facility.

Furthermore, our findings suggest that an organization’s progress to this level may not be automatic and may require additional intervention.

Funding Source: VA

• Measuring Non-Profit Hospital

Performance: A Non-Parametric Approach

Chul-Young Roh, Ph.D.

Presented By: Chul-Young Roh, Ph.D., Assistant

Professor, Public Health, East Tennessee State

University, Box 70674, Johnson City, TN 37614,

Phone: (423) 439-4483, Fax: (423) 439-6491,

Email: roh@etsu.edu

Research Objective: To examinine technical efficiency among non-profit hospital in USA from

2000-2004

Study Design: The DEA-based Malmquist index

Population Studied: 1532 non-profit hospital in

USA

Principle Findings: Rural non-profit hospital are less eficient than urban non-profit hospitals.

Middle size (the number of bed between 250 to

400) non-profit hospitals are more effieicnt than big and samll non-profit hospitals.

Conclusions: Non-profit hospitals should downsize to maximize the efficiency.


And rural non-profit hospitals need to strategic alliance with other rural hsopitals.

• Which Factors From an Internal Climate

Survey are Relevant to Orient Human

Resources Management in the Health Sector?

The Tuscan Experience.

Chiara Seghieri, Ph.D., Maria Giulia Senigallia,

M.A., Domenico Cerasuolo, M.A.

Presented By: Chiara Seghieri, Ph.D., researcher,

Health and Management Laboratory, Scuola

Superiore Sant'Anna, Piazza Martiri della Libertà,

33, Pisa, 56127, Italy, Phone: (+39) 050 883 832,

Fax: (+39) 050 883 832, Email: seghieri@ds.unifi.it

Research Objective: Healthcare institutions all over the world have been working on performance evaluation in terms of return on investment, efficacy, efficiency and the quality of the services that they provide. Indeed, Tuscany

Region has implemented a multidimensional system to assess performance evaluation of the

Health Authorities comprising 6 areas

(population health, consistency with the regional strategies, clinical and health assessment,

external assessment, internal assessment, efficiency and financial assessment). Among these areas, ‘‘internal assessment’’ has been demonstrated to be an important dimension to improved service delivery and thus to better health outcomes. Therefore, a climate survey within the Tuscan Health Authorities was carried out in order to explore which factors most impact employees’ motivation and job satisfaction.

Study Design: Factor analysis and reliability analysis were carried out on about 40 responses from the health care staff to explore how the questions measured underlying dimensions of organizational climate. Analysis of variance was then utilized to detect systematic differences in the factor scores among employees in terms of socio-demographic characteristics, as well as differences between organizational unites.

Population Studied: A representative sample of

4586 health care employees within 15 Tuscan

Health Authorities, year 2006.

Principle Findings: Four factors, referring to four different climate dimensions, were revealed and explain 70% of the variability of the items.

They were subsequently labelled: ‘‘team working’’, ‘‘management’’, ‘‘organization’’ and

‘‘communication’’. Moreover, employees were found to differ systematically in terms of sociodemographic characteristics across the 4 dimensions. Females, for instance are likely to be more satisfied of their organizational unit, communication and team working than males.

On the other side, the elder employees declare to be more satisfied of team working and communication than younger ones.

Conclusions: The results of the present study provide support for using an internal climate survey as a measurement tool for assessing the level of quality in Health Authorities. The study also demonstrates how the internal climate survey can help top management identifying targets of employees which differ in terms of satisfaction towards the climate dimensions and need a focused approach to improve their commitment and motivation.


Employee commitment is a necessary element for successful implementation of a total quality management programme. For these reason, the internal climate may be used as a warning indicator of potential organizational problems. In future, further investigations will be carried out to verify the relationship between the climate results and the other performance dimensions of the Tuscan evaluation system.

• Examining the Relationship Between

Clinical Practice Guidelines and Length of

Stay Through a Secondary Data Analysis

Moriah Shamian-Ellen, M.B.A., Ph.D., Dr.

Adalsteinn Brown, Ph.D., Dr. Rhonda Cockerill,

Ph.D.

Presented By: Moriah Shamian-Ellen, M.B.A.,

Ph.D., Ph.D. student, instructor, Health Policy,

Management, and Evaluation, University of

Toronto, 57 Glen Park Avenue, Toronto, M6B

2C1, CA, Phone: 416-256-4450, Email: moriah.ellen@gmail.com

Research Objective: To examine the relationship between the use of clinical practice guidelines (CPGs) and length of stay across numerous medical and surgical disease states throughout the province of Ontario.

Study Design: This research conducted statistical analyses on secondary data that was obtained from two different data sources: CPG usage was obtained from the Hospital Report

Research Collaborative (HRRC) and LOS data was obtained from the Canadian Institutes for

Health Information (CIHI). Descriptive statistics, correlations, and longitudinal analyses were conducted.

Population Studied: Acute care hospitals in

Ontario, Canada.

Principle Findings: Ten clinical areas were examined in 88 acute care hospitals over a two year period (2002-2003 and 2003-2004).

Differences in responses based on hospital type

(small, community, teaching) were examined and minimal differences were found. CPGs are used in Ontario hospitals to a varying degree in most disease states: both medical and surgical.

CPG usage and LOS did not change dramatically over the two years. The relationship between

CPG usage and LOS was only statistically significant in two disease states: pneumonia

(p=.033) and prostatectomy (p=.008). There were no significant relationships found in the longitudinal analysis.

Conclusions: This secondary data analysis did not find a strong relationship between CPG usage and LOS. Possible reasons for this are discussed, as are limitations and future research suggestions. This study adds to previous research by examining CPG usage across a wide range of disease states and in a large number of

Ontario hospitals. The results here are counterintuitive to other studies and systematic reviews that demonstrate a strong inverse relationship between CPGs and LOS.


This research suggests that CPG usage does not affect LOS. Health care administrators continuously struggle with the need to contain costs in health care as a whole but more specifically in hospitals. Policy makers are pushing for the use of CPGs in numerous health care settings to improve efficiency and reduce costs. However, this research demonstrates that a strong relationship, over time does not exist.

Policy makers and health care administrators should push for more large scale research studies to determine the overall and long term effects of the implementation of CPGs.

Funding Source: Canadian Institutes for Health

Research: Doctoral Research Award

• Organizational Decision-making Factors in

Adopting Patient-Centered and Efficiency

Innovations

Asta Sorensen, M.A., Amy E. Roussel, Ph.D.,

Jacqueline Amoozegar, B.A., Nancy Lenfestey,

M.H.A., Cindy Brach, M.P.P.

Presented By: Asta Sorensen, M.A., Health

Research Analyst, Health Care Quality, Research

Triangle Institute, International, 3040 Cornwallis

Rd/ PO Box 12194, Research Triangle Park, NC

27709, Phone: (919) 541-1238, Email: asorensen@rti.org

Research Objective: The aim of this study is to extend Rogers’ theory of innovation diffusion to focus on the interaction or fit between the innovation and the adopting organization. We explicate the decision-making factors applied by health care organizations in adopting patientcentered care and efficiency innovations. This research is guided by a framework that views adoption as a process, rather than an event, and encompasses the core elements of adoption decision-making: observability, relative advantage, complexity, costs, compatibility, and trialability.

Study Design: We conducted a series of openended interviews and case studies with decisionmakers who played a key role in innovation adoption decision process at six health care organizations that implemented efficiencyfocused innovations, four with patient-centered care innovations, and five with innovations focused on both. Data were analyzed using QSR

NVivo 7, incorporating inductive and deductive coding techniques.

Population Studied: The purposive sample of health care organizations was stratified by type of facility, population serviced, and characteristics of the adopted innovation including technological complexity, orientation towards people vs. technology, and degree of implementation complexity. The organizations represented a variety of settings, including inpatient and outpatient facilities, and served diverse priority populations. The adopted innovations included discrete interventions, sets of behaviors, practices, routines, ways of working, and associated administrative technologies that have evidence for patientcentered and efficient care.

Principle Findings: Relative advantage, or expected benefits, included improvements in existing care delivery processes, financial outcomes, patient outcomes, and patient satisfaction. When making their decisions to adopt new innovations, most organizational decision-makers considered the visibility of the benefits to the innovation’s users (i.e., providers) and senior management. Most respondents indicated that they had assessed the innovation’s compatibility with their organizational culture.

While many recognized the importance of innovation complexity in decision making, a number indicated that they did not assess what effects the innovation would have on their infrastructure and staffing levels, but rather

‘‘learned as they went.’’ Others relied on assessments provided by outside consultants or proceeded without considering this factor.

Participation in larger national, organizational, or community initiatives and availability of designated seed funding seemed to be important factors in making an innovation adoption decision. Financial costs, opportunity costs, and operational risks were important to at least half of those interviewed. The remainder of the interviewees indicated that they did not consider financial returns and made their decision to adopt because it was ‘‘the right thing to do.’’

Conclusions: Preliminary analyses suggest that most organizations focused their decisionmaking process on perceived benefits, visibility of results to users and senior management, compatibility with organizational culture, and costs, with less emphasis on innovation complexity, compatibility with other aspects of their organizations, and trialability.


Change agents, knowledge brokers, and others who wish to influence innovation adoption will benefit from understanding factors at play in organizational decision-making processes.

These findings are being used to develop an adoption decision tool to assist organizations in

their future decision-making efforts and will be an important first step in conceptualizing and building AHRQ’s National Innovations

Clearinghouse.


• The Influence of Organizational Factors on

Clinical Innovation: The Case of Hand

Hygiene Compliance

Jennifer Sullivan, Ph.D., Carol VanDeusen Lukas,

Ph.D., Ryann Engle, M.P.H., Marjorie Nealon

Seibert, M.B.A.

Presented By: Jennifer Sullivan, Ph.D., Research

Health Scientist, COLMR, VA Boston Healthcare

System, 150 S. Huntington Avenue (152M),


857-364-4438, Email: jennifer.sullivan@va.gov

Research Objective: Reducing hospital-acquired infections is a key issue in health care today.

One simple but effective strategy is good handhygiene (HH) practices. Yet while the value of hand hygiene has been widely demonstrated, hospital HH compliance rates are generally low.

The Department of Veterans Affairs (VA), now widely recognized as a leader in quality and patient safety, is giving priority to improving HH compliance and, more broadly, to evidencebased clinical practices. As part of a larger VA study to increase facilities’ use and adoption of evidence-based HH practices, we identified organizational factors associated with perceived

HH compliance.

Study Design: In 2006, staff participating in a

HH intervention were surveyed to describe their work environment, perceptions of quality care and compliance with HH procedures. The overall response rate was 41%. Factor analysis on 29 items using varimax rotation to maximize loadings on each factor yielded six organizational factors: 1) facility priority to quality care, 2) work team learning, 3) work team skills in improvement, 4) accountability, 5) management support, and 6) clinical care coordination. These factors were tested using a multi-trait analysis resulting in 88% significant item discriminant validity. Alpha values for 5 out of 6 resulting scales were above .80. The dependent variable, overall mean compliance, was the average of respondents’ estimates of the perceived compliance levels for 6 types of staff within the facility. Respondents had to answer 50 percent of the 6 compliance items to be included in this analysis. Linear regression analysis was conducted, clustering by regional network and facility using robust standard errors. Job category of respondents and perceived barriers to having 100% hand hygiene compliance were included as control variables.

Population Studied: The final study sample

(N=550) included VA facility employees likely to be involved in the HH intervention and staff affected by the efforts to improve HH compliance rates in 17 participating VA medical centers in three VA regional networks. The sample composed of 80% nurses, 17% physicians, and 3% other clinical staff.

Principle Findings: Overall model fit was statistically significant with R-squared = .25. Two organizational factors, work team learning (using data to track progress and learning from others in facility) and management support (help with resource allocation, and coordination across services) were positively and significantly associated with perceived HH compliance. One control variable, heavy workload as a barrier to

HH compliance, was significantly and negatively associated with perceived HH compliance. Job category of respondents, clustered into physicians and nurses/other clinical staff, was not significant.

Conclusions: With JCAHO now monitoring HH as part of its accreditation process, many hospitals are paying closer attention to monitoring and to increasing compliance levels.

Our findings suggest that working to improve work team effectiveness ---- particularly team learning -- and providing management support are promising strategies to improving HH compliance. The findings are also consistent with the literature on implementation of clinical innovations, suggesting broader application to organizational approaches to integrating evidence-based practices into clinical operations.

Funding Source: VA

• Productivity-Enhancing Technologies in

Medicine: Which Types of Physician Practices

Are Early Adopters and Which Do Without?

Jonathan Sunshine, Ph.D., Cristian Meghea,

Ph.D.

Presented By: Jonathan Sunshine, Ph.D., Senior

Director for Research, Research, American


Reston, VA 20191, Phone: 703-648-8924, Email: jsunshine@acr.org

Research Objective: Especially with health costs increasing rapidly, adoption of efficiencyenhancing operational technologies (for example, electronic medical records) should be pursued. However, adoption of such

technologies has been disappointingly slow, especially outside the hospital setting. Hence, our objective is to investigate what types of physician practices are early adopters and what types are lagging adopters of ‘‘operational technologies,’’ (We conceptualize operational technologies as being distinct from direct care technologies (such as laproscopic surgery), and as being more likely to affect efficiency with relatively little effect on patient outcomes.)

Study Design: We investigate hypotheses found in the literature about early adoption. Several radiology technologies are the technologies studied. We carry out logistic regression on data from the American College of Radiology's

(ACR’s) 2003 Survey of Radiologists, a stratified random-sample survey with a 63% response rate and 1,924 responses. We investigate three hypotheses about early adoption: 1)

‘‘Organizational culture’’ drives it, in which case we expect academic practices to be the early adopters. 2) Strong cash flow or profits drive it.

Hence, private practices and suburban practices should lead, and government practices and those in main cities lag. 3) Scale economies in new technologies and in acquiring reliable information about these technologies are important. Hence large practices should lead and small practices and practices in non-metro areas should lag. Our examples of new technologies are PACS (picture archiving and communication systems) and voice-recognition software. Both are relatively new and are limited in dissemination. To study severe laggards in technology adoption, we study two burdensome modes of operation that radiology practices have now generally abandoned: (1) having the radiologist him/herself manually hang and take down the films to be interpreted and 2) having nighttime coverage possible only by being onsite, rather than at a distance. In both situations, two technologies, one old and one newer, are available to eliminate the burden.

Population Studied: Radiology practices in the

U.S.

Principle Findings: In logistic regression, solo practices and practices in non-metropolitan areas have decreased odds of having PACS; academic practices and medium-large practices

(11-14 radiologists) have increased odds.

Academic practices have enhanced odds of using voice recognition. Practices in the West and those serving only hospitals are particularly likely to have the radiologist hanging films.

Academic and medium-large practices are particularly unlikely to do so. Practices serving only non-hospital sites (which typically do not function after-hours) are likely to have no mechanism for coverage at a distance. Medium to medium-large practices (size 5-14) are particularly unlikely to be in this situation.

Conclusions: Scale economies and, even more, organizational culture seem to explain early adoption of new technology. Surprisingly, we do not find evidence of any effect of practices’ finances. Determinants of being a serious laggard with respect to established technologies are less clear, but substantial size seems a deterrent.


Although financial rewards have been most discussed as the way to encourage physician practices to adopt modern operational technologies, they may have less effect than expected. Conversely, efforts to change organizational culture and to get physicians into larger groups may be unexpectedly effective.

• Models of Public Private Partnerships

Audrey Trigub-Clover, Masters, Health Services

Administration

Presented By: Audrey Trigub-Clover, Masters,

Health Services Administration, Project

Manager, 5821 Cote St-Luc # 8, Hampstead,

Québec, H3X 2G2, CA, Phone: 514 777 4812,

Email: a.trigub.clover@umontreal.ca

Research Objective: Study objectives: The study objectives are twofold . First, to capture the dominant types of partnerships through a taxonomy (a taxonomy is a classification of a series of observations of a given reality into fairly homogeneous groups). Second, to establish a relation between this taxonomy and healthcare systems performance.

Study Design: Research design and methods:

This study compares the types of PPP in eleven

OECD countries selected on the basis of the role played by the private sector in health care. Three aspects of the health care system are used to capture the types of PPP : governance (mostly public or the market forces play a significant role), financing (public, private or mix) and the provision of health services (public, private or mix) based on ownership of hospitals and on whether physicians are free entrepreneurs or employees of hospitals. The 2000 World Health

Report is used to assess the performance of these eleven countries. The performance indicators relate to level of health, equity in health, responsiveness, health care costs, objective attainment and overall performance.

Principle Findings: Results: Consistent with the hypothesis, even though mathematically the number of possible combinations is higher, endogenous pressures toward uniform configurations include functional relationships among organizational components result in only few possible models of P3s. From the study, there emerge six models that combine level of public regulation, sources of financing and delivery of health services. Following, each model is related to outcomes in health (health attainment, rresponsiveness, financial equity, global objective attainment, per capita expenditure and overall health performance). It is observed that whether P3s in finance and delivery are present or absent, the key factor of success seems to be the presence of high public regulation.

Conclusions: Public regulation is the key success factor, as it is always those models with strong public regulation that obtain the best overall results. Assuming the limits of this study, it can be said that the efficacy of P3s at the delivery and financing dimensions are still a function of a strong regulatory frame when confirming relation with positive outcomes in health.


The results of the study could support the interventions in publicly regulated contexts, of

P3S both for Financing and Delivey.

Nevertheless, further research is still greatly needed and most of the complex configurational questions should be explored taking into account a larger time span to assess the viability of different models of P3s for maintaining and improving health systems.

Funding Source: University of Montreal

• Organizational and Management Factors

Affecting Quality Improvement

Thomas Wan, Ph.D., M.H.S., Ning Jackie Zhang,

M.D., Ph.D., M.P.H., Seungchun Paek, M.S.

Presented By: Thomas Wan, Ph.D., M.H.S.,

Professor, Doctoral Program in Public Affairs,


Drive, Orlando, FL 32826, Email: twan@mail.ucf.edu

Research Objective: Quality improvement in nursing homes is a pivotal mission of the

Centers for Medicare and Medicaid Services.

Although concerted efforts have been made to standardize resident-based quality measures, little is known about factors that may impede or facilitate the changes in resident outcomes. The study’s objective is two-folds: 1) to develop an aggregate, summary index of resident outcomes for portraying the pattern and trajectory of the quality of care; and 2) to identify relative importance of organizational and management factors that influence the pattern and trend of quality improvement in a period of four years.

Study Design: 10,201 nursing homes were included. The outcome-based measures of nursing home care quality were derived from 15 indicators calculated from MDS. All residents in the study nursing homes were included (N= 14 million).

Population Studied: A panel of nursing homes and their residents were studied. Each of the fifteen indicators of resident care outcomes for each facility, generated from MDS data for four years, was included in the computation of the percentage deviation from the mean (e.g., d1 =

[o1- o1/ o1]*100, where o1 refers to a given outcome indicator for a facility and o1 refers to an average value of o1 for all facility studied in four years). An average index of all fifteen percentage deviations for each facility was then computed to summarize its overall quality performance. A latent growth curve model of resident care quality, consisting of an intercept

(the initial level of quality performance) and a slope (the growth trend of quality improvement), was developed and empirically evaluated, using organizational and management factors as timeconstant predictor variables. In addition, predictor tree analysis was performed to identify the key characteristics of high-performing facilities in terms of the overall quality of resident care.

Principle Findings: The paper presents important findings of a new quality scorecard designed to assess and monitor multiple qualityof-care dimensions of nursing home performance. The score card uses longitudinal data of resident care outcomes to identify performance benchmarks and compute summary indexes comparing each facility to the national benchmarks. The four-year measures of quality index were relatively stable with moderate correlations, ranging from 0.432 to 0.522. Seven predictor variables accounted for 18.1% of the variance in the slope (growth trend) and 18.6% in the intercept (initial status). There was an inverse relationship between the two growth factors.


The findings underscore the importance of using organizational and management factors in classifying the relative performance of quality improvement in nursing homes.

Funding Source: CMS

• Organizational and Market Factors

Associated with Nursing Home Financial

Performance

Robert Weech-Maldonado, Ph.D., Christopher

Johnson, Ph.D., Kathryn Hyer, Ph.D., Zhou Yang,

Ph.D., Alex Laberge, M.B.A., P.T.

Presented By: Robert Weech-Maldonado, Ph.D.,

Associate Professor, Department of Health

Services Research, Management and Policy,

University of Florida, PO Box 100195, Gainesville,

FL 32610, Phone: (352) 273-6080, Email: rweech@phhp.ufl.edu

Research Objective: Nursing homes are experiencing increased revenue constraints as a result of changing reimbursement policies and declining demand for nursing home care. At the same time, nursing homes are facing increasing costs pressures as a result of higher nurse staffing and liability insurance costs. As a result, the financial performance of the nursing home industry has been deteriorating in recent years.

Using longitudinal data, this study examines the relationship between organizational and market characteristics and nursing home financial performance, and whether this relationship varies by financial performance measure.

Study Design: The data for this study comes from the Medicare and Medicaid Cost Reports, the On-line Survey Certification of Automated

Records (OSCAR), and the Area Resource File

(ARF). The dependent variable consists of financial performance tier: low (bottom quartile), medium (2nd and 3rd quartiles), and high

(upper quartile). Two financial performance measures include operating margin and total profit margin. Organizational predictors include size, ownership (for-profit status), chain affiliation, payer mix, occupancy rate, and case mix, while market factors include competition

(Herfindahl Index and excess capacity), metropolitan area, and county per capita income. Ordered probit regression is used to model the relationship between financial performance tier and organizational and market characteristics, with year as a fixed effect.

Standards errors are adjusted for clustering due to repeated observations for facilities over time using the Huber/White correction.

Population Studied: All Medicare and Medicaid certified nursing homes in Florida for the period of 2000-2004, approximately 575 facilities per year.

Principle Findings: Facilities with a higher operating margin are more likely to be for-profit, to have a higher Medicare and Medicaid census and a higher occupancy rate. On the other hand, facilities with a higher total profit margin are more likely to have a lower Medicaid census and a higher occupancy rate, and are more likely to be located in less competitive markets.

Conclusions: The relationship between financial performance and organizational and market factors varies by financial performance measure.

Occupancy rate is the single most important factor positively associated with both measures of financial performance. While for-profit nursing homes perform better based on the operating margin, this advantage disappears once the total margin is considered. This may be explained by the not-for-profit homes’ tax exempt status and their greater ability to subsidize their operations with non-patient revenues. While Medicaid reimbursement in Florida seems to cover adequately residents’ costs of care, nursing homes need Medicare and private pay residents to improve their total margin. Results suggest that greater competition hurts nursing homes’ total margin.


Nursing homes provide care to one of the most vulnerable populations, and their financial success is critical for their long-term survival.

Understanding the organizational and market factors associated with nursing home financial performance is critical for both managers and policymakers. This information can aid managers in implementing strategies aimed at improving their financial performance, while policymakers can evaluate the impact of longterm care policy on financial performance.

Funding Source: Administration on Aging

• Dutch Healthcare Performance Assessment

2006: Access, Quality and Costs

Gert Westert, Ph.D.

Presented By: Gert Westert, Ph.D., Prof. dr.,

National Institute of Public Health and the

Environment/ Tilburg University, P.O. Box 1,

Bilthoven, 3720 BA, NL, Phone: +31302743934,

Email: gert.westert@rivm.nl

Research Objective: Performance of the public sector is an important issue in most western countries. In the Netherlands the Dutch Ministry of Health initiated a nationwide healthcare performance project (ZORGBALANS) that is able to take the pulse of the Dutch health system, every two years. The aim of the

presentation is to report on the development of the national performance indicator framework and to present findings from the first Dutch healthcare report that was released in May 2006.

Study Design: The ZORGBALANS team produced the report in two stages. The first stage defined a comprehensive performance indicator framework. This part was done in collaboration with the OECD. The second stage saw the development of appropriate measures for reporting quality, accessibility and cost.

International and time comparisons were also made. The report uses a list of 125 indicators covering 20 domains such as effectiveness of curative care and patient safety.

Population Studied: The Netherlands in 2004.

Principle Findings: The overall picture that emerges is that the health care system is accessible for all in the Netherlands (37 indicators). Since 1980s the rise in costs ---- measured with 26 indicators - is in line with other EU countries; just above the EU-15 average.

However, between 2000 and 2004 the system’s costs of care rose substantially. Quality of care

(68 indicators) is above average in many respects. However, there is still much room for improvement with respect to the effectiveness of prevention and care, patient safety, coordination of care and integrated care. Especially, large variation in performance by place, among care providers exist. On 15 indicators huge variation in quality performance is observed, making this to top priority of health policy in the years ahead.

Conclusions: In general the Netherlands had an accessible health care system in 2004. Health care expenditures rose substantially between

1990 and 2004, but in line with the trend in the

EU-15. Holland ranks little above average in cost development in the EU-15 and OECD countries.

Quality of health care is for most indicators above average, compared to other OECD countries. However, there is room for improvement in the following domains: effectiveness of prevention, cure and care, patient safety and continuity of care.


The first Dutch health care report has some strong and weak points. One particular strength is that the performance framework used has a solid international foundation (Arah et al, 2006).

The set of indicators used is firmly rooted in the current Dutch health policy. Measures and indicators not always match perfectly. Time and space comparisons were limited, because of

(international) data availability and comparability. The Dutch Ministry of Health will use the report to steer the future direction of its policies. A quest for quality is likely to emerge following the report’s publication.

Funding Source: Ministry of Health

Medicaid, SCHIP & State

Health Initiatives

•

The State Child Health Insurance Program

(SCHIP) and Pre-pregnancy Coverage of

Teenage Mothers

E. Kathleen Adams, Ph.D., Norma I Gavin, Ph.D.,

M Femi Ayadi, Ph.D., Cheryl Raskind-Hood,

M.S., M.P.H.

Presented By: E. Kathleen Adams, Ph.D.,

Professor, Health Policy and Management,

Rollins School of Public Health, 1518 Clifton

Road NE, Atlanta, GA 30322, Phone: 404-727-

9370, Fax: 404-727-9198, Email: eadam01@sph.emory.edu

Research Objective: The substantial individual and societal costs incurred with teen pregnancy may be lowered by pre-pregnancy insurance coverage. Implementation of the State Children’s

Health Insurance Program (SCHIP) program in

1997 allowed states to expand Medicaid to uninsured children through age 18 years in families with incomes at or below 200% of the

Federal Poverty Level. We investigated the effects of this policy change on the pre-pregnancy insurance coverage of teens with live births in eight study states: Arkansas, Florida, Maine,

New York (upstate only), Oklahoma, South

Carolina, Washington and West Virginia.

Study Design: We examined Pregnancy Risk

Assessment Monitoring System (PRAMS) data in eight states from 1996----2000. PRAMS is a state-level population-based surveillance system that assesses maternal behaviors, experiences, and insurance coverage before and during a woman’s pregnancy and during her child’s early infancy. Data on state policy indicators, county characteristics, and wage/employment data were merged to the individual woman’s data available in PRAMS. Logit models and difference-indifferences analysis were used to test whether coverage changed significantly from before to after SCHIP implementation for teen mothers relative to the control group. Effects were allowed to vary by the study states’ program structure: 1) Medicaid expansion only (Arkansas,

Oklahoma, and South Carolina), 2) separately administered or ‘‘stand-alone’’ program

(Washington and West Virginia), or 3) a

combination of these (Florida, Maine, and New

York).

Population Studied: All teens (ages 11-19) and a control group of women ages 20-24 with live births in the study states and in the study states’

PRAMS sample (n = 26,465).

Principle Findings: We found significant and positive effects of SCHIP on pre-pregnancy insurance for teen mothers but this effect depended on the structure of the states’ SCHIP program. Specifically, SCHIP increased teen mothers’ pre-pregnancy insurance coverage by

10% to 20% in states that used SCHIP funds to expand their existing Medicaid program or combined this approach with a stand-alone, often private, SCHIP program. We found a positive effect on coverage reported as both private and Medicaid in these states. This indicates teens/families may construe SCHIP coverage as private perhaps due to the use of separate names or ‘‘branding’’ of this program by the states and/or other features such as premiums.

Conclusions: SCHIP expansions appear to have some positive effects on teen mothers’ insurance coverage. States that used SCHIP funds to expand their Medicaid program did show increased coverage among this selected group of teens. Yet, the public nature of the

SCHIP program may not have been recognized by participating teens.


Pre-pregnancy insurance coverage may allow unintended pregnancies to be avoided, medical conditions to be better managed, and early and adequate prenatal care to be provided to teens who carry a pregnancy to term. States should review the penetration of program coverage among low-income eligible teens and consider program features that may encourage enrollment.

Funding Source: CDC

• The Breast and Cervical Cancer Prevention and Treatment Act (BCCPTA) in Georgia:

Results from 2003

E. Kathleen Adams, Ph.D., Sarah C. Blake, M.A.,

Cheryl Raskind-Hood, M.S., M.P.H., Linien

Chien, M.S., M.P.H., Mei Zhou, M.S., M.A.,

Jonathan M. Liff, Ph.D., M.S.

Presented By: E. Kathleen Adams, Ph.D.,

Professor, Department of Health Policy and

Management, Emory University Rollins School of

Public Health, 1518 Clifton Road, NE, Atlanta, GA

30322, Phone: 404-727-9370, Fax: 404-727-9198,

Email: eadam01@sph.emory.edu

Research Objective: The Breast and Cervical

Cancer Prevention and Treatment Act (BCCPTA) created a new optional Medicaid eligibility category for uninsured women (< 65) screened at certain CDC-funded screening sites and in need of treatment for breast or cervical cancer or precancerous cervical conditions. Our overall objective is to examine the impact of BCCPTA in

Georgia. As a first step, we used 2003 Medicaid claims and enrollment data to examine BCCPTA enrollment and describe how this new coverage fits into Georgia’s overall coverage of women with these cancers.

Study Design: We used 2003 Medicaid claims and applied broad lists of diagnosis and procedure codes in order to find women with any evidence of breast and/or cervical cancers in

Georgia’s Medicaid program. We then used

Medicaid enrollment data to group women by their eligibility category on their first cancerrelated claim during the year: 1) BCCPTA; 2) welfare or pregnancy-related; or 3) disabled women. Finally, we used paid claims to calculate costs incurred for any service regardless of diagnosis, during 2003 and compared demographic characteristics and costs of

BCCPTA women to those in other Medicaid eligibility categories.

Population Studied: Women with breast and/or cervical cancer enrolled in Georgia’s Medicaid program in 2003.

Principle Findings: Over 2,300 women were enrolled in Georgia’s BCCPTA program in 2003, and they accounted for over one-third of all women identified with cancer claims. Over half of BCCPTA enrollees were non-Hispanic white women, while a third were African American women. A majority of BCCPTA and disabled women had breast cancer while over threequarters of women in the welfare or pregnancyrelated category had cervical cancer. BCCPTA women tended to be younger than women in the disabled category and had slightly lower annual costs. Breast cancer cases among BCCTPA and disabled women cost Georgia's Medicaid program around $20,000, while these cases among the pregnant/welfare eligible cost around

$12,000. There was more variation in costs for cervical cancer cases; BCCTPTA women averaged about $9,800 annually, pregnant/welfare eligible averaged about $6,200 and the disabled, around $19,700.

Conclusions: Both BCCPTA and traditional

Medicaid eligibility can serve as critical safety nets for women with breast and/or cervical cancer. While BCCPTA women are younger than

the disabled, they appear more like them in terms of costs than the even younger women served in the pregnant/welfare eligibility group.


Georgia’s BCCPTA program creates a potentially new and quicker pathway into Medicaid for lowincome and uninsured women with breast or cervical cancer. If BCCPTA Medicaid programs can enroll women earlier in their cancers or help prevent new cervical cancer cases, there can be reductions in morbidity and mortality as well as total costs.


•

BadgerCare Plus: A Simple Program

Milda Aksamitauskas, M.P.P.

Presented By: Milda Aksamitauskas, M.P.P.,

Senior Policy Analyst, Policy Implementation

Center, Wisconsin Department of Health and

Family Services, 1 West Wilson Street, Room

650, Madison, WI 53702, Phone: 608-266-9336,

Fax: 608-266-7882, Email: aksamm@dhfs.state.wi.us

Research Objective: Medicaid was initially designed to provide health care coverage only for children, single, divorced, widowed, or incapacitated parents, and pregnant women who were receiving cash assistance. Over time with the incremental expansion of Medicaid to cover more groups as well as with welfare reform,

Medicaid and its related programs have evolved from part of the welfare program to a health care safety net on which children and pregnant women in or near poverty, and unemployed, under-employed, and working poor parents rely to meet their health care needs. This expansion of coverage has created a patchwork of complex eligibility rules and laws that are costly for states to administer and which often discourage qualified families from enrolling. Medicaid eligibility rules were developed at the time AFDC used dollar-for-dollar budgeting such that every additional dollar of household income reduced

AFDC cash assistance unless partially or wholly disregarded, exempted, or deducted. This is not the case for Medicaid where eligibility is determined on a pass/fail basis. The medical coverage benefit provided to a family that is

$500 below the income limit is the same benefit provided to a family that is only $1 below the limit. With the creation of BadgerCare Plus,

Wisconsin is redesigning its state Medicaid and

SCHIP programs to simplify eligibility and expand access through the combination of its several Medicaid funded programs into a single health care safety net program for children, parents, relative caretakers, and pregnant women. BadgerCare Plus will have new financial eligibility criteria that are more congruous with the pass/fail dynamic and the new role of

Medicaid as a health care program for lowincome families, many of whom are working. In addition, Wisconsin links application and eligibility determination process between nutrition assistance programs, like Food Stamps, and Medicaid. Such programs are essential for the on-going good health of families and children yet many times has been ignored.

BadgerCare Plus attempts to align many of its eligibility policies and processes with the

Wisconsin Food Stamp program.

Study Design: The study starts with a literature review about complex Medicaid/SCHIP eligibility rules and how they affect coverage and access to health care. Then the paper reviews findings in coverage gaps in Wisconsin for Medicaid/SCHIP participants. For example, more than 25 percent of all children currently enrolled in Wisconsin

Family Medicaid, BadgerCare (SCHIP), or

Healthy Start programs have gaps in their eligibility because of these rules. These gaps last for a median length of three months hampering the ability of care management organizations to provide continuous preventive care. In addition, the unnecessary administrative cost to process nearly 800,000 changes when many do not actually affect eligibility for Family

Medicaid/BadgerCare results in expenditures of more than $12 million each year. Following the discussion of current policy implications, the paper will analyze how Wisconsin is proposing to change the rules and the implementation issues associated with these changes. The paper is a qualitative analysis of the policy decision process regarding eligibility rule simplification.

Population Studied: About 500,000 participants in the Wisconsin Medicaid, SCHIP,

Healthy Start programs.

Principle Findings: AFDC based Medicaid eligibility rules for children, relative caretakers and pregnant women can be simplified dramatically without cutting people off of the program.

Conclusions: Simplification of eligibility rules is a good public policy; it addresses the needs of program participants, reduces administrative costs, and reflects the realities of health care safety net dynamics.


No other state, to our knowledge, is proposing to simplify out-dated eligibility rules so dramatically. Some of Wisconsin’s proposed changes can be achieved under the DRA 2005

and Medicaid state plan amendments, while others will require a federal waiver. For many families, Medicaid, SCHIP, and other Medicaidfunded programs are an interdependent health care safety net. Policies that support seamless transition from one program to another (from financing perspectives) are critical to minimize disruption in coverage.

Funding Source: Wisconsin Department of

Health and Family Services

• Estimating the Cost of Interpreter Services to State Medicaid Programs

Ann Bagchi, Ph.D.

Presented By: Ann Bagchi, Ph.D., Health

Researcher, Health, Mathematica Policy

Research, 600 Alexander Park, Princeton, NJ

08540, Phone: (609) 716-4554, Fax: (609) 799-

0005, Email: abagchi@mathematica-mpr.com

Research Objective: Using qualitative methods and analyses of available secondary data, this study sought to: (1) estimate the size of the limited English proficient (LEP) population within the Connecticut Medicaid program, (2) evaluate the availability of interpreter services to

LEP Medicaid beneficiaries, and (3) estimate the cost of providing face-to-face interpreters, trained in medical terminology, for all health care encounters.

Study Design: In 2002, the Office of

Management and Budget (OMB) provided a report to Congress that examined the cost of improving access to interpreter services for persons with limited English proficiency. The present study replicated the OMB’s methodology for estimating the cost of interpreter services in health care encounters, using data from the 2000 U.S. Census, data from the Medicaid Statistical Information

System (MSIS) for the state of Connecticut,

Medicaid enrollment data, and additional secondary sources.

Population Studied: The study population included Connecticut residents with limited

English proficiency who were enrolled in the state’s Medicaid program.

Principle Findings: An estimated 22,353 individuals with limited English proficiency were enrolled in Connecticut’s Medicaid program in

2003, representing 4.6 percent of the program’s beneficiaries. Data systems for identifying and tracking patients’ preferred languages are lacking; in hospitals these data exist in ‘‘silos’’ which inhibit the ability to track use of services and project future need. Medicaid managed care organizations (MCOs) (which provide coverage to three-quarters of Connecticut’s Medicaid beneficiaries) are required to provide interpreter services under their capitation rates. Three of the four Medicaid MCOs in Connecticut provide interpreter services through a telephone language line; only one (representing around 11 percent of all the state’s Medicaid beneficiaries) routinely provides face-to-face interpreters to its enrollees. Many physicians enrolled in Medicaid through the state’s managed care network appear to be unaware of the availability of interpreter services for their patients.

Connecticut’s Medicaid program does not currently pay for interpreter services that may be provided to the one-quarter of beneficiaries who are enrolled in fee-for-service. The cost of providing medically trained, face-to-face interpreter services for all beneficiaries was estimated at $4.7 million.

Conclusions: The majority of Connecticut

Medicaid beneficiaries lack access to medically trained, face-to-face interpreters during health care encounters. Connecticut can ensure access to these services and help offset their costs by structuring its Medicaid and SCHIP programs to take advantage of available federal matching funds. Participation in the federal matching program would reduce the state’s share of costs for interpreter services to $2.35 million.


The United States has a large and growing population with limited English proficiency.

Providing interpreter services to LEP patients improves both access to health care and the quality of care provided and has the potential to reduce health care spending in the long-term.

This study provides an easily replicated method for State Medicaid programs to estimate (1) the size of their LEP beneficiary populations and (2) the cost of providing interpreter services to their enrollees. States can then use this information to determine the cost and feasibility of structuring a program to make use of available federal matching funds.

Funding Source: Connecticut Health

Foundation

• Funding for Translation and Interpretation

Services Provided by Public Health Insurance

Programs

Marisa Cox, M.A., Alexandra Stewart, J.D.

Presented By: Marisa Cox, M.A., Sr. Research

Associate, Health Policy, George Washington

University Medical Center, 2021 K street NW,

Washington, DC 20006, Phone: 202 530 2307,

Fax: 202-296-0025, Email: mcox@gwu.edu

Research Objective: To identify the range of options available to public insurance programs for accessing state funding for language access services at two critical entry points.

Study Design: Researchers conducted key informant interview with 10 state

Medicaid/SCHIP programs that receive federal matching funds for translation and interpretation services for LEP beneficiaries.

Population Studied: The affected population is

Medicaid beneficiaries who experience limited

English proficiency.

Principle Findings: 1. 10 states utilize the federal match to provide language services under

Medicaid/SCHIP. 2. States categorize LEP services using one of two methods which impacts the level of available federal match. 3.

Source of state portion may vary. 4. States have adopted various billing methods.

Conclusions: Language access services are essential to state performance, under federal laws which emphasize access, understandability, and quality. The link between language and health care quality and reduction of disparities underscores the need for all states to seek solutions within their public programs.


State Medicaid/SCHIP administrators should recognize opportunities to identify all funding possibilities for LEP services

Funding Source: California Endowment

•

Trends in Medicaid Pharmacy Benefits:

1999 to 2002

Domenico Esposito, Ph.D., Ann D. Bagchi,

Ph.D., James Verdier, J.D., Deo Bencio, B.S.

Presented By: Domenico Esposito, Ph.D.,

Researcher/Health Economist, Health,

Mathematica Policy Research, Inc., 600

Alexander Park, Princeton, NJ 08540, Phone:

609-275-2358, Fax: 609-799-0005, Email: desposito@mathematica-mpr.com

Research Objective: To highlight trends in prescription drug use and costs among

Medicaid beneficiaries from 1999 to 2002 using

Centers for Medicare & Medicaid Services data that provide detailed and comparable state-bystate information by beneficiary type.

Study Design: Compare medication utilization and costs for Medicaid beneficiaries using

Medicaid Analytical eXtract (MAX) data (1999 to

2002). (2002 MAX data will be available in

January 2007 and included in this presentation.)

Population Studied: All fee-for-service Medicaid beneficiaries in the United States with at least one month of prescription drug coverage, including those dually eligible for Medicare, whose drugs are now covered by Medicare Part

D health plans.

Principle Findings: Despite no change between

1999 and 2001 in the average number of prescriptions claims per month (1.5 claims) among all Medicaid beneficiaries (including dual eligibles), monthly pharmacy costs per beneficiary rose from $69 to $83. In both years, the highest cost drug groups were antipsychotics and antidepressants. The largest increase in costs (from $187 to $260) was among full-year nursing facility residents whose average number of claims per month rose from 5.0 to 5.7.

Average monthly pharmacy costs and use also rose for disabled Medicaid beneficiaries (from

$154 to $208 and by 0.3 claims per month). The percentage of children covered by Medicaid with at least one claim increased from 49.8 percent in

1999 to 57.9 percent in 2001. Among beneficiaries 20 years old or younger, the percentage with antipsychotic or antidepressant claims rose from 3.8 to 4.7 percent. Among dual eligibles alone, the average number of claims per month rose from 3.3 to 3.8 and monthly reimbursement costs increased from $157 to

$211. Monthly pharmacy costs rose considerably for dual eligibles who were full-year nursing facility residents (from $181 to $249) and for disabled dual eligibles younger than 65 (from

$189 to $250). The increase in use among dual eligibles was particularly evident among high prescription drug utilizers. For instance, the percentage of dual eligibles with at least two prescriptions per month rose from 49.8 to 54.3 percent and the proportion with annual pharmacy costs greater than $3,000 increased from 16.3 to 25.3 percent. (There was substantial state-by-state variation on most measures, which will be highlighted in the presentation.)

Conclusions: Between 1999 and 2001, the largest absolute dollar increases in average monthly Medicaid prescription drug expenditures occurred among disabled beneficiaries and full-year nursing facility residents. The same pattern was also evident among dual eligible beneficiaries, although the differences in some cases were even larger.


This study provides valuable information for

Medicare Part D plans that now serve dual eligibles and Medicaid agencies that remain

responsible for the drug costs of nonduals.

Understanding the Medicaid subpopulations for whom medication use and costs are rising the fastest over time can help providers and policymakers determine how best to structure benefits to account for these use patterns and minimize drug costs for states and the federal government. In addition, information on the specific drug groups that account for the highest costs can help decision makers target areas to stem future spending growth.

Funding Source: CMS

• Gaps in Coverage for Children in Medi-Cal

Gerry Fairbrother, Ph.D., Amy Cassedy, Ph.D.

Presented By: Gerry Fairbrother, Ph.D.,

Professor, Health Policy and Clinical

Effectiveness, Cicinnati Children's Hospital

Medical Center, 3333 Burnet Avenue, Cincinnati,

OH 45229-3039, Phone: (513)636-0189, Fax: (513)

636-0171, Email: gerry.fairbrother@cchmc.org

Research Objective: To characterize gaps in coverage for all children and for children in different eligibility categories in California's

Medicaid program (Medi-Cal).

Study Design: This was a longitudinal descriptive study of gaps and stability in Medi-

Cal. We followed children over a three-year period noting proportion with gaps in Medi-Cal as a whole and within major eligibility categories.

Population Studied: The study population was all children enrolled in Medi-Cal in the three year period between July, 2002 and June, 2005. We grouped children into Medi-Cal eligibility categories using the enrollment codes, relying on

The Guide to Medi-Cal Programs to classify codes into major groupings.

Principle Findings: There were 2.71 million children in the Medi-Cal program as of June,

2005. The Medi-Cal sub-grouping that includes children in families receiving cash assistance

(CalWORKs) accounted for 29% of all children in

Medi-Cal, while another 45% of Medi-Cal children were in the subgrouping for families whose incomes would qualify for cash assistance, but who are not actually receiving this assistance (1931(B)). Together these two eligibility categories accounted for almost 3 children out of every 4 in Medi-Cal. In contrast, only approximately 8% of Medi-Cal children are in the programs for families with incomes between 100 and 200% FPL. Another 3% of

Medi-Cal children are disabled and as such qualify for Social Security Income (SSI). The remaining children were in a transitional, foster care or other Medi-Cal program. Overall, 22% of

Medi-Cal children had gaps in coverage in three year period (left and returned to the program).

At any given point during the three years, approximately 235,000 children were in a gap.

This number varied from 3% with gaps for children in eligible for Medi-Cal by virtue of receiving SSI to 30% for children in eligibility categories corresponding to being in families with incomes 100-200% FPL. 16% and 26% of children in CalWORKs and 1931(B) programs

(Medi-Cal eligibility groupings related to eligibility for cash assistance) had gaps. No matter what the eligibility category, median gap length was either 3 or 4 months. Gaps were associated with changes in eligibility codes and zip codes before and after the gap.

Stability was markedly different for children in eligibility categories: 87% of the disabled children on SSI were enrolled in Medi-Cal for three full years. 67% of children eligible for

Medi-Cal by virtue of receiving cash assistance had been enrolled for three full years and 42% of the children eligible for, but not receiving cash assistance had been enrolled for three full years.

In sharp contrast, only an average of 28% of children eligible because their family incomes were from 100-200% FPL were enrolled for three years.

Conclusions: Large numbers of seemingly eligible children had gaps in coverage. Gaps were associated with family life changes, such as moves or changes in family circumstances that result in a change in eligibility code. Further, gaps were more likely for children in eligibility groupings not related to cash assistance or disability.


More assistance is needed at renewal time to help families retain coverage for their eligible children.

•

A National Look at Existing Medicaid

Reimbursed Prenatal Case Management

Programs

Sarah Forrestal, Sarah G. Forrestal, Jaime

Slaughter, Jenna Khan, Amanda A. Schultz

Presented By: Sarah Forrestal, Community

Health Sciences (MC 923), University of Illinois at Chicago School of Public Health, 1603 W

Taylor Street, Chicago, IL 60612, Phone: 312-355-

0700, Email: sforre2@uic.edu

Research Objective: Medicaid in 32 states reimburses for targeted, non-medical case management of high risk pregnant women, but

readily available Medicaid reports do not provide information on the structure or expenditures for these programs. While these programs represent a small portion of the Medicaid budget, clinical trials have found prenatal case management effective in improving birth and child health outcomes if provided as a standardized professional program. The purpose of this project is to provide a national description of the extent and structure of Medicaid prenatal case management programs.

Study Design: Data were collected from each state Medicaid office, and subsequently from a sample of programs. As of 2006, 32 states reimbursed providers of prenatal case management. Lists of providers were obtained from 30 of the 32 states, and sampled programs were contacted to obtain data about program size, structure, and practices.

Population Studied: The population of interest is Medicaid reimbursed prenatal case management programs.

Principle Findings: Based on information available at state websites, from telephone interviews with state personnel, and subsequent conversations with case management programs, we were able to identify variations in the basic structure of the programs. Of 30 states for which we have data, 9 states use private providers, 17 use a mix of private and state providers (e.g., health departments), and only 4 are exclusively run by the state. One state contacts with a private vendor conducting case management exclusively via telephone.

Complete lists of programs within each state were obtained from the state Medicaid offices, and then cleaned and verified for accuracy of program information, yielding a final count of

1105 programs across the nation. Based on programs for which we have data (n=136), the number of programs per state ranged from 1 to

121, with a median of 26 per state. The programs had an average of 4.7 persons (range 0 to 26), or an average of 3.5 FTEs (range 0 to 81). The 9 states with private providers had an average of

7.25 programs per state, compared to 58.3 programs per state among the states using both private and state run programs. However, the average number of employees per program did not vary significantly across the three types of provider mix. In preliminary analyses correlating the number or type of program with birth outcomes, only one significant association

(r=0.69) was identified; states with more

Medicaid reimbursed births had programs with more FTEs. Unfortunately, it appears that states with more FTEs did not have lower rates of preterm births. The relationship between prenatal case management structure and birth outcomes thus remains elusive at the aggregated state level.

Conclusions: Nationally, Medicaid reimbursed prenatal case management programs vary considerably in size and program structure, with most states relying partially or exclusively on private providers. Additional research is needed to identify relationships between the number and quality of the programs with state-level birth health statistics.


Policy implications include a need to have better state supervision of prenatal case management providers so that evidence based protocols are followed.


•

Fiscal Conditions, Politics, and State

Medicaid Spending

Rachel Garfield, M.H.S.

Presented By: Rachel Garfield, M.H.S., Doctoral

Candidate, Department of Health Policy,

Harvard University, 180 Longwood Avenue,


617-432-0173, Email: garfield@fas.harvard.edu

Research Objective: Though many states maintain or even expand Medicaid in the face of economic downturns, the program is not immune from cuts during fiscal crises in all states. Existing research shows no clear pattern as to which states are able to overcome fiscal pressure to cut program spending or at what point in a deficit period Medicaid is cut. This paper addresses this issue by examining how state Medicaid spending responds to state fiscal crises, as well as how state politics lead states to react differently to state fiscal crises. Unlike most previous research, the study also considers the role of political institutions related to the budget process in shaping state Medicaid spending.

Study Design: The study draws on crosssectional, time-series, state-level data compiled for this project. Analysis uses random and fixed effects models to estimate the impact of key policy measures. The empirical models examine how total state Medicaid spending changes as a function of state fiscal conditions, state political environment (ideology, interest group power, and party control), state budget rules (ability to carry deficit, gubernatorial veto power, and tax and expenditure limits), and state demographics.

Population Studied: The sample includes all 50 states for the years 1988 through 2004.

Principle Findings: Measuring state fiscal health using year-end balances as a percent of state expenditures, results indicate that Medicaid operates in a counter-cyclical spending pattern, with state Medicaid spending increasing more quickly when balances are low. Political factors appear to impact the rate of change of state

Medicaid spending, with influential provider groups and more liberal public ideology associated with larger state spending increases, holding fiscal conditions constant. Democrat control of the state legislature is associated with decreased Medicaid spending, but findings are not robust across model variations. The magnitude of budget rules’ impact on state

Medicaid spending is also sensitive to the model used; across models, limits on the ability to carry a deficit are associated with lower state Medicaid spending, while gubernatorial veto power does not significantly impact Medicaid spending.

Neither politics nor budget rules appear to significantly impact the association between year-end balances and state Medicaid spending.

Conclusions: These results confirm reports that

Medicaid follows a counter-cyclical spending pattern, increasing during tight fiscal times.

They also highlight the role of state politics in state Medicaid spending patterns by showing the importance of interest group power and public ideology. Ongoing work will explore the impact of other measures of fiscal health, such as unexpected fiscal shocks and their interaction with state politics, on state Medicaid spending.


Fully understanding how state Medicaid spending changes during state fiscal crises can help guide federal policy actions to maintain or standardize the program during such times; it can also help predict state responses to increased flexibility. Findings may also help state policymakers in budget prediction.

• Medicaid Eligibility Expansions, Enrollment, and Prenatal Care Use among Pregnant Teens in Florida and Georgia

Norma Gavin, Ph.D., May Kuo, Ph.D., M.P.H., E.

Kathleen Adams, Ph.D., M. Femi Ayadi, Ph.D.,

Beth Lasater, M.S.P.H., ,

Presented By: Norma Gavin, Ph.D., Senior

Research Economist, RTI International, 3040

Cornwallis Road, Hillsborough, NC 27709-2194,

Phone: (919) 541-6432, Fax: (919) 990-8454,

Email: gavin@rti.org

Research Objective: The State Child Health

Insurance Program ( SCHIP) directly increased public coverage and indirectly increased

Medicaid enrollment as many applicants were found to be Medicaid eligible. This manuscript measures the indirect or ‘spillover’ effects of

SCHIP on the timing of pregnant teens’

Medicaid enrollment and initiation of prenatal care (PNC). Florida used SCHIP funds to speed up the federally mandated expansion of

Medicaid coverage to teens aged 15 to 19 with family incomes under 100% of poverty (i.e.,

OBRA teens) and to expand an existing separate school-based insurance plan for children aged 5 to 18 with family incomes under 200% of poverty. Georgia used their SCHIP block grant to implement Peach Care, a new stand-alone insurance program for children up to age 18 with family incomes up to 200% of poverty. By 2001 nearly all OBRA teens in Georgia had aged into

Medicaid coverage. We hypothesized that this new coverage enabled improved access to preventive care before pregnancy and prenatal care (PNC) during pregnancy.

Study Design: We used Medicaid enrollment and claims data for Florida and Georgia and a difference-in-difference approach to estimate the impact of SCHIP on: (1) whether women eligible regardless of pregnancy status were enrolled 9 or more months prior to delivery; and (2) late initiation of PNC ( first visit occurred within 3 months of delivery). We compared changes in

Medicaid enrollment and PNC initiation over time (pre- and post-SCHIP) among teenaged relative to 20- to 24-year-old pregnant Medicaid enrollees. We controlled for race/ethnicity,

Medicaid eligibility category, county-level indicators, and selected medical risk factors.

Population Studied: We included 64,670 women in Florida under age 25 with a Medicaidcovered delivery in fiscal years 1995 (10/1/94 -

9/30/95, pre-SCHIP) or 2001 (10/1/00 - 9/30/01, post-SCHIP) and 56,101 women in Georgia under age 25 with a Medicaid-covered delivery in calendar year 1995 (pre-SCHIP) or fiscal year

2001 (post-SCHIP). We excluded beneficiaries with incomplete enrollment records; undocumented immigrants; and women enrolled in HMOs, Medicare, or a private insurance plan.

Principle Findings: Results varied for Florida and Georgia. In Florida, prepregnancy Medicaid enrollment increased over time for all study subjects but teens had a significantly smaller increase than 20-to-24-year-olds. In contrast, prepregnancy Medicaid enrollment decreased for all study subjects in Georgia but the drop for

teens was not as great as among 20-to-24-yearolds. In Florida, as hypothesized, teens had a greater decline (3.0 percentage points) in the probability of initiating PNC late or not at all compared to the women in their early twenties whereas in Georgia teens experienced a slight (1 percentage point) increase in the probability of initiating PNC late or not at all. This increase in late PNC initiation among teens in Georgia was even greater (4.3 percentage points) when the sample was restricted to eligibility categories not dependent on pregnancy status.

Conclusions: Spillover effects of SCHIP implementation on Medicaid enrollment duration and early initiation of PNC among pregnant teens were small at best and varied by state.


Insurance coverage in the preconceptional period is an effective, but not sufficient, method of increasing early initiation of PNC among pregnant teens.

Funding Source: CDC

•

Integrating Medicare and Medicaid Data to

Plan Healthcare Cost-Effectiveness

Daniel Gilden, M.S.

Presented By: Daniel Gilden, M.S., President, ,

JEN Associates, 5 Bigelow Street,Cambridge, MA

02139, Phone: (617) 868-5578, Fax: (617) 868-

7963, Email: dmg@jen.com

Research Objective: Policy experimentation designed to integrate Medicare and Medicaid for dual eligible populations heavily depends on creating patient-level databases for planning, management and evaluation. This research demonstrates how comparative analysis of linked Medicare and Medicaid data can serve state program planning efforts. The databases, derived from Medicare-Medicaid files, incorporate information across dimensions that include financing, patterns of disease, quality of care, and health care outcomes. Differences in the costs of care are accounted for by the higher level of morbidity in the dually eligible population. State-level variations in Medicaid eligibility thresholds tend to substantially affect the size of the ‘‘Well’’ vs. Frail elderly. A series of heterogeneous subgroups that exhibit demographic and frailty patterns different than observed in the overall Medicare population are identified and used to suggest program planning and evaluation considerations.

Study Design: Comparative analysis between the dually and singly eligible elderly and disabled populations is used to demonstrate how linked

Medicare and Medicaid data can help state and federal policymakers understand the level of resources required to support special state programs. The data used for the analyses derive from a fully integrated Medicaid-Medicare payment and enrollment database developed from the Medicare national 5% annual population sample linked with the national

Medicaid State Information System (MSIS) data, the first national Medicaid administrative information source for research and program development studies that allow for uniform state comparisons. The research design serves to heightening awareness that the dually eligible population is highly heterogeneous in terms of its broad ranges of disabilities, impairments and diseases but also in terms of state variations in qualification for Medicaid eligibility.

Population Studied: The comparative analysis focuses on selected states (FL, MA, MN, NH,

TX, VT, WI) provided support by the Medicare

Medicaid Integration Program (MMIP), a multistate Robert Wood Johnson Foundation initiative to help states plan, implement and manage new systems of care for dual eligibles.

Principle Findings: Vermont has the most promising risk profile of all the MMIP states examined here. About 34% of Vermont’s ‘‘Frail’’ are community-dwelling Medicaid enrollees. In every high risk condition category, Vermont has the highest statewide percentage in Medicaid.

The risk concentration in Medicaid maximizes the potential for creating a successful nursing home diversion intervention. Florida, in contrast, keeps a large fraction of their risk population outside Medicaid. In Massachusetts,

Minnesota, Texas and Wisconsin, large portions of the high risk population are institutionalized.

Here interventions to facilitate deinstitutionalization when possible and to managed primary and acute care use more effectively could save money.

Conclusions: As MMIP implementation proceeds in states, linked Medicare and

Medicaid data will continue to play an important role in managing operations and identifying areas for improvement. Surveillance of diagnoses and claims from program participants and high risk beneficiaries outside the dual eligibile program serves as a potential basis for new program design as well as an evaluation resource. Benchmarking of outcome rates, care services and expenditures all provide information on achievement of program goals and budget neutrality projections. States will want to be especially aware of how to avoid cost-shifting

from Medicare to Medicaid that could happen if

Medicare special needs plans evolve without explicit links to Medicaid.


The lessons learned from State and Federal investments in integrated acute and long-term care programs for dual eligibles can enormously enriched the understanding of the challenges associated with providing care to a large proportion of the sickest and most impaired segments of the US population. These lessons can also provide a model for better systems of care for all populations.


•

Shaping High Performance Health Systems:

Key Findings from a Study of State Policies and Practices across Multiple State Agencies

Catherine Hess, M.S.W., Sonya Schwartz, J.D.,

Jill Rosenthal, M.P.H., Alan Weil, J.D.

Presented By: Catherine Hess, M.S.W., Senior

Program Director, National Academy for State

Health Policy, 1233 20th Street,NW, Washington,

DC 20036, Phone: 202-903-0101, Fax: 202-903-

2790, Email: chess@nashp.org

Research Objective: 1. To identify state policies and practices contributing to high performing health systems, consistent with the

Commonwealth Fund's Commission on a High

Performance Health System. 2. To describe state adoption of important and innovative policies and practices contributing to high performance health systems.

Study Design: Major domains and criteria for selecting state policies and practices for study were developed in relation to the work of the

Commonwealth Fund's Commission on a High

Performance Health System. Literature reviews were conducted in fall 2005 to identify: similar relevant studies assessing state policy performance; evidence and recommendations for state health policy and practice in domains of interest; and sources of recent information collection for all states on relevant health policies and practices. Based on the literature review and advice from a subgroup of Commission members, domains were finalized and policies and practices for study selected. These are: 1.

Coverage of Essential Benefits, with the goal that all people have equitable and affordable health coverage; includes state polices and practices addressing: oPublic coverage beyond federal minimums, oPrivate sector strategies such as market regulation, oEnrollment and retention promoting continuous coverage. 2. Quality,

Efficiency and Value, with the goal that all people get the right care at reasonable cost, and get equitable care that is, safe, patient-centered, and coordinated; includes state policies and practices addressing: oValue purchasing, including performance incentives and disincentives, oPublic reporting of patient safety and quality indicators, oQuality forums and agendas. 3.

Health Systems Infrastructure, with all people having access to systems of personal health care and population-based public health services that promote long and healthy lives and that have capacity to improve; includes state policies and practices addressing: oPopulation based health prevention and promotion policies and practices, oInformation systems and technology, oProvider availability and access (including safety net).

Information for the study is drawn from recent state policy surveys; new surveys of six state agencies and offices in 51 jurisdictions; and follow-up interviews on potentially innovative policies and practices. The methodology was presented at last year’s AcademyHealth meeting.

Surveys were fielded at the end of October,

2006, and as of January 9, responses from at least one state agency had been obtained for 50 jurisdictions. The draft study report is due to be completed by March 31, 2007, well before the

June meeting.

Population Studied: This study focuses on health policies of the fifty United States and the

District of Columbia.

Principle Findings: The study will describe state performance on multiple elements reflective of important state roles in shaping high performing health systems in the three domains identified above. The study also will identify and describe trendsetting, innovative approaches that states are taking to improve health systems performance.

Conclusions: This ambitious study addresses state roles in promoting high performance in health systems, roles that necessarily cross agency and program lines. The study’s conclusions will provide a ‘‘big picture’’ view of the impact states are having and the potential for states to do more to advance a high performance health systems agenda.


The study can be utilized by states and others to develop, refine and advance policy agendas and implement practices to promote high performing health systems.

Funding Source: CWF

• Retention in Child Public Health Insurance in San Mateo County

Embry Howell, M.S.P.H., Ph.D.

Presented By: Embry Howell, M.S.P.H., Ph.D.,

Principal Research Associate, Health Policy

Center, Urban Institute, 2100 M Street,N.W.,


Email: ehowell@ui.urban.org

Research Objective: Many children lack health insurance coverage, because their parents do not renew their coverage. Studies have used varied methods to measure retention, and there is little reliable information on the level of retention across health plans, health insurance programs, and geographic locations. This project developed a method for studying retention in child public health insurance programs using routine administrative data bases in one pilot county, in order to disseminate the method to other places, compare retention rates across settings, learn from different methods for improving retention, and improve retention in child public health insurance programs.

Study Design: In San Mateo County, California most publicly insured children are enrolled in a single health plan. We used data from the health plan data base, as well as from the One-e-

App on-line enrollment data base, to monitor retention in three public programs: Medi-Cal

(Medicaid), Healthy Families (SCHIP), and

Healthy Kids (a special county-based program to cover uninsured children under 300% of poverty). Monthly cohorts of children enrolled in

2003 and 2004 were tracked to determine when and why they left the program and returned

(‘‘churners’’), or left and did not return. ‘‘Annual retention’’ was the proportion of children still enrolled 15 months after initial enrollment, and

‘‘long-term retention’’ was those still enrolled after 30 months after enrollment. The reason for leaving was coded in the One-e-App database, although it was frequently missing.

Population Studied: Children enrolled in public health insurance programs in the Health Plan of

San Mateo in 2003 and 2004.

Principle Findings: Retention rates varied by public program, and were generally lower than expected by county officials. Although all three programs guarantee continuous eligibility for one year following initial enrollment (unless a child leaves the county or ‘‘ages out’’), after the renewal process (at 12 months) a substantial proportion of children in all three programs were no longer enrolled (about 50 percent). By 30 months, only about a third of children were still enrolled. The highest retention was for Healthy

Kids, who have few other insurance options, but even for that program only 35.4 percent of children were enrolled after 30 months. The reasons for leaving were difficult to discern from the available data, since the parents of most children who left the programs could not be contacted. ‘‘Churning’’ was also a problem; about 5 percent of Healthy Families and Healthy

Kids children left and returned within the study period, with a higher percentage (7.6%) for

Medi-Cal.

Conclusions: It is possible to develop reliable measures of retention from administrative databases. To do this, it is important to monitor cohorts of children over time. Data should be enhanced to incorporate better reasons for why children leave.


Public health insurance programs must develop improved approaches to monitoring and improving retention. Improving contact with parents at the time or renewal is also critical. It is also important for children’s health insurance programs to share data on retention, as well as on successful initiatives to improve retention.

Funding Source: California HealthCare

Foundation

• Medicaid Budget Cuts: Will They Adversely

Impact the Health Care of Medicaid-Covered

Children?

Kyle Jones, B.A., Emmanuel Ngui, Dr.P.H., John

Meurer, M.D., M.B.A., Glenn Flores, M.D.

Presented By: Kyle Jones, B.A., Summer

Researcher, Center for the Advancement of

Underserved Children, Medical College of

Wisconsin, 6095 N Green Bay Ave #203,

Glendale, WI 53209, Phone: (801) 660-0535,

Email: kbjones@mcw.edu

Research Objective: The 2005 Deficit Reduction

Act calls for reduction of Medicaid benefits and increased patient cost-sharing through copayments and premiums. The impact of these changes on Medicaid recipients is unclear. The goal of this study was to assess perceptions of parents of Medicaid-covered children regarding the potential impact of Medicaid reform on children’s health care.

Study Design: Ethnographic interviews were conducted of parents of Medicaid-covered children. Parents were asked 40 questions to assess knowledge, beliefs, attitudes, and intended behaviors related to Medicaid reform.

Population Studied: Parents of Medicaidcovered children attending an urban pediatric clinic in Milwaukee, Wisconsin.

Principle Findings: The 49 interviewed parents had a median age of 28 years; 90% were African-

American, 64% were high school graduates, and

41% had children with chronic conditions. 54% of the children’s visits were for sick care. Most parents were unaware of Medicaid reform, and the remainder were confused about reform.

Although a few parents stated that the changes were reasonable, most parents did not.

Financial hardship was cited as a major consequence of reform, leading to increased use of government entitlement programs, increased debt, and possibly bankruptcy. One mother stated, ‘‘What was the purpose of being on

Medicaid if you could afford to pay for it?’’

Parents also expressed concern about sacrifices they would have to make to pay co-payments. ‘‘I probably wouldn’t be able to pay rent, probably wouldn’t be able to get food…If that was added, we would probably be on the street.’’ Other sacrifices included taking additional jobs, working longer hours, and cutting back on medication for themselves. In response to copays and premiums, parents would defer needed preventive care for children (‘‘Like for a regular check up and he’s like doing fine to me, I wouldn’t bring him if I had to pay.’’); defer sick care; increase their reliance on charity care; and increase use of EDs (‘‘I’d rather take him to the

ER [than pay a $10 co-pay].’’). Parents were almost evenly split in their reactions to a $10 copay, but there was a much more negative response when asked about a $20 co-pay, with many parents responding as did one mother: ‘‘I wouldn’t even come, it’s too much money.’’

Many parents expressed concern that the reform would negatively impact the overall well-being of their family, ‘‘With three children, I’m already struggling, you know, just to make ends meet…I think that would be terrible if I have to cut back on their health care just because I can’t afford it.’’

Conclusions: Parents of Medicaid-covered children report that current Medicaid reform will result in increased financial and non-financial hardship; deferral of preventive and sick care for children; increased reliance on charity care; increased ED visits; and compromised overall health and well-being for children and families.


These findings suggest that Medicaid reform could cause less continuity of care, greater unmet healthcare needs, greater societal burden, and higher future healthcare costs.

Funding Source: Wisconsin Medical Society

Foundation

• Is There Differential Retention of Children with Special Health Care Needs In SCHIP?

Tamarie Macon, B.S., Jane E. Miller, Ph.D.,

Dorothy Gaboda, Ph.D., Theresa Simpson, B.S.,

Joel Cantor, Sc.D.

Presented By: Tamarie Macon, B.S., Institute for

Health, Health Care Policy, and Aging Research,

Rutgers University, 30 College Avenue, New

Brunswick, NJ 08901, Phone: (732) 887-4133,

Email: teemac@eden.rutgers.edu

Research Objective: To determine whether children with special health care needs (CSHCN) are more likely to remain in New Jersey’s State

Children’s Health Insurance Program (SCHIP) and less likely to become uninsured than non-

CSHCN. Children with special health care needs

(CSHCN) use more health services than other children; hence health insurance is critical for them.

Study Design: We used the 2003 NJ FamilyCare

(NJFC) Supplement to the New Jersey Family

Health Survey. Children were randomly selected from the universe of children enrolled in NJFC as of May 2002 and their families surveyed during summer 2003. The CSHCN Screener (developed by The Child and Adolescent Health

Measurement Initiative) was used to identify five types of special health care needs (SHCN). We conducted multivariate analyses to determine which children were more likely to have any special health care need. To assess whether adverse retention into SCHIP was occurring, we estimated multinomial logistic regression models of final enrollment status according to the presence of any (one or more) SHCN, controlling for demographic characteristics and

SCHIP plan (income) level.

Population Studied: A total of 679 index children who were randomly selected from the universe of children enrolled in NJFC as of May

2002; four children were excluded from the analyses because of ineligibility for SCHIP or missing data on final enrollment status. The sample was stratified according to enrollment status, SCHIP plan level, and whether or not parents were also enrolled in NJ FamilyCare.

Principle Findings: Roughly one out of every five children in NJ FamilyCare had at least one

SHCN. Older children and boys had greater odds of having special health care needs than others. Children with special health care needs had only one-quarter the odds of becoming disenrolled and uninsured, compared to children without special health care needs, even when controlling for age, sex, race/ethnicity, and

SCHIP plan level. There was no difference in likelihood of finding other health insurance according to CSHCN status.

Conclusions: Children with special health care needs were more likely than children without such needs to be covered by health insurance at the time of the survey ---- either by retaining

SCHIP coverage or having disenrolled and found other insurance.


There appears to be adverse retention in NJ

FamilyCare, which is good news for families with

CSHCN and their advocates. As the federal authorization of the program approaches, these higher health care costs for these children should be considered in federal and state budget planning for SCHIP. Further research should investigate the prevalence and cost of the five types of health care needs encompassed in the

CSHCN Screener. Finally, although it appears

CSHCN are covered continuously, the adequacy of CSHCN’s insurance, the third component of the Maternal and Child Health Bureau’s health insurance core outcome, should be examined.


•

Florida's Low-Income Pool (LIP) Program:

Distribution of LIP-Related Payments Before

Medicaid Reform

Niccie McKay, Ph.D.

Presented By: Niccie McKay, Ph.D., Associate


Management & Policy, University of Florida, PO

Box 100195, Gainesville, FL 32610-0195, Phone:

(352) 273-6076, Fax: (352) 273-6075, Email: nmckay@phhp.ufl.edu

Research Objective: In 2006, the state of

Florida implemented a broad reform of its

Medicaid program. One element of the reform is the Low-Income Pool (LIP) program, designed to ensure continued government support for the provision of healthcare services to Medicaid, underinsured, and uninsured populations; the

LIP program will distribute $1 billion per year.

Before Medicaid reform, a similar program was in place, called the Upper Payment Limit (UPL) program. Although the funding for both the UPL and LIP programs comes from local governments, matched by funding from the

Centers for Medicare and Medicaid Services

(CMS), LIP payments are capped at $1 billion per year. Another important difference is that funding under the UPL program was only for inpatient hospital services, while LIP funding can be used for any ‘‘Provider Access System’’ that provides a certain level of services to Medicaid, underinsured, or uninsured patients. The objective of this study is to examine the distribution of LIP-related payments during the period before reform was implemented in order to provide a baseline for examining the effects of the LIP program.

Study Design: The approved waiver from CMS covers a five-year period beginning July 1, 2006.

For symmetry, this study will cover the period

July 1, 2001 through June 30, 2006. Although the reform LIP program substituted for the prereform UPL program, providers also receive related funding from other programs.

Consequently, comparable funding must be tracked in order to give the ‘‘full picture’’ of how such payments are distributed; this study will track LIP-related payments from the Regular

Medicaid Disproportionate Share Hospital

(DSH) program and the Hospital Exemptions to

Reimbursement Ceilings program, in addition to payments from the UPL program. Before reform, LIP-related payments went almost exclusively to hospitals. The study thus will examine the relationship between LIP-related payments and the following hospital characteristics: urban/rural location; teaching status; ownership type; size; and payer mix.

Population Studied: All Florida hospitals receiving LIP-related payments over the period

July 1, 2001 through June 30, 2006. Florida’s

Agency for Health Care Administration (AHCA) will supply the data to track LIP-related payments by hospital by year. Data on hospital characteristics will come from required reports submitted annually to the state of Florida.

Principle Findings: During the period July 1,

2004 through June 30, 2005, distributions from the UPL program were $639 million, from the

Regular Medicaid DSH program were $201 million, and from the Exemptions to Ceilings program were $300 million, for a total of $1.1 billion. The study will examine how these LIPrelated payments varied by hospital characteristics, over the five years preceding

Medicaid reform in Florida.

Conclusions: The study results will yield conclusions about the distribution of LIP-related payments in the period before Florida Medicaid reform was implemented.


This study will provide important information on how Medicaid can best structure programs for the support of ‘‘safety net’’ and other providers having large numbers of patients who are lowincome and/or with little or no insurance coverage.

Funding Source: State of Florida, Agency for

Health Care Administration

•

Quality of Life Assessment within Medicaid

Complex Care Management

Richard Meenan, Ph.D., M.P.H., David Feeny,

Ph.D., David Mosen, Ph.D., Mark Spofford,

Ph.D., David Labby, M.D., Ph.D., Rebecca

Ramsay, M.P.H.

Presented By: Richard Meenan, Ph.D., M.P.H.,

Assistant Program Director, Kaiser Permanente

Center for Health Research, 3800 N. Interstate

Avenue, Portland, OR 97227, Phone: 503-335-

2484, Fax: 503-335-2424, Email: richard.meenan@kpchr.org

Research Objective: For patients, providers, and policymakers, health-related quality of life

(HRQL) is an increasingly important measure of quality healthcare. Little is known, however, about comprehensive HRQL assessments among Medicaid members receiving care management and whether such management improves outcomes. Study purposes were to: 1) compare HRQL scores among members of

CareOregon (CO), a nonprofit Medicaid health plan serving 100,000+ members, enrolled in

CO’s Complex Care Management (CCM) program vs. nonenrollees, and 2) evaluate CCM in maintaining or improving HRQL.

Study Design: CO staff administered the Health

Utilities Index Mark 2 and 3 (HUI) during existing phone-based health risk assessment interviews. The HUI® measurement system is a generic, preference-scored, comprehensive system for measuring health status, HRQL, and producing utility scores. The HUI Mark 3 (HUI3) includes the dimensions of vision, hearing, speech, ambulation, dexterity, emotion, cognition, and pain, and describes 972,000 unique health states. HUI scores were collected at baseline and 4+ months later.

Population Studied: CO members over age 18 previously identified as CCM candidates through existing health risk assessments. Missing data were imputed where possible.

Principle Findings: Responses totaled 643 (75% female for CCM assignees (N=255 [40%]) and nonassignees (N=109 [17%]); 43% assignment unknown). 25% of assignees were over age 64 vs. 36% of nonassignees (F = .01). Self-reported prevalence of comorbidities was invariant between groups. Mean baseline HUI3 for assignees was 0.19 (sd = 0.30) on a 0-1 (deadperfect health) scale; 0.25 (sd = 0.29) for nonassignees. Means are well below the 2002-

03 adult US population HUI3 norm of 0.81.

‘‘Pain’’ produced the lowest mean singleattribute HUI3 utilities (0.34 [assignees], 0.42

[nonassignees]), and was the most commonly reported dimension of health status affected in both groups (80% of all respondents reported moderate or severe pain). Other dimensions-----e.g., emotion, cognition, ambulation------exhibited moderate or severe deficits. 137 CCM candidates were interviewed at baseline and 4-5.5 months later (99 assignees, 38 nonassignees). Mean 4+month change for assignees was an improvement in HUI3 of 0.04 (sd = 0.27) vs. no mean change in HUI3 (sd = 0.29) for nonassignees. Group differences were not statistically significant, although the 0.04 HUI3 improvement among assignees is clinically important. The largest single-attribute HUI3 improvements among assignees (vs. nonassignees) were in emotion (0.07), cognition

(0.04) and speech (0.04).

Conclusions: Pain, ambulation, and emotion burdens were well known to CO, although not their magnitude. Cognition burdens had been underrecognized, an observation with important implications for organizing and managing CCM.

The validity of CO’s existing case identification algorithm is supported by overall burden observed and by consistent single-attribute decrements among assignees (vs. nonassignees). The four-month gain in HRQL indicates that CCM-related utilization reductions apparently do not come at the expense of patient outcomes.


CCM is a core competency in managing the clinical and financial risks of CO’s highest-need members. Management believes that patientreported outcomes such as the HUI are critical to building CCM’s evidence base, strengthening

CO’s existing case identification algorithm, and providing an important dimension of program assessment.

Funding Source: Kaiser Permanente

Community Benefit Initiative

•

A New Public/Private Model to Expand

Health Insurance Coverage in Arkansas

Kevin Ryan, J.D., M.A., Paula Card-Higginson,

B.A., E.L.S., Jennifer L. Shaw, M.A.P., M.P.H.,

Dr.P.H. (can.), Joseph W. Thompson, M.D.,

M.P.H.

Presented By: Kevin Ryan, J.D., M.A., Assistant

Professor / Executive Associate Director, College of Public Health / Arkansas Center for Health

Improvement, University of Arkansas for Medical

Sciences, 1401 West Capitol Avenue, Suite 300

Victory Building, Little Rock, AR 72201, Phone:

(501) 526-2244, Fax: (501) 526-2252, Email: ryankevinw@uams.edu

Research Objective: For individuals, being uninsured is correlated with poor health outcomes and increased healthcare expenses.

For the US healthcare system, widespread lack of health insurance is a substantive cost driver.

Arkansas experienced an increase in the overall percentage of uninsured between 2001 and 2004

(15.2% to 17.2%), according to a survey by the

Arkansas Center for Health Improvement. While people of all ages lack insurance, rates of uninsurance disproportionately affected lowincome adult Arkansans aged 19-64 years (25% in 2004), and more specifically 19-44 year olds

(30% in 2004). Most Arkansans with health insurance receive coverage as a benefit of employment, yet the majority of Arkansas employers report inability to offer coverage due to a lack of affordable coverage options. The majority (61%) of the uninsured were working in either full-time (45%) or part-time (16%) jobs in

2004. In response, Arkansas applied for a

Medicaid Health Insurance Flexibility and

Accountability (HIFA) Waiver to create an employer-based safety net benefit program

(ARHealthNet). We describe the unique characteristics of this public-private partnership, and discuss engagement by employers and uptake by employees.

Study Design: ARHealthNet was approved by the federal government on March 3, 2006 and began offering benefits to enrollees on 1/1/07.

The employer-based program offers an encounter-limited safety net benefit package (6 outpatient visits, 7 inpatient days, 2 outpatient procedures annually, and 2 prescriptions monthly). To qualify, employers must certify to have not offered health insurance coverage as a benefit for the 12 contiguous months prior to enrollment and to guarantee 100% participation by employees (of all income levels). Arkansas obtained approval to subsidize employees earning under 200% FPL using a combination of state tobacco settlement dollars and federal matching funds.

Population Studied: Uninsured, working

Arkansans aged 19-64 years and Arkansas employers not offering health insurance as a benefit.

Principle Findings: ARHealthNet is administered by a third party administrator

(TPA), NovaSys of Arkansas. In the first 30 days of employer recruitment, the TPA reported 606 contacts by prospective employers. Of those, twelve employers enrolled in the program representing 33 enrollee members.

Conclusions: ARHealthNet represents a unique state-level option for expanding health insurance coverage to employed low-income adults utilizing a combination of state and federal funds. We will monitor and report uptake of this program by eligible employers and employees to determine its long-term potential for reducing the level of uninsurance in Arkansas.


Rates of uninsurance continue to increase for the nation and Arkansas, negatively impacting individual health outcomes, family finances, and systemic healthcare costs. Federal solutions to address this issue have not been forthcoming.

Arkansas has created a public-private partnership that, if successfully implemented, may represent a healthcare coverage model for other similarly situated states to emulate.


• Has Welfare Reform Affected Insurance

Coverage During Pregnancy for Unmarried

Low-Skilled Women?

Kosali Simon, Ph.D., Arden Handler, Dr.P.H.

Presented By: Kosali Simon, Ph.D., Assistant

Professor, Policy Analysis and Management,

Cornell University, 106 MVR Hall, Ithaca, NY

14850, Phone: 607 255 7103, Fax: 607 255 4107,

Email: kis6@cornell.edu

Research Objective: To provide national estimates of the impact of welfare reform on the health insurance status of low-skilled women at various points in pregnancy.

Welfare reform had far reaching consequences for unmarried low-skilled women and their children, including their health insurance status.

Those who otherwise would be receiving cash assistance may have lower rates of health insurance if they failed to enroll separately for

Medicaid (whose rules did not tighten over this time period), or if the new employment they entered did not provide health benefits.

Administrative difficulties involved in accessing

Medicaid separately from cash welfare may also have been a factor in the short run. Given the importance of access to health care at all points in the pregnancy rather than just delivery alone, we look at how welfare reform has affected insurance status prior to conception, during pregnancy, and after the birth of the child.

Study Design: Our study design is based on state variation in the timing of welfare reform

(AFDC waivers and TANF implementation). Our research looks at the effect of these policies on health insurance of unmarried mothers with

High School completion or less (our treatment group) during a particularly important life event: pregnancy. We look at the effects of these policies over the time period 1990-1999, as well as over the time period 1990-2003 to explore the long run vs. short run impacts. Our comparison group consists of married mothers with High

School completion or less whose insurance experiences control for other forces acting over time within a state that might otherwise confound our results. All analyses control for other relevant determinants of health insurance, and cluster standard errors at the state level.

Population Studied: Nationally representative data from the Survey of Income and Program

Participation (SIPP) 1990-2001 panels. Sample limited to women who have children during the panel period.

Principle Findings: We find that welfare waivers of the 1990s have had no statistically discernible impacts on insurance status around the time of pregnancy, but that TANF implementation appears to have sometimes decreased access to

Medicaid health insurance, increased access to employer health insurance, and lead to a decrease in overall insurance, depending on the point in pregnancy considered and the time period of the study. When using data from 1990-

2000, which is more comparable to data used in prior studies, we found larger negative effects pre-pregnancy in Medicaid and any health insurance coverage relative to results using

1990-2003 data, but similar results one month prior to birth and 10 months post birth.

Conclusions: This study shows that pregnant women were not insulated from the negative effects on health insurance due to welfare reform in the short or long run. However, the impact on their pre-pregnancy insurance seems to be less severe in the long run. Of interest for further study and discussion are the effects of declines in insurance coverage 10 months after birth.


These findings are of significant importance for the design of policies that aim to improve maternal and child health. This is due to the link between health insurance and access to affordable care during pregnancy and during the interconceptional period, an issue that is gaining increased attention as a point of intervention.

• Service Needs of Medically Fragile Children in Georgia

Angela Snyder, M.P.H., (Ph.D. expected May

2007), Amanda Phillips-Martinez, M.P.H.,

Beverly Tyler, Mei Zhou, M.S., M.A.

Presented By: Angela Snyder, M.P.H., (Ph.D. expected May 2007), Senior Research Associate,

Georgia Health Policy Center, Georgia State

University, 14 Marietta Street Suite 221, Atlanta,

GA 30306, Phone: 404-651-5001, Fax: 404-651-

3147, Email: angiesnyder@gsu.edu

Research Objective: To identify the gaps in health services experienced by families no longer eligible for the TEFRA/Katie Beckett option through Georgia's Medicaid Program.

Study Design: Mixed method approach consisting of descriptive and bivariate analysis of

2005 calendar year Medicaid claims of children eligible through the Katie Beckett class of assistance. Utilization by service category and costs to Medicaid versus third party payers will be assessed. Focus groups of parents who experienced a loss of public coverage for their medically fragile child who live in both urban and rural settings augment the claims analysis.

Population Studied: 6573 children who were eligible for Georgia Medicaid services under the

Katie Beckett class of assistance during calendar year 2005. Two focus groups were also performed; each included 12 parents of medically fragile children who lost public coverage. One focused on families living in a rural setting and the other families living in an urban area of the

State.

Principle Findings: 71% of the children had at least one non-zero third party liability payment for services. The Medicaid payment on average was $5,032 per patient annually. For the 71% with at least one third party insurance claim, the average third party liability per patient was

$2,878 annually. More than half of the Medicaid payments were in three categories of service: therapeutic services (including physical, occupational and speech therapies), prescription drugs, and durable medical equipment. While the additional insurance also had the highest claims in the prescription drug and medical equipment categories, very few claims were paid for therapy services. These results were consistent with the parental focus groups in which parents discussed the need for assistance in securing and paying for weekly therapy services for their children.

Conclusions: For a large majority of the families who receive services through the TEFRA/Katie

Beckett Medicaid option in Georgia, Medicaid is the secondary payer. While the costs to

Medicaid of insuring these medically fragile children are over three times more than the costs for an average Medicaid enrollee in

Georgia ($1,345), the ancillary services that parents rely on Medicaid to pay for help to keep children in their homes and communities for care rather than more expensive institutions.


States or entities planning services for families of medically fragile children should be aware that public insurance programs, in general, are designed to better support home and community based care. Private insurance is more likely to pay for the child’s core medical needs rather than the ancillary services parents want and need to benefit their children’s quality of life. Ensuring access to therapeutic services for these families may be a cheap and cost effective way to meet the needs of this vulnerable group of children.

Funding Source: The Georgia Department of

Human Resources through The Community

Foundation for Greater Atlanta

•

Rates of Depressive Symptomatology and

Treatment in a Random Sample of Florida

Medicaid Enrollees

Zoe N. Swaine, M.S., Robert G. Frank, Ph.D.,

Andrea Lee, M.S., Heather Steingraber, B.A.,

Natalie C. Blevins, M.S., ,

Presented By: Zoe N. Swaine, M.S., Graduate

Assistant, Department of Clinical & Health

Psychology, Florida Center for Medicaid and the

Uninsured, College of Public Health and Health

Professions, University of Florida, PO Box

100227, Gainesville, FL 32610, Phone: (352) 273-

5931, Fax: (352) 273-5061, Email: zoe@phhp.ufl.edu

Research Objective: It has been widely shown that depression is frequently under diagnosed in outpatient settings and despite the existence of effective treatments, non-treatment is common.

This problem is particularly prevalent among low-income populations who are at a higher risk for depression. This study aimed to assess the prevalence of depressive symptomatology among Florida Medicaid enrollees, and the diagnosis and treatment rates of depression by physicians in ambulatory practice.

Study Design: Telephone surveys were conducted with a random sample of 2411 Florida

Medicaid enrollees between August 2004 and

March 2005. The point prevalence of a major depressive episode (either single or recurrent) was assessed through use of the Composite

International Diagnostic Interview (CIDI). The

CIDI is a comprehensive, fully structured interview designed for use by trained lay interviewers to assess psychological disorders.

The CIDI does not specify whether a depressive episode occurs in the course of a major depressive disorder or whether it occurs in the course of another psychological disorder (for example bipolar disorder or schizophrenia). It is widely used in epidemiological research and has been validated among many populations. The

Patient Health Questionnaire (PHQ-9) was used to support diagnosis of moderate to severe depressive symptomatology (a PHQ-9 score of

10 or higher). Medicaid claims were compiled for the years 2002, 2003 and 2004 to assess rates of diagnosis by physicians and treatment rates.

The International Classification of Diseases

(ICD-9) diagnostic codes (including all primary and secondary diagnoses), Current Procedural

Terminology (CPT) codes and therapeutic drug class codes were extracted from the claims data.

Population Studied: The population under study included a random sample of 2411 Florida

Medicaid enrollees.

Principle Findings: Results showed that one quarter of the sample met criteria for a major depressive episode as measured by the CIDI and confirmed by the PHQ-9. By contrast 7% of the sample, who had claims data, were physiciandiagnosed with a type of major depressive disorder (single episode, recurrent or unspecified). The lack of exclusion of other primary psychological diagnoses discussed above means that these depressive episodes cannot be fully attributed to a major depressive disorder. Practice guidelines for the treatment of symptoms of depression, irrespective of the etiology (with the exclusion of general medical conditions), includes antidepressant treatment and therapy. Of the 120 patients diagnosed with depression by their physician, 82% received at least one prescription for antidepressants. These rates are comparable with previous research on treatment rates of physician-diagnosed cases.

Thirty six percent of physician-diagnosed cases received at least one mental health visit

(including, but not limited to psychiatric evaluation, psychotherapy, or psychoanalysis), as assessed by the CPT codes. The rates of antidepressant treatment among surveyidentified cases of depression was 56% and 10% of survey-identified cases received at least one mental health visit.

Conclusions: This data shows there is a discrepancy between self-reported

symptomatology in the survey and physician diagnosis and treatment.


Further research must be done to determine whether this reflects an under diagnosis by physicians or whether other factors not assessed here may lead to this disparity.

Funding Source: State of Florida, Agency for

Health Care Administration

• The Impact of Organizational

Characteristics on Medicaid Managed Care

Enrollees: Evidence from Florida’s Medicaid

Reform

Amy Yarbrough, Ph.D., Christy Harris Lemak,

Ph.D.

Presented By: Amy Yarbrough, Ph.D., Assistant


Management, and Policy, University of Florida,

P.O. Box 100195, Gainesville, FL 32610-0195,

Phone: (35)271-6069, Fax: (352)273-6075, Email: ayarbro@phhp.ufl.edu

Research Objective: Medicaid enrollees represent a vulnerable segment of society, therefore, it is important to understand the influence both health plans (HMOs) and provider service networks (PSNs) have on access and quality of care. Studies of health plan organizational and environmental characteristics and their relationships to quality are rare and there are no studies that specifically examine

PSNs. Recent efforts to reform Florida

Medicaid, including the development of PSNs, offer a unique setting to extend research on health plan characteristics, access and quality.

We examine relationships between health plan

(HMO) and provider service network (PSN) characteristics and measures of quality and access in two Florida counties.

Study Design: Organizational data obtained from both CEO interviews and the Florida

Agency for Health Care Administration (AHCA) will be used in conjunction with selected survey data using both the Consumer Assessment of

Healthcare Providers and Systems (CAHPS) and the Healthplan Employer Data and Information

Set (HEDIS) measures to identify significant differences in plan quality and access.

Organizational and environmental characteristics of interest include the following:

(1) public vs. private ownership, (2) national or multi-state presence vs. local market coverage only, (3) focus specific to government payers or more diversified, (4) size of organization, and (5) level of competition in the county. CAHPS measures of interest include measures pertaining to (1) health plan satisfaction rating,

(2) getting care quickly, and (3) getting needed care. HEDIS measures include (1) adolescent and well child visits, (2) prenatal and postpartum care, (3) child and adolescent immunizations,

(4) asthma care, and (5) diabetes screening.

Population Studied: Medicaid enrollees in

Medicaid HMOs and PSNs in Broward (Fort

Lauderdale area) and Duval (Jacksonville) counties in Florida, which includes 12 plans and

6 networks covering over 80,000 Medicaid recipients.

Principle Findings: Florida’s Medicaid Reform began in September of 2006 with 12 HMOs and

6 PSNs participating in the program so far. In

Broward county, 9 HMOs and 4 PSNs are operational, with HMOs capturing approximately

57% of the market share. In Duval county, 3

HMOs and 2 PSNs are operating, and over 70% of the market share belongs to 2 providers.

Market share is split evenly between HMOs and

PSNs, with HMOs representing 51% of market share and PSNs representing the remaining 49 percent. Overall, 47% of the providers are publicly traded, and 47% are multi-state organizations. Approximately 59% of participating organizations are focused either on

Florida’s Medicaid reform specifically or on government programs. After the initial 6 months of reform, CAHPS and HEDIS measures will be analyzed to assess preliminary differences in quality among plans.

Conclusions: Based on the differences observed in the HMOs and PSNs participating in

Medicaid reform, we will assess variation in provider quality and access based on differing plan and network organizational and environmental characteristics.


The provision of high quality care is vital to the success of Florida’s Medicaid reform initiative.

Information on the types of health plans capable of delivering the highest levels of quality and access can be factored into future decisions regarding reform initiatives in both Florida and the rest of the country.

Funding Source: Florida Agency for Health Care

Administration (AHCA)

• Medicaid Payments for Pediatric Dental

Services

Mina Zadeh, M.P.H., currently a doctoral student, Scott Hutchison, M.S., Sarah Ambrose,

M.P.A.

Presented By: Mina Zadeh, M.P.H., currently a doctoral student, Program Analyst/Team Leader,

Office of Inspector General, US Department of

Health and Human Services, 61 Forsyth Street,

SW, Suite 3B80, Atlanta, GA 30303, Phone: 404-

562-7739, Fax: 404-562-2994, Email: mina.zadeh@oig.hhs.gov

Research Objective: The objectives were: (1) to assess the appropriateness of Medicaid payments for pediatric dental services, and (2) to identify and assess edits used in the States to process Medicaid claims.

Study Design: Inappropriate payments for

Medicaid represent a potential emerging vulnerability to both State and Federal budgets.

All State Medicaid agencies are required by law to implement claims analyses (including medical record review) in their claims processing systems. To ensure appropriateness of payments for claims, States implement fully automated computer edits that are coded into their Medicaid claims processing system. The purpose of system edits is to ensure that the services billed by providers are properly processed and paid in accordance with Federal and State laws, regulations, and policies. If a claim triggers a system edit, it may be suspended, denied, or paid and reported to the

State for further review.

Population Studied: A medical record review was completed on 1,824 Medicaid services that were rendered during January to June of 2003 in five selected States. Data was collected from all

50 States to identify and assess system edits that were used to process Medicaid pediatric dental claims.

Principle Findings: In this report we determined the appropriateness of Medicaid payments for pediatric dental services that were rendered in five States during calendar year 2003.

We also obtained data from States on the system edits they used to process Medicaid claims. We identified a number of challenges associated with analyzing this data and will be able to report on these challenges. This report is in draft and has not been signed by the Inspector General.

We expect to have the report signed by the time of the conference.

Conclusions: This report is in draft and has not been signed by the Inspector General. We expect to have the report signed by the time of the conference.

Implications for Policy, Practice or Delivery: In this report, we provide policy recommendations to the Centers for Medicare & Medicaid Services on how they can improve the Medicaid program.

The intent of this report was to ensure the appropriate use of the Federal funds and prevent fraud, waste, and abuse of the funds.

Funding Source: Department of Health and

Human Services

• The Medicaid Cost-Containment Strategies and Health Quality Outcomes in Medicaid

Enrollees

James Zhang, Ph.D., James X. Zhang, Ph.D.

Presented By: James Zhang, Ph.D., Research

Associate Assistant Professor, Medicine, The

University of Chicago, 5841 S. Maryland Avenue,

(MC 2007), Chicago, IL 60637, Phone: (773)834-

1956, Fax: (773)834-2238, Email: xzhang@medicine.bsd.uchicago.edu

Research Objective: Since 2001 states have been intensifying their efforts to control rising healthcare costs in their Medicaid programs. The federal government has afforded states control in the management of their healthcare budget deficits and a primary way in which states have attempted to solve their fiscal problems is by implementing Medicaid cost-containment strategies. This study examines the relationship between nine Medicaid cost-containment policies and enrollees’ satisfaction with healthcare services and unmet healthcare needs.

Study Design: A cross-sectional analysis was performed, using a sample of 2,283 Medicaid enrollees from the 2003 Community Tracking

Study. Multivariate regression analyses were conducted to ascertain the association between the cost-containment strategies and health quality outcomes including enrollees’ satisfaction with healthcare services and unmet healthcare needs, controlling for respondents’ race, age, sex, education, family income, family type, and general health status.

Population Studied: A sample of 2,283

Medicaid enrollees from the 2003 Community

Tracking Study

Principle Findings: The results show that enrollees who lived in states that had implemented strategies to reduce healthcare spending reported higher rates of dissatisfaction with healthcare than enrollees in other states.

Eligibility reductions or restrictions demonstrated the strongest correlation to enrollee dissatisfaction levels. By contrast, no statistically significant association was found between cost-containment policies and unmet healthcare needs, except in states where

Medicaid fraud detection programs were implemented.

Conclusions: The Medicaid cost-containment strategies and health quality outcomes in

Medicaid enrollees were closely associated. This result may also be indicative of Medicaid patients being very price sensitive, causing any actions that raise the price of healthcare to significantly reduce the medical services consumed by those enrolled in Medicaid. This tendency represents an important finding in that small changes in medical costs could potentially have a considerable impact on many low-income

Americans’ access to quality healthcare.


The study suggested policymakers should attempt to develop other programs to complement Medicaid and compensate for its deficiencies. They should also direct funding toward determining the specific dimensions of

Medicaid cost-containment that have influenced enrollees’ perceptions of healthcare.

• Encouraging Eligible Children’s

Participation in Public Health Insurance: The

Role of National Awareness Campaigns

Jeanette Ziegenfuss, B.A.

Presented By: Jeanette Ziegenfuss, B.A.,

Doctoral Candidate, Health Policy and

Management, University of Minnesota, 2221

University Avenue, #345, Minneapolis, MN

55414, Phone: 612.327.1938, Fax: 612.624.1493,

Email: zieg0100@umn.edu

Research Objective: More than 70 percent of uninsured children remain uninsured because while eligible, they are not enrolled in public health insurance programs. This study evaluates the role of national awareness campaigns in promoting public insurance programs for children. The impact of national campaigns has not been assessed although widely believed to be important for awareness and subsequent enrollment. This study identifies the role of outreach on enrollment by examining the national Robert Wood Johnson’s ‘‘Cover the

Uninsured Week’’ and ‘‘Back to School’’ campaigns. We 1) document the change in enrollment in public insurance between 1996 and 2005, 2) identify markets targeted by RWJ, 3) quantify the funding levels and media coverage of each awareness campaign, and 4) estimate the relative impact of these campaigns in increasing public program enrollment controlling for other factors known to increase enrollment.

Study Design: A quasi-experimental design is utilized to estimate the extent that national awareness campaigns influence program participation. The key explanatory variables are the campaigns, which vary with respect to timing and targeted markets, both by geography and race/ethnic subpopulations. Campaign variables and state program features are merged with the

Current Population Survey Annual Social and

Economic Supplement (CPS-ASEC). Controlling for program, family, and individual characteristics, the campaigns’ impact on enrollment is estimated. To validate the results, monthly enrollment patterns relative to the timing of the campaigns are documented using

Medicaid enrollment data.

Population Studied: Children 18 years and under living in the U.S. estimated to be eligible for public health insurance coverage between the years 1996 and 2005 constitute the population of interest.

Principle Findings: Some, but not all, of the variation in the portion of children eligible but uninsured by state, demographic subpopulation, and over time can be attributed to the presence of national awareness campaigns. Children living in states identified as target markets for these campaigns were more likely to be enrolled in a public program after the campaign than they were before the campaign. This change was not seen in non-targeted markets. Likewise, children in targeted demographic subpopulations (i.e.,

Hispanic children in Florida) were more likely to be enrolled.

Conclusions: The RWJF national awareness campaigns positively impact enrollment in public insurance programs. There is evidence that they are more effective for certain subpopulations, such as children of adults with higher educational attainment. The differential effects and the remaining unexplained differences point to the need to further conceptualize education and outreach.


Eliminating uninsurance as a way to increase access to health care and improve health status is one of the goals of Healthy People 2010. From the beginning of SCHIP implementation, effective outreach has been cited as a necessary factor for program success. However, because of the difficulties in measurement it is often cited as an immeasurable confounder in studies of the impact of program design on enrollment. This research provides a systematic analysis of the extent to which education works to increase enrollment. In the context of incremental reform, it is important to determine the extent behavior can be motivated by external forces. As states move toward consideration of universal coverage

for children, understanding factors associated with enrollment is increasingly important.


Medicare

•

Disabled Medicare Beneficiaries:

Benchmarking Drug Coverage on the

Threshold of Part D

Amy Davidoff, Ph.D., Bruce Stuart, Ph.D.

Presented By: Amy Davidoff, Ph.D., Assistant

Professor, Pharmaceutical Health Services

Research, U Maryland School of Pharmacy, 220

Arch Street, Baltimore, MD 21201, Phone:

(410)706-5397, Fax: (410)706-5394, Email: adavidof@rx.umaryland.edu

Research Objective: The Medicare

Modernization Act created a new drug benefit

(Part D), provided through a combination of

Medicare Advantage and stand-alone prescription drug plans (PDPs). Baseline (pre-

Part D) patterns of supplemental medical and prescription coverage have been documented for the elderly. However, given their unique patterns of marital status, age, and labor force participation, non-elderly disabled Medicare beneficiaries are likely to have different patterns of supplemental coverage. This study uses the most recent national survey data to estimate supplemental medical and prescription drug coverage, and examine the association between coverage and access for this vulnerable Medicare population.

Study Design: This study uses bivariate and multivariate methods to analyze data from the

2005 National Health Interview Survey (NHIS), characterizing patterns of supplemental medical and prescription drug coverage, and the relationship between coverage and unmet need for prescription drugs. The NHIS collects current information on whether privately purchased plans cover prescription drugs. For persons reporting Medicaid, Military, or Medicare

Advantage plans we assume that drug coverage is provided, but recognize that this may overstate coverage estimates. The primary focus is the non-elderly disabled beneficiary; patterns are compared to the elderly beneficiary population.

Population Studied: Non-elderly, disabled but non-institutionalized adult Medicare beneficiaries (N=1,546).

Principle Findings: Preliminary estimates for the non-elderly disabled beneficiaries indicate that 42% lacked supplemental medical coverage,

27% were enrolled in Medicaid (‘‘dual eligible’’),

20% reported employment related and 7% reported non-group or other private insurance.

Overall, 45% lacked any source of drug coverage and 23% reported unmet need for prescription drugs; 37% of those without drug coverage reported unmet need, as did 24% of those with

Medicaid. Being near-poor and Hispanic were associated with lower rates of drug coverage. Of those without drug coverage, 26% were poor and another 21% had incomes below 150% of

FPL. Among non-institutionalized elderly

Medicare beneficiaries, a smaller proportion lacked supplemental medical coverage (26%) or were enrolled in Medicaid (7%), while 34% reported employment related coverage and 28% reported Medigap or other private coverage.

While 42% lacked prescription drug coverage, only 5% reported unmet need for prescription drugs.

Conclusions: Almost half of disabled non-elderly

Medicare beneficiaries lacked prescription drug coverage in 2005, and lack of coverage was associated with high levels of unmet need. Those most likely to lack drug coverage were among those typically facing access disparities. Patterns differed for the elderly and access problems were much less frequent.


Implementation of Medicare Part D is likely to have important impacts on coverage and access to prescription drugs, particularly for those without other sources of coverage, and for those with elevated drug needs. The non-elderly disabled Medicare beneficiaries could benefit substantially from access to Part D coverage. As many have incomes that qualify them for subsidized coverage, participation rates should be high. The transition to Part D for duals may have mixed effects on access. High rates of unmet need suggest that current coverage is inadequate, but the transition may create new access barriers. These impacts should be monitored closely to ensure adequate coverage and access for this vulnerable population.

•

The Results from a Service-Specific

Payment Approach as a Replacement for the

Current Medicare Payment Method

Martey Dodoo, Ph.D., Robert Phillips, Jr,, M.D.,

M.S.P.H.

Presented By: Martey Dodoo, Ph.D., Senior

Economist, The Robert Graham Center, 1350

Connecticut Avenue, NW, Ste 201, Washington,

DC 20036, Phone: 202-331-3360, Fax: 202-331-

3374, Email: mdodoo@AAFP.org

Research Objective: Medicare uses the

Conversion Factor/Sustained Growth Rate

(CF)/SGR) method to pay physicians for their services. Most consider the CF/SGR method flawed. The CF/SGR was designed to redistribute spending to primary care and control service volume and spending. However, it has failed to achieve either of these objectives. Researchers, policy makers and Federal legislators want to revise, eliminate or replace CF/SGR, but seem unable to identify good alternatives. In this study we present the results of estimations of the elasticity of the CF to changes in its elements, and computer simulations of a service-specific approach to Medicare physician payments ---- an alternative to the current payment method.

Study Design: We specified and estimated a model that simulates CMS calculations of the

CF/SGR portion of the current Medicare physician payment method, and calculated the point elasticity of CF to changes in its main elements. We derived a replacement for the current method based on the same formulae but with separate formulae for Evaluation and

Management (E&M) services, and separate formulae for non-E&M services. Our replacement includes a 3% Medicare Economic

Index (MEI) floor for E&M services to promote primary care. We estimated the budget implications of such a payment method using

Medicare claims data for 2004.

Population Studied: Medicare beneficiaries and physicians.

Principle Findings: We found CF to be relatively inelastic with respect to the SGR (e = 0.479) and actual expenditure levels (e = 0.674), and relatively elastic with respect to MEI (e = 9.645) and expenditure target levels (e = -2.184). In the

CF range 25 to 40, each unit increase in the CF results in a 3% increase in budget expenditures.

With the service-specific payment approach, which we propose as a replacement for the current CF/SGR, Medicare could accrue about

$1.3 Billions net savings per year with each 1% increase in the MEI floor. We also demonstrated that temporary Congressional overrides of the

CF are more damaging in the long-term for the

Federal budget and for physicians.

Conclusions: As presently constructed, we cannot effectively enhance the CF/SGR method by simple tweaks of the SGR or other elements of the Medicare payment method.


Our study demonstrates we can redesign the

Medicare physician payment method so we pay for what we really need. What we need are better outcomes for beneficiaries so we can provide incentives to primary care to produce that and to control Medicare spending. Our proposed E&M service-specific payment system achieves those aims. It also provides a system in which one can focus on achieving adequate accountability by each group of physicians separately. Secondly it allows policy makers to set up policy specific measures to promote access to primary care, case management and cognitive services. Third, it will provide the potential for focusing on formula changes to fulfill the intent of the 1989

OBRA legislation.

• Antidepressant Selection and Adherence in

Dual Eligibles Newly Initiated on

Antidepressant Therapy

Jalpa Doshi, Ph.D., Steven Marcus, Ph.D., Daniel

Polsky, Ph.D., Pengxiang Li, Ph.D.

Presented By: Jalpa Doshi, Ph.D., Research

Assistant Professor, Division of General Internal

Medicine, University of Pennsylvania, 423

Guardian Drive, Blockley Hall 12th Floor,

Philadelphia, PA 19104, Phone: 215-898-7989,

Fax: 215-898-0611, Email: jdoshi@mail.med.upenn.edu

Research Objective: Antidepressants are the most commonly used psychotropic drugs in low income and disabled individuals with both

Medicare and Medicaid (i.e. dual eligibles).

Adherence to antidepressant therapy is critical in the management of depression and has been shown to improve outcomes for other comorbidities as well. This paper examines antidepressant selection and adherence in dual eligibles newly initiated on antidepressant therapy.

Study Design: This study uses the 1999-2000

Medicaid claims data from all 50 states and D.C.

The study sample consists of noninstitutionalized dual-eligibles with a diagnosis of depression (ICD-9-CM 296.2, 296.3, 298.0,

300.4, 309.1, or 311) who newly initiated antidepressant therapy between 01/01/2000 and

06/30/2000. Patients without 6-months of continuous Medicaid eligibility before and after the first antidepressant fill date in this period

(i.e. index date) were excluded. New initiation of antidepressants was defined based on the absence of any previous antidepressant use in the 6 months prior to the index date.

Antidepressants were classified as old generation (e.g. tricyclic antidepressants,

MAOIs) or new generation antidepressants (e.g.

SSRIs, SNRIs). Adherence was measured as the proportion of days with antidepressant use (i.e. medication possession ratio [MPR]) in the 180day period after the first antidepressant fill date.

Patients who had an MPR > 80% were defined as being adherent. Multivariate analyses were conducted to identify demographic, clinical, and state-level variables associated with antidepressant selection and adherence.

Standard errors were adjusted for clustering of individuals within states.

Population Studied: 28,996 aged and disabled dual eligibles who were newly initiated on antidepressant medications for depression across all 50 states plus D.C.

Principle Findings: The sample had a mean age of 56.2 years and was predominantly female

(70%) and white (67%). About 41% of the sample included disabled under age 65 dual eligibles. About 93% of the sample was initiated on a new generation antidepressant (66% on

SSRIs and 27% on other new agents). The mean

MPR in the overall sample was 0.56. Only 33% of the sample was adherent (i.e. MPR >= 0.80).

Multivariate analyses revealed that disabled under age 65 duals were more likely to receive newer antidepressants than elderly duals [OR 2.8

95% CI (1.5-5.4)]. Initiation on a new antidepressant was an important predictor of adherence to antidepressant therapy [OR 2.1

95% CI (1.4-3.1)]. African Americans had significantly lower odds of adherence compared to Whites [OR 0.35 95% CI (0.15-0.80)] and this racial difference persisted even among the subset initiated on a new antidepressant [OR

0.34 95% CI (0.14-0.83)]. No other demographic or state-level variables were associated with antidepressant adherence.

Conclusions: The vast majority of the dualeligibles with depression were initiated on new generation antidepressants; however, adherence to antidepressant treatment was poor overall and substantially lower among African

Americans.


This study highlights the suboptimal adherence patterns to antidepressant medications in dual eligibles in the pre-Part D era. It will be critical to monitor the impact of the transition of dual eligibles from Medicaid to private Medicare Part

D plans on adherence to antidepressants in this vulnerable population. While Part D rules require all antidepressant agents be covered on plan formularies, it remains to be seen as to how the opposing influences of drug management tools (e.g. prior authorization, step therapy requirements) and quality improvement efforts

(e.g. medication therapy management programs) under Part D will influence antidepressant selection and adherence.

Funding Source: National Institute on Aging, the Boettner Center for Pensions and Retirement

Security at the University of Pennsylvania, and

National Institute of Child Health and

Development Population Research Infrastructure

Program

• Does Medicare Need Two Payment Systems for Inpatient Psychiatric Units?

Edward Drozd, Ph.D., Jerry Cromwell, Ph.D.

Presented By: Edward Drozd, Ph.D., Senior

Research Economist, RTI International, 1440

Main Street, Suite 310, Waltham, MA 02451,

Phone: 781-434-1716, Fax: 781-434-1701, Email: edrozd@rti.org

Research Objective: Acute hospitals are currently paid differently for Medicare psychiatric inpatients based on location------patients in units classified as Medicare-Certified Distinct Part

Psychiatric Units (DPUs) and are paid for on a per diem basis under the new Inpatient

Psychiatric Facility Prospective Payment System

(IPF-PPS), whereas others are paid for on a percase basis under the Acute Inpatient Prospective

Payment System (IPPS). Payment for these patients under the IPPS was intended for occasional patients admitted to facilities without organized units. However, certifying a unit as a

DPU is optional, and many ‘‘scatterbed’’ patients may be treated in organized units. This study examines the case mix and cost differences across these care settings to help evaluate whether maintaining two distinct payment systems is warranted.

Study Design: Claim-level data on all Medicare discharges during 2003----2005 were extracted from the 100% National Medicare Provider

Analysis and Review (MedPAR) datasets. These data were supplemented by Medicare Cost

Report data to convert claim charges to costs.

Case mix was measured using Medicare

Diagnosis Related Groups (DRGs), AHRQ

Healthcare Cost and Utilization Project (HCUP)

Comorbidity Software, and Project teamdeveloped comorbidities. Both descriptive and regression analyses of per diem costs between patients discharged from DPUs, from units other than DPUs in hospitals with a DPU, and from hospitals without a DPU were conducted to find differences in case mix across these settings and

the contribution of those settings to revenues and cost.

Population Studied: Medicare patients discharged from an inpatient psychiatric facility in 2004.

Principle Findings: Of the 625,222 Medicare discharges with a psychiatric DRG in 2004, a total of 249,220 (39.9%) were not discharged from a DPU. Patients in DPUs have greater average lengths of stay than do non-DPU patients (11.1 versus 5.8 days) even when controlling for DRG and comorbidity status.

DPU patients are on average younger those not discharged from a DPU. DPUs treat significantly fewer DRG 012 and 023 (Degenerative Nervous

System Disorders, and Nontraumatic Stupor and

Coma, respectively) and substance abuse (DRGs

433 and 521----523) patients. Major depression patients in DPUs are five times as likely to undergo electroconvulsive therapy (ECT) than are such patients not in DPUs. Non-DPU discharges also exhibit higher rates of comorbidities (46.6% versus 41.8%), largely due to medical comorbidities. Total average per diem costs are lower in DPUs than in DRG units, by more than $125 per day, due entirely to greater average per diem ancillary costs. After controlling for case mix, per diem cost differences across these settings are small (less than 2%).

Conclusions: There are distinct differences in case mix between DPU and non-DPU patients, with neurological-based psychiatric and substance abuse disorders, and medical comorbidities, more prevalent among non-DPU patients. These case mix differences account for nearly all of the cost differences across these settings.


Understanding the degree to which case mix differences in these patients across care settings can explain cost differences can help guide CMS’ policies of maintaining separate payment systems for these patients.

Funding Source: CMS

•

Promoting Proactive Health Care Coverage

Decision Making among Medicare

Beneficiaries

Jack Fyock, Ph.D., Sunyna Williams, Ph.D., Amy

Heller, Ph.D., Christopher Koepke, Ph.D.

Presented By: Jack Fyock, Ph.D., Vice President,

GFA, Market Strategies, 1725 Duke Street,

Alexandria, VA 22314, Phone: 703-229-5206, Fax:

703-229-5219, Email: jack_fyock@marketstrategies.com

Research Objective: Medicare beneficiaries have the opportunity to change their health care coverage during the annual open enrollment period. Beneficiaries can decide whether to keep their current coverage or select a coverage option that better fits their health care needs.

One of the Centers for Medicare & Medicaid

Services’ (CMS) communication objectives is to promote this annual review. This goal of this research was to develop a comprehensive conceptual model of health behaviors and attitudes in relation to encouraging Medicare beneficiaries to more actively engage in their healthcare decision making and thus, make more informed decisions.

Study Design: The study consisted of a limited literature review, focus groups designed to develop a conceptual model of health decisions centered on health behavior change factors, personal responsibility, and personal attributes and a telephone survey. From the qualitative work, a matrix was developed that matched survey questions to each of the six psychosocial factors leading to the development of the survey.

This survey used the decision whether or not to enroll in Medicare Part D as an example of making a health coverage decision.

Population Studied: Medicare Beneficiaries 65 years of age and older.

Principle Findings: The literature review identified six psychosocial factors (i.e., significance, greater good, confidence, ability, role models, and rewards) as having the potential to influence proactive Medicare decision making. Findings from focus groups supported the notion that these psychosocial variables and personal responsibility relate to how Medicare beneficiaries make health decisions. The telephone survey findings also provided support to the notion that these psychosocial variables could play a role in encouraging active decision making related to

Medicare health care coverage. A series of regression analyses conducted on four dependent measures related to a decision about enrolling or not in a Medicare PDP and each psychosocial factor alone found that Rewards,

Transparency, Relying on Others, Self-Efficacy, and Personal Responsibility all predicted proactive decision making. Results from the regression analysis of all six factors together and select personal attributes, however, suggested that the psychosocial variables may be unrelated to the decision to compare plans. Latent class analysis investigated whether the non-significant effect associated with these factors was being

masked by the existence of differing groups within the overall sample. This latent class analysis revealed the existence of two contrasting segments. The first segment, covering twothirds of the sample, appears to represent beneficiaries that compared plans on their own, whereas the second group, about one-third, relied on others when deciding on a PDP.

Conclusions: In the coming years, beneficiaries will have more ways to package their health care coverage and the scope of their options will be extensive. Results of this study suggest that

CMS could leverage several well-known factors associated with behavior change models that would advance active decision making.


The results also show, however, that to accomplish this task, CMS may need to develop different sets of communication messages tailored to dissimilar audience segments.

Funding Source: CMS

• Dual Eligibles and the Transition to

Medicare Part D: Findings from the Part D

Community Monitoring Collaborative

Swati Garg, M.P.H.

Presented By: Swati Garg, M.P.H., Research

Analyst, Community Service Scoeity, 105 East

22nd Street, New York, NY 10010, Phone: (212)

614-5582, Fax: (212) 614-9441, Email: swatikgarg@gmail.com

Research Objective: The Medicare Part D

Community Monitoring Collaborative Project was commissioned to determine the effects of the Medicare Prescription Drug Benefit on

Medicaid and Medicare eligible consumers in

New York. As of January 1, 2006, this new benefit fundamentally changed the way dual eligible consumers accessed their medications.

This study was designed to assess how complicated that switch was for dual consumers.

Study Design: The Community Service Society collaborated with seven community-based organizations that provide direct client services to dual eligible populations. The community based partners collected individual case data from clients who had Part D issues from

November 2005 through August 2006. The data collection form documented the types of problems and resolutions clients encountered while navigating the Part D benefit. Case data were maintained in MS Access and SPSS data files, and analyzed by the project manager.

Population Studied: Dual consumers seemed least prepared for the switch to Part D because their prescription drug needs were previously well met by Medicaid. To attain a comprehensive view of the impact of Part D, community based organizations that work with different segments of the dual eligible consumer population were selected. All dual eligible consumers who sought assistance from the partner organizations were eligible included in the study.

Principle Findings: 783 cases documenting specific problems with Part D were collected.

The majority of problems were related to enrollment and auto-assignment into Part D plans; 64.2% of all cases had at least one enrollment/auto-assignment issue. 44.6% of cases reported a consumer difficulty with filling prescriptions. 16.2% of cases had an issue with choosing a plan, and 15.6% of cases had a language barrier issue. In 15.1% of all cases clients went without a needed prescription, and in 8.7% of cases clients paid out-of-pocket beyond the standard copays to obtain their medication. Problems with the Medicaid Wrap declined after March ’06 (10.1% vs. 3.1%), suggesting that Medicaid wraparound protections worked for duals.

Conclusions: The implementation of the Part D drug benefit was particularly hard for its most vulnerable consumers. This program requires the individual to navigate a complex system and contribute financially in order to access prescription medications. For dual eligible consumers, the increased complexity and cost sharing introduced by Part D is detrimental to their prescription drug access.


The data suggest that the Medicaid Wraparound worked to cover prescription drugs and other medications that were not covered by dual consumers’ Part D plans. The wrap likely reduced the incidence of forgone medications in

2006, but in 2007 the end of the wrap will likely increase prescription access problems. The initial implementation and auto-assignment problems that arose in 2006 are likely to cause difficulty again in 2007 because benchmark plans are drastically changing, and many dual consumers will again be switched. Even for those proactively choosing a plan, the increase in complexity in 2007 as well as the lack of access to accurate information may make choosing a plan difficult

Funding Source: United Hospital Fund; New

York Community Trust; Altman Foundation

• Assessing the Impact of Medicare Reforms at the State Level: The State Medicare Impact

Profile Pilot Project

Stephanie Jarosek, R.N., B.S.N., Donna Spencer,

M.A., Timothy Beebe, Ph.D.

Presented By: Stephanie Jarosek, R.N., B.S.N.,

Research Assistant, Health Policy and

Management, School of Public Health,

University of Minnesota, State Health Access

Data Assistance Center (SHADAC), 816

Yorktown Place, Eagan, MN 55123, Phone: (612)

625-9135, Fax: (612) 624-1493, Email: herb0079@umn.edu

Research Objective: As Medicare faces the challenges of growing health care costs and a growing elderly population, ongoing reforms are likely. Currently, comprehensive and systematic data concerning the impact of Medicare reforms at the state level is lacking. This pilot project assesses the feasibility of compiling comparable state-level indicators to examine the impact of

Medicare reforms on individual states and variation of impact by state context. Two recent

Medicare reforms chosen for the pilot project were the introduction of means testing for

Medicare Part B premiums and the redistribution of Graduate Medical Education ----

GME- resident caps financed by Medicare.

Study Design: Reform topics were selected to examine and highlight reform impacts from multiple perspectives, e.g., state governments, beneficiaries, health care markets, and providers.

Microdata and summary data were compiled and analyzed at the state level to assess differences between the states on select pilot indicators regarding the two reforms. The five states chosen for the pilot were Florida,

Minnesota, North Dakota, Pennsylvania, and

Washington.

Population Studied: Microdata from the 2002 to 2004 American Community Survey were used to assess the impact of high income means testing of Medicare Part B premiums on elderly beneficiaries. To examine the impact of the reallocation of GME slots on hospitals, we relied on provider-level data from the Centers for

Medicare and Medicaid Services -CMS-, including the 2002 Hospital Cost Reporting

Information System and correspondence with states regarding the redistribution of Direct and

Indirect Medical Education -DME and IME- slots.

We also used summary data from the National

GME census to inform the analysis.

Principle Findings: There is significant state variation across the reform indicators. The number of elderly affected by Part B premium means testing in each state ranged from 1.6 percent in North Dakota to 4.2 percent in

Florida, while 2.9 percent of the United States elderly population was affected overall. The redistribution of GME slots also impacted states differently. All states in our pilot experienced a net gain in DME slots, but the number of slots ranged from 5.5 in North Dakota to 107.1 to

Pennsylvania. Florida and Pennsylvania experienced net losses in IME slots, -30.4 and -

9.9, respectively, while the other 3 states gained between 2.5 and 24.9 slots. Information compiled on select pilot indicators qualitatively informs the variation but is unable to provide complete explanation; for example, number of providers in each state does not fully explain the variation in the redistribution of resident slots.

Conclusions: Generating systematic data to assess the impact of Medicare reforms at the state level is challenging but valuable. Further investigation into the factors contributing to important state variations and compiling data on these indicators would aid in modeling state impacts for decision making.


The variation observed in the impacts of

Medicare reform highlights the importance of considering the consequences of Medicare reform at local, regional and state levels and highlights a role for states and other groups, such as the National Governor’s Association, in

Medicare policy debates.

Funding Source: Mayo Foundation for Medical

Education and Research

•

Does Knowledge of Future Medicare

Coverage Impact Current Health Care

Decisions?

Tricia Johnson, Ph.D., Andrew Garman, Psy.D.,

Scott King, M.A., Anthony Perry, M.D.

Presented By: Tricia Johnson, Ph.D., Director,

Center for Health Management & Policy

Research, Health Systems Management, Rush

University, 1700 West Van Buren Street, TOB

Suite 126B, Chicago, IL 60612, Phone: (312) 942-

7107, Fax: (312) 942-4957, Email: tricia_j_johnson@rush.edu

Research Objective: Fragmented care and duplicated services have historically plagued the management of chronic conditions in the elderly, where care has focused on treating acute episodes of illness rather than chronic problems.

Decisions made by the near elderly prior to becoming eligible for Medicare about the timing

and types of services used to manage chronic conditions, such as diabetes and heart disease, ultimately affect their health status and patterns of health care use at the time of Medicare enrollment. This project explores differences in the decision making processes between the near elderly with chronic conditions who delayed needed care until receiving Medicare and those who obtained timely care. Specifically, this study examines how uninsurance and under-insurance impact health care decisions for the near elderly with chronic conditions.

Study Design: This project identifies factors associated with the decision to delay health care needed to treat a chronic medical condition. A two-phase qualitative analytic process is used, applying a modified critical incident methodology. The first phase includes a series of in-depth interviews with key informants ---- twenty individuals who had diabetes, hypertension and/or arthritis and had recently become eligible for Medicare coverage. Individuals were asked to explain their thought processes at a time when they had to make important decisions regarding seeking or delaying health care for their chronic condition(s), shedding light on the interplay between the symptoms and severity of the health condition and insurance, employment and other barriers to access. Critical incidents were identified and content classified using a grounded theory approach. Interview findings were validated through a follow-up survey of the key informants.

Population Studied: Individuals age 65 to 67 with Medicare coverage and have diabetes, hypertension or arthritis.

Principle Findings: Results of the in-depth interviews and follow-up survey identify qualitative and quantitative differences among persons who decide to delay care for their chronic conditions and describe the perceived importance of knowledge about future Medicare eligibility, current insurance coverage and other factors in making health care decisions. These results are used to develop a more comprehensive set of hypotheses on the relationship between insurance coverage, health care and chronic conditions.

Conclusions: A more detailed understanding of the decision making processes and moneyhealth trade-offs made by the near elderly with chronic conditions is needed. These results help to identify the specific ways in which various factors serve as barriers to care and to design interventions to reduce the disabling effects of chronic illness for this high cost and highly disabled segment of the population.


Understanding the long term effects of individuals' decisions about how to manage their chronic conditions before turning age 65 is critical, as policymakers search for ways to stem the rising health care costs associated with chronic illnesses. These results directly inform the policy debate on the importance of Medicare buy-in programs and the Medicare eligibility age by filling an important void in understanding the implications of uninsurance and under-insurance for the near elderly with chronic illnesses.

• A Business Case for Quality in Medicare

John Kautter, Ph.D., Gregory C. Pope, Ph.D.,

Jeremy Green, B.A.

Presented By: John Kautter, Ph.D., Senior

Economist, Health Care Financing & Payment,

RTI International, 1440 Main Street, Suite 310,

Waltham, MA 02451-1623, Phone: (781) 434-1723,

Fax: (781) 434-1701, Email: jkautter@rti.org

Research Objective: A fundamental requirement for the success of pay-forperformance initiatives is the development of methodologies for the measurement and profiling of provider quality and efficiency of care performance. In this study we conduct a simulation of a valid and operationally feasible quality and efficiency profiling methodology for large physician organizations.

Study Design: We test the profiling methodology on organizations serving Medicare fee-for-service beneficiaries in the Boston metropolitan statistical area (MSA) during 2002.

We identify physician organizations and their patients in Medicare claims, profile the quality and efficiency of care they provide, and describe their patient populations and service mix. Our statistical power analysis of the statistical testing of efficiency differences showed that only large physician organizations with 2,000 or more patients could be reliably profiled for efficiency.

Population Studied: Large physician organizations serving Medicare fee-for-service beneficiaries in the Boston MSA during 2002.

Principle Findings: Among the 30 physician organizations with at least 2,000 beneficiaries,

21 provided composite quality that differed statistically from the Boston MSA average.

Eleven organizations exhibited relatively high quality based on their composite quality scores, and 10 organizations exhibited relatively low quality. We found that patient casemix------and to a much lesser extent, geographic location and hospital teaching status------ accounts for most of

the variation in the per capita Medicare expenditures of patients assigned to large physician organizations. These adjustments reduce the expenditure variation among organizations by 87 percent. We also examined the relationship between quality and efficiency performance in large physician organizations.

There appears to be a positive relationship between measured quality and efficiency, with physician organizations exhibiting higher quality also exhibiting higher efficiency. The physician organization in our sample that scored highest on quality performance also scored highest on efficiency. Over all 30 organizations we profiled, we estimate that a 10 percentage point increase in the composite quality score is associated with a 3.7 percentage point reduction in actual versus predicted cost of care.

Conclusions: Our findings suggest that large physician organizations exhibiting high quality of care tend to also exhibit high efficiency. Although the findings about the correlation of quality and efficiency are limited to the profiling indicators, geographic area, sample of physician organizations, and time period used in this study, and statistically are not exceptionally strong, they are suggestive and do add support for a business case for quality in Medicare.


The absence of a business case for improving health care quality is widely acknowledged to be a major obstacle to improving health care. One necessary condition for making a business case for quality is knowledge of the relationship between quality and efficiency. If it can be shown that high quality physician organizations are also the most efficient, then this would add support for a business case for quality. Medicare, and other payers, could improve both the quality of care and its efficiency by directing patients to these providers.

Funding Source: CMS

• The Impact of the Inpatient Psychiatric

Facility Prospective Payment System (IPF-

PPS) on Rural Provider Closure Risk

Jan Maier, M.P.H., R.N., Fred Thomas, Ph.D.

Presented By: Jan Maier, M.P.H., R.N., Research

Associate, , RTI International, 1440 Main Street,

Suite 310, Waltham, MA 02451, Phone: 781-434-

1731, Fax: 781-434-1701, Email: jmaier@rti.org

Research Objective: The implementation of the

Inpatient Psychiatric Facility Prospective

Payment System (IPF-PPS) necessarily involves an increase or decrease in Medicare payments to inpatient psychiatric facilities (IPFs). Payment reductions raise concerns about possible closures. Although this may not be a concern overall across the country, closures could undesirably restrict access to critical inpatient psychiatric services in some rural or isolated areas. The likelihood of lower psychiatric payments is of particular concern for smaller rural units because they operate under diseconomies of scale. Any unit, regardless of its size, requires minimum RN and expensive psychiatric services as well as bed accommodations and services. This study simulates the potential impacts of lower payments under the new IPF-PPS on the likelihood of closure and on any subsequent restrictions in beneficiary access to inpatient psychiatric care.

Study Design: The main data source for this study is a hospital-level dataset, giving 2002 hospital costs, Medicare psychiatric revenues, and estimated average IPF-PPS payments per case, used to estimate the impact on facilities of the IPF-PPS. The difference between the total actual Medicare payment and the estimated IPF-

PPS payment gives the change in per diem

Medicare revenues. The difference between estimated IPF-PPS payments and total cost yields the expected Medicare margin under the

IPF-PPS. Both of these measures are used to construct a closure risk indicator. The facilities in the most negative quartile are targeted for the subsequent closure analysis. Facilities are also classified by urbanicity and distance to nearest inpatient psychiatric provider.

Population Studied: Inpatient psychiatric facilities and Medicare beneficiaries.

Principle Findings: Over 1,800 IPFs care for

Medicare beneficiaries. Rural providers are disproportionately small (10 or fewer beds), accounting for 31% of all rural providers (versus

8% for other areas). Because of their lower occupancy rates, small rural IPFs are 30% more costly on a per diem basis, after controlling for case mix, average length of stay, and rural location adjustors in the IPF-PPS. The median distance between small psychiatric units and their nearest neighbor (110 miles) was the same as that for other rural providers. Small rural psychiatric units also tend to treat a significantly larger proportion of Medicare patients with dementia-related disorders than do larger units

(14% versus 7%), generally related to their greater tendency to treat elderly patients.

Conclusions: Small rural facilities’ lower occupancy rates and small number of beds result in fixed costs that cannot be spread over a

large number of patients. The IPF-PPS features an adjustment for rural providers, but does not fully cover the higher costs of small rural providers.


Unless smaller inpatient units are able to increase their occupancy rate, it is likely they will be adversely affected by the new IPF-PPS.

However, CMS has specifically omitted adjustors for occupancy rates from other payment systems to encourage efficient production of care.

Understanding the role of these providers in the psychiatric care systems in their areas is important for CMS to understand how the IPF-

PPS may affect Medicare beneficiaries in these areas.

Funding Source: CMS

•

Openings and Closures of Inpatient

Rehabilitation Facilities, 1996-2004

Trudy Mallinson, Ph.D., Larry Manheim, Ph.D.,

Orit Almagor, M.A., Holly DeMark, B.A., Allenn

Heinemann, Ph.D.

Presented By: Trudy Mallinson, Ph.D., Clinical

Research Scientist, Center for Rehabilitation

Institute of Chicago, 345 E. Superior Street,

Onterie 960, Chicago, IL 60611,

Email: trudy@northwestern.edu

Research Objective: Inpatient rehabilitation facilities (IRFs) provide intensive rehabilitation to patients with both acute and chronic disabilities who are admitted to stand-alone (freestanding) hospitals or units of acute care hospitals. In

2002, Medicare implemented prospective payment (PPS) for IRFs. This study examines the impact of PPS on IRF openings, closures, conversions, and changes in bed size.

Study Design: This retrospective study identified openings, closings, conversions and change in bed-size among IRFs pre-prospective payment

(1996-2001) and post-PPS (2002-2004). Data were extracted from the Hospital Cost Report

Information System (HCRIS). For IRFs existing in 1996, logistic regression methods predict odds of closing, as a function of introduction of

PPS, controlling for time trend, for-profit status, teaching hospital status, bed size, and geographic region. A similar analysis was conducted to examine likelihood of IRFs having opened between 1996 and 2004. For IRFs open during the entire period we estimate the impact of PPS on bed size and total patient days using fixed effects regression analysis.

Population Studied: 297 Freestanding Inpatient

Rehabilitation Hospitals and 1168 IRF units.

Thirty IRFs that opened and converted to a long term care hospital (LTCH) in less than 12 months were not included in the analysis.

Principle Findings: In the pre-PPS period (1996-

2001), 257 new IRFs opened and 100 closed or converted to another PAC setting. In the post-

PPS period (2002-2004), 127 new IRFs opened and 72 closures. Over the entire period, there was an average annual growth of 2.2% in the number of IRFs and 1.9% annual growth in IRF beds. Random effects logistic regression models indicated no effect of PPS on the likelihood of

IRFs that were open in 1996 closing in the PPS era, however they were more likely to close if they were smaller (fewer than 50 beds) or were freestanding facilities. In a separate random effects regression model for hospitals open in

2004, there was an overall trend toward fewer openings and this decrease was significant after

2002. In addition, IRFs were more likely to open if they were for-profit, rural, small, and freestanding. Results also found an overall trend toward increasing numbers of beds and patient days. Existing for-profit IRFs, relative to not-forprofit IRFs, had greater declines in patient days.

Conclusions: IRF PPS did not have a significant effect on closures and did not discourage openings, nor did it have a significant effect on number of beds, or total patient days. Not-forprofit IRFs significantly increased IRF patient days over the period by increasing admissions to more than offset their decline in LOS. For-profit

IRFs were generally less able to maintain total patient days in the face of declining LOS compared to not-for-profits.


PPS did not appear to have an immediate impact on IRF openings or closures. However, regulatory changes accompanying PPS, such as the ‘‘75% rule’’ may have greater impact going forward.

Funding Source: NIDRR-National Institute of

Disability and Rehabilitation Research

•

The Medical and Long-Term Care Trajectory of Elderly with Congestive Heart Failure

Stephanie Maxwell, Ph.D., Tim Waidmann, Ph.D.

Presented By: Stephanie Maxwell, Ph.D., Senior

Research Associate, Health Policy Center, Urban

Institute, 2100 M Street, NW, Washington, DC

20037, Phone: 202-261-5825, Email: smaxwell@ui.urban.org

Research Objective:

Congestive heart failure (CHF) is the leading diagnosis of Medicare hospitalizations, the fourth leading cause for Medicare-covered nursing home admissions, and a common diagnosis among nursing home residents.

AHRQ estimates that about 795,000 elderly with

CHF had preventable hospitalizations in 1999, making CHF an important target for disease management programs. This study analyzed patterns of hospital, nursing home, and ambulatory encounters and spending among a national cohort (n=347,582) of elderly first hospitalized with CHF in 1999.

Study Design: This is a retrospective, longitudinal study of a national cohort of elderly who were first hospitalized for CHF in 1999.

Medicare enrollment and claims data through

2002 were used to identify patterns over three years of Medicare service use and spending and enrollment in Medicaid. Nursing home patient assessment data were use to identify nursing home entry. Bivariate analyses of outcomes were conducted, stratified by patient and area characteristics. Survival models were used to estimate the effects of covariates on the instantaneous risk of an outcome, through measuring the elapsed time before an outcome is observed. Survival analysis jointly accounts for utilization and mortality risk, which is important when studying a high-mortality population such as elderly with CHF. Two-part use and spending models were used to estimate models, by type of Medicare service, for the first six months following CHF hospitalization and for the three years following CHF hospitalization.

Charlson-Deyo comorbidity indices and prior nursing home use were used to control for health status.

Population Studied: National cohort of

Medicare elderly with congestive heart failure.

Principle Findings: In the three years following initial hospitalization for CHF: 36% had additional CHF hospitalizations; 68% were hospitalized for other conditions; 42% had SNF stays; 15% entered a nursing home (non-

Medicare stays); 7% enrolled in Medicaid; 56% died; and Medicare spending over the study period averaged $35,000.

After controlling for comorbidities, sex, race, and age we find substantial variability across states in utilization and expenditures as well as in the risks of rehospitalization, nursing home admission, and death.

Conclusions: The increasing longevity of the

U.S. population and the movement of the ‘‘Baby

Boom’’ generation into older ages, where risks and expenditures for chronic disease, functional decline, and long-term care use are high, add urgency to the need for more information about the elderly with chronic disease and their risk for long-term care use. This study provides a national baseline of the patterns of medical and nursing home service use among the elderly with

CHF- the leading cause of morbidity among the elderly and an important subject of disease management programs.


We found significantly higher CHF rehospitalization among African Americans, which may suggest the importance of targeting this population for disease management programs. The substantial level of non-CHF hospitalizations may suggest the importance of broadening the scope of disease management programs for elderly with CHF.

Funding Source: CMS

•

Utilization of New Medicare Screening and

Preventive Services among Medicare

Beneficiaries 65 years of Age and Older

Margaret McDonald, Ph.D., Robin P. Hertz,

Ph.D., Alan N. Unger, Ph.D., Michael B. Lustik,

M.S.

Presented By: Margaret McDonald, Ph.D.,

Director, US Outcomes Research, Pfizer Inc, 235

East 42nd Street, New York, NY 10017, Phone:

(212)733-3093, Fax: (646)441-6014, Email: margaret.m.mcdonald@pfizer.com

Research Objective: In 2005, Medicare expanded the scope of covered preventive services for its beneficiaries to include cholesterol testing, diabetes screening, and, for newly enrolled beneficiaries, a ‘‘Welcome to

Medicare’’ physical examination. However, utilization of these 3 new services remains unknown. The objective of this research was to determine the 2005 utilization rates of these new preventive services as well as utilization of previously established preventive services covered by Medicare in a nationally representative sample of Medicare beneficiaries aged 65 and older.

Study Design: Cross-sectional observational study design. Web-enabled questionnaire administered to a nationally representative sample of adults 65 years of age and older.

Population Studied: Medicare beneficiaries 65 years of age and older

Principle Findings: Among the 5,253 Medicare survey respondents aged 65 and older, 95% had at least one visit to a physician in 2005. Men were significantly more likely than women to

have received the 3 newly offered preventive services: 92% of men vs. 89% of women received cholesterol testing; 75% vs. 68% received a diabetes screening test; and 73% vs.

67% had a physical examination. Of the 8% of newly enrolled beneficiaries to Medicare in 2005,

67% reported having had a physical exam, although only 10% reported that it was a

‘‘Welcome to Medicare’’ physical exam. Blacks had significantly higher rates than whites of having received diabetes screening (84% vs.

68%) and physical examinations (77% vs. 67%).

Medicare beneficiaries with employer-sponsored retiree health benefits were also significantly more likely than those without retiree health benefits to have received diabetes screening and a physical exam. Seventy-five percent of

Medicare beneficiaries had an influenza shot; rates were significantly lower in blacks than whites (65% vs. 76%). Utilization of other established Medicare preventive services included: colonoscopy (27%); prostate specific antigen test (66%); mammogram (69%); glaucoma and macular degeneration testing

(71%, 54%, respectively); and bone density

(28%). With the exception of bone density testing, Medicare enrollees with a high school education or less had significantly lower utilization rates for these established services.

Conclusions: A high percentage of Medicare beneficiaries received Medicare’s newly covered cholesterol and diabetes screening in 2005, while two thirds of new enrollees received a ‘‘Welcome to Medicare’’ physical examination. Utilization rates for influenza and other established preventive services covered by Medicare were less than optimal and varied by race and educational status.


Efforts aimed to raise physician awareness of current practice patterns for clinical preventive services along with targeted educational programs for older adults on the benefits of screening and prevention may improve national utilization rates.

•

The Effect of Medicare Advantage Payment

Rates on Enrollment and Benefits

Lauren Nicholas, M.P.P., Sherry A. Glied, Ph.D.

Presented By: Lauren Nicholas, M.P.P., Doctoral

Candidate, School of Social Work, Columbia

University, 1255 Amsterdam Avenue, Doctoral

Program, 9th Floor, New York, NY 10027, Phone:

(202) 246-8020, Email: ln2123@columbia.edu

Research Objective: This research determines whether legislatively determined payment rates to Medicare managed care plans effect program enrollment, availability of particular benefits and choices for beneficiaries.

Study Design: Fixed effects regression using panel data from 1998-2005. Data on plan benefits are drawn from the Centers for

Medicare and Medicaid Services (CMS)

Medicare Compare Access database. MA payment rates are drawn from the CMS

Medicare Advantage Rate Calculation Data spreadsheets. The number of Medicare beneficiaries and MA enrollees by county is taken from the CMS Medicare Managed Care State

County data file for the quarter ending December

2005. Additional data is drawn from the Area

Resource File.

Population Studied: County-level observations on elderly Medicare beneficiaries in over 3,100 counties in the United States.

Principle Findings: In accordance with earlier studies, we find that higher payment rates to

Medicare managed care plans cause higher county-level enrollment. Our research will also show the relationship between variations in plan payment rates and access to benefits and costsharing for beneficiaries.

Conclusions: Payment rates play an important role in determining enrollment and access to benefits in Medicare managed care.

The patterns of benefits provided by MA plans and the out-of-pocket costs faced by MA plan enrollees vary by geographic area.


Enrollment in Medicare Advantage plans has grown to over 7 million nationwide. In addition, payments to MA plans above average fee-forservice costs amounted to $5.2 billion dollars in

2005. Given the increasing scope and importance of this program, it is imperative that stakeholders examine the impact of the MA program on enrollees and consider whether the purported advantages of private MA plans ---- namely, the provision of better benefits and lower cost-sharing ---- hold true for enrollees throughout the country.

Funding Source: CWF

• Medicare Advantage? The Effects of

Medicare Managed Care on Preventable

Hospitalizations

Lauren Nicholas, M.P.P.

Presented By: Lauren Nicholas, M.P.P., doctoral student, School of Social Work Doctoral

Program, Columbia University, 1255 Amsterdam

Avenue, New York, NY 10027, Phone: 212-851-

2381, Email: ln2123@columbia.edu

Research Objective: This study tests whether

Medicare managed care plans improve quality of care for Medicare patients by providing preventative services. The study compares rates of preventable hospitalizations amongst managed care and fee-for-service Medicare patients.

Study Design: Instrumental variables negative binomial regression models are used to correct for unobserved selection into Medicare managed care plans. Inpatient hospitalization data is analyzed to identify ambulatory care sensitive

(preventable) hospitalizations, a commonly used indicator of outpatient quality of care. Data from

1998-2004 are analyzed to control for time and county fixed effects.

Population Studied: Medicare beneficiaries aged 65 and over residing in Arizona, Florida,

New Jersey and New York between 1998 and

2004.

Principle Findings: Medicare managed care plans are associated with lower rates of ambulatory care sensitive (preventable) hospitalizations when data is not corrected for unobserved selection into managed care. This research will determine whether these findings are robust to corrections for managed care status.

Conclusions: Medicare managed care plans may be able to improve quality of care provided to Medicare beneficiaries by emphasizing appropriate preventative care and therefore reducing ambulatory care sensitive hospitalizations.


Although recent policy changes have encouraged enrollment in Medicare managed care plans, especially for low-income beneficiaries, little is known about quality of care provided by these plans. This research will provide new information about quality of care under Medicare managed care so that policymakers and beneficiaries can make informed decisions about enrollment.

Funding Source: John A. Hartford Foundation

• The Effect of HMOs on the Care of

Medicare Beneficiaries at the End of Life

June O'Leary, Ph.D., Kateryna Fonkych, Ph.D.,

Emmett Keeler, Ph.D., Glenn Melnick, Ph.D.

Presented By: June O'Leary, Ph.D., Consultant,

Health, RAND Corporation, 1776 Main Street,

P.O. Box 2138, Santa Monica, CA 90407-2138,

Phone: (909) 482-1702, Email: oleary@rand.org

Research Objective: Our prior work indicates that California Medicare beneficiaries who joined a health maintenance organization experienced an 11-18 percent reduction in total inpatient days per year relative to fee for service beneficiaries, depending on whether they joined an independent practice association or group/staff model HMO, respectively. We sought to investigate whether these effects persisted or were different when focusing on a subset of beneficiaries prior to death.

Study Design: The unit of analysis was personyear. A two-part model was specified where the first part was a logistic regression of the probability of any hospitalization and the second part was an ordinary least squares regression of the logarithm of total days of stay given at least one hospitalization. The main independent variable, representing the effect of HMOs on inpatient utilization, was defined as the proportion of time spent in an HMO in each year. The main outcome measure, total inpatient days per year, was estimated by recombining the two parts of the model.

Population Studied: Medicare enrollment data from the Center for Medicare and Medicaid

Services Denominator file was linked to patient discharge data from the California Office of

Statewide Health Planning and Development for

1994 through 2001. All beneficiaries who died between June 1998 and June 2001 and became entitled to Medicare at least five years prior to their death were identified. From this population, only beneficiaries who could be classified into one of the following five categories were retained: (1) enrolled in an HMO for the entire study period, (2) enrolled in Medicare FFS for the entire study period, (3) enrolled for 12 months in FFS and then switched and remained in an HMO until death, (4) started as group 3 but then switched back to FFS prior to death, (5) started the study period in an HMO and disenrolled to FFS before death. This sampling yielded 82,967 decedents.

Principle Findings: Two years prior to death, decedents of Kaiser Foundation Health Plan used 58.3 percent fewer total inpatient days relative to FFS decedents. The effects were 36.2 and 43.6 percent for decedents of IPA and other group/staff model HMOs, respectively. Fewer total days resulted from a lower probability of hospitalization and shorter length of stay. The effects were smaller during the last year of life, with reductions of 45.5, 26.6, and 27.1 percent,

for Kaiser, IPA, and other group/staff model

HMO decedents relative to FFS decedents, respectively.

Conclusions: During the late nineties, California

Medicare HMOs significantly reduced the total inpatient days of care for decedents relative to

FFS. The effect was greatest for Kaiser, a large group model HMO that has been serving

California Medicare beneficiaries for over 20 years.


Further research is needed to understand how

HMOs reduce inpatient utilization, particularly at the end of life, and its impact on outcomes such as costs and quality.

Funding Source: Center for Health Financing,

Policy and Management, University of Southern

California

• Impact of the Medicare Part D Drug Policy on Dual Eligible Adults with Serious Mental

Illness

Michael Tutty, M.H.A., Alexis Henry, Sc.D.,

OTR/L, Leslie Olin, B.A., Susan Murray, M.P.H.,

ANP, Paul Kirby, M.A.

Presented By: Michael Tutty, M.H.A., Senior

Project Director, Center for Health Policy and

Research, University of Massachusetts Medical

School, 222 Maple Avenue, Shrewsbury, MA

01545, Phone: (508) 856-4350, Fax: (508) 856-

4456, Email: michael.tutty@umassmed.edu

Research Objective: The Medicare

Modernization Act (MMA) went into effect on

January 1st, 2006, at which point dual eligible beneficiaries ---- persons eligible for both

Medicare and Medicaid ---- were required to obtain drug coverage through private prescription drug plans (PDPs). Prior to implementation of the MMA, dual eligibles received prescription drug coverage from

Medicaid. To prevent a lapse in coverage, dual eligibles who did not choose a plan on their own by December 31st were automatically enrolled in a PDP. However, because PDP assignments were random, a PDP may or may not have matched an individual dual eligible member’s particular drug needs. In general, drug formularies used by PDPs are more restrictive and require more cost-sharing than Medicaid.

These factors could significantly impact drug coverage for many dual eligibles, particularly those with serious mental illnesses (SMI)

(schizophrenia, bipolar disorder, or major depression), for whom medication disruptions are of particular concern. This study examines non-elderly, dual eligible MassHealth (Medicaid) members with SMI, while transitioning to a

Medicare PDP, to understand their experiences with selecting and enrolling in a PDP, and with gaining access to needed medications.

Study Design: Data for the study is being collected using focus group methodology. We are examining the experiences of dual eligible members with SMI using a PDP from the perspectives of three informant groups: 1) members with SMI; 2) community-based mental health service providers (case managers and other frontline service providers) who work with members with SMI; and 3) psychiatrists who prescribe medications for members with SMI.

Focus groups of each type are being conducted from November 2006 through February 2007 across various geographic locations throughout

Massachusetts.

Population Studied: The population studied comprises non-elderly, dually eligible

MassHealth (Medicaid) members with serious mental illness using a Medicare prescription drug plan.

Principle Findings: Preliminary findings from consumer focus groups indicate that some dually eligible members with SMI experienced problems obtaining medications immediately after the transition, particularly those autoenrolled into a PDP. Most were able to resolve these problems without experiencing medication disruptions by changing to an alternative PDP.

The study is currently in the field; data will also be collected from focus groups composed of psychiatrists and community-based providers, who may bring a different perspective.

Conclusions: Focus group data obtained for this study suggests that transferring prescription coverage for dually eligible beneficiaries from

Medicaid to Medicare PDPs presents unique challenges with respect to the SMI population.

Although some members actively compared plans and selected the best option for their needs, many who were auto-enrolled found their

PDP did not cover needed medications. This created a need for members to become more engaged or seek assistance in navigating the system.


Information about this population’s transition under the MMA is relevant for two audiences.

First, it is of interest to health policy-makers and advocates who are monitoring the implementation and impact of the MMA.

Second, information collected from dual eligible beneficiaries with SMI and mental health service providers about successes and shortcomings of the PDPs can be used to develop strategies to address problems at the direct care delivery level.

Funding Source: Commonwealth Medicine

Grants Initiative

Population & Public Health

• Accuracy of Self-Reported Assessments of

Local Health Department Pandemic

Preparedness

George Avery, Ph.D., M.P.A., Dave McKinnis,

Ph.D., Pamela Aaltonen, M.S., R.N., George

Avery, Ph.D., M.P.A., Deborah Koester, M.S.N.,

R.N.


Assistant Professor, Health and Kinesiology,

Purdue University, 800 West Stadium Avenue,

West Lafayette, IN 47907, Phone: (765) 496-

3330, Fax: (765) 496-1239, Email: gavery@purdue.edu

Research Objective: This project examines differences between self-reported preparedness by county health departments using the CDC

Pandemic Influenza Planning Self-Assessment and findings produced by an audit of county health department planning efforts in Indiana.

Study Design: In April 2006, each LHD completed a self-assessment designed by the

Centers for Disease Control and Prevention. In

May 2006, Purdue received these selfassessments as a starting point for the gap analysis procedure, which was designed by the

Purdue team. This procedure consisted of two steps: (1) completion of an Audit Tool during a conference call or site visit with each LHD, and

(2) development of a final gap report for each

LHD. Quantitative and qualitative analyses were performed on the self-assessment data and

Audit Tool data. Results of audits were compared to self-assessment reports to evaluate accuracy or capacity of the tool in identifying gaps in planning efforts.

Population Studied: The study population consisted of local (county and municipal level)

94 health departments in each of 92 Indiana counties.

Principle Findings: Audits revealed that selfassessments were typically out-of-date or only marginally accurate. Inaccuracies were caused by unclear wording in self-assessment questions as well as insufficient resolution in allowable numerical responses. Even with these shortcomings, self-assessment analyses did capture state-wide and district patterns, although captured patterns were not necessarily accurate.

Conclusions: Although the CDC Pandemic

Influenza Planning Self-Assessment does capture wide area patterns, significant differences exist between audit findings and selfreported data at the local level, raising concerns that the Self-Assessment tool does not accurately capture efforts by local health departments.


Caution should be used in the application of the

CDC Pandemic Influenza Planning Self-

Assessment tool due to differences between selfreports and audit findings.

Funding Source: Indiana State Department of

Health

• Trends of Outpatient Breast Cancer Surgery from 1993 to 2002

John Bian, Ph.D., Michael T. Halpern, M.D.,

Ph.D., Joseph Lipscomb, Ph.D.

Presented By: John Bian, Ph.D., Health Services

Researcher, Epidemiology and Surveillance

Research, American Cancer Society, 1599 Clifton

Road NE, Atlanta, GA 30329-4251, Phone: 404-

329-4312, Fax: 404-327-6450, Email: john.bian@cancer.org

Research Objective: The use of outpatient surgery in the U.S., including outpatient surgery for breast cancer, increased rapidly over the past two decades. Two previous studies examined trends in outpatient breast cancer surgery till

1996, using claims or hospital discharge data.

Thus, there is a critical need for better understanding of current practice trends for outpatient breast cancer surgery. This paper examined the trends of outpatient mastectomy and of breast-conserving surgery with lymph node dissection (BCS/LND) among Medicare fee-for-service (FFS) patients >= 65. In addition, we examined the associations of patients’ demographic, clinical, and socioeconomic characteristics with the likelihood of receiving outpatient breast cancer surgery.

Study Design: The main data were linked 1993-

2002 Surveillance, Epidemiology and End

Results (SEER) and Medicare claims data. The analyses focused on 8 states with SEER registries. The other data source was the Area

Resource File. Our analysis first depicted the

time trend of outpatient delivery for either surgery. We then used multivariable logistic regression models to examine the associations of patient/county-level characteristics with the likelihood of receiving outpatient breast cancer surgery, analyzing the mastectomy and

BCS/LND patients separately.

Population Studied: We identified a breast cancer cohort including women >= 65 who were

Medicare FFS patients at diagnosis, were found to have unilateral breast cancer, and received mastectomy or BCS/LND as first-course treatment. The mastectomy sample included patients in the cohort diagnosed with stage 0-IV cancer, while the BCS/LND sample included patients diagnosed with stage 0-II cancer only

(as per accepted clinical guidelines). The dependent variable in either sample was the surgery delivery setting (inpatient or outpatient), determined from claims data. The explanatory variables were patient’s demographic and clinical characteristics and county-level proxy variables for availability of health care resources and socioeconomic status.

Principle Findings: During the 10-year period from 1993-2002, 13% of 27,175 mastectomy patients had outpatient delivery, compared to

64% of 16,039 BCS/LND patients. For the mastectomy patients, the proportion of outpatient delivery increased from 3% in 1993 to

20% in 2000 and leveled off afterward. For the

BCS/LND patients, the proportion increased from 40% in 1993 to 78% in 2002. In the multivariable regression analyses, patients with greater comorbidities, measured by Charlson index scores higher than one, were significantly less likely to receive either outpatient mastectomy (odds ratio=0.298, P<0.01) or

BCS/LND (odds ratio=0.250, P<0.01). Older patients, patients with more advanced disease, and patients living in urban or more affluent areas were more likely than younger patients, patients with early stage disease, and patients living in rural or less affluent areas to receive outpatient mastectomy or BCS/LND (P<0.01).

Furthermore, whites had a higher likelihood of receiving outpatient breast cancer surgery than non-whites (P<0.05).

Conclusions: The likelihood of receiving outpatient breast cancer surgeries among

Medicare FFS patients >= 65 increased rapidly during the 10-year period from 1993-2002.

Future research is needed to evaluate quality and outcomes of outpatient breast cancer surgery.


As the Breast Cancer Patient Protection Act of

2005 (a bill) has highlighted the public policy concern about outpatient breast cancer surgery, our findings provide the public with timely evidence for informed decision-making.

•

The Role of Community-Based Patient

Assistance Programs in Meeting the Needs of

Women with Breast Cancer

Nina Bickell, M.D., M.P.H., Kruti N. Shastri,

M.P.H., Kezhen Fei, M.S., Andrea Geduld,

L.C.S.W., Nina A. Bickell, M.D., M.P.H.

Presented By: Nina Bickell, M.D., M.P.H.,

Associate Professor, Health Policy, Mount Sinai

School of Medicine, 1 Gustave L. Levy Place, Box

1077, New York, NY 10029, Phone: (212) 659-

9567, Fax: (212) 423-2998, Email: nina.bickell@mssm.edu

Research Objective: Women with breast cancer report varying needs that may interfere with their ability to obtain necessary treatments.

Numerous, high-quality community-based patient assistance programs exist, however, their ability to identify and meet women's needs is uncertain. We surveyed women with breast cancer attending such programs to assess the programs' ability to identify and meet their needs.

Study Design: Survey of cohort of women attending patient assistance programs.

Population Studied: We surveyed 117 (59% white; 42% minority) women utilizing 9 highquality patient assistance programs in the NYC area about their expectations, needs and experiences. The programs determined the survey distribution method that would ensure their clients' comfort and confidentiality.

Principle Findings: When asked what they hoped to get from the programs, 92 (89%) women wanted information, 102 (95%) psychosocial support and 15 (20%) practical assistance. 75% had all or most of their needs identified and met. 70% stated programs met needs they were unaware they had. Minority women were less likely to report having all or most of their needs identified (57% vs 84%; p<0.01) and met (60% vs 84%; p<0.01), independent of type of need.

Conclusions: There are numerous high-quality community-based patient assistance programs that are extremely effective at identifying and meeting the needs of women with breast cancer.

However, minority women appear less likely to have needs identified and met by these programs.


By identifying and meeting the needs of women

with breast cancer and addressing barriers to care, patient assistance programs may enable greater access and adherence to effective care and may improve women's experience throughout their cancer treatment.

Funding Source: NCI

• Measuring Health Outcomes in Wisconsin

Bridget Booske, Ph.D., M.H.S.A., David Kindig,

M.D., Ph.D., Angela Kempf, M.A., Jessica

Athens, M.A., Patrick Remington, M.D., M.P.H.

Presented By: Bridget Booske, Ph.D., M.H.S.A.,

Senior Scientist, Population Health Institute,

University of Wisconsin School of Medicine and

Public Health, 610 Walnut Street, Madison, WI

53717, Phone: (608) 263-1947, Fax: (608) 262-

6404, Email: bbooske@wisc.edu

Research Objective: The objective of the

‘‘Making Wisconsin the Healthiest State’’ project is to identify the most effective investments for and to monitor Wisconsin’s progress towards becoming the nation’s healthiest state with less health disparity. This is a research and translation effort funded by the Wisconsin

Partnership Fund for a Healthy Future (Blue

Cross Program) to a)assess Wisconsin’s population health in a way that can be periodically compared with the population health of other US states (using existing secondary data), and b) develop recommendations so that we can efficiently achieve the goal of being the healthiest state.

Study Design: During the first part of the project, we have spent time characterizing the population health of Wisconsin and Wisconsin communities. This involved identifying and assessing multiple measures of health outcomes

(such as mortality and health-related quality of life) by life stage and their distribution and disparity across the state. We have also compared the population health of Wisconsin with that of other U.S. states, as well as relative trends across states for these multiple health measures. We used results of these analyses to develop and release the first Health of Wisconsin

Report Card this year. The Report Card contains grades for Wisconsin’s overall health and health disparities and proposes targets for 2015.

Population Studied: Wisconsin State in comparison to the rest of the U.S.

Principle Findings: While Wisconsin currently ranks fairly well in terms of overall mortality and health-related quality of life, there is much greater disparity across multiple subgroups in

Wisconsin than in many other states.

Furthermore, Wisconsin has seen less improvement over time than other states. If current trends in mortality continue in Wisconsin and other states, Wisconsin will drop in rank relative to other states.

Conclusions: The first Health of Wisconsin

Report Card 2007 focuses on our population health outcomes and gives Wisconsin grades on a series of outcome measures.


Report cards containing grades or ranks are an effective way of disseminating knowledge and stimulating discussion about the need to improve overall health and reduce disparities.

Future reports will go on to identify the priority programs and policies that Wisconsin must adopt in order to improve its outcomes or grades.

Funding Source: Wisconsin Partnership for a

Healthy Future

• Occupational Injuries in Workers With and

Without Worker Compensation Coverage

Julia Costich, J.D., Ph.D., Terry L. Bunn, Ph.D.,

Valerie J. Nicholson, M.D., M.H.A., Folami O.

Tayo

Presented By: Julia Costich, J.D., Ph.D., Chair,

Dept. of Health Services Management, UK

College of Public Health, 121 Washington

Avenue, Lexington, KY 40536, Phone: 859-257-

6712, Fax: 859-257-3909, Email: julia.costich@uky.edu

Research Objective: A complete accounting of work-related injury requires investigation that goes beyond worker compensation data. Labor market restructuring has led to an increase in the proportion of contingent workers (e.g., independent contractors or part-time) who are not covered by worker compensation (WC), particularly in high-risk industries. Non-covered workers’ injuries can be difficult to identify as work-related. Emergency departments routinely identify work-relatedness in their intake documentation but do not include it in standard reports. Migrant health centers routinely collect work-related data only on pesticide exposure.

Study Design: We used data from two provider sites: an academic health center’s emergency department (ED) and a federally-funded migrant health center (MHC). ED data on 12 consecutive months of work-related occupational injury patient encounters (n=1020) were reviewed for third-party coverage status, demographic variables, mechanism of injury (e-code),

comorbidities, and discharge destination. In addition to descriptive statistics, logistic regression analysis determined relationships among variables. Narrative analysis of MHC data covering 12 consecutive identified 50 patients with work-related injuries, none of which were covered by worker compensation (WC).

Population Studied: Injured workers in central

Kentucky.

Principle Findings: About 20% (208/1020) of

ED patients reporting work-related diagnoses were not covered by WC. Racial and ethnic minorities were significantly more likely to lack

WC (25% versus 11%). The large majority (92%) of injured workers without WC also lacked health insurance coverage of any kind. Workers without

WC were more likely to be injured in falls (29% vs. 21%), overexertion presenting as musculoskeletal injury (19% vs. 10%), and cutting/piercing (18% vs. 14%) injuries. MHC patients were Latinos and complaints were primarily musculoskeletal (78%), including untreated fractures, piercing wounds, and falls; exposure to pesticides and other toxic substances was the second most frequent cause of work-related symptoms (10%).

Conclusions: Reliance on WC data alone understates the aggregate incidence of occupational injury, most markedly for high-risk occupations, populations, and job tasks.


Work-relatedness indicators collected routinely in

ED and outpatient settings should be incorporated into accessible reporting systems to facilitate more accurate and comprehensive surveillance and better-targeted interventions.

•

Cost Associated with High Alcohol

Consumption within the Military Health

System’s TRICARE Prime Enrolled Population

Tim Dall, M.S., Nancy K. Fagan, Ph.D., Samuel

T. Olaiya, Ph.D., David N. Tornberg, M.D.,

M.P.H., Yaozhu Chen, M.P.A., Yiduo Zhang,

Ph.D.

Presented By: Tim Dall, M.S., Vice President,

The Lewin Group, 3130 Fairview Park Drive, Suite

800, Falls Church, VA 22042, Phone: 703-269-

5743, Email: tim.dall@lewin.com

Research Objective: Estimate Department of

Defense (DoD) medical and non-medical costs associated with alcohol consumption among a population eligible to enroll into the military

TRICARE Prime health plan option.

Study Design: Cost-of-disease model developed by combining information from DoD and civilian health surveys and studies; DoD healthcare encounter data for 3.5 million enrollees; and the epidemiology literature on the increase risk of alcohol consumption related comorbidities

Population Studied: 4.2 million DoD active duty personnel, dependents and retirees eligible to enroll into the military’s TRICARE Prime health plan option

Principle Findings: An estimated 2.1 million

(73%) enrollees age 17 and older consumed alcohol in 2005. Approximately 31% of adult enrollees are light-to-moderate drinkers; 29% are infrequent binge drinkers; and 13% are heavy drinkers. The estimated costs to the in 2005 for detoxification and treatment for accidents and comorbidity cases associated with high alcohol consumption were approximately $527 million.

Binge drinking is found associated with higher absenteeism from work and lower productivity of active duty personnel. The estimated productivity loss to DoD due to binge drinking is 454,000

FTE work days, which includes 269,000 FTE days lost for absenteeism and 185,000 FTE days lost from reduced work performance. The estimated cost to DoD in 2005 for this productivity loss was $56 million, including $33 million due to absenteeism and $23 million due to reduced performance while working.

Our simulation model suggests that a 15% decrease in heavy binge drinking and a 8% decrease in infrequent binge drinking among the study population altogether could produce future cost savings of $403 million for DoD over a 10 year period, including $178 million in medical expenditures and $105 million in non-medical expenditures.

Conclusions: Based on our analysis, 5% of

Tricare medical expenditures are attributed to alcohol use.


Intervention and prevention programs for high alcohol consumption might be cost effective in reducing health care expenditures, improving productivity, and improving quality of life for the

DoD population.

Funding Source: TRICARE Management Activity

•

Cost Associated with Overweight and

Obesity within the Military Health System’s

TRICARE Prime Enrolled Population

Nancy Fagan, Ph.D., Nancy K. Fagan,, Ph.D.,

Samuel T. Olaiya, Ph.D., David N. Tornberg,

M.D., M.P.H., Yaozhu Chen, M.P.A., Yiduo

Zhang, Ph.D.

Presented By: Nancy Fagan, Ph.D., 5111

Leesburg Pike, Suite 510, Falls Church, VA 22041,

Phone: 703-681-3636, Email: nancy.fagan@tma.osd.mil


Defense (DoD) medical and non-medical costs associated with overweight and obesity among a population eligible to enroll into the military

TRICARE Prime health plan option.

Study Design: Cost-of-disease model developed by combining information from DoD and civilian health surveys and studies; DoD healthcare encounter data for 3.5 million enrollees; and the epidemiology literature on the increase risk of comorbidities related to excessive body weight

Population Studied: 4.2 million DoD active duty personnel, dependents and retirees eligible to enroll into the military’s TRICARE Prime health plan option

Principle Findings: In 2005, an estimated 2.2 million (about 53%) enrollees were overweight

(1.3 million) or obese (877,000). Men, in general, are more likely than women to be overweight, and prevalence of overweight and obesity increases with age. The estimated total cost to the treat the portion of comorbidity cases associated with overweight and obesity was about $1.4 billion (2005 dollar). Overweight and obese active duty personnel are found more likely to be absent from work and exhibit lower productivity than their colleagues who are not overweight. The estimated total FTE work days lost from absenteeism and below-normal productivity associated with active duty personnel being overweight or obese is 1.0 million and 66,000 respectively. The annual cost to DoD is $171 million for absenteeism and $11 million for reduced job performance.

Our simulation model suggests that a 5% decrease in body weight among those who are overweight and obese could produce future cost savings of $1.3 billion for DoD over a 10 year period, including $599 million in medical expenditures and $750 million in non-medical expenditures


Tricare medical expenditures are attributed to excessive weight.


Intervention and prevention programs for weight loss might be cost effective in reducing health care expenditures, improving productivity, and improving quality of life for the DoD population.


• Policy Making in Climates of Uncertainty and Complexity: The Use of Futures Studies

Sally Fawkes, B.Sc., Grad Dip Health Ed, M.B.A.

Presented By: Sally Fawkes, B.Sc., Grad Dip

Health Ed, MBA, Rseaerch Fellow, School of

Public Health, La Trobe University, Bundoora

Campus, Melbourne, 3070, AU, Phone: (613)

94793526, Email: s.fawkes@latrobe.edu.au

Research Objective: While there is considerable theory associated with what foresight (or futures studies) can be used for and what methods are available, little research has been done to shed light on the actual use of futures studies in policy-making ---- the reasons for their use, why certain methods are deployed rather than others, who benefits from their use, the intended and unintended consequences of their use, the costs associated with their use in relation to the benefits. Despite these weaknesses in our knowledge, significant funds have been invested in conducting futures studies and the institutions that support such work.

This research derived from an interest in how health policy is made in environments that are complex and rapidly changing. The research objective was to produce empirical evidence of how and why research about the future (futures studies) is used in the public health policymaking process.

Study Design: The study used case study methodology. Preparation of case studies involved collecting, compiling and analysing a range of data: - Semi-structured interviews with key informants from USA, UK and Australia. Key informants were individuals who were relevant to each specific case of public health policy-making; and individuals who had significant professional experience of public health policy-making in general and in the general policy area of the case.

- Relevant international grey literature, policy documents and primary source documents; -

Peer reviewed literature across several bodies of knowledge. Interviews and documents were analysed to shed light on how the set of values, interests, actors and processes particular to the cases influenced the choice of futures studies and how futures studies were used. Additionally, interviews with key international actors in public health policy-making were undertaken and published documents and grey literature were analysed to enable examination of the general questions of how and why futures studies are used in public health policy-making. Case and cross-case analysis used models of policy making and research utilisation.

Population Studied: Three contemporary examples of policy-making were selected on the basis of their use of a form of futures studies

and their prominence as a policy initiative in their national context: (1) USA - The Future of the Public's Health in the 21st century (2002)

(2) United Kingdom - Securing Our Future

Health: Taking A Long-Term View [The Wanless

Review] (2002) (3) Australia - Health Goals and

Targets in the Year 2000 and Beyond (1993).

Principle Findings: To date, research findings have confirmed other research that public health policy making has a strong tendency to be influenced by a mix of short term political and economic imperatives and a weak tendency to be explicitly developed to achieve long term social, economic and population health objectives. This research has found that when 'the future' or futures are explicitly considered in the policy making process, short term objectives may play an influential role in the choice of futures studies method used, the participants engaged in the policy making process and the eventual outcomes of the process.

Conclusions: There has been increasing interest internationally in strengthening the evidencebase for policies on specific health topics, such as local interventions to increase access to health services, national policies to reduce health inequalities and the use of international agreements to increase consumer product safety. At the same time, there has been a move towards strengthening the evidence-base for the process of policy making. This research focussed on the latter theme. The use of foresight is generally associated with gaining a strengthened strategic perspective in policy making, particularly during times of rapid change when thinking about and planning for the long term are very challenging. Given the complex interactions of technological, social, environmental and political trends in contemporary societies such as the USA and

Australia, it may be expected that the use of foresight will increase, as efforts are made to reduce the high levels of uncertainty associated with choosing the best courses of action to achieve particular goals. This research found that when futures studies are used in the policy making process, some new ways of thinking about population health and new policy options may be introduced for consideration. However, short term priorities are likely to have the 'last word' on policy decisions.


Using futures studies such as scenarios and trend projections can benefit the policy process associated with the long term development of population health by introducing new ways of thinking, new players and legitimising new policy options. Investments in futures studies are recommended as useful inputs to the policy making process.

•

Do Workplace Health Promotion Programs

Promote Healthy Behavior?

Curtis Florence, Ph.D.

Presented By: Curtis Florence, Ph.D., Assistant

Professor, Health Policy and Management,

Emory University, Rollins School of Public

Health, 1518 Clifton Road NE, Atlanta, GA 30322,

Phone: (404) 727-2818, Email: cfloren@sph.emory.edu

Research Objective: Relatively little is known on a population level for the United States regarding the health promotion programs that employers engage in, employees’ willingness to participate in these programs, or in the effect of this type of health promotion on worker productivity or health care costs. In this study, we use the 1998

National Health Interview Survey (NHIS) to examine the impact of workplace health promotion (WHP) programs that promote exercise and nutritional behavior to lose or maintain weight. Since workers who have access to WHP programs may not be a random subset of all workers, estimates of program impact must account for the potential endogeneity of program availability.

Study Design: We employ the size of an employees worksite as an instrumental variable to control for the potential endogeneity of the availability of WHP programs. We estimate bivariate probit models for program availability and participation in exercise or weight loss.

Population Studied: Workers aged 18 to 64 at worksites with 50 or more employees.

Principle Findings: We find that access to WHP programs appears to have a substantial impact on exercise and nutritional behavior. However, when controlling for the endogeneity of program availability, the programs do not demonstrate a statistically significant impact on exercise or nutritional behavior. Statistical tests from the bivariate probit models confirm that program availability is endogenous. This suggests that programs are offered at worksites where the employees have a strong interest in participating in exercise or weight loss.

Conclusions: Given the recent increase in overweight and obesity in the U.S. population, there is great interest in interventions which can change the behavior that leads to weight gain.

One such potential intervention is workplace programs to promote exercise and healthy

eating. However, our results show that these programs do not have statistically significant impacts on healthy behavior when controlling for the endogeneity of program availability.


Could it be reasonably inferred from our results, then, that workplace health promotion programs are not a potentially effect tool for increasing healthy behavior related to weight? Not necessarily. What these results imply is that there is not a statistically significant average treatment effect as these programs are currently constituted. In order to increase healthy behaviors, future interventions should focus more on changing the behavior of the

‘‘marginal’’ worker who is not affect by current programs.

Funding Source: CDC

•

Why is Depression an Under Treated

Disorder? A National Study

Tahany Gadalla, Ph.D.


Professor, Social Work, University of Toronto,

246 Bloor Street West, Toronto, Ontario, M5S

1A1, Phone: (416) 946-0623, Fax: (416) 978-7072,

Email: tahany.gadalla@utoronto.ca

Research Objective: This research aims to: (1) examine risk factors of major depressive disorder

(MDE) in Canadian women, (2) study the determinants of untreated MDE, and (3) identify barriers to seeking treatment for MDE.

Study Design: The present study is based on secondary data analyses of data collected in the

2002 Canadian Community Health Survey.

Adopting Anderson’s framework for health service utilization, 11 predictors of health service utilization are classified into three groups of predisposing, enabling and need factors. Need factors include self-rated physical health, perceived social support, suicide ideation, chronic health condition(s), number of MDE episodes and self-rated stress. Predisposing factors include age, length of time in Canada, language skills and family type. Enabling factors include income adequacy and educational level.

Logistic regression analysis and chi-square tests are used to analyze the data.

Population Studied: The sample used for this research includes 20,211 women 15 years of age and over, who participated in the 2002 Canadian

Community Health Survey.

Principle Findings: Prevalence and Risk factors:

Of the 20,211 women who responded to the survey 5.9% met the criteria for having at least one MDE episode in the previous year. Eighty eight percent of these women reported that their depression significantly interfered with their normal routine, occupation, academic or social activities or relationships. The highest rates of

MDE were found among women younger than

30 years of age, single-mothers with young children, low income women, those with chronic health conditions, high levels of daily stress and low levels of social support. Approximately

25.4% (296) of women with MDE had suicidal thoughts, compared with only 2.4% (460) of non-depressed women. Seeking treatment:

Only 56.4% of the women who were identified as having MDE reported accessing health services in the previous year. The type of mental health service accessed by women with MDE was strongly associated with their age, education, length of time in Canada, language skills, income adequacy, physical health, stress level and chronic health conditions. Need factors were the strongest predictors of seeking treatment followed by predisposing factors and enabling factors. The odds of not seeking treatment for

MDE were highest for single mothers with adult children, women with low social support and those with less than a high school diploma.

Barriers to treatment: Among women who were identified by the survey as having MDE, 303

(26.1%) reported unmet mental health care needs. The majority of these women (69.0%) reported acceptability barriers whereby they chose not to seek mental health care either because of competing demands on their time or because of their attitudes towards mental illness.

Sixty nine women (22.8%) reported problems with service availability as reasons for their unmet mental health care needs, such as long waiting periods and unavailability of help in the area or at the time required. Forty six women

(15.2%) reported accessibility barriers such as cost, lack of transportation, child care or scheduling issues as reasons for their unmet mental health care needs.

Conclusions: Young age, being a single-mother with young children, poverty and lack of social support were identified as risk factors for MDE.

Close to 50% of women with MDE do not seek treatment for it. The type of mental health service they seek (primary care vs specialist care) was strongly associated with their age, education, length of time in Canada, language skills, income adequacy and physical health.

Acceptability barriers, whereby women chose not to seek mental health care because of competing demands on their time and/or because of their

attitudes towards mental illness, were the most frequently reported reasons for not seeking treatment for MDE.


Findings indicate a need for prevention policies targeting women at high risk of depression as well as specific strategies to raise awareness of all aspects of this disorder including early detection of symptoms and the importance of seeking treatment. Effort should be directed to reduce stigma associated with mental illness in general and to educate the public to recognize the symptoms of MDE, emphasizing the importance and the potential benefits of treatment.

•

The Effect of Obesity on Hospitalization:

The ARIC Study

Euna Han, Ph.D., Kimberly Truesdale, Ph.D.,

Dan Taber, M.H.A., Juhaeri, Ph.D., June Stevens,

Ph.D.

Presented By: Euna Han, Ph.D., Post Doctoral

Research Associate, Nutrition, Health Policy and

Administration, The University of North Carolina at Chapel Hill, 1700 Baity Hill Drive, Apt 324,

Chapel Hill, NC 27514, Phone: 919-923-7392,

Email: eunhan@email.unc.edu

Research Objective: Obesity increases the risk of several diseases including cardiovascular disease, diabetes and some types of cancer.

Although those chronic diseases are important causes of hospitalization, the few studies that have examined associations between obesity and hospitalization have provided mixed results. To our knowledge none have examined effects of obesity on hospitalization among African

Americans, a group known to have higher rates of hospitalization than the general population.

The objective of this study was to examine associations between hospitalization and weight status in Whites and African Americans comparing the normal weight (body mass index

(BMI): 18.5-24.9) to overweight (BMI: 25.0-29.9) and obese (BMI: =30kg/m2).

Study Design: Follow-up years were calculated as years from baseline to the discharge date (if hospitalized) or censor date (date of death or

December 31, 2002). Unadjusted rates were calculated as the number of cases divided by person-years of follow-up. Adjusted hazard ratios were calculated using the Cox model with the normal weight group as the reference, adjusting for age, gender, ethnicity, field center, smoking, drinking, education, and physical activity.

Population Studied: Data were from the

Atherosclerosis Risk in Communities (ARIC)

Study, a prospective investigation of the etiology and history of atherosclerosis in four, geographically dispersed American communities. Using cohort and community surveillance methods, hospitalizations that occurred after baseline (1987-89) and before

December 31, 2002 were identified for over 99% of ARIC participants, and discharge dates were recorded. The analysis dataset included 15,365

White and African American aged 45-64 after excluding underweight (BMI<18.5) participants

(n=142), participants missing relevant variables

(n=182), or standard ethnicity exclusions

(n=103).

Principle Findings: Overall, the unadjusted hospitalization rate was 64.6 per 1,000 personyears in normal weight adults. The adjusted hazard ratios for hospitalization in overweight

(1.1, 95% CI: 1.1, 1.2) and obese (1.4, 95% CI: 1.3,

1.4) were significantly higher compared to normal weight adults. Stratification showed that the unadjusted hospitalization rates per 1,000 person-years were higher in African Americans than in Whites within gender groups.

Overweight was associated with small, statistically significant, increases in hospital rates in White women (1.2, 95% CI: 1.1, 1.3) and men

(1.1, 95% CI: 1.1, 1.2), but similar modest increases were not statistically significant in

African Americans. Regardless of ethnicitygender group, obese adults had higher hospitalization rates compared to normal weight adults in the same ethnicity-gender group. The hazard ratios were 1.4 (95% CI: 1.3, 1.6) in White women, 1.3 (95% CI: 1.2, 1.6) in African American women, 1.3 (95% CI: 1.2, 1.4) in White men, and

1.2 (95% CI: 1.1, 1.6) in African American men.

Conclusions: Rates of hospitalization were higher in overweight (statistically significant in

Whites only) and obese adults compared to normal weight adults.


The current high prevalence of obesity means that even small obesity----related increases in the rate of hospitalization will result in marked effects at the population level. Our work indicates that obesity prevention could reduce hospitalizations, a major component of rising health care costs.

Funding Source: Sanofi-Aventis

• The Effect of Obesity on Quality of

Occupations

Euna Han, Ph.D.

Presented By: Euna Han, Ph.D., Post doctoral research associate, Health Policy and

Administration, The University of North Carolina at Chapel Hill, 1700 Baity Hill Drive, APT 324,

Chapel Hill, NC 27514, Phone: 919-923-7392,

Email: eunhan@email.unc.edu

Research Objective: The objective of this study is to understand the effect of obesity on labor market outcomes, particularly, wages. Several studies have linked obesity to wages. However, the validity of their estimation results remained questionable due to some weaknesses of their methods, mainly dubious or restricted way controlling for endogeneity of BMI.

Study Design: Wages were assessed separately by gender as a function of BMI splines, and interactions of BMI splines with two race dummies (non-Hispanic Black and Hispanic).

The endogeneity of obesity was controlled in a two-stage instrument variable estimation model with over-identifying exogenous instruments with conjunction of individual random effects model.

Over-indentifying exogenous instruments for obesity included the following state-level variables: cigarette prices, per capita number of restaurants, per capita number of food stores, fast-food price, cost of alcoholic drinks (inclusive of beer, wine, liquor), and cost of food.

The Heckman selection model was used to control for the selection into the labor force participation with identifying instruments at state level inclusive of unemployment rate, number of business establishments, and number of Social Security Program beneficiaries.

Population Studied: This study uses the

National Longitudinal Survey of Youth 1979

(NLSY79). NLSY79 provides ongoing panel information with a nationally representative sample of 12,686 young men and women who were 14 to 22 years old when first surveyed in

1979. Confidential geographic information has been additionally obtained as well as publicly available portion of the data.

Principle Findings: The instruments were supported for exogeneity and strength for explaining BMI. The study results indicate that incremental increase of BMI after being overweight has a negative effect on wage earnings for both males and females even after adjusting selection into the labor force participation.

Conclusions: The results confirm a wage penalty for women who increase their weight, measured by BMI. The marginal effect of a oneunit increase in BMI is a decrease in hourly wages by 3.9%. In contrast, wages increase with

BMI for men, but the effect is not statistically significant.


The results support the understanding of the economic cost of obesity to an individual beside its adverse effect on health. The spillover effect of obesity will increase the total cost of obesity to both individuals and society as a whole. The negative effect of obesity on the labor market outcomes will raise more attention to epidemic of obesity from both individuals and society.

•

Validation of a Derived Indicator of Low

Health Literacy

Amresh Hanchate, Ph.D., Michael Paasche-

Orlow, M.D., M.P.H.

Presented By: Amresh Hanchate, Ph.D.,

Research Associate, General Internal Medicine,

Boston University School of Medicine, 720,

Harrison Avenue, Suite 1108, Boston, MA 02118,

Phone: 617-638-8889, Fax: 617-638-8026, Email: hanchate@bu.edu

Research Objective: Current research on the role of low health literacy for healthcare utilization and health outcomes is limited to datasets with an in-person administered health literacy indicator. Here we present the comparative performance of a derived low health literacy indicator, based only on demographic characteristics, and a test-based (Test of

Functional Health Literacy in Adults, TOFHLA) indicator in predicting selected health outcomes.

Study Design: The underlying support for this derived measure, based on age, gender, race and highest educational achievement, is the finding of a strong association between tests of health literacy and socio-demographic information routinely measured in survey data. The derived indicator used in this study is obtained from a logistic regression model of TOFHLA-based health literacy indicator (‘‘marginal’’ and

‘‘inadequate’’ versus ‘‘adequate’’) on the selected socio-demographic measures. Sensitivity and specificity were also estimated. We examined the performance of the derived literacy indicator as a covariate in models of two health outcomes

(poor/fair self reported general health (binary

indicator) and SF12 physical health score

(continuous)). A series of parallel regression models were estimated, one using the TOFHLAbased indicator and the other using the derived indicator (ensuring that the latter series excluded the underlying socio-demographic indicators), for each outcome.

Population Studied: 1998 survey of 3,260

Medicare beneficiaries, aged 65 or older, enrolled in the Prudential Healthcare managed care program in four US geographic areas (Cleveland,

OH; Houston, TX; south Florida and Tampa,

FL). All were administered an in-person survey which included the short version of TOFHLA.

Principle Findings: a) The derived indicator of low literacy from a logistic model of TOFHLAbased literacy had a sensitivity of 74% and specificity of 77% with 76% correctly classified

(and area under curve of ROC of 0.82). A linear regression approach yielded 79% correct classification rate. b) In the regressions (both logistic and linear) of the two health outcomes, the estimated associations with TOFHLA-based indicator were well approximated by the derived indicator. The odds ratio (OR) of reporting poor/fair health was the same (OR=1.6) regardless of the choice of low literacy indicator

(TOHFLA-based or derived). In the linear regression of SF12 physical score, the coefficient

(excess SF12 score among low literacy) for the

TOFHLA-based low-literacy indicator was -1.3 and that for the derived indicator was -1.7. Note that while the regression using TOHFLA-based included the underlying socio-economic measures as covariates, the regression using the derived indicator excluded these.

Conclusions: Socio-demographic characteristics can predict low health literacy and a derived indicator of low health literacy has similar predictive capacity as a direct measure of health literacy for the outcomes evaluated.


Since the underlying measures for the derived low health literacy indicator are readily available in a variety of rich existing datasets (from CDC,

AHRQ and CMS), by using the derived indicator model a much wider array of health outcomes as well as health utilization indicators become available for investigation. Also, as information on these underlying measures can be collected via telephone, the model provides a novel and useful mechanism for identifying people likely to have low literacy for future research.

• Longitudinal Changes in Body Mass Index

Categories and Healthcare Expenditures

Drew Helmer, M.D., Ranjana Banerjea, Ph.D.,

Usha Sambamoorthi, Ph.D.

Presented By: Drew Helmer, M.D.,

Physician/Researcher, Center for Healthcare

Knowledge Management, VA-NJ Health Care

System, 385 Tremont Avenue (129), East Orange,

NJ 07018, Phone: 973-676-1000, Fax: 973-395-

7111, Email: helmer@njneuromed.org

Research Objective: In cross-sectional studies, obesity in individuals is associated with higher healthcare costs compared to normal weight.

However, the association between change in obesity status and healthcare costs is not well established. We examine the association between change in obesity and healthcare expenditures over a two-year period.

Study Design: A retrospective analysis of three longitudinal cohorts (2000-2001; N=995; 2001-

2002; N=1,959; and 2002-2003; N=1,321) from the Medical Expenditure Panel Survey data. We categorized individuals by their change in body mass index (BMI - weight in kilograms/height in meters squared) between baseline and follow up year, as 1) Stayed normal (BMI 18.5-24.99 in both years; N= 1,366), 2) Healthy loss (decrease in

BMI in individuals with baseline BMI >=25; N =

272), 3) Stayed overweight (BMI 25-29.99 in both years; N = 1,254), 4) Stayed obese (BMI>=30 in both years; N = 747), and 5) Unhealthy gain

(increase in BMI in individuals with baseline BMI

18.5-24.99; N = 636). We fit separate ordinary least squares regression models of change in

BMI to each category of logged total, inpatient and pharmaceutical expenditures, controlling for gender, age, race/ethnicity, marital status, education, employment status, poverty status, health insurance coverage status, usual source of care provider type, physical health status, mental health status, smoking status, exercise, coexisting medical conditions, and cohort year.

Population Studied: The civilian noninstitutionalized U.S. population over 65 years old.

Principle Findings: Average expenditures for those who stayed normal was $6,793, those with a healthy loss $9,745; stayed overweight $6,687 and stayed obese $7,789. After controlling for other variables, those with a healthy loss had higher inpatient expenditures and higher pharmaceutical expenditures compared to individuals who stayed normal. Higher pharmaceutical expenditures were also seen in individuals who stayed overweight or obese.

Healthcare expenditures for individuals with

unhealthy gain were not significantly different from those who stayed normal.

Conclusions: Healthy loss in BMI, persistent overweight, and persistent obesity were associated with higher healthcare expenditures.


Healthy loss is associated with greater expenditures in the subsequent year suggesting short-term challenges to policy makers investing in obesity prevention and treatment. More years of observation may be required to accurately assess whether healthy loss in BMI results in reduction in expenditures.

Funding Source: VA

•

Exploring the Perceptions of Healthy Aging among Chinese Adults in Hong Kong

Linda Yin King Lee, Ph.D., Rocky Yuk Keung Fan,

Ph.D.

Presented By: Linda Yin King Lee, Ph.D.,

Assistant Professor, Nursing Team, School of

Science & Technology, The Open University of

Hong Kong, 30 Good Shepherd Street, Ho Man

Tin, Kowloon, Phone: (852) 2768 6806, Fax:

(852) 2789 1170, Email: yklee@ouhk.edu.hk

Research Objective: Like many areas in the world, Hong Kong is facing an ageing population. The proportion of Hong Kong population aged 65 and over is projected to rise from 11.7% in 2003 to 27% in 2033. To address the potentially marked impact of the ageing population, healthy ageing is advocated. As perception of healthy ageing affects one’s expectation and can identify areas to be enhanced, this study aimed to investigate the perceptions of healthy ageing among Chinese adults in Hong Kong.

Study Design: This cross-sectional study adopted a qualitative approach and data were collected from semi-structured interviews. Each interview lasted for one hour and focused on identifying participants’ definition of healthy ageing and its contributory factors. Participants’ current preparation for own ageing was also explored. The interview data were recorded, transcribed, and coded for thematic analysis.

Population Studied: The target population was the Chinese adults in Hong Kong who would be in the elder group in the 2030s. A purposive sample of twelve Chinese adults was invited to participate. Participants were selected based on the criteria that at least one female and one male were identified from each of the age groups 18-

25, 26-30, 31-35, 36-40, 41-45, and with different occupation nature and status.

Principle Findings: Findings showed that

Chinese adults generally perceived healthy ageing as having physical, psychological, family, social and financial components. The significant ways to achieve healthy ageing were having a family with both spouse and children, owning a flat, being financially independent, having friends, participating in social activities, and being supported and accepted. However, findings also revealed that Chinese adults were not actively preparing for their ageing owing to a number of perceptual and contextual factors.

Conclusions: Findings suggest that promoting healthy ageing in Hong Kong can be a challenging task. For instance, the desire of a traditional family structure has been complicated by the increasing prevalence of divorce, remarriage, singlehood, and declining in birth rate. Special effort should be paid to maintain the family structure or facilitate people to adjust to the change in family value. To prepare for healthy ageing, people are also advised to perform regular exercises, have regular savings, and participate in social activities.


Findings provide valuable implications to the policy makers for preparing a healthy aged population in the future. Additional effort is recommended to educate the public about the significance of healthy ageing and how people should prepare for their ageing, strengthen the primary health care system, and support recreational and social activities. Promoting the traditional family value among the population is also worthwhile for consideration.

•

Religious Community Social Support and

Health Status in a Diverse Population

Sara Levin, B.A., Joshua P. Metlay, M.D., Ph.D.,

Judith H. Maselli, M.S.P.H., Carlos A. Camargo,

Jr, M.D., Dr.P.H., Ralph Gonzales, M.D.,

M.S.P.H.

Presented By: Sara Levin, B.A., IMPAACT

Project Coordinator, Medicine, University of

California, San Francisco, 3333 California Street,

Suite 430, San Francisco, CA 94118, Phone: (415)

502-0820, Fax: (415) 514-0425, Email: sklevin@medicine.ucsf.edu

Research Objective: Typical social support measures reference friends, family or significant partners, and have shown associations with health status and clinical outcomes. We examined the characteristics of a new scale to assess social support from a religious community as an additional domain of social

support, including a test of its association with self-rated health status.

Study Design: We performed a cross-sectional analysis of a convenience sample of patients seeking care for cough illness in US emergency departments. The 12-item Multidimensional

Scale of Perceived Social Support (4 items per each domain of family, friends, special person) was administered with 4 similarly framed items designed to assess social support from a religious community (church, mosque, synagogue, temple, or other religious community center); higher scores indicated more support (7-point Likert). Self-rated health was based on a single question (scaled excellent to poor).

Population Studied: Surveys were completed by

484 subjects with the following characteristics: mean age 46 years; 59% male; 46% White, 27%

Black, 18% Hispanic; 81% medically-insured.

Principle Findings: Factor analysis showed the religious community items correlated with each other, and were distinct from the other domains.

Among the 4 domains of social support, only the religious community support domain was significantly associated with better overall health status (using multivariable ordinal logistic regression analysis: OR: 1.34 [95% CI: 1.13-1.60].

In addition, support from a religious community was more strongly associated with health status in blacks than in whites (blacks: OR: 2.54 [95%

CI: 1.55-4.16]; whites: OR 1.24 [1.01-1.52]).

Conclusions: The religious community support questions measure a distinct domain of social support, separate from measures of support from family, friends or significant others.


Future studies of social support and health should take into account the significance of support from a religious community, especially among black patients.


• Financaing Newborn Screenings: Sources,

Issues, and Future Considerations

Michele Lloyd-Puryear, M.D., Ph.D., Donna

Williams, B.S., Kay Johnson, M.P.H., Marie Y.

Mann, M.D., M.P.H., Lauren Raskin Ramos,

M.P.H.

Presented By: Michele Lloyd-Puryear, M.D.,

Ph.D., Chief, Genetic Servies Branch, Division of

Services fro Children with Special Health Needs,

MCH Bureau, HRSA, 5600 Fishers Lane, Rm 18-

A-19, Rockville, MD 20857, Phone: 301-443-8604,

Fax: 301-443-1080, Email: MPuryear@hrsa.gov

Research Objective: State Public Health agecnies currently face the challenges of financing state-of-the-art newborn screening systems, which feature tests for more conditions, use of new laboratory technology, staff with skills to use new technology, and more effecetive follow-up with families. The pressures on State public health agencies reflect the coming together of parental concern, private sector marketing, and public opinion. The objective of this resaerch was to document the sources and uses of funding for newborn screening programs.

Study Design: Two types of data are reported.

The primary data comes from a survey of State public health agencies conducted from

Novemebr 2004 - February 2006. These survey data are supplemented with findings from seven case studies: California, Maryland, Minnesota,

Mississippi, New York, Oklahoma, and Oregon.

The authors particiapted in the design of both the survey and the case studies, as well as analysis of the data reported by the States.

Population Studied: The survey population in this research included state public helath agency newborn screenign programs.

Principle Findings: Concurrent to the expansion in newborn screening panels has been the increased dependence of newborn screening programs on fees. Findings suggest that the general trend in the amount of funding for newborn screening programs is increasing.

Additional laboratory costs for technology, expansion of testing panels, increased follow-up resulting from additional screening tests, and costs for associated public health services accounted for the need for additional funds.

Funding increases emanate primarily from fees

(22), and to a lesser extent from Medicaid (10),

Title V MCH Block Grant (7), and State general revenue funding (3). Twenty States reported no change in the level of Medicaid or Title V fiscal support, and 23 had no increase from State revenues.

Conclusions: Regardless of the source of funds, the available evidence indicates that states are committed to maintaining their programs and securing the necessary financing for the initial screening through diagnosis. Use of federal funding is currently limited; however, pressure to provide dedicated federal funding would likely increase if a national recommendation for a uniform newborn screening panel were to be issues.


With recent increases in costs, fees, and government support, newborn screening has

attained greater health care financing visibility.

One major misperception is that tax dollars are the primary source of newborn screening funds.

When State public health officials request additional funding support from legislatures and governors, they are often confronted with budget constraints. Yet in most States the majority of program funding comes from fees and not from

State or Federal sources. A valid funding concern in many States relates to matching funds that are required to support screening for newborns receiving Medicaid assistance. These concerns are of greater concern in the States with larger percentages of Medicaid births. Additional funding concerns for program infrastructure and follow-up arise in States where laboratory services may be contracted to private sources without proper attention to the continuing public health follow-up and service activities that may arise from the testing.

• Benchmarking Community Health Centers’

Performance: Multivariate Analysis of

Efficiency

Sam Marathe, M.D., M.B.A., M.P.H., M.H.A.,

J.D., Ph.D., Thomas T.H. Wan, Ph.D., Lawrence

Martin, B.S., M.S.W., M.B.A., Ph.D., Kevin

Sherin, M.D.

Presented By: Sam Marathe, M.D., M.B.A.,

M.P.H., M.H.A., J.D., Ph.D., Research Associate,

COHPA, UCF, 3280 Progress Drive, Orlando, FL

32816, Phone: (904) 347-3434, Fax: (904) 823-

1284, Email: ssmarathemd@gmail.com

Research Objective: In 1999, Community

Health Centers (CHCs) served 12 million people, primarily the uninsured, the minorities, and the poor. The need for improving organizational efficiency is especially pressing for CHCs due to their assumption of a disproportionate burden in caring for the uninsured within limited budgets.

The research objective of this study is to benchmark CHC performance in terms of efficiency, and examine factors that affect variation in CHC efficiency.

Study Design: A non-experimental panel study with CHC as the unit of analysis. Data were compiled from the CHC administrative data systems between years 2000 and 2004. The

CHC data file was merged with the Area relationships among the contextual, organizational structural (design), and performance variables. Analytical techniques included data mining with predictor tree analysis of high-performance CHCs, data envelopment analysis (DEA) of technical efficiency, and latent growth curve modeling of multi-wave performance indicators of technical and cost efficiency. The analytical model of Context-

Design-Performance was validated by multivariate modeling techniques.

Population Studied: 493 CHCs.

Principle Findings: Data mining and predictor tree analysis of factors influencing the variation in CHCs’ technical and cost efficiency yielded inconsistent results. A declining trend in technical efficiency scores over the five-year study period was observed. The three factors that influenced technical efficiency at the initial period of the study were: the percentages of

Medicare, Medicaid, and Hispanic population being served by the CHCs. The five factors that positively influenced the variation in cost efficiency at the initial period were: the initial score of technical efficiency, the percentage of

Hispanic patient population, staffing mix (ratio of providers to total staff), pay mix (ratio of federal grant dollars to total revenue), and the percentage of Medicare eligible. The initial level of technical efficiency was not statistically significantly associated with the growth trend of cost efficiency. The two factors influencing the growth trend of cost efficiency were the growth trend of technical efficiency (with a positive influence) and the initial level of cost efficiency

(with a negative influence). The explanatory power of the contextual and organizationalstructural predictors was much greater for cost efficiency than for technical efficiency.

Irrespective of the efficiency measures, contextual factors had much greater influence than design (organizational structural) factors on

CHCs’ efficiency. The three study hypotheses supported by multivariate analysis were: technical efficiency is associated with contextual factors and organizational factors; cost efficiency is associated with contextual factors and organizational factors; and technical efficiency positively affects cost efficiency.

Conclusions: The most important finding was that the change in CHC technical efficiency positively affects the change in CHC cost efficiency. The study lends support to contingency theory and confirms the independent and additive influences of contextual and organizational predictors on efficiency.


The study findings have practical implications.

Innovative solutions such as deployment of decision support software can assist poorly performing CHCs to achieve better cost efficiency through optimizing technical efficiency.

This study offers a strategy to guide changes in the current CHC program evaluation and performance improvement.

•

Changes in Weight among a Nationally

Representative Cohort of Individuals Aged 70 and Over, A Longitudinal Analysis

Hongdao Meng, Ph.D., Xiaoxing He, M.D.,

M.P.H.

Presented By: Hongdao Meng, Ph.D., Assistant

Professor, Public Health, Stony Brook University

Medical Center, HSC, Level 3, Rm 071, Stony

Brook, NY 11794, Phone: 631-444-7281, Fax: 631-

444-3480, Email: homeng@ notes.cc.sunysb.edu

Research Objective: To examine the trends of changes in weight and the influences of chronic diseases and functional status on these trends of weight change from 1993 to 2002 among

American individuals aged 70 and over.

Study Design: This study used longitudinal design. We used the Asset and Health Dynamics among the Oldest Old (AHEAD) study sample, a companion database of a national panel study, the Health and Retirement Study (HRS). We used data from five waves of the surveys (wave 1,

1993, wave 2, 1995; wave 3, 1998; wave 4, 2000; wave 5, 2002). We first fitted an unconditional means model (with no predictors) to describe changes in weight over time, then we fitted an unconditional growth model (adding wave as the only predictor) to describe the same trend but allowing inter-individual variation in the rates of change. Finally, we fitted a model controlling for key covariates at baseline (age, race, income, education, Body Mass Index [BMI], activities of daily living [ADL], instrumental activities of daily living [IADL], number of chronic diseases, smoking and alcohol drinking status). All models were estimated for men and women separately.

Population Studied: A nationally representative cohort of 7441 U.S. adults aged 70 and over in

1993 who lived in the community.

Principle Findings: The average BMI of the sample was 25.3 at baseline 1993. 4.7% was underweight, 46.1% normal weight, 36.1% overweight, and 13.1% obese. The mean age of the sample was 77.5 and 61% were female.

African Americans accounted for 8% of the sample and 5% were Hispanics. In general, about 0.06 kg weight decline is observed in each two-year period among men and women. For both men and women in this study, age,

Hispanic ethnicity, BMI, number of chronic diseases, and functional status at baseline were primary predictors of both magnitude of weight change and the rate of change over the 10-year study period.

Conclusions: Among U.S. individuals aged 70 and over, body weight declined even in the absence of disease, particularly in the very old and those with higher baseline BMI. In this elderly population, changes in body weight are significantly associated with chronic diseases and functional status.

Implications for Policy, Practice or Delivery: In the ‘‘oldest old’’ population, public health messages regarding weight control should target weight loss rather than weight gain. Public health campaigns promoting chronic disease prevention, balanced nutrition, and life-style interventions for body weight and physical functioning maintenance should take into consideration of individual differences to meet diverse needs of the population. Future research should be focused on understanding health implications of these trends.

• Identifying a Minimum Data Set of Public

Health Tasks, Knowledge and Resources for

Network Analysis

Jacqueline Merrill, R.N., M.P.H., D.N.Sc., Angela

Wantroba, M.S.N., Kristine M. Gebbie, R.N.,

Dr.P.H.

Presented By: Jacqueline Merrill, R.N., M.P.H.,

D.N.Sc., Associate Research Scientist,

Biomedical Informatics, Columbia University,

622 West 168th Street, VC 5, New York, NY

10032, Phone: 212 305 3194, Fax: 212 305 3302,

Email: jacqueline.merrill@dbmi.columbia.edu

Research Objective: Organizational network analysis is an empirical, descriptive technique for studying organizational structure, based on social network and graph theories. It is used extensively in the private sector to aid management. A prior feasibility study demonstrated that the technique has utility for public managers, but found that a survey instrument was needed to accurately capture public health work. As part of ongoing research to refine network analysis techniques for use in public health we identified a minimum set of public health task, knowledge and resource items to form the basis for a standardized survey instrument to conduct network analysis in any local health department.

Study Design: A multi-step qualitative method was applied. Over 500 task, knowledge and resources items were extracted by the research team from established sources including

accreditation and evaluation instruments, workforce surveys, competencies, operational definitions, and business processes through a technique of iterative review. Items were deduplicated and consolidated by cross walking them with the Essential Services of Public

Health, and with the 10 most common activities identified in the NACCHO 2005 National Profile of Local Health Agencies. The resulting 58 tasks,

75 knowledge and 68 resource items were reviewed by panel of public health practice experts who provided their opinion on the suitability of each item to be included in a set to capture the work likely to be performed in any health department. The experts both added and removed items. These were validated by formatting the expert panel's results into a prototype survey that was completed and reviewed with a focus group of public health practitioners recruited from local health departments in NY State.

Population Studied: This study extracted public health task, knowledge and resource items from documents produced by representative public health organizations. Eight public health practice experts and 14 practitioners participated in the research process.

Principle Findings: Analysis of the focus group findings resulted in a minimum set of 44 discrete tasks, 54 knowledge items, and 55 resource items that are based on established practice documentation. These items can be applied across health departments that may vary in composition yet conduct activities captured by the minimum set of items.

Conclusions: The resulting survey instrument is being pilot tested in two local health departments as a prelude to wider application.

Ultimately the instrument will produce standard results to support local management decisions, to build baselines for network performance, and to allow comparisons between departments that can inform system-wide infrastructure development.


Beyond their utility for conducting network analysis, a minimum set of public health tasks, knowledge and resources that have been validated in practice can potentially be used broadly to understand and document public health work processes, to build uniform job descriptions and to develop frameworks for training and education

Funding Source: Pfizer 2006 Public Health

Scholar Award

• Trends in Chronic Conditions: How

Important is Population Aging?

Lauren Olsho, Ph.D., Matthew H. Kim, M.S.

Presented By: Lauren Olsho, Ph.D., Economics,

Associate, Domestic Health, Abt Associates, 55

Wheeler Street, Cambridge, MA 02138, Phone:

(617) 520-2326, Fax: (617) 349-2675, Email: lauren_olsho@abtassoc.com

Research Objective: Much has been made in the popular press of the potentially disastrous implications of population aging for the United

States health care system. Despite a consensus in the academic literature that such fears are overblown, methodological standards implicitly reflect the notion that population aging is a more important driver of population health trends than are other types of sociodemographic shifts.

Direct standardization is commonly used to adjust for changes in the age composition of the population over time, but similar adjustment for shifts in poverty rates, education levels, and racial or ethnic composition are rare if not unheard of.

Study Design: I apply direct standardization to data on high cholesterol, hypertension, and obesity in order to adjust for changes in poverty, educational attainment, racial/ethnic composition, and sex in addition to the standard adjustment for changes in the age distribution.

Population Studied: A nationally representative sample of 23,796 adults surveyed as part of the

National Health and Nutrition Examination

Surveys.

Principle Findings: I find that changes in these other sociodemographic factors have outweighed the influence of population aging in driving population trends in obesity and hypertension over the past decade and a half, and were a significant driver of trends in high cholesterol over this period as well. In particular, broad improvements in poverty and education have significantly mitigated upward trends in rates of obesity and hypertension. Increases in the population proportion of Hispanics, who have, on average, lower rates of hypertension and high cholesterol, have had a similar dampening effect on rising prevalence of these conditions.

Conclusions: While population aging has certainly had a significant impact on population health trends, it is clear that the influence of these other factors has been at least as important over this time frame.


This finding is of particular relevance for

policymakers, since population aging is an essentially irreversible trend ---- but education, poverty, and even the racial and ethnic makeup of the population are potentially quite sensitive to policy changes. The indirect influence of these types of policies on health may therefore be similarly large in magnitude.


•

Association Between Intention for Lifestyle

Change and Actual Change

Chih-Wen Pai, Ph.D., Dee W. Edington, Ph.D.

Presented By: Chih-Wen Pai, Ph.D., analyst,

Health Management Research Center, University of Michigan, 1027 E. Huron, Ann Arbor, MI

48104, Phone: (734) 647-2717, Fax: (734) 763-

2206, Email: cwpai@umich.edu

Research Objective: To examine the association between intention for lifestyle change and actual change.

Study Design: Health risk appraisal (HRA) was a voluntary wellness program for employees at a multi-state manufacturing company. This HRA system assessed 15 health risks. Employees were also asked about if they planned to make any lifestyle change. In connection with planning for change, we focused on three health risks: physical inactivity (exercise less than one time per week), current cigarette smoking, and overweight (body mass index 25 or higher). We applied logistic regression models to assess the association of intention for change in 2004 with actual behavioral change in 2005. Also included in the model were age, sex, 14 other health risks, family history of diseases, and enrollment in lifestyle management program.

Population Studied: Employees who took HRAs in both 2004 and 2005 and were at high risk for a specific health risk in 2004.

Principle Findings: Individuals who were undecided about their changes in physical activity level were at higher risk than the other groups. The highest percent of the overweight population was observed among the individuals who planned to lose weight (80%), followed by undecided ones (62%). Among physically inactive individuals, those planning to increase physical activity level were more likely to become physically active than those who did not have such an intention (odds ratio1.79, p<0.001).

Similarly, intention to quit smoking was positively associated with actually quitting cigarette smoking (odds ratio 1.94, p<0.05) among smokers. The majority (84%) of overweight individuals remained overweight regardless of their intention for change.

Planning for losing weight was not positively associated with greater weight loss (odds ratio

0.76, p>0.05).

Conclusions: Those who planned for making changes were more likely to become more physically active and cut down cigarette smoking.

However, weight loss was not associated with individual’s readiness to change.


Cognitive-rational models of behavior change contend that readiness to change facilitates actual change. This study lends support to this argument for behaviors like physical activity and smoking. Individuals may benefits from differential wellness programs based on their readiness for change and health risks. Those ready-to-change individuals are good candidates for direct behavioral intervention. To overcome insensitivity about risk of physical inactivity among physical inactive individuals, interventions such as knowledge/awareness enhancing programs may be needed in order to reach the tipping point for both attitude and subsequently behavior modification. On the other hand, successful weight change requires more than mere individual mental readiness, especially for the overweight population. To close the readiness-action gap and produce desired outcome, a more comprehensive effort is essential to tackle different aspects of lifestyles including physical activity, diet/nutrition, and weight control in addition to periodical health communication.


•

The Effect of Repeated Participation in

Worksite Health Risk Appraisal on Health

Care Cost

Chih-Wen Pai, Ph.D., Joel Bender, M.D., Ph.D.,

Dee W. Edington, Ph.D.

Presented By: Chih-Wen Pai, Ph.D., analyst,

Health Management Research Center, University of Michigan, 1027 E. Huron, Ann Arbor, MI

48104, Phone: 734-647-2717, Fax: 734-763-2206,

Email: cwpai@umich.edu

Research Objective: To assess whether repeated participation in worksite health risk appraisal (HRA) has any impact on lowering health care cost among employees.

Study Design: One multi-state manufacturing company started its worksite, voluntary HRA program in 1996. The HRA system estimates 13 health risks, including body weight, stress, life satisfaction, health perception, and physical

activity level. HRA data from 2001 to 2003 were used to measure health status of the individual employees. Estimates of health care cost were based on medical and pharmacy claims from

2001 to 2005, adjusted for inflation to reflect year

2005 dollar equivalent. We applied generalized linear model to assess the impact of HRA frequency on recent health care cost. Recent health care cost was defined as two-year (2004-

2005) mean annual cost. Key independent variable was the frequency of HRA participation between 2001 and 2005: none, one, two or more

HRAs. Also included in the model were age, sex, frequency of previous HRA participation (1996-

2000), risk status (2001-2003), and mean health care cost 2001-2002.

Population Studied: Hourly employees who were continuously employed and enrolled in the same health plan (indemnity vs. PPO) from 2001 to 2005. Medicare beneficiaries and those aged

65 or over (as of 2005) were excluded from analysis.

Principle Findings: The final analysis included

53,482 indemnity and 31,086 PPO employees.

The majority of employees (83% and 79%, respectively) did not take any HRA in the past five years, and very few (6% and 7%, respectively) took HRA two or more times.

Consistent findings from these two employee groups indicated that after controlling other variables there was a linear association between

HRA frequency and recent health care cost.

Those taking HRA two or more times had the lowest cost, while non-participants had the highest cost with one-time HRA participants ranking in the middle. Statistical significance of

HRA frequency (p<0.05) was observed only for those employees in the PPO plan.

Conclusions: Around 20% of the employee population took at least one HRA in five years.

Lower health care cost was associated with participation in two or more HRAs. One-time

HRA participants also had a lower health care cost than non-participants.


This study confirms a dose effect of HRA participation on health care cost. This finding supports the value of providing regular health status assessment at worksite. More cost saving can be realized with more frequent HRA participation. HRA serves as the first step for many worksite wellness programs, often followed by individually tailored feedback on recommendations for health management.

Health behavior theories contend that periodic exposure offers repeated opportunities to motivate changes. Employers can offer employees incentives to participate in HRA, a measure already adopted by many employers. In addition, employers may consider healthy environmental approach that encourages low risk maintenance and fosters lifestyle change in order to achieve long-term savings.


• Consequences of Ignoring VA Data in

Studies of Medicare Enrolled Cancer Patients

Ruth Perrin, M.A., Ruth Perrin, M.A., Qiuying

Zhang, M.S., Kristin Koelling, M.P.H., Rosario

Ferreira, M.D., MAPP, Denise Hynes, Ph.D., R.N.

Presented By: Ruth Perrin, M.A., Health

Information Analyst, VIReC, Veterans

Administration, Hines VA Hospital, PO Box

5000, (151V), Hines, IL 60141, Phone: 708-202-

4195, Fax: 708-202-2415, Email:

Ruth.Perrin@va.gov

Research Objective: Health services researchers often rely on Medicare claims data to identify disease-specific cohorts and for information on health care use and costs among the elderly.

Veterans, who comprise 25% of the U.S. elderly population, may also receive care within the VA system. The objective of this study was to describe differences in research results obtained when VA data are excluded from the analysis.

Study Design: As part of a national study, a retrospective cohort of incident colon cancer patients who were 66 years old or older and eligible to use both VA and Medicare between

1999 and 2001 was identified from California

Cancer Registry data. We examined characteristics of the sub-group who used the VA system exclusively for their healthcare. For the group who used Medicare only or a combination of Medicare and VA healthcare, we compared

Charlson scores computed using a combination of Medicare and VA data with scores obtained without the benefit of VA data. We then examined practice patterns for stages I-IV colon cancer and compared results obtained with

Medicare and cancer registry data versus results obtained with Medicare, registry and VA data together.

Population Studied: Elderly veterans with colon cancer.

Principle Findings: The California cohort comprised 633 veterans with Stage I-IV colon cancer. Ninety-seven (15%) of the cohort were users of VA healthcare only and had no Medicare claims data. Compared with the full cohort, the

97 VA-only patients were more likely to be male

(98% vs. 93%), African American (26% vs. 16%),

younger (47% vs 59% over age 75), and diagnosed at Stage IV of their cancer (28% vs.

18%). This group also had a lower mean

Charlson score (0.76, SD 0.99 vs. 0.93, SD 1.11, not including their cancer diagnosis). Among the remaining 536 patients, many received care through both VA and Medicare. Linking VA data with a registry and Medicare linked dataset, we uncovered 3 more colectomies (for a total of

474) and evidence of chemotherapy for 4 more patients (total 176). Charlson scores computed for the 536 using Medicare data only were lower

(mean 0.83, SD 1.05 and 20.9% with a score of 2 or higher) than those computed after VA data were added to the dataset (mean 0.96, SD 1.13, and 24.8% with a score of 2 or higher).

Conclusions: The 97 patients who used VA healthcare exclusively differed substantially from the full cohort of veterans. Incomplete data on patients who used some VA care resulted in fewer cases with evidence of colectomy and chemotherapy. Charlson scores computed without VA data underestimated comorbidity.


Researchers’ reliance on Medicare data alone in studies of elderly cohorts will systematically exclude the 18% of elderly veterans who use VA healthcare exclusively, a group that differs in important ways from the general population.

Further, research study designs may need to account for missing data on elderly veterans who receive care in both the VA and Medicare systems.

Funding Source: VA

•

Assessing Local Health Department

Capacity and Performance in Diabetes

Prevention and Control

Deborah Porterfield, M.D., M.P.H., Janet Reaves,

R.N., M.P.H., Thomas R. Konrad, Ph.D., Curtis

Dickson, Bryan Weiner, Ph.D., Joanne Garrett,

Ph.D.

Presented By: Deborah Porterfield, M.D.,

M.P.H., Assistant Professor, Social Medicine,

UNC Chapel Hill, CB #7240, Chapel Hill, NC

27599, Phone: 919-843-6596, Fax: 919-966-7499,

Email: porterfi@email.unc.edu

Research Objective: In order to improve the public health system’s ability to prevent and control chronic diseases, we must first understand current practice, and develop appropriate and valid strategies for measuring performance. The objectives of this study are to measure capacity and performance of North

Carolina local health departments (LHDs) in the prevention and control of diabetes and to investigate what characteristics of LHDs and communities are associated with higher performance.

Study Design: We conducted a cross-sectional mailed survey of LHDs in North Carolina in

2005. The survey was based on the work of the

National Public Health Performance Standards

Program. Survey responses were linked to county-level data, including estimated diabetes prevalence, availability of primary care, and sociodemographic information, and data from a national survey of LHDs. Capacity was defined as full time equivalent staff (FTEs) and performance as the self-reported provision of a program or service. A 10-point total index of performance was created across the 10 Essential

Services. Bivariate associations between the performance index and LHD and community characteristics were examined.

Population Studied: All 85 local health departments in North Carolina. The designated respondent was the health director or their designee(s).

Principle Findings: The response rate was

100%. LHDs reported a mean of 0.43 FTEs

(range 0-6) in diabetes prevention and 0.49

FTEs (range 0-7) in control. Forty percent reported no FTEs in prevention or control. Selfreported performance varied across Essential

Services. Activities more commonly reported by

LHDs include providing information to the public and policy makers (76%), providing health education for persons with diabetes (58%), providing primary care for persons with diabetes

(37%), and screening for diabetes (74%). Half have a coalition with a focus on diabetes. Less than half reported assessing whether primary care or diabetes education were available in their community. Activities least commonly reported were involvement in public policy (17%), research (5%), or evaluation (11%). The mean score on the performance index was 3.5 (sd 1.9).

Characteristics associated with better performance included larger population size of the jurisdiction, larger LHD size, and accreditation of the LHD. Better performance was also associated with a history of funding from the state health department (index of 4.1 for those with funding vs. 3.2 for those without) or from a local foundation (index of 6.7 for those with funding vs. 3.4 for those without).

Conclusions: Most health departments have limited capacity to conduct or coordinate diabetes prevention or control in local communities. Although self-report of some programs and services is relatively high,

limitations of measurement include the inability to assess amount, reach, or quality. Total performance of the LHD was not higher in localities of greater need (higher diabetes prevalence or less availability of primary care). A history of external funding was most strongly associated with LHD performance.


Chronic diseases cause the majority of morbidity and mortality in the US, yet are traditionally neglected in local public health practice.

Although some LHDs in our study are able to provide diabetes-related services and programs, our findings suggest an opportunity to enhance local public health practice through targeted funding.

Funding Source: Pfizer Scholars Grants in

Public Health

• Development, Dissemination, and

Utilization of Public Health Systems Research

Resources

F. Douglas Scutchfield, M.D., Nikki Lawhorn,

M.P.P., Ashley McCarty, B.S., Michelyn Bhandari,

Dr.P.H., M.P.H., Allison Amrhein, M.P.H.

Presented By: F. Douglas Scutchfield, M.D.,

Peter P Bosomworth Professor of Health

Services Research and Policy, Health Services

Management, University of Kentucky College of

Public Health, 121 Washington Avenue, Room

105, Lexington, KY 40536-0003, Phone: (859)

257-5678 X 82024, Fax: (859) 257-2821, Email: scutch@uky.edu

Research Objective: This study examined descriptive records of datasets and instruments for inclusion in a Public Health Systems

Research (PHSR) subset of the Health Services and Sciences Research Resources (HSRR) database maintained by the National Library of

Medicine (NLM) and seeks to 1) disseminate information about the PHSR subset and related research to the PHSR research community; and

2) facilitate utilization of this resource by PHSR researchers.

Study Design: We reviewed existing HSRR datasets and related PHSR literature to create a

PHSR subsection of the HSRR database. The

PHSR subset contains data resources which address key areas of PHSR including: access to and utilization of public health services; systems assessment; workforce development; finance/spending; and program and policy planning. After creation of this PHSR dataset, mini-grants were awarded to post-doc or junior faculty within three years of their terminal degree who proposed secondary data analysis projects using a database found in the PHSR subset.

A survey of known PHSR researchers was conducted to determine awareness, utilization, and value of the PHSR subset.

Population Studied: The population studied included databases currently available in the

HSRR database and other public health databases that were identified as potentially useful to PHSR researchers. In addition, we were able to determine the type of databases that have utility for junior faculty based on their use of this resource and ascertain the value of this product by those currently doing PHSR.

Principle Findings: 122 databases and survey instruments have been tagged PHSR in the

HSRR database. Of those, approximately 110 originated from the HSRR database. The remaining 12 were identified through various methods, including literature review and collaboration with leading public health organizations and agencies. The majority of databases tagged PHSR met criteria for multiple areas, the most common being access to and utilization of public health services and systems assessment and evaluation.

Nearly 100% of the funded mini-grant proposals utilized the 12 datasets that were newly identified. Mini-grant topics include public health partnerships, performance standards, preparedness and capacity, and public health practice enhancement.

Conclusions: Development of the PHSR section of the HSRR database has strengthened the capacity to conduct public health systems research, as evidenced by the nearly exclusive use of newly identified datasets in the mini-grant projects. While the HSRR database already contained useful information for PHSR, the addition of PHSR specific databases has increased activity in the field and highlights the need for maintainence and further identification of PHSR datasets/instruments.


The PHSR subset is vital to the continued growth and development of the discipline. Increasing access to and awareness of PHSR resources should be an important part of the agenda for continued development of the PHSR field.

This project furthers that goal by providing the opportunity for mini-grant recipients to present their research results at a PHSR conference in

April 2008 and submit papers for publication in a peer-reviewed journal supplement.

Dissemination of the mini-grant findings will increase awareness of the PHSR database, attract new researchers to the field, and enhance

the data resources which are necessary to further develop the discipline.


•

Evaluating the Ecological Assocaition of

Casino Industry Economic Development on

Community Health Status and Funding for

Public Health in the Mississippi Delta Region

Eduardo J. Simoes, M.D., M.Sc., M.P.H., Raml

Moonesighne, Ph.D., Xueyuan Wang, M.P.H.,

Lovetta Brown, M.D., M.P.H.

Presented By: Eduardo J. Simoes, M.D., M.Sc.,

M.P.H., Director, Prevention Research Centers

Program, Centers for Disease Control and

Prevention, Koger Center - MS K-45, Atlanta, GA

30341, Phone: 770-488-5395, Fax: 770-488-5486,

Email: esimoes@cdc.gov

Research Objective: The purpose of this study was to evaluate the ecological association between the presence of casino industry economic development and improvements in community health status and funding for public health services in two areas of the Mississippi

Delta Region: Tunica County in the State of

Mississippi and Pemiscot County in the State of

Missouri.

Study Design: An ecological approach was used to evaluate whether communities having casinos attained better health status and funding for public health than similar communities without casinos. County-level data on 23 variables readily available from state health department records and other sources were used for an eleven-year period 1993-2004. A logic model using these variables was developed to guide the analysis. A linear regression model was built using a stepwise approach and hierarchical regression principles with many dependent variables and a set of fixed and non-fixed independent variables.

Population Studied: This study was limited to the Mississippi Delta Region of the United

States. Two counties in this region with casinos,

Tunica County, Mississippi and Pemiscot

County, Missouri were analyzed in addition to two comaprison non-casino jurisdictions,

Tallahatchie County, Mississippi and Mississippi

County, Missouri.

Principle Findings: Overall this study found a lack of association between the presence of a casino and desirable health related outcomes and increased funding for public health services.

Improvements in health outcomes were not identified nor was funding substantially increased. Some gaming revenues were used to make changes in the environment to promote health but significant increases in funding for local public health services were not found in either of the two counties with casino gaming.

Conclusions: Analysis such as this should be combined with other routine public health assessments post implementation of economic development strategies to increase knowledge of health outcomes and shifts in socioeconomic position that may be expected to accrue from economic development projects. Without this basic knowledge, decisions will not be supported with evidence and course corrections or strategies for improvement (ie, dedicated gaming tax revenues for public health functions) will not emerge.


Findings from this research are relevant for policymakers and taxpayers when debating community economic development strategies.


• Validation of Social Security Administration

Death Master File for Use in Epidemiology and Large Database Studies

Jonah Stulberg, M.P.H., Heather Beaird, Ph.D.

Presented By: Jonah Stulberg, M.P.H., Student,

Epidemiology and Biostatistics, Case Western

Reserve University, School of Medicine, 10900

Euclid Avenue, Cleveland, OH 44106-4945,

Phone: 216-368-3197, Fax: 216-368-3970, Email: jjs42@case.edu

Research Objective: To evaluate the reliability of using the Social Security Administration Death

Master File as a source of mortality data for use in epidemiologic research.

Study Design: Sensitivity and specificity analysis of the Social Security Administration's Death

Master File using Ohio Death Certificates as the gold standard. Further, this merged dataset was analyzed to elucidate variation in Death Master

File sensitivity with regard to demographic variables.

Population Studied: All Ohio citizens and noncitizens who died in Ohio between January 1,

1999 and December 31, 2002.

Principle Findings: The Social Security

Administration correctly identified 91.25% or

404,763 of the 443,572 total deaths that occurred between 1999 and 2002. Underreporting of deaths by the SSA was most prominent in certain demographic groups including individuals below 65 years of age and those who were never married. For the study period, each year of death was associated with a statistically

significant improvement in the probability that the SSA would correctly identify a known death.

Conclusions: The Social Security Administration

Death Master File has made significant improvements to the administrative processes between 1999 and 2002 allowing them to record deaths for individuals with greater than 90% sensitivity. While this may be a useful resource for confirming deaths of individuals within certain study cohorts, researchers may need to adjust their analysis based on these statistical sensitivities. These results support the use of several suggested methods for integrating the

Death Master File into validating vital statistics in large cohort studies.


Few studies exist to validate the Social Security

Administration's Death Master File using a large enough cohort for demographic analysis, and this study highlights the important variations of sensitivity previously not described in the literature. Health Services Researchers that use the Death Master File will need to account for these sensitivities before drawing conclusions with their data. Future analysis to confirm these results in other years and using other state death certificates will help further elucidate these issues.

• Civil Service Laws: Friend or Foe of State

Health Departments

Patricia Sweeney, J.D., M.P.H., R.N., Elizabeth

Ferrel Schmidt, J.D.

Presented By: Patricia Sweeney, J.D., M.P.H.,

R.N., Assistant Professor, Department of Health

Policy and Management, University of

Pittsburgh, 3109 Forbes Avenue, Suite 210,

Pittsburgh, PA 15260, Phone: 412-383-2400, Fax:

412-383-2228, Email: psweeney@pitt.edu

Research Objective: The purpose of this research is to identify the scope and variability of state public health department personnel management and to determine the impact civil service laws have upon state public health department human resource functions.

Study Design: The Human Resource Director of each State Health Department was mailed a survey asking the Director to identify which agency in their state was authorized to perform each of 26 different human resource functions deemed to be progressive and market responsive in the literature. In addition, each

Director was asked to rate the degree to which state civil service laws impacted their health department’s ability to perform each of the identified functions. For each personnel function listed, the human resource director reported whether state civil service law prohibited, constrained, permitted, encouraged, or mandated the state health department to undertake the activity. Simultaneously, research was conducted which analyzed civil service laws of each state.

Population Studied: State Public Health

Departments and the state civil service/merit laws regulating state health deparment human resource functions.

Principle Findings: 31 states and US Territories responded to the survey. The greatest restraint imposed by civil service laws was reported in the areas of job classification modification, pay scale alteration, and the ability to promote personnel based upon attainment of performance standards. State Civil service laws were identified as a negative factor when recruiting state health department personnel. States reporting that civil service laws had a neutral impact upon health department hiring had recently undergone legislative revision providing more autonomy in health department personnel management.

Conclusions: Civil service laws in many states restrict the state health deaprtment's ability to hire and retain personnel that possess the competencies needed to perfom the essential public health services relevant to their positions.

States that have recongnized this negative impact have revised civil service laws for certain positions identified as critical to public health.


Civil Service Laws across the country should be reviewed and revised to reflect more contemporary, market responsive personnel management standards.


• Impact of a Community-based Integrated

Management of Childhood Illnesses (IMCI)

Effort in Gegharkunik, Armenia

Michael Thompson, M.S., Dr.P.H., Tsovinar

Harutyunyan, M.P.H.

Presented By: Michael Thompson, M.S.,

Dr.P.H., Assistant Professor, Health Behavior &



Charlotte, NC 28223-0001, Phone: (704) 687-

8980, Fax: (704) 687-6122, Email: methomp1@uncc.edu

Research Objective: Health status in the

Martuni region of Gegharkunik marz, Armenia had precipitously declined following Armenia’s

independence in 1991. In response, the

American Red Cross (ARC) and the Armenian

Red Cross Society (ARCS) implemented the

World Health Organization’s Community IMCI

(integrated management of childhood illnesses) strategy via a combination of peer health education and mass media, complementing recent clinical IMCI training at primary care centers. From December 2002-November 2003,

387 Community Health Volunteers from 16 villages were trained as peer educators, and approximately 5,000 caretakers of children under

5 were counseled on key nutrition and health practices.

Study Design: The program’s impact was assessed using a pre-post independent sample design. The instrument collected respondent demographic characteristics, knowledge, attitudes and practices consistent with 10 health indicators targeted by the intervention.

Population Studied: At baseline and at followup, 300 mothers were selected for face-to-face interview using a stratified simple random sampling of households with at least one child under 24-months of age.

Principle Findings: The assessment confirmed the population’s poor health status and limited parental knowledge and application of recommended child care practices. The campaign reached the target communities: 67% had seen media messages within the past month, 82% had received the IMCI informational booklet, and 30% had seen other campaign materials. At follow-up, evidence of the success of the program included: exclusive breastfeeding increased 31.4%, maternal awareness of child illness signs increased 30%, knowledge of HIV increased 28.5%, and physician attended deliveries increased 15%.

Conclusions: This evaluation documented the significant and substantial impact of the

Community IMCI program on both knowledge and practice in rural areas of Armenia.


Consideration should be given to continuing and expanding this project.

Funding Source: American Red Cross

• Factors Associated with Weight Loss in

Overweight or Obese Adults

Rui Wang, Ph.D., Michael Shambaugh-Miller,

Ph.D.

Presented By: Rui Wang, Ph.D., Health Data

Analyst, Preventive and Societal Medicine,

University of Nebraska Medical Center, PSM

984380 UNMC, Omaha, NE 68198, Phone:

4025599397, Fax: 4025597259, Email: richardwang@unmc.edu

Research Objective: To investigate factors associated with self-reported weight control status of overweight or obese adults in America.

Study Design: Using 2005 National Behavioral

Risk Factor Surveillance Survey data, variables that might affect a person’s attitude toward losing weight, including gender, race, education, age, Body Mass Index (BMI), overweight-related disease (having at least one of the following diseases: diabetes, hypertension, high blood cholesterol, heart attack, angina or coronary disease, or stroke), getting advice from healthcare provider about losing weight, and having sufficient social and emotional support

(SSES) were selected in this study. A multivariate logistic regression method was used to estimate the association between the above factors and the likelihood of trying to lose weight. SUDAAN software was used to adjust for the complex survey effects.

Population Studied: Overweight or obese adults in America were studied. Data included 34,339 overweight or obese adults (19,443 women and

14,896 men) who answered the question in the

2005 Behavioral Risk Factor Surveillance System

(BRFSS) survey about if they received advice from healthcare providers to lose weight. The mean age of the sample was 52.12 years; 57.15%

(19,626) were overweight and 42.85% (14,713) were obese.

Principle Findings: About 63% of the total population studied expressed that they wanted to lose weight (52% among the overweight group and 77% among the obese group). About 24% of total population studied were given advice by a doctor, nurse, or other health care provider about losing weight. The following associated factors could affect the likelihood of trying to lose weight: being advised to lose weight from professional health care provider (the odds of trying to lose weight for those who got advice were 4.7 times the odds for those who got no advice, 95% CI: 4.1 to 5.3, p<0.01), BMI (the odds for those who were obese were 2.2 times the odds for those who were overweight, 95% CI:

2.0 to 2.4, p<0.01), gender (the odds for males were 0.4 times the odds for females, 95% CI: 0.4 to 0.5. p<0.01), education (the odds for those with a college or higher degree were 1.4 times the odds for those with less than a college degree, 95% CI: 1.3 to 1.6, p<0.01), having at least one overweight-related disease ( the odds for those with at least disease were 1.3 times the odds for those with no disease, 95% CI: 1.2 to

1.4, p<0.01), age (the odds for those aged 65 years and older were 0.6 times the odds for those aged 40 to 64 years, 95% CI: 0.6 to

0.7,p<0.01), and getting SSES (the odds for those who always or usually got SSES were 1.1 times the odds for those who never to sometime got SSES, 95%, CI: 1.0 to 1.2, p=0.03).

Conclusions: About 62% of all the Americans are overweight or obese. In this study, we found only about 24% of people who answered the question in the 2005 Behavioral Risk Factor

Surveillance System (BRFSS) survey were given advice by a doctor, nurse, or other health care provider about losing weight. The leading factor that may affect the attitude of losing weight for overweight patients was receiving advice from a healthcare provider, followed by BMI, gender, and education; SSES also plays a very important role.


Increased body weight was closely linked to increased disease and disability occurrence.

Majority of the overweight adults expressed their willingness of losing weight. Overweight/obesity prevention programs and counselling needed to be provided by healthcare providers. Education and SSES also significantly affected a patient’s attitude toward losing weight.

• Smoking and Alcohol Drinking: The Links

Between Social Capital and Improved Health?

Hongmei Wang, Ph.D., Mark Schlesinger, Ph.D.

Presented By: Hongmei Wang, Ph.D., Assistant


UNMC, 984350 Nebraska Medical Center,

Omaha, NE 68198-4350, Phone: (402)559-9413,

Fax: (402)559-7259, Email: wxiaohan2002@yahoo.com

Research Objective: A growing number of studies have suggested the positive health effects of social capital measured as either the density of social networks or interpersonal trust.

In spite of the seemingly ample evidence that links interpersonal trust to improved health status, the causal relationship is yet to be established. Researchers propose that community stock of trust is linked to improved health through promoting healthy norms and inhibiting a person’s unhealthy behaviors such as smoking and binge alcohol drinking.

However, relatively few studies have examined empirically the proposed associations to date.

This paper employs data from rural China to test how social capital is associated with smoking and alcohol drinking behaviors and whether the association is different for subgroups of the population.

Study Design: This paper adopts multivariate logistic regression analyses, adjusting for survey design effects, for main analyses. The outcome variables are indicators of intensity and quitting of smoking and alcohol drinking. The measures of smoking behavior include three binary variables indicating whether a person is a current smoker of any amount, a heavy smoker who smokes over 20 cigarettes per day, or a previous smoker. Similarly, measures of alcohol drinking behavior are three dummies indicating whether a person is a current drinker of any amount, a binge drinker who drinks over 50 grams of alcohol in one setting, or a previous drinker.

Social capital is measured at both individual level and village level using eight trust questions and two mistrust questions. Individual trust and mistrust indices are constructed separately and both measures were aggregated at village level.

A rich set of variables including demographics, health risk measures, social economics factors, and sanitary measures are controlled in the models. Stratified analyses based on gender and chronic conditions are also conducted to examine their interaction effects with social capital.

Population Studied: The analyses focus on rural residents in 22 villages in China who are 15 years to 85 years old. The data employed is from a stratified random sample in the 2002 household survey of the Harvard Rural Mutual Healthcare

Project. The final sample size is 9608.

Principle Findings: (1) Both individual-level and village-level social capital have a significant impact on smoking and alcohol drinking behaviors. Village-level social capital appears to be a strong and consistent predictor of healthrelated behaviors, compared to individual-level social capital. The effects of social capital on smoking, however, follow a dissimilar pattern to that on alcohol drinking. (2) For smoking, village trust and mistrust both are associated with lower probability of smoking. The protective effect of village trust appears to be from its association with less take-up of heavy smoking, whereas that of mistrust is from its association with more quitting. This pattern of effects is most significant for men regardless of a person’s chronic conditions. (3) For alcohol drinking, we find that village trust is associated with more drinking and village mistrust is associated with less drinking. The protective effect of mistrust appears to be from its association with less takeup of binge drinking. Only for women with

chronic conditions, high levels of trust show protective effects from drinking.

Conclusions: The empirical results suggest that social capital influences smoking and alcohol drinking behaviors differentially in rural China. It also provides us with evidence that links trust to more alcohol drinking and mistrust to lower probability of heavy smoking. While seemingly surprising, these findings are in line with the social contagion theory that trusting people are more likely to follow the norms of the community even if the prevailing norms are health damaging. In rural areas of China where smoking and alcohol drinking are highly prevalent, higher levels of social capital may not necessarily be connected with more healthy lifestyles.


This main finding, together with the complications of social capital effects on health behaviors for subgroups of the population, should be taken into account when forming relevant public health policies.

•

Comprehensive Health System Reforms: A

Comparative Analysis of Massachusetts and the Netherlands

Jennifer Wrathall, B.A. Psychology; MPH candidate 2007, Jennifer Wrathall, M.P.H. candidate 2007

Presented By: Jennifer Wrathall, B.A.

Psychology; MPH candidate 2007, Graduate

Student, Management, Policy and Community

Health, University of Texas School of Public

Health, 7777 Greenbriar #3057, Houston, TX

77030, Phone: 832-655-8012, Email: jenwrathall@gmail.com

Research Objective: This paper will compare and contrast two current health systems reforms: the Massachusetts Health Care Reform

Act, to be fully implemented in July, 2007 and the Dutch Health Insurance Act

(Zorgverzekeringswet), implemented in January,

2006. The goal is to examine whether or not the combination of several reform elements will lead to successful health system reforms that preserve and expand access, control costs, and benefit society.

Study Design: This study employs secondary analysis of both qualitative and quantitative research. It is inspired by Dixon-Woods synthesis of evidence methodology (Journal of Health

Services Research Policy, January 2005).

Population Studied: The populations studied are the State of Massachusetts and the

Netherlands.

Principle Findings: Two recent health system reform plans - undertaken in very unlike circumstances, for different reasons, and in dissimilar geographical locations - share important similarities. Both Massachusetts and the Netherlands have implemented plans that involve mandatory coverage, guaranteed issue, community rating, and subsidies for the poor.

Insurance plans will be provided by the private insurance market in the Netherlands and by a mixture of the private and public sectors in

Massachusetts. Affordable packages that cover basic needs will be available for the poor in both regions. In the Netherlands, unlike

Massachusetts, competition is exclusively about the price of the basic health insurance package that all companies are required to offer. Results from Massachusetts will be at least another year in coming. Principal analyses will include results from the first stages of implementation, i.e. the number of people purchasing new plans, consumer satisfaction, etc.

Conclusions: Results from the Netherlands from their first year of implementation of these reforms show that consumers are dissatisfied with the changes but enthusiastic about having a choice of insurance plans. Consumers are finding it more difficult to choose a plan since the reform was implemented, and many are distrustful of the new system. Even in a highly competitive market, with a level playing field for participating insurance companies, cost containment is still elusive. Nor is it necessarily a "break-even investment" for the insurance companies. Results from Massachusetts will be forthcoming and policy experts are predicting that Massachusetts will have many of the same problems observed in the Netherlands.

Implications for Policy, Practice or Delivery: It will take several more years to reach a clearer conclusion about whether or not this combination of reform strategies will be successful in these regions. By comparing and analyzing these two examples of systematic health system reforms, we may find successes in the expansion of health care to the uninsured

(Massachusetts) but the need to find new mechanisms for controlling costs.

•

Cost Associated with Tobacco Use Within the Military Health System’s TRICARE Prime

Enrolled Population

Yiduo Zhang, Ph.D., Nancy K. Fagan, Ph.D.,

Samuel T. Olaiya, Ph.D., David N. Tornberg,

M.D., M.P.H., Yaozhu Chen, M.P.A., Yiduo

Zhang, Ph.D.

Presented By: Yiduo Zhang, Ph.D., 3130 Fairview

Park Drive, Suite 800, Falls Church, VA 22042,

Phone: 703-269-5603, Email: yiduo.zhang@lewin.com


Defense (DoD) medical and non-medical costs associated with tobacco use among a population eligible to enroll into the military TRICARE Prime health plan option.

Study Design: Cost-of-disease model developed by combining information from DoD and civilian health surveys and studies; DoD healthcare encounter data for 3.5 million enrollees; and the epidemiology literature on the increase risk of tobacco use related comorbidities

Population Studied: 4.2 million DoD active duty personnel, dependents and retirees eligible to enroll into the military’s TRICARE Prime health plan option.

Principle Findings: Approximately 1.4 million

(49%) enrollees age 17 and older were current or former smokers in 2005. Among adult enrollees, approximately 647,000 (22%) are former smokers; 418,000 (14%) are light smokers;

266,000 (9%) are moderate smokers; and

113,000 (4%) are heavy smokers. An estimated

176,000 of the study population use smokeless tobacco. The estimated cost to TRICARE Prime in 2005 to treat the comorbidity cases associated with tobacco use was $574 million. Moderate-toheavy smoking is found associated with higher absenteeism and lower productivity while at work. The estimated productivity loss to DoD is

568,000 FTE work days, including 488,000 FTE days lost due to absenteeism and 79,600 FTE days lost due to below-normal work performance. The $86 million annual productivity loss to DoD includes $75 million for absenteeism and $11 million for reduced job performance. Our simulation model suggests that a 5% decrease in smoking prevalence could produce future cost savings of $79 million for

DoD over a 10 year period, including $45 million in medical expenditures and $34 million in nonmedical expenditures.


Tricare medical expenditures are attributed to tobacco use.


Intervention and prevention programs for smoking cessation might be cost effective in reducing health care expenditures, improving productivity, and improving quality of life for the

DoD population.


Prevention & Treatment of

Chronic Illness

•

Determinants of Emergency Room

Utilization by the U.S. Population with

Diabetes

Joyce Addo-Atuah, M.S., Teresa Waters, Ph.D.,

Shelley White-Means, Ph.D., Dick Gourley,

Pharm.D.

Presented By: Joyce Addo-Atuah, M.S., PhD

Candidate, College of Graduate Health Sciences,

University of Tennessee Health Science Center,

847 Monroe Avenue, Room 205M, Memphis, TN

38163, Phone: (901) 448-1738, Fax: (901) 448-

4731, Email: jaddoatu@utmem.edu

Research Objective: The objectives of this study were (1) To provide an estimate of emergency room utilization by the United States population with diabetes in 2003 and (2) To examine the relationship between the utilization of ER by the population with diabetes and selected demographic and clinical variables. These variables were age, gender, race, ethnicity, marital status, insurance status, educational level, family income, census region, locality, body mass index, and comorbidities/complications.

Study Design: This was a cross sectional study consisting of a retrospective analysis of emergency room utilization by individuals with diabetes. The data source for the study was the

2003 MEPS Household Component Full Year

Consolidated File (MEPS HC-079, 2003). ICD9-

CM code 250 (diabetes) was used to identify people reporting diabetes in the MEPS data file.

Individuals with the usual diabetes-associated complications/comorbidities were further identified with the relevant ICD9-CM codes and the data merged by the person identification number DUPERSID. The response or outcome variable of interest was the utilization of emergency room care reported in MEPS as total

ER visits in 2003(ERTOT03). The likelihood of ER use in the population with diabetes was examined by a logistic regression with the dichotomous outcome having at least one ER visit (yes/no). To examine how each of the independent variables predicted total ER utilization by the study population, regression models using the method of least squares were run with the log transformed total ER visits as

the outcome variable. All computations and analyses incorporated the MEPS sampling weights to obtain estimates for the noninstitutionalized US civilian population with diabetes in 2003.

Population Studied: Individuals reporting diabetes in the 2003 MEPS Household

Component Full Year Consolidated File.

Principle Findings: There were 5.4 million ER visits by 24.4% of people reporting diabetes in

2003. The population with diabetes were 46.7% male, 40.4% elderly, 77% Caucasian, 66% had high school or higher level of education, 6.4% were uninsured, 51% were obese, and 62% had comorbidities especially hypertension. Of those with ER visits, 67.19% had only one ER visit; the rest had two or more ER visits with a mean of 1.5 visits. Young adults (19-29 years) were more likely to visit the ER than other adults (30-64 years). Individuals with public insurance were more likely to visit the ER than those with other insurance. Obese individuals, those with comorbidities, and those with low or middle income were more likely to visit the ER than those without these characteristics. Age was negatively associated with total ER use

(p<0.001), as was being Hispanic (p<0.01), being married (p<0.04), having higher education

(p<0.02), and being obese (p<0.02). On the other hand, having Medicare coverage was associated with an increase in total number of

ER visits (p<0.01), as was being on Medicaid

(p<0.05), having lower educational level

(p=0.05), and having comorbidities (p<0.001).

Race, gender, income status, census region, or locality were not significantly associated with the total number of ER visits.

Conclusions: Lower educational level, public insurance, and comorbidities are important predictors of emergency room utilization by individuals with diabetes. This might indicate the need for appropriate interventions to reduce ER use by individuals with diabetes.

Implications for Policy, Practice or Delivery: 1)

The management of diabetes needs to be maximized so as to minimize ER visits by people with diabetes. 2)Approprite interventions including patient education would be needed to optimize the management of diabetes and minimize ER use. 3)The details of the Medicare and Medicaid coverage may need to be reevaluated so as to promote access to all the services needed by people with diabetes so as to reduce their ER use.

• The Costs of a Sedentary Lifestyle in

Persons with Arthritis

Orit Almagor, M.A., Rowland W. Chang, M.D.,

M.P.H., Chin H. Lee, M.D., M.P.H., Larry M.

Manheim, Ph.D., Dorothy D. Dunlop, Ph.D.

Presented By: Orit Almagor, M.A., Statistical

Analyst, Department of Physical Medicine and

Rehabilitation, Northwestern University, 7719

Heatherton Lane, Potomac, MD 20854, Phone:

(240)499-8020, Fax: (240)499-8020, Email: oalmagor@northwestern.edu

Research Objective: Assess the prevalence of persons with physician-diagnosed arthritis who have sedentary activity levels and estimate the direct medical costs associated with a sedentary compared to an active lifestyle using data from a national probability sample.

Study Design: We identified persons reporting physician-diagnosed arthritis from the 2003

Medical Expenditure Panel Survey (MEPS), which was linked to the National Health

Interview Survey (NHIS). NHIS physical activity questions were used to identify persons with sedentary (absence of moderate- or vigorous- physical activity or <10 minutes of either moderate- or vigorous physical activity per week) versus active lifestyles. Cost of a sedentary lifestyle was defined as the difference in medical expenditures as compared to active lifestyles. All analyses were weighted and accounted for complex sampling design using STATA software to provide valid inferences for the U.S. population.

Population Studied: We identified 2,467 persons reporting physician-diagnosed arthritis from 10,218 adults included in the 2003 Medical

Expenditure Panel Survey (MEPS).

Principle Findings: Among 2,467 adults with arthritis aged 18 or older, 43% were sedentary.

Sedentary adults with arthritis had significantly greater unadjusted medical expenditures

($2,079, 95% Confidence Interval

[CI]=$951,$3,208) and out-of-pocket expenditures

($279, 95% CI=$51,$508) when compared to active adults. Sedentary adults were significantly older (64 vs. 57 years), non-White (24% vs.

16%), female (71% vs. 64%), less educated (35% vs. 16% high school or less), smokers (24% vs.

20%), and obese (10% vs. 4%) compared to active adults. After adjusting for age, gender,

BMI, functional limitations, smoking and economic status, a sedentary lifestyle was associated with 16% more medical expenditures and 14% more out-of-pocket expenses.

Conclusions: Based on national data, 43% of persons with arthritis lead sedentary life styles.

Sedentary lifestyle is associated with higher total

medical expenses, an issue that has policy implications since such costs are shared by the government, private insurers, and individuals.

Sedentary lifestyle also is associated with higher out-of-pocket costs, which are solely born by the individual.


Public health programs that effectively increase physical activity in persons with arthritis may help to control national medical costs and reduce the medical expenses incurred upon persons with arthritis.

Funding Source: NIH

•

Impacting Hospitalizations on Medicare

Beneficiaries in Puerto Rico: Initial Results of a Population Based Disease Management

Program

Juan Alonso-Echanove, M.D., Agustín

Fernandez, M.D., Merni Rodriguez, R.N., Hector

Méndez, M.D., Josefina López, M.D., Rick

Shinto, M.D.

Presented By: Juan Alonso-Echanove, M.D.,

Vicepresident Epidemiology, Epidemiology,

MMM Healthcare, Inc., Federico Costa # 54,

Hato Rey, PR 00918, Phone: (787) 378-3768, Fax:

(787) 300-5503, Email: juan.alonso@mmmhc.com

Research Objective: To assess impact on hospitalization rates among members enrolled in 'Cuidándote Más' (CM), a population-based disease management program for patients with specific chronic conditions (CHF, Coronary

Artery Disease, Diabetes Mellitus, COPD, and

Renal Insuficiency), and identify specific subpopulations benefiting from it

Study Design: Retrospective cohort study

Population Studied: All members affiliated in

MMM (the largest MA-Plan in Puerto Rico) for

>12 months before January 6, 2006 (date CM was launched). Baseline hospitalization rates were compared to hospitalization rates during the Intervention Period (IP) for two cohorts, the

CM (CMC) and Non CM (NCMC). The baseline period was 12 months before a reference date

(RD) and the IP was from the RD to November

1st, 2006. For CMC, the RD was the enrollment date in CM; for NCMC, the RD was the CMC’s median enrollment date. Patients were stratified in risk categories according to CMS’s Risk

Adjustment Factor (RAF) and the number and type of chronic conditions. Rates were calculated per 1,000 member-years (K). We calculated expected and averted admissions based on NCMC growth rate. Chronic conditions were defined using CMS’s assigned

HCC codes for 2006.

Principle Findings: The study population included 21,240 (CMC) and 21,997 (NCMC) members. Both cohorts had similar MMM’s affiliation time (33 months), but CMC had a higher average age (71 vs 69 years; P=0.001) and average RAF (1.5 vs 1.2 P<.001). In CMC, 41% of the members had one chronic condition, 21% had two, and 11% had three or more compared to 33%, 12%, and 6% in NCMC. Overall baseline rates, adjusted to RAF and # chronic conditions, were 14% higher for CMC (264K vs 231K;

P<0.001). However, IP rates were 6% lower for

CMC compared to NCMC (298K vs 318K;

P<0.001) representing an increase of 13% and

38% respectively and substantial admissions

(1,326) and cost (over $6 million) averted. Both, baseline rates and its change in the IP, differed largely by cohort and risk category (range for baseline: 45 K to 809 K; range for change: -15.1% to +190%). In CMC patients with CHF only, rates decreased 9% vs an increase of 34% in

NCMC

Conclusions: Our preliminary data reveals substantial variation in hospitalization rates among our MMM cohorts during the intervention period. CMC hospital admission rates increased significantly less than the NCMC.

Specific risk groups, seemed to benefit from our

CM disease management program. Further risk adjustment and the role of specific interventions and of Part D is currently being analyzed


Population-based disease management programs for specific conditions may substantially impact hospitalizations among medicare beneficiaries in areas with high prevalence of these conditions

• Patient Assessment of Chronic Illness Care among Hispanic Diabetic Population

Abraham Aragones, M.D., Eric Schaefer, M.D.,

David Stevens, M.D., Nirav R. Shah, M.D.,

M.P.H.

Presented By: Abraham Aragones, M.D., Fellow,

Medicine and Public Health Research, Medicine,

New York University School of Medicine, 92 7th

Avenue Apt 9, Brooklyn, NY 11217, Phone: 917-

912-8075, Email: aragoa01@med.nyu.edu

Research Objective: The Chronic Care Model

(CCM) identifies the essential elements of a health care system that encourage high-quality chronic disease care. The Patient Assessment of

Chronic Illness Care (PACIC) is an instrument

developed to assess the quality of patientcentered care consistent with the CCM. This study evaluates the PACIC in an urban Hispanic diabetic population.

Study Design: Hispanic diabetic patients completed the Spanish version of the 20-item

PACIC questionnaire as well as a set of questions on socio-demographic and cultural factors. The PACIC consist of 5 scales (Patient

Activation, Delivery System Design / Decision

Support, Goal Setting / Tailoring, Problem-

Solving / Contextual, and Follow-up /

Coordination) as well as an overall score; it is scored on 5 point scale (1 equals patient perceives very little care was consistent with

CCM and 5 equals patient perceived most of their care was consistent with the CCM).

Population Studied: Hispanic diabetic patients were recruited at a primary care clinic of a large municipal hospital in New York City that has implemented the CCM since 2003. Hispanic diabetic patients that used this clinic as their regular source of care for more than 2 years and spoke Spanish as their primary language were enrolled.

Principle Findings: Fifty patients completed the

PACIC questionnaire as well as sociodemographic and cultural questionnaires. The mean overall PACIC score was 3.08 (SD 0.82), for Patient Activation was 2.94 (SD 1.2), for

Delivery System Design / Decision Support was

3.81 (SD 1.0), for Goal Setting / Tailoring was

2.84 (SD 1.0), for Problem-Solving / Contextual scale was 3.43 (SD 1.25), and for Follow-up /

Coordination scale was 2.4 (SD 0.83). Mean acculturation level, measured by the Marin scale, was 1.8. We found no association between the

PACIC scores and level of acculturation, gender, age, marital status, level of education, country of birth, years since migrated to the United States or insurance status (all P>0.4).

Conclusions: PACIC scores among Hispanic diabetic patients were consistent with previously published scores from patients of other ethnicities. The PACIC score showed no association with socio-demographic and cultural characteristics.


The PACIC questionnaire appears to be a useful tool to assess care consistent with the various dimensions of the CCM in a heterogeneous

Hispanic population.

•

A Little Help from My Friends: Effect of

Social Networks on the Diagnosis and Control of Diabetes

Arshiya Baig, M.D., M.P.H., Jose J. Escarce,

M.D., Ph.D.

Presented By: Arshiya Baig, M.D., M.P.H.,

Robert Wood Johnson Clinical Scholar,

Department of Medicine, Divison of GIM/HSR,

UCLA, 911 Broxton, 3rd Floor, Los Angeles, CA

90024, Phone: 310.794.2206, Fax: 310.704.3288,

Email: abaig@mednet.ucla.edu

Research Objective: Studies have found that strong social networks improve health and reduce mortality. No study has assessed whether one explanation for these effects is that social networks promote earlier diagnosis and better control of chronic disease. We assessed the effect of social networks on receiving a diagnosis of diabetes among adults with laboratory evidence of the disease and on control of diabetes among diagnosed diabetics.

Study Design: We estimated multivariate logit regression models to assess the effect of social networks on the likelihood of being diagnosed with diabetes by a health care provider among adults with laboratory evidence of diabetes.

Among known diabetics, we estimated models to assess the effect of social networks on control of blood glucose, blood pressure, and lowdensity lipoprotein (LDL) cholesterol. We measured the strength of social networks using a score based on respondents’ reports of the number of phone calls and get-togethers per week with family and friends, attendance of religious services, memberships in clubs or other organizations, and attendance at club meetings.

Our models controlled for age, gender, race, income, education, family history of diabetes or cardiovascular disease, insurance, marital status, comorbidities, body mass index, and smoking.

Population Studied: We used data from the

Third National Health and Nutrition Examination

Survey (NHANES III, 1988-1994), and included

882 diabetics age 20 or older who had an 8-hour fasting blood glucose test and were not pregnant or breastfeeding. We identified persons with diabetes as those who reported a provider diagnosis of diabetes, were taking diabetes medications, or had a fasting glucose over 125 mg/dl. We defined diagnosed diabetics were those who reported a diagnosis or were taking medications; undiagnosed diabetics were those who did not report a diagnosis and were identified exclusively through the fasting glucose level. Criteria for glucose, blood pressure, and

LDL cholesterol control were based on clinical recommendations.

Principle Findings: Among the 882 diabetics,

59% had received a diagnosis from a provider.

The regression analyses found that diabetics with higher social network scores were more likely to have received a diagnosis, other things being equal. The odds ratio of 1.18, 95% CI, 1.04-

1.34, corresponds to an increase in the probability of diagnosis from 54% to 64% as the social network score rises from the 25th to the

75th percentile of the distribution. However, social network scores did not affect glucose, blood pressure, or LDL cholesterol control among diagnosed diabetics.

Conclusions: Diabetics with stronger social networks were more likely to know they had diabetes, although social networks did not influence the control that diagnosed diabetics had of their disease.


Our findings reinforce the importance of social connections and active participation in the community for people with chronic disease.

Further understanding of the mechanism through which social networks impact the diagnosis of diabetes may represent a promising strategy to improve diabetes identification and management.


• Effects of Mental Problems and Binge

Drinking on Adherence to Treatment for

Hypertension: A California Population Study

Jim E. Banta, Ph.D, M.P.H., Mark G. Haviland,

Ph.D., Kelly B. Haskard, M.A., Summer L.

Williams, M.A., M. Robin DiMatteo, Ph.D.,

Donald L. Anderson, M.D.

Presented By: Jim E. Banta, Ph.D, M.P.H.,

Assistant Professor, School of Public Health,

Loma Linda University, 26490 Veronica Court,

Loma Linda, CA 92354, Phone: (909) 558-7753,

Fax: (909) 558-0469, Email: jbanta@llu.edu

Research Objective: To determine the effects of poor mental health and excessive alcohol use on adherence to hypertension medications among

California adults who had been told by a doctor that they had hypertension.

Study Design: Secondary analysis of a crosssectional telephone survey, the 2003 California

Health Interview Survey (N = 42,044). Subjects were respondents who had been told by a doctor that they had hypertension. Statistical analyses included bivariate comparisons of hypertensive adults versus non-hypertensive adults and multivariable logistic regression, with the binary dependent variable being taking versus not taking hypertension medications (i.e., adherence versus non-adherence). A jackknife approach was used to account for the raked weights released in the public-use dataset. The main independent variables were mental problems

(number of days with poor mental health in the past 30 days) and binge drinking (five or more drinks at one time in the past 30 days).

Covariates included age, sex, race/ethnicity, language, income, education, insurance coverage, work status, social support, smoking, rural/urban, and health status (self-reported

BMI, co-morbid diabetes, cancer, heart disease, and asthma).

Population Studied: Representative sample of all adults living in California.

Principle Findings: Six million adults had hypertension, 23.5% (95% C.I. 23.0-24.0%) of all

California adults. Of those with hypertension,

39.7% (38.5-41.0%) reported having at least one poor mental health day, 11.1% (10.4-11.9%) reported binge drinking, and 32.3% (31.2-33.4%) were not taking hypertension medications.

Logistic regression revealed a positive relationship between poor mental health and non-adherence: 1-5 days of poor mental health

(O.R. 0.80, 95% C.I. 0.68-0.95), 6-20 days (O.R.

0.67, 95% C.I. 0.55-0.81), and 21 to 30 days (O.R.

0.66, 95% C.I. 0.52-0.84). Binge drinking was not a significant predictor of non-adherence

(O.R. 0.98, 95% C.I. 0.78-1.24). Factors associated with non-adherence (p < .05, odds ratios < 1) included being young and otherwise in good health, being Latino, having less than a high school education, being a non-citizen, being uninsured, and having no usual source of medical care. Factors associated with adherence

(p < .05, odds ratios > 1) were being older, having poor self-reported health status, having co-morbid diabetes or heart disease, being overweight or obese, being African American, graduating from college, and having prescription insurance coverage.

Conclusions: After adjusting for sociodemographic and health status variables, poor mental health was a significant predictor of medication non-adherence among adults with hypertension, whereas binge drinking was not.

Adherence improved with increasing age, education, and insurance. Mental health problems may lead to nonadherence through effects on cognitive functioning, poor motivation, and lack of social resources.


These findings suggest that improvements in mental health may lead to increased medication adherence among hypertensive adults. It may be

beneficial for health care providers to screen for and address mental health problems among their hypertensive patients. These findings also suggest that interventions to improve adherence should be directed towards young adults,

Latinos, and individuals with poor health coverage and no usual source of medical care.

Funding Source: Forest Laboratories, Inc.

•

Clinical and Patient-Reported Measures of

Healthcare Quality for Sickle Cell Vaso-

Occlusive Crisis

Mary Catherine Beach, M.D., M.P.H., Sophie

Lanzkron, M.D., Lakshmi Lattimer, B.A., Neda

Ratanawongsa, M.D., Carlton Haywood, M.P.H.,

Neil R. Powe, M.D., M.P.H., M.B.A.

Presented By: Mary Catherine Beach, M.D.,

M.P.H., 2024 East Monument Street, Room 2-

521, Baltimore, MD 21287, Phone: 410-614-1134,

Email: mcbeach@jhmi.edu

Research Objective: Patients with sickle cell disease (SCD) have reported problems receiving high quality care when seeking treatment for vaso-occlusive crisis (VOC), but no validated measures exist to evaluate how well pain during

VOC is managed. The purpose of this study was to develop and test the reliability and validity of quality of care measures for Emergency

Department (ED) management of VOC.

Study Design: Brief cohort study. We used clinical practice guidelines to develop measures that could be abstracted from the medical record and reported by patients. We assessed inter-rater and test-retest reliability of chart-abstracted measures and used logistic regression to assess predictive validity by determining the association between all measures and (a) pain improvement at 8 hours and (b) admission to the hospital (vs. discharge home).

Population Studied: Adults with VOC seen in the ED.

Principle Findings: In 54 ED visits by 32 patients, most patients reported improvement in pain at 8 hours (56%) and most were admitted to the hospital (72%). Almost all patients received IV fluids (96%) and narcotics (93%),

60% received non-narcotics, 20% were reassessed hourly (of those who were not, 79% had an interval >2 hours without reassessment), and 50% had ineffective treatments modified.

Less than half reported (most or all of the time) that medications were given as soon as needed

(18%), were changed if not working (44%), and that alternative strategies were offered (17%).

Chart-abstracted measures had intermediate to excellent inter-rater (overall % agreement range

0.70-1.0, kappa range 0.44-1.0) and test-retest reliability (overall % agreement range 0.77-1.0, kappa range 0.50-1.0). Frequent reassessment had excellent predictive validity: patients who had intervals of >2 hours between reassessments were more likely to be admitted

(OR 10.2, 95%CI 1.5-69.8, p=0.02) and patients who were reassessed hourly had greater improvement in pain (OR 7.9, 95%CI 0.9-72.2, p=0.07). Those who had treatments modified were slightly less likely to be admitted (OR 0.11,

95%CI 0.01-1.6, p=0.10). Administration of IV fluids, narcotics, and non-narcotics had no predictive validity. No patient-reported measures were associated with improvement in pain or hospital admission. All associations were similar for patients with and without frequent painful crises, and remained unchanged after adjustment for potentially-confounding patient characteristics.

Conclusions: High quality of care was not uniformly attained in this sample of SCD patients with VOC. Our study provides preliminary evidence that measures of pain management quality have good reliability and that frequent reassessment and possibly modification of ineffective treatments have predictive validity. However, it was difficult to establish predictive validity of patient experience measures.


Larger studies are needed to corroborate these findings, so that providers can monitor and improve the quality of care for patients with SCD.

Funding Source: Blaustein Pain Fund

•

Who Utilizes Post-Cardiac Event

Rehabilitative Services? Comparative

Statistics from Medicare’s Lifestyle

Modification Program Demonstration

(LMPD)

Sarita Bhalotra, M.D., Ph.D., Donald Shepard,

Ph.D., Gail Stickler, Ph.D., Moaven Razavi,

M.Sc., Rana Sugghayar, M.Sc.

Presented By: Sarita Bhalotra, M.D., Ph.D. 415

South Street, Waltham, MA 02454, Phone: 781

736 3960, Email: bhalotra@brandeis.edu

Research Objective: Brandeis University is conducting a process and outcomes evaluation of LMPD for feasibility and cost effectiveness.

Demonstration sites provide either the Dr. Dean

Ornish Program for Reversing Heart Disease® or the Mind/Body Medical Institute program.

Feasibility evaluation includes examining

implementation processes to identify barriers, challenges, and successes. Cost-effectiveness evaluation includes clinical effectiveness, quality, and utilization of health services. The multimethod analytical model includes data from case studies, participant and control surveys, claims, and medical records.

Study Design: The LMPD survey collected characteristics regarding health, clinical status, family history, lifestyle including diet, exercise, substance use, medications, knowledge about health and cardiac conditions, satisfaction with care, self-efficacy, social support, perceived stress, hostility, living arrangements. It was administered at baseline, Years One and Two to participants. Controls identified through a clinical algorithm from Medicare claims data were surveyed at Years One and Two. Controls were stratified according to their utilization of cardiac rehabilitation (CR). We report baseline characteristics of LMPD participants; comparative statistics between participants and controls who did and did not utilize CR; and three text variables.

Population Studied: Survey results were obtained from 470 LMPD participants at baseline, 349 at Year One, and 258 at Year Two.

Survey results were obtained from 652 controls at Year One, and 449 at Year Two. Some results were also compared with statistics on the overall

Medicare population (e.g. smoking rates, education).

Principle Findings: Many descriptive, comparative, and trend data will be presented, e.g. at baseline, 65.3% of the 470 participants are male, 96.5% are non-Hispanic Whites, average age is 72.3 years. Thirty-nine percent have at least a four-year college degree. Mean

BMI is 27.2, 13.8 % report current hypertension,

24.7% report current high cholesterol, 0.9% are current smokers and 84.3% rate their health status as good to excellent. Similar statistics are reported for controls, and observations are trended across cohorts and longitudinally; for example, LMPD and CR utilizers were significantly more likely to own their home as compared to non-CR beneficiaries, LMPD participants were significantly more likely to have never smoked, significant differences were observed in self-efficacy, hostility, etc.

Conclusions: Patient profiles were obtained on enrollees into LMPD, and controls who did or did not engage in CR. The three groups matched well on claims-based attributes, but significant differences were found by lifestyle choices, socio-economic characteristics, race/ethnicity, gender, and other attributes amongst the three groups. In general, CR utilizers were more similar to LMPD participants than non-CR utilizers.


The enormous increase in the prevalence of chronic illnesses underscores the importance of tertiary prevention for improving quality and reducing cost and clinical burden of disease.

Despite the provision of an enhanced lifestyle modification Medicare benefit (LMPD), enrollment was very low. Utilization of an existing Medicare benefit of proven efficacy, CR, is likewise very low. By providing comparative statistics among utilizers of LMPD, CR, and those who joined neither program, policy-makers maybe able to formulate customized policies that can influence delivery system and practice options for enhancing referrals, encouraging recruitment, and promoting retention in such lifestyle and self-management programs.

Funding Source: CMS

• Patient and Provider Perspectives on

Impact of Chronic Conditions on Health-

Related Quality-of-Life: Identifying Domains for a New Combined Health-Related Qualityof-Life Instrument

Mark Bounthavong, Pharm.D., Anandi V. Law,

Ph.D.

Presented By: Mark Bounthavong, Pharm.D.,

Outcomes Research Fellow, Social and

Administrative Sciences, Western University of

Health Sciences, 309 E Second Street, Pomona,

CA 91766, Phone: (909) 469-5468, Fax: (909)

469-5428, Email: mbounthavong@westernu.edu

Research Objective: To examine patient and provider perspectives about the impact of having diabetes, hypertension, and/or hyperlipidemia

(DHH) on patient health-related quality of life

(HRQL), in order to identify domains for a new combined HRQL instrument for these conditions.

Study Design: Exploratory qualitative design was used to elicit patient and provider responses. Separate questionnaires were developed for patients and providers to examine the impact of chronic disease(s) (DHH) from different perspectives. Patient survey contained thirteen demographic and nine content questions that asked how the disease(s) affected patient HRQL, how HRQL would change if the condition(s) disappeared and the impact of medication. Provider survey examined their perception of how the disease(s) affected their

patient’s HRQL and crucial factors for improving their patient’s HRQL. The study and instruments were approved by the Institutional Review Board

(IRB).

Population Studied: In-depth interviews were conducted at the university medical center community clinic and off-campus ambulatory care clinics. Patients were identified by medical center staff or by using convenience sampling from a senior center. Patients were included if they had one or more of the conditions and spoke English. Providers working with DHH patients were identified among university faculty and community practitioners; and included physicians, pharmacists, and physician assistants.

Principle Findings: Of the total 154 patients that met the inclusion criteria, 38 (24.7%) completed the interviews. Three independent judges content analyzed patient responses and proposed 7 categories except the medication question had 4 categories (medication inconvenience, medication side effects, forgetfulness, and general well-being). In response to the impact of disease(s) on quality of life, patients ranked physical functioning first followed by diet, emotional well-being, general well-being, social functioning, no change in

HRQL and medications. Index of inter-rater reliability was greater than 80% for all categories.

Of 16 providers who were contacted, 12 (75%) completed the survey; majority of whom were community pharmacists. Provider categories were somewhat different. Responding to key ways in which DHH affects a patient’s HRQL, providers ranked lifestyle modification (LM) i.e., diet and exercise, first followed by complications, medication, self-care, emotional well-being, education, social functioning, physical activity

(e.g., dancing, sports, vacationing) and resources (ability to pay). Crucial aspects of managing disease(s) to improve HRQL were: education, life style modification, and medication-related issues. Physical activity and emotional well-being were lowest on the list.

There were a total of 4 disagreements between the three judges, but all were resolved through discussion.

Conclusions: Patient and provider perspectives on impact of one or more chronic conditions

(DHH) on HRQL were similar in 4 areas. The differences were in how these impacted HRQL, i.e., patients focused on activities relevant to daily life that were affected, while providers based it on processes of therapy management and self-care (education, implementation of LM).


Although differences in provider and patient perspectives are not unexpected, understanding of patient motivations is vital to planning chronic care programs that will increase patient proactive role, adherence to regimens and lead to successful outcomes. The patient-relevant domains identified in this study will be used to develop a combined HRQL instrument for DHH.

• Managing Depression to Improve Diabetes

Self-Management

Joe Burton, M.S., Carla Bann, Ph.D., Daren

Anderson, M.D., Claire Horton, M.D.

Presented By: Joe Burton, M.S., Researcher, RTI

International, 1440 Main Street, Suite 310,

Waltham, MA 02451, Phone: 781-439-1710, Fax:

781-434-1701, Email: joeburton@rti.org

Research Objective: Improving diabetes selfmanagement includes both lifestyle changes and, often, adherence to regimes for taking prescription medications. Both the lifestyle and medical management of diabetes can be challenging for persons with diabetes mellitus and can be particularly challenging for individuals with depression. We examine the differences in outcomes between persons who exhibit depressive symptoms compared to those who do not and review the successes of interventions in improving the self-management behaviors among both groups.

Study Design: As part of a three-wave, comprehensive telephone survey, we assessed the key self-management behaviors of diet, exercise, smoking, and self-monitoring. We also assessed mental health status through eight of the nine questions composing the patient health questionnaire (PHQ-9). The PHQ-9 is typically used in practice settings to screen for depressive symptoms; in this study we used it to gauge overall mental health status among the participants in the various diabetes programs.

We collected glycated hemoglobin levels and blood pressure values over time from medical registers and linked these to the survey responses. We analyzed mental health status, behaviors, and clinical outcomes through a series of multivariate regression and survival analyses.

Population Studied: The Robert Wood Johnson

Foundation funded 14 programs designed to advance diabetes self-management and improve community supports for diabetes care. The programs varied in terms of the clinical settings, populations served, age ranges, and racial/ethnic

backgrounds. Participants from 11 of the programs were surveyed up to three times.

Principle Findings: Controlling for several personal and program characteristics, we found persons who reported poorer mental health

(more depressive symptoms) were less confident in being able to solve problems related to diabetes, had a family history of diabetes and were more likely to smoke; persons reporting better mental health tended to be married, younger, and reported greater access to resources and support for managing their illness. Persons in better mental health exercised more and ate better compared to those with poorer mental health, but both groups reported similar levels of self-monitoring. Eating behaviors------perhaps the most challenging dimension of change------were better among those in good mental health even when controlling for marriage, reported supports, and confidence.

Clinical indicators and depressive symptoms improved slightly over time among those followed longitudinally.

Conclusions: The relationship between mental health and behavior change is complex and challenging to measure and particularly so among persons with diabetes because of the bidirectional nature of depression and diabetes.

Addressing depression is an important part of diabetes care and, when treated, can lead to improved self-management behaviors and, ultimately, improved clinical outcomes.


Persons with diabetes from underserved, disadvantaged or minority populations have high rates of depressive symptoms, which might affect their ability to self-manage their disease.

Mental health status appears to moderate behavior change, suggesting that strategies for improving mental health be a core component of self-management programs. Understanding the role of mental health in diabetes care and more generally, chronic illness care, can lead to improved programs for improving selfmanagement, lifestyle behaviors, and well-being.


•

Rethinking Rehabilitation Services for

Children with Physical Disabilities: Using

Participatory Action Research in the Process of Service Reorganisation

Chantal Camden, Pht, M.Sc., Ph.D. (cand),

Bonnie Swaine, Pht, Ph.D., Sylvie Tétreault, Erg,

Ph.D., Sophie Bergeron, Carole Lambert

Presented By: Chantal Camden, Pht, M.Sc.,

Ph.D. (cand), Student, research coordinator,

Rehabilitation, Biomedical Sciences Program

(rehabilitation option), Université de Montréal, and Centre de Réadaptation Estrie, 300, rue King

Est, Sherbrooke, J1G 1B1, Canada, Phone: (819)

563-3495, Fax: (819) 346-4580, Email: chantal.camden.1@ulaval.ca

Research Objective: 1. Identify children with physical disabilities and their families service needs within the context of a paediatric rehabilitation program in rural Québec, Canada,

2. Identify the Strengths, Weaknesses,

Opportunities and Threats of the existing program to assist in the future reorganisation of services, 3. Describe the usefulness of the SWOT analysis as a tool for facilitating change and for quality assessment, and, 4. Identify the program objectives of the future service model.

Study Design: A Participatory Action Research approach is being employed during the process of reorganising rehabilitation services and developing a new service model for the program.

Focus groups were conducted with clinicians and managers, mothers of children with a physical disability and community partners to identify service needs. A SWOT analysis of the existing service model was completed.

Objectives for the new service model were developed during weekly team meetings, over a three-month period.

Population Studied: A SWOT analysis was completed with 44 clinicians from various disciplines, such as physical and occupational therapists, currently providing rehabilitation services to more than a 1000 families, annually.

To enhance the efficiency of the reorganisation process, small working committees were created composed of 7 consumer, 5 service provider and

7 community partner representatives. Groups participated in different stages of the process.

Service provider representatives, the program director and the two clinical coordinators participate in the weekly team meeting.

Principle Findings: The most frequent needs identified by parents of disabled children related to service needs in the community, including continuity of care. Current program strengths identified using the SWOT with clinicians included favourable organisational climate and multidisciplinary approach. Weaknesses included long waiting times and disparities with respect to access and type of services.

Opportunities included working with community partners, while threats of the new service model included fear of losing professional autonomy.

The SWOT appears to be a very useful tool to promote awareness among clinicians regarding

current program functioning and future service reorganisation. Program objectives include improving access to care, improving impact on children’s social participation, fostering wellbeing of the different actors concerned and implementing mechanisms into service organisation for continuous quality improvement.

Conclusions: A PAR approach and the use of

SWOT seem to have facilitated the identification of service needs and the process of reorganising rehabilitation service provision. Waiting times and linking to community services were identified as major concerns by all participants.

The new service model will address these issues and thus should be more responsiveness to children’s needs by providing timely and appropriate services linked with the community partners.


The active participation of different actors concerned in the decisional and analytical processes described above should facilitate the reorganisation of rehabilitation services. It enabled considering the perspectives of different key actors and the attainment of knowledge about the needs that should be addressed in the new service delivery model. The SWOT analysis appears to be an interesting tool for change management as well as the process of quality improvement.

Funding Source: ANEIS (U of Montreal) scholarship, Québec Ministry of Health and

Social Services and the Office des Personnes

Handicapées du Québec.

•

Measuring Patient Activation in a

Commercial Disease Management Population

Joyce Chen, M.H.S., M.B.A., Qin Ye, M.D., M.S.,

Wanda F. Allison, R.N., Joseph D. Restuccia,

Dr.P.H., Judith Hibbard, Dr.P.H.

Presented By: Joyce Chen, M.H.S., M.B.A.,

Senior Manager, Outcomes & Analytics, Pfizer

Health Solutions, 1601 Cloverfield Blvd Ste 200

South, Santa Monica, CA 90404, Phone: (310)

586-2536, Fax: (310) 586-2342, Email: joyce.chen@pfizer.com

Research Objective: Patients with chronic disease who are knowledgeable about their conditions, possess self-management skills, and have confidence that they can play an active role in managing their own health are considered

‘‘activated.’’ The Patient Activation Measure

(PAM) developed and validated by Hibbard and colleagues is a 13-item questionnaire designed to measure an individual’s stage of activation. We have adapted the PAM instrument into the PAM-

Plus for use as part of a telephonic disease management (DM) process by adding five additional unscored items. The aim of this project was to conduct a preliminary assessment of the feasibility and utility of using the PAM-Plus as part of a commercial DM program.

Specifically, we were interested in whether the application of the PAM-Plus helped care managers to better understand an individual patient’s experience, identify a patient’s level of activation, and counsel patients more effectively.

Study Design: The 8-week pilot study was conducted with BlueCross BlueShield of South

Carolina’s (BCBSSC’s) asthma, diabetes, and cardiovascular DM programs. Each care manager administered the PAM-Plus to up to five patients currently participating in DM.

Patients were required to have a confirmed diagnosis and have been enrolled in one (or more) of the DM programs for at least 6 months. Care managers completed a survey following each administration of the PAM-Plus, plus a final summary questionnaire to provide feedback on the experience of administering the instrument and their impressions about its value in counseling patients.

Population Studied: Nine BCBSSC nurse care managers who manage DM patients telephonically were the primary respondents.

Their responses were based on administering the PAM-Plus survey to a total of 40 adults participating in one of BCBSSC’s DM programs, randomly sampled from a population of over

2,000 currently enrolled patients.

Principle Findings: Care managers reported the

PAM-Plus was particularly useful in reinforcing the patient’s role in their own care, and that it was well-accepted by patients as part of their ongoing care management program. Answers to individual PAM-Plus items, rather than the overall stage of activation, were cited as most useful for guiding care planning and goal setting with patients. Because of these benefits, care managers recommended use of the PAM-Plus early in the care process ---- during an initial or follow-up conversation with a newly enrolled patient ---- to provide a standardized approach to assess, document, and guide the patient’s engagement and participation in his or her own care.

Conclusions: Measurement of patient activation is important as part of chronic care management programs, but until recently has not been easily assessed or documented in a structured format.

The PAM-Plus is a concise tool for this purpose,

and is feasible for inclusion in an ongoing commercial DM program.


The PAM-Plus is a useful tool for efficiently measuring a patient’s current stage of activation that can be used by care managers to best tailor educational and other interventions. Future research should assess the relationship between stage of patient activation and health outcomes achieved.

• Comparing Hospice and Non-Hospice

Patient Survival among Patients Who Die

Within a 3 Year Window

Stephen Connor, Ph.D., Bruce Pyenson, F.S.A.,

M.A.A.A., Kathryn Fitch, R.N., M.A., Carol

Spence, R.N., M.S., Kosuke Iwasaki, FIAJ,

M.A.A.A.

Presented By: Stephen Connor, Ph.D., Vice

President, Research and International

Development, National Hospice & Palliative

Care Org, 1700 Diagonal Rd, Suite 625,

Alexandria, VA 22314, Phone: (703) 837-3149, Fax:

(703) 837-1233, Email: sconnor@nhpco.org

Research Objective: To study the difference of survival periods of terminally ill patients between those using hospices and not using hospices.

Study Design: In this retrospective cohort study, we used an innovative prospective/retrospective case control method and Medicare administrative data to measure time until death starting from dates that were narrowly defined within the data. We performed a Kaplan-Meier analysis of the cohorts and used multiple regression models to evaluate the difference of survival periods of terminal illness patients between those using hospices and those not using hospices. For each disease cohort, a set of specific clinical events was used to define an indicative event and a date to measure the beginning point for time to death. Sources of the Data from the Centers for Medicare and

Medicaid Services (CMS), we used Medicare 5%

Sample Data in 1998, 1999, 2000, 2001, and

2002. Additional data were obtained from the

Health Care Financing Administration Standard

Analytic File (SAF) of Medicare 5% Sample

Hospice Claim Data in 1999, 2000, 2001, and

2002, which contain more detailed information on the hospice claims including hospice start and end dates.

Population Studied: Medicare beneficiaries were identified from 1999 claim data if they met indicative marker criteria for any of the 6 diseases and died within 3 years of the indicative marker date. The restriction of the data to people who die within 3 years of the indicative marker was meant to be a surrogate for clinical judgment, as claim data is not a completely accurate predictor of terminal decline. Strictly speaking, this data restriction means our results apply to cases where a clinician is very sure the patient will die within 3 years. The diseases were congestive heart failure (CHF), breast cancer, colon cancer, lung cancer, prostate cancer, and pancreatic cancer. Patients were identified as having one of the 6 diseases if they had at least one inpatient hospital claim or at least two part

B claims with different service dates. We identified 4,493 patients that met our criteria for the 6 diseases. Of these patients, 2,095 (47%) received hospice care for at least one day.

Principle Findings: For the 6 patient populations combined, the mean survival was 29 days longer for hospice patients than for nonhospice patients. The mean survival period was also significantly longer for the hospice patients with CHF, lung cancer, pancreatic cancer, and marginally significant for colon cancer (p=0.08).

Mean survival was not significantly different

(statistically) for hospice versus non-hospice patients with breast or prostate cancer.

Conclusions: We found that for certain welldefined terminally ill populations, patients who choose hospice care live an average of 29 days longer than similar patients who do not choose hospice. This pattern persisted over 4 of the 6 disease categories studied, though there was substantial variation in the mean length of survival according to diagnosis. Of note, the largest difference in survival between the hospice and non-hospice cohort was for the CHF patients where relatively few patients chose hospice care. CHF patients who eventually chose hospice had a mean survival of 402 days compared with 321 days those who did not.


Our findings are important in helping to dispel the myth that hospice care hastens a patient’s death. This myth may stem in part from the fact that hospice professionals not uncommonly admit patients who are in very poor shape and near death. Indeed, many patients continue to be referred late for hospice or palliative care.

Funding Source: NHPCO

•

Pain Self-Management Skills among

Primary Care Patients with Pain and

Depression

Teresa Damush, Ph.D., Jingwei Wu, M.S.,

Matthew J. Bair, M.D., Jason M.Sutherland,

Ph.D., Kurt Kroenke, M.D.

Presented By: Teresa Damush, Ph.D., Research

Scientist, HSRD Center of Excellence on

Implementation of Evidence Based Practices,

Richard L Roudebush VAMC, 1481 W. 10th

Street, HSRD 11H, Indianapolis, IN 46202,

Phone: 317-988-2258, Fax: 317-988-3222, Email: tdamush@iupui.edu

Research Objective: Enhancing selfmanagement skills can improve outcomes related to chronic pain. However, the range of skills among patients seeking primary care is complicated by depression which is present in

30-50% of chronic pain patients. Therefore, we assessed the effect of depression on pain selfmanagement skills.

Study Design: We collected and analyzed baseline data from a randomized trial testing the effectiveness of a stepped-care intervention involving anti-depressant medications and a pain self-management program delivered by a nurse care manager. We used forward step-wise multiple regression to assess the effect of depression on 3 core pain self-management skills: exercise duration, cognitive strategies

(positive self-talk, visualization), and stress reduction (progressive muscle relaxation). We utilized Lorig and colleagues (1996) outcome measures for health education and intervention to measure self-management skills and selfefficacy. Parameter estimates are reported as beta-coefficients and p-values. Covariates in the models included demographics, medical comorbidity, baseline pain and depression severity, self-efficacy, clinic site, and study arm.

We assessed pain severity using the Brief Pain

Inventory and assessed depression severity using SCL20.

Population Studied: We recruited patients from urban medical center and VA primary care clinics. At baseline, all patients (N=440) met the inclusion criteria of having chronic pain (> 6 months) in low back, knee or hip, and half met criteria for clinical depression (PHQ-9 score >

10). Participants were 52% men; 62% White; 33%

African-American and had a mean age of 59 years.

Principle Findings: In the final model, correlates of exercise duration included medical comorbidity (-12.2, p<.01), depression selfefficacy (11.9, p<.0001), and female gender (-

34.6, p<.01). In other words, exercise duration was negatively affected by medical comorbidity, but greater in males and those with more depression self-efficacy. For cognitive symptom management, parameter estimates included age

(-1.2, p<.01), depression self-efficacy (6.8, p<.01), and depression severity (19.7, p<.02).

Depression self-efficacy (0.3, p<.04) was the only correlate of mental stress management.

Conclusions: Pain self-management skills may be more adversely affected by lack of confidence in one’s ability to manage commonly cooccurring depressive symptoms than the actual severity of the depression itself. Interventions designed to build confidence to manage depression symptoms and promote cognitive symptom management strategies may be necessary to improve outcomes in primary care patients with pain and depression.


Allocating time and resources to deliver patient self-management programs adjuvant to primary care may help improve the outcomes of primary care patients with pain and depression.


• The Social, Political and Economic

Implications of Different Interpretations of

Data Regarding Chonic Diseases and

Morbidity in High Age

Claudia Diederichs, M.A., Friedrich Wilhelm

Schwartz, Prof. Dr. Med.

Presented By: Claudia Diederichs, M.A.,

Research Assistant, Epidemiology, Social

Medicine and Health System Research,

Hannover Medical School, Karl-Wiechert Allee 1,

OE 5410, Hannover, 30625,Denmark, Phone:

0049-511-532-4450, Fax: 0049-511-532-5347,

Email: diederichs.claudia@mh-hannover.de

Research Objective: Low birth rates and the rise in average life expectancy due to improved living conditions and better health care have resulted in demographic changes towards an increasingly aging society in many industrialised countries.

These changes are often associated with an assumed burden of a growing number of senior citizens with chronic diseases and rising morbidity in high age, exerting high pressure on the health care system and society in general.

For research on this subject mainly two different sources of data are used: population based surveys and statistical data based on hospital admissions, health insurances and prescriptions.

The research objective is to point out that the results and interpretations of these data sources differ substantially, strongly influencing the social, political and economic implications.

Study Design: The results and interpretations of various data sources are compared and exemplary differences are highlighted and explained. The real world implications of these different interpretations are presented.

Population Studied: German adults, public health insurance members

Principle Findings: Firstly, data from public health insurances show a continuous and pronounced increase in morbidity from the age of 45 onwards. In contrast to this, the current disability-free average life expectancy in Germany is 65. This difference can be explained by the fact that severe disabilities with a need for care are not simply associated with the process of aging but are the result of an accumulation and the negative synergetic effects of multiple chronic diseases of a few individuals. Secondly, according to data from the ambulant care system more than 40 % of the 70 to 85 year old people have at least one the following chronic diseases: cardiovascular diseases, diabetes, asthma / COPD or breast cancer. On the other hand population based surveys have shown that even in very high age the majority of people does not require professional care. Additionally, about

30% of the men and 40% of the women over 70 years describe their own health situation as positive. Thirdly, according to health insurance data the most important diagnosis are cardiovascular diseases analogous to their financial impact on the health system. In contrast to this, in population based surveys patients rank the diseases according to their impact on their own quality of life: with diseases of the skeleton being at the top followed by cardiovascular diseases, circulatory disorders and hearing impairment.

Conclusions: The first point implies a high and so far unused preventive potential, since the majority of risk factors for chronic diseases are dependent on the individual life style.

Secondly, statistical data often emphasises the ill and disabled in favour of healthy individuals, resulting in a negatively distorted picture of senior citizens in the public.

Thirdly, an effect of the different rankings is that the preferences of old people concerning the distribution of health resources are not adequately considered.


The implications are a stronger consideration of preventive potentials, the promotion of a more positive and realistic picture of the competencies of old people in society and the allocation of resources according to their needs and preferences.

Funding Source: Hannover Medical School

• Disease Burden and Treatment Patterns for

Patients with Chronic Illness Within the

Military Health System, Veterans Health

Administration, Medicaid, and Commercial

Insurance Plans

Teresa Gibson, Ph.D., Christine Vogeli, Ph.D.,

Todd Lee, Pharm.D, Ph.D., Julia Hidalgo, Sc.D.,

Thomas V. Williams, Ph.D., Alexandra Shields,

Ph.D.

Presented By: Teresa Gibson, Ph.D., Director,

Research Division, Thomson Medstat, 777 E.


Phone: 734.913.3481, Fax: 734.913.3850, Email: teresa.gibson@thomson.com

Research Objective: We compared the experiences of patients under 65 years old who received health care benefits via the military health system (TRICARE), the Department of

Veterans Affairs (VA), Medicaid, or employersponsored plans in federal Fiscal Year (FY) 2003 to lend further insight into chronic care across four major components of the U.S. healthcare system. We analyzed the prevalence and key performance indicators for eight chronic conditions identified as high priority areas for quality improvement by the Institute of

Medicine: hypertension, major depression, diabetes, tobacco dependence, ischemic heart disease (IHD), severe mental illness (SMI), persistent asthma, and stroke.

Study Design: A cross-sectional comparison of prevalence rates and utilization patterns in

FY2003 between the four systems was performed. Common criteria were developed to select patients with each of the eight conditions.

Prevalence rates, a set of condition-specific measures and average expenditures per capita were reported for each condition. Except for

IHD and tobacco dependence, the primary indicator selected was the disease-specific hospital admission rate. For IHD, the primary indicator was the disease-specific emergency room (ER) visit rate. The secondary indicator was the disease-specific, 30-day hospital readmission rate. For tobacco dependence the percent of patients receiving both bupropion and nicotine replacement therapy was reported. To enable comparisons of the rates across the populations direct standardization to the age and sex distribution of the US population was performed. All pairs (e.g., VA to commercial) of adjusted rates were compared using a

standardized rate ratio with a Bonferroni correction.

Population Studied: Continuously-enrolled beneficiaries in four health systems: the DoD’s

TRICARE Prime managed care plan (N=

2,963,987), veterans receiving care within the VA

(N= 2,114,739), Medicaid enrollees in five states

(N=5,554,974), and a large national sample of employer-sponsored commercial insurance enrollees (N= 5,212,833).

Principle Findings: For the majority of the conditions, the estimated prevalence rates were highest in the VA and Medicaid populations, which, to some extent reflects the level of severity in these populations, but also underscores the higher rates of common chronic illnesses in these government programs.

Prevalence rates were generally lower in

TRICARE and commercial plans. Medicaid beneficiaries also had the highest hospitalization rates in four of the six conditions where hospitalization rates were measured as the outcome. As for 30-day readmissions, the VA rates were significantly higher than the rates in the other three groups. For all conditions except

IHD and stroke, Medicaid expenditures were highest, and the other systems were comparable.

For IHD the VA expenditures were lower than all of the other systems. Finally, commercial and

Medicaid expenditures were highest for stroke and VA and TRICARE were lowest.

Conclusions: These results reveal the many challenges facing each of these systems and highlight the need for continued assessments along with system-specific interventions, when warranted.


Similarities in disease burden and patterns of care can lead to information sharing across populations and systematic differences can lead to targeted interventions to improve the quality and cost-effectiveness of the healthcare delivered to patients with chronic illness.

Funding Source: DoD - Center for Health Care

Management Studies, TMA

•

Evaluation of the PRIISME Chronic Disease

Management Program at Five Sites in

Ontario, Canada

Julie Gilbert, M.Sc., Ph.D., Wendy Young, M.A.,

Ph.D., Jiahui Wong, M.D., Ph.D., Sarah

Robertson, ABC, BA Hons

Presented By: Julie Gilbert, M.Sc., Ph.D.,

Manager of Research and Knowledge Transfer, ,

The Change Foundation, 200 Front Street West,

Suite 2501, Toronto, Ontario, M5V 3M1, CA,

Phone: (416) 205-1443, Fax: (416) 205-1440,

Email: jagilbert@changefoundation.com

Research Objective: PRIISME is an initiative of

GlaxoSmithKline Inc. representing a communitybased and patient-centred approach to chronic disease management. PRIISME aims to achieve the optimal management of chronic diseases through a focus on disease prevention, diagnosis, treatment, drug compliance, and follow-up. The PRIISME initiative was first introduced in Quebec, Canada in 1999 and brought to Ontario in 2003 at five acute care centres. These five centres were evaluated as part of this study. The objectives of the evaluation were to study 1. the effectiveness of

PRIISME in improving outcomes for patients, providers, the organization, and the broader community and 2. enablers of the implementation of this patient-centred model of care.

Study Design: A case study design was used at each site. Knowledgeable stakeholders were identified at each hospital and invited to participate in the evaluation. These included community pharmacists, physicians, nurses, educators, specialists, administrators and academic researchers. Interviews and focus groups were conducted using semi-structured protocols. A before-and-after study was also conducted at four of the five sites to study patient outcomes.

Population Studied: Many Ontarians report problems finding their way through the healthcare system and accessing the services that are available. They often receive conflicting information from their healthcare professionals.

This study focused on individuals with COPD and diabetes who enrolled in one of five

PRIISME disease management programs in

Ontario as well as the individuals running these programs. In this Canadian province, health care is universally insured and hospitals' core budgets are funded by the provincial Ministry of

Health and Long-Term Care.

Principle Findings: Patients: The program had a positive impact on patients, who became more aware of the resources in their hospital and in the community and were given a better sense of control over their disease. At some sites, participants’ number of symptoms significantly decreased by at least one symptom per week.

Patients were also receiving more consistent information. Providers: Providers’ knowledge of best practices for asthma increased. Better knowledge about the chronic condition and improved skills in dealing with the chronic

condition were reported; finding resources, use of spirometry, use of standardized tools, and better compliance with guidelines. Impact on the communities: Interviewees at all five sites noticed an improvement in continuity of care, including information flow between providers, better partnerships among providers, more referrals from the emergency room and family physicians to the clinic, and more widespread use of standardized letters to family physicians.

The community appreciated the tools and education, especially at convenient times and locations.

Conclusions: The PRIISME model and the public-private partnership it engendered were reported to improve outcomes for patients, providers and the broader community. PRIISME has moved these communities towards being more integrated systems.

Implications for Policy, Practice or Delivery: It was broadly acknowledged that resources from

GlaxoSmithKline Inc. and the PRIISME model itself were key enablers of the program, helping communities improve services for people with chronic conditions. This evaluation highlights the importance of: shared accountability for the provision of patient-centred care for individuals with a chronic disease; cross-sectoral multidisciplinary committees; local solutions to locally identified gaps; and the use of evidencebased tools and processes for chronic disease management.

Funding Source: GlaxoSmithKline, Inc and The

Change Foundation

•

Effects of Health Care Use on the

Diagnosis, Treatment and Survival of

Disabled Women with Breast Cancer

Elizabeth Habermann, M.P.H., Beth A. Virnig,

Ph.D., M.P.H., Sara B. Durham, M.S., Nancy N.

Baxter, M.D., Ph.D.

Presented By: Elizabeth Habermann, M.P.H.,

Graduate Student, Health Policy and

Management, University of Minnesota, MMC

729, 420 Delaware Street, Minneapolis, MN

55455-0341, Phone: 612-625-9135, Email: habermann@umn.edu

Research Objective: To assess the effects of health care use on stage at diagnosis, treatment, and survival for disabled women with breast cancer.

Study Design: We compared demographic and tumor characteristics, stage at diagnosis, treatment, and survival for disabled women who were high or low users of health care in the 6 to

18 months prior to their breast cancer diagnosis.

We used ordinal logistic regression to compare stage at diagnosis between our health care use cohorts, controlling for confounders. For patients with invasive non-metastatic breast cancer who underwent treatment, we used logistic regression models to determine the effect of health care use on cancer treatment, controlling for confounders. We evaluated overall survival and disease specific survival using Kaplan-Meier curves and proportional hazards Cox models.

Population Studied: We used the linked

Surveillance Epidemiology and End Results ----

Medicare database to identify disabled women ages 40 through 65 diagnosed with breast cancer from July, 1992 through December, 1999. We excluded patients with a previous cancer diagnosis, whose cancer was noted at autopsy or death certificate, or were diagnosed with cancer less than 18 months after entering Medicare for disability.

Principle Findings: We identified 1,639 disabled women who developed breast cancer. Of these,

49 percent were in the low-use cohort and 51 percent were in the high-use cohort.

Women with more contact with the health care system in the 6 to 18 months prior to breast cancer diagnosis were more likely to have an early-stage diagnosis than other women. Fewer high-use women were diagnosed with stage III or

IV disease than in the low-use cohort, at 14.1 percent and 18.4 percent of staged cancers, respectively. Rates of unstaged cancers were similar in the two use cohorts.

In multivariate analysis, the high-use cohort was statistically significantly more likely to be diagnosed at an early stage than the low-use cohort, OR=1.34. Approximately 98 percent of women in each cohort with invasive nonmetastatic breast cancer underwent some form of surgical treatment. We did not find significant differences in use of mastectomy, radiation following breast conserving surgery, or reconstruction after mastectomy. Kaplan-Meier curves show superior overall, but not diseasespecific survival, in the low-use cohort. Following multivariate adjustment, the low-use cohort has significantly superior survival for both overall and disease

Conclusions: Differences in breast cancer stage at diagnosis, treatment and survival differ depending on the level of health care use in the period 6 to 18 months prior to breast cancer diagnosis. Further study of this issue using more recent data will follow.


Studies of cancer care in the disabled are extremely limited. This research has relevance for a large number of people funded through the public purse and identifies an important new group for disparities research.

Funding Source: American Society of Clinical

Oncology

•

Potentially Disabling Conditions and Health

Service Utilization among Participants in the

Kansas High-Risk Health Insurance Pool

Jean Hall, Ph.D., Janice Moore, M.A., M.B.A.,

M.S.W.

Presented By: Jean Hall, Ph.D., Assistant

Research Professor, KU-CRL, Division of Adult

Studies, University of Kansas, 1122 W. Campus

Rd, Room 521, Lawrence, KS 66045-3101, Phone:

(785) 864-7083, Fax: (785) 864-7799, Email: jhall@ku.edu

Research Objective: The Kansas Demonstration to Maintain Independence and Employment tests the hypothesis that access to a program of medical assistance and other supports can improve health status and quality of life and prevent or forestall loss of employment and independence due to a potentially disabling condition for participants in a state high risk pool. A first step in this research is to document the medical conditions and functional limitations experienced by participants and their health care utilization patterns prior to and after an intervention that provides enhanced health care coverage and reduced out-of-pocket costs.

Study Design: The Demonstration is a four-year longitudinal experimental study with half of participants receiving treatment as usual and half receiving enhanced services and supports.

Enhanced services and supports include substantial premium subsidies and reductions in out-of-pocket costs for intervention group members as well as intensive case management.

Short- and long-term outcomes are documented through individual surveys and administrative data.

Population Studied: Participants are individuals between ages 18 and 60 enrolled in the Kansas high risk pool who work at least 10 hours per week or 40 hours per month. These individuals are uninsurable in the private market due to preexisting conditions and experience high premium, deductible, and co-insurance rates in the high risk pool.

Principle Findings: First year findings provide a descriptive study of participants’ health conditions, functional status, and healthcare utilization patterns pre- and post- intervention.

Participants experience high rates of potentially disabling conditions including: cancers; diabetes; mental illnesses; back pain/spinal disorders; neurological impairments; and cardiovascular and respiratory conditions. Forty percent reported difficulty with at least one activity of daily living (ADL). Based on body mass index, eighty percent of participants are overweight or obese and 13% are morbidly obese. Despite these serious health conditions, many participants had very low rates of health care utilization pre-intervention. Analysis of early post-intervention utilization data provides insights on unmet needs among this population.

Conclusions: Participants in state high risk pools experience many potentially disabling conditions and functional limitations. The high cost of coverage in combination with the medically severe conditions experienced by enrollees make it likely that they meet the definition of ‘‘underinsured’’ (Short & Banthin,

1995), with out-of-pocket costs well exceeding

10% of their income. In turn, these individuals are likely to have difficulty accessing needed health care services and are thus at higher risk for long-term disability (Kaiser Commission on

Medicaid and the Uninsured, 2002). As the study continues, a better understanding of the range of conditions experienced by these individuals, their functional limitations, and their specific unmet service needs may help pinpoint intervention components that can prevent the downward spiral to full disability, loss of employment, and dependence on public insurance programs.


Historically, risk pool participants in Kansas transition to federal disability programs at a rate

10 times greater than the general population.

Currently, 33 states operate high risk pools.

Specific and targeted early interventions for these populations could provide a cost-effective means for states and the federal government to prevent future disability, dependence, and higher costs.

Funding Source: CMS

• Colorectal Cancer Survivors with Stomas:

Greatest Challenges and Coping Skills

Mark C. Hornbrook, Ph.D., Robert Krouse, M.D.,

Carmit McMullen, Ph.D., Marcia Grant, Ph.D.,

Carol Baldwin, R.N., Ph.D., Lisa Herrinton, Ph.D.

Presented By: Mark C. Hornbrook, Ph.D., Chief

Scientist, The Center for Health Research,

Northwest/Hawaii/Southeast, Kaiser

Permanente Northwest, 3800 North Interstate

Avenue, Portland, OR 97227-1110, Phone: (503)

335-6746, Fax: (503) 335-2428, Email: mark.c.hornbrook@kpchr.org

Research Objective: To assess the greatest challenges faced by colorectal cancer survivors in managing their stomas and living with their cancers over the past five to 20 years or more and patients methods of coping with these challenges.

Study Design: We analyzed the qualitative stories of colorectal cancer survivors who have received permanent ostomies for treatment of colorectal cancers. Many of them have also received radiotherapy and chemotherapy.

Participants completed the City of Hope

Colorectal Cancer Quality of Life Survey and also completed open-ended questions about their greatest challenges in coping with their stomas, problems with the location of their stomas, and problems with managing their pouches. We used qualitative research techniques to identify key themes in each area. The investigator team coded each text entry independently. We reviewed discrepant codes and revised the coding form. A second round of review of the coded text responses was conducted until consensus was reached on all themes mentioned by respondents. The final themes were then sorted into meta-themes.

Population Studied: We surveyed all colon and rectal cancer survivors (at least 5 years’ postdiagnosis) with permanent stomas for the years

2000-2006 regarding their health related quality of life. Patients were identified from tumor registries in Kaiser Permanente Hawaii, Kaiser

Permanente Northern California, and Kaiser

Permanente Northwest.

Principle Findings: Results ranged from no problems and responses indicating high levels of adaptation and functional abilities for patients with permanent stomas, to problems with interference between pouch location and clothing, repeated infections of the stoma, problems with diarrhea and/or constipation, problems with diet selection and control, social phobia, sexual functioning, occupational functioning, and total disability. Example #1: ‘‘I try to be upbeat about my ostomy and have named my stoma ‘Fred.’ When my ostomy is having gas problems, I say ‘Be quiet Fred!’ or at bridge parties and my ostomy is rumbling, my friends will say ‘Fred, quiet down.’" Example #2:

‘‘My biggest challenge has been worries or nervousness about embarrassing problems with noises that I can't control. This is especially difficult in public places -- in church, classes, stores. I sometimes don't eat before attending church -- or other quiet places. How should I handle an incident if it happens? Eating out with friends can be difficult as gas may accumulate and I have a huge bulge in my clothing. I don't like to empty the pouch in a public bathroom if I don't have to as the odor and difficulty of cleaning up is hard.’’

Conclusions: Many high functioning CRC survivors demonstrate cognitive and behavioral coping strategies that appear to be teachable skills to CRC survivors who have more difficulties coping and adjusting to their change in body image, self-management requirements, and sexual needs.


The Institute of Medicine’s report on cancer survivorship called for more research on the long-term medical and behavioral implications of living as a cancer survivor, including the late effects of chemotherapy, radiotherapy, and surgical therapies. Cancer survivors require greater emotional support and self-care skills.

Funding Source: NCI

• Changes in Hospital Readmissions for

Diabetes-Related Conditions

H. Joanna Jiang, Ph.D., Bernard Friedman, Ph.D.,

Roxanne Andrews, Ph.D.

Presented By: H. Joanna Jiang, Ph.D., Senior

Social Scientist, Center for Delivery,

Organization, and Markets, Agency for

Healthcare Research and Quality, 540 Gaither

Road, Rockville, MD 20850, Phone: 301-427-1436,

Fax: 301-427-1430, Email: joanna.jiang@ahrq.gov

Research Objective: There is some evidence suggesting improvement in the processes of diabetes care in the U.S. The hospitalization rate among people with diabetes has also slightly declined since the late 1990s. Nonetheless, multiple hospitalizations by the same individuals have been found to be common among diabetes patients, suggesting potential access to care or quality of care problems related to secondary and tertiary preventive care. The purpose of this study is to examine changes in hospital readmissions for diabetes-related conditions over time to enhance our understanding of the quality and efficiency of diabetes care.

Study Design: In each year the first admission

(including subsequent transfers) was defined as index admission. Patient unique number was

used to identify any readmission for diabetes or diabetes-related complications within 180 days after discharge of the index admission.

Differences in the likelihood of readmission between 1999 and 2003 cohorts, for all diabetesrelated conditions combined, as well as for each major type of complications, were examined through logistic regression, controlling for patient demographic, clinical, and socioeconomic characteristics. Savings in hospital costs potentially achieved through reduced readmission rates were also estimated.

Population Studied: All adult nonmaternal patients covered by private, Medicare, or

Medicaid insurance who were hospitalized for diabetes-related conditions in six states (Arizona,

California, Missouri, New York, Tennessee, and

Virginia), and identified from statewide inpatient databases.

Principle Findings: Overall, readmission rates for diabetes-related conditions were relatively high among those who had been hospitalized, ranging from 1 in 5 among private patients to about 3 in 10 among Medicare or Medicaid patients. The risk-adjusted odds of having a readmission within 180 days postdischarge was about 6% lower (p<.05) in 2003 than in 1999 for private patients or Medicare HMO enrollees.

Among Medicaid patients, the odds of being readmitted for acute diabetes complications, lower extremity complications, and renal complications increased in 2003 by 145%, 44%, and 37%, respectively (p<.001). Among

Medicare patients, the odds of being readmitted for renal complications, congestive heart failure, and stroke were also significantly higher in 2003

(p<.001). Reducing readmission rates for all 3 payers by 5% would save $164 million in hospital costs in a 6-month period.

Conclusions: Small improvements in reducing hospital readmissions for diabetes-related conditions were observed in a four-year period mainly among the privately insured. In contrast, readmissions for several potentially preventable diabetes complications increased dramatically among Medicaid patients, suggesting a growing gap between private and Medicaid patients.


Hospital readmission rates for conditions related to diabetes can be used to measure the quality and efficiency of diabetes care. Effective discharge planning and coordination for followup care that involves community providers and trains patients for self-management of their conditions, can help prevent diabetes complications as well as some readmissions resulting from those complications. For patients covered by Medicare or Medicaid, interventions should be designed to more effectively prevent particular complications and hospital readmissions, which can yield substantial cost savings.


• Effect of Quality of Depression Care on

COPD Outcomes for Patients with COPD and

Depression

Neil Jordan, Ph.D., Todd A Lee, Pharm.D., Ph.D.,

Marcia Valenstein, M.D., M.S., Kevin B Weiss,

M.D., M.P.H.

Presented By: Neil Jordan, Ph.D., Research

Assistant Professor, Mental Health Services &

Policy Program, Northwestern University, 710 N

Lake Shore Drive, Suite 904, Chicago, IL 60611,

Phone: 312-503-6137, Fax: 312-503-1259, Email: neil-jordan@northwestern.edu

Research Objective: Patients with chronic obstructive pulmonary disease (COPD) frequently have co-occurring depressive disorders. Evidence-based depression care is associated with improved treatment compliance for patients with other medical conditions (e.g., coronary artery disease), which may lead to improved comorbid outcomes. The objective of this study is to examine whether receipt of evidence-based depression care is associated with better hospital and mortality outcomes for patients with COPD and depression.

Study Design: In this retrospective cohort study, we assessed the extent to which patients received depression care that was concordant with VA treatment guidelines for depression.

Guideline-consistent depression treatment during the 12-week acute phase is defined as (1) having >= 84 day supply of antidepressant medication during the 114 days after the index depression diagnosis, and (2) having at least 3 outpatient follow-up visits. Multivariate methods were used to analyze the relationship between receipt of guideline-concordant depression care and 1-year and 2-year COPD-related hospitalizations and all-cause mortality.

Population Studied: Using VA administrative data, we identified veterans with COPD in FY99 that experienced a new onset or recurrent episode of major depressive disorder during

FY99-FY02. Patients needed to be free of a depression diagnosis for one year, and without claims for antidepressant prescriptions for 90 days prior to their index depression diagnosis.

Patients with an extended care stay or a

diagnosis of schizophrenia or bipolar disorder were excluded.

Principle Findings: We identified 5,517 patients with COPD and depression. More than twothirds of the sample was over age 65, and 97% were male. Only 9.9% of the cohort received both guideline-concordant antidepressant coverage and follow-up visits. Patients that received guideline-concordant depression care were at similar risk for 1- and 2-year COPDrelated hospitalization compared to persons that did not receive guideline-concordant depression care. Receipt of evidence-based depression care was also unrelated to mortality risk. Having a

COPD-related hospitalization during the year prior to the depression episode was the strongest predictor of subsequent COPD-related hospitalization. Age, being nonwhite, having at least two comorbidities, being seen in pulmonology specialty care, and having been hospitalized for any cause prior to the depression episode were the strongest predictors of mortality.

Conclusions: Most VA patients with COPD and an acute depressive episode receive suboptimal depression care. The provision of evidencebased, acute phase depression treatment is not associated with improved intermediate COPD outcomes for these patients.


Future research should investigate the relationship between patient adherence to depression guidelines and adherence to COPD treatment.

Funding Source: VA

•

How Do Health Behaviors and Body Mass

Index (BMI) Relate to Self-Rated Health for

Latino Immigrants?

Deanna Kepka, M.P.H., M.A., Guadalupe X.

Ayala, Ph.D., M.P.H., Andrea Cherrington, M.D.,

M.P.H.

Presented By: Deanna Kepka, M.P.H., M.A.,

PhD Student, Health Services, School of Public

Health and Community Medicine, University of

Washington, Box 357660, Seattle, WA 98195,

Phone: 206-321-0936, Fax: 801-454-1457, Email: kepka@u.washington.edu

Research Objective: To improve health education outreach strategies, this study explores the relationship between a self-rated health measure, self-reported health behaviors, and measured BMI for an understudied Latino immigrant population in the southeast region of the United States. Latinos are at particularly high risk for obesity compared to other demographic groups. Individuals’ decisions about whether or not to engage in health behaviors related to weight hinge, in part, on their knowledge of the risks associated with being overweight or obese and the expected outcomes of engaging in those health behaviors.

The impetus to engage in health behaviors may be higher if people recognize themselves being in poor health as a result of being overweight or obese.

Study Design: This cross-sectional study included a 15-minute one-on-one bilingual structured interview investigating self-rated health, obesity related health behaviors, acculturation, and demographic characteristics, paired with height and weight measurements.

Self-rated health was assessed with the following question, ‘‘Compared to other people your age, would you say your health is excellent, very good, good, fair or poor?’’ Interviews and measurements took place at health fairs and a local flea market in central North Carolina in

2004.

Population Studied: Two hundred and two adult Latino immigrants (mean age=31.6,

SD=8.3, 54% female) participated in the study.

Individuals born in a Latin American country were classified as Latino immigrants. On average participants had resided in the United States for

7.7 years (SD=5.8). English language acculturation was fairly low, and almost half used their country of origin to describe their ethnic identity. More than 85% of the sample was from

Mexico, 12% from Central America, and 1% each from South America and the Caribbean.

Principle Findings: Participants reporting good to excellent health reported engaging in physical activity during the past month (p<.05), eating more fruits and vegetables (p<.001 and p<.01 respectively), and watching less television

(p<.01) than those who reported fair to poor health. However, the majority of participants did not meet current physical activity and diet recommendations (16% meeting activity recommendations; mean number of fruits consumed daily=2.13 (1.52); mean number of vegetables consumed daily=1.90 (1.48)). In contrast to previous studies, self-rated health status did not correlate with BMI for men and women. There was a trend for Latino men who were overweight or obese to perceive their health status as good to excellent compared to men who were normal weight who more often viewed themselves to be in fair or poor health (p<.09).

The above relationships did not change after controlling for important covariates.

Conclusions: These data suggest that more detailed self-rated health measures should be examined for Latino immigrants in relation to an array of self-reported health behaviors and actual health indicators. This could include further investigation of self-rated health in relation to

BMI as it differs for Latino men and women.


The development of patient education materials for Latino immigrants that promote accurate assessment of self-rated health as it relates to weight status could increase motivation for behavior changes aimed at preventing and decreasing overweight and obesity for this at risk population.

Funding Source: Lineberger Comprehensive

Cancer Center at the University of North Carolina at Chapel Hill

•

Self-Efficacy in Patients With Chronic

Conditions, Across Organizational Models of

Primary Health Care: Preliminary Results

Jean-Frederic Levesque, M.D., Ph.D., Debbie

Feldman, Ph.D., Caroline Dufresne, M.Sc.

Presented By: Jean-Frederic Levesque, M.D.,

Ph.D., Medical consultant - researcher, Centre de recherche du CHUM, Institut national de sante publique du Quebec, 1301 Sherbrooke est,

Montreal, H2L 1M3, CA, Phone: (514) 528-2400 ext:3216, Fax: (514) 528-2512, Email: jflevesq@santepub-mtl.qc.ca

Research Objective: Non-communicable chronic diseases affect a high proportion of developed countries’ ageing populations. This raises challenges for the provision of health care services for these persons, especially in primary health care (PHC) settings. Although patients’ self-efficacy in managing chronic illness care is seen as one of the ways to tackle these challenges, not much research has been done to document it in PHC settings. This study aims to assess the levels of self-efficacy - and its variation

- across different PHC models.

Study Design: Face-to-face interviews were conducted by professionally trained interviewers using validated questionnaires (Self-efficacy for managing chronic illness scale; Self-efficacy for managing depression scale; SF-36). PHC models were defined according to specific predetermined classification criteria. Linear regression models assessed the association of

PHC models with scores of self-efficacy, controlling for age, sex, self-rated health and chronic illness status.

Population Studied: Patients with one of four chronic diseases (diabetes, heart failure, arthritis, chronic obstructive pulmonary disease) from participating PHC clinics from Montreal, Canada and its surroundings were contacted between

June and October 2006.

Principle Findings: We present results from the first 245 patients participating from 14 PHC organizations. Mean age of participants was 69 years and 54% were females. As principal source of care for their chronic illness, 13% identified a community health centre (CHC), 20% a family medicine group (FMG), 7% a solo physician,

36% a medical polyclinic, and 25% a specialist physician. Average self-efficacy score for managing chronic illness was 6.7 (maximum of

10). It was higher among patients with diabetes

(7.9) and among patients affiliated to solo private practitioners (6.9) and private medical polyclinics (7.1) compared to patients affiliated with local community health centers (6.0) and family medicine groups (6.3). However, in multiple regression models (R square = 0.36), higher self-efficacy at managing general health problems was associated with better self-rated health and with having diabetes as main chronic illness. Self-efficacy scores did not vary across

PHC organizational types, sex or age in multiple models. The average self-efficacy at managing depression score was higher at 7.6 and did not vary according to chronic illness. Only self-rated health was associated with higher self-efficacy at managing mental health problems in multiple models.

Conclusions: Moderate levels of reported selfefficacy at managing their chronic illness were found in a population of patients followed in

PHC settings. This suggests that improvements could be achieved to enhance elderly populations’ capacity to actively participate in managing their care. Patients recruited from community health centers and family medicine groups reported lower health status than those recruited from solo and private polyclinic settings which may be associated with differences in self-rated health among their clients. However, the study being cross sectional, it remains difficult to discern whether certain types of patients prefer different PHC models, or conversely, whether certain models are better at promoting self-efficacy among their patients.


These preliminary results suggest that PHC organizations face different challenges in providing chronic illness services. However, services aiming at increasing self-efficacy should be promoted in all PHC settings.

Funding Source: Canadian Institute for Health

Research

•

Economic Evaluation of Standing Order

Programs to Increase Pneumococcal

Vaccination Rates in Hospitalized Elderly

Chyongchiou J. Lin, Ph.D., Kenneth J. Smith,

M.D., M.Sc., Donald M. Middleton, M.D.,

Richard K. Zimmerman, M.D., M.P.H., Mary

Patricia Nowalk, Ph.D., R.D., Mark S. Roberts,

M.D.

Presented By: Chyongchiou J. Lin, Ph.D., associate professor, Radiation Oncology,

University of Pittsburgh, Shadyside Place 110,

580 South Aiken Avenue, Pittsburgh, PA 15232,

Phone: 412-235-1060, Fax: 412-623-1290, Email: cjlin@pitt.edu

Research Objective: To estimate the cost effectiveness of standing order programs (SOPs) for 23-valent pneumococcal polysaccharide vaccination (PPV) of elderly (aged 65 or older) hospitalized patients.

Study Design: In 2004, a 1094-bed, tertiary care facility implemented a pharmacy-based SOP, and a 200-bed community hospital implemented a nursing-based SOP for PPV. Newly admitted patients were screened for eligibility and eligible patients were offered PPV. Cost-effectiveness

(CE) analyses were restricted to those 65 years and older and were based on vaccination rates pre and post SOP, US invasive pneumococcal disease (IPD) incidence rates, and other published sources. One-way and multivariate sensitivity analyses using program costs, hospitalization costs, vaccine costs, length of stay, age, and PPV vaccination rate were conducted to determine if the CE ratio estimates were robust to variation of parameter values.

Population Studied: Inpatients 65 years and older who were not previously vaccinated with

PPV.

Principle Findings: In the tertiary care hospital,

2,631 patients were eligible for PPV during the pre-SOP period (July 1, 2002 through June 30,

2003) with 122 vaccinations. There were 3,626 patients eligible for PPV during the post-SOP period (May 1, 2004 through April 30, 2005) with

1,271 inpatient vaccinations, a vaccination rate increase from 4.6% in the pre-SOP period to

35.1% after the implementation of SOP in the tertiary care hospital (P<0.001). In the community hospital, there were 315 eligible patients in the pre-SOP period (October 2003) with 0 vaccinations and 215 eligible patients in the post SOP period (October 2004) with 33 vaccinations, an increase from 0% in the pre-

SOP period to 15.3% in the post-SOP period

(P<0.001). In the base case cost-effectiveness analysis, from a societal perspective, both the pharmacy-based and nursing-based SOP were cost saving, due to program costs (pharmacybased: $4.16/patient screened, nursing-based:

$4.60/patient) and vaccine costs ($18.33/dose) being offset by savings from IPD cases avoided

(costing $12,436/case) due to the program. In sensitivity analyses, a SOP for PPV vaccination was cost saving compared to no SOP unless the vaccination rate was improved by <16% in the tertiary care hospital or <11% in the community hospital; SOPs remained cost saving with individual variation of other model parameters over plausible ranges. SOPs cost less than

$20,000 per quality adjusted life year gained if programs improve vaccination rates at least 10% and program costs are not greater than $17 per patient screened.

Conclusions: SOP-based PPV vaccination of elderly patients is cost-effective, and perhaps cost saving, compared to no SOP.


Standing orders for inpatient immunization have the potential to raise vaccination rates in an effort to reach Healthy People 2010 goals and save costs from a societal standpoint.

Funding Source: CDC, Association for

Prevention Teaching and Research (APTR)

• Estimating the Cost and Benefit of Better

Asthma Care

Soeren Mattke, M.D., D.Sc., Priya Sharma, , Paco

Martorell, Ph.D., Floyd Malveaux, M.D., Ph.D.,

Julie Kennedy, M.P.A., Nicole Lurie, M.D.,

M.S.P.H.

Presented By: Soeren Mattke, M.D., D.Sc.,

Scientist, RAND, 1200 S Hayes Street, Arlington,

VA 22202, Phone: 703-413-1100, Email: mattke@rand.org

Research Objective: While asthma has become an inherently treatable disease, actual treatment continues to fall short of recommended care, especially for disadvantaged populations.

Improving care for this multifactorial disease asthma has to go beyond pharmacologic therapy and has to address lifestyle and environmental factors, especially allergens. Thus, innovative ways of delivering and financing care are needed.

We set out to answer the following questions:

1.What are the gaps in the quality of asthma care for children and adults? 2. What are the clinical and policy implications of those gaps (e.g.,

excess morbidity and mortality, avoidable hospitalizations, lost school/work days)? 3.

What would it cost to close the quality gaps?

4.What would be the return on investment/costbenefit ratio of better asthma care?

Study Design: We searched the available literature for studies on gaps in asthma care, their impact and cost of closing them. We identified 2,786 reports and selected 164 for inclusion in a structured review.

Principle Findings: Most studies focused on one of three endpoints: inhaled corticosteroids

(ICS) for quality and rates of ER visits and hospital admissions for impact. But no study linked the treatment rate with inhaled steroids to

ER and hospital utilization, except in the context of a multifaceted intervention. We also found insufficient evidence to estimate the cost of reducing the gaps in quality and the return on investment for interventions that attempt to close the gap. Researchers used a staggering variety of criteria to recruit their study patients and a staggering number of definitions of their endpoints. After rebasing the endpoints to common definitions, we found enormous variation in the three common endpoints. ICS treatment rates ranged from 10 to 94 percent, hospital admission rates from zero to 53 admissions per 100 patient years and ER visits from zero to 80 per 100 patient years. Adjusting for disease severity and race/ethnicity only accounted for a small part of this variation but showed that sicker patients have higher treatment rates and ER and hospital utilization rates and that minority patients have lower ICS treatment rates.

Conclusions: Although the quality of asthma care is an area of active research, it is impossible to derive reasonably bounded consensus estimates for the cost and benefits of better asthma care.


More economic evaluations of interventions to improve asthma care are needed and researchers should adopt consensus definitions for key outcomes to allow cross-study comparisons and integration of evidence.

• Attributable Cost Analysis of the

EnhanceWellness Program

Charles Mayer, M.D., Elizabeth Phelan, M.D.,

M.S., Jim LoGerfo, M.D., M.P.H., Barbara

Williams, Ph.D.

Presented By: Charles Mayer, M.D., Senior

NRSA Fellow, Family Medicine, University of

Washington, 1959 NE Pacific Street, Seattle, WA

98115, Phone: 206 285-9014, Email: cjmayer@u.washington.edu

Research Objective: The EnhanceWellness (EW, formally known as Health Enhancement

Program) Program has demonstrated improved health benefits for participants but has never been evaluated for costs. Objective: To examine if EnhancWellness Program participants have lower health care costs and utilization than a matched control group of GHC enrollees.

Study Design: A retrospective cohort, attributable cost analysis

Population Studied: Setting: King County,

Washington Participants: Group Health enrollees 65 years and older who participated

EnhanceWellness Program anytime beginning in

1998, matched 3:1 by age and gender to Group

Health Enrollees that did not participate in EW.

Principle Findings: 218 EW participants were matched to 654 controls. Average age was 78.6 and 72.4% were female each group. Before the intervention began, EW participants had a significantly greater preventive index score, charlson score, diabetes registry, heart disease registry prior year and primary care costs. There were no other significant differences in prior year total costs, inpatient costs, hospitalizations, or hospital days between the two groups. Adjusted total first year cost following the index date was an insignificant 2.9% lower in the intervention group (p= .77) while the second year costs was

37% higher in the intervention group (p=.02).

Conclusions: In the1998 randomized controlled trial of EnhanceWellness, significant health improvements were demonstrated. In this EW cost analysis, an insignificant 2.9% decrease in total costs was found for the first year. In the second year, which would corresponded to 6 to

18 months after a person stopped participating in the program, a significant cost increase of

37% occurred. This indicates that

EnhanceWellness has significant health benefits and is cost neutral during the time of intervention and possibly the following six months.


Policy makers should consider making

EnhanceWellness an ongoing program for interested participants. A larger randomized controlled trial with a cost effectiveness analysis arm would be necessary to definitively support these findings.

Funding Source: CDC

• Development of Performance Measures for a Multi-Level Diabetes Initiative in New

Zealand

Rob McNeill, Ph.D., M.A.(Hons), B.A., Janet

Clinton, Ph.D., Paul Brown, Ph.D., Eman Radwan

Presented By: Rob McNeill, Ph.D., M.A.(Hons),

B.A., Senior Research Fellow, Centre for Health

Services Research and Policy, School of

Population Health, The University of Auckland,

Private Bag 92019, Auckland, New Zealand,

Phone: +64 9 3737599 ext.82384, Email: r.mcneill@auckland.ac.nz

Research Objective: Efforts to stem increasing rates of obesity and Type 2 diabetes in developed countries have led to the development of a variety of initiatives. One of the most innovative and expansive is an effort in New Zealand.

Introduced in 2004, ‘‘Let’s Beat Diabetes’’ (LBD) is a 5 year, multi-level initiative in South

Auckland (population approximately 440,000) involving local interventions to prevent diabetes and reduce morbidity and mortality associated with diabetes. The intervention includes initiatives to reduce sedentary behaviour, coordinate healthcare providers to provide early detection and integrated management of diabetes, develop accords with the food industry and schools to increase availability of healthy and affordable nutritional options, and social marketing campaigns to change community attitudes and practices. However, for the initiative to continue to be supported by funders and the community, it must be demonstrated to be effective. As it can take many years to reduce levels of obesity and rates of diabetes, the challenge is to develop key performance indicators that incorporate the multiple levels of the initiatives and link these efforts to long term outcomes. This paper presents the indicators that have been developed and the some of the results at baseline.

Study Design: The key indicators were developed using a theoretic model that was informed by various health behaviour models.

These indicators were selected in consultation with academics, providers, funders and members of the community to ensure that they were theoretically robust yet relevant to the stakeholders. Each performance measure was then assessed to determine the availability of exisiting and ongoing data, with new data collection being implemented where no data existed.

Population Studied: Data was for the population of South Auckland (Counties

Manukau).

Principle Findings: The results present the status of the key indicators at the time of the introduction of LBD. The analysis revealed that there was little information on some indicators suggested by the theoretical model as being critical to the success of the initiative. Existing data was available for many of the performance measures relating to clinical indicators but less data was available to inform risk factor indicators. Thus, additional types of information must be collected to identify whether the initiatives are impacting on the population.

Additionally, many of the existing datasets identified by this study are only updated every 5-

10 years, which places limitations on the reporting timeframe for evaluating the effectiveness of the program.

Conclusions: Monitoring the effectiveness of large-scale population-based interventions for

Type 2 diabetes can be achieved through the use of existing administrative databases supplemented by new data collection where necessary. Some issues regarding the reliability and availability of data from existing datasets were identified. The existence of other similar initiatives, both local and national, also pose a significant challenge to the interpretation of any chages that are observed in these idicators over time.


The approach adopted by this study provides a reliable and cost-effective method of outcome evaluation for these types of long-term programs for preventing diabetes and diabetes-related deaths. LBD is similar to initiatives currently being implemented in the US and other countries. Identifying the success of these initiatives will require comparing the results with outcomes from other communities or countries.

For this reason, it is important that the key indicators are internationally accepted. The results here can assist researchers of initiatives in other communities in developing key indicators and thus successfully monitoring the impact of these types of programs.

Funding Source: Counties Manukau District

Health Board, Auckland, New Zealand

• The Association of Provider Satisfaction with Health-Related Outcomes for Adults

With Persistent Asthma

David Mosen, Ph.D., M.P.H., Michael Schatz,

M.D., M.S., Richard Mularski, M.D., M.S.P.H.,

Chris Jentz, M.H.S.A., Jim Bellows, Ph.D.

Presented By: David Mosen, Ph.D., M.P.H.,

Senior Program Evaluation Consultant, Center for Health Research, Kaiser Permanente

Northwest, 3800 N Interstate Avenue, Portland,

OR 97236, Phone: 503-335-6637, Fax: 503-335-

2424, Email: david.m.mosen@kpchr.org

Research Objective: Patient satisfaction is an increasingly important measure of quality healthcare for consumers, health leaders and policy makers. However, few studies have examined the relationship of patient satisfaction on health-related outcomes for adults with persistent asthma. We examined the association of patient satisfaction with asthma-specific quality of life, asthma control, overuse of shortacting beta agonist (SABA) medication and asthma-specific hospitalizations and/or emergency department (ED) utilization.

Study Design: We examined survey and administrative data for 2,021 adult persistent asthmatics enrolled in a large group model

HMO. Persistent asthmatics were identified during calendar year 1999 using HEDIS inclusion criteria. In Fall 2000, the same patients were surveyed regarding their overall satisfaction with asthma care using a valid/reliable question (1=very poor, as bad as health care can be, 10=excellent, as good as health care can) developed by the Foundation for

Accountability (FACCT). The measure was transformed into a 0-100 scale and dichotomized into low satisfaction (0-50) and high satisfaction (51-100). Asthma-specific quality of life and control problems were assessed using the 1) Mini Asthma Quality of

Life Questionnaire (AQLQ, 1=lowest QOL,

7=highest QOL) and 2) the Asthma Therapy

Assessment Questionnaire (ATAQ, 0=no control problems 4=4 control problems), respectively.

SABA medication overuse and ED use/hospitalizations was measured via administrative data in 2001. Multiple logistic regression was used to model the independent relationship of patient satisfaction on concurrent

AQLQ score (high quality of life vs. low quality of life) and asthma control (< 1 control problems vs. > 2), and future SABA overuse (overuse vs. no overuse) and asthma-specific ED use/hospitalizations in the following year (> 1 vs. none); adjusting for age, gender, race/ethnicity, educational attainment, income, reflux status, and smoking status.

Population Studied: Adults with persistent asthma.

Principle Findings: Overall, the population reported high satisfaction with asthma care

(Mean=76.5, S.D.=22.0). After adjusting for demographic factors, smoking status, and reflux status, adults with high satisfaction were more likely to report high AQLQ scores (OR = 1.7 95%

CI = 1.4 ---- 2.3), 1 or fewer control problems (OR =

2.4 95% CI = 1.9 ---- 3.1) and lower SABA overuse

(OR = 0.72 95% CI = 0.53 ---- 0.98), compared to adults with low satisfaction. Higher satisfaction was not associated with asthma-specific ED use/hospitalizations.

Conclusions: We did not identify an association between satisfaction and reduced asthmaspecific ED use/hospitalizations; this negative finding could include insensitivity of the FACCT instrument and/or ED and hospital utilization as outcome measure.


The study findings highlight the need to better understand and improve overall patient satisfaction. Possible explanations for the association between patient satisfaction and improved asthma outcomes may include better patient-provider interactions and increased patient activation, but the available database does not allow causal pathways to be clearly delineated. Measuring and targeting quality initiatives on satisfaction may have added benefit to important aspects of asthma care, although our analysis did not demonstrate an association with lower disease specific utilization. Future prospective research is needed to examine whether targeting improvements in satisfaction with asthma care result in subsequent improvement in asthma-specific outcomes.

•

A Systematic Review of Telephone-Based

Applications to Support Chronic Disease Self-

Management

Carly Muller, Bachelor of Podiatry, Post Graduate

Diploma Public Health, Master of Public Health,

Assoc Prof, Dean Schillinger, M.D.

Presented By: Carly Muller, Bachelor of Podiatry,

Post Graduate Diploma Public Health, Master of

Public Health, Harkness Fellow, General Internal

Medicine, Univeristy of California San Francisco,

1001 Potrero Avenue, Ward 13 Building 10, San

Francisco, CA 94132, Phone: 415 341 7544, Fax:

415 206 5586, Email: cmuller@medsfgh.ucsf.edu

Research Objective: To perform a systematic literature review to examine the population-level reach (including population engagement and intervention use) and effectiveness of telephone-

based health programs used in the proactive treatment of people with chronic diseases.

Study Design: English language articles were extracted from Medline, PsychInfo, CINHAL,

Cochrane Library and Journals@OVID. Case series studies less than 10 subjects were excluded. Articles that targeted patients with one or more chronic diseases and used one or more

‘tele-applications' aimed at improving patient self management were included. We excluded articles that described diagnosis and/or treatment focused services, help lines, and models where the telephonic component was inextricable for evaluation.

Population Studied: Twenty-two articles have been identified (N= 922). Interventions cover: diabetes (41%), CVD (23%), multiple conditions

(23%), mental health (9%) and arthritis (4%).

The median sample size was 85 (range 14-591).

Interventions used health providers, such as a nurse or case manager (n=12), and/or automated technologies (n=12) to deliver functions such as education, reminders and monitoring. 73% (n=16) had comparison groups

(10 studies were RCTs, 2 retrospective case controls, 3 concurrent control and 1 pseudorandomised study) and 27% (n=6) were pre/post case series.

Principle Findings: Of the 22 studies, 9 specified enrolled versus non-enrolled population sizes and 3 reported the total population characteristics. The reach in these studies ranged from 11% to 66% of the total population, and the enrolled appeared representative of the larger population. Six studies examined the level of patient use and interaction with the intervention (an important determinant of effectiveness) and reported positive results. Studies with a comparison group (n=16) measured intervention effectiveness differently. When compared with the comparison group, effects at intervention completion were reported as significant in improving self efficacy (n=4), behavior change

(n=1), physiologic indicators (n=1), functional indicators (n=8), health service access (n=3), provider practice change (e.g. guideline use, n=1), reduction in hospital and ED utilization

(n=1) and return on investment (n=1). These studies also reported non-significant effects in some behavior change measures (n=3), functional indicators (n=6) and office visits

(n=1). Short-term maintenance following intervention completion (range 8-12 weeks) was measured in 19% (n=3) of studies with a comparison and found to be significant. No studies investigated long-term maintenance.

Conclusions: Published literature regarding proactive telephone-based interventions that target individuals with chronic conditions is not sufficiently robust to estimate representativeness of studied populations, intervention reach, intervention effectiveness or potential long-term maintenance of effects.


The global increase in chronic disease poses a challenge for health systems oriented towards diagnosis and treatment of acute conditions. The health care system must reorient provision of care for chronic disease sufferers to provide evidence-based interventions that maximize patient function and prevent disability. Current evidence suggests that telephonic technologies are a potential solution, but future studies must move beyond measuring patient-centered outcomes to provide evidence on the whole picture as a basis for policy development.

Funding Source: CWF

• Social Support and Health among the

Chronically Ill

Emily Joy Nicklett, M.S.W.

Presented By: Emily Joy Nicklett, M.S.W.,

Doctoral Student, Health Management & Policy,

University of Michigan, 109 South Observatory,

SPH II, Ann Arbor, MI 48109, Phone: 917-399-

4092, Email: enicklet@umich.edu

Research Objective: Using diabetes mellitus as a case study, this analysis will examine the correlates of social support and health among the chronically ill, with regimen adherence at its center. The primary hypothesis is that social support is negatively associated with health status decline, controlling for regimen adherence and health status. The secondary hypothesis is that social support is positively associated with adherence to regimen components.

Study Design: First, support for regimen components are tested for influence on health decline, controlling for adherence and health status. The primary independent variables are social support and regimen adherence pertaining to six diabetes regimen components.

Health status change is determined from 2002-

04. Control variables address health, relationships; and demographic characteristics.

Health includes self-reported health status, morbidity, and duration of diabetes. Social relationships include marital status and informal diabetes-related care from family/friends.

Demographics include age, gender, education and race/ethnicity. Second, I regressed social

support on its corresponding attribute of adherence, including controls. All health and diabetes variables, social variables, and demographic control variables will be included in the series of regressions.

Population Studied: Data were analyzed from the Health and Retirement Study (HRS) 2002 and 2004 waves and the 2003 Diabetes

Supplement. In 1992, 12,654 communitydwelling individuals born between 1931-41 participated in HRS (response rate 81.7%).

Adjusting for respondent mortality, the response rates have remained above 84% in the six subsequent waves. The 2003 Diabetes

Supplement was mailed to the 2,381 eligible cases reporting a diagnosis of diabetes in the

2002 HRS. The analytic sample is restricted to respondents indicating that they had diabetes mellitus and its corresponding regimen, as well as subsequent participation in the 2004 HRS wave (n=1,562).

Principle Findings: In the first model, checking feet was significantly negatively associated with health decline (odds reduction 48%). Support for exercising was significantly positively associated with health decline, with increased odds of 76%.

None of the interaction or remaining regimen support variables were significant. Further, the social relationship variables (marital status and informal care) were positively associated with health decline, although the relationship is not significant. Finally, we find that age and years of education are significantly positively associated with decline. Race/ethnicity and gender were also not statistically significant. The series of ordinal logistic regression models tested the relationship between social support and regimen adherence. Each highly significant, we find a onelevel increase in social support increases the odds of adherence to the regimen by percentages of 59 (medications), 61

(appointments), 62 (checking blood sugar), 62

(checking feet), 70 (exercising), and 110

(following eating plan).

Conclusions: Social support appears to be protective for some regimen components

(checking feet for wounds or sores), but a susceptibility factor for others (exercising). Social support is, however, highly associated with adherence for each regimen attribute, controlling for other factors.


Subsequent analyses------qualitative and quantitative------are necessary to better understand how support influences health trajectories and disease pathways for different groups. With social stratification at its center, such research can shed light on potential protective factors of social support for individuals and communities.

•

Surgical Treatment for Uterine Fibroids:

Adverse Events, and 1-Year Re-treatment

Rates

Ronald J. Ozminkowski, Ph.D., David W. Lee,

Ph.D., Ginger Smith Carls, M.A., Ronald J.

Ozminkowski, Ph.D., Shaohung Wang, Ph.D.,

Teresa B. Gibson, Ph.D.

Presented By: Ronald J. Ozminkowski, Ph.D.,

Director, Health & Productivity Research, ,

Thomson Medstat, 777 East Eisenhower

Parkway, 903R, Ann Arbor, MI 48108, Phone:

(734) 913-3255, Fax: (734) 913-3850, Email: ron.ozminkowski@thomson.com

Research Objective: To estimate the rate of adverse events and surgical retreatment within 1 year of initial surgical treatment of uterine fibroids, for women with commercial insurance.


MarketScan Commercial Claims and Encounters insurance databases for 2000-2003. 22,915 women were treated surgically for uterine fibroids. Potential adverse events were identified via review of CPT procedure codes. Events were observed for one year after the date of surgery and included: blood loss, fever, bowel obstruction, transfusion, uterine perforation, vaginal discharge, urinary tract infection (UTI), urinary retention, and severe abdominal pain.

Population Studied: Women with uterine fibroids in private insurance plans.

Principle Findings: 85.7% were treated with hysterectomy, 7.8% with myomectomy, 4.9% with endometrial ablation, and 1.6% with UAE.

Every adverse event except severe abdominal pain and UTI occurred in fewer than 2.5% of patients with any form of interventional treatment. Abdominal pain and UTI were significantly more likely for hysterectomy patients and myomectomy patients (p < 0.05), than for other surgical patients. 18.7% of hysterectomy patients had abdominal pain, versus 14.7% for myomectomy, and less than 2% for UAE and endometrial ablation. UTI occurred among

13.6% of hysterectomy patients and 8.7% of myomectomy patients, and in less than 1.5% of other patients. 1-year re-treatment rates were highest for endometrial ablation (30.5%). Retreatment rates for other procedures were less than 7%.

Conclusions: Most adverse events were rare, but severe pain and UTI seem problematic, especially for patients with hysterectomy and

myomectomy. Re-treatment rates for patients undergoing endometrial ablation were much higher than for patients treated other ways.


Doctors and patients should be educated about the clinical consequences of surgical treatment for uterine fibroids. Development of, and investment in, non-surgical inteventions may be warranted.


• Effects of Psychosocial and Economic

Circumstances on Allostatic Load in an

Employed Population

Douglas Roblin, Ph.D., Peter Joski, M.S.P.H.,

Junling Ren, M.Ed., Edmund Becker, Ph.D.

Presented By: Douglas Roblin, Ph.D., Senior

Research Scientist, The Center for Health

Research / Southeast, Kaiser Permanente

Georgia, 3495 Piedmont Road, NE, Building 9,

Atlanta, GA 30305, Phone: 404-364-4805, Fax:

404-364-7361, Email: Douglas.Roblin@KP.Org

Research Objective: Stressful psychosocial and economic circumstances increase risk of impaired immunologic response and end-organ disease (such as kidney and coronary disease).

Allostatic load is a measure that quantifies stress-related physiologic dysregulation. The extent to which psychosocial and economic circumstances affect allostatic load in employed, insured populations has received little attention.

We studied: 1) the association of allostatic load with psychosocial and economic circumstances of working age adult enrollees of a group-model

MCO, and 2) whether these circumstances had a differential association with allostatic load among cohorts of patients with substantially different clinical conditions and prognoses.

Study Design: Data were collected on a mixed mode survey in 2005 of 25-59 year old MCO enrollees employed by large public and private employers in the Atlanta area. Enrollees

(N=5,309) were randomly sampled from 3 cohorts defined from MCO databases: diabetes, elevated lipids without CAD, and "low risk". The survey included measures of household income, work and social climate (MIDUS), patient activation (PAM-13), and height and weight

(BMI). Allostatic load was measured from BMI and recent lab results for serum albumin, creatinine, LDL, HDL, HbA1c and creatinine clearance. Points were assigned for the extent of abnormality on BMI and each lab result and summed for each respondent. The association of allostatic load with household income and social climate controlling for patient covariates was estimated using general linear models.

Population Studied: 2,224 respondents (42% response rate): 652 with diabetes, 792 with elevated lipids, 780 low risk

Principle Findings: Overall, allostatic load was highest among adults with diabetes (mean of

4.93 points), moderate among adults with elevated lipids (3.75) and lowest among low risk adults (1.59, p<0.05). Adults with diabetes also reported, on average, the lowest activation, least supportive networks of families and friends, and lowest household incomes (all p<0.05 compared to low risk adults). Among adults with diabetes, allostatic load had significant graded associations with household income (higher with lower income), social climate (higher with less supportive, more stressful circumstances), and activation (higher with lower activation; all p<0.05). Allostatic load was significantly associated only with patient activation among adults with elevated lipids and was not significantly associated with psychosocial or economic circumstances of low risk adults.

Conclusions: Compared to adults with elevated lipids or low risk adults, the health of adults with diabetes appears to be most sensitive to psychosocial and economic circumstances. Low levels of activation, stressful networks of family and friends, and low household incomes were associated with increased allostatic load.


Adults with diabetes and poor physiologic control are at increased risk for development of microvascular and macrovascular complications.

Adverse psychosocial circumstances and economic deprivation, by increasing allostatic load, may contribute to that risk, even among employed adults with comprehensive prepaid benefits. MCOs should explore the potential of case management programs targeted to adults with diabetes to improve psychosocial support for the practice of healthy behaviors (exercise, diet) that can reduce allostatic load.

Funding Source: CDC

•

The Effect of a Diabetes Care Management

Program on Costs in a Medicaid Population

Dennis Scanlon, Ph.D., M.A., B.A., Christoper

Hollenbeak, Ph.D., Jeffrey Beich, Ph.D., Arnold

Milstein, M.D.

Presented By: Dennis Scanlon, Ph.D., M.A.,

B.A., Associate Professor, Health Policy &

Administration, Penn State University, 119B

Henderson Building, University Park, PA 16802-

6500, Phone: (814) 865-1925, Fax: (814) 863-

2905, Email: dpscanlon@psu.edu

Research Objective: This paper examines the effect of a diabetes care management program

(CMP) on the costs and quality of care provided to Medicaid patients treated at Caresouth (CS), a multi-site Federally Qualified Health Clinic

(FQHC) in South Carolina, USA.

Study Design: The CS diabetes registry was used to identify Medicaid patients that were being treated for diabetes under the CMP beginning with its inception in 2001. In addition, seven years of claims and enrollment data (1998-

2004) from the South Carolina Medicaid program were used to verify the CS patients eligibility for Medicaid and to identify non CS patients that were Medicaid recipients with a diagnosis of diabetes and being treated by otherwise comparable FQHC clinics.

Other FQHCs in South Carolina that had not adopted the CMP were identified as control clinics. To allow for the comparison of pre-post differences in costs, we used claims data to identify CS patients that were diagnosed with diabetes at least one year prior to the CS CMP

(n=199) and for which claims data was available.

We then used propensity scoring methods to identify a comparable control group of 199 non

CS patients from comparable FQHCs that had not undertaken a similar CMP. For the entire sample, we computed difference-in-difference estimates for total health care payments, and for payments in four categories (non-hospital outpatient visits, inpatient hospital care, hospital outpatient care, and outpatient pharmacy).

Estimates were computed using a random effects regression model at the individual patient level controlling for patient characteristics (age, gender, race, comorbidity index), time, and whether the patient was in the treatment or control group. Since, unlike cost data, detailed clinical data was only available for CS patients, we modeled the change in HBA1c levels, BMI, and blood pressure as a function of time in the post period.

Population Studied: Medicaid and Medicare beneficiaries with diabetes who were treated in

Federally Qualified Health Clinics. The clinics of interest primarily served rural areas in the state of South Carolina. Caresouth (CS), an FQHC operating multiple clinics in South Carolina, implemented an Institute for Healthcare

Improvement (IHI) diabetes disease CMP in

2001. The CMP included multiple interventions designed to implement the chronic care model, including the development of a patient registry, the adoption and implementation of diabetes care guidelines, the use of automated decision support tools, physician education, the adoption team based approach to treatment utilizing nurses and other non-physician providers, and enhanced patient education regarding self management.

Principle Findings: The change in average annual total payments for CS vs control patients was not significantly different. Payments were also similar for 3 of the 4 categories, with the exception being sligntly lower hospital outpatient payments for CS patients. The clinical indicators improved for CS patients over time, suggesting the program had clinical benefit even though there was no measurable overall cost reduction.

The lack of cost savings may be due to the relatively short time horizon used.

Conclusions: Diabetes care management programs may improve patient care, but are unlikely to result in overall program savings, at least in the short run.


While the chronic care model and other approaches to successfully treating diabetes and other chronic illnesses exist, policy makers should understand that these approaches do not necessarily reduce overall health care costs, even though they may result in patient improvements.

Funding Source: California Healthcare

Foundation

• Self-Management of Blood Pressure After

Stroke

Arlene Schmid, Ph.D., OTR, Teresa Damush,

Ph.D., Linda Williams, M.D., William Jones,

M.D., Laurie Plue, M.S.

Presented By: Arlene Schmid, Ph.D., OTR,

Assistant Professor/Post-doctoral Fellow,

Occupational Therapy/HSR&D, Indiana

University/Roudebush VA, 1140 w michigan street, Indianapolis, IN 46202, Phone: 317-278-

9018, Email: araschmi@iupui.edu

Research Objective: This study elicited the knowledge and blood pressure (BP) management strategies used by veterans who had previously sustained a stroke or TIA

(transient ischemic attack). The objective of this research was to identify barriers and facilitators to successful BP self-management (SM) after stroke.

Study Design: We used a prospective mixed methods design including a structured survey questionnaire and focus group methodology to conduct a formative evaluation of BP SM after

stroke. We held 4 focus groups that were moderated by a trained group leader. Transcripts were transcribed and coded for themes.

Population Studied: All subjects had a stroke or

TIA in the previous 12 months and were veterans. All but one of the 28 subjects were male,16 survived a stroke, and 12 survived a TIA.

The average age was 67 with no significant differences between stroke and TIA groups.

Principle Findings: Quantitative results indicated: 75% of all participants monitored their own BP in the last month; 82% knew their systolic BP target was < 140 and 86% recognized their diastolic BP was to be < 90. SM strategies discussed in focus groups included: BP monitoring, BP medication, development of a routine, diet, stress management, and exercise.

Barriers to BP SM included: difficulty with BP monitors or lack of knowledge regarding the meaning of the information and when to contact a physician; trouble with remembering to take medications; lack of interest in lifestyle modification; and reliance on the body and symptoms as a reminder for medication and monitoring. In contrast, facilitators of BP management included: the desire for a relationship between the patient, provider, and health care system; the idea of the ‘‘teachable moment’’, the time directly after the stroke or

TIA, may be used as a time to encourage BP monitoring and modification; and increased health awareness as some stroke and TIA survivors were more receptive of lifestyle changes in order to prevent recurrent strokes; and thus a general increased interest seen in some for life style modification.

Conclusions: Results from both quantitative and qualitative analyses indicate three main BP management themes: the health care provider is important to hypertension management; there are numerous SM strategies utilized; and the time following the stroke or TIA may be an important teachable moment to discuss risk factor modification. In general, participants were aware of the need for lowered BP, and some attempted to change something. However, others lacked the information and knowledge to effectively manage their BP placing them at risk for a second stroke.


This research indicates that while many of those who have survived a stroke or TIA attempt to manage BP, not all are successful and not all even attempt management. This preliminary research enlightens BP management and provides key elements of a successful program to improve the SM of BP after stroke or TIA.

Future programming needs to fully involve the patient, provide education to the family and the patient, and assist in the development of a routine for BP management and life-style modification.

Funding Source: VA QUERI

• What Does Surgical Treatment for Uterine

Fibroids Really Cost?

Ginger Smith Carls, M.A., David W. Lee, Ph.D.,

Ronald J. Ozminkowski, Ph.D., Teresa B. Gibson,

Ph.D., Shaohung Wang, Ph.D., Elizabeth A.

Stewart, M.D.

Presented By: Ginger Smith Carls, M.A.,

Economist, Thomson Medstat, 318 Warren

Street, A17, Brooklyn, NY 11201, Phone: 718-852-

4697, Email: Ginger.Carls@thomson.com

Research Objective: To investigate the direct and indirect costs of uterine fibroid surgery.


MarketScan Commercial Claims and Encounters insurance databases for 2000-2003. 22,915 women with commercial insurance coverage were treated surgically for uterine fibroids.

Direct short-run costs included all inpatient, outpatient, and pharmaceutical services for 14 days before surgery until the hospital discharge date, or the date of outpatient surgery. Analyses of long run (1-year) costs accounted for differences between women in terms of their historical (pre-surgery) medical expenditures.

Indirect costs based on absenteeism and shortterm disability program use were included for the subset of employed women with available data. Propensity score weighting and exponential multiple-regression analyses were used to control for demographic and casemix differences in sample members with different types of surgery.

Population Studied: Women with uterine fibroids who are covered by private insurance plans

Principle Findings: Of patients electing surgery,

85.7% underwent hysterectomy, 7.8% myomectomy, 4.9% endometrial ablation, and

1.6% uterine artery embolization (UAE). Shortrun average costs per patient were highest for hysterectomy ($17,225), followed by myomectomy, ($16,460), UAE ($14,064), and endometrial ablation ($6,825). Lost work and disability accounted for 18.0% of total costs for

UAE, compared to 28.7% for endometrial ablation, 40.9% for hysterectomy, and 42.1% for myomectomy. The same pattern was noted for long-term costs.

Conclusions: Uterine fibroid surgical treatment costs are high. Symptomatic treatment via endometrial ablation costs less. Absenteeism and disability are important components of the costs of uterine fibroid treatments for employers and the health care system.


Doctors, patients, and health plan administrators should be educated about the costs and benefits of treatment alternatives.

Further development of and investment in nonsurgical treatment options may be warranted.


•

‘‘When I Was Young You Didn’t Ever

Contradict a Doctor’’: Older Adults’

Experiences Getting Treatment for Persistent

Pain in the Age of Patient-Centered Care

Carrie Farmer Teh, Ph.D., Jordan F. Karp, M.D.,

Arthur Kleinman, M.D., Ph.D., Charles F.

Reynolds III, M.D., Debra K. Weiner, M.D., Paul

D. Cleary, Ph.D.

Presented By: Carrie Farmer Teh, Ph.D., NIMH

Postdoctoral Fellow, Western Psychiatric

Institute and Clinic, University of Pittsburgh, 3811

O'Hara Street, Pittsburgh, PA 15213, Phone: (412)

383-5139, Fax: (412) 383-5412, Email: tehc@upmc.edu

Research Objective: Older adults with persistent pain seek treatment in a healthcare environment increasingly based on a model of patient-centered care. Although there have been numerous articles published about what patientcentered care means for physicians and other providers, there has been little mention in the literature about the effects of this transformation of care on patients. This paper addresses this gap by exploring the treatment experiences of older adults with persistent pain.

Study Design: Using semi-structured in-depth interviews, we explored the experiences of 15 older adults seeking treatment for persistent pain. Transcripts were analyzed using a grounded theory approach. As interviews and their transcripts were completed, data were coded line-by-line and then were categorized through a process of constant comparison. The categories were used to develop central themes.

Population Studied: Ten women and five men, ages 68 to 83, living in western Pennsylvania, with chronic low back pain. All participants experienced pain ‘‘every day or almost every day’’ and had lived with pain for at least 3 months.

Principle Findings: Participants described a complex tug-of-war between wanting to be in charge of their pain treatment (patient as the

‘driver’), and wanting to be taken care of by their provider (patient as a ‘passenger’). When participants acted as ‘drivers’, they exerted control over their treatment decisions and the care they received by asking for or refusing specific treatments, speaking up for themselves, and experimenting with their medications. When participants acted as ‘passengers’, they relinquished control to their health care providers and allowed them to make treatment decisions on their behalf. In addition, participants placed a high priority on having meaningful relationships with their providers, wanting to feel as though their provider ‘‘knows them’’ and understands their sociocultural context.

Conclusions: The movement towards patientcentered care may have complex repercussions for older adults with persistent pain, who are caught in the middle of this transformation at a stage in life where they are likely to interact frequently with the medical system. Delivery of patient-centered care to older adults with persistent pain requires an understanding of where each patient falls on the ‘‘driverpassenger’’ spectrum and an emphasis on shared decision-making.


To enhance shared decision-making and the provision of patient-centered care, providers and patients must communicate about patients’ preferences regarding their role in decisionmaking. For this to succeed, health system changes such as restructuring care to allow time and adequate provider compensation for the critical conversations central to shared decisionmaking are also necessary.


• Do Patients Enrolled in Telephonic

Coaching Program Think These Programs

Help?

Samir Thaker, M.S.P.H., Timothy G. Ferris, M.D.,

M.P.H., Kristen L. Solemina, M.P.H.

Presented By: Samir Thaker, M.S.P.H., Medical

Student, Lerner College of Medicine, Cleveland

Clinic, 2552 Overlook Road #4, Cleveland Hts,

OH 44106-2496, Phone: (440) 227-3642, Fax:

(443) 773-0854, Email: thakers@ccf.org

Research Objective: Despite widespread use, little outcomes data supports the effectiveness of telephonic health coaching (THC) for patients with chronic illness. As part of our evaluation of a THC program for chronically ill patients with

Medicaid insurance, we sought to determine patients’ experience of the helpfulness of the program for managing their chronic illness. The

THC program identified patients at high risk for readmission through provider referrals and predictive modeling, called patients and assessed health care coaching needs, provided ongoing coaching for those patients who were determined may benefit, and enrollees patients with 24/7 access to nurses trained in THC.

Study Design: Cross-sectional analysis of a 45item telephone survey administered in English and Spanish assessing patient perceptions of program helpfulness for 1) improving understanding of their illness, 2) improving selfmanagement skills, 3) improving recognition of early symptoms, 4) improving medication adherence, and 5) improving communication with health care providers. We looked for an association between intensity of the intervention

(as judged by number of calls), placing an inbound call, a social worker referral and selfreported helpfulness of the program.

Population Studied: Conducted in an Eastern

Massachusetts integrated delivery system, enrolled participants included 2001 community dwelling patients with at least one of ten common chronic conditions and either a hospitalization or more than one emergency department visit in the year prior to enrollment.

We surveyed patients who had spoken with a health coach in the preceding five months and completed 533 surveys with an adjusted response rate of 44%.

Principle Findings: Data collection has ended and results are being analyzed. Preliminary findings suggest that most respondents felt the program improved their ability to communicate with healthcare providers (84%), improved the quality of care they received (77%) and improved their ability to manage their illness (78%).

Satisfaction levels were higher for females,

African Americans, and patients referred to a social worker by the program. Future analyses will test whether patient satisfaction was associated with intervention intensity, age, selfreported health status and additional satisfaction-related subscales included in the survey.

Implications for Policy, Practice or Delivery: A handful of chronic conditions such as diabetes and heart failure are highly responsive to patient self-management and remarkably common among the most frequent users of health services. This suggests there may be room for improvement in how health systems approach disease management for high-utilization patients with one or more of these conditions.

By assessing patient satisfaction with PHCC we hope to improve the telephonic health coaching services the program provides and thereby enhance patients’ ability to self-manage their chronic conditions. More broadly, information about patient satisfaction with the PHCC model of disease management will be useful to others interested in telephonic health interventions and chronic care improvement. Both fields are expanding rapidly and this study will contribute important information about how best to structure future disease management initiatives.

•

Foot Surveillance was Associated with

Reduce Risk of Major Amputation among

Patients with Diabetes

Chin-Lin Tseng, Dr.P.H., Drew Helmer, M.D.,

M.S., Anjali Tiwari, M.S.S.B., M.S., James

Wrobel, D.P.M., M.S., Usha Sambamoorthi,

Ph.D., Leonard Pogach, M.D., M.B.A.

Presented By: Chin-Lin Tseng, Dr.P.H., Health

Science Specialist, Center for Healthcare knowledge Management, 385 Tremont Avenu,

#129, East Orange, NJ 07018, Phone: (973)676-

1000X2028, Fax: (973)395-7114, Email: tseng@njneuromed.org

Research Objective: Diabetes is the major underlying cause for most amputations in

Western countries. The Lower-extremity amputation (LEA) rates in the United States have remained highly variable despite better understanding of their causes and initiatives to reduce their incidence. Our objective was to evaluate the provision of foot surveillance among patients with diabetes and its association with risk of major lower-extremity amputations.

Study Design: This was a retrospective study of

Veteran Health Administrative and Medicare claims data. The follow-up period was from the beginning of fiscal year (FY) 1999 until the end of FY 2000. Individuals who died without major amputations during the follow-up were censored.

All independent variables including foot surveillance, age, sex, race, and medical comorbidities were derived from the one-year baseline period FY 1998. We defined foot surveillance to include primary and preventive footcare services in the podiatric and vascular surgery clinics during the baseline 12 months.

We coded presence or absence of foot surveillance for each quarter in the baseline year and then summed these quarterly visit variables into a variable of consistence of care(range: 0-4).

We categorized individuals into four risk classification according to the consensus of the

International Working Group on the Diabetic

Foot (Group 0 had not defined foot risk condition; Group 1 had only microvascular complication including neuropathy, retinopathy or chronic kidney disease; Group 2 had microvascular complication and presence of either foot deformity or Peripheral vascular diseases; Group 3 had foot ulceration or minor lower-extremity amputations. We used Cox proportional regressions to assess the association between foot surveillance and major amputations for each risk group.

Population Studied: 399,603 veterans with diabetes, alive in FY 1998, and without prior major amputations during FY1997-1998

(n=399,603).

Principle Findings: There were 3780 incurred major amputations during FY 1999-2000; individuals in the more severe foot-risk group had higher major amputation rates (range: 4.3 to

30.3 per 1000). On average, 23.8% had annual foot surveillance. The percentages of having foot surveillance increased with increasing risk classification group severity: 12.9% (Group 0),

24.7% (Group 1), 44.5% (Group 2), and 60.8 %

(Group 3). Our multivariate Cox regression models showed that having foot surveillance reduced the risk of major amputation, but only for patients in Groups 2 and 3. For example, patients in Group 3 who received foot surveillance consistently for 3 calendar quarters were 32% less likely to have major amputations than patients who did not have foot surveillance:

(adjusted hazard ratio(AHR)= 0.68; 95% CI:

0.58-0.79); in the same Group 3, those who received 4 quarters of surveillance were 42% less likely to have major amputations (AHR=0.58,

95% CI=0.50-0.68).

Conclusions: The consistency of foot surveillance was independently associated in a graded fashion with lower risk of major amputations among individuals with diabetes at high risk for foot complications. A low proportion of veteran patients with diabetes had annual foot surveillance.


Our results suggest that foot surveillance may need to be improved and prioritized, and this may results in fewer major amputations.

Funding Source: VA

•

Adherence to Preventive Medications among Patients with Migraine

Ozgur Tunceli, Ph.D., Jennifer Elston Lafata,

Ph.D.

Presented By: Ozgur Tunceli, Ph.D., post doctoral fellow, Center for Health Services

Research, Henry Ford Health System, One Ford

Place, 3A, Detroit, MI 48202, Phone: 313-874-

5454, Fax: 313-874-7137, Email: otuncel1@hfhs.org

Research Objective: Although effective migraine preventive therapies exist, non-adherence to therapies and its implications remain unknown.

We estimate the prevalence of non-adherence to migraine preventive agents, and evaluate the factors associated with non-adherence and the association between non-adherence and care outcomes.

Study Design: Cross sectional study using data from a telephone interview linked with HMOclaims data for the 24-month period preceding interview date. Using interview data, cases were identified as those meeting the International

Headache’s criteria for strict migraine (SM) and probable migraine (PM). Interviews were also used to obtain patient reports of disability and health status. Medical and pharmaceutical claims data were used to construct 24-month pharmaceutical and total (medical + pharmaceutical) costs (log transformed for modeling). Pharmacy claims data were used to construct measures of medication gaps between the first and last dispensing for a migraine preventive agent during the 24-month period

(i.e., cumulative number of days without supply/number of days between the first and last dispensing date). Adherence was evaluated in 4 categories: anti-depressant agents, anticonvulsant agents, anti-hypertensive agents, and a combination of all three. Patients with gaps of

20% and more were considered non-adherent.

Differences in patient characteristics by nonadherence status were evaluated using generalized estimating equations (GEE).

Multivariable GEE models were used to assess the association between non-adherence and patient outcomes.

Population Studied: Eligible subjects were 18 to

55 year old, health plan enrollees who incurred at least one encounter to a provider between June

2000 and November 2001. The interview process identified 1265 SM and 1252 PM cases.

Among these, 354 SM and 302 PM had a dispensing for 2 or more migraine preventive medications during the 24-month study period and were eligible for inclusion here.

Principle Findings: The prevalence of nonadherence to anti-depressants was 48% (n=421),

31% were non-adherent to anti-hypertensives

(n=301) and 59% were non-adherent to anticonvulsants (n=37). Using the combined measure (n=656), 42% of SM and 39% of PM cases were non-adherent. Non-adherent patients were significantly (p<0.05) younger (45 vs. 43 years), more likely to be African American

(30 vs. 19%), report lower household income (30 vs. 22% reported income <$20,000), and seen in the emergency department (29 vs. 23%).

Non-adherent patients incurred significantly lower pharmaceutical costs compared to adherent patients ($1823 vs. $2922). In models that adjusted for socio demographics characteristics, medication non-adherence remained negatively associated with pharmaceutical costs (p<.0008). No significant associations were detected between medication non-adherence and total medical care cost, disability or health status.

Conclusions: Non-adherence to migraine preventive agents is prevalent among migraine sufferers. Those at risk of non-adherence are younger patients of African American race with low household incomes who are seen in the emergency department. While medication adherence is associated with increased pharmaceutical costs, no benefit in terms of either health or medical care cost offset was found.


Efforts are needed to improve adherence to known effective therapies among migraine patients, especially among those belonging to socio-economically disadvantaged subgroups.

Future studies should explore further the association of migraine preventive medication adherence and patient-centered outcomes, including efforts to evaluate the sensitivity of associations to different levels of adherence.

• Medication Adherence and Work Disability among Patients with Diabetes

Kaan Tunceli, Ph.D, Cathy J Bradley, Ph.D.,

Jennifer Elston Lafata, Ph.D., L Keoki Williams,

M.D., M.P.H., Huiwen Zeng, M.A., Manel

Pladevall, M.D., M.S.

Presented By: Kaan Tunceli, Ph.D, Research

Scientist, Center for Health Services Research,

Henry Ford Health System, One Ford Place,

Detroit, MI 48202, Phone: (313) 874-5485, Email: ktuncel1@hfhs.org

Research Objective: Medication adherence is critical for the long-term wellbeing of patients with diabetes. Medication adherence results in improved clinical outcomes and by extension, physical outcomes. However, no empirical study has examined the relationship between medication adherence and patient functioning in patients with diabetes. This study examines the associations between medication adherence and work disability as an objective measure of patient functioning.

Study Design: A continuous measure of medication gaps (nonadherence) was constructed from 4 years (2001-2004) of pharmacy claims data for both oral antidiabetic agents and lipid-lowering drugs during the four years preceding cohort inception. Patients who had gaps less than 20% of the time for their medication between the first and last prescription fills were considered ‘‘adherent.’’ At study inception, patients participated in mail and telephone surveys that included information on work disability, diabetes self-management skills, autonomous motivation, and socio-demographic characteristics. We used multivariate logistic regressions to examine the effects of medication adherence on the probability of work disability.

Models controlled for diabetes self-management skills, autonomous motivation, comorbidities, body mass index (BMI), age, race, marital status, levels of education, and household income.

Population Studied: 2,973 patients with diabetes met the following criteria: At least 2 dispensings in each drug class per year (i.e., at least 2 dispensings for an oral antidiabetic agent, and at least 2 dispensings for a lipid-lowering agent); 18 years or older in 2001; at least 1 laboratory test for HbA1c, and 1 cholesterol

(either total or low density lipid) test; and health plan continuous enrollment. Response rate for survey was 69% (n=2,038). Our final sample compromised 1,754 patients with diabetes, of which 21% reported that they were work disabled

(i.e., had impairment or a health problem that kept them from working).

Principle Findings: In the models that control for baseline sociodemographic characteristics, adherence decreased the likelihood of work disability for both oral antidiabetic agents (OR,

0.78; P < 0.10) and lipid-lowering drugs (OR,

0.72; P < 0.05). In the models that controls for diabetes self-management skills, autonomous motivation, comorbidities, BMI as well as sociodemographic factors, adherence to lipid-lowering drugs was negatively associated with work disability (OR, 0.69; P < 0.05). Adherence to oral antidiabetic agents was also negatively associated with disability but not statistically significant (OR, 0.87; P = 0.35). Both adherence measures were jointly significant in the models predicting work disability (P < 0.05).

Conclusions: Our findings suggest that nonadherence to medications for antidiabetic agents, and lipid-lowering drugs among diabetic patients were associated with a greater risk of work disability.


Nonadherence to medications among patients with diabetes likely imposes economic burdens to patients, families and society not only leading to complications and higher medical care expenditures due to poor control of modifiable risk factors but also increasing work disability and thereby productivity losses. In the assessment of the cost-effectiveness of interventions to improve medication adherence, the effects on work disability of adherence should be considered as well as those on medical care costs and other outcomes.

Funding Source: National Institute of Diabetes and Digestive and Kidney Diseases

• Development of the Pediatric Asthma

Impact Survey: A New Tool for Monitoring

Outcomes in Children

Diane Turner-Bowker, Ph.D., Mark Kosinski,

M.A., Gladys Tom, M.S., Matthew Stiefel, M.P.A.,

David Mosen, Ph.D.

Presented By: Diane Turner-Bowker, Ph.D.,

Senior Scientist, Research & Development,

QualityMetric Incorporated, 640 George

Washington Highway, Lincoln, RI 02865, Phone:

(401)334-8800, ext. 230, Fax: (401)334-8801,

Email: dtbowker@qualitymetric.com

Research Objective: Using modern psychometric methods (Item Response Theory

(IRT)), a new short-form was developed for measuring the impact of asthma on a child’s health-related quality of life (HRQOL) that is easy for clinicians to use, and for clinicians and consumers to interpret.

Study Design: An item bank was developed as part of a larger survey designed to study the impact of asthma and its treatment among pediatric asthma patients enrolled in Kaiser

Permanente’s (KP) Care Management Institute

(CMI) from 1999-2000. The original survey, administered by mail and completed by parents of the pediatric sample, consisted of 104 items assessing the child’s generic HRQOL, asthmaspecific HRQOL, asthma control, asthma symptoms, use of care and services for asthma, demographic information, and caregiver’s

HRQOL and satisfaction with care.

Population Studied: The sample included children with persistent asthma, who met the following criteria: (1) continuous enrollment during the selection period (calendar year 1999) and during the measurement period (calendar year 2000); (2) during the selection period had at least four asthma medication dispensings OR at least one emergency department (ED) visit with a principal diagnosis of asthma OR at least one hospitalization with a principal diagnosis of asthma OR at least four asthma outpatient visits with at least two asthma medication dispensings; and (3) between the ages of 5 to 17 at the time of survey administration. Of the

7,390 eligible members contacted to participate in the study, 70% completed and returned the survey for a final working sample of 5,178 participants.

Principle Findings: Asthma-specific impact items were factor analyzed to evaluate assumptions of unidimensionality and local independence, prerequisites for using IRT methods to calibrate and score item responses on a common scale. Results from trace lines analyses, item parameter estimation, range and content coverage were considered in selecting a subset of 39 items to represent the pediatric asthma item bank. This subset of 39 items was programmed as a dynamic health assessment

(DYNHA PAIS), and served as the bank from which the Pediatric Asthma Impact Survey (PAIS-

6) short-form was developed. The final six items selected for the PAIS-6 were those that best predicted asthma impact scale scores based on the total bank of 39 items (IRT Total scale) and cover all content areas (global impact, physical functioning, psychological distress, social functioning, role functioning, vitality, and impact of symptoms) defined by the item bank. Item responses are weighted and summed to derive a score. Weights assigned to each item response choice were selected to produce a score that closely approximates the score derived from the total item bank (IRT Total scale) for comparability. Validity studies demonstrate the tool’s ability to discriminate among patients differing in asthma symptoms, level of severity, and extent of control.

Conclusions: The PAIS-6 is a new brief, yet comprehensive and valid static short-form instrument for monitoring pediatric asthma outcomes, suitable for application in a variety of settings.


Enhancing the accessibility of patient-based assessments will make asthma management more effective in meeting patient care needs.

Funding Source: QualityMetric Incorporated and Kaiser Permanente

• A New Electronic Tool to Aid Interpretation of Results from the SF-36 Health Survey

Diane Turner-Bowker, Ph.D., Mark Kosinski,

M.A., Julie Zhao, M.A., John E. Ware, Jr., Ph.D.

Presented By: Diane Turner-Bowker, Ph.D.,

Senior Scientist, Research & Development,

QualityMetric Incorporated, 640 George

Washington Highway, Lincoln, RI 02865, Phone:

(401)334-8800, ext. 230, Fax: (401)334-8801,

Email: dtbowker@qualitymetric.com

Research Objective: To develop a web-based service that facilitates comparison of individual research study results to representative population-based norms and published literature for the ‘‘SF family’’ of generic health-related quality of life (HRQOL) instruments, including the SF-36 Health Survey, a widely-used tool cited in more than 7,500 publications including approximately 1,000 published randomized controlled trials. Prototyped for use in obesity research, the ‘‘Norm-Based Interpretation

Guidelines (NBIG)’’ service was designed to: (1) automatically transform SF-36 scores ranging from 0-100 to norm-based scores (NBS); (2) enable users to define a query based on study group characteristics, and provide populationbased norms adjusted for age, gender, severity

(in this case, Body Mass Index (BMI)), and coexisting conditions; and (3) summarize findings from the current ‘‘SF’’ obesity research literature.

Study Design: A NBS calculator was programmed to linearly transform SF-36 scales and summary measures to have a mean of 50 and standard deviation of 10 in the 1998 U.S. general population, easing score interpretation and facilitating comparability across scales and

‘‘SF’’ survey forms. Multiple regression analyses were conducted on a combined SF-36 dataset to evaluate the relationship between several predictor variables and SF-36 scores. Predictor variables included gender, age, severity (BMI), and medical conditions. The model intercept represents the comparison, a ‘‘well’’ group

(females, ages 35-44, BMI less than 25, no medical conditions). In this additive model, regression coefficients representing the unique contribution of each independent variable were used to program adjustable norms. A literature review was conducted to identify ‘‘SF’’ publications in the area of obesity research.

Data were extracted, and all data scored on a 0-

100 scale were transformed to NBS. Graphs were produced using Excel. A list and description of the research studies, and graphed data were programmed for review by users.

Population Studied: The combined sample

(N=15,186) included SF-36 data from four sources: 2000 General Population Study

(n=2,425), 1998 General Population Study

(n=6,742), National Survey of Functional Health

Status (NSFHS) (n=2,474), and Medical

Outcomes Study (n=3,545). The combined sample was weighted in accordance with age and gender characteristics of the 1998 U.S.

Census.

Principle Findings: A prototype NBIG system for obesity research was programmed for

Internet-based administration. System features include a NBS calculator, representative population-based adjustable norms, and an actuary of results from the current research literature. The prototype includes online instructions, educational information and help features, as well as a hard copy user’s guide. The system was developed for pilot testing with a partnering pharmaceutical organization, and recommendations for improvements to finalize the system are documented.

Conclusions: NBIG facilitates interpretation of scores in relation to norms and benchmarks from the published literature.


NBIG offers researchers and practitioners an efficient resource to help interpret results from the SF-36, a tool used widely for outcomes monitoring.

Funding Source: QualityMetric Incorporated and Johnson & Johnson

•

Projection, Stereotyping, And The

Perception Of Chronic Medical Conditions






(585)273-5464, Email: peter_veazie@urmc.rochester.edu

Research Objective: To test two hypotheses:

First, people with chronic medical conditions

(CMC) are more likely than those without CMC to project personal characteristics onto judgments regarding the population with CMC.

Second, people without CMC are more likely to use stereotype information to characterize the population with CMC.

Study Design: The study used a secondary analysis of survey data. Two equations were

estimated: The dependent variables were (1) agreement with the statement ‘‘Most people who have chronic medical conditions are elderly’’, and

(2) the square-root of judged percent of the general population with CMC. The explanatory variables in the first equation were an indicator of CMC, respondent age, and their interaction; the explanatory variable in the second equation was the CMC indicator. Specification tests identified the square-root transformation for the second equation, rejected sex as a moderator, and rejected the need for additional control variables. We estimated a Probit model for variable 1 and a linear regression model for variable 2. The first hypothesis implies (1) age has a positive effect among those with CMC, (2) the effect of age is larger than among those without CMC, and (3) people with CMC judge a higher proportion of people have CMC. The second hypothesis implies that the effect of age in the first model among those without CMC should not be significant. The corresponding null hypothesis tests were based on the normal approximation of the parameter estimates using a robust estimate of the cross-equation parameter covariance matrix.

Population Studied: The data comprise 1123 adults from the Chronic Illness and Caregiving national cross-sectional sample conducted in the year 2000 by Harris Interactive Inc. Caregivers of persons with CMCs are excluded. Data were weighted for demographic composition of the

U.S. population and to adjust for oversampling of people with CMC.

Principle Findings: Results confirm hypothesis

1: The associated joint null hypothesis was rejected in favor of a one-sided alternative (pvalue < 0.00001). Results confirm hypothesis 2: the associated null hypothesis was not rejected

(p-value = 0.543).

Conclusions: These findings indicate people with CMCs are more likely to project characteristics onto the CMC population; hence, over-generalization of personal characteristics influences judgments regarding the CMC population.


To the extent results generalize to other personal attributes, these findings imply that the characterization of the typical person with chronic illness varies more among those who have CMC than among those who do not have

CMC; those who do not have CMC tend to have a more homogeneous stereotypic representation. This difference in personal representation of the chronically ill, between those who have CMC and those who do not, implies a potentially greater variation in support among those with CMC for the particulars of policies addressing CMC. Although those with

CMC may be more likely to encourage policies benefiting the CMC population and even if they wish only to benefit most affected persons regardless of their own state (i.e. they are altruistic), the variation in judgments regarding who is most affected may mitigate support for any particular policy.

• Treatment Decision Making, Stress and

Emotional Well-being among Older Women

Diagnosed with Breast Cancer

Gayle Weaver, Ph.D., James S. Goodwin, M.D.

Presented By: Gayle Weaver, Ph.D., Associate

Professor, Division of Rehabilitation Sciences,

University of Texas Medical Branch, 301

University Boulevard, Galveston, TX 77555-1137,

Phone: (409) 772-9446, Fax: (409) 747-1638,

Email: gweaver@utmb.edu

Research Objective: The present study examined level of participation in the treatment decision process among older women who were newly diagnosed with breast cancer. Using the crisis model, we also examined whether or not stage of breast cancer and level of perceived stress from breast cancer mediate the relationship between decision making concerns and depressive symptomatology. It was hypothesized that early stage breast cancer and low perceived stress will be associated few decision concerns and low depressive symptomatology.

Study Design: This cross-sectional study was part of a larger investigation which explored the effects of nurse case management on breast cancer care for older women with two waves of data collection. Data for this presentation were extracted from the first wave (baseline interview) which included face-to-face interviews using a structured questionnaire. Interviews lasted approximately 75 minutes. Information was collected on stage of diagnosis (via medical records), treatment decision concerns, involvement in treatment decision, perceived stress, depressive symptoms, emotional health ratings, and socio-demographic factors. Data analyses included Pearson correlation, oneway

ANOVAs, and simple linear regression.

Population Studied: The population studied was 241 women, aged 59 and older, who were newly diagnosed with breast cancer. These women were recruited through 60 surgeons who practiced in the Gulf Coast region of Texas.

Principle Findings: The majority reported low depressive symptomatology, high ratings of emotional health, having enough time and information to make decisions, and some level of involvement in the treatment decision. At least two-thirds reported the treatment decision to be their own and half indicated that the surgeon asked their treatment preference. About

70% made their decisions about breast surgery treatment within a week (52% made their decision within two days). Nearly all participants

(97%) were satisfied with the decision process.

Most were diagnosed in the early stages of breast cancer (7% in situ, 62% localized). Over half reported moderate to high stress (54%), and fears of cancer returning (74%), losing a breast

(55%), vomiting (55%), and dying from cancer

(52%). High scores on the decision concerns index were associated with higher depressive symptomatology and perceived stress. However, stress and stage at diagnosis did not mediate the association between treatment concerns and depressive symptoms.

Conclusions: Contrary to previous studies, the older women in this study indicated participation in the treatment decision process for breast cancer. However, those who had concerns about breast cancer and the effects of treatment reported greater depression symptomatology.

Thus, during the discussion of treatment options, it may be important to assess and provide effective coping strategies for depression and cancer fears.


While these findings indicate involvement in breast cancer treatment decision among older women, further research is needed to closely investigate older women's definition of involvement and develop better measures of decision-making participation. It is possible that these women considered participation to be simply "giving the surgeon and other providers permission to treat", considering that a large percentage making a decision within a couple of days.


Research

• Mammography Use among Elderly

Colorectal Cancer Survivors

Xinhua Yu, M.B., Ph.D., A. Marshall McBean,

M.D., M.Sc.

Presented By: Xinhua Yu, M.B., Ph.D., Research

Associate, Division of Health Policy and

Management, University of Minnesota, MMC 97

Mayo, 420 Delaware Street SE, Minneapolis, MN

55455, Phone: (612)624-1411, Email: xinhuayu@umn.edu

Research Objective: Increasing numbers of cancer patients survive five or more years after the diagnosis of cancer. Previous studies have shown that elderly survivors of breast and uterine cancer had higher mammography rates than women with no history of cancer. However, one study of elderly colorectal cancer survivors reported a lower quality of health services including lower mammography rates in that group compared with non-cancer people. The objective of our study is to examine the patterns and determinants of mammography utilizations among older women who survived colorectal cancer for more than five years in a more recent cohort.

Study Design: Retrospective cohort design using National Cancer Institute (NCI) Survival,

Epidemiology, and End Results (SEER) data linked to Medicare claim data from the 2003 merge. Propensity score matching method was used to form a non-cancer comparison group to correctly compare the mammography use with the colorectal cancer survivors.

Population Studied: Female colorectal cancer patients who were diagnosed from 1973 through

1999, aged 67 or older, had survived five or more years after cancer diagnosis, and lived in the

SEER areas. The comparison population was those who had no history of cancer during the study period and also resided in the SEER areas.

Principle Findings: The age-adjusted mammography rate was 49.0 per 100 among colorectal cancer survivors, 12% higher than the matched women with no history of cancer (44.6 per 100). This finding persisted across all sociodemographic factors (race, zip code household income level, Medicare ‘‘state buy-in’’ status), comorbidity levels measured by the Charlson

Index, number of physician visits for the purpose of ‘‘evaluation and management’’, and type of medical specialist visited. Among cancer survivors, there was a significant and positive linear association between the number of physician visits for evaluation and management and the mammography rate. This pattern was also found among cancer survivors with a

Charlson score of zero. However, the effect of physician visits disappeared among those with a

Charlson Score >= 1. Those who visited gynecologists had the highest mammography rates, and compared with those who only visited primary care physicians, the adjusted odds ratio

(OR) was 2.98 (95%CI: 2.41-3.69); among those

seen by an oncologist, the adjusted OR was 1.65

(95%CI: 1.49-1.84).

Conclusions: Elderly colorectal cancer survivors were more likely to receive a mammogram than similar women with no history of cancer. More physician visits for evaluation and management and being seen by a gynecologist or oncologist increased the likelihood of receiving mammography among survivors. However, when there were competing demands for treatment of comorbidities during office visits, the positive effect of increased physician visits disappeared.


For patients with comorbidities, increasing physician contact such as office visits for evaluation and management could increase the chance of receiving mammography. Physicians should increase the priority for preventive services such as mammography during office visits in which comorbidties compete for attention.

Funding Source: NCI

Private Health Insurance

• The Effect of Long-Term Care Disability on

Long-Term Care Insurance Ownership: a

Probability Model

Shuli Brammli-Greenberg, M.A.

Presented By: Shuli Brammli-Greenberg, M.A.,

Health economist, Researcher, Smokler Center for Health Policy Research, Myers-JDC-Brookdale

Institute, JDC hill POB 3886, Jerusalem, 91037,

IL, Phone: 972-2-6557481, Fax: 972-2-5612391,

Email: shuli@jdc.org.il

Research Objective: Caring for the elderly and the disabled poses a major challenge to health and welfare systems around the world. The public funding for health and welfare activities is limited worldwide, and therefore there is a growing recognition among policymakers of the need for involving private agencies in financing long term care. Long Term Care Insurance

(LTCI) is one of the main policy options debated today around the world. However, the percentage of people who purchase this insurance worldwide is small. Insurance theory suggests that in a world of asymmetric information, those who are more likely to use the insurance (high risk) will purchase it (adverse selection). The objective of this study was to examine a hypothesis, based on empirical evidence from the private individual LTCI market in Israel, that those who purchase individual insurance are in fact less likely to need it, and therefore, to use it.

Study Design: The "probability of being disabled in at least one ADL" was calculated using the

Central Bureau of Statistics Survey of People Age

60 and over. This variable defines to a high degree an individual's risk of needing LTC in the future. The variable ‘‘probability of being disabled’’ was added to a model that examined the probability of owning private individual LTCI, which was estimated based on the Myers-JDC-

Brookdale Institute data set of Israel's adult population. A test of robustness of the conclusion was undertaken.

Population Studied: The Central Bureau of

Statistics, 1997 Survey of People Age 60 and

Over - Interviews with 5,065 elderly people living in the community. Myers-JDC-Brookdale

Institute biannual surveys of Israel's adult population (conducted since 1995). 1,908 people were interviewed in 2003; the response rate exceeded 81%.

Principle Findings: The CBS data show that the risk of becoming disabled rises with age.

However, in any age group some people are at greater risk of becoming disabled, depending on other characteristics (gender, chronic illness, marital status, country of birth, education).

"The probability of being disabled" has a very great negative independent effect on "ownership of individual LTCI’’ controlling for sociodemographic and health characteristics. The higher the individual's risk of being disabled, the lower his or her probability to own LTCI.

Conclusions: In Israel, individuals at high risk of needing long-term care are less likely to own any form of LTCI. The empirical analysis is supported by an analysis of LTCI policy conditions, which revealed that the insurance companies prefer to exclude high-risk individuals from insurance rather than offer them a more expensive policy.

On the other hand, there are some barriers to an individual's purchase of LTCI that are not necessarily related to selection but rather to individual preferences. The paper discusses whether our finding is due to selection or to consumer choice.


This study has highlighted a possible source of inefficiency and loss of social welfare in the private Israeli LTC insurance market. This had broad implication for the regulation of the individual private LTCI market by the Israeli insurance Comptroller.

Funding Source: Myers-JDC-Brookdale Institute

• Prescription Drug and Office Visit Copay,

Office Visit Travel Distance and the Use of

Emergency Department Visits

William Cecil, M.B.A., John Barnes, M.A., M.B.A.,

Terence Shea, Pharm.D.

Presented By: William Cecil, M.B.A., Director,

Health Policy Research, Health Policy Research,

BlueCross BlueShield of Tennessee, 801 Pine

Street -1E, Chattanooga, TN 37402, Phone: (423)

763-3372, Fax: (423) 755-5100, Email: bill_cecil@bcbst.com

Research Objective: To assess the impact of prescription drug and office visit copayment level and office visit travel distance on emergency department use.

Study Design: An observational study was made of claims data to evaluate changes in copayment level and use of physician office visits, prescription drugs and emergency room visits.

Least squares dummy variable regression was used to test for fixed effects across a four period balanced panel of 9,194 members. Copayment changes for benefit tiers 1 (generic), 2 (preferred brand) and 3 (non-preferred brand) drugs were tested in addition to office visit copayment changes and access distance changes. Age, gender, region of residence, DxCG score and emergency department copay were included in the control variables.

Population Studied: A commercially insured population that were continuously enrolled for a four year period from January 2001 through

December 2004.

Principle Findings: Emergency department visits, in 2002, were lower following increases in office visit copay, increases in access distance to primary care physicians in 2003 and 2004 and increases in tier-1 prescription drug copayment.

Increases in tier-3 prescription drug copayment were followed by higher emergency department expenditures.

Conclusions: This study illustrates that there is a significant relationship between the benefit design for physician office visits, prescription drugs, travel distance to the physician office and emergency department visits.


There may be adverse health or health care use consequences to both low and high prescription drug copayment levels.

•

What About Everyone Else? Prescription

Drug Coverage for the U.S. Non-Elderly

Population

Amy Davidoff, Ph.D., Bruce Stuart, Ph.D.

Presented By: Amy Davidoff, Ph.D., Assistant

Professor, Pharmaceutical Health Services

Research, U Maryland School of Pharmacy, 220

Arch Street, 12th floor, Baltimore, MD 21201,

Phone: (410)706-5397, Fax: (410)706-5394,

Email: adavidof@rx.umaryland.edu

Research Objective: With the focus on implementation of Medicare Part D, little attention has been paid to prescription drug coverage for children and non-elderly adults.

Prescription drug spending in the U.S. has risen to 11% of total health spending, and is a critical component of management of chronic health conditions. Employer surveys indicate that most private plans offered to workers cover prescription drugs, but there has not been a comprehensive examination from the population perspective. This study uses the most recently available national survey data to address patterns of drug coverage for children and nonelderly adults, and the association with perceived access to care.

Study Design: This study uses bivariate and multivariate methods to characterize patterns of prescription drug coverage and examine the association between coverage and prescription drug access. The source of data is the 2005

National Health Interview Survey (NHIS). The

NHIS collects information on public and private sources of current insurance coverage, including single service prescription drug plans and prescription drug coverage as part of general medical plans. The NHIS also captures demographic characteristics, income, service use and unmet need for prescription drug and other types of care.

Population Studied: Children (<age 18) and non-elderly adults (age 18-64) with private insurance coverage.

Principle Findings: We find that 64% of children and 72% of non-elderly adults have private medical insurance, and almost all, (94% of children and 92% of adults) have prescription drug coverage. However, the 4% of children and

6% of non-elderly adults with non-group insurance are less likely to have drug coverage,

(81% of children, 79% of adults), compared to

95% of both children and adults with employer sponsored coverage. Among children with prescription drug coverage, only 1.6% report unmet need and 14% report chronic use of a prescription drug, compared to 4% reporting unmet need and 9% using prescription drugs for those with private medical insurance but no drug coverage. Similar patterns prevail among adults.

Multivariate analyses will explore the sociodemographic and employment characteristics associated with private drug coverage and the association between coverage and access.

Conclusions: Most, but not all persons with medical coverage also have coverage for prescription drugs, particularly those who purchase coverage in the non-group market. The presence of drug coverage is associated with lower rates of unmet prescription drug need, and higher use rates among children.


Both medical and prescription drug coverage are essential to facilitate appropriate and adequate treatment for chronic conditions. Almost all persons receiving medical coverage through an employer also have prescription coverage, but this study does not provide information on generosity of coverage As drugs continue to increase as a percent of total spending, employers may increase premium cost sharing and/or reduce drug plan generosity. Thus trends over time must be monitored. Persons using the non-group market to obtain medical coverage are less likely to obtain prescription coverage.

Those policies have been found to have other coverage limitations, and the results of this study indicate that they are also limited in their prescription drug coverage.

•

Bundling Payment into Episodes of Care:

Beyond the 80-20 Rule

Laura J. Eaton, M.D., M.P.H., Harold S. Luft,

Ph.D.

Presented By: Laura J. Eaton, M.D., M.P.H.,

Postdoctoral Fellow and Clinical Instructor,

Family Medicine and The Institute for Health

Policy Studies, UCSF, 3333 California Street, Suite

265, San Francisco, CA 94118-1944, Phone: (415)

661-3538, Fax: (415) 476-0705, Email: leaton@fcm.ucsf.edu

Research Objective: It is commonplace to note that 80% of effects come from 20% of the causes. Recognizing such concentration in healthcare allows us to consider more effective payment mechanisms. Traditional payment methods ,e.g., fee-for-service, global capitation, promote overuse or under-use of health services.

Instead of paying for everything on a service-byservice------or yearly basis, bundling some provider payments around an episode-of-care would increase efficiency and improve quality of care.

We explore the types of clinicians, facilities, and other resources involved in various kinds of episode-of-care.

Study Design: A cross-sectional study of the distribution of types of providers and costs using nationwide claims data from several large health plans. All services are grouped into episodes of care using commercially available software which we then categorized as Major/Interventional which usually involves a hospitalization, Chronic

Illness Management, Minor Acute and

Preventive.

Population Studied: De-identified claims data of 796,635 commercially insured members from several large nationwide health plans during

January 1, 2003-December 31, 2004. This is a

10% sample of our data------the full set will be used in the final analyses.

Principle Findings: Four percent of all episodes were Major Acute/Interventional, accounting for

48% of total cost; 21% of episodes were Chronic

Illness Management, accounting for 24% total cost; 61% were Minor Acute, accounting for 26% of total cost; and 14% were Preventive, accounting for 3% of total cost. Seventy-five percent of all medical management costs arose from the Chronic Care management and Acute

Minor categories; 66% of all surgical costs were in the Major Acute/Interventional category; and

56% of outpatient prescription medication costs were incurred in the Chronic Care Management category.

Conclusions: Using administrative data and widely available episode grouper, risk adjustment and statistical applications, it is possible to categorize episodes-of-care. Our findings suggest alternative payment approaches for system redesign. For example, an expansion of

DRGs to include associated professional fees would bundle the costs associated with nearly half of all medical care, reducing administrative costs and improving efficiency incentives.

Monthly payments for chronic illness management could address risk avoidance problems.


Implementing new provider payment approaches based on episodes-of-care would align the incentives of providers and health plans to promote more efficient resource use while better meeting the needs of patients with respect to cost, access, delivery, quality, and outcomes.

Restructuring payments, however, will require more in-depth understanding of different providers who will be affected by such change.


• Employer Offers of Private Health

Insurance to Retiring Baby Boomers

Christine Eibner, Ph.D., Alice M. Zawacki, Ph.D.,

Elaine M. Zimmerman, Ph.D.

Presented By: Christine Eibner, Ph.D., Associate

Economist, Economics and Statistics, RAND

Corporation, 1200 South Hayes Street, Arlington,

VA 22202, Phone: (703) 413-1100 Ext. 5913, Fax:

(703) 414-4726, Email: eibner@rand.org

Research Objective: One of the most pressing policy concerns given the growing number of retiring baby boomers is access to health insurance. Two primary sources of health insurance for older adults are Medicare and employer-sponsored retiree health insurance

(RHI). Coverage through employer-sponsored

RHI is threatened by increases in premiums and the new Medicare prescription drug benefit.

Previous research exploring RHI has focused on descriptive trends without adjusting for business characteristics that may have changed over time.

Further, many studies have relied upon data collected from retirees themselves or establishment-based information from large employers. In this paper, we use a nationally representative sample to evaluate trends in RHI offers and contribution requirements, holding constant business and local labor market characteristics. We also analyze which business and local labor market characteristics have the largest impact on RHI access and cost.

Study Design: Holding constant businesses characteristics such as union presence and industry, we evaluate changes over time in the predicted probability that an establishment provides RHI, the predicted probability that new retirees are eligible for RHI, and predicted retiree contribution requirements. We also analyze establishment characteristics and local labor market conditions that influence RHI access and affordability. All models are weighted by the share of workers over the age of 50 at each establishment, allowing us to understand trends in RHI provision for older workers.

Population Studied: Data come from the

Medical Expenditure Panel Survey----Insurance

Component (MEPS-IC), a nationally representative sample of establishments containing information RHI offers and characteristics of the establishment, firm, and labor force. A drawback of the MEPS-IC is that questions related to RHI have changed frequently over time. We focus on data from

2001 to 2004, a period where questions remained relatively stable.

Principle Findings: In contrast to prior work reporting declines during the 1990s, we find that provision of RHI for both early and Medicareeligible retirees increased from 2001 to 2004.

This increase may be related to the wording of the MEPS-IC questionnaire. Specifically, establishments are asked whether they provide

RHI, implying both that RHI is available, and that at least some retirees take-up the benefit.

Even if offers decline over time, take-up may increase as the population ages. In spite of this issue, eligibility for new retirees at establishments that currently provide RHI declined between 2001 and 2004. Further, retiree contribution requirements increased over the period studied.

Conclusions: Fewer new retirees were eligible for RHI benefits in 2004 than they were in 2001.

Further, conditional on an RHI offer, contribution requirements increased over time.

While RHI offers were more prevalent at larger establishments and establishments with a union presence, changes in these characteristics did not explain trends in offers and contribution requirements. Local labor market characteristics such as the unemployment rate did not affect

RHI provision or affordability.


These results suggest that some older workers who anticipated receiving RHI from their employer are no longer eligible for benefits. If the expectation of RHI affected savings decisions, these individuals may not be financially prepared for retirement.

•

Characteristics of Children in High-

Deductible Health Plans

Alison A. Galbraith, M.D., M.P.H., Dennis Ross-

Degnan, Sc.D., Stephen B Soumerai, Sc.D., Irina

Miroshnik, M.S., Frank Wharam, M.B., Tracy A

Lieu, M.D., M.P.H.

Presented By: Alison A. Galbraith, M.D., M.P.H.,

Instructor, Department of Ambulatory Care and

Prevention, Harvard Medical School and

Harvard Pilgrim Health Care, 133 Brookline

Avenue, 6th floor, Boston, MA 02215, Phone:

(617)509-9893, Fax: (617)859-8112, Email: alison_galbraith@hms.harvard.edu

Research Objective: High-deductible health plans (HDHPs) are a new and controversial strategy that increases patient responsibility for health care costs via deductibles of >$1,000 per family. Scant data exist on children in HDHPs.

The aim of this study was to examine differences in clinical and demographic characteristics of

children enrolled in HDHPs compared to traditional plans.

Study Design: This was a cross-sectional study using health plan claims and enrollment data.

We used multivariate hierarchical models to assess clinical and demographic predictors of the primary outcome, whether the family switched to a HDHP. Families could have switched to a HDHP by choice or because the employer offered only a HDHP.

Population Studied: The study included children aged 0-18 years whose families enrolled in a traditional HMO in a large Massachusetts managed care organization for a 12-month baseline period between 2001 and 2004, then either switched to a HDHP or stayed in the traditional plan. For each HDHP family, we selected 8 contemporaneous control families who stayed in the traditional plan. Children were stratified by whether their families had a choice of plans (the Choice group) or were offered only one plan by the employer (the No Choice group).

Principle Findings: The Choice group included

214 children who switched to a HDHP and 1,708 who remained in the traditional plan; the No

Choice group had 1,839 and 13,733 children, respectively. Choice group children had increased odds of switching to the HDHP if their families had fewer children (p=0.032) and lower baseline out-of-pocket health care expenditures

(p=0.046). For the No Choice group, the odds that a child’s family was offered only an HDHP by the parent's employer were higher among families with fewer children (p=0.025), lower baseline total health care expenditures

(p=0.007), and residence in neighborhoods with lower household income (p<0.001). Presence of a chronic condition, morbidity, and expenditures for the child were not significantly associated with HDHP enrollment for either group.

Conclusions: Families in HDHPs tend to have fewer children and lower baseline health care expenditures than those in traditional plans.

However, lower income families may be more likely than higher income families to have employers who require a switch to a HDHP.


Further research is needed on the effects of

HDHPs on child health, especially for lowincome children.

Funding Source: Harvard Pilgrim Health Care

Foundation; Charles H. Hood Foundation

•

Patient and Plan Design Factors Influencing

Switching to Formulary Statin Agents After

Formulary Status Change of Atorvastatin

Amit Kulkarni, Ph.D., Henderson, Rochelle, M.A.

Presented By: Amit Kulkarni, Ph.D., Director of

Research, Research and Product Management,

Express Scripts Inc, 13900 Riverport Drive,

Maryland Heights, MO 63043, Phone:

3147027940, Fax: 3147027993, Email: akulkarni@express-scripts.com

Research Objective: Assess impact of a formulary status change on utilization and switching patterns of atorvastatin users.

Study Design: This was a cross sectional, cohort study of current atorvastatin users targeted for a patient notification campaign informing them of the formulary status change. On January 1, 2006 atorvastatin was changed from formulary to nonformulary status, increasing the copayment for current atorvastatin users. A formulary notification letter listing formulary options and copayment savings, materials to share with the patient’s physician, a 1-800 number and a website to obtain additional information were sent to patients beginning October 1 through

December 31, 2005. Patients logging onto the web site or calling in received additional targeted messaging. Pharmacy claims were examined beginning January 1 through June 30, 2006 to determine use of statin therapy and switching to a formulary agent. For purposes of analyses, patients were grouped by where they filled their final atorvastatin prescription in 2005, retail vs

Home Delivery (HD). Bivariate chi-square and multivariate logistic modeling examined the predictors of switching to formulary preferred medication.

Population Studied: Current atorvastatin users enrolled in commercial health plans (i.e., no

Medicare or Medicaid) with a three tier copay structure.

Principle Findings: A total of 211,083 patients

(retail n=108,146/HD n=102,937) met the study inclusion criteria. A majority of the study population were male (53.6%), average age 61.4

(±11.9) with mean 30-day equivalent copayment differential in HD of $11.47 (±5.58) and $17.94

(±5.49) in retail. Just over 91% continued statin therapy in 2006, with 42.2% switching to formulary agents; 33.1% switching in retail and

51.8% switching in HD. Controlling for patient demographics, across both retail and HD models, factors positively influencing switching to a formulary preferred alternative included: use of low dose atorvastatin in 2005, step therapy, prior statin switching in 2005, continuous user at time of notification, seeking information by calling or web usage, and higher preferred/non-preferred brand copayment

differential Compared to those paying a differential of =$10 in retail, those paying from

$11 to $15, $16 to $20, and $21 and higher had a

35% (95% CI=1.31-1.39), 42% (95% CI=1.37-1.46) and 80% (95% CI=1.74-1.88) increase in the odds of switching. In HD, compared to those paying a differential =$15 those paying $16 to $30, $31 to

$40, and $41 and higher had a 20% (95%

CI=1.17-1.23), 23% (95% CI=1.20-1.26) and 60%

(95% CI=1.55-1.64) increase in odds of switching to preferred agent. Step therapy with grandfathering (continuous users not targeted) increased the odds of switching by 1.3 in both retail and HD and step therapy without grandfathering increased the odds of switching by 4.5 (95% CI=3.48-5.69) and 3.0 (95% CI=2.17-

4.00) in retail and HD, respectively.

Conclusion:

Conclusions: Several plan design and demographic factors influenced the likelihood of switching to formulary agents, many within the control of plan sponsors.


Understanding the drivers of formulary adherence can aid plan sponsors in predicting utilization change and implementing more effective educational programs.

Funding Source: Express Scripts Inc.

•

How Do You Argue Against the Use of a

High-Cost Medical Treatment When A

‘‘Quality of Life’’ Measure is Not Available?

Andrea McAllister, B.S.

Presented By: Andrea McAllister, B.S., Decision

Support Consultant, Knowledge Discovery,

Highmark Inc., 120 Fifth Avenue, Pittsburgh, PA

15222, Phone: 412-544-0664, Fax: 412-544-0700,

Email: andrea.mcallister@highmark.com

Research Objective: To (1) identify patients who began use of a monthly injectable asthma treatment during 2004. (2) Examine total healthcare, medical and pharmacy, utilization and cost one year pre- and post- initiation of a new asthma treatment. (2) Examine the costeffectiveness of a high-cost injectable medication used for the treatment of asthma.

Study Design: A pre/post total healthcare cost analysis is performed on all patients receiving an initial newly introduced asthma treatment during

2004. All medical and pharmacy claims incurred one year prior to the patient’s initiation of this treatment as well as one year subsequent to this initiation are examined. Outpatient Emergency

Room (ER) as well as Inpatient stay data is examined as well. Changes in utilization and cost are studied and summarized to create a

‘‘total impact’’ of the use of this new asthma treatment.

Population Studied: The entire commercial population of a large health insurer is considered for this study. Of these members, all which receive an initial treatment of a particular highcost injectable asthma drug during 2004 is included for the purposes of this study.

Principle Findings: There were slight increases in per patient per month (PPPM) costs for medical (non-study treatment) claims and outpatient ER visits, and larger decreases in asthma pharmacy. However, the combined impact of these changes is minimal compared to the increase in medical costs related to the study treatment.

Conclusions: It is clear from the findings that the use of this drug is not cost-effective for the health insurer. However, what is missing from this study is a measure of the impact that this new asthma treatment has on the patient’s quality of life. Even though there was a small increase in Outpatient ER visits, there was a decrease in inpatient stays which can be assumed to significantly impact a patient’s quality of life. What about the impact of the drug treatment itself? How do we as a health insurer measure how much better a patient feels after one of these injections, let alone after a string of these monthly injections? Unless we directly contact these patients and survey them personally, we can’t.


What this study brings to light is an issue that all insurers as well as policy makers have to confront at some point: how do we justify the use of high-cost drug treatments when the evidence of cost-effectiveness is not there? Do we just assume that the patients are feeling so much better that we agree to cover it, go back to the manufacturer and negotiate lower drug costs, or dialogue with patients to see is they are truly benefiting from the new treatment? As we all know, newer isn’t necessarily better and these same patients may be just as well off physically remaining on the same, older, treatments. Or are they? Only the patients would know that and that information isn’t readily available, at least not to internal researchers like me.

•

Increasing Out of Pocket Expenses Increase

Barriers to Care

Holly Rodin, Ph.D., Lynn Blewett, Ph.D., Micheal

Davern, Ph.D.

Presented By: Holly Rodin, Ph.D., Sr. Field

Researcher, Health Systems, SEIU, 2997

Chatsworth Street N, Roseville, MN 55113,

Phone: (651) 490-5035, Email: holly.rodin@seiu.org

Research Objective: To empirically examine how increasing out-of-pocket health care expenditures affect the likelihood of experiencing barriers to care.

Study Design: We estimate two logistic regressions modeling the probability of experiencing barriers to care. The first logistic regression models the probability of being unable to obtain care when needed and the second models the probability of delaying needed care. The variable of interest in these models is family health care burden. Family health care burden is defined as the total family out of pocket expenses for health care, not including premium costs, as a percentage of family income. These models include control variables including insurance status, education, age, race, other demographic characteristics, employment status, industry and employer size.

The method of recycled probabilities is used to isolate the marginal effect of increasing amounts of health care burden on barriers to care controlling for other characteristics.

Population Studied: The Medical Expenditure

Panel Survey 2004 is used for this analysis.

Respondents under the age of 65, reporting outof-pocket spending are included in the analysis, with a sample size of 26,281.

Principle Findings: As the amount of health care burden increase the likelihood that individuals will be unable to obtain needed care and the likelihood that people will delay needed care increases. Holding all other characteristics constant, increasing health care burden from less than 10 percent of family income to 20 percent or more of family income increases the percentage of people unable to obtain needed care from 3.1 percent to 4.8 percent, compared to the rate for the uninsured at 9.1 percent. This same increase in health care burden increases the percentage of people delaying needed care from 4.0 percent to 7.3 percent, slightly less than the rate of 7.9 percent for the uninsured.

Conclusions: Increasing health care burden increases the likelihood that people will experience barriers to care, even when controlling for insurance coverage. Being uninsured has more of an impact on obtaining care than does increasing health care burden, but in terms of delaying care, increasing health care burden closes the gap between the insured and the uninsured.


Employers and government programs continue to struggle with ways to control health care costs. One approach has been to shift increasing costs of health care directly to individuals, by including coinsurance, deductibles, and co-pays into plan designs, as well as increasing out-ofpocket maximums, or by offering high deductible health plans. This research indicates that caution should be taken when cost shifting health care expenditures to individuals as they are more likely to delay needed care and to be unable to get care as a result of that increasing health care burden. An unintended consequence of the cost-shift will likely be more barriers to care for those with insurance coverage. Other methods of cost control that do not increase barriers to care should be considered.

• Recent Consolidation of the Health

Insurance Industry: No Evidence for Adverse

Effects

Gregory Ruhnke, M.D., M.S.

Presented By: Gregory Ruhnke, M.D., M.S.,

General Internal Medicine Fellow, Institute for

Health Policy, Massachusetts General Hospital,

50 Staniford Street, 9th floor, Boston, MA 02114,

Phone: 617-724-3545, Fax: 617-724-4738, Email: ruhnke@stanfordalumni.org

Research Objective: There is concern among health care providers and leaders of organized medicine that consolidation of the health insurance (HI) industry is undermining the ability of competition to control costs. However, a relationship between consolidation and premiums has not been demonstrated. This analysis assessed for adverse effects of consolidation by investigating whether a relationship exists between HI market consolidation and temporal changes in premiums, number of uninsured persons, or small businesses offering HI to their employees.

Study Design: The percentage of state commercial insurance enrollment accounted for by the three largest health plans in 2002 was used as a measure of consolidation (MC) of each state’s HI market. The Herfindahl-

Hirschman Index was used as a secondary MC.

The Medical Expenditure Panel Survey (MEPS) was used to obtain state-level single and family coverage premium data in 1998 and 2004. Using these data, the percentage change in mean state premium (MSP) from 1998 to 2004 was the

primary marker of adverse effect (MAE).

Additional state-level MAEs analyzed were: the percentage change from 1998 to 2004 in (a) the proportion of small businesses offering HI to their employees; and (b) the number of uninsured persons. The percentage change in

MSP and the other two MAEs were regressed on each of the two MCs, separately (six regressions). The following state-level variables were also entered into the regressions: median household income, median age, proportions of each state's population White, Black, and

Hispanic. In addition, to adjust for exogenous trends in use of medical technology and distribution of health care plan types (both of which influence average premiums and exhibit geographic variation), the following state-level covariates were also entered: mean per capita

Medicare expenditure and percentage of population enrolled in HMOs.

Population Studied: The sample of small businesses and individuals with employersponsored HI surveyed in MEPS.

Principle Findings: From 1998 to 2004, mean single and family premiums increased by 70% and 79%, respectively. Graphical and simple correlation analysis (coefficient=0.19) revealed no relationship between the MCs and the percentage change in MSP in each state. In the regression analyses, neither of the MCs predicted the percentage change in MSP or the change in number of uninsured persons to statistical significance (due to small parameter estimates rather than large standard errors).

However, the percentage of state commercial insurance enrollment accounted for by the three largest health plans did predict (p=0.03) an increase in the proportion of small businesses offering HI from 1998 to 2004.

Conclusions: This analysis suggests that HI market consolidation is not having an adverse effect on average premiums, the number of uninsured persons, or small businesses' ability to offer HI to their employees.


Despite concern regarding adverse effects of the consolidation of the HI industry, there is no evidence to support the necessity of anti-trust legislation. Better risk pooling and lower administrative costs may be affording large HI companies profit increases without a consequent effect on premiums. Further analyses may investigate whether less comprehensive health plans (with curtailed benefit packages and greater out-of-pocket expenditures) are more common in consolidated HI markets.

Funding Source: NIH National Research Service

Award

•

Physician Responses to Implementation of

Tiered Provider Networks by Health Plans

J William Thomas, Ph.D., Gino A. Nalli, M.P.H.,

Andrew F. Coburn, Ph.D.

Presented By: J William Thomas, Ph.D.,

Professor, Institute for Health Policy, University of Southern Maine, 356 Shore Road, Bremen,

ME 04551, Phone: 207-529-2009, Fax: 207-529-

2409, Email: jwthomas@usm.maine.edu

Research Objective: In 2006, all of the nation’s largest national health insurance companies ----

Aetna, CIGNA, Humana, United, Wellpoint ---- as well as many regional health plans were utilizing tiered physician networks in which physicians are partitioned, usually by clinical specialty, into two or three subgroups on the basis of measured quality and/or cost efficiency performance.

Health plan members then are given financial incentives, most frequently differential copayments, to utilize physicians in the high performance tiers. The purpose of this study was to investigate physician responses to tiered network initiatives, including the degree to which such initiatives motivate physician practices to pursue quality and cost efficiency improvements.

Study Design: A telephone survey with in-depth interviews of physician practices in 4 markets in which tiered network products were being offered by health plans.

Population Studied: The study’s sampling frame was provided by two national health insurance companies that operate tiered physician networks in each of the four markets studied. For sampling purposes, practices were divided into four quadrants: high tier practices having relatively large tiered-network-plan patient volume, high tier practices with relatively small tiered-network-plan patient volume, low tier practices having relatively large tiered-networkplan patient volume, and low tier practices with relatively small tiered-network-plan patient volume.

Principle Findings: Survey questions addressed, among other things: (1) physician attitudes toward design and implementation issues (e.g. validity of performance measures used, adequacy of underlying data, and manner in which performance scores and tier assignments were communicated to patients); (2) tiered network impacts on physician practices, including patient volume and revenue.; and (3) practice changes to improve measured

performance (e.g., practice management systems, ordering patterns). We find that when physicians do not accept the legitimacy of a tiered network, whether because of concerns about validity of performance measurement or the tiering implementation process, or for other reasons, they are unlikely to implement practice changes to achieve quality and/or cost efficiency improvement.

Conclusions: Tiered networks seek to improve quality and cost efficiency by shifting patient demand from low to high performing providers, and by motivating all providers to strive for performance improvement in order to achieve high tier status. This study highlights the importance of physician acceptance of the legitimacy of the tiering process (as influenced by identifiable design and implementation features and processes) for the effectiveness of tier network strategies in improving efficiency and/or quality.


Implementation of tiered physician networks has increased greatly in recent years. Health plan ability to achieve goals of improved quality and cost efficiency is greatly enhanced when design characteristics of the tiered network (e.g., accuracy and completeness of input data, validity of performance measures, tier definitions) and the process by which the tiered network is implemented (e.g., communication of tier assignments to members) is accepted by physicians.


•

Sample Size Considerations in Economic

Profiling of Physicians

J William Thomas, Ph.D.

Presented By: J William Thomas, Ph.D.,

Professor, Institute for Health Policy, University of Southern Maine, 356 Shore Road, Bremen,

ME 04551, Phone: 207-529-2009, Fax: 207-529-

2409, Email: jwthomas@usm.maine.edu

Research Objective: As of 2006, all of the largest national health insurance companies in the United States were using claims databases to construct economic profiles of physicians in their provider networks. However, profiling methodologies differ in important aspects from one company to another. The purpose of the study reported here is to investigate one of the differences ---- minimum number of episodes required for profile construction ---- and its implications for profile accuracy in classifying physicians as cost-efficient, average, or costinefficient.

Study Design: Claims data were processed through an episode grouper. Actual cost and expected cost were calculated for each defined episode, and responsibility for episodes was attributed to physicians who accounted for the majority of episode professional and prescribing costs. Simulation analyses were used to investigate relationships between minimum sample size and accuracy of classification of physicians. In other analyses, physicians were profiled and ranked within specialty from most to least cost-efficient, using the same set of minimum sample sizes considered in the simulation analyses, and consecutive year rankings were compared for consistency.

Population Studied: Physicians serving members of a mixed model HMO in Southeast

Michigan. Analyses were performed for cardiologists, family practitioners, general surgeons, and neurologists.

Principle Findings: The majority of physicians identified as cost-efficient or cost-inefficient in episode-based analyses are correctly classified.

However, measures of physician cost-efficiency used in economic profiles are imperfect. The larger the required minimum episode sample size, the fewer the misclassifications that occur.

Appropriate panel size minima are likely to differ among clinical specialties and may differ depending upon whether the primary focus of economic profiling is identifying cost-efficient or identifying cost-inefficient physicians. In any economic profiling program, selection of the appropriate minimum panel size will involve trade-offs between profile accuracy and percentage of physicians profiled. In situations where physician practice patterns are unstable over time, using economic profiling information to restrict member access to cost-inefficient physicians might not promote health plan cost objectives.

Conclusions: In any specific economic profiling context, minimum episode sample size may need to be negotiated between network physicians, whose interests argue unequivocally for larger minima, and the health plan, which is interested both in profile accuracy and in the percentage of network physicians that can be profiled. Different minima may need to be defined for different clinical specialties.


Information to support decisions and/or negotiations on minimum episode sample sizes should be developed and made available to health plans and physicians. To promote

consistency among economic profiling efforts nationally, the same information could be used, for example by National Committee for Quality

Assurance (NCQA), for proposed minimum sample size standards or norms.


• Predicting Employees Who Switch Health

Plans: Do Ratings of Plans and Providers

Matter?

Lisa Zubkoff, Ph.D., Ann Barry Flood, Ph.D.

Presented By: Lisa Zubkoff, Ph.D., Post-Doctoral

Fellow, Center for the Study of Provider Behavior,

Veterans Affairs, 16111 Plummer Street (152),

Sepulveda, CA 91343, Phone: (818) 891-7711 x7169, Fax: (818) 895-5838, Email: lisa.zubkoff@va.gov

Research Objective: Each year at open enrollment, some employees voluntarily switch health plans. After taking employee demographics and market variations into account, we examined the importance of type of plan and employees’ apparent satisfaction with their plan and provider, and how these predicted intent to switch.

Study Design: We performed secondary analyses of a 1998 survey of 30,876 randomly sampled employees designed to evaluate health plans, as contracted with Medstat by 34 Fortune

500 firms. We grouped plans into four basic types: fee-for-service (FFS), health maintenance organizations (HMO), point of service (POS), and preferred provider organizations (PPO).

Survey variables analyzed included employees’ detailed and overall ratings of their health plans and providers and their intent to switch. We used stepwise regression to examine determinants of employee’s ratings of their plan and providers beginning with type of plan followed by ‘controls’ for employee sociodemographic and health characteristics, market attributes, and region. We then performed two logistic regressions to identify ‘predictors’ of intent to switch health plans using these same variables and either 1) overall ratings of health plan or provider or 2) ratings of specific measures about the health plans or providers.

Population Studied: 30,876 employees of 34 firms located in 20 US markets and insured within 192 plans.

Principle Findings: Forty-seven percent of employees were enrolled in an HMO, 27% in

POS, 12% in PPO, and 14% in FFS. Being enrolled in an HMO or PPO was a statistically significant predictor of satisfaction with health plans (standardized beta = .112, p<.001 and beta

= .045, p<.001 respectively), while being in a

POS had no effect (beta = -.01, p>.01).

Satisfaction with plan (OR = .941, p<.001) and provider (OR = .988, p<.001) predicted lower intent to switch as did type of plan. When examining the specific measures about plans and providers, HMO users were least likely to switch plans compared to FFS (OR = .729, p<.001); PPO was intermediate (OR = .838, p<.001) and POS was indistinguishable (OR =

.821, p>.01). When examining the overall ratings of health plans and providers, HMO enrollees were least likely to switch plans (OR = .676, p<.001), followed by POS enrollees (OR = .712, p<.001), and then PPO enrollees (OR = .820, p<.001) when compared to FFS enrollees.

Conclusions: Type of plan was an important predictor of being satisfied with providers and plans. HMO users tended to be more satisfied about all aspects, especially when compared to

FFS. They were also least likely to switch plans.


These findings about HMO enrollee’s higher satisfaction and greater stability are somewhat at odds with the current backlash against managed care. Likewise, the importance of HMO for predicting satisfaction based on measures of health plans and providers was surprising. While the survey period preceded major managed care backlash, it may be that the dissatisfaction arose particularly where employees felt ‘forced’ to choose some hybrid of managed care while

HMO had more ‘loyal’ consumers. In summary, changing specific health plan performance measures may not be as important to produce overall satisfied customers as finding the right match between employee and type of health plan.

Quality: Measuring &

Improving Quality

• A Method for Assessing Optimal Physician

Performance

Susan Abend, M.D., David Roberson, M.D., Jean

Connor, R.N., D.N.Sc., CPNP, Gareth Parry,

Ph.D., Nina Rauscher, M.S., R.N., C, ONC,

CRRN, Kathy Jenkins, M.D., M.P.H.

Presented By: Susan Abend, M.D., Executive

Director, Healthcare Quality Management

Group, 495 Concord Street, Framingham, MA

01701, Phone: (508) 620-4535, Email: sabend@pol.net

Research Objective: Accurate assessment of physician performance is essential to making valid comparisons between individual physicians and physician groups. However, while there are measures of adequate healthcare delivery for specific conditions, there are currently no measures of ideal physician performance, and this concept remains largely undefined. The goal of this study is the development of a method for defining and measuring ideal physician performance, so that practitioners, trainees and patients will have a clear sense of the behaviors that constitute optimal therapeutic interactions.

Study Design: An exploratory inquiry employing focus groups of families, physicians, and hospital administrators associated with

Children’s Hospital Boston (CHB) was developed to determine the attributes of excellent physician care. Groups were asked to relate aspects of excellent therapeutic encounters, (either experienced or witnessed) and to then come to a consensus regarding the importance of each attribute described. Groups were then asked to review current methods of physician assessment, including core competencies, patient satisfaction surveys, and the Ambulatory Care Experiences Survey (ACES) and to consider the incorporation of those measured attributes into the prioritized list.

Population Studied: Parents of children treated at CHB, department chairs at CHB, and CHB hospital administrators.

Principle Findings: The groups developed consensus around the following two major domains: 1) Meeting Patient Needs and 2)

Meeting Professional Needs. Nine criteria were identified for the Patient Needs domain. These included conscientiousness and knowledge of patient details, leadership in achieving consensus decisionmaking, dedication of time, focus, establishment of trust and a respectful partnership, accessibility, the active coordination of care between consultants and other services, and follow-up on the effectiveness of interventions. Seven criteria were identified for the Professional Needs domain. These included the active promotion and development of innovation, the validation of skill and judgment by knowledgeable colleagues, active knowledge sharing, accessibility to colleagues, better than expected patient outcomes, and timely completion of administrative responsibilities.

Conclusions: Excellent physician performance can be described as optimally fulfilling the criteria within each of two domains: Patient

Needs and Professional Needs. A summary score for each physician may be represented as coordinates on a matrix representing both domains. Further assessment and analysis will determine valid and reliable assessments of each of the criteria.


The development of a method for identifying ideal physician performance can serve as a scaffold for physicians' achievement of optimal performance, as well as providing a method by which patients and third party payors can identify optimal quality healthcare.

Funding Source: Children's Hospital Boston

• Health Related Quality of Life (HRQoL) as a

Tool to Assess Quality of Epilepsy Care

Ruzan Avetisyan, M.D., M.P.H., Barbara G.

Bokhour, Ph.D., Mary Jo V. Pugh, Ph.D., R.N.,

Dan R. Berlowitz, M.D., M.P.H., Lewis E. Kazis,

Sc.D., Georgia Montouris, M.D.

Presented By: Ruzan Avetisyan, M.D., M.P.H.,

Research Associate, Health Policy and

Management, Boston University School of Public

Health, 715 Albany Street, Talbot building,

Boston, MA 02118, Phone: (617) 414-1437, Fax:

(617) 414-1398, Email: ruzana@bu.edu

Research Objective: While quality indicators are available to assess the care provided for patients for a number of chronic diseases, no formal measures have been available for epilepsy. The purpose of this project was to develop both evidence-based and patient oriented quality indicators and measurement tools for adults with epilepsy receiving health care services in routine primary care settings.

Study Design: This study used a multi-method design approach, with qualitative analysis of epilepsy patients’ focus group data to identify domains and dimensions of care important to adults receiving epilepsy care.

We conducted six focus groups with epilepsy patients from Boston Medical Center, stratified by race/ethnicity and gender. Issues discussed included: patient perceptions of epilepsy, quality of care received, and impact of epilepsy on patients’ lives. Analysis revealed patient importance given to impact of epilepsy and its treatment on overall health related quality of life

(HRQoL) and health status (functional limitations). Consequently, we used procedures informed by grounded theory methodology to identify main dimensions and domains of

HRQoL affected by epilepsy and its treatment.

Subsequent analysis differentiated the domains of HRQoL and its’ determinants: a distinction

that is not often recognized in previous quality of life studies.

Population Studied: A convenience sample of

35 adult epilepsy patients: 18 men and 17 women, from an inner city medical center.

Principle Findings: The focus group discussions revealed specific areas of patients’ health related quality of life (HRQoL) affected by epilepsy that were reflected in existing theoretical models of HRQoL. In addition, our study found domains that have not been recognized before, or that were only partially developed: Isolation and dependence on others because of driving restrictions/ immobility; Success or failure of coping with epilepsy; Feeling of uncertainly related to treatment effectiveness and seizure control; Unawareness and uncertainty about treatment side effects; Feeling secure about availability of care; Attachment/ bond with health providers; Gender/Sex specific issues: Women’s issues and Men’s issues.

Conclusions: Focus groups revealed HRQoL domains that are related to processes and quality of care. Patients strongly linked quality of care with their quality of life. This corroborates previous work with other diseases that identifies

HRQoL as an important component of quality measurement. These focus groups identified domains of HRQoL specific to epilepsy which represent important components of quality of care. Development and validation of scales to measure these constructs will provide an important avenue to assess and improve the quality of care from the perspective of the patient.


Development of comprehensive HRQoL measurements that incorporate domains strongly related to patients’ experiences of care, provides an outcome measure that is linked to quality of care and can be used to evaluate and improve clinical care of patients with epilepsy.

Funding Source: CDC

• A Retrospective Assessment of Quality

Performance for Acute Myocardial Infarction

Care in Hospital: A Time-Stamped Data

Analysis

Jay Bae, Ph.D., Kia Powll-Threets, M.S., Jennifer

Flynn, M.P.P., Kevin Mayo, Ph.D.

Presented By: Jay Bae, Ph.D., Health Outcomes

Scientist, Global Health Outcomes, Eli Lilly and

Co., Lilly Corporate Center DC 1833, Indianapolis,

IN 46285, Phone: (317) 651-8360, Fax: (317) 433-

2997, Email: Bae_Jay@Lilly.com

Research Objective: The CMS Pay-for-

Performance measures for hospital quality include the Acute Myocardial Infarction (AMI) care. To assess the hospital performance for

AMI at baseline, this study retrospectively assessed AMI care quality in a sample of acute care hospitals under a usual non-demonstration environment. Hospital and patient characteristics were also examined with respect to the quality criteria.

Study Design: The Premium ACTracker

(Solucient Inc.) is a de-identified hospital database that contains comprehensive information on hospital patient care, including time stamps on select interventions. Using the timestamp information, we constructed detailed timeline of care for each inpatient episode. A subset of performance measures per CMS

Hospital Quality Initiative (HQI) was assessed.

Quality measures supported by the data are: aspirin on arrival, beta blocker on arrival, thrombolytic within 30 minutes, and percutaneous coronary intervention (PCI) within

120 minutes. Distributions of all time-dependent variables are also reported.

Population Studied: Total 17,895 patients, admitted to any one of 26 hospitals with a cardiac catheterization lab for a diagnosis of AMI between 1/1/2002 and 12/31/2005. Appropriate exclusion rules were applied to count eligible patients. Most common patient type was male

(60.3%) and 65 years of age or older (58.8%).

Sample hospitals are 23% teaching, 88% urban, and by region, 27% North East, 31% North

Central, 27% South, and 15% West.

Principle Findings: Across the all AMI admissions in the 26 hospitals studied, average quality score on aspirin on admission (= 24 hours) was 64.4%, while average score of beta blocker on admission was 52.9%. Thrombolytic use within 30 minutes was met in 46.9% of the admissions. Angioplasty within 120 hours of admission was met in 46.9% of the admissions.

Overall, composite quality scores were higher for male or younger patients (significance level p=

0.05) than those for female or older patients.

Rural hospitals scored particularly low in aspirin on admission criterion with the score of 26.0% compared to 66.8% of the urban hospitals.

Hospitals in the South Region performed lower than the rest. Data trend showed that the AMI care quality score did not improve between 2002 and 2005 despite the overall increasing awareness of the HQI over time.

Conclusions: Retrospective assessment of AMI care quality indicated that there is considerable room for quality improvement in the hospitals

examined. Variability of quality by certain hospitals or patient characteristics was confirmed to be a challenge for the HQI as it is being extended to all Medicare acute care hospitals.


The retrospectively analyzed quality data helps inform the HQI policy about the baseline performance for AMI care in a nondemonstration environment without financial incentives. Lagging performance at baseline for certain hospital types and geographic regions suggests areas of both challenge and opportunity for which most quality improvements can be potentially realized.

Quality disparities by patient characteristics.

Funding Source: Eli Lilly & Daiichi Sankyo

• Indianapolis Discovery Network for

Dementia (IDND)

Malaz Boustani, M.D., M.P.H., Stephanie

Munger, B.S., Youcef Sennour, M.D., Ann Hake,

M.D., Rebecca Evans, M.D., Noll Campbell,

Pharm.D., CGP

Presented By: Malaz Boustani, M.D., M.P.H.,

Regenstrief Institute, Inc., 1050 Wishard

Boulevard, RG6, Indianapolis, IN 46202, Phone:

317-630-7200, Email: mboustani@regenstrief.org

Research Objective: To develop a local and diverse network of dementia researchers, clinical providers, and policy makers who are interested in improving the care for patients with dementia in Indianapolis.

Study Design: The Network uses the Complex

Adaptive System theoretical framework and the

Reflective Adaptive Process to facilitate and sustain effective interactions among its members.

Principle Findings: The Network was established in February of 2006 and it includes

37 active members representing geriatrics, neurology, psychiatry, pathology, neuropsychology, social psychology, nursing, social work, primary care, geriatric pharmacy, health services research, epidemiology, pharmaceutical industry, Alzheimer advocacy, state policy makers, health administration, and biostatistics. These members are affiliated with

12 local organizations. The network uses two types of communication among its members.

The first is a three hour face-to-face meeting that includes all members and is held every two to three months. The second is a project-based workgroup meeting that focuses on a specific task and includes a segment of the network members. Over the past 6 months, the network was able to build a web-based resource center, completed 4 full-day educational seminars on cognitive impairment in a hospital setting, successfully received funding to test a research enrollment process that uses the local

Alzheimer’s Association help line, facilitated the submission of two NIH applications, tested a new group interaction method called

‘‘consultancy’’ and has been able to maintain a

66% attendance rate with an average of three meetings attended per member.

Conclusions: Building a local interdisciplinary

‘‘think-tank’’ network in dementia would facilitate conducting various collaborative research, educational and quality improvement programs that meet the local research, clinical, and community needs relevant to dementia.


Despite substantial quality improvement efforts, numerous best practice guidelines, and excellent clinical and basic research activities over the past three decades, the Institute of Medicine (IOM) identified sub-optimal health care quality, compromised patient safety, and waste in our current health care system. The IOM recommended the need for system thinking and integrated, productive, locally sensitive collaboration among the various members of the local community, health care systems and research organizations. Such collaboration will ensure that 21st century American health care systems deliver safe, effective, patient-centered, timely, efficient, and equitable care.

•

Family Satisfaction with Long-Term Nursing

Home Care: Does Quantile Regression Give

Us a Different Picture?

John Bowblis, M.A., Ph.D. Candidate, Judith A.

Lucas, Ed.D., APN, Stephen Crystal, Ph.D.

Presented By: John Bowblis, M.A., Ph.D.

Candidate, Graduate Assistant, Institute for

Health, Health Care Policy and Aging Research,


Brunswick, NJ 08901, Phone: (732)932-8111, Fax:

(732)932-6872, Email: JBowblis@rci.rutgers.edu

Research Objective: Policymakers and consumers are interested in both upper and lower performers on overall NH satisfaction for selection decisions and targeting quality improvements. We hypothesize there are differences in effects of facility characteristics, particularly in the extreme upper and lower quantiles of NH satisfaction, as has been the case with deficiencies. Current techniques, such

as OLS regression are limited, since they model the relationship between explanatory covariates and the mean of the satisfaction distribution without considering scale or distribution shape.

We use quantile regression to model the relationship between facility characteristics and the upper and lower quantiles of NH satisfaction. QR provides a more complete picture of the effects of explanatory covariates for facilities at different percentiles in the distribution of overall facility satisfaction.

Study Design: Family members of NH residents were asked to rate overall satisfaction using The

Massachusetts Nursing Home Satisfaction

Survey. Facility response rate was 66 percent.

Averaged individual scores for each facility were merged with OSCAR facility data. OLS regression and QR were used to determine factors associated with satisfaction at the facility level.

Population Studied: 12,720 respondents from

288 non-hospital based nursing facilities.

Principle Findings: The facility satisfaction scores for the state ranged from 3.0 to 4.9 out of

5 with both a mean and median of 4.2, SD=

0.30. OLS results indicated smaller, non-chain, nonprofit facilities had higher satisfaction levels.

Other significant facility factors associated with higher satisfaction included higher occupancy rate, greater proportion of private-pay residents, more administrative and CNA staff hours, and lower proportion of residents with pressure ulcers. QR results verified the direction of OLS results, but significance varied depending on the percentile reached by the facility in the state satisfaction distribution. Facility size, nonprofit sponsorship, proportion private-pay, and pressure ulcers were found significant in OLS but were significant in QR only for those facilities scoring above the 50th percentile. Chain membership was associated with a change in satisfaction score of -0.154, p<0.001 points for a facility in the 90th percentile but only -0.045 points in the 25th percentile, p=0.821.

Conclusions: Facility characteristics have differing effects on family NH satisfaction, with strength and significance of associations dependent on the percentile reached in the state satisfaction distribution. We found significant effects of variables in the upper quantile of the satisfaction distribution but not the lower.

Quantile regression may be a useful tool to understand more clearly differences in the effects of explanatory covariates for facilities at different percentiles in the distribution of overall facility satisfaction.


Family satisfaction scores for nursing homes capture unobservable aspects of nursing home quality that cannot be measured using current administrative data such as OSCAR or MDS.

Posting average facility consumer satisfaction scores on a website would provide a selection and monitoring tool for nursing home consumers. However, further methodological work is needed to find the most informative way to report these results. As state and federal governments seek to reduce the information asymmetries about the quality in nursing homes, public reports will need to provide guidance to consumers in how to interpret scores.

Funding Source: Massachusetts Department of

Public Health

• Variations in Safety Culture Perceptions

James Bramble, Ph.D., Robert J. McQuillan,

M.D., Kimberly A. Galt, Pharm.D., Kevin Fuji,

Pharm.D.

Presented By: James Bramble, Ph.D., Associate

Professor, Creighton Health Services Research

Program, Creighton University Medical Center,

School of Pharmacy and Health Professions,

2500 California Plaza, Omaha, NE 68117, Phone:

(402)280-4129, Fax: (402)280-4809, Email: jbramble@creighton.edu

Research Objective: Human error is wellrecognized as one of the leading causes of death and morbidity in hospitalized patients. It is known that efforts to improve the culture of safety through teamwork among a group of highly trained individuals can improve performance through reducing errors. This indepth case study reports on the variation in the perception of health professionals about the safety culture prior to an educational intervention designed to develop a shared set of values, beliefs, attitudes and behaviors.

Study Design: We administered a crosssectional survey to collect data on the patient safety culture in the peri-operative environment.

Central to the data collection efforts was the involvement of key personnel; specially, the Chair of Surgery, the Chair of Anesthesiology, and the

Nurse Director of Preoperative Services. To measure the dependent variable, patient safety culture, we used AHRQ’s Hospital Survey on

Patient Safety Culture. Chi-square analysis was used to determine any significant relationships.

Population Studied: The population for this study is the peri-operative staff which includes surgeons, anesthesiologists, nurses, technicians,

a pharmacist, and others who have an integral part of the culture in that area. We excluded staff who infrequently participate in the patient care unit, who work in multiple patient care units or are absent for substantial periods of time. This represents 159 people who we asked to participate in completing the survey. To date there has been a 64% response rate from this group. Additionally, surgical and anesthesiology residents were invited to participate (n= 61) and

50% have responded.

Principle Findings: When asked to grade the unit from A to E (A is high), on patient safety,

57.78% of the nurses graded the unit a C or D compared to 44% of the physicians. In terms of teamwork within the preoperative area, 28.9% of the nurses had a negative perception of the support for one another within the unit while only 12% of physicians felt that way (p = 0.079).

33.3% of nurses felt that patient safety is never sacrificed to get more work done compared to 72

% of physicians (p<0.001). When asked if the procedures and systems in the unit are good at preventing errors 48.9% of nurses responded favorably compared 68.0% of physicians (p =

0.082).

Conclusions: While the significance of the finings is mixed, we can draw two important conclusions from the data critical to the success of any intervention attempting to improve the culture of safety. First, it appears that there is a distinct discrepancy between the views that nurses hold and those that physicians have.

Second, nurses generally have a lower opinion of the safety culture than do physicians. In order to get everyone to have a shared set of values, beliefs, attitudes and behaviors we must first address the void between nurses and physicians regarding their perceptions of safety.


The premise is that no difference between groups should exist if a shared model of the culture of safety exists. A comparison assessment of culture perceptions between health professionals is essential to learning if a shared safety culture has been achieved.

Funding Source: Health Futures Foundation

• Organizational Characteristics Associated with Quality-related Activities in Federally

Supported Health Centers

Barbara I. Braun, Ph.D., Barbara A. Bartman,

M.D., M.P.H., Ron Hazen, M.P.H., Nicole

Wineman, M.A., M.P.H., M.B.A., Linda K.

Owens, Ph.D., Charles A. Daly, M.H.A.

Presented By: Barbara I. Braun, Ph.D., Project

Director, Division of Research, The Joint

Commission, 1 Renaissance Boulevard,

Oakbrook Terrace, IL 60181, Phone: 630-792-

5928, Fax: 630-792-4928, Email: bbraun@jointcommission.org

Research Objective: To assess the extent and frequency of Health Services and Resources

Administration (HRSA)-supported health center quality-related activities and their association with organizational characteristics.

Study Design: A mailed questionnaire was used to conduct a cross-sectional assessment related to: infection control, risk management, environmental safety, and quality improvement staff resources; diagnostic study follow-up and patient tracking activities; staff training and education; and credentialing, privileging and job performance evaluation. Data were stratified by location (urban or rural), size (large, medium and small) as measured by the distribution of total full time equivalent (FTE) staff and accreditation status.

Population Studied: All eligible 2002 HRSA

Bureau of Primary Health Care-supported health centers (n=831).

Principle Findings: 290 health centers responded (34.9%); including 150 centers accredited by the Joint Commission, 149 rural centers, 140 medium, and 71 small health centers. Slightly more accredited centers responded than non-accredited centers (39.9% to 31.9% p<0.05). The mean (and standard deviation) for the number of FTEs dedicated to quality improvement was 1.2 (sd 1.5), risk management 0.8 (sd 1.5), environmental safety

1.0 (sd 1.6), and infection control 0.6 (sd 1.1).

Eighty-two percent of centers reported they had a consistent method and 92% reported designated staff for determining follow-up from mammograms. Seventy-seven percent reported they had a consistent method for tracking whether patients received care from referred specialists. About 90% required staff orientation on patient safety, patient rights and infection control. More than 75% of clinical staff job evaluations incorporated chart review, direct observation, results of quality assurance activities, patient and staff complaint information and patient satisfaction survey results. Bivariate analysis revealed that accreditation status was associated with the number of staff dedicated to quality improvement activities, risk management and environmental safety; the number of quality improvement projects conducted; the frequency

of inspecting emergency equipment; the consistency of mammogram follow-up; and the immediacy of reporting critical lab values to providers. There were a few differences by location or size, such as number of patient grievances filed and total FTEs. In the multivariate analysis, accreditation status had a positive impact on the frequency with which clinical records were audited, specific credentialing and privileging methods were used, certain review processes occurred, and on the percentage of staff trained on specific topics.

Conclusions: The specific types and frequency of quality----related activities do not vary by health center size and location. In general, there is uniformity of practice and health centers are doing well on most activities. Opportunities to improve care were related to infection control and medication error training. Accreditation affected the frequency of quality improvement projects, training and competency verification, and appears to confer a greater likelihood that centers have specific processes in place designed to improve the quality of care delivered.


This study provides a basis to examine strategies which could support more widespread adoption of activities to assist health centers in integrating ongoing quality improvement into their daily operations.


• Insured Californians Report High

Satisfaction with Health Care

Meghan Cameron, M.P.H., Dylan Roby, Ph.D.

Presented By: Meghan Cameron, M.P.H., Senior

Research Associate, Center for Health Policy

Research, UCLA, 10960 Wilshire Boulevard,

Suite 1550, Los Angeles, CA 90024, Phone: (310)

794-0929, Fax: (310) 794-2686, Email: mecameron@ucla.edu

Research Objective: Research has shown that patient satisfaction with the health care they receive is an important component in addressing quality of care in terms of process, structure, and health outcomes. This study examines the satisfaction of insured individuals by comparing those in HMO plans to those in Preferred

Provider Organizations (PPOs) or Fee-for-Service

(FFS) plans. Furthermore, this study looks at levels of preventive services by insurance plan type to determine whether any discrepancies exist between the groups in accessing health care or receiving necessary services.

Study Design: The data estimate for this study came from the 2003 California Health Interview

Survey (CHIS). CHIS is a random-digit dial telephone survey of households from every county in California, and is representative of the state’s non-institutionalized population. Patient satisfaction was measured using a ten-point scale in which patients were asked to self-rate their health care experience. The patient scoring scales used in CHIS 2003 have been tested in many clinical settings, and were determined to be more reliable than comparable scoring systems (Ware and Hays, 1998). Scores of five or better indicate ‘‘good,’’ ‘‘very good,’’ or

‘‘excellent’’ care. Preventive services such as cancer screening and asthma management were self-reported by respondents who had health insurance and reported visiting a doctor within the past two years.

Population Studied: Insured individuals aged 0-

64 living in California during 2003.

Principle Findings: More than 24 million (96%) insured Californians report ‘‘good’’ to ‘‘excellent’’ satisfaction with their health care, while the

900,000 individuals with ‘‘fair’’ or ‘‘poor’’ satisfaction (3.6%) are more likely to delay seeking medical care and to have experienced problems getting the necessary health care.

Across all insured individuals covered through privately-purchased or employer-based plans,

Medi-Cal, or Healthy Families, HMO enrollees report fair or poor satisfaction with their health care significantly more than individuals in

PPO/FFS arrangements (3.8% vs. 3.3%, p<0.05).

However, when looking at Medi-Cal or Health

Families separately, those in PPO/FFS plans are more likely to report low satisfaction with care than their HMO counterparts, although the two groups are not significantly different (5% vs.

4.2%). Similarly, rates of preventive services are generally high among California’s insured population. CHIS 2003 data show rates of breast cancer screening, colon cancer screening, and asthma management plans that are higher for

HMO enrollees than for those in PPO/FFS plans; PPO/FFS patients have higher levels of prostate cancer screening and daily medication to control asthma. Interestingly, comparing

CHIS data to the Health Plan Employer Data and

Information Set (HEDIS) show that those preventive measures absent from HEDIS are not a priority for HMO plans, as these rates are substantially lower than for the indicators included in HEDIS. For indicators specifically tracked by HEDIS, HMO enrollees have higher rates, while PPO/FFS patients have better rates

for services not tracked by HEDIS (such as prostate cancer screening).

Conclusions: Satisfaction scores and screening rates vary depending on individual insurance coverage. While the majority of individuals

(96%) report a positive health care experience, many of these individuals are not obtaining recommended preventive services for their age group, gender, and/or disease condition.


These findings underscore the need for patients to obtain the proper preventive care for their age group and condition, regardless of HMO or

PPO/FFS plan enrollment. Based on the finding that the preventive services tracked by HEDIS have higher rates of use, expanding HEDIS reporting to include other preventive service measurements may be an efficient way to help increase the use of preventive services for all insurance plans.

Funding Source: California Office of the Patient

Advocate

• A Review and Synthesis of the Cost and

Benefits of the Medical Tort System in the

U.S.

Christopher Conover, Ph.D.

Presented By: Christopher Conover, Ph.D.,

Assistant Research Professor, Center for Health

Policy, Duke University, Box 90253, Durham, NC

27708, Phone: (919) 613-9369, Fax: (919) 684-

6246, Email: conoverc@hpolicy.duke.edu

Research Objective: The central objective of this paper is to develop a comprehensive estimate of the costs and benefits of the medical tort system taking into account its goals of compensating injured victims but also of deterring medical errors.

Study Design: A formal literature search was conducted for literature addressing each of the major impacts of the medical tort system. our search was two-pronged, focused both on the traditional peer-reviewed literature, including

MEDLINE, CINAHL, Health Affairs (full text), ISI

Web of Knowledge, Lexis-Nexis, PAIS,

Dissertation Abstracts and Books in Print using a

1975-2004 publication time-frame. We also systematically explored specified organization

Web sites to locate ‘‘gray’’ literature as needed to fill in gaps. The impacts examined included government regulatory costs (federal and state), industry compliance costs (including malpractice premiums, physician time losses, and compensation paid to victims), indirect effects

(including avoidable defensive medicine, increased patient travel times and the health gains resulting from deterrence) and social welfare losses (including efficiency losses from higher taxes and from industry compliance burdens). For each domain, a synthetic estimate of regulatory costs and benefits was calculated using a standardized procedure that systematically assembles evidence from the literature regarding each of these areas (e.g., morbidity and mortality losses all have been monetized using a common value of statistical life year). Lower and upper bound estimates were derived using minimum and maximum parameter estimates for the various components used to calculate regulatory impacts.

Population Studied: Results apply to the entire

U.S.

Principle Findings: Our final estimate of the

2004 cost of the U.S. medical tort system is

$115.0 billion (minimum=$45.8b., maximum=$185.0b.). The area of greatest uncertainty concerns the costs associated with avoidable defensive medicine ($12 to 147 billion).

Estimated benefits are $35.1 billion

(minimum=$9.8b., maximum=$302.3b.). The area of greatest uncertainty (and least studied of the impacts examined) concerns the medical tort system’s deterrent effects of on the incidence of medical injuries ($0 to $289 billion).

Conclusions: The medical tort system is associated with sizable costs relative to its benefits (in terms of compensating victims and increasing patient safety). This is an area worthy of further research to reduce our uncertainty about the system’s effects. In order for its deterrent benefits to outweigh its costs.The system would have to achieve a 21% reduction in the rate of negligent medical injuries that would otherwise exist were no such system in place.

Implications for Policy, Practice or Delivery: It is beyond the scope of this paper to assess the merits of particular reforms, but it appears tens of billions of dollars in social costs could be avoided were the system reformed. Until and unless researchers can demonstrate a sizable deterrent effect, the case for making such reforms will persist.

• Dance of the Call Bells: Using Ethnography to Evaluate Patient Satisfaction with Quality of Care

Lynn Deitrick, R.N., Ph.D., Joanna Bokovoy, R.N.,

Dr.P.H., Anne Panik, R.N., M.S., CNAA

Presented By: Lynn Deitrick, R.N., Ph.D.,

Medical Anthropologist/Ethnographer, Health

Studies, Lehigh Valley Hospital and Health

Network, 17th & Chew Streets, PO Box 7017,

Allentown, PA 18105, Phone: 610-969-2293, Fax:

610-969-2247, Email: Lynn.Deitrick@lvh.com

Research Objective: To understand the role patient call bells play in patient and staff perceptions about quality of care and patient satisfaction.

Study Design: Ethnographic research was conducted by hospital ethnographer on a 36 bed medical-surgical unit over a 3 month period. 60 hours of observation were conducted over all 3 shifts. 23 in patients, 9 family members and 17 staff members were interviewed. Unit maps were developed and photographs were taken to provide additional data.

Population Studied: In-patient med-surgical unit including staff, patients, and their families.

Principle Findings: Call lights were the most frequently cited concern among patients interviewed. Patients reported that delays in getting call bells answered were common and were also concerned about the amount of time it took to carry out their requests once the light was answered. Some patients reported they never got what they asked for once the light was answered. Staff interview data suggests that there is disagreement among staff about whose responsibility it was to answer patient call lights.

Communication through call bells consisted of 3 interrelated components that had an impact on the efficiency of communication between patients and unit staff. These included 1. answering the call bell, including who answered, where it was answered and how long it took for someone to respond 2.communicating the patient’s request, included telling the right person about the request and 3.following through with the request- doing what the patient asks in a timely manner. Nurses were eager to hear the results from this research. They took ownership of this issue and brainstormed ideas about how to improve this aspect of patient care.

Results provided a deeper understanding of the nuances of power and control embedded within the issue of patient-caregiver communication and empowered unit staff to find solutions to the call bell problem.

Conclusions: Call bells are an integral part of the patient experience. Call bells and requests to staff remain one of the few ways that patients can exercise control over their care and their existence on the unit. This research also demonstrates the value of ethnographic methods as measurements tools in capturing insights into clinical issues related to quality and patient satisfaction. Ethnographic methods provided an in-depth understanding of the multiple facets of communication on the inpatient unit via call bells in more detail than a survey alone would provide .


Nurses and administrators should understand that the call bell is the patient life-line, and failure to promptly answer and follow through on patient requests via call bells can impact patient safety as well as judgments patients make about satisfaction with care.

Ethnography was used in this research to identify clinical problems and provide understanding of the problem from the perspective of multiple stakeholders. This research also provides an example of how to deploy ethnographic methods in the clinical setting, and can be replicated by researchers at other institutions.

•

Quality of Care in a Community-Based

Oncology Practice: A Pilot Case Study

Daniel Dohan, Ph.D., Karen Rappaport, M.D.,

Ph.D., Peter Eisenberg, M.D.

Presented By: Daniel Dohan, Ph.D., Asst

Professor, Inst for Health Policy Studies, UC San

Francisco, 3333 California St. Suite 265, San

Francisco, CA 94118, Phone: 415-476-0751, Fax:

415-476-0507, Email: daniel.dohan@ucsf.edu

Research Objective: To conduct an exploratory study of how quality of care is understood and how it should be measured in a communitybased oncology practice.

Study Design: Mixed-method including quantitative analysis of medical records and ethnographic analysis of delivery. We used Stata

(version 8.2) to analyze a retrospective database of medical records of patients who died between

2000-2003 (n=677) regardless of date of cancer diagnosis. We collected qualitative data during 1-

2 days per week of observation starting in June,

2006 and via open-ended interviews with patients. We used standard ethnographic methods to record fieldnotes, voice-recorded interviews, and entered all data into qualitative data analysis computer software to code and identify themes of interest.

Population Studied: A community-based practice of 4 oncologists treating 650 new patients and providing 9100 office visits per year.

Principle Findings: Quantitative findings suggest that treatment patterns are fairly consistent among providers within the study practice. For example, all providers within the practice had similar probabilities of treating non-

small cell lung cancer (NSCLC) patients, of which there were 124 in the data base, with a platinum-based chemotherapy (29.4% to 52.4%; p=0.85) ---- a pattern of care conforming to published guidelines. Qualitative data suggests that overall similarity in care provided masks differences in styles of care apparent in observation and reported in interviews. For example, direct observation and reports from providers and patients all showed substantial variation in how providers discussed treatment options and prognosis with patients. The practice used various formal (i.e. meetings and written forms) as well as informal (i.e. casual conversations) mechanisms to coordinate care.

Providers (and patients) reported a range of views regarding the utility of formal mechanisms to coordinate care; there was consensus that the informal processes for coordinating were valuable and effective.

Conclusions: While a single case study is not generalizable, it suggests some of the factors that should be considered in translating results from large-scale studies ---- for example, about types and patterns of over- or under-treatment ---- into quality-improvement efforts within individual community-based oncology practices.

Medical records provide insights into what care was provided while qualitative data reveals how care was delivered and potential mechanisms for change. Future mixed-method case study research should examine the generalizability of these findings.


Defining and measuring the quality of cancer care has received increasing attention in recent years, notably from the National Initiative on

Cancer Care Quality (NICCQ) and Quality

Oncology Practice Initiative (QOPI), large studies that share a common goal of improving quality of care at the practice level. This study provides aid in interpreting and implementing findings from NICCQ and QOPI by examining issues these larger studies are not designed to address such as: How closely does the practice and do individual providers adhere to accepted treatment guidelines? Is it possible to characterize patterns of care for the practice as a whole, or is there substantial variation in patterns of care among providers within a single practice? What social and organizational mechanisms shape similarities and differences between providers within a single practice?

Funding Source: Foundation for Integrative

Oncology

• Improving the Patient Experience: Results

From a Physician Collaborative

Kelle Eason, M.P.H., Kelle Eason, M.P.H., Neil

Solomon, M.D.

Presented By: Kelle Eason, M.P.H., Healthcare

Data Analyst, Scientific Analysis, Lumetra, 1

Sansome Street, San Francisco, CA 94104,

Phone: 415-677-2168, Fax: 415-677-2191, Email: keason@caqio.sdps.org

Research Objective: This paper describes the development and delivery of ‘Improving the

Patient Experience’, a collaborative project which assists 12 California physicians to make improvements in physician-patient communication, coordination of care, and timely access and service. We will demonstrate how a planned training curriculum and regular feedback to practices can have measurable effects on patient satisfaction, and how those improvements can strengthen the business of physician practices.

Study Design: Four Independent Physician

Associations (IPAs) in California recruited 12 physicians: nine Primary Care physicians

(including one Pediatrician), two OB-GYNs, and one Dermatologist. Each physician was matched to a control on IPA affiliation, baseline performance scores, the specialty, age, and gender of the physician, and the location and practice size. There are two evaluation phases to the project- a survey at the end of the collaborative and a survey 6 months post collaborative- for both the participating and control physicians. Physicians will be evaluated on the key measures in each of the domains adapted from the California statewide Patient

Assessment Survey. A baseline measurement will reflect visit dates prior to any interventions implemented. A random sample of patients will be surveyed until 30 completed surveys per physician are collected for baseline, end of collaborative and 6 months post collaborative measurements. The surveys are conducted by a voice response system using a standard script administered by an experienced third party vendor. The intervention consists of a 12-month intensive training program developed by national experts and accessed by participants through a combination of on-site meetings and teleconferences. Practices are taught to use rapid cycle tests of change to make accelerated improvements in the three domains. In addition, participants receive routine feedback through a monthly survey on a sample of their patients.

Population Studied: All patients of the participating physicians and their matched controls are eligible for the patient survey if they had a visit date during the period of interest.

However, once a patient participated in the survey, they were ineligible for future participation, so that no patient was surveyed twice, regardless of subsequent visits to the same physician.

Principle Findings: Data from baseline and five monthly measurement cycles have been collected. Statistically significant improvements have been observed among the intervention group (in aggregate) in Overall Rating of Care and Care Coordination. Highly engaged practices have shown accelerated improvements in most measures. Data collection will be completed in

March 2007, with the exception of the six months post-collaborative survey.

Conclusions: Preliminary results of intervention doctors’ performance compared to baseline indicate that participation in an intense training program demonstrates significant improvement in patient experience scores for highly engaged physicians, some or little improvement for moderately engaged physicians, and no improvement for physicians with low engagement.


We know of no other intensive collaborative shown to improve patient satisfaction that has demonstrated success under controlled conditions. Although preliminary, this program may represent the first reproducible practicelevel intervention that improves patient satisfaction with care.

Funding Source: CWF

• Transitions in Care: Communication During

Handoffs

Joan Fitzmaurice, R.N., Ph.D., Theresa Gallivan,

M.S., R.N., Michele Williams, Ph.D., John Carroll,

Ph.D., Carol Camooso Markus, R.N., M.S., Katie

Farraher, B.A.

Presented By: Joan Fitzmaurice, R.N., Ph.D.,

Director, Office of Quality & Safety,

Massachusetts General Hospital, 55 Fruit Street,

VBK 619, Boston, MA 02114, Phone: (617) 726-

5255, Fax: (617) 726-4304, Email: jfitzmaurice@partners.org

Research Objective: Untoward events in acute care settings often involve communication failures, with the potential to negatively affect both the quality of patient care and patient safety. The main objectives of the major study are to: understand characteristics of technical and relational communication during handoffs; describe the adequacy of the handoff; and examine feasibility and generalizability of the methods and procedures. This presentation focuses on technical or clinical communications.

Study Design: This observational study utilized qualtitative and quanitative methods. Eighty handoffs between nurses at change of shift on one medical unit were observed and audiotaped.

Nurse completed a brief survey of handoff experience. An advanced practice nurse (APN) reviewed patient records. A structured tool was developed, field tested, and utlized to abstract relevant clinical information for listing of active clinical issues. The APN analyzed the handoff transcript, and rated each clinical issue on 3 point adequacy scale. To insure interrater reliabiity, a second APN reviewed transcript and adequacy rating. Thirteen handoffs were identified for further analysis, and agreement achieved through discussion. Patient acuity and unit workload were used to approximate patient complexity and unit activity. An 80 item survey examining relational behaviors was administered at the beginning of the study period,and a 10 item rating of handoff quality was completed immediately following the shift report by both incoming and outgoing nurse. Two advanced practice nurses reviewed the handoffs for adequacy with acceptable rater reliability

Population Studied: Twenty six nurses participated in the study, average experience 2-5 years. Patients were complex, with greater than

90 per cent requiring high level nursing care for medication, fluid, pulmonary, cardiac managment, assistance with activities of daily living and active educational needs.

Principle Findings: The mean handoff duration was 5.4 minutes, with range of 1-12. Mean questions asked during handoff was 7.2, ranging from 2-27. Twenty-four per cent of handoffs judged adequate, 34 percent insufficient, the remainder were patients known to incoming nurse. Two hundred sixty three active clinical issues were identified from the medical records.

Patients had a mean of 4 active issues, ranging from 2-6. Sixty-seven percent of the issues were mentioned during handoff. Management of problem and next steps discussed in 70 and 76 percent of problems respectively. Interestingly

RN's rated effectiveness of handoffs 6.7, positivity 6.6, and information availability 5.9 on

7 point scale.

Conclusions: These findings are important to begin to understand what happens during this important phase of transitions in care between

providers. Early results suggest that while two thirds of problems were communicated to the incoming nurse, about one-third were not.

Further analysis is focusing on examining characteristics of the non-communicated clinical issues and their management, as well as the apparent incongruity between nurse perception of handoff and actual adequacy. We will also be exploring potential relationships between handoff adequacy and nurse experience.

Although the methods utilized to capture handoff information were effective, we are concerned about the intrusiveness of such data collection on the natural environment as well as the resources required for observation, data abstraction, and further analysis. This observational approach may have limited application.


Because existing research lacks structured methods for describing technical communication in a health care context, our inital exploratory study focused on development of methods and measures. Patterns of behaviors most related to effective communication will assist in further educational and policy efforts.

Funding Source: Risk Management Foundation,

MIT Grant

• Associations Between Outcomes Reflecting

Quality of Care and Medicare's Hospital

Compare Quality Measures

David Foster, Ph.D., M.P.H., Sivana T. Heller,

M.D., M.P.H.

Presented By: David Foster, Ph.D., M.P.H.,

Chief Scientist, Center for Healthcare

Improvement, Solucient, a Thomson business,

5400 Data Court, Suite 100, Ann Arbor, MI

48108, Phone: (734) 669-7982, Fax: (734) 930-

7611, Email: dfoster@solucient.com

Research Objective: To evaluate the extent to which hospital performance on Medicare's

Hospital Compare Quality Measures is associated with better performance on other important quality indicators, such as inpatient mortality, complications, patient safety outcomes, and mean length of stay.

Study Design: Cross-sectional study of hospital inpatient care during calendar year 2004.

Quality measures from the Hospital Compare

Web site were matched with Solucient 100 Top

Hospitals data containing measures of riskadjusted in-hospital mortality, complications, patient safety, and average length of stay among

Medicare inpatients.

Population Studied: Medicare medical and surgical patients, age 65 and older, in short-term, acute-care hospitals.

Principle Findings: A total of 3,827 hospitals were available for study after matching the

Hospital Compare and Solucient 100 Top

Hospitals data. General linear models that were specific to Quality Measure (e.g., beta blocker at arrival) and Clinical Group (e.g., Heart Attack;

Pneumonia) produced 33 results that were statistically significant. Hospitals with better performance on seven Heart Attack Quality

Measures had associated better performance on one or more of the following outcomes: mortality, patient safety, and length of stay

(p<0.0001 to p=0.045). Better performance on

Heart Failure Quality Measures, with the exception of assessment of left ventricular function, was associated with better performance on mortality, complications, patient safety, and length of stay (p<0.0001 to p=0.0239). Better performance on all five of the Pneumonia core measures was associated with better performance on one or more of the following outcomes: mortality, patient safety, and length of stay (p<0.0001 to p=0.0470). Finally, better performance on one Surgical Care Improvement

Quality Measure, ‘‘Prophylactic antibiotics discontinued within 24 hours after surgery end time,’’ was associated with a better patient safety outcome (p=0.0043). Further analyses of two clinically specific groups, heart attack and heart failure, produced similar findings, in that better performance on core measures was significantly associated with lower risk-adjusted rates of mortality, patient safety adverse outcomes, and mean length of stay.

Conclusions: These results support the hypothesis that good hospital performance on specific quality measures may correlate significantly with better performance in general on important quality outcome measures, such as mortality, complications, patient safety outcomes, and average length of stay.


Hospital performance measures are useful predictors of quality of care.

Funding Source: Solucient,

• Evaluation of Quality Performance

Outcomes of the Managed Care

Organizations and Prepaid Inpatient Health

Plans that Provide Healthcare Services to the

Puerto Rico Medicaid Managed Care Plan

Enrollees

Hector Garcia Maldonado, M.P.H., Migdalia

Lugo, B.B.A.

Presented By: Hector Garcia Maldonado,

M.P.H., Director, Planning and Clinical Affairs,

Puerto Rico Health Insurance Administration, P

O Box 195661, San Juan, PR 00919-5661, Phone:

(787)474-3300, Fax: (787)474-3346, Email: hgarcia@ases.gobierno.pr

Research Objective: To evaluate the appropriateness or quality of care of the

Medicaid Managed Care plan related to the access and promptness to services, and outcomes of care provided by the Managed Care

Organizations (MCO) and Prepaid Inpatient

Health Plans (PIHP) during the fiscal year 2002 through 2005.

Study Design: Quality assessment and performance improvement analysis were done focused on clinical management, medical record review and provision of preventive services at the

Independence Practice Association level (IPA).

In addition, medical record review was performed considering a sample of 3,500 records. Performance measures were obtained from the National Committee on Quality

Assurance (NCQA) regarding the Health

Insurance Employer Data Information Set

(HEDIS) on effectiveness of care, access/availability of care and use of service.

The analysis was performed by an External

Quality Review Organization (EQRO) as required by the Federal regulation under 42 CFR 438.358.

Population Studied: A total of 31,103 medical records of the beneficiaries of the Government

Health Insurance Plan were reviewed that represent 93,609 visits at the primary care level reaching services provided by approximately

1,203 Primary Care Physicians distributed in the eight health regions of Puerto Rico.

Principle Findings: Medical record review shows that physical exam was performed on 51% of the enrollees. Nearly 98% of Medicaid enrollees had and needed a referral service. The review shows that only 36% of physicians at the

IPA level documented the medical record. Only

10% provided preventive services according to

Early Prevention and Screening Diagnostic Tests

(EPSDT) requirements. In addition, 85% demonstrated an appropriate management of the enrollee health condition according to the

Department of Health Clinical Practice

Guidelines. Three out of four enrollees felt satisfied with the mental health services provided by the Managed Behavioral Healthcare

Organization (MBHO; i.e., APS). All HEDIS measures for Puerto Rico MMC plan are below the national benchmark percentiles and averages; for example, cervical cancer screening is 35% for Puerto Rico while in the U.S. is 62% for measurement years 1997 to 2003.

Conclusions: State Medicaid Office and its agent, Puerto Rico Health Insurance

Administration refocused the quality assessment and performance improvement program.

Corrective and preventive action plans have been requested at the MCO and IPA level to develop improvement strategies regarding the medical record documentation and increase the delivery of preventive services according to the EPSDT requirements.


Currently an implementation plan is in place to address the new focus of the quality program at the MCO and PIHP level to comply with Federal and State regulations.

Funding Source: CWF

•

Improving Hospital Performance on

National Measures of Smoking Cessation

Counseling

Joanne Hafner, R.N., M.S., Scott C. Williams,

Psy.D., David J. Morton, M.S., Richard G. Koss,

M.A., Jerod M. Loeb, Ph.D.

Presented By: Joanne Hafner, R.N., M.S.,

Associate Project Director, Health Policy

Research, The Joint Commission, One

Renaissance Boulevard, Oakbrook Terrace, IL

60181, Phone: (630)792-5970, Fax: (630)792-

4970, Email: jhafner@jointcommission.org

Research Objective: Evaluate the impact of a

Joint Commission intervention designed to help lower-performing hospitals improve their performance on three nationally-standardized measures for smoking cessation counseling for patients with acute myocardial infarction, heart failure, or pneumonia.

Study Design: Chief Executive Officers in the intervention group received a letter and tool-kit from The Joint Commission, designed to encourage and assist hospitals improve smoking cessation counseling practices. The letter included a brief description of the study, hospital measure rates, and a statement that performance would be tracked by the Joint

Commission. The tool-kit included a series of evidence-based recommendations and journal articles supporting and outlining smoking

cessation counseling improvement practices, a list of smoking cessation websites, and additional resource materials. The control group received neither the letter nor tool-kit. On-site interviews were conducted at 14 hospitals following the measurement data collection period.

Population Studied: Two hundred and ten Joint

Commission-accredited hospitals with smoking cessation counseling performance measure rates in the lowest national quartile for at least one of three measures for two consecutive quarters, fourth quarter 2004 - first quarter 2005, were identified and randomly assigned to either an intervention, n= 99, or control, n=99, group.

Hospitals with fewer than 20 cases per measure per quarter were excluded. Twelve additional hospitals, affected by Hurricane Katrina, were also excluded.

Principle Findings: By first quarter, 2006, no statistically significant differences were observed in performance measure rates between the intervention and control group. Both the intervention and control goups, however, showed statistically significant improvement from baseline for all three measures, p<0.05.

Over nine months, performance measure rates improved, on average, 19, 29, and 30 percentage points from baseline for acute myocardial infarction, heart failure, and pneumonia measures, respectively. Of the 99 hospitals in the intervention group, 14 improved their performance measure rates by over 50 percentage points, while rates at 6 hospitals deteriorated from baseline. On-site interviews revealed that many hospitals had instituted changes well before receiving the materials.

Several participants reported that the materials would have been useful, and could have accelerated their improvement efforts, had the study been conducted earlier. Hospitals reported that the resource materials' recommendations frequently mirrored and reinforced their own program's activities.

Interviews also suggested that hospitals adopting smoke-free campus policies were more committed to providing smoking cessation counseling services than other hospitals.

Conclusions: The hospital quality measurement environment is a dynamic one, which includes public reporting of hospital data by the Joint

Commission and Centers for Medicare and

Medicaid Services, as well as highly visible payfor-performance initiatives. Within that context, neither the letter nor resource materials had a measurable impact on performance measure rates. The letter and resource materials may have been more useful had the study occurred earlier in the measure implementation timeline.


As new national quality measures are developed and implemented, evidence-based resource materials should also be developed and made available to hospitals.

Funding Source: The Smoking Cessation

Leadership Center, University of California, San

Francisco

• Surgeon Volume, Operative Mortality and

Quality of Care

Amresh Hanchate, Ph.D., John D. Birkmeyer,

M.D.

Presented By: Amresh Hanchate, Ph.D.,

Research Associate, General Internal Medicine,

Boston University School of Medicine, 720,

Harrison Avenue, Suite 1108, Boston, MA 02118,

Phone: 617-638-8889, Fax: 617-638-8026, Email: hanchate@bu.edu

Research Objective: For many surgical procedures, apparent surgeon volume-outcome relationships may reflect systematic differences in quality of care as well as patient severity. As important patient severity differences may be unobserved, we use hospital-level fixed effects

(FE) regression to estimate the relationship between operative mortality and surgeon volume, and compare results with those from more commonly used random effects (RE) regression.

Study Design: A voluminous literature strongly suggests that for many surgeries, low-volume surgeons have higher operative mortality compared to their high-volume counterparts. To what extent does this protective volume-effect reflect better quality for care? This is largely unknown since most of this literature rests on

RE models that fail to allow for systematic hospital-level differences in unobserved i) patient severity , and ii) process of care differences. For instance, if high-volume hospitals attract a disproportionately larger share of sicker patients then the surgeon volume-effect is likely to be underestimated, if a greater proportion of highvolume surgeons are in high-volume hospitals.

In FE regression, surgeon volume effect is estimated by limiting comparisons across surgeons within same hospitals, thereby adjusting for systematic unobserved hospitallevel differences. These estimates are compared with RE model that captures 3-level hierarchical nesting (patients, surgeons and hospitals).

We examine five cardiovascular procedures

(coronary artery bypass graft, aortic/mitral heart valve replacement, carotid endarterectomy, lower-extremity bypass, elective repair of abdominal aortic aneurysm) and four cancer resections (colectomy, nephrectomy, lobectomy). Operative mortality rate per 100 surgeries for each surgeon in each hospital is the outcome measure. Surgeon volume is measured in tertiles. Other covariates are patient demographics, diagnoses-based morbidity and area-level income. Regressions estimated excess operative mortality for low and medium volume surgeons relative to high volume counterparts.

Population Studied: We study a total of 644,839 surgeries from data based on 100 percent of inpatient Medicare Fee for Service data for 1998 and 1999.

Principle Findings: a) High-volume surgeons were more likely to be in high-volume hospitals, and low-volume surgeons and low-volume hospitals. 52% of high-volume (highest volume tertile) surgeons were in high-volume (highest tertile) hospitals, while only 5% were in lowvolume (lowest tertile) hospitals. In contrast, only 15% and 55% of low-volume surgeons were in high-volume and low-volume hospitals respectively. b) For eight of the nine procedures, low volume surgeons had higher operative mortality relative to higher volume surgeons. In all eight cases FE estimates indicate larger excess mortality rate from low volume surgeons compared to RE estimates ---- for carotid endarterectomy this is 1.8% (FE) vs. 0.9% (RE); for lower-extremity bypass FE=3.5% and

RE=1.8%; and for nephrectomy FE=2.2% and

RE=1.5%. c) Estimates of residual mortality by hospitals suggest the presence of systematic unobserved factors that result in lower-thanexpected operative mortality among low volume providers ---- plausibly due to more complicated patients going to higher volume hospitals.

Conclusions: Lower surgeon volumes are associated with substantially higher excess operative mortality than previously estimated.


While low-volume surgeons have even greater operative mortality compared to high-volume counterparts than previously estimated, there is also evidence that sicker patients are less likely to go to low volume providers. Therefore some of the potential gains from regionalizing surgical care have already been realized.


• Measuring Clinicians' Patient Centered Care

Attitudes, Practices and Related

Organizational Factors in Military Hospitals

Margarita Hurtado, Ph.D., M.H.S., San Keller,

Ph.D., Chris Evensen, M.S., January Angeles,

M.P.P., Erica Eisenhart, B.S., Kimberly Williams,

Ph.D.

Presented By: Margarita Hurtado, Ph.D.,

M.H.S., Principal Research Scientist, Health

Policy and Research, AIR, 10720 Columbia Pike,

Ste 500, Silver Spring, MD 20901, Phone: (301)

592-2215, Fax: (301) 593-5791, Email: mhurtado@air.org

Research Objective: To develop a valid and reliable instrument to assess clinicians’ patient centered care (PCC) attitudes and practices, and organizational factors that might affect its delivery in military hospitals.

Study Design: A literature and survey instrument review were used to define the construct and identify existing items. Key informant interviews and focus groups with physicians and nurses were used to refine the construct. We drafted an initial set of 88 items on attitudes, practices and opinions on barriers to PCC, designed as 5-point Likert scales

(agree/disagree scales for attitudes and opinions, and never/always scales for reports).

Cognitive interviews were used to test comprehension. A revised version of the 66-item survey was piloted. Responses were analyzed to examine item quality and distribution. Inter-item correlations, exploratory factor analyses and internal consistency reliability were used to define and assess the properties of scales regarding PCC attitudes, practices and barriers.

Stepwise linear regression analyses were used to examine construct validity and potential associations among the variables of interest.

Population Studied: We held focus groups with physicians and nurses at 3 MTFs in TRICARE’s

North Region. The survey was piloted with 186 clinicians at 17 Army and Air Force hospitals, representative of all MTFs with respect to size, region and service branch. 79% of clinicians were active duty and 21% were civilians; 28% were physicians, 72% were RNs.

Principle Findings: Exploratory factor analyses indicated that a subset of items proposed to measure PCC attitudes (10), and PCC practices with respect to the clinician-patient relationship

(5) and shared decision making (9), display good psychometric properties. The three proposed scales have acceptable levels of internal consistency reliability (alpha = 0.75 to 0.93). We

also examined 2 potential 5-item scales related to potential organizational barriers to PCC-----management of work and military culture------but internal consistency reliability estimates were borderline (alpha = 0.70 to 0.72).

Conclusions: The PCC survey of clinicians at military hospitals displays promising measurement properties with respect to the assessment of both attitudes and practices regarding patient centered care and identified variations in one or both of these areas across

Army and Air Force clinicians, as well as active duty and civilian clinicians. Barriers to PCC were identified at the item level but not at the scale level. A high level of specificity is required to identify potential areas for improvement, so we recommend that all items on PCC barriers be retained until further evidence can be accumulated.


PCC is essential to high quality care. This survey provides a means of identifying clinician attitudes and organizational factors that can affect PCC and could be targets for quality improvement. It can also be used to assess delivery of PCC from the clinician's perspective.

To our knowledge, it is the first such instrument developed, and an important complement to patient reports of their experiences with care.

Further testing is needed to examine its measurement properties in civilian hospitals.

Funding Source: TRICARE Military Activity- DoD

•

Effective Disclosure of Medical Accidents to

Deter Dispute: Hypothetical Vignette Studies

Hiroo Ide, M.A., Hideo Yasunaga, M.D.,

Tomoaki Imamura, Ph.D., Kazuhiko Ohe, Ph.D.

Presented By: Hiroo Ide, M.A., Assistant

Professor, Department of Planning, Information, and Management, The University of Tokyo hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-

8655, Phone: 81-3-5800-5716, Fax: 81-3-5800-8765,

Email: idea-tky@umin.ac.jp

Research Objective: A ‘full-disclosure policy’ is considered as an effective measure to deter medical disputes, however, few studies have been conducted on the contents of disclosure.

This study aimed to clarify how both the contents of disclosure and the subject’s characteristics might contribute to deterrence of dispute in 3 clinical settings: accidents in childbirth (CB), misdiagnosed thoracic aortic aneurysms (TAA), adverse drug event (ADE).

Study Design: We prepared hypothetical vignettes to describe adverse events, and conducted a survey via the Internet. The vignettes included the following 6 or 7 factors as disclosure components: (1) presence or absence of disclosure; (2) who discloses; (3) admittance of responsibility; (4) offer to waive medical costs;

(5) apology; (6) cooperation to obtain a second opinion; and (7) severity. Each factor had 2 options. Subjects were provided one vignette from 65 to 130 possible combinations at random and asked questions on physician’s responsibility (Question 1), on what their reaction might be as a patient/family member

(Question 2), and their characteristics.

We performed Chi-square tests and logistic regression analysis. All statistical analyses were conducted using the SPSS version13.0 software

(SPSS Ltd., Chicago, USA). A p value less than

0.05 was considered to be statistically significant.

Population Studied: We sampled men and women from approximately 230,000 panel members, aged 30 to 39 y for CB and 40 to 59 y for TAA and ADE, using stratified random sampling. An e-mail requesting participation was sent to 660, 1,620 and 1,320 subjects, respectively.

Principle Findings: The response rates were around 30% for each setting. When the truth was not disclosed, a significantly higher proportion of subjects held the physician responsible in all clinical settings (Question 1). The rate of ‘‘I will claim’’ answer in CB and TAA was significantly higher in subjects who didn’t trust in medicine

(Question 2).

Logistic regression analysis for Question 1 showed that ‘‘presence or absence of disclosure’’ was the most significant factor affecting subjects’ responses for CB and TAA. The subjects’ responses for Question 2 significantly depended on ‘‘who disclosed’’ for CB and TAA.

Another significant factor was gender, however, its significance depended on clinical settings. On the other hand, ‘‘Apology’’ was not a statistically significant factor in each hypothetical setting.

Conclusions: This study demonstrated that physicians could improve relationships with patients and families by disclosure, and deter disputes. Moreover, the absence of an apology didn’t affect the hypothetical patient/family response, and this finding may relieve physician’s psychological resistance to disclose medical accidents. More studies are required to clarify the ‘who, what, when, and how’ of disclosure in specific clinical settings.


This finding supports a full disclosure policy. The current thinking of physicians is that this policy is an efficient deterrent to disputes, but their opinions are based simply on anecdotal evidence. This study will be used as evidence when we discuss policies on medical dispute resolution.

Funding Source: The Ministry of Health, Labor, and Welfare, Japan

• Consumer Assessment of Hospital

Services: Focus Group Discussion with

Patients from Tertiary Hospitals and the

Public Hospitals in South Korea

Minah Kang Kim, Ph.D., Eunkyung Kim, Ph.D.,

R.N., Yoon Kim, M.D., M.A.

Presented By: Minah Kang Kim, Ph.D., Assistant

Professor, Public Administration, Ewha Womans

University, Daehyun-dong, Seodaemun-gu,

Seoul, Phone: 821062614725, Email: minahkang@ewha.ac.kr

Research Objective: As an effort to improve quality of hospital services, Korean government recently started a national program to evaluate hospital performance. Conducting a patient survey is an important part of the program, which intends to reflect patients’ perspective in the evaluation efforts. This study was conducted to guide development of consumer assessment survey tool to evaluate patient experiences during hospitalization. We asked patients which domains of hospital quality should be included in the patient evaluation of hospital services and which ones are most important for the patients.

We also investigated whether opinions varied between the patients who stayed at tertiary hospitals and those from the public hospitals. In addition, we intended to find various qualitative aspects of patient experiences that are not usually derived from structured patient surveys.

Study Design: Six focus groups were conducted in three cities of South Korea. Group discussion was focused on various aspects of medical services that patients experienced during hospitalization. In addition to moderated discussions, patients also completed a card sorting exercises that asked them to rank 27 survey items in order of importance in evaluating quality of medical services. Each discussion lasted about 2 hours. We analyzed the transcribed interviews using grounded theory methodology. Two investigators independently coded and resolved disagreements by consensus.

Population Studied: A total of 36 patients who have recently been hospitalized were recruited.

Groups were organized to be homogeneous in terms of hospital types: Three groups were consisted of patients who were hospitalized at the tertiary hospitals and the rest had inpatient stays at the public hospitals. Groups were structured to be heterogeneous with respect to age, gender, and educational attainment.

Principle Findings: Various aspects of hospital services were identified by the participants.

Regardless of hospital types, items that were identified as important in evaluating the quality of hospital services were closely congruent with domains that were included in the HCAHPS surveys, rather than domains that were included in the current patient surveys that have been used in Korea. While patients with hospitalization experiences at tertiary hospitals and those at the public hospitals consistently emphasized that communication with doctors and nurses was the most important domain in evaluating the hospital services, patients from the public hospitals expressed deep concerns on structural features of the hospital as well as cleanliness of the hospital room and bathroom.

While patients from the public hospitals reported that proximity is also important in choosing the hospitals, participants in general agreed that opinion of other patients was an important guidance for their choice of hospitals.

Conclusions: Regardless of hospital types and patient characteristics, patients consistently reported that doctor communication with patients is most important in defining the quality of medical care services during hospitalization.

Patients from the public hospitals had more specific concerns and complaints about hospital facility and cleanliness.


All together, these results showed that despite the stark differences in medical culture and health delivery system between South Korea and the US, the HCAHPS seemed to reflect Korean patients’ interest and preferences in evaluating hospital services better than current patient surveys. Further research is warranted to evaluate the reliability and validity of HCAHPS when it is applied to patients in South Korea and to the patients from the public hospitals in particular.

Funding Source: Korean Ministry of Health and

Welfare

• Post Hysterectomy Hematocrit: A Learned

Routine or Clinically Useful?

Sharon Kimmel, Ph.D., A.S.C.E., Sharon R.

Kimmel, Ph.D., ASCE, Craig Koller, M.Ed.,

Patrice Weiss, M.D., F.A.C.O.G.

Presented By: Sharon Kimmel, Ph.D., A.S.C.E.,

Sr. Research Scientist, Health Studies Unit,

Lehigh Valley Hospital & Health Network, 17th &

Chew Sts, Allentown, PA 18013, Phone: 610-969-

2498, Fax: 610-969-2247, Email: sharon.kimmel@lvh.com

Research Objective: 1.Identify clinical parameters supporting/negating need of routine post-hysterectomy complete blood count (CBC) draw for hematocrit evaluation. 2.Compare differences in pre, intra, and post-operative clinical indicators for blood transfusion.

3.Propose clinical predictive parameters for posthysterectomy CBC ordering.

Study Design: Retrospective case-control.

Review of 230 cases randomly selected out of 871 hysterectomies. Potential predictor variables collected: 1)characteristics: age, height, weight, history of cardiovascular disease, previous abdominal/pelvic surgery; 2)pre-operative: hemoglobin/hematocrit, vital signs; 3)intraoperative: surgical duration (incision to closure), hysterectomy type, fluid intake/output, estimated blood loss (EBL); 4)post-operative: serial hemoglobin/hematocrit, vital signs, intake/output, length of stay. Patients receiving a blood transfusion post hysterectomy

(Transfused) were compared to those who did not receive a transfusion (Non-Transfused) using chi-square or t-test. Discriminate analysis used Receiver-Operating-Characteristic (ROC) curve. Cut-off values were identified to maximize sensitivity. Sensitivity, specificity, positive/negative predictive-values, odds-ratio were calculated for proposed clinical predictive parameters. P-value <=0.05 were considered statistically-significant (SS).

Population Studied: Patients receiving hysterectomy at an 845-bed academic, community hospital during January 2004-June

2005.

Principle Findings: Demographics described sample mean age 49.83B111.35, BMI 29.11B17.50, and predominantly white (87.2%). 35.5% (82) indicated history of cardiovascular-disease and

60.8% (140) indicated previous abdominal/pelvic surgery. Transfusion-rate was

10.4% (24), excluding oncology cases rate was

7.8% (14). Hysterectomy type was 65.6 (151) abdominal, 18.7% (43) laparoscopic and 152%

(35) vaginal. No SS in demographic or hysterectomy type.. Pre-surgery: Transfused had lower: hematocrit (36.25B14.35) than Nontransfused (39.09B14.90) p=0.001; hemoglobin

(11.77B11.59), Non-transfused (13.17B11.60) p=0.001 and higher heart-rate (86.68B179.69) than Non-transfused (86.68B113.81) p=0.011.

No SS difference in systolic/diastolic bloodpressure (Transfused

124.91B119.32/71.45B113.86; Non-transfused

130.88B120.45/73.12B112.07; p=0.192, 0.546 respectively) Intra-surgery: Transfused had higher EBL (815.91B1640.01) than Nontransfused (290.89B1219.70) p=0.001, surgical time (191.91B183.19) Non-transfused

(126B146.74) p=0.001, and lower input-output ratio (0.88B10.11) than Non-transfused

(0.90B10.15) p=0.010. Post-operative:

Transfused patients had lower first hematocrit

(29.73B15.14) than Non-transfused (32.68B14.37) p=0.004, hemoglobin (9.98B11.63) Nontransfused (10.92B11.45) p=0.006, and higher heart-rate (91.27B114.38) than Non-transfused

(80.07B113.54) p<0.001. No SS difference in systolic/diastolic blood-pressure (Transfused

126.18B116.61/73.18B19.82; Non-transfused

124.64B118.38/69.09B110.98; p=0.706, 0.095 respectively) Multiple ROC analysis revealed SS discriminate function for hematocrit at 0.699

(95%CI:0.579, 0.819); hemoglobin 0.734

(95%CI:0.609, 0.860); EBL 0.776 (95%CI:0.668,

0.883). 116 cases had complete data to calculation diagnostic testing; 14.7% (17) received blood-transfusions. Cases meeting at least one parameter of pre-hematocrit <=

36g/dL, pre-hemoglobin <=12g/dL, and EBL

>=425 yielded sensitivity=0.94, specificity=0.65, positive-predictive value=0.30, negative predictive value=0.98. Odds ratio=29.26, p<0.001 (95%CI3.71, 229.81).

Conclusions: Three primary clinical indicators were identified to aid decision-making of ordering post-hysterectomy CBC. Patients meeting at least one parameter were indicated at-risk for transfusion. Post-op CBC is indicated for these patients. This approach focused on prediction of transfusion. Validation of the model for additional patients is being performed.


Practice of routine post-operative CBC is convention to identify bleeding and other complications. Patients with complications typically require blood-transfusion.

Approximately 544,000 hysterectomies are performed annually with an approximate 3-8% incidence of blood-transfusion. Routine ordering of one/multiple CBCs post-hysterectomy may incur unnecessary patient ‘‘sticks’’ and hospital costs. In this study, three main clinical

indicators were identified, that may aid physicians in their decisions on ordering posthysterectomy CBC.

•

A Comparison of Claims-Based Inpatient

Hospital Quality Measures Calculated Using

Medicaid and Hospital Data Sources

Paul Kirby, M.A., Aniko Laszlo, M.B.A., M.A., Eric

Masters, M.P.H., Lobat Hashemi, M.S.

Presented By: Paul Kirby, M.A., Project

Associate, Center for Health Policy and Research,

University of Massachusetts Medical School, 222

Maple Avenue, Higgins Building, Shrewsbury,

MA 01545, Phone: (508) 856-4335, Fax: (508) 856-

4456, Email: paul.kirby@umassmed.edu

Research Objective: To determine whether a state Medicaid agency can use its own centralized claims database to construct inpatient quality measures based on administrative data, rather than relying on hospitals to separately report their own data.

Study Design: Medicaid claims data for hospital inpatients discharged between October 1, 2004 and September 30, 2005 was collected from a convenience sample of six Massachusetts hospitals. Separately, claims data for these six hospitals were obtained from the state’s

Medicaid Management Information System

(MMIS) claims database. A set of six administrative data based quality measures

(Cesarean Section, Vaginal Birth After Cesarean

Section, Obstetrical Trauma With and Without

Instrument, Injury to Neonate and Neonatal

Mortality) was calculated twice for each hospital, using the two separate data sources. Z-scores were then calculated to determine whether the quality measure scores had any significant differences, and Kappa statistics were computed to assess the degree of agreement between the underlying data sources.

Population Studied: The analysis was limited to a convenience sample of six Massachusetts hospitals, which accounted for more than onefifth of all Medicaid inpatient discharges in the state during the study period.

Principle Findings: One hospital was dropped from the analysis because of data quality problems in its data submission. Scores calculated for the five remaining hospitals from each data source had no statistically significant differences. Kappa scores for the agreement between the underlying data sources were high, ranging from 0.75 to 1.0 (scores calculated for each of six measures in each of five hospitals).

Conclusions: Our findings suggest that the state Medicaid agency may be able to calculate claims-based quality measurements using existing Medicaid claims data, thereby lowering the administrative burden that hospitals would face if they had to calculate and report Medicaidonly data to the agency. Currently most hospitals that report to the Medicaid agency are reluctant to break out Medicaid-only data.


This research presents a preliminary case for state Medicaid agencies to calculate quality measurements themselves, using existing administrative data sources. In addition to reducing administrative burden on hospitals, running quality measures in-house can help to minimize variations in data formats, programming methods, payer coding, DRG groupers, and other sources of error.

•

Physician Specialty and Receipt of Care in

Excess of Guideline Recommendations among Cancer Survivors

Jennifer Elston Lafata, Ph.D., Lonni Schultz,

Ph.D., Jan Simpkins, M.A., Ozgur Tunceli, Ph.D.,

Greg Cooper, M.D.

Presented By: Jennifer Elston Lafata, Ph.D., research scientist, Center for Health Services

Research, Henry Ford Health System, One Ford

Place, 3A, Detroit, MI 48202, Phone: 313-874-

5480, Fax: 313-874-7137, Email: jlafata1@hfhs.org

Research Objective: We and others have documented both under- and over-use of surveillance care among cancer survivors relative to guideline recommendations. The factors associated with such use, particularly care in excess of that recommended, remains unknown.

We evaluate the association of physician specialty and other factors on the receipt of surveillance care in excess of consensus-based guideline recommendations during the first year following treatment with curative intent among cancer survivors.

Study Design: Cross sectional cohorts in which receipt and indications for examinations and procedures were abstracted from medical records. Over-care was defined as receipt of (1) local recurrence testing of a frequency greater than recommended, (2) physical exams of a frequency greater than recommended, or (3) any metastic disease testing within 12 months following treatment, or (4) meeting the criteria for 12-month guideline recommendations before

10 months post-treatment. Actuarial methods were used to estimate excess care receipt at 12

months post-treatment by physician specialty

(primary care, oncologist, or surgeon/relevant specialist). Cox regression models that included time varying indicators reflective of the specialty of physician(s) seen were used to evaluate association of physician specialty on excess care receipt adjusting for patient age, gender, race, marital status, insurance coverage, income, and cancer stage and treatment.

Population Studied: Cohorts of patients aged

30 years and older diagnosed with local or regional breast, colorectal, endometrial, lung, and prostate cancer between 1990 - 1995 were identified via an academic health system’s tumor registry (N=100 per site).

Principle Findings: Prostate cancer survivors were most likely to receive excess care (96%), followed by endometrial (91%), breast (90%), lung (80%), and colorectal (78%) patients. Each of the physician specialty indicators was significantly (p<0.05) associated with excess care receipt in each model. Among breast, colorectal, endometrial and lung patients, seeing the oncologist was particularly associated with excess care receipt (Hazard Ratio [HR] = 3.9, 7.2,

11.3 and 7.3, respectively). Corresponding differences in excess care receipt at 12 months by those seeing/not seeing the oncologist were

99.6% vs. 72.9% among breast patients, 100% vs. 73.8% among colorectal patients, 100% vs.

88.1% among endometrial patients and 100% vs.

72.9% among lung patients. Among prostate patients, seeing either the urologist (HR=25.4) or oncologist (HR = 17.9) was particularly associated with excess care receipt, with 12month differences being 99.7% vs. 84.9% and

99.8 vs. 94.3%, respectively. The association between excess care receipt and other included factors was not consistent across models.

Conclusions: The majority of cancer survivors receive care in excess of recommendations.

Each of physician specialties was associated with an increased likelihood of excess care in the 12 months following cancer treatment, with the likelihood tending to be greatest for those patients seeing the oncologist.


As 1 in every 3 people will find themselves among the ranks of cancer survivor before their death, it is imperative that future studies address why physicians and patients elect not to follow existing guidelines as well as the health and cost implications of surveillance care receipt of varying intensities.

Funding Source: NCI

• Cost-Based Physician Profiling:

Investigating the Stability of Physicians

Scores Across Time.

Antonio Legorreta, M.D., M.P.H., Yingxu Zhao,

Ph.D., William Wright, B.A., Amanda Gilmore,

M.P.H., Antonio Legorreta, M.D., M.P.H.

Presented By: Antonio Legorreta, M.D., M.P.H.,

Adjunct Associate Professor, Health Services,

University of California, Los Angeles School of

Public Health, 21650 Oxnard Street, Suite 550,

Woodland Hills, CA 91637, Phone: (818) 676-

2872, Fax: (818) 715-9934, Email: legorreta@ucla.edu

Research Objective: To evaluate the stability of cost-based physician profiling scores across two years in a private payer preferred provider organization setting.

Study Design: Three years of administrative facility, physician, and pharmacy claims were grouped into episodes of care using the

Symmetry Episode Treatment Group (ETG™)

Software. Physician level scores were calculated based on the episodes encountered by each physician during 2004 and 2005. Episodes were excluded from analysis if they met any of the following criteria: if the majority of the total episode costs could not be attributed to a single provider, if the total episode costs were identified as an outlier, if the member to which the episode was assigned was not continuously enrolled during the episode period, or if the episode occurred outside of the 2004 or 2005 analysis period. Rather than scoring physicians using the traditional ETG risk adjustment approach, whereby physicians total episode costs are compared to the average cost within the same

ETG, we produced a unique expected episode based cost for each unique physician-episode pair, taking into consideration differences in patient and physician level factors. Physicians who did not have at least 30 total episodes were excluded. The standardized cost difference

(SCD) was applied to the average actual and the expected costs for each physician to produce a measure of physician practice efficiency. Each physician’s SCD score was then assigned a corresponding percentile rank. Only physicians who met scoring criteria in both measurement years were compared in the final analysis. The difference in physician scores during 2004 and

2005 were compared using a paired t-test.

Population Studied: A commercial health plan population including approximately 450,000 member lives and 2,500 providers was examined.

Principle Findings: We scored 1,590 physicians in 2004 and 1,639 physicians in 2005. A total of

1,590 physician’s scores, in 49 specialties, were compared during the two periods. On average physicians scores changed less than 1% (0.05%) and the difference in physician scores was not significantly different between years (P>0.90).

Only 392 (24.6%) physicians had a score than changed greater than 25% in either direction.

Conclusions: Utilizing advanced regression modeling techniques which adjust for patient and physician level differences in utilization can produce relatively stable physician cost scores across a two year period. While this comparison is performed with only two years of physician scores and applied to a relatively small private payer population, it nevertheless addresses an area of concern that has yet to be investigated


Measuring providers on both quality and cost is the future of physician profiling. Scoring physicians on cost of care relative to their peers could provide a two-fold benefit to the healthcare system through lower costs through reduced utilization and influence physician practice patterns through direct peer-to-peer comparisons. Concerns among physicians about the reliability of episode based cost profiling and the resulting stability of physician scores are legitimate and should be addressed to garner physician support for such programs.

• Fairness of Clinical Quality Metrics for

Diabetes: The Impact of the Absence of

Nuance

Antonio Legorreta, M.D., M.P.H., Joe Kim, M.D.,

M.P.H., William Wright, B.A., Matthew

Robinson, M.P.H., Antonio Legorreta, M.D.,

M.P.H.

Presented By: Antonio Legorreta, M.D., M.P.H.,

Adjunct Associate Professor, Health Services,

University of California, Los Angeles School of

Public Health, 21650 Oxnard Street, Suite 550,

Woodland Hills, CA 91637, Phone: (818) 676-

2872, Fax: (818) 715-9934, Email: legorreta@ucla.edu

Research Objective: To identify areas where the current National Committee for Quality

Assurance (NCQA) measures of comprehensive diabetes care may fail to identify important quality gaps.

Study Design: We evaluated two important areas where the current Health Plan Employer

Data and Information Set (HEDIS) metrics for comprehensive diabetes care may be inaccurate or imprecise in assessing appropriate diabetic care: the failure to identify over-utilization in testing and the imprecision with regards to appropriate intervals of testing in incident type 1 and type 2 diabetics. For over-utilization, we counted the frequency of HbA1c testing per diabetic member in a commercial health plan.

For imprecision, because the measures do not allow adequate time for incident cases of diabetes to receive recommended screening tests or reflect differences in current guidelines for screening incident type-1 diabetic patients, we therefore assessed the impact of removing type 1 and incident diabetic patients from the measures.

Population Studied: A commercial health plan population including approximately 450,000 member lives and 2,500 providers was examined. The plan has been identified as having a relatively stable patient population over time. Administrative facility, physician, and pharmacy claims, along with patient eligibility information were included.

Principle Findings: Of 33,102 diabetes patients,

15.4% received 5 or more HbA1c tests with a maximum of 26, 5,584 were incident and 5,896 were identified with type 1 diabetes.

Conclusions: The lack of specificity in the current NCQA comprehensive diabetes measures may mean that these are inaccurate measures of appropriate diabetic care. They do not account for over-utilization as they only capture minimum rates of testing and do not differentiate between incident and prevalent diabetics and type-1 diabetics where frequent testing may not be clinically indicated. Further research should be conducted to assess these possibilities and to develop algorithms which avoid such limitations.


As more and more emphasis has been placed on rating health plans and individual providers by performance, it will be necessary to ensure that metrics are accurate. Our findings suggest that further refinements need to be made in some of the most widely used measures of diabetic care.

•

A Richer Nursing Skill Mix Improves the

Efficiency of Nursing Hours: Myth or Truth?

Yu-Fang Li, Ph.D., R.N., Chuan-Fen Liu, M.P.H.,

Ph.D., Elliott Lowy, Ph.D., Nancy Sharp, Ph.D.,

Anne Sales, M.S.N., Ph.D., Jack Needleman,

Ph.D.

Presented By: Yu-Fang Li, Ph.D., R.N., Research

Health Science Specialist, HSR&D, VA Puget

Sound Health Care System, 1100 Olive Way,

Suite 1400, Seattle, WA 98101, Phone: (206) 768-

5383, Fax: (206) 764-2935, Email: yufang.li@va.gov

Research Objective: Two competing hypotheses on the efficiency of nurse staffing have been advanced, but there is little empirical research to support either argument. In the first hypothesis, a richer nursing skill mix, or a higher proportion of registered nurses (RNs), leads to increased total patient care costs because of the higher salaries paid to RN staff. In the second hypothesis, a richer skill mix permits lower overall nurse staffing level because of the decreased need for supervising non-RN staff who are unable to perform the full range of nursing functions; this could lead to equal or lower total patient care costs. We tested these hypotheses by examining whether a richer skill mix increases costs, controlling for quality of care measured by incidents of nurse-sensitive inhospital complications.

Study Design: This is a cross-sectional study with a study period between 2/03-6/03. Data for analyses were drawn from: 1) the VA Decision

Support System labor input file, 2) VA administrative databases for patient characteristics, health outcomes, and facility characteristics, and 3) non-VA national databases on labor market and health service area characteristics. We used a 2-step multilevel regression model to analyze the associations between nurse staffing, measured as nursing hours per patient day (HPPD) and nursing skill mix, and patient care costs, controlling for patient demographics and health outcomes and facility and market characteristics. Analyses were corrected for clustering at the nursing unit level.

Population Studied: The analysis included

139,361 inpatient admissions to 292 acute medical/surgical units at 125 VA medical centers.

Principle Findings: The mean of inpatient costs per admission was $9,119, ranging from $684 to

$581,679. High cost admissions were associated with patients who were married, younger and white race, had a long inpatient stay, developed a complication during the hospitalization, underwent surgical procedures, or had been transferred to an intensive care unit. Higher facility case mix and higher market level wage index were also positively associated with inpatient costs. The average HPPD per unit was

7.3 hours for total nursing, 4.4 for RN, 1.8 for licensed practice/vocational nurses, and 1.1 for nurse aids. RN skill mix was 61% on average.

Nurse staffing differed significantly according to complexity groupings of VA medical centers, with facilities in the most complex group adopted a higher RN HPPD or skill mix than the other groups. Risk adjusted inpatient costs per admission was positively associated with RN

HPPD (coefficient = 527, p < .001), total nursing

HPPD (coefficient = 366, p < .001), and RN skill mix (coefficient = 38, p < .001), but was not associated with non-RN HPPD.

Conclusions: Nurse staffing might be a relatively stable measure that reflects the demand to provide care based on the complexity of patient population served. Associations between inpatient costs and total nursing HPPD and RN skill mix suggest that a richer nurse staffing may increase patient care costs after adjusting for patient, facility, and market level characteristics.


Understanding the cost-effectiveness of nurse staffing structures, and the impact of resource allocation on patient care costs, is critical for informed decision making about nurse staffing.

Funding Source: VA

• Early Termination of Adjuvant Therapy for

Breast and Colorectal Cancers in Rural

Georgia

Joseph Lipscomb, Ph.D., Theresa W. Gillespie,

Ph.D., Kevin Ward, M.P.H., Michael Goodman,

M.D.

Presented By: Joseph Lipscomb, Ph.D.,

Professor of Health Policy and Management,

Health Policy and Management, Rollins School of Public Health, Emory University, 1518 Clifton

Road NE, Atlanta, GA 30322, Phone: (404) 727-

4513, Fax: (404) 727-9198, Email: jlipsco@sph.emory.edu

Research Objective: Recent patterns-of-care studies report that cancer patients often do not complete prescribed therapy. Early termination of guideline-concordant treatment has been associated with adverse clinical outcomes, including poorer survival. Yet, little is known of factors that predict such early treatment discontinuation; the percentage of patients who

‘‘dropout’’ of prescribed therapy; or whether early termination may be clinically appropriate. The aims of this study were to examine: 1) frequency of failure to complete prescribed treatment for breast, colorectal (CRC), lung and prostate cancers within the first year post-diagnosis, and

2) patient-, provider-, system-, and tumor-related factors that were associated with early termination of cancer therapy.

Study Design: A population-based, retrospective medical record review was conducted. A total of

3996 cases diagnosed in 2001-2003 were identified from the Georgia Comprehensive

Cancer Registry with data collected from medical records by trained abstractors; 3949 cases were available for analysis. Data on termination of adjuvant therapy were analyzed descriptively by tumor type.

Population Studied: Cases were identified among residents of a largely rural 33-county region of southwest Georgia, representing a lower socioeconomic status. Study population included cases of breast, colorectal (CRC), lung and prostate cancers evaluated for treatment delivered during the first year following diagnosis. Since failure to complete adjuvant chemotherapy with a goal of cure may have more adverse consequences than treatment given for palliation of advanced disease, this report focuses only on cases treated for Stage I and II breast cancer and Stage III CRC.

Principle Findings: Of 854 total cases of stage I-

II breast cancer, 323 received chemotherapy

(38%). Of the 293 cases for which treatment was stopped within the first year post-diagnosis, the primary reason for stopping was completion of treatment (86%); 8% stopped due to significant toxicity; 2% for other clinical reasons, with one case for disease progression. In 2% (7 cases) treatment was discontinued due to patient factors (patient refused, did not show up, or lack of support). Similar findings are reported for the

556 CRC cases analyzed, of which 179 represented stage III CRC. Of these, 124 (69%) received adjuvant chemotherapy. For the 117 cases of stage III CRC who had stopped chemotherapy within 12 months following diagnosis, the majority (67%) were because treatment was completed; 12% due to toxicity;

8% for disease progression; 3% for patient death. For stage III CRC, 4% of cases stopped treatment early due to patient refusal and 3% because patient did not show up.

Conclusions: In this rural population, a small proportion of cases stopped adjuvant chemotherapy early due to patient-related factors; more cases discontinued treatment for clinical indications.


Review of practice patterns using only administrative data to study early termination of cancer treatment may not reveal actual reason for stopping. Further study of underlying factors of early termination is needed to design appropriate interventions to promote completion of prescribed therapy, consistent with highquality cancer care. Some factors may require clinical interventions, such as proactive management of treatment-related toxicities.

More detailed patient-reported outcomes would enhance understanding of patient factors that may contribute to early termination of potentially curative therapy.

Funding Source: CDC

• Partnerships for Quality: Lessons in

Translating Research into Practice

Debra Lipson, M.H.S.A., Marsha Gold, Sc.D.,

Melanie Au, M.P.P., Katherine Gruene Segersten,

M.P.P.

Presented By: Debra Lipson, M.H.S.A., Senior


Maryland Avenue, S.W., Washington, DC 20024,

Phone: 202-484-4684, Email: dlipson@mathematica-mpr.com

Research Objective: To evaluate AHRQ’s

Partnerships for Quality (PFQ) grant program and identify its lessons about how to use partnerships among researchers, providers, and other key stakeholders to accelerate the translation of research findings into practice on a broad scale through public-private partnerships led by organizations well-positioned to reach end-users.

Study Design: Based on a conceptual framework that portrayed how each program component linked to each other, and how program participants interacted, we conducted a qualitative study of inputs, interactions and outcomes. We conducted 94 structured interviews with: 1) AHRQ program staff responsible for the design and implementation of PFQ, 2) Project Investigators for the 20 grantees, 3) relevant collaborators and partners participating in each of the 20 grant projects.

Interviews were supplemented by document review and observation of some PFQ grantee meetings.

Population Studied: The study population was comprised of 20 AHRQ PFQ grantees, as well as

AHRQ-managed activities designed to foster collaboration across the 20 grantees. Grantee organizations included provider organizations, health care professional societies, employer coalitions, research organizations and state government agencies, among others. Each grantee formed a partnership among researchers, providers, and other organizations at the local, regional, and national level to conduct quality improvement efforts in various health care settings and focused on various health conditions.

Principle Findings: Although final results of the

PFQ program are not yet available for all 20 grant projects, the PFQ program appears to have improved health care quality and safety in many of the provider organizations involved. Some grantees had more significant outcomes than others, as measured by indicators of project reach, implementation, effectiveness, sustainability and potential for broader diffusion.

The evaluation identifies grantee characteristics and processes that appear to be associated with more effective partnerships for accelerating the uptake and implementation of evidence-based guidelines. AHRQ’s oversight of the projects and the cross-grantee meetings and other forms of collaboration helped some grantees to expand the reach of their projects.

Conclusions: While PFQ grantees did not have the scale of impact originally expected by program developers at AHRQ, or promised in the request for applications, many PFQ grantees attained significant accomplishments and generated important lessons about 1) the use of partnerships to accelerate the translation of research into practice and 2) innovative methods for improving quality of care in specific health care settings, or for specific health care conditions.


The PFQ program generated capacity and knowledge that can support other AHRQ efforts to translate research into practice. Grantee experiences and findings also provide important lessons for other national funders about how best to support partnerships for quality improvement at the regional and local level.


• Family Satisfaction: How Do Respondent and Facility Characteristics Relate to

Satisfaction With Nursing Home Care?

Judith A. Lucas, Ed.D., A.P.N, John Bowblis,

M.A., Carrie Levin, Ph.D., Brian Robinson, Ph.D.,

Eun K. Paek, M.A., Stephen Crystal, Ph.D.

Presented By: Judith A. Lucas, Ed.D., A.P.N,

Assistant Research Professor, Institute for

Health, Health Care Policy and Aging Research,


Brunswick, NJ 08901, Phone: (732)932-6940,

Fax: (732)932-6872, Email: jlucas@ifh.rutgers.edu

Research Objective: Several states have initiated reporting of Long-term Care (LTC) satisfaction survey results to help consumers make informed choices and to promote facility quality improvement (QI). Family members are often the ones who make LTC selection decisions. To support better-informed consumer choice and provide feedback to support quality improvement, it is crucial to understand what contributes to satisfaction with nursing home

(NH) care and life. This study examined the associations of satisfaction with family member respondent and facility characteristics.

Study Design: We used the Massachusetts

Nursing Home Satisfaction Survey, specifically developed to reflect aspects of NH care important to family members. Family members of residents were asked to rate satisfaction with the specific domains of staff/administration, physical environment, activities, care, meals, and resident rights. Facility data were obtained from

OSCAR. Bivariate and multivariate models examined associations between satisfaction in each domain and respondent and facility factors, including staffing and quality of care.

Population Studied: 12,720 family members of long-term care residents in 288 non-hospital based facilities in one state. Family member was broadly defined, including spouse, relative, responsible party, guardian/conservator. 66% of facilities and 64% of family members participated.

Principle Findings: Respondent factors significantly associated with higher satisfaction were lower education, older age, male gender, and less frequent visitation. Facility structure variables showed similar relationships across all six domains: larger facilities, members of chains, and facilities with a higher proportion of

Medicaid residents have lower family satisfaction levels across the domains. Nonprofit and government facilities had significantly higher satisfaction ratings than for-profits in all domains except physical environment.

Interestingly, religious nonprofits showed significantly higher satisfaction ratings for staff/administration, activities, care, and resident rights, compared to secular nonprofits.

Urbanicity, occupancy rate and resident acuity level showed little effect. Effects of increased key administrative staff hours were positive and significant in the domains of physical environment, activities, and resident rights.

Increased RN and CNA staff hours were associated with higher scores across all domains, yet only CNA staffing attained significance. Reliance on a larger proportion of contracted nursing staff was negatively associated with satisfaction, but only reached marginal significance for the care domain. As

expected, better clinical quality measures (e.g., proportion of acquired pressure ulcers) and fewer deficiencies were associated with higher satisfaction.

Conclusions: Family satisfaction in the specific domains studied is responsive to respondent characteristics, and facility structure, staffing, and quality of care factors. These consumer satisfaction scores show the same general direction as other commonly used quality indicators (e.g., deficiencies).


Family member satisfaction scores may be used with other measures in consumer selection decisions. Results support the benefits of smaller facility size, nonprofit sponsorship, and richer CNA staffing in producing satisfying care.

Satisfaction surveys may help facilities refine resource allocation to optimize satisfaction levels. A clear understanding of how factors affect different aspects of quality is important and may inform future policies (e.g., minimum staffing levels, reimbursement, pay for performance) that could affect consumer satisfaction.

Funding Source: Massachusetts Department of

Public Health

• Characteristics of Veterans Admitted to

Veterans Health Administration (VA)

Hospitals With Acute Myocardial Infarction

(AMI)

Kelly McDermott, M.A., Predoctoral, Charles

Maynard, Ph.D., Anne E. Sales, Ph.D., Elliott

Lowry, Ph.D., Stephan Fihn, M.D., M.P.H.

Presented By: Kelly McDermott, M.A.,

Predoctoral, Research Assistant, VA Puget Sound

HCS, Department of Veteran Affairs, 511 E. Roy

St. #313, Seattle, WA 98102, Phone: 206 366

5271, Email: kmcdermo@u.washington.edu

Research Objective: Unlike many other health care systems, most medical centers operated by the Department of Veteran Affairs (VA) do not routinely receive patients through the emergency medical system leading to not only a relatively low volume of patients with AMI, but also a substantial proportion of patients who present relatively late after symptom onset. Because of these circumstances, the outcomes of patients with the most serious form of AMI, ST-elevation myocardial infarction (STEMI), might be more similar to those of patients with non-STEMI

(NSTEMI) than in other systems of care. We sought to compare the characteristics and outcomes of patients with STEMI and NSTEMI who were admitted to VA facilities during FY04-

05.

Study Design: We performed a retrospective cohort study using a national 100% sample of inpatients discharged from VA facilities with a diagnosis of STEMI or NSTEMI using data from detailed, standardized abstracts of the medical record (External Peer Review Program) for patients admitted during FY04-05 and from national patient care databases.

Population Studied: A total of 12,243 patients were admitted to VA facilities with a discharge diagnosis of STEMI (n=2,231) or NSTEMI

(n=10,012) in FY04-05 excluding those transferred in from the community and those experiencing an AMI after hospitalization. In addition, only the first admission for each patient is included in this analysis.

Principle Findings: Patients with STEMI were younger (mean 65.6 vs. 69.4, p<0.001), were less likely to have coexisting conditions, and were less likely to have been on cardio-protective medications (aspirin, beta-blockers, ACE inhibitors, antiplatelet agents and lipid lowering medication) prior to admission. Patients with

STEMI were more likely to present to a surgerycapable hospital (57.8% vs. 52.9% p<0.001) and during night hours (21.1% vs. 16.9% p<0.001).

Although patients with NSTEMI were more likely to present more than 12 hours after symptom onset, a considerable proportion of both groups arrived after this optimal time for treatment. (37% vs. 52% p<0.001). Unadjusted mortality was similar for patients with STEMI and NSTEMI (in-hospital 8% vs. 7% p=0.169, 30day 10% vs. 11% p=0.789). However, patients with STEMI had a significantly higher likelihood of both in-hospital (OR=1.86 p<0.001) and 30day (OR=1.62 p<0.001) mortality after adjustment for age, presenting symptoms, medical conditions, biomarkers, time of arrival, and treatment.

Conclusions: Among the population of AMI patients admitted to VA facilities during FY04-05, there were notable differences in the characteristics of those with STEMI versus

NSTEMI. In adjusted analysis, patients with the more severe diagnosis of STEMI had a much higher likelihood of both in-hospital and 30-day mortality.


Understanding the patient characteristics and outcomes of the VA AMI population is essential for developing valid policies and appropriate interventions to improve the quality of care for patients with AMI in the VA.

Funding Source: VA

• Assessing Potentially Inappropriate

Prescribing in the Elderly Medicare

Population

Sandra Nuñez, M.P.H., Laura Stewart, R.N.,

M.P.A./H.S.A., C.P.H.Q.

Presented By: Sandra Nuñez, M.P.H.,

Healthcare Data Analyst III, Scientific Analysis,

Lumetra, 1 Lumetra Street, San Francisco, CA

94104, Phone: (415) 677-8448, Fax: (415) 677-

8436, Email: snunez@caqio.sdps.org

Research Objective: Medicare’s Part D prescription drug (PD) plan presents an opportunity to conduct accurate and comprehensive quality assessment in PD delivery among the elderly. Aging and a disproportionately higher rate of PD consumption place the elderly at higher risk of medication misuse. Potentially inappropriate medication (PIM) prevalence is 20%-25%, depending on the selected list of drugs to avoid

(e.g., 2003 Beers criteria). This study reports the

PIM consumption prevalence among Medicare’s

Part D beneficiaries enrolled in six California Part

D health plans. The primary outcome measure is the prevalence of enrollees who filled a prescription for one or more PIM. A secondary objective is to compare enrollees with at least one PIM to enrollees without any PIMs; outcomes include: patient demographics, number of unique prescriptions, and prescriber information.

Study Design: This cross-sectional study assesses the PIM prevalence among Medicare beneficiaries aged 65 and older. Pharmacy claims data for six California health plans are examined retrospectively. Enrollees with at least one pharmacy claim during the study period

(January 1, 2006-December 31, 2006) are included in the analysis. Inappropriate medication use is defined by three sources: 2003

Beers criteria, Zhan modification of the Beers criteria, and HEDIS 2006. The Beers list includes 33 potentially inappropriate drugs, and the Zhan criteria divides the Beers drug list into three major classifications: ‘‘always avoid’’,

‘‘rarely appropriate’’, and ‘‘some indications’’.

The HEDIS 2006 quality measure identifies drugs from the Beers list that should always be avoided in the elderly.

Population Studied: Medicare and Medicare-

Medicaid beneficiaries 65 years of age or older, enrolled in a Medicare Advantage PD Plan

(MAPD) and/or a stand-alone PD plan (PDP) in

California, with at least one or more prescription fills between January 1, 2006-December 31, 2006 are included in the study.

Principle Findings: To date, six months of pharmacy claims data have been reviewed for

PIM use, including approximately 268,000 enrollees aged 65+. Overall, 25.8% of these enrollees received at least one Beers PIM and

15.9% received at least one HEDIS PIM. Only

8.0% of these PIMs were classified as ‘‘always avoid’’ and 35.5% ‘‘some indication’’. Women were more likely to receive a Beers and/or

HEDIS PIM than men (26.9% vs. 24.3%, 12.5% vs. 8.0%, respectively). Enrollees receiving 10 or more unique medications of any type were also more likely to receive a beers and/or HEDIS PIM

(33.6% and 22.6%, respectively).

Conclusions: Preliminary results are consistent with the PIM literature; we will have additional data by May 2007 to include in analyses.

Pharmacy claims data are an important tool in the identification and reporting of potentially inappropriate medication use. These results can be used to inform Part D sponsors of their prescribing quality; and to design appropriate institutional quality improvement efforts aimed at reducing the rate of PIMs.


Part D data provides a unique opportunity to conduct robust quality assessment in the delivery of PDs. Quality improvement efforts targeted towards prescribing can be based on accurate and validated research using pharmacy claims data.

Funding Source: CMS

• Screening for Health Literacy With an Ice

Cream Label

Chandra Y. Osborn, Ph.D., Barry D. Weiss, M.D.,

Terry C. Davis, Ph.D., Pat F. Bass III, M.D.,

Michael S. Wolf, PhD, MPH, ,

Presented By: Chandra Y. Osborn, Ph.D., Health

Services Research Fellow, Institute for


Feinberg School of Medicine, 676 N. St. Clair

Street,Suite 200, Chicago, IL 60611, Phone: (312)

695-6956, Fax: (312) 695-4307, Email: cosborn@northwestern.edu

Research Objective: The prevalence and health consequences of limited health literacy have been detailed in a growing literature. The Rapid

Estimate of Adult Literacy in Medicine (REALM)

and Short Test of Functional Health Literacy in

Adults (S-TOFHLA) are the most commonly used literacy assessment tools in health care settings. Recently, Weiss and colleagues developed The Newest Vital Sign (NVS); a literacy screening tool, requiring patients to read and demonstrate an understating of a ‘‘Nutrition

Facts’’ label taken from a pint of ice cream. The

NVS is brief and available in English and

Spanish. Information on the validity of the NVS is limited to a single study that compared it with the full-length TOFHLA. The purpose of our research was to extend the psychometric evaluation of the NVS by conducting two separate studies to examine the criterion validity of the NVS, using the REALM and shortened, S-

TOFHLA as the reference standards; and the predictive validity of the NVS compared to the S-

TOFHLA.

Study Design: Study 1 was conducted at an urban public hospital in Shreveport, Louisiana.

Patients completed in-person interviews, and responded to the REALM and NVS. Study 2 was conducted at community clinics in Grand

Rapids, Michigan. Participants completed inperson interviews, and responded to the S-

TOFHLA, NVS, and measures of health status, knowledge, and behaviors. Most recent blood pressure and cholesterol levels were obtained from patients’ medical records.

Population Studied: Study 1 included 129 patients (mean age = 49): 74% female, 61%

African-American, 24% did not complete high school, and 35% had some education beyond high school. Study 2 included 119 patients (mean age = 55): 70% female, 61% African-Americans,

39% did not complete high school, and 35% had some education beyond high school.

Principle Findings: The AUROC curve for the

NVS was 0.71 with the REALM, and 0.73 with the

S-TOFHLA. The NVS was correlated with the

REALM, r = 0.41, and S-TOFHLA, r = 0.61; and was reliable in studies 1 (a = 0.81) and 2 (a =

0.71). In Study 1, the NVS had a sensitivity of

100% and specificity of 16.3% for predicting inadequate literacy according to the REALM. In

Study 2, the NVS had a sensitivity of 94.6% and a specificity of 63.4% for predicting inadequate literacy according to the S-TOFHLA. Multiple regression models tested predictive validity. The

NVS was less effective than S-TOFHLA for predicting cholesterol and hypertension knowledge, health status, total cholesterol, and systolic and diastolic blood pressure.

Conclusions: The NVS identifies patients with limited literacy skills, but is prone to misclassify patients with more adequate literacy according to the REALM and S-TOFHLA. The S-TOFHLA is more specific than the NVS for detecting low literacy as a correlate of adverse health outcomes.


The performance of the NVS in both studies suggests that it may be useful as a clinical screening tool when high sensitivity is acceptable, but less in research settings that require precision in measurement. It should be noted that health literacy experts currently do not recommend literacy screening unless adequate responses to limited literacy are available and in place.

Funding Source: CDC

• Is There a Relationship between Service

Quality, Technical Quality and Outcomes for

Patients with Type 2 Diabetes in Primary Care

Clinics?

Michael Parchman, M.D., M.P.H., Amer Kaissi,

Ph.D., Jacqueline Pugh, M.D., Raquel Romero,

M.D.

Presented By: Michael Parchman, M.D., M.P.H.,

Associate Professor, VERDICT Research Center,

South Texas Veterans Health Care System, 7400

Merton Minter Blvd (11C6), San Antonio, TX

78229-4404, Phone: 210-617-5314, Fax: 210-567-

4423, Email: parchman@uthscsa.edu

Research Objective: Patient satisfaction is a widely used indicator of the quality of health care services delivered. However, the relationship between service quality, technical process quality, and intermediate clinical outcomes such as control of glucose, blood pressure (BP) and lipids is poorly understood, especially in small primary care clinics. The objective of this study is to assess these relationships for patients with type 2 diabetes in these settings.

Study Design: A cross-sectional observation study was conducted in 20 small, diverse, autonomous primary care clinics in the South

Texas Ambulatory Research Network.(STARNet)

Patient satisfaction was measured as patients’ responses to survey questions regarding satisfaction with: overall quality of care; questions being answered; access to the clinic after hours; explanation of test results; staff’s courtesy and professionalism; and physician’s courtesy and professionalism. Technical process measures of quality were percentage of patients in each clinic who had the following within the past 12 months: referral for dilated eye exam, foot exam, two BP measurements, one glycosolated hemoglobin (A1c) measurement,

one urine micro albumin measurement, and one lipid measurement. Intermediate clinical outcomes were good control of A1c (<=7.0), BP

(<=130/80) and LDL-cholesterol (<=100).

Associations were evaluated using the Spearmen correlation coefficient.

Population Studied: Approximately thirty patients in each clinic completed the surveys.

(n=617) Their charts were abstracted to assess process and outcome quality measures.

Principle Findings: Patient satisfaction was consistently associated with process measures: satisfaction with questions answered, explanation of results and physicians’ courtesy and professionalism were all positively associated with four process measures .

Satisfaction with staff courtesy and professionalism was positively associated with three process measures. However, satisfaction with overall quality of care was positively associated with only two process measures.

Satisfaction with access was associated with good blood pressure control, and satisfaction with staff and physicians’ courtesy and professionalism were positively associated with good A1c control. An overall satisfaction score that incorporates all six questions was associated with an aggregate score for process measures (all six processes done within the past six months) but not with an aggregate outcome measure (all three outcomes within targets).

Only two associations were found between process and outcomes measures: clinics in which HbA1c measurements and lipid measurements were done more likely to have good A1c control.

Conclusions: In primary care clinic settings, overall service quality is associated with technical quality, but patient satisfaction with quality of care was only associated with only two of six process measures. The relationship between service quality and intermediate clinical outcomes is not as consistent. Of greater concern is the finding that clinics who do well on technical process of care measures do not necessarily do well with control of A1c, BP or lipids.


Primary care clinics that are patient-centered may also have systems in place to ensure that technical processes are accomplished. However, the linkage between service quality and patient outcomes as well as technical quality and patient outcomes is tenuous and deserves further study.


• Enhancement of Identifying Cancer

Specialists Through AMA and UPIN Registry

Data in Addition to Medicare Claims

Lori A. Pollack, M.D., M.P.H., Adamache W,

Ph.D., Richardson LC, M.D., Eheman CR, Ph.D.,

Ryerson AB, M.P.H.

Presented By: Lori A. Pollack, M.D., M.P.H.,

LCDR USPHS, Medical Officer, Division of

Cancer Prevention and Control, Centers for

Disease Control and Prevention, 4770 Buford

Hwy NE - Mailstop K-55, Atlanta, GA 30041,

Phone: (770) 488-3181, Fax: (770) 488-4569,

Email: lop5@cdc.gov

Research Objective: Physician specialty is often examined in relation to the delivery and outcome of health services. The objective of our study was to identify cancer specialists who provided care to long-term cancer survivors using data from Medicare claims, and determine how many additional physicians were classified as cancer specialists when the Unique Physician

Identification Number (UPIN) Registry and

American Medical Association (AMA) Masterfile specialty data were used in addition to the specialty data contained on Medicare claims.

Study Design: We obtained Medicare data for individuals that had been identified as being diagnosed with female breast, colorectal, prostate, uterine, or bladder cancer through the

Surveillance, Epidemiology and End Results

(SEER) program during the years 1992 through

1997. We compiled a list of distinct UPINs and corresponding provider specialty codes for each practice setting from 1992-2003 physician

(carrier) and hospital outpatient Medicare claims and compared the list to the UPIN Registry. We also obtained specialty data from the AMA

Masterfile. We counted the number of cancer specialists identified by each data source individually and when all three data sources were combined; then we calculated the number and percentages of additional cancer specialists identified when UPIN Registry and AMA data were used in addition to the Medicare provider specialty codes.

Population Studied: Our study sample consisted of continually-enrolled Medicare beneficiaries age 65 years and older who had a first ever study cancer diagnosed during 1992 through 1997 and had survived at least five years since diagnosis. We excluded those who were enrolled in Medicare managed care. The provider sample was limited to the physicians

(MDs/DOs) found in the claims of the final study sample of cancer survivors.

Principle Findings: For the final study sample of

104,871 long-term cancer survivors, there were

228,211 unique physicians identified. The SEER-

Medicare data identified 6,988 of these physicians as cancer specialists (radiationoncology, medical-oncology, hematology, surgical-oncology, hematology-oncology, gynecology-oncology, or musculoskeletaloncology). The addition of UPIN Registry and

AMA data captured an additional 1,269 (18%) and 1,303 (16%) respectively for a total of 9,560 cancer specialists. Using just the specialty code as found on Medicare claims, we found that

42,445 (41%) cancer survivors received care from a cancer specialist more than 5 years after an initial cancer diagnosis. When UPIN Registry and AMA specialty were used in conjunction with Medicare claims specialty, it was found that

50,119 (48%) of cancer survivors received care from a cancer specialist >5 years after an initial cancer diagnosis, an increase of 18% when compared to SEER-Medicare alone.

Conclusions: The physician specialty variable provided on Medicare claims overlaps with specialty data from the UPIN Registry and AMA data. Used collectively, these data sources can enhance the ability to identify physician specialties. The value added of capturing additional cancer specialists depends on the research objective and must be weighed against the cost and effort of obtaining these alternative data sources.


Using different sources can increase the number of cancer specialists identified for health service research.

Funding Source: CDC

• Medical Products Safety Network, MedSun, an Interactive Surveillance System,

Eliminating Barriers to Reporting of Events

Involving Medical Device Problems by

Creating Two-Way Communication Between

FDA and the Acute-Care Clinical Community

Kristine Powell, B.A., Clarice Brown, M.S., Doris

Northrup, M.A.

Presented By: Kristine Powell, B.A., Project

Director, Surveys and Epidemiology Services

Division, Social & Scientific Systems, 1100

Wayne Avenue, Silver Spring, MD 20882, Phone:

301-628-8265, Fax: 301-628-0301, Email:

TPowell@s-3.com

Research Objective: Hospitals, nursing homes, and other healthcare facilities are required to report adverse medical device events that result in serious illness, injury, or death to the U.S.

Food and Drug Administration's Center for

Devices and Radiological Health, CDRH, and/or device manufacturers under the Safe Medical

Devices Act. In 2002, in an effort to improve its post-marketing surveillance program, CDRH launched the Medical Products Safety Network,

MedSun, an Internet-based system that is designed to be an easy and secure way for hospitals to report adverse medical device events, as well as events involving potential for harm and close calls. The purpose of this presentation is to describe MedSun, a voluntary surveillance system that places an emphasis on creating an interactive relationship between FDA and the clinical community to learn about, understand, solve and prevent medical device problems and to provide timely feedback to health professionals to improve patient safety.

Study Design: MedSun currently involves representatives of 350 participating acute care non-federal hospitals throughout the U.S. that are trained to recognize medical device adverse events and events involving potential for harm and report to FDA using a web-based reporting tool.

Population Studied: MedSun began in 2002 with 25 facilities on the East Coast and has expanded to 350 acute-care facilities with geographic representation from across the US.

It currently includes many large tertiary centers as well as and a mix of other acute-care hospital types and sizes.

Principle Findings: Since 2002 there have been more than 6000 reports made to MedSun, some of which have more than one type of event.

These have included reports of 138 deaths, 615 serious injuries and 809 minor injuries associated with medical devices. There were over 4802 reports involving potential for harm, close calls, or product complaints. Reporting rates vary by hospital but have increased over the years. In the most recent years, MedSun facilities contributed more reports to FDA on medical device problems than were submitted from all other non-MedSun hospitals and user facilities. The keys to MedSun’s success include the design of a non-burdensome web-based reporting tool; selection of MedSun representatives in each hospital that have access to information involving device problems; provision of a variety of timely, useful feedback to MedSun facilities through newsletters, audio conferences, database searches, safety tips and an annual conference and a reporting system that provides a high level of data security.

MedSun reports have generated important signals of emerging medical device problems and information in MedSun reports have allowed

FDA and manufacturers to take regulatory and non-regulatory action that contribute to patient safety.

Conclusions: The quality and quantity of medical device problem reporting is improved by eliminating reporting barriers, e.g., liability concerns, paperwork burden, and lack of problem recognition, and by developing an interactive relationship between FDA/MedSun and the clinical community.


MedSun represents a major step forward in overcoming the barriers to reporting of adverse events and events involving potential for harm.

It has greatly enhanced FDA’s postmarketing surveillance program.

Funding Source: Food and Drug Administration

• The Application and Outcomes of a

Comprehensive Performance Improvement

System

Jan Pringle, Ph.D., Lois Edmondston, B.S.,

Anthony Snow

Presented By: Jan Pringle, Ph.D., 3401 Fifth

Avenue, Falk Clinic, Room 454, Pittsburgh, PA

15213, Phone: (412) 647-4304, Email: lae19@pitt.edu

Research Objective: The University of

Pittsburgh’s School of Pharmacy (UPSOP) has been developing a comprehensive performance improvement system that involves substance use disorder providers regularly collecting information from clients during and even following treatment, receiving reports based upon the data collected, and learning how to use the reports to make indicated clinical/programmatic changes.

Study Design: Residents: All current residents are required to complete a monthly form which summarizes their status in each area being studied; education, abstinence, employment, and criminal justice involvement. The data are entered into an Access database. Reports are produced and given to program representatives monthly, quarterly, and annually. Post-

Discharge: Discharged clients are contacted monthly until 6 months post-discharge. The interview concentrates on the status of the following aspects of their recovery: employment, housing, criminal justice involvement, and abstinence. Data are entered into an Access database. Reports are produced and given to the program representatives monthly. The reports are used by the program to continually monitor the progress of the residents and determine any areas where clinical/programmatic changes may be necessary. All forms were developed through a collaboration of UPSOP and program leadership.

Population Studied: UPSOP has been applying this system to a ¾ way house program located in Pittsburgh, Pennsylvania with notable success.

A ¾ way house provides men who are involved in the local criminal justice system with a safe, sober, and supportive environment to begin recovery while attending outpatient treatment.

The program objectives are to help the residents continue their recovery plan by participating in outpatient treatment, 12-step meetings, 5MC aftercare meetings, life skills training, and sober recreational activities and to help the residents reintegrate into their community with permanent stable housing and independent living skills.

Principle Findings: The results of the application of this comprehensive performance improvement system were as follows: Results from the most recent interview of residents currently in the program indicate 52.4% of the residents are employed or actively seeking employment, 97.4% have no probation/parole violations, 90.5% have had no relapse, and

85.7% are currently enrolled in or have completed an educational program. At 6 months post-discharge, clients interviewed reported 95.7% reside in stable housing, 88.1% have not relapsed, 91.5% have no probation/parole violations, and 42.6% are employed.

Conclusions: The presentation or poster will discuss how the program used the data to make specific programmatic changes to improve overall performance, and the role of the UPSOP in providing ongoing technical assistance and mentoring.


This approach can be applied to other similar programs in order to better meet the needs of clients by enhancing program services via a realtime data collection and reporting system.

Funding Source: PA Department of Health

Bureau of Drug and Alcohol Programs (BDAP)

• What Consititutes High Quality Epilepsy

Care?

Mary Jo Pugh, Ph.D., R.N., Dan R. Berlowitz,

M.D., M.P.H., Georgia Montouris, M.D., Barbara

Bokhour, Ph.D., Lewis Kazis, Sc.D.

Presented By: Mary Jo Pugh, Ph.D., R.N.,

Research Health Scientist, VERDICT, South

Texas Veterans Health Care System, 7400

Merton Minter BLVD, San Antonio, TX 78023,

Phone: 210-842-3807, Fax: 210-567-4423, Email: pughm@uthscsa.edu

Research Objective: Providers are increasingly being held accountable for the quality of care provided. While quality indicators have been used to benchmark the care for a number of chronic and acute disease states, no such measures are available for evaluating the care provided to adults with epilepsy. In order to assess and improve care, it is critical to develop valid quality indicators. Recognizing that most care is provided in primary care and general neurology clinics, we developed a set of clinically relevant quality indicators for primary care providers to evaluate the care of adults with epilepsy in routine care settings.

Study Design: We used a modified Delphi process (RAND appropriateness method) to develop the adult epilepsy quality indicators with three rounds including feedback of results for each of the rounds. As there are a number of extant systematic reviews regarding treatment of epilepsy in adults, we began by comprehensively reviewing the literature and existing clinical guidelines to develop an initial list of quality indicators. This list was enriched with indicators derived from patient focus groups where patients discussed their perceptions of what constitutes quality of care for adults with epilepsy to identify a 51 total indicators. We then convened a 10-member expert panel to rate the appropriateness (validity) and feasibility

(reliability) of each item as an indicator of high quality epilepsy care using a 9-point likert scale.

The first round of ratings by the expert panel occurred prior to a face-to-face meeting. At the meeting, panel members received a summary of group ratings alongside their own rating. After face-to-face discussion, items were revised and sent to panel members for a second rating.

Items where three or more ratings were outside the three point range that included the median were considered to have disagreement and excluded from the final round of rating for necessity (which failure to recommend would be viewed as improper clinical judgment). Items found to be both appropriate and necessary were primary quality indicators; those rated as appropriate but not necessary for high quality care were secondary indicators.

Population Studied: Expert panel of 10 nationally and internationally recognized epileptologists, neurologists, and general internists and 17 patients receiving care in the neurology clinic of a urban medical center in the northeastern United States.

Principle Findings: We found consensus on 24 evidence based and 5 patient based indicators of quality. Of these, the panel identified 20 primary indicators and 9 that were appropriate, but not necessary for high quality care. While the level of evidence appeared to influence approval of some indicators, several primary indicators were based primarily on expert opinion.

Conclusions: Out of 51 preliminary quality indicators, 20 were identified as both valid and necessary; three were based on patient focus groups.


The results of this work may be used as a guide for primary care clinicians who provide care for the majority of adults with epilepsy, and may be used as a tool to improve and assess the quality of care provided to this population.

Funding Source: CDC

• Moving Beyond Individual Performance

Measures: Developing "Suites of Measures" for ED Quality of Care

Asma Razzaq, B.Sc.H., M.P.H., Patrice Lindsay,

R.N., Ph.D., Geoffrey M. Anderson, M.D., Ph.D.

Presented By: Asma Razzaq, B.Sc.H., M.P.H.,

Epidemiologist, Institute for Clinical & Evaluative

Sciences, G1 06, 2075 Bayview Avenue, Toronto,

M9B 6C4, CA, Phone: (416) 480-4055 ext. 7460,

Fax: (416) 480-6048, Email: asma.razzaq@ices.on.ca

Research Objective: Performance measures in health care have traditionally been used in isolation to assess quality of care. The objectives of this study were to 1. determine the relationship among clinical indicators of

Emergency Department(ED) care, 2. develop

‘‘suites of measures’’ to comprehensively assess

ED quality of care, and 3. establish benchmarks for quality ED care where trade offs exist between indicators.

Study Design: A retrospective cross sectional cohort design with routinely gathered administrative health data was used to calculate process and outcome indicators for four clinical conditions (asthma, pneumonia, ankle injuries, and transient ischemic attack (TIA)) treated in the ED. The performance indicators were riskadjusted length of ED stay, short stay (less than

48 hours) admissions, long stay (greater than 48 hours) admissions, ankle x-ray rate, return visit

ankle x-ray rate, return visits to the ED at 24 hours, 72 hours and 7 days, and follow up visits to a physician within 7 days for TIA patients.

Population Studied: All 4,671,317 ED visits to

174 EDs in Ontario, Canada for 2003-04.

Principle Findings: For all clinical conditions, longer length of stay in the ED was associated with fewer return visits to the ED and admissions to hospital. The number of short stay admissions and long stay admissions was positively associated. Return visits to the ED within 24 hours, 72 hours, and 7 days were all positively correlated. For TIA patients, admission to hospital was associated with fewer visits to physicians within 7 days of the ED visit.

For ankle injuries, there was a significant trade off between x-ray rates at the initial visit and x-ray rates on return visits.

Conclusions: Three main relationships amongst the indicators have implications for quality improvement. For indicators that are positively correlated, some indicators may be combined or eliminated. For those not correlated, all indicators are required in a "suite of measures".

Negative correlation amongst the indicators suggests that there is a trade off and modelling of the relationship may reveal benchmarks that optimize all indicators. Using these methods, a core suite of indicators can be created to measure overall quality in the ED by clinical condition.


This is the first comprehensive attempt to assess quality using a suite of previously developed, validated, and reliable measures. This methodology assists in elucidating benchmarks where it has historically been difficult to set such targets. Both the methodology employed in this study and the condition specific suites of measures can be used by other jurisdictions to develop suites relevant to other clinical conditions or other acute care settings, and measure ED quality of care in a more comprehensive and meaningful manner.

Understanding the tradeoffs between clinical indicators gives a deeper understanding to the interplay of the various components that create quality and can assist managers and clinicians in developing more effective quality improvement initiatives.

Funding Source: Ministry of Health & Long

Term Care

•

The Impact of Medicaid Utilization Rate on

Colorectal Cancer Outcomes in California

Kim Rhoads, M.D., M.S., M.P.H., Leland

Ackerson, Ph.D. candidate, Joan Y. Reede, M.D.,

M.S., M.P.H., Ashish K. Jha, M.D.

Presented By: Kim Rhoads, M.D., M.S., M.P.H.,

Clinical Fellow in Colorectal Surgery, Colorectal

Surgery, UC San Francisco/Mt Zion Cancer

Center, 2330 Post Street, Suite 260, San

Francisco, CA 94143, Phone: 415-885-3625, Fax:

415-885-3886, Email: kfrhoads@yahoo.com

Research Objective: To determine the impact of hospital fiscal constraints------based on Medicaid utilization rates--on colorectal cancer mortality; and to evaluate the impact of academic affiliation and surgical volume on these outcomes.

Study Design: Patient-level records from the

California Cancer Registry were linked to discharge abstracts from California’s Office of

Statewide Health Planning and Development.

High Medicaid hospitals were defined as those serving more than 40% Medicaid patients.

Outcomes included mortality at 30 days and 1 year. Two-tailed tests of significance were performed using SAS 9v1 for univariate analyses; and multilevel multivariable modeling was performed using MLwiN 2.0.

Population Studied: All patients undergoing operation for colorectal cancer in California during the years 1998 to 1999 were included

Principle Findings: high Medicaid hospitals had significantly higher rates of 30 day and 1-year mortality. These differences persisted in the multivariable models. Adjustment for academic affiliation did not alter these findings.

Adjustment for surgical volume decreased the odds of 30 day, but not 1-year mortality.

Differences by race disappeared after accounting for hospital Medicaid status.

Conclusions: High Medicaid hospital type negatively impacts colorectal cancer mortality.

Neither academic affiliation, nor surgical volume completely neutralizes this effect.


While these findings may offer a glimpse into the roots of racial/ethnic disparities in national colorectal cancer outcomes, the results clearly indicate the need for further examination of institutional-level disparities as they affect mortality from this disease.

Funding Source: California Endowment

•

Elements of and Barriers to Achieving

Quality Breast Cancer Care in a Managed

Care Population

Nancy Rodriguez, R.N., B.S.N., C.P.H.Q.,

P.A.H.M., Sandra White, M.D., FACR, M.B.A.








Research Objective: To evaluate elements of quality breast cancer care, screening and diagnosis, treatment, supportive care, and patient satisfaction in a managed care population and provide a descriptive assessment of barriers to receiving standard of care treatment for breast cancer.

Study Design: A 1999 pilot study by Blue Cross of California developed a model of quality breast cancer care assessment composed of: Screening and Diagnosis, i.e. mammograms, early stage at diagnosis, Treatment, i.e. breast conserving surgery or BCS, chemotherapy, radiation after

BCS, Supportive Care, i.e. assessment and management of pain and anemia, and Patient

Satisfaction. A retrospective review of Blue

Cross Blue Shield of Georgia breast cancer patients from 2001 to 2003, including review of medical and pharmacy claims, and evaluation of those elements which could be obtained solely from medical claims, specifically mammograms, breast conserving surgery, and radiation after

BCS or XRT.

Population Studied: 7,864 BCBSGA female patients diagnosed with breast cancer from medical claims between 2001 and 2003.

Principle Findings: Despite an insured population, results were no better than the national average. The BCBSGA HEDIS breast cancer screening rate was 72 to 78, the BCS rate was 33 to 38, and the XRT rate was 55 to 65. The

BCBSGA Breast Cancer Care Physician oncology specialists, and Layperson breast cancer survivors and advocate organization leaders,

Advisory Panels evaluated these data and concluded that the radiation rates after BCS might be related to surgeon and patient misinformation about the need for radiation after surgery to prevent recurrence of the disease.

They also recommended that patients and physicians should be equipped with complete information on current treatment guidelines and a checklist tool to promote informed decision making. The Advisory Panels identified the following general barriers related to breast cancer care: Lack of easily understandable information, i.e., too much, too technical, misinformation, Lack of knowledge of the process of diagnosis and treatment, The unique, personal nature of adjusting to a breast cancer diagnosis, Intimidation, Lack of understanding of patient rights related to breast cancer treatment.

Conclusions: Review of the literature revealed that radiation therapy after BCS could improve the survival rate from 10 to 30 percent. We determined that improving the rate of radiation therapy after BCS offered the best opportunity for

BCBSGA to improve care and benefit members with breast cancer. However, because breast cancer is a very complex disease and treatment decisions are highly personal, it is impractical to develop an educational component addressing just one element of breast cancer treatment.

Additionally, while many materials are available to convey breast cancer information, many of these items are not easily understood by a patient and do not promote informed decision making.


Materials need to provide current treatment guidelines, and be suitable for a diverse audience of specialist and non specialist physicians, and patients. Material design should incorporate health literacy principles, and should guide patients through the decision making process.

Development of a new, comprehensive educational campaign for patients and physicians was needed to satisfy these requirements.

Funding Source: QM Department Operating

Budget

•

Impact of Pediatric Telemedicine

Consultations on Diagnostic and Therapeutic

Advice, and Parent Satisfaction

Patrick Romano, M.D., M.P.H., James P. Marcin,

M.D., M.P.H., Stacey L. Cole, B.S.

Presented By: Patrick Romano, M.D., M.P.H.,

Professor of Medicine and Pediatrics, , University of California Davis, 4150 V Street; PSSB Suite

2400, Sacramento, CA 95817, Phone: (916)734-

7237, Email: psromano@ucdavis.edu

Research Objective: Among children receiving remote pediatric critical care consultations in rural emergency departments (EDs), we compared the frequency of diagnostic and therapeutic advice and parent satisfaction of care for those receiving telemedicine consultations compared with those receiving telephone consultations.

Study Design: This was a prospective cohort study with non-random assignment of telemedicine services to eight rural EDs in

California where pediatric critical care consultations from an academic pediatric center are available 24/7. Five rural EDs served as concurrent control sites. Consulting physicians indicated whether the consultation (telemedicine versus telephone) resulted in changes in diagnostic and therapeutic advice. Parents were given a survey to measure their satisfaction and experiences related to quality of care. Medians for all measures were compared using a Mann

Whitney U-Test.

Population Studied: We included children presenting to the rural EDs between June 2004 and June 2006, triaged in the highest category at presentation (i.e., those children considered seriously ill or injured) who received a telemedicine or telephone consultation. This study included children older than one day and younger than 17 years of age.

Principle Findings: Comparing patients who received telemedicine consultations at the eight telemedicine sites (N=37) with patients who received telephone consultations at the five control sites (N= 14), the consulting physician more frequently requested additional diagnostic studies (51.3% vs 7.7%; p=0.02) and recommended more therapeutic interventions

(40.5% vs 14.3%; p=0.08) in telemedicine consultations. Parental satisfaction was significantly higher with telemedicine (N=22) than with telephone consultation (N=24) for courtesy of ED nurses (6.71 vs 5.79, p<0.01), courtesy of ED physicians (6.71 vs 5.75, p<0.01), knowledge and skill of the ED physician (6.48 vs

5.54, p<0.01), explanation of what was done for a child (6.55 vs 5.29, p<0.01), overall ED quality of care 6.59 vs 5.62), and overall ED experience

(6.62 vs 5.29, p<0.01).

Conclusions: When compared to telephone consultations, telemedicine consultations for acutely ill and injured children provided from an academic pediatric center to rural EDs result in more diagnostic and therapeutic advice and higher parent satisfaction with care.


The differences noted between telemedicine and telephone consultations to rural EDs suggest that telemedicine should be considered as a means of addressing disparities in care provided to children in rural EDs. Research currently underway will explore whether telemedicine consultations to rural EDs are associated with a lower incidence of medication errors and better global quality of care.

Funding Source: AHRQ, HRSA, California

Health Foundation

• Physician Use of Health Professionals and

Support Staff in Caring for a Population-

Based Cohort: Results from the Los Angeles

Women’s (LAW) Study

Danielle Rose-Ash, Ph.D., Diana Tisnado, Ph.D.,

May Tao, M.D., Melinda Maggard, M.D., Patricia

Ganz, M.D., Katherine Kahn, M.D.

Presented By: Danielle Rose-Ash, Ph.D., Post-

Doc, DCPCR, UCLA-JCCC, 650 Charles Young

Drive South, Los Angeles, CA 90095-6900,

Phone: (310) 206-1926, Fax: (310) 206-5553,

Email: droseash@ucla.edu

Research Objective: Understanding whether physicians, as compared to their staff, complete common tasks during patient visits with physicians could reveal useful insights into variations in care. Physicians may vary in the strategies they use to assure delivery of high quality care at the lowest cost. Some physicians delegate tasks, while others complete the tasks themselves to optimize efficiency. Little is known about variations in who completes office tasks and how this may influence patient care and outcomes.

Study Design: Cross-sectional survey of physicians who treat breast cancer patients. We asked who: documents medication use; speaks with a febrile patient (103°) regarding course of care, and; follows up with the patient the following day. Response options were: 1) the physicians themselves; 2) other health professionals (RN, LVN), 3) administrative staff or 4) no set policy. In logistic regressions, we tested the likelihood of the physician performing each task themselves compared with delegating.

We tested for bivariate and multivariate associations with physician age, gender, specialty, practice setting (county or medical school; HMO; solo practice; single specialty group (SSG); multispecialty group (MSG)) and large practice size (>=50 physicians versus fewer). Analyses were weighted for survey nonresponse and controlled for clustering at the office level.

Population Studied: We surveyed all medical oncologists, radiation oncologists, and surgeons practicing in Los Angeles County identified by a population-based cohort of women with incident breast cancer identified from the cancer registry

(76% response rate, n=348).

Principle Findings: A majority of physicians reported documenting medication use (69%) and speaking with a febrile patient regarding course of care themselves (65%). Forty percent reported that they themselves would follow up

with the febrile patient the next day. In multivariate analyses, surgeons were more likely than medical oncologists to report documenting medication use themselves (p<0.001).

Physicians in HMOs, SSGs and MSGs were less likely than physicians in solo practice to document medication use (p<0.05 for both), except for physicians in large MSGs were more likely to document medication use themselves

(p<0.01). Radiation oncologists were more likely than medical oncologists to report speaking with a febrile patient themselves (p<0.05). County or medical school physicians were less likely to report speaking with the febrile patient themselves compared to HMO (p<0.05) or solo practitioners (p<0.001). Physicians in SSGs were less likely to report speaking with the patient compared to solo practitioners

(p<0.001). Physicians in large settings were less likely to report speaking with the febrile patient

(p<0.05). There were no statistically significant differences in the likelihood of a physician following up the next day.

Conclusions: Significant specialty, practice setting and practice size differences exist in the tasks performed by cancer physicians.

Physicians in solo practice appear less likely to delegate tasks, while medical oncologists and physicians in large practices appear more likely to delegate tasks compared to others.


Understanding variations in practice style and their predictors are a first step in understanding how structure influences care and outcomes.

Next steps include determining if tasks performed by physicians as compared with their designee influences care or outcomes.

Funding Source: California Breast Cancer

Research Program

• Physician Practice Styles and Referral

Patterns: A Model from Breast

Danielle Rose-Ash, Ph.D, Diana Tisnado, Ph.D.,

May Tao, M.D., Melinda Maggard, M.D., Patricia

Ganz, M.D., Katherine Kahn, M.D.

Presented By: Danielle Rose-Ash, Ph.D, Post-



Phone: (310) 206-1926, Fax: (310) 206-5553,


Research Objective: Physicians may vary in the strategies they use to assure delivery of high quality care at the lowest cost. Some physicians delegate tasks, while others complete the tasks themselves to optimize efficiency. Little is known about variations in who completes office tasks and how these may influence patient care and outcomes.

Study Design: Cross-sectional survey of physicians who treat breast cancer patients. We asked: who documents medication use; who speaks with a febrile patient (>=103°) regarding course of care, and; follows up with the patient the following day. Response options were: the physicians themselves; other health professionals (RN, LVN), administrative staff or no set policy. In logistic regressions, we tested the likelihood of physicians performing each task themselves compared with delegating. We tested for bivariate and multivariate associations with physician age, gender, specialty, practice setting (county or medical school;

HMO; solo practice; single specialty group

(SSG), multispecialty group (MSG)) and large practice size (>=50 physicians). Analyses were weighted for survey non-response and controlled for clustering at the office level.

Population Studied: We surveyed all medical oncologists, radiation oncologists and surgeons identified by women from a population-based cohort of women with breast cancer identified by the LA County cancer registry (76% physician response rate, n=347).

Principle Findings: Physicians indicated substantial variations in practice style. Of 10 aspects of care evaluated, 14% respondents indicated managing >=7 aspects without another physician, and 12% indicated involving another physician in all 10 aspects of care. Among physicians reporting comanagement for at least one of 10 tasks (n=327), 39% reported shared responsibility for <=3, 39% for 4-6, and 16% for

>=7 tasks. Among physicians reporting usually referring management for a listed task to another physician (n=291), 67% referred for 1-3 tasks, and

16% for >=4 tasks. While most (87%) of physicians indicated they were involved in some way with all 10 tasks, 12% indicated they were not involved in 1-3 of the 10 tasks.

In multivariate analyses, compared to medical oncologists, radiation oncologists and surgeons were less likely to report caring for tasks on their own (both p<0.001), more likely to report comanaging care with another physician (p<0.01 and p<0.05, respectively), to report referring patients (p<0.001 for both), and indicating they were not involved in care compared to medical oncologists (p<0.001 for both). HMO physicians were more likely to report comanaging care compared to physicians in solo practice (p<0.05). County government or medical school physicians were more likely to

indicate being involved compared to physicians in solo practice (p<0.05) or HMO doctors

(p<0.05).

Conclusions: Significant differences exist in the tasks performed by cancer physicians across specialty, practice setting and practice size.

Physicians in solo practice appear less likely to delegate tasks, while medical oncologists and physicians in large practices appear more likely to delegate tasks compared to others.


More research is needed to understand how differences in practice styles might affect outcome. We plan on exploring this further in linked physician and patient datasets.


Research Program

• Disparities in Quality of Care of Smokers with Chronic Conditions: NHANES III, 1988-

1994

Danielle Rose-Ash, Ph.D.

Presented By: Danielle Rose-Ash, Ph.D, Post-



Phone: (310) 206-1926, Fax: (310) 206-5553,


Research Objective: Much has been written about physician bias on such patient characteristics such as age, gender or race/ethnicity. Less is known about potential physician bias on patient behaviors, e.g. smoking. We test here for differences in quality of care between smokers and non-smokers among respondents with self-reported diabetes, hypertension or high blood cholesterol, to determine if smokers were more likely to receive appropriate care, given the higher risk associated with smoking, or if physicians exhibited potential bias towards smokers.

Study Design: Cross-sectional analysis of

NHANES III data, 1988-1994, designed to provide national estimates of the health and nutritional status of U.S. population.

We performed logistic regression using Stata 9.0 to estimate how often patients reported receiving quality care for their diabetes, hypertension or high blood cholesterol. Measures (n=21) included good control of condition, medication prescribed, and lifestyle advice to improve health

(lose weight, exercise more) and avoid complications associated with condition (for diabetes, eye exams and information about diabetic retinopathy). We tested for bivariate and multivariate associations with smoking status, age, gender and race/ethnicity. Standard errors were computed using the first-order Taylor series linear approximation.

Population Studied: From NHANES III, we subset the adult population (n=20,030) by affirmative responses to questions regarding health status, e.g., diabetes (n=1,509), hypertension (n=4,313) and high blood cholesterol (n=3,243). We further subset data to focus only on respondents who reported seeing a physician at least twice in the previous year, to avoid reporting poor quality care for respondents who did not utilize healthcare.

Principle Findings: Out of 21 measures, there was only 1 measure where smokers were more likely to receive advice compared to non-smoker, among hypertensives, smokers were more likely to receive advice to stop smoking (p<0.001).

Among hypertensives, smokers were less likely to receive advice to lose weight (p<0.01) or change their diet because of their hypertension (p<0.05).

Among those with high blood cholesterol, smokers were less likely to receive advices to change their diet (p<0.05), lose weight (p<0.05) or exercise more (p<0.05). Among diabetics, there were no statistically significant differences between smokers and non-smokers.

Conclusions: Among those with hypertension and high blood cholesterol, smokers were less likely to receive appropriate care compared to non-smokers. There were no differences among diabetics. While some of the differences may be attributable to differences in weight between smokers and non-smokers, these findings indicate there may be important differences in care between smokers and non-smokers.


While much has been written about the need for smoking cessation efforts, there may be additional concerns about physician bias toward smokers. More research is needed about physicians’ attitudes towards smokers, and if efforts are need to mitigate potential biases in care.


•

Community-Acquired Pneumonia in the

Elderly: Evidence for Marked Improvement in

30-Day Mortality

Gregory Ruhnke, M.D., M.S., Douglas M.

Norton, B.A., David M. Cutler, Ph.D.

Presented By: Gregory Ruhnke, M.D., M.S.,

General Internal Medicine Fellow, Institute for

Health Policy, Massachusetts General Hospital,

50 Staniford Street, 9th floor, Boston, MA 02114,

Phone: 617-724-3545, Fax: 617-724-4738, Email: ruhnke@stanfordalumni.org

Research Objective: Our objective is to quantify

30-day mortality trends in elderly Medicare patients diagnosed with community-acquired pneumonia (CAP). We hypothesize decreasing mortality over time with the largest changes in patients with severe CAP and comorbidities.

Study Design: Our analyses used all claims

(1987----2001) of a random 20% patient sample from the Centers for Medicare and Medicaid

Services' Research Identifiable Files, restricted to those beneficiaries over age 64. Cases of CAP were identified by ICD-9 codes shown to have a diagnostic sensitivity of 84% and specificity of

86%. Logistic regression was performed with 30day mortality as the dependent variable and the following independent variables: dummy variables for each year (1987 is the reference year), age by 5-year category, gender, and 25 of the 29 comorbidity variables defined by the

AHRQ Comorbidity Software. Four were excluded from the final model due to likely coding biases. Due to incomplete comorbidity information, inpatients admitted from nursing homes were excluded from the analysis. The same regression was also performed on subsets of patients with (a) no comorbidities to isolate changes due solely to the care of CAP; (b) complicated diabetes mellitus (DM) to estimate the effect of treatment of a major comorbidity on the mortality trends (complicated DM chosen to limit diagnostic and coding changes over time); and (c) electrolyte abnormalities (EA) as a marker of severe CAP to assess the contribution of severely ill patients to the overall trends. Our primary result was the odds ratio (OR) of death in each year relative to 1987.

Population Studied: The population studied was Medicare beneficiaries over age 64 diagnosed with CAP. The CAP subjects included

775,936 outpatients (annual mean 51,729) and

1,519,052 inpatients (annual mean 101,270).

These groups were combined to eliminate any impact of shifts to outpatient care in recent years.

Principle Findings: Compared to 1987, the adjusted OR of dying within 30 days of CAP decreased annually throughout this period such that the OR was 0.699 (95% CI 0.682----0.716) in

2001. The OR for the no-comorbidity subset decreased to 0.831 (95% CI 0.799----0.865) in

2001. The OR for the DM subset decreased to

0.599 (95% CI 0.526----0.683) in 2001. The OR for the EA subset decreased to 0.647 (95% CI

0.612----0.683) in 2001.

Conclusions: These findings show an overall adjusted 27.3% decrease in 30-day mortality of elderly patients with CAP from 1987 to 2001. The effect appears greater in patients with complicated DM and EA relative to those without comorbidities, suggesting that the overall improvements are partially attributable to improved treatment of comorbid conditions and the subset of severely ill CAP patients.


Our findings suggest that changes in the care of pneumonia patients, which may include assessment of oxygenation, early antibiotics, and other aspects of pneumonia pathways, have decreased mortality in CAP patients. Policy efforts should be directed at implementation of these measures. Improved treatment of common comorbidities will improve outcomes in pneumonia patients. Shift to outpatient treatment has not adversely affected outcomes and should be the object of initiatives to reduce costs.

Funding Source: NIH National Research Service

Award

•

Evaluating the Feasibility of a Program to

Recognize Physicians Providing High Quality

Back Pain Care

Sarah Sampsel, M.P.H., Sarah Hudson Scholle,

M.P.H., Dr.P.H., Philip Renner, M.B.A., Johann

Chanin, R.N., M.S.N., Phyllis Torda

Presented By: Sarah Sampsel, M.P.H., Assistant

Director, Quality Measurement, Quality

Measurement, National Committee for Quality

Assurance, 2000 L Street,NW #500,


Fax: 202-955-3599, Email: sampsel@ncqa.org

Research Objective: Test the feasibility of data collection, the definition of eligible patients, variation and performance rates for 16 newly developed quality measures and structural standards for low back pain care. This program identifies physicians who provide high-value, conservative, patient-centered care and is designed with an understanding that patients may seek the care of various practitioners for treatment of a back pain episode. The measures reflect that physicians are accountable for providing high-quality care from the outset of patient contact and for understanding and considering previous treatment history to help avoid inappropriate treatment.

Study Design: The measures,standards and research protocol were developed under the direction of an expert clinical panel. The pilot test

was conducted in 15 sites with 49 physicians of various specialties, including orthopedic surgery

(21), neurosurgery (9), primary care (1), chiropractic care (9), physiatry (6), and occupational health, sports medicine and pain management (3) in a wide range of geographic locations. Each practice site was provided with measure specifications and a data collection tool to abstract the records of 25-35 patients with an eligible back pain diagnosis. Qualitative interviews were conducted with the pilot test sites to gain additional feedback on program feasibility and burden.

Population Studied: Patients aged 18 years and older with a diagnosis of back pain and treatment duration of at least 42 days were eligible for the pilot test. In addition, care must have been rendered between January 1, 2004 and

December 31, 2005. A total of 1655 patients were screened for inclusion, of which 1295 were eligible for the program. Patients were distributed among the following age categories:

18 ---- 44 years (33%), 45 ---- 64 years (45%), and

65+ years (21%); 52% of the patients were female.

Principle Findings: For most measures, the patient eligibility criteria appeared to be feasible.

Measures assessing initial visit components, medical assistance with smoking cessation, and re-assessment of pain and function applied to the majority of sampled patients; few patients were eligible for repeat imaging. There was considerable variation in performance rates, which ranged from a mean of 4% for reassessment of pain for patients in continuous treatment to a mean of 71% for assessment of smoking status and medical advice for cessation if current smokers. The most problematic measures were those focused on overuse of services; floor and ceiling effects, small denominator sizes and difficulty operationalizing exclusions made the measures difficult to specify and one measure was deleted from the set as a result.

Conclusions: The pilot test resulted in the determination that a back pain recognition program is feasible and would be a significant start toward efforts to improve the quality of care for patients with back pain. The pilot test resulted in adjustments to some tested measures as well as defining the eligible population.


This program may be a challenge for many physicians but will lay out a path to deliberate patient-centered care for low back pain that is evidence-based and offers the potential to reduce costs associated with unnecessary services.

•

Use of Lipid-Lowering Agents and Lipid

Control among Men and Women

Sarah Scholle, Dr.P.H., M.P.H., Sarah Shih,

M.P.H., Simon Tang, M.P.H., David Schaaf,

M.D., Henry Solomon, M.D., FACP, FACC, L.

Gregory Pawlson, M.D., M.P.H., FACP

Presented By: Sarah Scholle, Dr.P.H., M.P.H.,

Assistant VP, Research, NCQA, 2000 L Street,

NW Suite 500, Washington, DC 20036, Phone:

202-955-1726, Fax: 202-955-3599, Email: scholle@ncqa.org

Research Objective: A growing body of literature demonstrates gender disparities in the

LDL control among managed care populations, while gender disparities are not seen in hypertension control and diabetic control. Data on whether these disparities may be explained by differences in patient characteristics or treatment are lacking. This study compared the use of lipidlowering agents and lipid control among men and women enrolled in commercial and

Medicare managed care plans.

Study Design: We obtained records for 9,109 patients identified as having hypertension from

24 volunteer health plans. Fifty-five percent of the patients were ages 60 years or older and 53.4 percent women. Thirty-three percent of the 9,109 patients are Medicare insured. A majority of the population reside in the southern census regions, 77.6 percent.

Population Studied: 1,154 women and 1,101 men with hypertension who also had a diagnosis of dyslipidemia and a valid LDL value recorded.

Principle Findings: Women and men in the sample did not differ in age, average number of medications, and whether they were hospitalized during the year, although 42.7 percent of men compared to 35.3 percent of women had coronary heart disease Of the women, 40.2 percent compared to 55.1 percent of men met recommended LDL level of less than 100dL.

Overall, 60.4 percent of women compared to

66.1 percent of men used lipid lowering agents.

However, the use of lipid lowering medications was similar among women and men whose lipid levels were above the recommended level; 54.3 percent for women versus 55.7 percent for men.

Similar trends are observed in hierarchical regressions controlling for patient age and lipid treatment; further analyses will consider the impact of co-morbid conditions and additional treatment variables.

Conclusions: Gender disparities in achievement of recommended lipid control levels care were noted and were not associated with lower use of lipid lowering medications in this national sample of commercial and Medicare managed care health plans. While there is ample room for improvement in lipid control for both men and for women, special attention must be directed to gender gap in obtaining control. More information is needed about the extent to which the disparity reflects clinical inertia, a failure to intensify treatment in women, poorer adherence by women, or other factors.


Monitoring quality of care by gender and other important subgroups is essential for uncovering disparities and observing whether disparities are decreasing over time. The continued presence of disparities suggests the need for interventions tailored to the needs of populations that show disadvantages, whether these disadvantages are based on gender or other factors. Improvements based on learning more about barriers for specific subpopulations have the potential to improve care for all.


• Management of Hypertension and Co-

Morbid Cardiovascular Risks

Sarah Shih, M.P.H., Sarah Hudson Scholle,

Dr.P.H., M.P.H., Simon Tang, M.P.H., David

Schaaf, M.D., Henry Solomon, M.D., FACP,

FACC, L. Gregory Pawlson, M.D., M.P.H., FACP

Presented By: Sarah Shih, M.P.H., Senior

Healthcare Analyst, Research, NCQA, 2000 L

Street, NW Suite 500, Washington, DC 20036,

Phone: 718-885-2544, Fax: 202-955-3599, Email: shih@ncqa.org

Research Objective: Few studies currently assess the level at which patients with multiple disease conditions are maintained at the recommended guidelines for cardiovascular prevention. Increasingly, patients at highest risk for adverse health outcomes and high health care costs are co-morbid for hypertension, diabetes, dyslipidemia, or coronary heart disease, CHD. In this study, we examine the maintenance of patients with hypertension and co-morbid cardiovascular, CV, conditions.

Study Design: Retrospective review of administrative and chart data used to identify persons with hypertension who had their blood pressure controlled to less than 140 over 90 mmHg. Additional information regarding comorbidities was collected through medical record review and administrative data sources.

This study compares rates of maintenance for persons with co-morbid conditions based on nationally recommended guidelines established by the Adult Treatment Panel III and Joint

National Committee. Thresholds for management by national reports are to lower BP to 130 over 80 mmHg, HbA1c to 7.0, and LDL to

100 mgdL or 70 mgdL for patients with CHD.

For HEDIS, treatment thresholds are BP to 140 over 90mmHg, HbA1c to 9.0, and LDL to 100 mgdL.

Population Studied: We obtained records for

9,109 patients identified as having hypertension from 24 volunteer health plans. Fifty-five percent of the patients were ages 60 years or older and

53.4 percent women. Thirty-three percent of the

9,109 patients are Medicare insured. A majority of the population reside in the southern census regions, 77.6 percent.

Principle Findings: Of the 2,062 patients with hypertension only, 64.9 and 30.3 percent met the

HEDIS and National BP goals respectively. Of the 3,245 patients co-morbid with diabetes, 57.9 percent met HEDIS and 29.8 percent met

National goals for BP and HbA1c. Of the 4,810 patient co-morbid with dyslipidemia, 51.5 percent met HEDIS and 20.4 percent met National goals for BP and LDL. For the 3,025 patients comorbid for CHD, 54.5 percent and 22.8 percent met HEDIS and National goals for BP and LDL.

For the 1,081 patients co-morbid with more than one other condition, 52.3 met HEDIS and 19.8 met National goals for BP, LDL, and HbA1c.

Conclusions: While risk for CV events and death increase in patients with hypertension and multiple co-morbidities, the proportion of patients with BP controlled is minimally higher or in the case of diabetes, is lower. For patients with hypertension and one other risk factor, control of both is highest in patients with diabetes and lowest in patients with cholesterol.

For patients with all four risk factors, only 19.8 percent meet the recommended control levels using national guidelines. Adherence to HEDIS measure thresholds is higher than national guidelines as guidelines often reflect ideal treatment goals, whereas HEDIS metrics are often based achievable goals in a broad population.


Data from clinical trials and variation in control levels achieved in practice suggest that better control of BP and other CV risk factors can be improved above the rates seen in this study. A composite metric including blood pressure,

HbA1c, and LDL values, may be useful in

tracking control in persons with hypertension and other CV risk factors.

Funding Source: Pfizer, Inc.

•

Workforce Perceptions of Hospital Safety

Culture: Development and Validation of the

Patient Safety Climate in Healthcare

Organizations Survey

Sara Singer, M.B.A., Laurence Baker, Ph.D.,

David Gaba, M.D., Mark Meterko, Ph.D., Alyson

Falwell, M.P.H., Amy Rosen, Ph.D.

Presented By: Sara Singer, M.B.A., Senior

Research Scholar, Center for Health

Policy/Primary Care and Outcomes Research,

Stanford University, 117 Encina Commons,

Stanford, CA 94305, Phone: (617) 495-5047, Fax:

(617) 325-7451, Email: ssinger@hbs.edu

Research Objective: Evidence increasingly suggests that having a culture that recognizes the central importance of safety is a key component of successful hospital safety improvement efforts. This has generated interest in tools to measure the strength of safety culture that can help drive efforts to improve it.

With a goal of expanding the set of available tools to cover areas not well captured by other safety culture surveys, this paper describes the development of an instrument------the Patient

Safety Climate in Healthcare Organizations

(PSCHO) survey------for assessing workforce perceptions of hospital safety culture, and efforts to assess its reliability and validity.

Study Design: We describe the development, implementation, and psychometric testing of the

PSCHO survey. In an attempt to be as broadly based as possible, the PSCHO was developed from a list of key topics pertinent to maintaining a culture of safety in organizations that face hazardous conditions, based on relevant literature and review of existing safety climate surveys. A draft questionnaire to address these topics was pilot tested it in four preliminary studies of hospital personnel. We iteratively modified the questionnaire based on experience and respondent feedback, and distributed the final revised version to workers from 105 hospitals in 2004. We conducted a range of tests on the resulting data. Principally, we randomly divided respondents into derivation and validation samples. We applied exploratory factor analysis to responses in the derivation sample and used those results to create scales in the validation sample, which we subjected to multi-trait analysis.

Population Studied: 21,496 hospital workers from 105 hospitals (survey response rate= 51%).

Principle Findings: Analyses identified nine constructs, three organizational factors, two unit factors, three individual factors and one additional factor. The organizational factors include senior managers’ engagement in patient safety, organizational resources for patient safety, and overall level of emphasis on patient safety at the facility. The work-unit dimensions are unit norms for patient safety and unit recognition and support for safety efforts. The three individual-level factors include fear of shame, fear of blame, and learning and selfawareness of safety risks. Evidence for discriminant validity is excellent, and for convergent validity and reliability is good.

Constructs identified include some that are present in other surveys, as well as new constructs.

Conclusions: It is possible to measure key salient features of hospital safety culture using a valid and reliable 38-item survey and appropriate hospital sample sizes. Importantly, this instrument is shorter than other available instruments, which may help with response rates. This instrument may be used in further studies to better understand the impact of safety climate on patient safety outcomes.


Continued development of safety culture research tools could benefit efforts to improve patient safety. The PSCHO instrument can be a valuable tool for assessing culture. The hierarchical segmentation of factors into tiers related to the organization as a whole, the work unit, and the individual may be valuable for future work.


• Service Use and Functional Outcome in a

Frail Population: When More is not Better

Helena Temkin-Greener, Ph.D., Dana B.

Mukamel, Ph.D., Alina Bajorska, M.S.

Presented By: Helena Temkin-Greener, Ph.D.,

Associate Professor, Community and Preventive

Medicine, University of Rochester School of

Medicine, 40 Chalet Circle, Rochester, NY 14642,

Phone: (585)275-8713, Fax: (585)461-4532, Email:

Helena_Temkin-Greener@urmc.rochester.edu

Research Objective: The literature documents that Medicare service use variations are

unwarranted and cannot be explained by patient characteristics. To date, there has been little riskadjusted empirical evidence as to the relationship between service use and functional outcome among the frail, chronically ill elderly.

The Program of All-Inclusive Care for the Elderly

(PACE) offers a unique model within which to investigate this relationship. In this study, we:

1) examine the extent of variation in the utilization of acute, long-term care, and rehabilitative services; and 2) assess whether programs providing more/fewer services have better/worse functional outcomes.

Study Design: We estimated five models measuring each program’s propensity to provide the following services: number of hospitalizations; number of short-term

(LOS<=90 days) admissions to nursing homes; day center attendance days per month; therapy encounters per months; and days of personal home care per month. For each program, we also estimated one program-level health outcome, change in functional status of the participants over time. Finally, we examined the impact of each of the five services on programlevel functional status. Mixed regression and

GEE loglinear Poisson models, as well as bootstrap procedure were employed in the study.

Population Studied: The analytical sample included 42,252 records for 9,853 individuals in

29 programs, over 3-years.

Principle Findings: Controlling for all other site effects, we examined the marginal effect on functional status over time for the 5 service types. Only hospital admissions had a statistically significant (0.196-0.825,95%CI) impact on functional status. Sites using more hospital care had worse functional outcomes.

We found no other significant relationship between functional change and service use. The program-level model also provides estimates of correlations between program-level measures.

Programs that provide more day center care have significantly (p<0.05) fewer hospital admissions (-0.408). Programs with greater propensity to provide therapy services also have significantly fewer hospital admissions (-0.291).

Conclusions: Greater program propensity to provide services does not appear to be associated with better participant outcomes in functional status. In fact, PACE programs providing higher intensity of hospital care demonstrate worse functional outcomes for their enrollees.


Health plans spend large amounts of money, mostly public funds, for services that are expected to increase or at least maintain the quality of care for their members. When evidence-based measures do not support that more care produces better outcomes, continuing widespread variations in service use are difficult to justify. Our findings suggest that such programs should re-examine the services they provide, and may wish to adjust the intensity with which they provide day center care and therapy. Greater focus on these services may lead to reductions in hospital admissions, better outcomes and cost savings.

Funding Source: NIA

•

Quality of Inpatient Care for Ischaemic

Stroke and Transient Ischaemic Attack at the

National Healthcare Group, Singapore

Matthias Paul Han Sim Toh, M.B.B.S., MMed,

Bee Hoon Heng, M.B.B.S., M.Sc., Ann Yin,

B.H.Sc., N Venketasubramanian, M.B.B.S.,

MMed, FAMS, Jason TS Cheah, M.B.B.S.,

M.Med, M.Sc.

Presented By: Matthias Paul Han Sim Toh,

M.B.B.S., MMed(Public Health), Assistant

Director, Health Services and Outcomes

Research, National Healthcare Group, 6

Commonwealth Lane #06-01 GMTI Building,

Singapore, 149547, Phone: (65) 6471-8971, Fax:

(65) 6471-1767, Email:

Matthias_TOH@nhg.com.sg

Research Objective: Compare the quality of inpatient care for treatment of ischaemic stroke and transient ischaemic attack (TIA) in the acute care hospitals of the National Healthcare Group

(NHG) in Singapore.

Study Design: A retrospective review of inpatient records for patients admitted to 3 acute care hospitals in 2004 with a diagnosis of stroke based on the quality indicators recommended by the Singapore Ministry of Health (MOH) Clinical

Practice Guidelines (CPG) for Stroke. The five key processes are brain scan within 24 hours, daily blood pressure monitoring, blood glucose testing on admission, electrocardiogram (ECG) monitoring and anti-platelet therapy where indicated. Other indicators include functional and social assessment, multi-disciplinary involvement and communication with patients or carers on prognosis and risk reduction. Rates were compared between the care of patients with ischaemic stroke and TIA. Data was analysed using SPSS.

Population Studied: Inpatients discharged from

2004 with a primary diagnosis of ischaemic stroke or TIA under the care of Neurology,

Neurosurgery, General Medicine or Geriatric

Medicine disciplines from the 3 hospitals in

NHG.

Principle Findings: A total of 448 patients were included. The majority had ischaemic stroke

(81.3%) and mostly under the care of Neurology

(31.3%), General Medicine (40.2%) and Geriatric

Medicine (16.6%) departments. Mean age of patients with ischaemic stroke was higher than those with TIA (72.2 vs 65.0 years, p<0.001).

About 38.6% of these patients had a previous stroke. The mortality among ischaemic stroke was 9.1% while all with TIA were alive at discharge. The length of stay for TIA was 3.6 days compared to 11.6 days for ischaemic stroke. All patients had daily blood pressure monitoring.

Rate for brain scan within 24 hours of admission was higher for ischaemic stroke (81.6% vis-à-vis

77.4% for TIA). Blood glucose testing was 96.1% for ischaemic stroke vs 95.2% for TIA. ECG within 24 hours of admission was 91.7% for ischaemic stroke vs 95.2% for TIA. Anti-platelet therapy was instituted in 80.5% of patients with ischaemic stroke and 79.8% for TIA.

For patients with ischaemic stroke, rate of swallowing assessment was 64.5%, physiotherapy 87.2% and occupational therapy

87.2%. There was greater documentation of communication of patients’ prognosis to relatives for ischaemic stroke (84.5% compared to 65.3% for TIA). However, the communication of risk education to patients was only 51.5% in ischaemic stroke and 50.6% in TIA.

Conclusions: There were minor differences in the rates of care among patients with ischaemic stroke and TIA. The rates of the 5 key process indicators were generally good but some could be improved further, especially performing a brain scan for patients within 24 hours of admission. More patients with ischaemic stroke could be referred to the multidisciplinary team of speech, occupational and physiotherapists. The communication of patients’ prognosis and education of risk factors for self management could be improved further especially for risk factor control.


Regular clinical review is necessary to identify practice variation and gaps. This allows benchmarking against one another, setting realistic targets and seeking continuous quality improvement.

Funding Source: National Healthcare Group

• Informing a Model for High Quality Cancer

Care --- Results from a Literature Review,

Patient, Focus Groups, Expert Interviews, and

Organizational Site Visits

Leah Tuzzio, M.P.H., Erin J. Aiello, M.P.H., Sarah

M. Greene, M.P.H., Beth Kirlin, B.A., Cheryl

Wiese, M.A., Ed H. Wagner, M.D., M.P.H.

Presented By: Leah Tuzzio, M.P.H., Project

Director, , Group Health Center for Health

Studies, 1730 Minor Avenue, Suite 1600, Seattle,

WA 98101, Phone: (206)287-2109, Fax: (206)287-

2485, Email: tuzzio.l@ghc.org

Research Objective: The Institute of Medicine’s

‘‘Crossing the Quality Chasm’’ report presents six aims that characterize high quality medical care: safety, effectiveness, efficiency, patientcenteredness, timeliness and equity. Using four perspectives------focus groups, expert interviews, site visits, and literature review------we examined the extent to which these six aims, plus a seventh aim------coordinated------are being met for people with cancer. We focused on early cancer care from diagnosis to surveillance, especially the transitions between care episodes, and sought to explicate barriers to quality care and the role that health system changes and information technology (IT) could play in improving quality of cancer care.

Study Design: We conducted a systematic literature review, and used qualitative methods to conduct semi-structured telephone interviews with experts in cancer care quality and informatics, and separate focus groups with patients with cancer, their families, and clinicians. The research team visited oncology and primary care practices and other cancer related organizations in three communities across the U.S. Each data collection component sought to elicit barriers and facilitators to high quality, patient-centered cancer care and policy.

Population Studied: The literature review included 474 peer-reviewed publications and additional ‘‘grey’’ literature including websites and technical reports. We interviewed 23 national experts (88% response rate). We sitevisited cancer care, primary care and advocacy organizations in Eastern WA, Detroit, MI, and

Boston and Worcester, MA. Seven focus groups, three in Spokane, WA, and four in Detroit, MI, included people who self-reported having been diagnosed with cancer; family members of people with cancer; physicians (medical and radiation oncologists, surgeons, and primary care physicians); and, other clinicians (nurses, social workers).

Principle Findings: A few key issues emerged from multiple data collection methods.

Prominent problems include lack of guideline adherence especially during diagnosis, surgery and follow-up; failure to coordinate care across transitions; delays during diagnosis often compounded by failures in coordination; lack of patient awareness of care options and empowerment to ask questions; lack of emotional and social support; unequal access to care due to inadequate medical insurance; reimbursement that rewards more aggressive therapy; and the lack of clear industry standards for oncology IT, and their high cost. Proposed solutions tended to focus on: adding nonphysician personnel to help coordinate care; IT improvements; and changing reimbursement to encourage greater attention to patient needs for information and psychosocial support.

Conclusions: Multiple transitions and high emotional distress characterize the early phases of cancer care. The lack of a cancer care

‘‘system’’, poor care coordination, and reimbursement that does not value patient education or psychosocial support conspire to make early cancer care a nightmare for many patients and families. Quality improvement in cancer care will require multi-pronged efforts to create coherent systems of care, supported by modern IT and reimbursement that supports high quality care. Based on our observations, we have developed a model of high quality cancer care.


The model for cancer care quality developed in this project hopefully will contribute to the design and testing of interventions to improve cancer care delivery.

Funding Source: NCI

• Measuring ICU Risk-Adjusted Length of

Stay Performance: Efficiently Measuring

Efficiency

Eduard E. Vasilevskis, M.D., R. Adams Dudley,

M.D., M.B.A., Michael W.Kuzniewicz, M.D.,

M.P.H., Mitzi L. Dean, M.H.A., Ronald Lane,

M.D., M.P.H., Eric Vittinghof, Ph.D.

Presented By: Eduard E. Vasilevskis, M.D.,

Health Services Research Fellow, General

Internal Medicine / Institute of Health Policy

Studies, University of California, San Francisco,

3333 California Street, Suite 265, San Francisco,

CA 94118, Phone: (415)477-1061, Fax: (415)514-

0214, Email: eduard.vasilevskis@ucsf.edu

Research Objective: There is growing interest in the measurement of efficiency variation among hospitals. One area of particular interest for the

JCAHO and several state reporting initiatives is the use of intensive care unit (ICU) resources as measured by length of stay (LOS). However, little is known about how best to risk adjust for differences among hospitals in their patient populations when evaluating ICU LOS.

Study Design: We calculated ICU LOS, truncated at 30 days to minimize impact of outliers. We used the clinical risk factors included in three validated mortality predication models, APACHE IV, MPM II, and SAPS II, for predicting LOS (APACHE had been used for LOS in a prior study). We estimated models on a

60% random sample of our data and assessed model accuracy with the remaining 40%. We compared mean observed and predicted ICU

LOS across deciles of predicted LOS to assess model calibration. We used paired Student’s ttests to assess for differences (p <0.05) between observed and predicted LOS, with adjustment for multiple comparisons (Bonferroni). We calculated observed:predicted LOS for individual hospitals to assess for variation in ICU efficiency.

Population Studied: We used data on ICU patients collected at 34 diverse California hospitals between 2002 and 2004 to evaluate variations in ICU LOS and to assess performance of three different LOS prediction models. We excluded: (1) ICU readmissions, (2) burn, trauma, or CABG patients, (3) ICU LOS < 4 hours, (4) age < 18.

Principle Findings: Among 12,579 total patients,

1,283 (10.2%) were excluded, leaving 11,296 patients. The mean and median ICU LOS were

4.1 and 2.0 days. In the validation sample, model R2s were: APACHE IV 0.191, MPM II

0.073, SAPS 0.044. Given our large sample size, the difference between mean observed and predicted LOS for each decile of predicted LOS differed significantly (p < 0.05) for 2, 0, and 5 of the ten deciles using APACHE IV, MPM II, and

SAPS II respectively. However, visual inspection of the calibration curves suggested reasonable calibration for APACHE and MPM, but poor calibration of SAPS. Plots of the observed:predicted LOS revealed that, regardless of model used for risk adjustment, there was 3fold variation in efficiency performance.

Spearman rank correlation coefficients showed high correlation among models’ assessments of hospital performance: 0.889 (APACHE ---- MPM),

0.8409 (APACHE ---- SAPS), and 0.892 (MPM ----

SAPS). APACHE, MPM, and SAPS identified 5,

6, and 8 outliers respectively. Concordance between LOS ratios was highest between

APACHE and MPM, agreeing upon 5 outliers.

Conclusions: Regardless of model used for risk adjustment there is up to 3-fold variation in ICU

LOS, with high correlation between the models in terms of hospital LOS rankings. APACHE IV and MPM II are better calibrated than SAPS II.


Large variations in risk-adjusted ICU LOS suggest this could be an important performance measure. Since choice of model has little impact on hospitals’ performance assessments, but

MPM II is well calibrated and involves significantly less data collection than APACHE or

SAPS, it may be an attractive tool for ICU LOS performance assessment.


• Organizational Resiliency: Responses to

Perceived Setbacks in Improving Door-to-

Balloon Times for Patients with Heart Attacks

Tashonna Webster, M.P.H., Leslie Curry, Ph.D.,

Martha Radford, M.D., David Berg, Ph.D., Harlan

Krumholz, M.D., S.M., Elizabeth Bradley, Ph.D.

Presented By: Tashonna Webster, M.P.H.,

Research Associate, Epidemiology and Public

Health, Yale University, 2 Church Street South,

Rm 409A, New Haven, CT 06520, Phone: (203)

764-9082, Fax: (203) 764-9078, Email: tashonna.webster@yale.edu

Research Objective: Despite the importance of prompt reperfusion in patients with ST-segment elevation myocardial infarction (STEMI), few hospitals meet national guidelines in this area.

National guidelines call for hospital median time from hospital arrival to angioplasty balloon inflation (known as door-to-balloon time) of 90 minutes or less. Previous research has documented a variety of strategies that hospitals can implement to reduce door-to-balloon time and has also suggested that all hospitals experience what they perceive as setbacks in their efforts to reduce door-to-balloon times.

This qualitative study examines the concept of organizational resiliency by describing the sources of and responses to setbacks identified by high-performing hospitals.

Study Design: We conducted a qualitative study using in-depth interviews (n=122) with key clinical and management staff involved in doorto-balloon time improvement efforts at 11 topperforming hospitals with exceptional improvement in the previous 4 years, based on door-to-balloon data from the National Registry for Myocardial Infarction, 1999-2002. Data for this analysis were derived from responses to interview probes concerning challenges during the 4-year trajectory of improvement and strategies used to address those challenges. We analyzed participant responses using the constant comparative method of qualitative data analysis. All data were entered into Atlas.ti

(Scientific Software Development, Berlin) to assist with organization and analysis of the data.

Population Studied: 11 top performing hospitals in door-to-balloon time participating in NRMI between 1999-2002

Principle Findings: We identified three common sources of setbacks described by hospital staff: 1) failures of inadequate system design, 2) interpersonal tensions between and within departments and disciplines, and 3) waning attention to door-to-balloon time performance.

High-performing hospitals responded to system failures by employing the quality improvement techniques of root-cause analysis and rapid data feedback to understand failures and stimulate redesign efforts. Interpersonal tensions and conflicts were reduced by teams repeatedly focusing on the shared goal of optimal patient care and by engaging senior management to apply pressure to mediate and resolve conflicts.

Waning attention to door-to-balloon time was addressed by reminding staff of the external pressures to improve door-to-balloon time (e.g., public reporting, market competition on quality of heart care), which provided motivation to refocus efforts.

Conclusions: For high-performing hospitals, setbacks were part of the process of improvement. Demonstrating an essential component of organizational resiliency, the hospitals responded to setbacks as a natural part of organizational change rather than allowing such challenges to derail improvement efforts.

Understanding how top performing hospitals work through such setbacks and continue their performance improvement may help other hospitals prepare for inevitable difficulties as they seek to meet national guidelines for door-toballoon time.


As health care organizations strive to improve quality, a variety of challenges persist, even among institutions that are top performers.

Learning how to enhance organizational resiliency is a critical aspect of skill for managers and practitioners seeking to sustain quality improvement efforts. High-performing hospitals describe continuous system redesign, negotiation of interpersonal conflicts, and sustaining a sense of urgency to improve as common strategies for persisting in the face of

challenges inherent to processes of organizational change.

Funding Source: National Heart, Lung, and

Blood Institute

• Total Hip Replacement Quality and Cost:

Practice Makes Perfect --- Procedure Volume

Predicts Operative Time, Mortality,

Rehabilitation, Total Costs, and LOS

Sudha Xirasagar, M.B.B.S., Ph.D., Herng-Ching

Lin, Ph.D.

Presented By: Sudha Xirasagar, M.B.B.S., Ph.D.,

Assistant Professor, Health Services Policy and

Management, University of South Carolina,

School of Public Health, 800 Sumter Street, Rm

116, Columbia, SC 29208, Phone: (803) 576

6093, Fax: (803) 777 1836, Email: sxirasagar@sc.edu

Research Objective: Early rehabilitation and complication prevention in Total Hip

Replacement (THA) are facilitated by prompt post-surgical healing, optimum biomechanics of the implant, and minimal (surgical) tissue damage, which are greatly impacted by the surgeon’s skill. Skilled surgeons are likely to have lower average operating times. We examined whether practice makes perfect for Total Hip

Replacement (THA) outcomes, by testing the following hypotheses: a) Increasing physician

THA volume (but not hospital volume) is associated with reduced operative time; b)

Increasing physician and hospital volume are associated with better outcomes (lower mortality and early initiation and sustained rehabilitation) and lower costs (total inpatient costs and length of stay, LOS); c) Lower operative time mediates physician volume-outcome and volume-cost relationship: operative time will significantly predict mortality, rehabilitation, inpatient cost and LOS.

Study Design: Retrospective analysis of population-based inpatient claims, excluding secondary and traumatic fractures. Proxy variables: Anesthesia costs (proportional to anesthetist time) for operative time, and physiotherapy fraction of inpatient cost for early and sustained rehabilitation. Other variables: As indicated, using log transformations when necessary. We used hierarchical linear and logistic regression modeling, adjusting for patient and physician demographics, hospital characteristics, and co-morbidities, introducing a random effect for hospital in the physician volume analyses, and for physician in the hospital volume analysis. To test physician and hospital volume versus operative time, we controlled for liver and kidney dysfunction, hypertension and diabetes, which impact intrasurgical decisions, and for other regressions, the

Charlson-Deyo Comorbidity Index. We sorted physicians/hospitals in ascending order of volume, to establish volume cutoffs such that patients fell into one of three volume groups of about equal cell sizes. Physician groups: Low

=24 cases, Medium 25-72, High =73. Hospital groups: Low =105, Medium 106-303, High =304.

Population Studied: All inpatient claims, 2001-

2003, from Taiwan’s National Health Insurance,

13,681 cases.

Principle Findings: Adjusted estimates show that, for physicians, increasing volume (low through high) predicts lower anesthesia cost

(13.2% less than the mean for high volume physicians), lower inpatient mortality, lower LOS

(16.6%), lower inpatient costs (3.2% less), and higher physiotherapy fraction of inpatient cost

(6.1%). For hospitals, increasing volume does not predict anesthesia cost, but predicts lower in-hospital mortality, inpatient cost, LOS, and higher physiotherapy cost fraction. Increasing anesthesia cost predicts higher (adjusted) inhospital mortality, inpatient cost and LOS, and lower physiotherapy cost fraction.

Conclusions: Surgical performance quality improves with increased physician volume, because volume predicts lower operative time, which in turn predicts lower adjusted inpatient costs, LOS, and inpatient mortality, and importantly, higher physiotherapy cost fraction of total inpatient costs. Hospital volume impacts cost, mortality and physiotherapy cost fraction, but not operative time, reflecting the role of ancillary care organization in quality and cost outcomes. Practice indeed makes perfect, and operative time is a subtle proxy for surgical skill.


Policymakers, payers and professional associations should collaborate to ensure procedure-credentialed physicians have a senior professional’s backup assistance during operations until they their (post-credential) procedure level crosses a threshold level. This will save lives, reduce costs, and facilitate speedy patient healing and functional rehabilitation.

• Developing A Pay for Quality-Adjusted

Efficiency System

Ning Zhang, M.D., Ph.D., M.P.H.

Presented By: Ning Zhang, M.D., Ph.D., M.P.H.,

Assistant Professor, Health Administration,


Drive, Orlando, FL 32826, Phone: 407-823-3344,

Email: nizhang@mail.ucf.edu

Research Objective: The emerging pay-forperformance system centers on quality to incentivize health care providers, and fails to include efficiency or productivity in performance evaluation. This study’s aims are to:1) demonstrate the feasibility of developing a quality-adjusted efficiency measurement; 2) evaluate its applicability as a method for benchmarking the performance; and 3) compare the pay-for-quality and pay-for-quality-adjusted efficiency systems in terms of their relative performance rankings.

Study Design: Medicare Cost Report data and

Online Survey, Certification, and Reporting

(OSCAR) annual survey data with multiple years were used to develop the quality-adjusted efficiency measurement. We conducted Data envelopment Analyses (DEA) to generate the facility specific efficiency scores based on seven years of longitudinal data (1997-2003). The inputs and outputs of efficiency scores include wage-index adjusted general administrative, inpatient, and ancillary costs and Medicare,

Medicaid, and other patient days, respectively.

Severity-adjusted OSCAR deficiencies were used as the adjustments for outputs of efficiency computation. DEA derived efficiency scores were then ranked to reflect the relative performance of nursing homes. Finally, we compared rankings based on sole quality and quality-adjusted efficiency and observed their differences.

Population Studied: All US skilled nursing homes certified by Medicare or Medicare from

1997-2003. Totally 58,529 facility-based observations (an average of 8,361 facilities peryear) were included over years after data cleaning.

Principle Findings: The quality-adjusted efficiency scores were successfully developed using the DEA approach. Relative rankings of nursing home performance in terms of qualityadjusted efficiency were produced as the balanced scorecard, with the maximum score of

100. The variations of the performance scores allow us to identify the top performers (top 25%) and low performers (bottom 25%) among all studied skilled nursing homes. The comparisons between the pay-for-quality and pay-for-quality adjusted efficiency systems suggest that two systems yield different benchmarks for nursing homes’ performance. The correlation between the two performance scores for the panel of the same nursing homes appears to be low but statistically significant.

Conclusions: The pay-for-quality-adjusted efficiency system offers benchmarks that are more comprehensive than theses generated from the pay-for-quality system. This comprehensive system could be considered as a balanced scorecard approach for reimbursing and rewarding better performing nursing home providers.


Developing a comprehensive balanced scorecard that includes efficiency measures represents an innovation that extends the current pay-forperformance system. This development makes a concerted effort to advancing the science of formulating a rigorous balanced scorecard method. How to integrate other performance indicators, such as equity and healthcare outcomes, into the pay-for-performance system needs to be explored.

Funding Source: CMS

Quality: Reporting &

Rewarding Performance

•

Physician Perspectives On Pay-For-

Performance Measures For Transitional Care

Alicia Arbaje, M.D., M.P.H., Kathryn J. Eubank,

M.D., Kenric A. Maynor, M.D., M.P.H., Joseph A.

Carrese, M.D., M.P.H.

Presented By: Alicia Arbaje, M.D., M.P.H.,

Clinical and Research Fellow, Division of

Geriatric Medicine and Gerontology, Johns

Hopkins University, 346 Homeland Southway,

Baltimore, MD 21212, Phone: 410-462-6775, Fax:

410-462-6775, Email: aarbaje@jhmi.edu

Research Objective: Despite substantial investments in recent years in patient safety and quality in medical care, transitional care has been relatively neglected. Transitional care involves the coordination of care for patients as they transfer across health care settings.

Suboptimal transitional care often results in poor patient satisfaction, unplanned health care utilization, and adverse events. The Medicare program is interested in pay-for-performance

(P4P) measures as a method to evaluate and improve the care of older adults. P4P may be an effective strategy to improve transitional care, but there are no standard quality indicators on which to base reimbursement. Provider attitudes towards P4P for transitional care will be critically important in ensuring the development and adoption of measures. The objective of this study was to identify and characterize physician

perspectives on P4P measures and their ability to affect the quality of transitional care.

Study Design: We conducted a qualitative study using 1-hour in-depth interviews with 18 physician informants.

Population Studied: Physicians were drawn from 4 sites of care in the greater Baltimore area:

1 hospital, 1 skilled nursing and rehabilitation facility, and 2 community-based clinical practices. The interviews explored physicians’ experiences with suboptimal transitional care and their suggestions for P4P measures to improve the quality of transitional care.

Principle Findings: Physicians had an average age of 44 years (range 32-74 years) and averaged16 years in practice (range 4-49 years).

Eight were women, 3 were Asian, 2 were African-

American, and 1 was Latino. In preliminary analyses, physicians characterized effective P4P strategies as incorporating 4 key elements: 1) independence from patient factors; 2) relevance to patient outcomes; 3) adaptability to changes in the health care system; and 4) incorporation of feedback. Physicians had specific suggestions for P4P measures for transitional care: 1) assurance of meaningful communication between providers; 2) completion of medication reconciliation at each transfer; 3) provision of patient education during care transitions; and 4) evaluation of primary care physicians’ satisfaction with the transfer of care. Physicians had differing perspectives regarding how they would implement P4P measures. Regarding communication, some physicians placed more importance on improving verbal communication between providers, while others placed more importance on improving electronic transfer of information.

Physicians also identified potential barriers for the successful implementation of P4P measures.

Some doubted whether health care providers would accept P4P as a model for reimbursement. Physicians were additionally concerned that P4P would unfairly penalize them for outcomes beyond their control, such as patient non-adherence to an established plan of care.

Conclusions: In this study, physicians described markers of effective P4P strategies for transitional care and suggested measures to improve the care transitions process.


Study findings illustrate important challenges in designing P4P measures for transitional care.

Understanding these challenges is important to ensure effective development, dissemination, and adoption of appropriate P4P measures.

Physicians’ perspectives may eventually contribute to the design of evaluation and reimbursement mechanisms to improve the quality of transitional care, which would be of great interest to patients, providers, payers, and policymakers.


• Psychometric Evaluation of Quality

Indicators for Potential Use in Quality

Composite Measures of Physician

Performance

Gerald Arnold Arnold, Ph.D., M.P.H., Weifeng

Weng, Ph.D., Halyna Didura, B.S., Eric S.

Holmboe, M.D., Rebecca S. Lipner, Ph.D.

Presented By: Gerald Arnold Arnold, Ph.D.,

M.P.H., Statistician, American Board of Internal

Medicine, 510 Walnut Street, Suite 1700,

Philadelphia, PA 19106, Phone: 215.446.3568,

Email: garnold@abim.org

Research Objective: Developing composite measures of physician performance across different medical conditions and practice characteristics using a subset of the ambulatory care measures endorsed by the National Quality

Forum (NQF) is considered. A psychometric analysis of measures from chart audits of patients with three chronic conditions: diabetes, cardiovascular disease, and hypertension is presented.

Study Design: The American Board of Internal

Medicine (ABIM) requires physicians to evaluate their practices as part of the Maintenance of

Certification program. One evaluation tool is the

ABIM’s Practice Improvement Module (PIM) with a chart audit component. Three PIMs commonly used are: Diabetes, Preventive

Cardiology (PC), and Hypertension. Reliability estimates based on intraclass correlation coefficients (ICCs) of process measures and clinical outcomes (e.g., lipids, blood pressure) will be compared (Fisher Z and Feldt tests) across medical conditions and practice characteristics. Additional analyses included plotting distributional characteristics, factor analyses, subgroup contrasts via mixed models, and assessment of case-mix adjustments.

Population Studied: 31,555 patient charts were audited by 1,320 physicians, with 638 completing

Diabetes, 368 completing PC, and 314 completing Hypertension.

Principle Findings: Process measures tended to have higher reliabilities than clinical outcome measures. For example, the reliability of annual lipid profiles for patients in the PC PIM, [ICC =

0.25: 95% CI (0.22 to 0.28)] is higher (p<0.01) than the reliability for proportion of patients with

LDL < 100 mg/dl, [ICC = 0.08, (0.07 to 0.09)].

This finding is consistent across the three chronic conditions. The degree of ICC similarity for the same measure among PIMs seems sensitive to the goal criterion. For example, proportion of patients having triglycerides < 150 mg/dl: [ICC ---- Diabetes = 0.05, (0.04 to 0.06)] versus [ICC ---- PC = 0.06, (0.05 to 0.08)] versus

[ICC ---- Hypertension = 0.06, (0.05 to 0.08)] are not significantly different (p>0.05) but when the criterion is shifted to triglycerides < 200 mg/dl then the reliability of the measure from the

Diabetes differs significantly from the PC and

Hypertension reliabilities [ICC ---- Diabetes = 0.04,

(0.03 to 0.05)]; [ICC ---- PC = 0.05, (0.04 to 0.07)]; and [ICC ---- Hypertension = 0.06, (0.04 to 0.07)].

ICC values with and without case-mix adjustments (gender, age, behavior, and other co-morbidities) tend to be similar. For example the ICC for proportion of diabetic patients

(Diabetes) with annual lipid profiles without case-mix adjustment [ICC = 0.23, (0.21 to 0.25)] versus with case-mix adjustment [(ICC = 0.23,

(0.20 to 0.25)]. Factor analyses and subgroup comparisons are in process.

Conclusions: The psychometric properties of the common measures across PIMs are dependent upon goal criterion values and patient case-mix. Therefore, the use of these measures in developing a composite for any specific condition must take this into consideration.

Implications for Policy, Practice or Delivery: In assessing the quality of physician healthcare via composite measures we must consider the reliability profiles of process and clinical outcome indicators collected within and across medical practice settings and chronic conditions.

The context of practice appears to be an important factor in the construction of composite measures.

Funding Source: ABIM, NQF

• Patient Safety Indicators in an Urban Public

Hospital System

Richard Baker, M.D., Deyu Pan, M.S., Kevin

Heslin, Ph.D.

Presented By: Richard Baker, M.D., Drew Center for Health Services Research, 2594 Industry Way,

Lynwood, CA 90262, Phone: 310-761-4722,

Email: rbaker2@ucla.edu

Research Objective: Patient safety information specific to the health care safety net are sparse.

In 2006, one of five acute care hospitals within the LA County public hospital system (LACPHS) underwent decertification by CMS secondary to patient safety concerns. Hospital decertification raised questions both with respect to the previous safety profile of the CMS decertified hospital (CMSDH) and the safety profile of

LACPHS relative to other hospitals. We used a validated, objective measure, AHRQ Patient

Safety Indicators (PSIs) to assess whether 1) patient safety issues in the CMSDH were longstanding and could be identified in a previous time period, 2) the CMSDH was a patient safety outlier within LACPHS or typical of the LACPHS, 3) the patient safety profile of

LACPHS differed substantially from the nonpublic hospitals in LA County?

Study Design: Longitudinal analysis in which we calculated hospital-level PSI counts

(numerators), acute-care hospitalizations

(denominators), observed, expected, and AHRQsmoothed rates (estimates of rates that are both risk-adjusted and smoothed across multiple years of data) for 21 PSIs for all hospitals in LA

County for two year intervals from 1991 to 2000 using California Office of Statewide Health

Planning and Development Data and AHRQ PSI software (version 2.0).The five hospitals within

LACPHS were ranked in two ways. For each hospital, we calculated the number of PSI rates less than the lower bound of the 95% confidence interval of the system (better than system), and the number of PSI rates higher than the upper bound of the 95% CI (worse than system).In addition the rank ( 1= best and 5 = worst) of the

21 PSIs was averaged for each hospital for comparison. Finally, the safety profile of the public hospital system was compared to non public hospitals by assessing the relative number of PSI rates that were outside the 95% CI for all hospitals in LA County.

Population Studied: 11 million patient discharges from 130 acute-care hospitals in Los

Angeles County from 1991 to 2000.

Principle Findings: The worst patient safety ranking of the CMSDH within the LACPHS over the study period was in 91/92 when it was ranked number 3 of 5 ( 3 PSIs worse than system

, 6 PSIs better than system , Average PSI rank

=2.8 compared to 2.0,2.3,3.4 and 3.5).The

CMSDH ranking consistently improved over time. In 99/00 the CMSDH was ranked 1 of 5 according to study criteria ( 1 PSI worse than system, 6 PSIs better than system, Average PSI rank = 1.9 compared to 2.4,3.1,3.1 and 3.8).The

LACPHS manifested both a higher number of

PSI rates less than (better) and greater than

(worse) than the 95%CI for all LA county hospitals compared to non public hospitals. The

CMSDH profile compared favorably to both.

Conclusions: PSI data indicate that from 1991 to 2000 the patient safety profile of the recently

CMS decertified public hospital was consistently as good or superior to other hospitals within the

LACPHS and compared favorably to nonpublic hospitals


Objective data indicate that institutional patient safety challenges leading to CMS decertification of a public hospital were neither longstanding or an inherent characteristic of the institution but the result of actions or system changes occurring after 2000.


•

The NPDB And Trends In Reporting

Provider Performance

Jane Bolin, Ph.D., J.D., B.S.N.

Presented By: Jane Bolin, Ph.D., J.D., B.S.N.,

Assistant Professor, Health Policy &

Management, Texas A&M HSC School of Rural

Public Health, TAMU-1266, College Staion, TX

77843, Phone: (979) 862-4238, Fax: (979) 862-

8371, Email: jbolin@srph.tamhsc.edu

Research Objective: Nearly 20 years have passed since Congress enacted what is now known as the Health Care Quality Improvement

Act (HCQIA), as part of Title IV of Public Law 99-

660. The HCQIA established the National

Practitioner’s Data Bank (NPDB), and made reporting of malpractice settlements, verdicts, and disciplining of providers a mandatory requirement for HC organizations in licensing, credentialing and peer review. The goal of this research is to investigate and examine negligence and professional misconduct reporting to the National Practitioner's Data

Bank (NPDB) in order to evaluate trends and changes healthcare provider quality performance.

Study Design: This research examines the

NPDB for selected healthcare professionals, examining a database of 385,833 professionals reported to the NPDB, exploring the nature of professional misconduct, reporting entities and sanctions by professional specialty. The study design is an investigational comparison of rates of malpractice reports, types of reports and reporting entity between 1986 and 2005.

Population Studied: The data source for this study is the entire National Practitioner’s Data

Bank, accessed through a publicly available data file maintained by the Division of Practitioner

Data Banks, Bureau of Health professions, at the

Health Resources and Services Administration

(HRSA). Both the NPDB and HIPDB are publicly available at www.npdb-hipdb.com For purposes of this research, variables of interest within the

NPDB database are all reports concerning physicians, nurses, dentists, pharmacists, psychologists/counselors, podiatrists and listing of the type of adverse action, specialty, and several categories of negligence or malpractice act or omission.

Principle Findings: The NPDB provides a rich and useful data resource for examining trends in negligence, intentional misconduct, as well as state and federal sanctions against health care professionals. Physicians are, by far the most reported health professionals (223,522 claims), followed by dentists (37,113), podiatrists (6,015), nurses (3,444), pharmacists (1,383) and psychologist/counselors (1,341). Overall, rates of claims and sanctions dropped for physicians, dentists, psychologists/counselors and podiatrists since 2000, while the number of claims and sanctions for nurses and pharmacists has increased since 2000. The vast majority of claims reports are made by malpractice insurance companies (64%), with state licensing boards involved in 15% of the claims, and hospitals making 4% of the claims.

Conclusions: This research demonstrates that a majority of NPDB reports are made by insurance companies and are associated with a malpractice settlement or verdict. State licensing boards have considerable influence and are responsible for a substantial percentage of reports as well.

Further investigation on rates and trends of specific practice deviation is warranted.


Since NPDB reporting is mandatory, there may be little opportunity for an individual healthcare professional to advocate, defend and otherwise avail him/herself of due process protections as they would in a state licensing board proceeding.

However, the NPDB has proven to be an important regulatory and quality monitoring resource for healthcare organizations and licensing boards.

Funding Source: Texas A&M Health Sciences

Center

•

The Performance Evaluation System In The

Tuscan Healthcare System: A Government

And Management Tool

Anna Bonini, M.A.

Presented By: Anna Bonini, M.A., Researcher,

Management and Health Laboratory, Scuola

Superiore Sant'Anna, piazza martiri della libertà

33, pisa, Italy, 56127, Phone: +39 050 883833, Fax:

+39 050 883834, Email: anna.bonini@sssup.it

Research Objective: In the last few years the

Management and Health Laboratory of Scuola

Superiore Sant’Anna has designed and implemented for the Tuscany region a multidimensional system to assess the Health

Authorities performance, with the aim of giving a general outline for the management of the

Health Authorities, useful both for evaluating performance and for enhancing and promoting the results achieved in the healthcare system.

Study Design: A multidimensional evaluation system has been developed and it includes an essential number of indicators (39), divided in six dimensions: population state of health, consistency with the regional strategies, clinical and health assessment, external assessment, internal assessment, efficiency and financial assessment. To provide an adequate representation of the results reported by the health authorities in each of the areas identified, a ‘‘target’’ diagram was used, divided into five assessment bands. The more a local health authority is capable of reaching objectives and obtaining results in the various performance areas, the nearer the centre of the target diagram is the performance indicator.

Population Studied: Object of the system is the multidimensional performance of the sixteen

Tuscan health authorities: four of them are teaching hospitals, integrated with the

Universities of Florence, Pisa and Siena; the other twelve are local health authorities that deliver their services throughout community hospitals, outpatient departments and prevention services to 3.500.000 tuscan citizens, using 6 billion of euros.

Principle Findings: The performance evaluation system has permitted to represent various aspects of Health Authorities, to which the regional administration, the top management and other shareholders refer either in terms of indicators and shared responsibilities. In the

Tuscan healthcare public context that strives to stand out for the process of cooperation and non competition among the providers of health care services, it has been important to plan and develop a transparent and shared system, capable of monitoring not only the economicfinancial results of the Health Authorities, but their capacity of pursuing the aims of the

Regional Health Care Plan as well. In this respect, the way the Institutions are managed and the output they obtain from the service delivery process, in terms of clinical quality and citizens’ satisfaction, gain great relevance.

Conclusions: At the second year of implementation, the evaluation system has been proven to be a reliable and valid instrument that helps the Regional government, on one side to evaluate its strategic action, and on the other side to promote a ‘‘managed’’ competition among the health authorities. The system is used continuously and systematically at a regional level, as a public policy tool that allows to enhance innovation and improvement without wasting resources, as can occur in a free market.


Performance evaluation in healthcare services links policy to management and can become the mean through which output results may be oriented to achieve better outcomes.

• Improving Quality: Performance-based

Contracts for Treatment of Substance Use

Disorders

Mady Chalk, Ph.D., Deni Carise, Ph.D., Jack

Kemp, Lynn Fahey, M.A.

Presented By: Mady Chalk, Ph.D., Director,

Center for Performance-based Policy, Treatment

Research Institute, 150 S. Independence Mall

West, Phildaelphia, PA 19106, Phone: (215) 399-

0980 x103, Email: mchalk@treasearch.org

Research Objective: To study the implementation of performance-based contracts with substance abuse treatment programs in which the performance requirements focus on measures of patient behavior and functional status rather than provider-level measures of treatment process or treatment delivery.

Study Design: Select and design measures of performance working with treatment providers; implement contracts with all outpatient treatment providers with financial incentives tied to measures, study implementation over a 3 year period.

Population Studied: All outpatient substance abuse treatment providers and their clients in the State of Delaware.

Principle Findings: Selection of patient-level behavioral goals as the operational definition of

"performance" in the system placed the authority and responsibility for the type, content, and quality of care delivery in the hands of the treatment providers; the process by which financial incentives were set fostered collaboration among the providers, rather than a

competitive environment; programs were able to share best practices with each other to optimize their performance since all could "win." The performance criteria were able to be met by most treatment providers.

Conclusions: Improving quality of care using performance-based contracts in treatment of substance use disorders is effective, providing the performance criteria are focused on improving the functional status of patients and patient behavior rather than simply establishing the specific methods by which care must be delivered. It may be more useful to create

"practice-based evidence" by studying these kinds of efforts to improve quality and the effectivness of treatment than to continue to focus exclusively on application of "evidencebased proactices" that are the result of clinical trials.


Performance-based contracts focused on patient outcomes rather than methods by which care is delivered can be negotiated with substance abuse treatment programs; financial incentives can be used effectively to improve the quality of care.


• High-Performance Health Plan Networks:

Early Experiences

Debra Draper, Ph.D., Allison Liebhaber, B.A.,

Paul B. Ginsburg, Ph.D.

Presented By: Debra Draper, Ph.D., Director of

Site Visits and Senior Researcher, Center for

Studying Health System Change, 600 Maryland

Avenue SW, Suite 550, Washington, DC 22025,

Phone: 202-484-4220, Fax: 202-484-9258, Email: ddraper@hschange.org

Research Objective: High-performance networks are a recent addition to the arsenal of tools that health plans and purchasers are using to curb costs and improve quality. The purpose of this research is to examine early experiences with these high-performance networks, including how they are defined and structured, initial market responses and challenges, and preliminary lessons learned.

Study Design: Findings are based on semistructured interviews conducted between May and September 2006 with approximately 20 respondents, including representatives of national health plans and regional plans offering high-performance networks in four target markets, as well as representatives of providers, employers, and benefits consultants knowledgeable about these local markets.

Population Studied: Four markets that have experience with high-performance networks, including Boston, Milwaukee, Seattle, and

California.

Principle Findings: Health plans have recently introduced high-performance networks, which are designed to encourage enrollees' use of providers, predominantly physician specialists, deemed high performing. While the exact specifications of high-performance networks differ across plans, they are derived by profiling physicians using some combined measures of efficiency and quality. Across markets, physicians expressed concern about these networks, including the methodologies used to determine the high-performance designations. Early adopters of high-performance networks are large national employers, and, while other employers have expressed growing interest, actual adoption has lagged. Initial enrollment in highperformance networks is limited, and the available evidence on their impact is largely anecdotal at this time. Preliminay lessons gleaned, however, indicate the need for: effective communications between plans and providers; use of measures of both costs and quality; industry standards around provider performance; and employer support.

Conclusions: As additional experience is gained with high-performance networks, their impact on service use, costs, and quality will become clearer. Initially, the focus of high-performance networks has been on the potential gains that might be achieved by moving some enrollees to higher performing providers.


System-wide, any gains that might be achieved by providers that are designated as highperforming are limited by their capacity. The larger potential is based on moving sufficient volume away from lower performing providers that they are motivated to improve, thereby improving the system overall. For this to be realized, health plans have to support physicians by providing sufficiently detailed and accurate information to identify for each provider those areas in which their performance is not measuring-up. The potential will also depend on the degree to which employers institute benefit structures that icentivize employees to shift to high performing providers, which in turn will be dependent on whether employees perceive high performance networks as something of value or as a reminder of what they disliked in the past about narrow provider networks.

Funding Source: California HealthCare

Foundation

•

The Drive Toward Quality: Do CMS Quality-

Process Measures Improve Quality Of Care In

The Emergency Department?

Reena Duseja, M.D., Sanford Schwartz, M.D.,

Ralph Gonzales, M.D., Carlos Camargo, M.D.,

Joshua Metlay, M.D., Ph.D.

Presented By: Reena Duseja, M.D., RWJ Clinical

Scholar, RWJ Clinical Scholars program,

University of Pennsylvania, 1303A Blockley Hall,

423 Guardian Drive, Philadelphia, PA 19104,

Phone: 215-573-2574, Fax: 215-573-2742, Email: rduseja@wharton.upenn.edu

Research Objective: The objectives of this study are to: 1) Identify hospital-level characteristics

(e.g. quality initiatives, emergency department

(ED) volume measures) associated with the level of performance on ED community acquired pneumonia (CAP) quality-process measure guidelines. 2) Evaluate whether performance on time-to-antibiotic administration for CAP is associated with performance on unreported quality measures, including inappropriate antibiotic prescription patterns for acute respiratory tract infections (ARIs) in EDs.

Study Design: The study is a cohort design using existing and prospective data collection from the Improving Antibiotic Use in Acute Care

Treatment (IMPAACT study), a multi-site clinical trial of interventions to improve the quality of antibiotic use for ARIs. Data analysis is limited to the 8 non-federal, academic-affiliated hospitals that participated in data collection from the winter periods of 2003-2006.

Population Studied: The source population for this study is subjects age 18 and older who present to the 8 academic-affiliated hospitals between the winter periods (November-

February) of 2003 through 2006. A random sample of 200 ARI visits (50/month) was sampled at each site during each winter season as part of the ongoing IMPAACT trial. All pneumonia cases have been sampled from this primary database.

Principle Findings: Data collection for the performance measures and unintended consequences and analyses are underway, and final results will be available to present at the meeting. Preliminary analyses over the first two years show the percentage of patients receiving antibiotics within 4 hours across 8 sites to be lower (33-45%) than on-line publicly reported data via the website, HospitalCompare (50-

70%).


The study results will help us to better understand whether large-scale quality improvement activities have unintended effects, and what systematic factors play a role in guideline implementation. Such results have important clinical and policy implications for the development and implementation of quality-of- process guidelines in ED settings.

Funding Source: VA and AHRQ

• Reports and Ratings of Care by African

American and White Medicare Managed Care

Enrollees

Marie Fongwa, Ph.D., M.P.H., R.N., William E.

Cunningham, M.D., M.P.H., Robert Weech-

Maldonado, Ph.D., M.B.A., Peter R. Gutierrez,

M.A., Ronald D. Hays, Ph.D.

Presented By: Marie Fongwa, Ph.D., M.P.H.,

R.N., Assistant Professor, Nursing, University of

California Los Angeles, 700 Tiverton Avenue, 3-

238 Factor, Los Angeles, CA 90095-6917, Phone:

310 825-4583, Fax: 310 267-0413, Email: mfongwa@sonnet.ucla.edu

Research Objective: Research Objective: There is increasing recognition of the value of patient reports and ratings of care for monitoring care and identifying areas needing improvement. The persistence of health disparities between African

Americans and Whites is well documented even among persons with similar health coverage. The nation’s goal to eliminate health disparities by

2010 sets a timeline for identifying disparities in health care and reducing them. The objective of the study was to examine the relationship between race/ethnicity and reports and ratings of care between African American and White

Medicare managed care health plan enrollees.

Study Design: Secondary data analysis of the

Consumer Assessment of Healthcare Providers and Systems (CAHPS?) 3.0 survey of 101,189

(White) and 8,791 (African American) Medicare enrollees (82% response rate) randomly sampled from 321 health plans. Data were collected by cross-sectional survey via mail

(84%) and telephone (16%). Measures in the

CAHPS? 3.0 survey include five multi-item composites measuring getting care quickly/timeliness, provider/doctor communication, office staff, and health plan customer service and four single-item global ratings of care from one’s personal doctor or nurse, specialists, overall health care, and health

plan performance. Multivariate regression models were calculated with race/ethnicity as the main independent variable and the CAHPS? composites and global ratings as dependent variables, controlling for age, gender, education, and self-rated health.

Population Studied: Africans Americans and

Whites Medicare enrollees. Participants who completed the Spanish-language version of the survey and/ or self-identified a belonging to an ethnic group other than White or African

American were excluded for the analyses.

Principle Findings: Compared with Whites,

African Americans were younger, less educated, and less healthy. Controlling for these variables,

African Americans reported worse experiences with getting care quickly, office staff helpfulness, getting needed care, health plan customer service (p = .0001 and effect sizes = .21, .04, .08, and .13, respectively), rating of specialist care (p

= .02 and effect size = .02), and rating of the health plan (p = .0001 and effect size = .08).

However, they reported better provider communication (p = .0001 and effect size = .07), and rated their personal doctor/nurse and health care more positively (p = .0001 and effect size =

.09; p = .001 and effect size = .02, respectively).

Conclusions: Communication and health care received from doctors and other providers is perceived positively by African Americans. These positive experiences may provide a useful model for improving other aspects of health care. The negative health plan overall rating probably reflects problems with the timeliness and accessibility of services provided. Improvements in the overall plan rating by African Americans

Medicare enrollees could lead to improvements in health and reduction of health disparities.


The more negative experiences with access to care, office staff interactions, and health plan customer service for African Americans point to areas for quality improvement.

Funding Source: NIA

•

Quality Improvement Drivers: Public

Reporting, Pay-for-Performance, and

Governance Oversight in a Multi-Hospital

System

Stephen Grossbart, Ph.D.

Presented By: Stephen Grossbart, Ph.D., Vice

President, Quality Management, Catholic

Healthcare Partners, 615 Elsinore Place,

Cincinnati, OH 45202, Phone: (513) 639-2784,

Fax: (513) 639-2762, Email: srgrossbart@healthpartners.org

Research Objective: Identify the impact of public reporting, pay-for-performance, and governance oversight on quality improvement in a multi-hospital system. This study tests the question: Did hospitals participating in the

Center for Medicare and Medicaid Services’

(CMS) ‘‘Premier Hospital Quality Incentive

Demonstration Project’’ have significantly different rates of improvement in the quality of care delivered compared to similar hospitals within the same system that did not participate in the voluntary demonstration project over the course of three year project?

Study Design: The study compares the impact of the Premier Demonstration, public reporting through the Hospital Quality Alliance, and the evolving role of governance oversight with particular attention to assessing the long-term impact of the Premier Demonstration project relative to internal and other external-drivers of quality improvement. A test group of four acute care hospitals within a single healthcare system that participated in the demonstration project in federal fiscal years 2004-2006 was compared to a control group of five hospitals that did not participate in the project. The study limited analysis to three clinical areas that are included in the Premier Demonstration: acute myocardial infarction (AMI), heart failure, and pneumonia.

Performance for the duration of the demonstration was compared to a baseline year measured in federal fiscal year 2003 for both participating and non-participating hospitals to determine if the rate of improvement from the baseline year was different between the two cohorts of hospitals over the next three years based on a composite opportunity quality score that was developed by Hospital Core

Performance Measurement Project for the Rhode

Island Public Reporting Program for Health Care

Services and modified by Premier, Inc. for use in their demonstration project. The study is a follow-up to earlier work completed in 2005.

Population Studied: Patients discharged between October 2002 and September 2006 with a diagnosis of acute myocardial infarction, heart failure, or pneumonia from 9 hospitals within Catholic Healthcare Partners. Catholic

Healthcare Partners is organized into 9 regional service areas in five states and includes 29 hospitals. The system is the largest healthcare provider in Ohio and also has hospitals located in Kentucky, Pennsylvania, and Tennessee. The study was limited to 9 hospitals with the highest

levels of service within the system, including open-heart surgery.

Principle Findings: Hospitals participating in the pay-for-performance demonstration project had significantly higher composite quality scores in each of the three clinical areas studied in the first year of the demonstration, however, by the third year, added pressure for public reporting of performance coupled with corporate goals that required all hospitals in the system to be accountable at leadership and governance levels, eliminated the significant differences that once separated the two cohorts. During the baseline year in 2003 the two cohorts had similar rates of overall performance, with participating hospitals starting at 80% and non-participating hospitals at 79%. In the first year of the demonstration project, participants experienced striking improvement in heart failure, and increased overall composite quality score to 90% vs. 86% for non-participants. The rate of year one increase for participants, at 9.8%, was significantly better than the non-participant rate of 6.7% (p-value <.001). The source of this difference was attributed primarily to heart failure care, where improvement from baseline to the first year for participating hospitals was

19% vs. 11% for non-participating hospitals (pvalue < .001). The pace of improvement was not as dramatic in federal fiscal year 2005 and nonparticipating hospitals began to catch-up. In

2005, the system expanded its internal accountability around quality performance to include all measures in the Premier demonstration for AMI, Heart Failure, and

Pneumonia for all hospitals in the system with the expectation that 3rd Quarter performance would rank in the top quartile. With accountability to senior leadership and the corporate board of trustees, participating hospitals reaching a composite score of 92% compared to non-participants at 90%.

Demonstration project hospitals had only a 2.6% increase in performance, significantly lower than non-participants, who improved by 4.4% (pvalue < .001). By year three, the difference between the two cohorts and their pace of improvement was virtually identical, fueled in part by increased internal accountability through the expansion of system measurements to include surgical care (also included in the

Premier project) and higher levels of expected performance. Participants in the project had an overall composite quality score 95%, a 2.7% improvement over the previous year. Nonparticipants improved 3.5% to 94% (p-value

=.015). Over the course of three years, performance at the two groups of hospitals converged. Between the 2003 baseline and

2006, significant differences in the amount of improvement no longer existed; participants in the demonstration project improved their overall composite quality score by 15.1% compared to

14.6% for non-participants (p-value =.543) over the course of three years.

Conclusions: Although the pay-for-performance demonstration clearly accelerated performance among participants in the early years of the project, by 2006, both cohorts of hospitals performed at virtually identical levels.

Performance among non-participants in years two and three of the demonstration actually outstripped those in the project. While nonparticipants had greater opportunity for improvement, the significant drivers of both public reporting and internal focus on quality improvement that included tying senior executive accountability to performance on quality indicators and board oversight of corporate quality objectives and goals, created a strong environment for improvement.


This analysis provides evidence that pay-forperformance initiatives significantly accelerate performance among a cohort of participating hospitals. But it also demonstrates that pay for performance models have a relatively short life span and other drivers bring about improvement, albeit at a slower rate, among non-participants. Within a single hospital system, the Premier Demonstration project’s influence was eclipsed by other internal and external drivers. The study provides important evidence that support the design of pay-forperformance that attempt to align of incentives with performance.

• Evaluation of the Use of the AHRQ Quality

Indicators

Peter Hussey, Ph.D., Soeren Mattke, Ph.D.,

Lindsey Morse, M. Susan Ridgely, J.D.

Presented By: Peter Hussey, Ph.D., Associate

Policy Researcher, RAND Health, RAND, 1200 S.

Hayes St. w6w, Arlington, VA 22202, Phone:

(703) 413-1100 x5460, Email: hussey@rand.org

Research Objective: The objective of this study was to assess the utility of the AHRQ Quality

Indicators (QIs) for various purposes including pay-for-performance (P4P), public reporting, quality improvement, and research.

Study Design: A qualitative research design was used, including (1) an environmental scan to

identify users of the AHRQ QIs, users of similar products, and developers of comparable indicator sets; (2) semi-structured interviews of

QI users and developers; and (3) case studies of

QI use in selected geographic areas

Population Studied: Sixty interviewees were selected from the total population of QI users and developers identified through the environmental scan. Two geographic areas,

Boston and Dallas-Fort Worth, were chosen for case studies.

Principle Findings: The AHRQ QIs are used by a variety of users in a variety of applications, and fill a unique role among QI sets. The QIs are generally highly regarded based on their importance, scientific soundness, usability, and feasibility. However, many users have concerns about the limitations of the administrative data underlying the QIs, although opinions differ on what these limitations imply for the appropriate use of the QIs, particularly for P4P and public reporting.

Conclusions: Numerous stakeholders are in need of quality measurement tools. The AHRQ

QIs are one of the main options available to meet many of these needs. They are the only indicator set available that uses available administrative data and is also publicly available and regarded as transparent and scientifically sound. However, additional research is necessary to determine the applicability of specific QIs to P4P, public reporting, and related uses. The AHRQ QIs are already widely used for these applications.


These findings suggest that AHRQ should continue its support of the AHRQ QIs program, invest in further improvements to the existing

QIs, and support research on the applicability of the QIs to P4P and public reporting.


• Does Compliance With Diabetic Care

Reduce Healthcare Costs Over Time?

Stephen Jones, M.S., William Westerfield, M.A.,

Scott Diaz, M.A.

Presented By: Stephen Jones, M.S., Sr. Bio-

Statistical Research Analyst, Health Services

Research Dept, BlueCross BlueShield of

Tennessee, 801 Pine Street, Bldg 3E,

Chattanooga, TN 37402, Phone: 4235356915, Fax:

4237858083, Email: stephen_jones@bcbst.com

Research Objective: To determine if quality of care, measured as compliance with recommended American Diabetes Association

(ADA) treatment guidelines, is associated with total healthcare costs over time within a diabetic member population.

Study Design: Conflicting results exist within current literature relative to the association between healthcare quality and healthcare costs.

To address these inconsistencies, we examined the relationship between overall member healthcare costs and member compliance with recommended ADA treatment guidelines over a

3-year time period. Yearly compliance and cost data was summarized at the member level.

Member compliance scores were calculated as the number of recommended guidelines received for each respective year. Per the ADA guidelines, a member could receive up to 5 treatments within a year (two hemoglobin tests, a cholesterol test, a microalbuminuria test, and an eye exam). Therefore, an overall compliance score for a member could range from 0 (no treatment) to 15 (all treatment received for all 3 years). Total healthcare cost dollars, dollars associated with diabetic care, risk scores, utilization metrics, comorbidities and demographics were extracted from claims data at the member and year level. Our hypothesis was highly compliant members would have lower overall healthcare costs over the 3 year study period.

Population Studied: Our study examined 2,169 health plan members from a large southeastern region MCO who were diagnosed with Type II diabetes between September 2002 and February

2003. Members qualifying for the study had 36 months of continuous enrollment and no prior chronic comorbidity diagnosis. Members ranged in age from 11 to 99 (median age =52) and approximately 54% were male.

Principle Findings: Primary findings suggest overall case-mix adjusted healthcare dollars decrease as member compliance increases.

Case-mix adjusted total dollars are approximately

2 times higher for less compliant members compared to highly compliant members. Mean compliance across the member population was approximately 7. Member compliance declined overtime from 46% in year 1 to 43% in year 3, and declined across all treatment guidelines except eye exams. Highly compliant members had fewer emergency room visits, inpatient stays and inpatient days compared to less compliant members. Approximately 78% of the study members were diagnosed with a chronic comorbidity following their diabetes diagnosis.

Highly compliant members received a postdiabetic comorbidity diagnosis approximately

100 days sooner and had overall risk-scores higher than less compliant members.

Conclusions: Our data support the hypothesis that improved quality of care is related to a reduction in overall healthcare costs once dollars are adjusted for illness severity. Our member population and risk score distribution suggests highly compliant members are sicker, perhaps providing these members with more opportunities to be compliant. Non-case-mix adjusted total dollars for highly compliant member could be higher because they are receiving more tests, procedures, or Rx scripts for diseases other than diabetes.


Our research suggests a positive return on investment over time is possible by implementing quality improvement programs.

However, prior to introducing quality related performance incentives, health plans should evaluate their member population relative to treatment compliance and overall adjusted and non-adjusted dollars. We recommend extending the time period beyond 3 years if possible.

Funding Source: BlueCross BlueShield of

Tennessee

• Certificate of Need and the Quality of

Hospital Care

Patricia Ketsche, Ph.D., M.H.A., M.B.A., Mei

Zhou, M.A., Dawuud Ujamaa, M.S.

Presented By: Patricia Ketsche, Ph.D., M.H.A.,

M.B.A., Associate Professor, Institute of Health

Administration and Georgia Health Policy

Center, Georgia State University, PO Box 3998,

Atlanta, GA 30302-3988, Phone: 404-651-2993,

Fax: 404-651-1230, Email: pketsche@gsu.edu

Research Objective: Certificate of Need (CON) laws are part of a health planning strategy that uses regulation to manage the allocation of health care resources and prevent duplication of services. CON creates barriers to entry that convey monopoly power to incumbent health care providers. Economic theory suggests that unregulated monopolies have higher prices and lower quality than firms in more competitive markets. However, competition that reduces patient volume for a given procedure may reduce overall quality of patient care. The potential for decreased quality associated with monopoly power may be offset by the potential for increased quality resulting from concentration of volume. One recent study of cardiac surgery outcomes for Medicare patients suggests CON is associated with improved mortality rates

(Vaughan-Sarrazin, 2003). We use AHRQ quality indicators to identify the effect CON on multiple measures of quality of hospital care.

Study Design: We utilize hospital discharge data from 11 states with a total of 191 markets with varying degrees of CON regulation. Three of these states have no CON regulation, while the others were surveyed to determine the scope and rigor of their regulatory processes. Hospital markets are defined by patient flows.

In order to examine the impact of Certificate of

Need regulations on quality, we employ 3 of the modules for inpatient quality indicators developed by The Agency for Healthcare

Research and Quality (AHRQ)using state hospital discharge datasets: Prevention Quality

Indicators (PQIs), Inpatient Quality Indicators

(IQIs), and Patient Safety Indicators. We use the module provided by AHRQ to calculate risk adjusted indicators which are then compared to expected rates. We aggregate the indicators to the market level and then report the percentage of markets where there is a failure in meeting an indicator. A failure is defined as have a risk adjusted rate that is statistically significantly different from the expected rate. For example, if the market’s risk adjusted mortality rate for

Congestive Heart Failure is statistically significantly greater than the expected rate, they are counted as failing that indicator. Failure rates are then examined at the market level controlling for market characteristics and the scope and rigor of CON regulation.

Population Studied: Privately insured patients in Colorado, Florida, Georgia, Iowa, Maine,

Massachusetts, Oregon, Washington, Utah,

West Virginia, and Wisconsin.

Principle Findings: We find substantial variation in the share of markets with failure rates for specific indicators. For example, 86 percent of

Georgia markets fail the Cesarean Delivery Rate indicator, compared with no markets with failures in Maine, Massachusetts, Utah or

Wisconsin. However, to date we have found no consistent statistically significant relationship between quality of care and CON regulation.

Additional analysis at the individual provider level is in process. This will allow for measurement of CON effect holding hospital characteristics constant.

Conclusions: Preliminary results suggest that

CON has no consistent and measurable effect on the overall quality of hospital care as measured by the AHRQ indicators.

Implications for Policy, Practice or Delivery: If these findings hold they suggest that strengthening or weakening CON regulation will have no measurable effect on the quality of hospital care.

Funding Source: State of Georgia

• Quality of Care Findings From the Medicare

Physician Group Practice Demonstration

Musetta Leung, Ph.D., Michael Trisolini, Ph.D.,

Gregory Pope, M.S., John Kautter, Ph.D., Sherry

Grund, R.N.

Presented By: Musetta Leung, Ph.D., Health

Services Researcher, Program on Health Care

Quality and Outcomes, RTI International, 1440

Main Street, Suite 310, Waltham, MA 02451-1623,

Phone: 781-434-1730, Fax: 781-434-1701, Email: mleung@rti.org

Research Objective: To measure the quality performance among participating physician groups in their care of Medicare beneficiaries.

Study Design: This Medicare pay-forperformance initiative measures the quality of care for ten large physician group practices

(PGPs). The project uses both administrative claims data from Medicare and manual chart abstraction to measure 32 quality indicators in four disease modules (diabetes, heart failure, coronary artery disease and hypertension) and in preventive care. Quality indicators were adopted from various sources, including the National

Committee for Quality Assurance and the

American Medical Association. Performance thresholds for meeting quality targets were based on the lesser of two values: the mean

2003 Medicare HEDIS values reported by

Medicare Advantage plans, or 75% compliance.

To date, all baseline results are available for the

10 diabetes measures, including 4 measures calculated from claims data and 6 measures calculated from chart abstraction data.

Population Studied: Medicare fee-for-service beneficiaries in the ten sites were included if they met the inclusion criteria by at least (1) having a plurality of services at a participating physician group, (2) having 2 or more evaluation and management visits to a physician’s office, (3) not enrolled in Medicare managed care programs, and (4) met the criteria for the disease module.

All beneficiaries with diabetes were evaluated for the claims-based diabetes measures, and a random sample of 615 beneficiaries were included for abstraction for the chart-based measures.

Principle Findings: The number of people included the diabetes module ranged from 911 beneficiaries to 4,986 beneficiaries across the

PGPs. Baseline results showed that for some measures, the groups were already performing well above the threshold targets. For example, hemoglobin A1c testing and control were performed and achieved by all PGPs (from 85.22 to 95.15 percent, and 90.52 to 96.51 percent, respectively). Most of the groups also met the quality measurement thresholds for controlling

LDL-cholesterol level below 130mg/dL and for urine protein testing (from 74.50 to 90.88 percent, and 61.73 to 87.60 percent, respectively). Nevertheless, there are a number of potential areas for improvement in diabetes care. First, none of the groups met the quality target for complete foot examinations (from 7.89 to 46.86 percent). Blood pressure management results were also low, with only one site meeting the threshold (from 45.23 to 77.18 percent).

Finally, preventive care among patients with diabetes also had low results, as 8 sites did not meet the threshold targets for influenza or pneumonia vaccinations.

Conclusions: Baseline quality measurement results for the PGP Demonstration show some room for improvement in a more comprehensive approach to care for diabetes patients. Sites may need to provide more intensive or improved services in some areas in order to meet all of the diabetes treatment guidelines.


Quality of care measurement and reporting will allow physician practices to evaluate their patterns of care for patients with chronic conditions, and allow them to track improvements over time. Paying for increased quality of care may provide additional resources or incentives for physicians groups to implement improvements.

Funding Source: CMS

• Changes in Patient Safety Indicators after

Critical Access Hospital Conversion

Pengxiang Li, M.A., John E. Schneider, Ph.D.,

Marcia M. Ward, Ph.D.

Presented By: Pengxiang Li, M.A., Student,

Health Management and Policy, The University of Iowa, 5229 Westlawn, Iowa City, IA 52242,

Phone: (319)335-8713, Email: pengxiangli@uiowa.edu

Research Objective: To examine the impact of

CAH conversion on hospital patient safety

Study Design: We employed quasi-experimental designs that use both control groups and

pretests. The hospital-year was the unit of analysis. Patient safety indicators (PSIs) were computed from Iowa State Inpatient Databases

(SIDs) using Agency for Healthcare Research and Quality (AHRQ) quality indicators software.

Four PSIs were available for all 89 Iowa rural hospitals across 8 years with the AHRQrecommended denominator >= 30 cases: PSI-5

(foreign body left in), PSI-6 (iatrogenic pneumothorax), PSI-7 (infections due to medical care), and PSI-15 (accidental puncture or laceration). We included two additional PSIs that had fairly large denominators for most hospitals to measure a broader scope of patient safety:

PSI-2 (death in low-mortality DRGs) and PSI-3

(decubitus ulcer). We built two composite PSIs, which are the weighted average of four PSIs and six PSIs. The weights are based on the frequency of the numerator of each PSI in our sample.

CAH status was extracted from the Iowa

Hospital Association. Case-mix variables were extracted from Iowa SIDs. Market variables came from the area resource file (ARF). We employed two multiple regression approaches. Using median splits from 8-year data of 89 Iowa rural hospitals, we developed binary variables for each

PSI, where 1 equals poorer performance and 0 equals better performance. We used GEE logit to examine the association between CAH conversion and the likelihood of poor performance for a hospital in a year. We also used random-effects tobit models to assess the effects of CAH conversion on continuous measures of PSIs. The models were adjusted for case-mix, market variables, and year dummy variables. Sensitivity analyses were used to examine the robustness of the findings.

Population Studied: Secondary data on hospital patient safety indicators (PSIs), hospital CAH status, patient case-mix, and market variables, for 89 Iowa rural hospitals during 1997-2004.

Principle Findings: CAH conversion in Iowa rural hospitals was associated with better performance of risk-adjusted rates of iatrogenic pneumothorax, selected infections due to medical care, accidental puncture or laceration, and composite score of four PSIs. The odds ratios of poor performance in CAH hospitals compared to rural PPS hospitals are 0.30 (CI:

0.14-0.64) for PSI-6, 0.29 (CI: 0.15-0.56) for PSI-

7, 0.40 (CI: 0.24-0.67) for PSI-15, and 0.49 (CI:

0.31-0.80) for composite score of four PSIs.

CAH conversion had no significant impact on the observed rates of death in low-mortality

DRGs, foreign body left during procedure, riskadjusted rate of decubitus ulcer, or composite score of six PSIs. The sensitivity analyses showed that our findings were robust.

Conclusions: CAH conversion in rural hospitals is associated with enhanced patient safety performance related to indicators for relatively prevalent infections and injuries.


We speculate that the most likely mechanism linking CAH conversion and improved quality performance is the change in payment mechanism from prospective to cost-based.

Enhancement of financial resources may have contributed directly to an expansion in quality enhancement activities and infrastructure. The

Medicare Rural Hospital Flexibility Program of

1997 appears to have attained its objective to improve quality of care for previously financially vulnerable rural hospitals.


•

Non-Primary Care Physicians’ Views on

Office-Based Quality Improvement and

Incentive Programs (P4P)

Karen Murphy, R.N., M.B.A., A.B.D.

Presented By: Karen Murphy, R.N., M.B.A.,

A.B.D., Ph.D. Candidate, Risk, Insurance and

Healthcare Management, Temple University,

1003 Oakmont Road, Clarks Summit, PA 18411,

Phone: 570-587-4879, Fax: 570-586-6997, Email: murphyk@temple.edu

Research Objective: As the pay for performance movement continues to evolve, the aim of this research study is to explore non-primary care physicians’ views on office-based quality incentive and improvement programs and identify factors that affect these views. Research questions include the following: 1) How do nonprimary care physicians' view office-based quality incentive programs? 2) What factors affect these views?

Study Design: The conceptual framework that guided the research examined how (a) incentive design (b) role of specialty societies (c) organizational structure (d) the dominance of the payer offering the incentive and (e) physician age and experience influence nonprimary care physicians' views of office-based quality incentive and improvment programs the dependent variable of interest.

Population Studied: Data was collected from

210 surveys completed by non-primary care physicians practicing cardiology, hematology and oncology, obstetrics and gynecology, orthopedic surgery and urology in Pennsylvania.

Principle Findings: The study finds that nonprimary care physicians are uncertain regarding the value of office-based quality incentive and improvement programs and their views vary based on several factors.

Conclusions: The pay for performance movement for physician services has evolved in large part in the absence of input from physicians and empirical evidence of its effectiveness. Currently, quality incentive and improvement program measures designed for non-primary care physicians’ i.e. physicians practicing in specialties other than pediatrics, family practice and internal medicine are limited.

Despite this void, there is an increasing movement among payers to broaden pay for performance to include non-primary physicians.

The extension of quality incentive programs to non-primary care physicians will require innovative approaches to implementation based on the diversity of the physician services.

Incentive design, specialty of the physicians practice and the dominance of the payer offering the incentive will be key considerations in determining the level of achievement in quality improvements of non-primary care physician services.


The attainment of systemic quality improvement through the use of incentives must include nonprimary care physicians.Historically, divergent physician reimbursement schemes based on physician specialty namely, primary care and non-primary care have failed to achieve intended results. Citing the fact that 40% of all physician services delivered to Medicare beneficiaries are rendered by non-primary care physicians, the

IOM Committee on Redesigning Health

Insurance Performance Measures, Payment and

Performance Improvement Programs recently called for the development of specialty measures that can be used in pay for performance programs for Medicare beneficiaries.

Implementation of pay for performance programs for non-primary care physicians will be more challenging than existing programs based on diversity of services delivered. In order to design effective programs for non-primary care physicians it is important for payers and policymakers to understand physicians’ views on incentives and also identify strategies such engaging the support of specialty societies that may be used to enhance the effectiveness of the programs.

• Should Diabetes Quality Measures be

Adjusted for Patient Depression Status?


Ph.D., William A. Rush, Ph.D., John C. Kluznik,

M.D., Lucy Rose Fischer, Ph.D., Heidi L.

Ekstrom, M.A.





Phone: (952)967-5034, Fax: (952)967-5022,


Research Objective: To test the hypothesis that among adults with diabetes, depression status is associated with worse glycemic control. If this is so, then accountability measures may require adjustment for proportion of patients with depression.

Study Design: We classified depression status based on ICD-9 depression codes (296.2,

296.20-26, 296.3, 296.30-36, 296.82, 298.0,

300.4, 311), and use of anti-depression medications as follows: (a) No evidence of depression, (b) mild depression------one or more depression codes, (c) moderate depression-----one or more depression codes plus one or more depression drugs, (d) severe depression------one or more hospital admissions with principal discharge diagnosis of major depression.

Multivariate linear regression models were used to adjust covariates including age, gender,

Charlson comorbidity score, number primary care visits and likelihood of A1c test.

Population Studied: Study subjects were 14,144 adults with diabetes mellitus.

Principle Findings: As depression severity increased from category (a) to (d) above, mean age decreased (p<.0001), proportion female increased (p <.0001), medical comorbidity increased (p<.0001), and number of primary care visits increased (p <.0001). A1c test rates were, from a to d 71.3%, 64.6%, 67.9%, and

62.8% (p <.0001). Unadjusted mean A1c was

7.7% in those with no depression (N=11,802),

7.7% in mild depression (N=1,475), 7.6% in moderate depression (N=754), and 7.5% in severe depression (N=113; p = .22). In a multivariate model that controlled for patient age, gender, comorbidity, primary visits and test likelihood, depression severity was not related to

A1c level (p= .12).

Conclusions: As depression status worsened, number of medical visits and medical comorbidity increased, but no evidence that worsening depression status is related to worse glycemic control.


There is considerable debate as to whether patient factors such as depression status should be considered when comparing diabetes accountability measures across providers or medial groups. These data suggest that adjustment for depression status is not necessary.


• Do Publicly Reported Comprehensive

Quality Measures Lead to Diabetes Care

Improvement? The Minnesota Experience

Patrick O'Connor, M.D., M.P.H., Gail M.

Amundson, M.D., Leif I. Solberg, M.D.





Phone: (952)967-5034, Fax: (952)967-5022,


Research Objective: There is considerable controversy over selection of accountability measures for diabetes quality of care. Here we describe our experience using a comprehensive diabetes quality of care measure, and present data on recent trends in diabetes quality of care since the measure was adopted by Minnesota

Community Measurement 4 years ago.

Study Design: Seven Minnesota health plans initiated Minnesota Community Measurement in

2002. The program measures and publicly reports care across multiple clinical domains in fifty plus primary care and multi-specialty group practices. To assess quality of diabetes care, the project classified each patient with diabetes as meeting or not meeting in all the following set of measures: glycated hemoglobin (A1c) <= 8%, BP

< 130/85 mm Hg, LDL-cholesterol (LDL) <=130 mg/dl, documented non-smoking status

(NSMK), and regular aspirin (ASA) use. This composite measure was developed and reported by HealthPartners beginning in 1999. Statistical comparisons across time and across groups were done using the Chi-square statistic and nested multivariate logistic regression models.

Population Studied: Performance data is derived from administrative databases and supplemented with data from clinical record review by trained nurse reviewers of a random sample of at least 60 adults with diabetes receiving care at each provider group.

Principle Findings: Provider groups are making vigorous efforts to improve diabetes care. The proportion of diabetes patients who met all 5 quality components was 7.6% in 2001, 11.7% in

2002, 12.0% in 2003, 15.5% in 2004, and 19.9% in 2005. In 2001 the range across provider groups was 0% to 20%, and in 2004 the range across provider groups was 1% to 40%. In 2001

6% of provider groups had over 15% of patient meeting this measure, and in 2004, 46% of provider groups had over 15% of patients at this goal (?2=20.8, p<.0001). In 2005, among the 5 measures, the one with the lowest proportion of patients at goal was BP (47.7%), followed by A1c

(65.7%), ASA (66.6%), LDL (66.8%), and NSMK

(70.1%).

Conclusions: These data show substantial improvement in diabetes care in a short period of time in a large geographically defined community. The remaining variation across medical groups suggests that further substantial improvement in community levels of diabetes care are possible, and that special attention to

BP control may be indicated for many of the participating medical groups.


These data demonstrate the feasibility to health plans and the acceptability to physicians of implementing publicly reported comprehensive measures of diabetes care in one metropolitan area. The data also suggest, but do not prove, that publicly reported comprehensive diabetes control measure may motivate medical groups to improve diabetes care.


Foundation

• Assessing Evidence of Compliance with

Quality Indicators for Breast Cancer

Treatment

Jean Owen, Ph.D., J. Frank Wilson, M.D.

Presented By: Jean Owen, Ph.D., Senior

Director, Quality Research, American College of

Radiology, 1818 Market Street, Suite 1600,

Philadelphia, PA 19103, Phone: (215)574-3164,

Fax: (215)928-0153, Email: jeanowen@comcast.net

Research Objective: To assess the existing evidence base for measuring proposed Quality

Indicators (QI) for breast cancer treatment by analyzing data in an existing database. To determine additional evidence needed to measure QI.

Study Design: QI were developed based on

National Comprehensive Cancer Network

(NCCN) guidelines for breast cancer management and were compared to published results of the Patterns of Care Study (PCS)

database of patients receiving breast conservation therapy (BCT) in 1998-99. The survey data came from a national survey with a two-stage stratified sample of radiation oncology practices that allowed calculation of national averages of defined measures for patients treated in all types of radiation oncology facilities. Data was extracted from on-site chart reviews of medical and radiation therapy records.

Population Studied: Patients diagnosed with

Stage I or II breast cancer, treated with BCT, who started radiation therapy (RT) in 1998 or 1999.

Ineligibility criteria included: purely ductal carcinoma in situ or lobular carcinoma in situ, gross multicentric disease, bilateral breast cancer, mastectomy as primary treatment, previous breast RT, brachytherapy only, and prior or concurrent malignancies (exept nonmelanoma skin cancer).

Principle Findings: Compliance results for QI derived from NCCN guidelines for workup are: mammography performed before excisional biopsy (97%), pathology review (96%), estrogen receptor status determined (83%), progesterone receptor status determined (81%), Her-2/neu test done and results known (31%) and for axillary staging ---- axillary dissection performed

(82%). QI for locoregional treatment for patients with negative axillary nodes are RT to whole breast with boost (87%); for patients with

1-3 positive nodes ---- the minimum recommended RT to whole breast + boost (51%),

RT to optional fields in addition to the minimum

(43%), thus patients receiving the minimum or more RT fields (94%); for patients with >= 4 positive nodes ---- the minimum recommended

RT to whole breast with boost to tumor bed and supraclavicular area (15%), RT also to optional fields (75%), thus patients receiving the minimum or more RT fields (90%).

Conclusions: Benchmarking utilization patterns provides a foundation for assessing appropriateness of care in the future. Although not collected originally for the purpose of measuring QI, the PCS database is a potentially rich data source that can be used to validate these measures. In addition to providing evidence on the usefulness of specific proposed

QI and identifying areas of practice needing improvement, this project allows recommendations for additional evidence-based

QI.


As policy makers implement pay for performance

(P4P) programs, finding data sources to benchmark QI is important. The required level of detail exceeds most current administrative data, while clinical trials provide data only for a limited set of specific and usually experimental treatments. Well designed surveys can provide a data source with sufficient detail for a broad range of QI and define additional data requirements to allow use of administrative data to implement P4P programs.

Funding Source: Pennsylvania Department of

Health, Tobacco Settlement Act 77-2001,

Commonwealth Universal Research

Enhancement for Fiscal Year 2005.

• Developing Accountability through

Regulation, Legislation and Accreditation:

Case Study of the Development of a Statewide

Outcomes System for Child and Adolescent

Out-of-Home Placement Settings

Vaishali Patel, Ph.D., M.P.H.

Presented By: Vaishali Patel, Ph.D., M.P.H.,

Post-Doctoral Fellow, Department of Psychiatry,

McGill University School of Medicine, Douglas

Hospital, Montreal, Email: vapatel@jhsph.edu

• Steps Taken by Hospitals to Submit Quality

Data and CMS's Efforts to Ensure Its

Reliability

Eric Peterson

Presented By: Eric Peterson, Senior Social

Science Analyst, Government Accountability

Office, 441 G Street, N.W., Washington, DC

20548, Phone: (202)512-8502, Email: petersone@gao.gov

Research Objective: The objectives we studied were: 1) are the data submitted by hospitals to

CMS about their quality of care reliable, and 2) what are the steps used by hospitals to submit the data on quality of care to CMS and to what extent does information technology (IT) support those steps? We refer to the data submitted by hospitals as the "quality data."

Study Design: For the first objective, we examined the reliability of the data submitted by hospitals for the quality measures by looking at the completeness and accuracy of the data submitted to and validated by CMS contractors.

For the second objective, we visited 8 hospitals and interviewed administrative, clinical and IT staff to learn about the process used to submit data about quality; we also interviewed HHS and

CMS officials and reviewed related agency documents.

Population Studied: For objective 1, we studied all hospitals submitting quality data to CMS. For

objective 2, we conducted case studies at 8 hospitals.

Principle Findings: The report related to the first finding has been released; the report on the second objective will have been released by the date of the annual meeting, but it still being prepared. Therefore, our findings and conclusions on the second objective are preliminary at this time. We found that 1) CMS has a process in place to assess the accuracy of the quality data submitted by hospitals, but does not have a means to check the completeness.

Furthermore, although most hospitals had high baseline accuracy scores, the accuracy for about a quarter to a third of hospitals, could not be established because CMS selected too few cases for review. 2) In this finding, we will describe the standard set of steps used by hospitals to gather the quality data required by CMS and examine whether IT helped facilitate the process by reducing the need for manual abstraction.

Conclusions: We concluded that CMS should continue to refine its methods for checking the reliability of quality data submitted by hospitals.

Furthermore, given the resources required by hospitals to submit the quality data to CMS, we will consider whether additional efforts are needed to facilitate the collection and submission of quality data by hospitals.


Given plans by the administration and Congress to continue public reporting of hospital performance, hospitals are increasingly being asked to submit quality and other clinical data to

CMS. These data are used to provide information to the public and are also being linked to payment. Given these uses, it is important that HHS is able to assure the reliability of the data and that efforts are undertaken to facilitate the collection and submission of quality data by hospitals.

Funding Source: GAO

• Incorporating Efficiency in P4P Models:

Identifying Centers of Excellence in Efficiency and Quality (CEEQs) for Cardiac Surgery in

New York State

Shadi Saleh, Ph.D., M.P.H., Edward Hannan,

Ph.D.

Presented By: Shadi Saleh, Ph.D., M.P.H.,

Assistant Professor, Health Management and

Policy, SUNY-Albany, 1 University Place,

Rensselaer, NY 12144, Phone: (518) 402-0299,

Fax: (518) 402-0414, Email: ssaleh@albany.edu

Research Objective: It is common knowledge that the ‘performance’ in most existing P4P programs refers to quality of care. However, a recent IOM (IOM, 2006) report that recommends emphasizing the delivery of efficient quality of care may expand the scope of performance in such programs to include efficiency measures. As such, investigations that examine the association between efficiency and outcomes measures and those that explore potential P4P approaches which incorporate efficiency and quality performance measures are merited. This study aimed at (1) examining whether there is an association between CABG and PCI hospital-level outcomes and efficiency and (2) identifying hospitals that can be classified as Centers for Excellence in Efficiency and Quality (CEEQs). The latter aim is an attempt to explore a potential role for efficiency in P4P models ---- as a performance measure, specifically for coronary revascularization procedures.

Study Design: The study used various data sources most of which have been extensively utilized by health services researchers. These include: (a) New York State Statewide Planning and Research Cooperative System (SPARCS) dataset, (b) New York State Cardiac Surgery

Reporting System (CSRS) (c) New York State

Percutaneous Coronary Angioplasty Reporting

System (PCIRS) (d) Medicare Hospital Cost

Report Public Use files (Cost Report) and

Medicare wage index files and (e) New York

State Vital Statistics records. The study’s main outcome measure was hospital-level riskadjusted in-hospital or 30-day mortality. The independent variable comprised two efficiency measures (hospital-level risk-adjusted costs and length of stay). Confounding variables (used as the basis for risk-adjustment) were primarily patient characteristics and included demographics (age and gender) in addition to patient risk factors. It is worth noting that two risk adjustment approaches were employed. The first used clinical risk factors (e.g. myocardial rapture, pulmonary artery pressure, previous

AMI, etc.), primarily derived from the CSRS and

PCIRS datasets, with the second using risk factors extracted from administrative data.

Population Studied: The study population comprised New York State residents who underwent an isolated CABG or PCI procedure in the state between January 1, 2001 and December

31, 2003. The unit of analysis used in the study was the hospital in which the procedure was performed. These included hospitals that were

certified by the State to perform both procedures between 2001 and 2003 (33 hospitals).

Principle Findings: The hospitals were classified into four quadrants: low and high risk-adjusted mortality rates (RAMRs) (clinical < or > 1.67 ---- administrative < or > 1.75) and risk-adjusted costs (RACs) (clinical < or > $15,234 ---- administrative < or > $15,208). The findings revealed great variation in efficiency among highquality (low RAMR) hospitals. However, no association was detected between RAMRs and

RACs using risk factors from clinical and administrative datasets. Similarly, the study results revealed no association between RAMR and the other efficiency measure, risk-adjusted

LOS (RALOS) (RALOS<8.15 days). However, the study identified three hospitals that can be classified as Centers of Excellence in Efficiency and Quality (CEEQs). These high-quality hospitals were found to be consistently efficient

---- across both efficiency measures, across procedures or both.

Conclusions: In conclusion, this is a critical phase in the evolution of P4P and its solidification as a permanent fixture of health care delivery and financing. As such, it is an optimal time for refinement before all parties involved get into a ‘comfort zone’ when they become less receptive to changes. Inclusion of efficiency as a desired performance outcome may be one of these refinements.


Starting in fiscal year 2007, Medicare will modify its current DRG weights from charge relative into cost relative. This means that Medicare ---- as a payer ---- has a strategic interest in reducing hospital costs as this will translate into lower weights (i.e. payments). Some may argue that the effect of incentivizing efficiency (in P4P programs) will be minimal and hence has a limited influence on a system-wide basis. This would be a valid argument; hence considerable initial financial incentives should be invested to see an effect. It is hoped that the financial incentives combined with recognition as CEEQs

---- imitate the effect of recognizing good HEDIS scores on improved quality will encourage a widespread push for efficiency. From a private payer perspective, the use of per diem rates as the most common payment method means that improved efficiency ---- reduced LOS ---- will directly affect commercial health insurance medical payout levels. As such, an incentive exists to incentivize providers to be efficient in addition to being high-quality.

Funding Source: AHRQ, The Commonwealth

Fund

• Medicare Payment Policy and Imaging

Appropriateness

Chris Sistrom, M.D., M.P.H., Niccie Mckay,

Ph.D.

Presented By: Chris Sistrom, M.D., M.P.H., Vice

Chair for Research and Informatics, Radiology,

University of Florida College of Medicine, P.O.

Box 100374, Gainesville, FL 32610, Phone: 352-

265-0291, Fax: 352-265-0279, Email: sistrc@radiology.ufl.edu

Research Objective: This study examines the relationship between evidence-based appropriateness criteria for neurologic imaging procedures and Medicare payment determinations. The primary research question is whether Medicare is more likely to pay for imaging procedures as the level of appropriateness increases.

Study Design: Cross-sectional study of national evidence-based practice guidelines and Florida

Medicare Part B payment policy for neurological imaging. In addition to descriptive and bivariate statistics, multivariate logistic regression on payment determination (yes or no) was performed.

Population Studied: Unit of observation is ICD-

9 code/CPT code, or medical condition/imaging procedure, combination. Data sources were

American College of Radiology Appropriateness

Criteria (ACRAC) and Medicare Local Medical

Review Policy (LMRP) for Florida.

Principle Findings: As the level of appropriateness increased, more medical condition/imaging procedure combinations were payable (low=61%, middle=70%, and high=74%). Using logistic regression, we found that the odds of a medical condition/imaging procedure combination with a middle level of appropriateness being payable was 48% higher

(95% CI on odds ratio=1.19-1.84) than for an otherwise similar combination with a low appropriateness. The odds ratio for being payable between high and low levels of appropriateness was 2.25 (95% CI=1.66-3.04).

Conclusions: Our results suggest that Medicare could improve its payment determinations for imaging by taking advantage of existing clinical guidelines, appropriateness criteria, and other authoritative resources for evidence-based practice.


Medicare Part B payment policy for medical imaging is currently being revised and consolidated. Use of evidence based

appropriateness guidelines would give providers a financial incentive that is aligned with bestpractice medicine.

•

Characteristics of Physician Pay-for-

Performance Programs

Melony Sorbero, Ph.D., M.S., M.P.H., Cheryl L.

Damberg, Ph.D., M.P.H., Susan L. Lovejoy, M.S.


M.P.H., Health Policy Researcher, , RAND


15213, Phone: (412) 683-2300, Fax: (412) 683-


Research Objective: Pay-for-performance (P4P) programs are increasingly utilized as a strategy for driving improvements in the quality and costefficiency of health care, but little is known about their design features and their impact on performance. This study sought to characterize the features of physician P4P programs, and whether the programs were having a positive return on investment or improvements in performance.

Study Design: Semi-structured interviews were held with program sponsors for a purposeful sample of the 135 identified private-sector P4P programs selected using the following criteria: inclusion of physician or physician groups as targeted program participants; representation of various types of sponsors and plan types; and either two or more years in operation or having unique program characteristics. Discussions were approximately 1-1.5 hours in length taking place January - March 2006. Discussions focused on program goals and objectives; factors influencing program design; involvement and awareness of providers; measures, data, and risk adjustment; program participants and eligibility criteria; incentive structure; program infrastructure; lessons learned; and program evaluation.

Population Studied: Twenty-four P4P programs were invited to participate; discussions were held with 20 programs (83% response rate).

Principle Findings: Planning typically started at least one year before the program’s implementation. Eight of the 20 sponsors had more than one P4P program with variation based on region, product line, provider type or program focus. All programs had the goal of improving quality and 12 sought to improve efficiency. Selection of clinical areas was most commonly driven by prevalence of clinical conditions, existence of evidence-based measures, and opportunities for improvements in care. All programs included clinical quality measures. HEDIS-like measures were commonly used for primary care physicians, but little consensus existed on clinical measures for specialists. Other types of measures included: resource use (n=15), patient experience (n=9), administrative (n=9), and information technology (n=6). The weighting of measure domains varied widely across programs. Data used to construct measures were claims and other administrative data (n=19), medical records (n=10), patient survey (n=11), and physician self report (n=7). Bonus payments were the most common form of financial incentive (n=16). There was variation in the methods used to finance incentives as well as the types of performance targets used to determine incentives. The share of participating providers receiving a payout ranged from 20 to

100 percent, reflecting philosophical differences among programs on whether to reward excellence or engage all physicians to encourage quality improvement. While sponsors universally felt their programs were improving care, few were conducting formal evaluations or return on investment calculations.

Conclusions: Substantial experimentation and variation is occurring as physician P4P programs are being developed nationally. However, there is a lack of evaluation to assess how different design elements influence achievement of P4P program goals.


The lack of program evaluation and ongoing program evolution make it likely that the impact of P4P programs on costs and quality will remain unclear. This provides CMS and other organizations developing P4P programs with few insights to guide selection between alternative options for program design elements.

Funding Source: Office of the Assistant


• Implementation Lessons from Physician

Pay-for-Performance Programs

Melony Sorbero, Ph.D., M.S., M.P.H., Cheryl L.

Damberg, Ph.D., M.P.H., Susan L. Lovejoy, M.S.


M.P.H., Health Policy Researcher, RAND


15213, Phone: (412) 683-2300, Fax: (412) 683-


Research Objective: In recent years, pay-forperformance (P4P) programs have been developed as a strategy for driving

improvements in the quality and cost-efficiency of health care. This study sought to characterize the features of physician P4P programs, understand lessons learned and challenges faced during implementation, and determine whether the programs were having a positive return on investment or improvements in performance.

Study Design: Semi-structured interviews were held with program sponsors for a purposeful sample of the 135 identified private-sector P4P programs selected using the following criteria: inclusion of physician or physician groups as targeted program participants; representation of various types of sponsors and plan types; and either two or more years in operation or having unique program characteristics. Discussions were approximately 1-1.5 hours in length taking place January - March 2006. Discussions focused on program goals and objectives; factors influencing program design; involvement and awareness of providers; measures, data, and risk adjustment; program participants and eligibility criteria; incentive structure; program infrastructure; lessons learned; and program evaluation.

Population Studied: Twenty-four P4P programs were invited to participate; discussions were held with 20 programs (83% response rate).

Principle Findings: Common themes for successful program implementation emerged from our discussions with program sponsors.

Sponsors did not view P4P alone as a solution for poor quality and rising costs, but felt it needed to be implemented as part of a set of strategies designed to change physician behavior. Keys to program success included physician involvement in program design and implementation (n=14) to raise physician awareness, enhance buy-in and reduce resistance to the program. Pilot testing of all measures and implementation processes was noted as critical (n=12); some sponsors that initially had not piloted their measured frequently viewed this as a mistake. P4P programs required substantial infrastructure and resources to support ongoing program operations.

Necessary infrastructure included processes to ensure accurate data (n=14), the ability to provide actionable performance feedback to providers (n=17), support for physicians

(n=19)(e.g., education, technical assistance, patient registries), and a process for physicians to appeal their scores (n=13). Sponsors recommended starting small to demonstrate success then expanding the program as it matures (n=14). Since P4P is relatively new and the best way to structure programs is not clear, sponsors stressed that some trial and error is involved and a willingness to modify the program based on provider feedback is needed to create an environment of trust and physician engagement.

Conclusions: Although substantial variation exists in the design of physician P4P programs, there are common themes for successful program implementation, including physician involvement and support, adequate program infrastructure and resources, an openness to physician input and willingness to modify program design, as well as a recognition that

P4P is not a panacea for today’s health care problems.


CMS and other organizations developing physician P4P programs can learn the keys to successful program implementation from existing programs. These are especially important in light of uncertainty regarding the most effective ways to design these programs.

Funding Source: Office of the Assistant


Workforce

• Academic Medical Culture as a Workforce

Issue: Early Findings from the National

Initiative on Gender, Culture and Leadership in Medicine (C-Change)

Arlene Ash, Ph.D., David Kern, M.D., M.P.H.,

Phyllis Carr, M.D., Peter Conrad, PhD, Sharon

Knight, Ph.D., R.N.

Presented By: Arlene Ash, Ph.D., Professor,

General Internal Medicine, Boston University

School of Medicine, 720 Harrison Ave #1108,


(617) 638-8026, Email: aash@bu.edu

Research Objective: Excellence in health care, biomedical research and medical education requires access to the full set of skills and perspectives of a diverse faculty. The National

Initiative, a partnership of 5 medical schools,

Brandeis University and the AAMC, explores and addresses the intransigent under-representation of women and minority faculty in senior and leadership roles in academic medical centers, and, more generally, problems in retaining and nurturing a diverse and vital medical faculty. This five-year action research project seeks to understand and change academic medicine’s culture to increase the satisfaction and productivity of all faculty.

Study Design: The interview subproject, whose early findings we report here, is a qualitative, hypothesis-generating research study based on

~100 in-depth hour-long semi-structured interviews with both men and women medical faculty at each of 5 geographically-dispersed demonstration site medical schools, including both public and private, and research intensive and community-based/primary care oriented schools. The interviews probed for aspirations of and motivation for a career in academic medicine, challenges to advancement, perceptions of gender discrimination, workfamily integration, and the use of authority in the work environment.

Population Studied: Participants are research scientists, medical and surgical subspecialists, and generalist faculty with doctoral-level degrees

(MD/DO/PhD, etc.). We oversampled from under-represented minority and generalist faculty. Each school cohort consists of male and female faculty at different stages in their academic careers as well as those who have left academic medicine.

Principle Findings: Issues of academic medical institutional culture, such as hierarchical structures, lack of transparency in decisionmaking, barriers to collaboration, and lack of community partnerships all deeply affect faculty retention and vitality. Some of these issues are more salient for women faculty than for men.

Conclusions: The same cultural issues that create barriers for the advancement of women and minorities in academic medicine also affect retention, satisfaction and the ability to realize their full potential for all faculty.


Deep changes in the culture of academic medicine are likely needed to facilitate collaboration and excellence in biomedical research or clinical practice, and to foster a medical community well-equipped to deal with the health care needs of a diverse population, particularly women and under-represented minorities. Other subprojects of the National Initiative are developing, piloting and evaluating mechanisms for effecting such change.

Funding Source: Josiah Macy Jr.

•

Health Disparities among America’s Health

Care Providers: Evidence from the Integrated

Health Interview Series, 1982 - 2004

Chiu-Fang Chou, Dr.P.H., Pamela Jo Johnson,

M.P.H., Ph.D.

Presented By: Chiu-Fang Chou, Dr.P.H., Post-

Doctoral Associate, Division of Health Policy and

Management, State Health Access Data

Assistance Center, University of Minnesota, 50

Willey Hall, 255-19th Avenue South, Minneapolis,

MN 55455, Phone: (612)624-1406, Fax: (612)624-

1493, Email: choux060@umn.edu

Research Objective: Substantial health disparities have been documented for the general population, yet there is a dearth of research on health disparities among health care providers. The purpose of this study is to examine the extent to which health status and work loss days due to illness or injury differ by race/ethnicity and health care workforce category.

Study Design: Data are from the Integrated

Health Interview Series (IHIS), a cross-sectional time series of harmonized data from the

National Health Interview Survey (NHIS). The

NHIS is a nationally representative household survey conducted annually in the U.S. since 1957.

Outcomes of interest are self-reported health status and work-loss days due to injury or illness.

Health care workforce categories include health diagnosing professions (e.g. physicians, dentists), health treating occupations (e.g. registered nurses, therapists), health technicians

(e.g. lab technicians), and health service workers

(e.g. health aides or orderlies). Covariates include race/ethnicity, age, sex, marital status, and educational attainment. Trends in health status and work loss days are examined by workforce category over time using ordered probit regression and Poisson regression analyses, accounting for the complex survey design. Racial disparities within workforce categories are also examined over time.

Population Studied: Adults between the ages of

20 and 64 employed in health care professions in the United States between 1982 and 2004.

Principle Findings: Overall, the proportion of health care workers reporting excellent health has declined over time. Interestingly, health status differs significantly by workforce category.

Moreover, there is a clear social gradient across workforce categories, which is widening over time. Within workforce categories, no significant racial disparities are detected in the proportion reporting excellent health among the highest class of workers, while there are significant racial disparities among health treating occupations and among health technicians. Health service workers tend to have lower health status than the general employed population.

Conclusions: The results suggest that health disparities do exist among health care workers.

Since health professionals from racial/ethnic minority and socioeconomically disadvantaged backgrounds are more likely to serve socially disadvantaged populations, health status of healthcare workers needs to be taken into account when setting policies and implementing programs intended to increase access to health care and create a healthy diverse workforce.


The racial/ethnic composition of the United

States is undergoing dramatic change. Yet, the health care workforce does not reflect the growing diversity. Moreover, studies of the health care workforce have focused on demand and supply of health professionals, while research examining the health status of health care workers and the implications for workforce diversity and workforce shortage is limited. A diverse, well-trained, and healthy healthcare workforce is key to improving the health status of the population; it is also an essential element of the nation’s commitment to the enhanced economic self-sufficiency of its citizens.

Therefore, it is critical to have a better understanding of how healthy the health care workforce is to provide better medical care, to improve the quality of care, and meet the needs of the neediest populations in the 21st Century.

Funding Source: National Institute of Health

• New Physicians and Health Professional

Shortage Areas

Chiu-Fang Chou, Dr.P.H., Anthony T. Lo Sasso,

Ph.D., Judith A. Cooksey, M.D., M.P.H ., Pamela

J. Johnson, M.P.H., Ph.D.

Presented By: Chiu-Fang Chou, Dr.P.H., Post-

Doctoral Associate, Division of Health Policy and

Management, State Health Access Data

Assistance Center, University of Minnesota, 50

Willey Hall, 255-19th Avenue South, Minneapolis,

MN 55455, Phone: (612)624-1406, Fax: (612)624-

1493, Email: choux060@umn.edu

Research Objective: Our goal is to understand the influence of personal characteristics, including educational debt and race/ethnicity among other factors, on new physicians’ decision to practice in a Health Professional

Shortage Areas (HPSAs).

Study Design: We use data are from a unique survey of exiting medical residents (i.e., completed residency training) in New York State and California acquired by the New York

Workforce Center at SUNY-Albany. The sample consists of physicians completing their residency training in New York State and California during the period 1998-2003, and who are beginning their careers in patient care throughout the

United States. Using the repeated cross-section data over the period 1998-2003, we model the decision to practice in a HPSA as a function of personal characteristics. The dependent variable is derived from the Area Resource File (ARF), which codes counties as full HPSA, partial HPSA or not HPSA. We use an ordered logistic regression to estimate the effect of gender, race/ethnicity, medical school, citizenship, educational debt, and physician specialty on the decision to practice in a HPSA.

Population Studied: The sample consists of approximately 9,700 physicians who completed their residency training in New York State and

California in 1998-2003 and who are beginning their careers in patient care.

Principle Findings: Preliminary regression results suggest that educational debt does not appear to be a factor in choosing to locate in a

HPSA. New physicians who graduated from foreign medical school, minority physicians, and those specializing in family practice or internal medicine are more likely to practice in HPSAs.

Conclusions: Given that educational debt does not appear to be an important factor affecting new physician location choices of HPSAs, our results suggest that the financial incentives associated with HPSAs are not necessarily attracting new physicians to practice in HPSAs.

Our results also suggest that other personal characteristics of new physicians may be more important predictors of who chooses to practice in HPSAs.


Our results stand to benefit state and national healthcare policymakers in better designing programs to meet the needs of underserved areas. The study of newly graduated physicians represents a distinct advantage over prior research. Once a physician decides on an initial location, it is costly for them to relocate because in addition to licensing issues, establishing a practice and acquiring a panel of patients is costly and time-consuming for most physicians.

Thus, understanding the factors affecting the initial location choice for physicians is particularly important because of the long-lasting labor force implications of the initial decision.


• Balancing Work and Home Life: Results of the AAMC Survey of Physicians Under 50

Clese Erikson, M.P.Aff., Edward Salsberg, M.P.A.

Presented By: Clese Erikson, M.P.Aff., Senior

Research Associate, Center for Workforce

Studies, Association of American Medical

Colleges, 2450 N Street, NW, Washington, DC

22037, Phone: (202) 828-0587, Email: cerikson@aamc.org

Research Objective: To better understand the practice patterns and career expectations of younger physicians in order to more accurately forecast the future FTE physician supply.

Study Design: A random sample of 12,000 active physicians under the age of 50 was drawn from the AMA’s Physician Masterfile and mailed a 96 item survey that asked about work hours, practice characteristics, satisfaction, ability to balance work and home life, the characteristics of an ideal position and basic demographics.

The initial mailing included a $2 bill as an incentive. Non-respondents were sent reminder post cards and a second mailing of the survey.

The survey received a 34% response rate.

Analyses of response likelihoods were conducted across a number of variables, including age, gender, specialty, and location of medical education. Standard response weighting procedures were implemented to reduce identifiable response bias.

Population Studied: Respondents included

4,056 practicing physicians under the age of 50.

60% were aged 40-49 and 40% were under 40;

39% percent of the respondents were female.

Principle Findings: Nearly three out of four respondents rated time for family and personal life as a very important factor in a desirable professional practice, though only half agreed they are able to balance work and personal life to their satisfaction. Fewer than half of respondents rated any of the other 15 factors

(including practice income, long-term income potential, and opportunities to advance professionally) as very important in a desirable practice location. Females are more likely to work part time, take extended leave of one month or longer, and work fewer hours per week

(p<.05). Not surprisingly, they are more likely to agree they can balance work and home life and control their schedule than their male counterparts (p<.05.) Males and females are equally satisfied with their career in medicine, specialty choice, job/position, and income.

Conclusions: Physicians under 50 appear to value balancing work and home life above compensation and career advancement opportunities. 24% of females under 50 work part-time and are a growing proportion of the physician workforce. Many males are interested in part-time hours, but do not have the option in their current setting. Traditional recruitment and retention measures may not be as effective with the next generation of physicians requiring employers and the public to rethink their approach to maintaining a stable physician workforce.


Changing values and/or work patterns may force changes in delivery system to accommodate the future workforce. Predicted future shortages of physicians could be even greater than expected if these physicians work fewer hours than previous generations.

Funding Source: AAMC and the AMA

• Drivers of Physician Job Satisfaction:

Implications From a Cross-National

Comparative Survey

Katharina Janus, Ph.D., Thomas G. Rundall,

Ph.D.

Presented By: Katharina Janus, Ph.D., Visiting


Management, Columbia University, 600 West

168th Street, 6th floor, New York, NY 10032,

Phone: (212) 342-4521, Fax: (212) 305-3405,

Email: kj2186@columbia.edu

Research Objective: To assess the associations between work-related monetary and nonmonetary factors and physicians’ work satisfaction as perceived by similar groups of physicians practicing at academic medical centers in Germany and the U.S., two countries that in spite of differing systems of financing and organizing medical care are simultaneously experiencing problems in maintaining their physician workforce.

Study Design: This study is a cross-national comparative survey. Based on existing satisfaction studies we designed a selfadministered questionnaire that contained 28 items, including items measuring several dimensions of physician job satisfaction; the monetary and non-monetary incentives the physicians experienced in the recent past; other job-related potential confounding factors; and socio-demographic questions. Respondents were asked to rate each job satisfaction item on five-point Likert scales regarding both satisfaction with and importance of the item. In

Germany, data collection took place from

December 2004 until February 2005; in the US, the time frame of collection was from October

2005 until March 2006.

Population Studied: We surveyed physicians at the teaching hospital of the Hannover Medical

School, at San Francisco General Hospital, a teaching hospital of the University of California,

San Francisco, and at Stanford Medical School.

The combined sample size was 1,589.

Principle Findings: Our study revealed that overall German physicians were less satisfied than U.S. physicians, which can be partially explained by cultural differences in expressing satisfaction and optimism and the rigidity characteristic of the German medical care system. With respect to particular work-related predictors of job satisfaction we found similar factors contributed to job satisfaction in both countries, including job security and financial rewards, control over medical decision-making, interaction and collaboration with colleagues, and contact with patients. To improve physicians’ satisfaction with working conditions, our results call for the implementation of policies and management practices that reduce the time burden on physicians to allow more time for interaction with patients and colleagues, increase monetary incentives, and enhance physicians’ participation in the development of patient care management processes and in managerial decisions that affect patient care.

Conclusions: This study sheds light on the underlying factors that contribute to physician job satisfaction in the US and Germany, and it provides insights into the reasons for physicians abandoning medical practice. Our data suggest that non-monetary factors are important determinants of physician job satisfaction besides monetary incentives that may augment or reduce physicians’ base incomes, and that this relationship transcends national boundaries.

Implications for Policy, Practice or Delivery: In order for a health system to recruit and retain physicians, it may be necessary for a system’s physician strategy to shift from focusing primarily on monetary and compensation-related factors to a broader focus that also incorporates non-monetary factors that affect physicians’ job satisfaction. This is of particular importance as human resources consume about 70% of the total health care budget and are the crucial production factor in health care delivery. If the drivers of physician satisfaction and decisionmaking are not understood quality and costeffectiveness objectives will be difficult to achieve in any health care system.

Funding Source: Fritz-Thyssen-Foundation

• Jobs to Careers: Partnerships, Pathways, and Progress for Frontline Healthcare

Workers

Heather Kane, Ph.D., Thomas Konrad, Ph.D.,

Jennifer Craft Morgan, Ph.D.

Presented By: Heather Kane, Ph.D.,

AHRQ/NRSA Post-doctoral Fellow, Cecil G.

Sheps Center, 605 Jones Ferry Road, CC5,

Carrboro, NC 27510, Phone: 919-960-3538,

Email: odonovan@email.unc.edu

Research Objective: Holding one-third of all health sector jobs and providing most instrumental care in the long-term and behavioral/mental health care sectors, frontline health and healthcare workers (FHWs), play a critical yet under-recognized role in health care and health related . FWHs are unlicensed, typically lack a 4-year college degree, earn under

$40K/year, and encounter significant barriers to career advancement. We examine constraints and facilitators across FHW types (e.g., racial/ethnic groups, sector-based groups, etc.) and the institutional barriers and facilitators to educational and career advancement. We analyze the content and locus of solutions that employers and educational organizations are considering to enable FHWs to proceed in careers, reduce turnover, increase job satisfaction, and optimize their potential to enhance quality and continuity in patient care.

Study Design: This study examines proposals

(N=190) submitted to the first round of The Jobs to Careers Initiative which invites employers to partner with educational organizations to develop career paths for FHWs’ advancement.

These proposals center on generating accreditation programs for work-based learning.

The program implementation and strategies for overcoming FHW barriers vary across sites.

These data are entered in the qualitative research program NVivo 7.0 and coded across structural and functional categories. Structure includes: 1) overall configuration (e.g., employer(s), educational institutions, workforce intermediaries); 2) scale (expected number of participants); 3) focus (e.g., occupations); and 4) history (new vs. existing partnerships). 5) geography (region, urban/rural, single/multisite) Functional attributes include: 1) barriers to educational advancement; 2) barriers to career advancement; 3) facilitators to educational advancement; 4) facilitators to career advancement; 5) institutional barriers; 6) institutional facilitators; 7) employer solutions; and 8) educational partner solutions.

Population Studied: All proposals submitted in response to the first round of a national solicitation.

Principle Findings: There appears to be a systematic relationship between the way in which the problem of FHW mobility is framed and the structure of the inter-organizational partnership.

A more diverse variety of solutions is proposed by partnerships that have a prior history of working together. Partnerships led by health care institutions more often identify FHW mobility barriers in the educational sector, while partnerships led by educational institutions see barriers in professional licensure and employer rigidity.

Conclusions: There has been a widespread and diverse response to a national solicitation to address to problems faced by frontline workers in health and health care. Innovative solutions developed by collaborative partnerships between employers and educational institutions constitute a promising development for this workforce.


Findings can inform workforce development in several ways. First, identifying common and unique barriers FWHs face may inform employers of employee needs, thus enabling them to understand and better address potential problems in their own organizations.

Conversely, employers could accentuate the facilitators in their organizations and better tailor efforts to target workers most likely to succeed in educational pursuits. Second, by examining proposed programs and career paths, this analysis identifies promising practices generated by employers and educational institutions to develop a frontline workforce at the community level. Other organizations might consider adopting such practices and programs for FHW.

These programs, in turn, may contribute to greater job satisfaction and reduce turnover.


• Nurse Faculty Shortages: An Impending

Crisis

Linda M. Lacey, M.A.

Presented By: Linda M. Lacey, M.A., Associate

Director: Research, North Carolina Center for

Nursing, 222 N. Person Street,Raleigh, NC

27601, Phone: (919) 715-0978, Fax: (919) 715-

3528, Email: lmlacey@northcarolina.edu

Research Objective: Like many states around the country, policy makers in North Carolina have recommended a substantial expansion of the nursing education pipeline in order to alleviate the growing nursing shortage. Is there sufficient faculty to support this goal?

Study Design: An estimation model was developed to forecast the supply of RNs from

2004 to 2020 with the proper credentials to teach in entry-level nursing education programs.

Multiple estimation models were developed to forecast faculty demand under different facultyto-student ratio scenarios for the years 2004 to

2020. The results of these models were compared to determine how well supply estimates match demand estimates.

Population Studied: RNs with Masters and doctoral degrees with a current license to practice and eligible to teach in an entry-level nursing education program. Baseline data, nurse faculty retirement patterns, and RN employment trends were drawn from historical analysis of

North Carolina RN licensure files.

Principle Findings: In 2006 the supply and demand for nursing faculty were in equilibrium.

But supply is expected to decline rapidly over the next 10 years at the same time that policy makers are calling for an increase in nursing student enrollments to offset the growing nursing shortage. Reduction in supply is affected by a large proportion of current nursing faculty reaching retirement age in the next 10 years and a historical reduction in the proportion of

Master's and doctorally prepared RNs who choose a faculty career.

Conclusions: Under current faculty-to-student ratios a severe shortage of nursing faculty is expected to occur over the next 10 years.

Immediate solutions are needed to avert the consequences of such a shortage.


The loss of an adequate supply of nursing faculty will subvert the intentions of many federal and state policies designed to increase the size of the nursing workforce. Strategies are needed to quickly increase the supply of nursing faculty and/or to make the available supply stretch further. This might involve changing the way nursing education is delivered in order to make the most of a limited faculty pool.

Funding Source: NC Center for Nursing

• Refinement of the Clinical Nursing

Expertise Survey

Eileen Lake, Ph.D.

Presented By: Eileen Lake, Ph.D., Assistant

Professor, School of Nursing, University of

Pennsylvania, 420 Guardian Drive, Philadelphia,

PA 19104-6096, Phone: 215-898-2557, Fax: 215-

573-2062, Email: elake@nursing.upenn.edu

Research Objective: Nurses’ clinical expertise is presumed to be an important factor related to quality of care. The lack of suitable survey-based measures of expertise limits research exploring the link between expertise and patient outcomes.

The Clinical Nursing Expertise Survey was developed from the findings of a landmark study,

Benner’s ‘‘From Novice to Expert.’’

The research objective of this study was to establish the psychometric and conceptual properties of the CNES.

Study Design: The CNES contains 34 nursing roles and functions. Nurses report their level of ability for each role or function on a five-point scale ranging from "competent" to "expert."

Sample items are: 1) Establish trust and good communication with patients and families; 2)

Devise and implement skin and wound care strategies that foster healing and comfort; and

3) Set priorities to effectively coordinate and meet multiple patient needs and requests.

Instrument properties were evaluated from survey data collected from staff nurses in four hospitals that participate in the National

Database of Nursing Quality Indicators

(NDNQI). To provide rigorous evidence of instrument generalizability, hospitals were selected to achieve diversity in nurse educational background and ethnicity. Instrument reliability and validity were evaluated across clinical and educational subgroups. Exploratory factor analysis of the survey items was conducted to determine its conceptual content. The intent was to identify expertise domains that may become instrument subscales.

Population Studied: All RN staff nurses on nursing units participating in the annual NDNQI nurse survey were eligible to participate. The response rate was 65% (n = 2457). The sample was 88% female and 39% racial or ethnic minorities. Half of the respondents had a BSN or higher degree. On average the nurses had 15 years of experience.

Principle Findings: The overall expertise score was 3.26 (SD = 1.13), equivalent to a ‘‘proficient’’ level of expertise. The sample range reflected the full hypothetical range of 1 (‘‘competent’’) to 5

(‘‘expert’’). The CNES exhibited excellent reliability (alpha = .98). Validity was supported by significant bivariate associations between the expertise score and nursing experience, preceptor experience, frequency of consultation by staff nurse colleagues for the nurse’s clinical judgment, and national clinical specialty certification. RNs with a diploma as their highest educational preparation reported greater expertise than nurses with associate’s or bachelor’s degrees, not controlling for age.

Nurses with master’s or PhD degrees reported the highest expertise. Two factors emerged from exploratory factor analysis: 1) The nurse’s relationship with patient and family and 2) the nurse’s clinical assessments and responses, and the nurse’s role in a team of providers.

Conclusions: The CNES is reliable and valid.

The CNES measures two domains of expertise.


Nurse survey measures of clinical expertise hold promise for informing hospital managers and leadership about the effect of differential expertise on patient outcomes. The two domains represented in the CNES could assist managers to evaluate and cultivate their nurses’ expertise. The CNES could be incorporated into nurse surveys for research and benchmarking purposes to broaden our assessment and understanding of nurses’ influence on the quality of care.


Research

• Modeling the Effectiveness of

Neuraminidase Inhibitors in Preventing

Healthcare Worker Absenteeism During

Pandemic Influenza

Vernon Lee, M.B.B.S., M.P.H., M.B.A., Mark

Chen, M.B.B.S., M.Med, M.Sc.

Presented By: Vernon Lee, M.B.B.S., M.P.H.,

M.B.A., Research Fellow, Health Services and

Outcomes Research, National Healthcare

Group, 1005 Lower Delta Road #02-01,

Singapore, 099309, SG, Phone: (65)9792-8896,

Fax: (65)6357-7465, Email: vernonljm@hotmail.com

Research Objective: One priority during an influenza pandemic is to maintain essential services such as healthcare during the pandemic’s peak. Studies have proposed that hospitals should consider stockpiling on neuraminidase inhibitors for treatment and prophylaxis. To provide policy guidance to reduce the pandemic’s impact on healthcare workers, this study analyzed the effectiveness of neuraminidase inhibitors in minimizing absenteeism.

Study Design: This study simulated a healthcare worker population in a deterministic SEIR, susceptible-exposed-infectious-removed, metapopulation model to evaluate strategies for

minimizing absenteeism during an influenza pandemic. Three strategies for healthcare workers were considered: providing symptomatic relief only, early treatment only of all symptomatic healthcare worker infections, and prophylaxis together with early treatment.

Population Studied: The model consisted of two distinct populations in Singapore ---- the general population of 4.35 million in 2005, and the public healthcare worker population estimated at 20,000.

Principle Findings: A pandemic with basic reproductive number of 2.5 resulted in peak healthcare worker absenteeism of 10% if symptomatic relief only was provided. Treatment only with neuraminidase inhibitors decreased peak absenteeism by 20%, while 8 weeks prophylaxis reduced it by 80%. For pandemics with higher reproductive numbers, peak absenteeism exceeded 20% occasionally and 6 weeks prophylaxis was sufficient to reduce peak absenteeism by 75%. Insufficient prophylaxis durations increased peak absenteeism compared to treatment only; and earlier pandemic detection and initiation of prophylaxis may render shorter prophylaxis durations ineffective.

For severe pandemics where peak absenteeism exceeded 10%, 8 weeks prophylaxis provided substantial reduction in peak absenteeism under a broad range of assumptions and scenarios on disease transmission and effectiveness of therapy.

Conclusions: Treatment and prophylaxis with neuraminidase inhibitors were shown to be more effective in reducing healthcare worker absenteeism compared to symptomatic relief.

However, prophylaxis may result in higher absenteeism compared to treatment only if adequacy and timeliness of prophylaxis cannot be achieved.


Countries must consider the effects of an influenza pandemic on essential services, especially in severe pandemics where the need for protection is greatest and short prophylaxis durations are sufficient to reduce the impact.

However, adequacy and timeliness of prophylaxis must be ensured through surveillance and effective decision making.

•

Do Increases in Supply Lead to

Improvements in the Distribution of Pediatric

Subspecialty Care

Michelle Mayer, Ph.D., M.P.H.

Presented By: Michelle Mayer, Ph.D., M.P.H.,

Research Assistant Professor, Health Policy and


Chapel Hill, CB #7590, Chapel Hill, NC 27599-

7590, Phone: 919-966-7666, Fax: 919-966-1634,

Email: michelle_mayer@unc.edu

Research Objective: One remedy to physician shortages is to increase supply; however, supply increases only ameliorate physician shortages if they lead to dispersion of physicians into underserved areas. The study objective was to examine whether recently certified pediatric subspecialists enter markets that previously lacked providers and determine if increases in supply are associated with increased geographic availability of care.

Study Design: Methods: For each pediatric subspecialty, we identified new entrants using

2005 data from the American Board of

Pediatrics. ‘‘New entrants’’ were defined as those providers who first obtained board certification in 2004 or 2005. First we examined whether new entrants were more likely than their counterparts to practice in Hospital Referral

Regions (HRR) that were lacking providers in

2003. Second, we examined whether the percent of HRR with at least one provider increased from

2003 to 2005. Finally we examined whether the number of providers in a HRR increased from

2003 to 2005 among those HRR that had any providers. All analyses were done separately for each subspecialty. Bivariate comparisons used

Fisher’s exact test to compare ‘‘new entrants’’ versus their counterparts and student’s t-test to compare supply at the HRR level between 2003 and 2005.

Population Studied: Subspecialty diplomates from the American Board of Pediatrics in each of

15 pediatric medical subspecialties.

Principle Findings: During the time period studied, the number of board certified pediatric subspecialists increased 5% overall. New entrants comprised 10% of pediatric subspecialists. New entrants were significantly more likely than previously certified providers to locate in an HRR that lacked a provider in 2003 for the following pediatric subspecialties: developmental behavioral pediatrics, neurodevelopmental disabilities, cardiology, infectious diseases, emergency medicine, nephrology, rheumatology and sports medicine.

Despite the statistical significance, the actual number of providers in previously unserved markets was small; consequently, the percent of

HRR with a provider did not increase

significantly with the exception of developmental behavioral pediatrics. Among HRR with a provider in 2003, the number of providers increased significantly between 2003 and 2005 for pediatric critical care medicine, neonatology, developmental and behavioral pediatrics, neurodevelopmental disabilities, pediatric cardiology, pediatric emergency medicine, and pediatric endocrinology.

Conclusions: Our findings suggest that increases in the number of pediatric subspecialists do not generally lead to improvements in the distribution of these providers. With the exception of developmental behavioral pediatrics, the percentage of HRR with providers was virtually unchanged between

2003 and 2005. The significant increases in the number of providers in HRR that already had providers suggest that increases in supply may actually reinforce the existing distribution for certain pediatric subspecialties.


Increasing the supply of pediatric subspecialists may do little to alleviate the existing maldistribution. Other approaches to increasing access to pediatric subspecialists may be more effective than merely increasing supply. Possible interventions include extending the National

Health Service Corps to include these providers, training internist subspecialists to care for adolescents in areas with constrained access to pediatric subspecialists, facilitating general pediatrician involvement in the care of chronically ill children through telemedicine links with distant pediatric subspecialists, and using non-physician providers to extend pediatric subspecialists.


• International Medical Graduates in the US

Danette McKinley, Ph.D., John Boulet, Ph.D.,

John Norcini, Ph.D., James Hallock, M.D.

Presented By: Danette McKinley, Ph.D.,

Research Scientist, Research and Data

Resources, FAIMER, 3624 Market Street,

Philadelphia, PA 19104, Phone: (215) 823-2231,

Fax: (215) 386-3309, Email: dmckinley@faimer.org

Research Objective: Deficits in the physician workforce in the US have historically been filled by graduates of medical schools outside the US and Canada (IMGs). Even though increases in

US medical school class size is planned, IMGs will continue to fulfill healthcare workforce needs in the US for some time. Therefore, it is worthwhile to consider the characteristics of this group in modeling solutions to workforce shortages. The purpose of this study is to provide a detailed overview of IMGs pursuing opportunities in the US physician workforce over the past decade.

Study Design: The Educational Commission for

Foreign Medical Graduates (ECFMG) is responsible for certifying all graduates of medical schools outside the United States (US), Canada, and Puerto Rico who wish to pursue residency training in the US. The ECFMG certificate is also necessary for medical licensure. As part of the

ECFMG application and certification process, detailed demographic data is collected. The

American Medical Association (AMA) maintains a comprehensive database on all physicians practicing medicine in the US; individual records can be linked to ECFMG data sources.

Population Studied: The current investigation describes the characteristics and workforce pathways of physicians who were ECFMG certified between 1997 and 2006. The ECFMG database was used as the primary data source.

For some secondary analyses, the 2005 AMA

Masterfile, including graduate medical education data, was linked to ECFMG data sources. While results are focused on IMGs, comparative data on all residents is presented. Variables of interest included, amongst others, medical school location, residency program specialty, and basic demographics such as gender and country of citizenship at medical school.

Principle Findings: Between 1997 and 2006,

81,786 IMGs (including US-citizen IMGs) were certified. These IMGS were citizens of 192 countries and political entities; a considerable proportion were citizens of Southeast Asia

(India, 21%; Pakistan, 6%), the US (18%), China

(4%) and the Philippines (3%) at the time they attended medical school. Over the 10-year period, 42% of the certificate holders were female (n=34,061) and 29% attended medical school outside their country of citizenship

(n=23,358). Of the 81,786 certificate holders,

49,281 (60%) appeared in the 2005 Masterfile.

This difference between the two data sets could be due to the lag between certification and entry to residency; the 2005 Masterfile was current through the end of 2004. Of those appearing in the Masterfile, 56% (n=27,669) were in residency programs in the US. The IMGs in this cohort were enrolled in Internal Medicine (n=10,235;

37%), Family Medicine (n=3,624; 13%);

Pediatrics (n=1,986; 7%) General Surgery

(n=1,505; 5%); Psychiatry (n=1,430; 5%) and

Obstetrics/Gynecology (n=932; 3.4%) programs.

Trends over the 10-year period will be presented in the full paper.

Conclusions: Although there are concerns about the migration of physicians to the US from developing countries, a number of ECFMG applicants and certificate holders emigrate to attend medical school, and are from the US and

Canada.


Changes in the pool of ECFMG applicants and certificate holders are likely to have some impact on the composition and quality of the US physician workforce, affecting workforce planning.

Funding Source: Other, Foundation for

Advancement of International Medical Education and Research (FAIMER®)

• From the Eye of the California Nurses

Association: A Brief History and Analysis of

California’s Mandated Nurse-to-Patient Ratio

Lakisha Miller, B.S.

Presented By: Lakisha Miller, B.S., Full-Time

Doctoral Student, Epidemiology and

Biostatistics, Division of Health Services

Research and Policy, Case Western Reserve

University, School of Medicine, 11418 Bellflower

Road, Cleveland, OH 44106, Phone: 404-932-

7411, Email: dr.lakishamiller@yahoo.com

Research Objective: Examines the impact of the mandated minimum nurse-to-patient ratio in acute care and psychiatric hospitals that went into effect in January 2004 (Bill AB394).

Study Design: Review of reactions to implementation of the mandate (AB394) by a prominent California organization------the

California Nurses Association's website. The purpose of the review was to find any articles, papers, or comments related to the implementation of AB394.

Population Studied: Nurses

Principle Findings: Strong opposition by the

California Nurses Association to the implementation through multiple protests. In addition, the implementation of AB394 has led to an increase (more than 43,000) in the number of actively licensed RN’s in California.

Conclusions: The reactions to the implementation of AB394 are still coming to fruition. Time is the best predictor of future reactions and policy directions that the California

Nursing Association will take.


As a future policy direction, increasing the number of ways that patients become of aware of their safety and providing more advocates for patient involvement will increase the voice that the CNA currently has. As for future management directions, one obvious direction would be for hospital administrators to get in compliance with AB394, if they are not presently in compliance.

Funding Source: No Funding, submitted as a final class paper for a health care management and policy course.

• Primary Care Employee Satisfaction: What are Key Drivers?

David Mohr, Ph.D., Michael Mayo-Smith, M.D.,

M.P.H., James Burgess, Ph.D., Martin Charns,

D.B.A.

Presented By: David Mohr, Ph.D., Investigator,

Center for Organization, Leadership and

Management Research, Department of Veterans

Affairs, VA Boston Healthcare System (152M),

Boston, MA 02130, Phone: 857-364-5679, Email: david.mohr2@va.gov

Research Objective: The study examined factors that influenced primary care employee satisfaction with their job, work quality, perceived customer satisfaction and intention to leave.

Study Design: A census survey was administered in 2006 to employees of the

Veterans Health Administration (VHA). The survey had a 70% response rate. We examined responses from primary care employees relating to their overall job satisfaction, perceived customer satisfaction, quality of work and intention to leave. Employees were asked to assign each of these four single items a score from 1 (very dissatisfied) to 5 (very satisfied). We created additional scales from the survey based on prior work and included those variables in the regression model along with context variables.

Cronbach’s alpha for all scales was above .80. In hierarchical linear analyses, we nested individuals within medical centers. We regressed the four employee attitude variables on: provider or non provider status, job demands, workplace civility, management support, material resources. Additionally, medical center variables used in the model included teamwork culture, bureaucratic culture, facility complexity, patient intensity, support staff per provider, rooms per provider and patient panel size.

Population Studied: The study used a sample of

6,878 primary care employees in 115 medical centers from VHA.

Principle Findings: Overall job satisfaction was influenced by several factors including management support (B=.40), material resources (B=.26), workplace civility (B=.21), teamwork culture (B=.19) and job demands (B=-

.11). Intention to leave was influenced by management support (B=-.43), bureaucratic culture (B=.38), workplace civility (B=-.29) job demands (B=-.16) and material resources (B=-

.09). Employees ratings of quality of their work was influenced most by material resources

(B=.27) and teamwork culture (B=.13).

Employees ratings of customer service were influenced by material resources (B=.44), teamwork culture (B=.18), workplace civility

(B=.08) and patient intensity (B=-.63).

Conclusions: Workplace civility and material resources had a significant influence on all four employee satisfaction variables tested.

Management support was also central in influencing employee responses. The results also suggested that culture plays a role, with bureaucratic culture being associated with greater intention to leave and a teamwork culture being associated with the three positive satisfaction attitudes. Primary care areas with high patient intensity reported lower perceived patient satisfaction scores. Available resources, measured in terms of support staff per provider, rooms per provider and panel size, were not significant in any of the models, suggesting workplace climate variables may have more influence than these resource variables.


Workplace civility may be an area susceptible to improvement through the use of training programs and could lead to more satisfied employees and ultimately to more satisfied patients, as patient satisfaction has been shown to be related to employee satisfaction in past research. Additionally, providing interventions to improve organizational culture may help to influence primary care employee satisfaction.

Funding Source: VA

• Are Rural Students Interested in Health

Care Careers?

Patricia Moulton, Ph.D., Rebecca J. Rudel, Ph.D.,

R.N., Bridget L. Hanson, B.A., Karyn M. Plumm,

Ph.D., Joanna Marino, B.S.

Presented By: Patricia Moulton, Ph.D., Assistant

Professor, Center for Rural Health, University of

North Dakota, 501 N. Columbia Road, Grand

Forks, ND 58202, Phone: 701-777-6781, Fax: 701-

777-6779, Email: pmoulton@medicine.nodak.edu

Research Objective: A few studies have examined student perceptions about nursing as a career (Grossman & Northrop, 1993; Stevens

& Walker, 1993; Buerhaus et al., 2005). This study was designed to take advantage of the accessibility to the younger generation (not to mention a high level of technological savvy) of the internet to obtain a larger sample of high school students across one rural state (North

Dakota). The objectives of this study are 1) what career field high school students are interested in, 2) whether high school students plan to attend college in North Dakota and 3) after college, whether high school students plan to work in North Dakota.

Study Design: This study utilized a mixed design method with both quantitative and qualitative components. A 47-question online survey was developed which includes both multiple-choice questions and open-ended questions examining demographics, future career plans including education and career field, where students plan to go to college and work after graduation.

Population Studied: A stratified sample of schools representing urban and rural counties in

North Dakota was selected. All schools in each of the selected counties were contacted and were asked if they would be willing to participate in the study. Twenty-five schools agreed to participate and distributed handouts to all students between grades 9-12 in their school.

These handouts directed students to an online survey. 568 students who volunteered to participate were entered into a drawing for an

IPOD-Nano.

Principle Findings: Thirty-eight percent are interested in a career in healthcare. Most of these students said they would like to go into medicine, nursing or physical therapy. Nearly half of these students showed interest in more than one choice, such as health care and business. Most students indicated that parents had the most influence on their future career choice (55%) with few indicating high school counselors (3%). Seventy percent of students plan to attend a four-year college in North

Dakota because they want to stay near home

(69%), the low cost of attendance (52%) and/or the academic reputation (43%). Twenty-nine percent of students plan to seek employment in

North Dakota after completing their education largely because their family lives in North

Dakota. However, one-quarter of students are uncertain as to the geographic location in which they wish to work.

Conclusions:

Most of the surveyed high school students plan to pursue higher education, many at a four year college or university in North Dakota. Reasons include affordability and reputation. One-quarter of high school students are unsure of where they would like to seek employment after obtaining their education. This sizeable percentage represents an excellent potential group for future recruitment. Students cited healthcare as a desired field for a future career more often than any other area, and many students were interested in nursing.


Recruitment efforts should focus on those students who are unsure of what geographic area they would like to seek employment including the possibility of employer-based tuition payment programs. Programs should also examine working with parents to provide information about health careers to their children.

Funding Source: North Dakota Board of

Nursing

•

Human Capital in the Nursing Workforce and Its Impact on Patient Outcomes

Ciaran Phibbs, Ph.D., Ann Bartel, Ph.D., Pat

Stone, R.N., Ph.D., Nancy Beaulieu, Ph.D.

Presented By: Ciaran Phibbs, Ph.D., Health

Economist, Health Econmics Resource Center,

VA Medical Center (152), 795 Willow Road,

Menlo Park, CA 94025, Phone: (650) 493-5000 x22813, Fax: (650) 617-2639, Email: cphibbs@stanford.edu

Research Objective: There is an emerging evidence base on the effect of nurse staffing levels on patient outcomes in acute care hospitals and increased interest in mandating nurse staffing ratios. But this focus on staffing levels ignores two important characteristics of the nursing workforce: skills and stability.

Guided by the theory of human capital, the primary purpose of this project is to move beyond analyses of nurse staffing levels and to provide a comprehensive econometric analysis of the impact of the skill level and the stability of the nursing workforce on nursing-sensitive patient outcomes.

Study Design: This is a longitudinal study using data from Veterans Affairs (VA) hospitals for the fiscal years 2003 through 2006. This project will first examine the relationship between nurse staffing and patient outcomes, and then add human capital variables to examine how they mediate the relationship between nurse staffing and patient outcomes. Measures of human capital are being derived from the VA’s

Personnel and Accounting Integrated Data

(PAID) system, which contains payroll data including employee qualifications, and employment history. Patient outcome variables were derived from the discharge abstract files.

All variables are being aggregated by month for each inpatient unit at each VA facility. Human capital variables include not only staffing (hours per patient day and skillmix) but also night and weekend staffing, certifications, tenure, employment status, stability of the provider team. Nursing sensitive patient outcomes were derived using the Agency for Healthcare

Research and Patient Safety Indicators software.

The outcomes being analyzed include those that there is previous evidence as being sensitive to nursing care delivery.

Population Studied: The initial analyses are being conducted using data from the VA’s medical (n=114) and surgical (n=98) intensive care units. The analysis will be extended to all

VA inpatient units.


This study will extend the literature on the relationship between nurse staffing and patient outcomes by using monthly data from each inpatient unit of the hospital. In contract, most previous studies have used annual data for all inpatients. The results should extend our knowledge on the relationship between nurse staffing and patient outcomes. A unique feature of our project is that we will be able to study nursing teams. For example, we can compare the impact on patient outcomes of a unit nursing staff that has worked together as a team for many months or years with a team that has been intact for a shorter period of time. A finding that the former staff is more productive (i.e. better patient outcomes) would indicate that hospitals should consider implementing teambuilding interventions and mechanisms to keep teams together. Our analysis will also enable us to compare the productivity of teams that are composed of regular full-time RNs with teams that have temporary nurses as members.


•

Trust in a Wired World!

Ebrahim Randeree, Ph.D., M.B.A., Lisa Williams

Presented By: Ebrahim Randeree, Ph.D., M.B.A.,





Research Objective: Beyond technological and policy initiatives, organizations have to create a culture of security built on trust. Trust, especially within an digitial healthcare enterprise is difficult to establish and requires development over time.

This paper explores the influence of trust based mechanisms in creating cultural shifts within organizations as the role of security initiatives increase.

Study Design: Conceptual paper with propositions and research models

Population Studied: Hospitals (data on one qualitative study complete)

Principle Findings: If security and privacy is to remain consistent and successful, implementation of security procedures and routines must become embedded in the culture of the organization.

Conclusions: Change based on trust relationships can be successful in creating a culture of security. Experiences within healthcare and outside of healthcare clearly show that information technology must be implemented carefully in order for potential benefits to be realized to prevent barriers from emerging and acceptance to occur. As technology continues its impact in healthcare, the adoption of EMRs and the long term effects of HIPAA will affect the culture of organizations.


The culture of security is based on new ways of thinking and behaving that must be reinforced by management initiatives. The level of trust within the organization and of the organization will impact the level of compliance. Employees must be trained on security procedures and risk measures and the effect that violations have on the organization, its reputation, its survivability, and it’s legal and monetary damages for violations; they must also be encouraged to take responsibility for their organization and be encouraged to take initiatives to improve security. Initiatives that provide opportunities for trust-building and culture reinforcement should be supported. Beyond technological and policy initiatives, organizations have to create a culture of security built on trust.

•

Retooling the Healthcare Workforce

Ebrahim Randeree, M.B.A., Ph.D., Darrell Burke,

Ph.D.

Presented By: Ebrahim Randeree, M.B.A., Ph.D.,





Research Objective: To review the chnaging nature of the healthcare workforce as IT adoption permeates the industry. To

Study Design: Conceptual paper - proposed models for testing and research avenues

Population Studied: healthcare workforces

(physicians, nurses, support staff)

Principle Findings: Changing demands in the environment are creating the need for a IT literacy model for healthcare workers.

Impact to large organizations is minimal while the solo and small group physician is being inundated with new technology solutions that are beyond the capabilities of the office staff.

Conclusions: EMR penetration will increase the need for skills levels and that will help to realize the efficiencies that IT promises (ROI, quality, etc.)


Workforce chnages have to be addressed

(beyond PDA training for MDs) - how information is stored and organized makes access and quality critical.

• Preliminary Findings From the 2007

ASTHO State Public Health Worker Shortage

Survey

Adam Reichardt, Melissa Lewis, M.P.H.

Presented By: Adam Reichardt, Senior Analyst,

Public Health Performance Improvement, Public

Health Systems, Association of State and

Territorial Health Officials, 1275 K Street, NW

Suite 800, Washington, DC 20005, Phone: 202-

371-9090, Fax: 202-371-9797, Email: areichardt@astho.org

Research Objective: The objective of this research project is to update the 2003 State

Public Health Worker Shortage Survey and to determine emerging trends and areas that may need to be addressed when considering policy options for the public health workforce.

Study Design: In the fall of 2006, ASTHO developed a survey tool of nearly 40 questions to be deployed to Human Resource Directors of

State Public Health Agencies. The survey was a cross-sectional tool designed to get a deeper understanding of the current workforce shortage crisis experienced in state public health agencies, and identify unique strategies for dealing with this crisis. The survey was designed to be

compatible to ASTHO’s previous worker shortage survey as well as compatibility with the

National Association of State Personnel

Executive (NASPE) Consolidated Survey.

Population Studied: The population in this study is all 50 state public health agencies as well as six U.S. Territories and the District of

Columbia. The survey will be sent to Human

Resource Directors of each agency.

Principle Findings: The survey will be deployed in January 2007. No findings can be made at this time.

Conclusions: This abstract proposes to deliver preliminary findings from the ASTHO survey.

Findings and conclusions will not be available until early-mid April.


ASTHO is hopeful that the results of this survey will influence state public health workforce policy. One objective of the survey is to demonstrate the need for further funding and broader policy input to solve the impending worker crisis. ASTHO also envisions the results of this survey to offer some unique solutions currently employed in some states that may be helpful to other states as they continue to meet this challenge.

Funding Source: CDC

• AAMC Survey of Medical School Expansion

Plans

Rajeev Sabharwal, M.P.H.

Presented By: Rajeev Sabharwal, M.P.H., Senior

Researcher, Center for Workforce Studies,

AAMC, 2450 N Street NW, Washington, DC

20037, Phone: 202-828-0979, Fax: 202-828-1125,

Email: rsabharwal@aamc.org

Research Objective: The AAMC Center for

Workforce Studies administered the third annual survey of all U.S. medical schools in the fall of

2006 to better understand and inform the expansion plans of medical schools.

Study Design: The survey was designed to track enrollment and expansion trends over time and to assess the likelihood of the respondents to expand their medical school enrollment. The

Center also gathered public information on new medical schools planned or under discussion in the U.S. to provide a more complete picture of the likely future enrollment.

Population Studied: The AAMC Center for

Workforce Studies administered the third annual survey to all allopathic U.S. medical schools in the fall of 2006.

Principle Findings: Seventy-one (58.6%) schools plan to increase their enrollment, including sixty-four schools with plans to increase their first year enrollment by five or more students by the 2011-12 academic year.

Forty percent of these enrollment increases would be equal to or in excess of 10% of the current enrollment. Of the schools with plans to increase enrollment, seven plan to increase their enrollment by over fifty students in the next five years, with two schools indicating plans for an enrollment increase of over 100 first-year students. Including students at potential new schools, total planned first-year enrollment for the 2011-12 academic year is 19,296. This represents an 17.1% increase in enrollment compared to the 2002-03 academic year. Of the

121 schools that responded to the survey, sixtythree have already conducted an assessment of the financial needs and/or implications of expansion; fifty-three schools have conducted an assessment of the depth and quality of the applicant pool. The respondents were most likely to report limited scholarship availability, classroom space, and ambulatory preceptors as

‘‘major’’ barriers to expansion. These are followed by costs, ambulatory training sites, lab space, hospital training sites, full-time clinical faculty, and library/study space as ‘‘major’’ barriers.

Conclusions: U.S. medical schools are attempting to respond to existing and expected physician shortages and the AAMC call for increased enrollment. Over half of U.S. medical schools plan to increase their first-year enrollment (or have already done so).


While these efforts are encouraging, they still fall short of the AAMC’s call for a 30% increase in first year enrollment in 2015. There have been numerous discussions regarding new U.S. medical schools, yet it remains to be seen how many of these schools will come to fruition, in addition to great uncertainty about the number of additional students these schools will be able to enroll in their early existence. As the population continues to rise over the next decade, current medical education and training activities are not likely to keep pace with the demand for health professionals.

•

Changes in the Registered Nurse Workforce in Rural Areas of the US Since 1980

Susan Skillman, M.S., Lorella Palazzo, Ph.C., L.

Gary Hart, Ph.D.

Presented By: Susan Skillman, M.S., Deputy

Director, Rural Health Research Center & Center for Workforce Studies, Family Medicine,

University of Washington, 4311 11th Avenue NE

Suite 210, Seattle, WA 98105, Phone: (206)543-

3557, Fax: (206)616-4768, Email: skillman@u.washington.edu

Research Objective: To examine how the demographic, education and practice characteristics of rural registered nurses (RNs) have changed since 1980.

Study Design: Using the federal Bureau of

Health Professions National Sample Survey of

RNs data (collected every 4 years from 1980 through 2004 and nationally representative) this study describes licensed RNs residing in rural and urban areas. RNs were categorized into urban, large rural, small rural and isolated small rural by residence and work location using the

Rural-Urban Commuting Area taxonomy.

Population Studied: Licensed RNs in the U.S.

Principle Findings: Since 1980 both rural and urban RNs have increased in number, percent employed in nursing, mean age, and age at first

RN degree. The proportion with baccalaureate nursing degrees or higher increased for both rural and urban RNs, but relatively fewer rural

RNs had baccalaureate or higher nursing degrees than did urban RNs. In the early 1980s, most RNs resided and worked in the same geographic types of areas: 89% of RNs residing in large rural areas worked there, 83% in small rural, and 69% in isolated small rural areas. By

2004 these percents had reduced to 76% in large rural, 58% in small rural and 36% in isolated small rural areas. The ratio of RNs per

100,000 population differed greatly depending on whether RN residence or work location was referenced: by residence the urban ratio was 833 in 2004 compared with 786 for rural RNs overall.

By work location, however, the comparable 2004 ratios were 853 for urban and 688 for rural overall, and there were 369 RNs per 100,000 population working in isolated small rural areas.

Over time the RN to population ratios, by work location, grew closer for urban and overall rural areas, but a sizable difference remained. From

1980 through 2004 the salaries of RNs residing in rural areas (regardless of their work location) remained lower than the salaries of their urban counterparts.

Conclusions: Since 1980 the RN workforce in both rural and urban areas grew, but it also aged. From 1980 through 2004, the proportion of urban RNs with baccalaureate or higher degrees increased more than for rural RNs. The more rural the residence of RNs the larger the proportion that commuted to more urban (less rural) areas for work. Across the past two decades all rural areas had lower ratios of RNs to population, by RN work location, compared with less rural and urban areas.


This study shows that the rural RN workforce aged since 1980, as did the urban RN workforce, suggesting that retirements will have a large impact on RN supply in both rural and urban areas during the coming decades. In addition, rural RN supply is effectively lower than urban supply because the more rural and isolated the community, the fewer the RNs who are working in that community and serving its residents.

More information is needed about rural nursing demand to determine whether rural communities are facing greater nursing shortages than urban and less rural communities.

Funding Source: HRSA, Office of Rural Health

Policy

• Past, Present, and Future of Diversity in

Health Care Management and Health Care

Organization’s Corporate Social

Responsibility.

Joceyn Steward, M.S.M.

Presented By: Joceyn Steward, M.S.M., Ph.D.

Student, Health Services Administration,

University of Alabam at Birmingham, 2909

HIghland AVE SO #803, Birmingham, AL 35205,

Phone: 706-394-0284, Email: jsteward@uab.edu

Research Objective: Diversity in the health care workforce is important to the future of health care. As the number of minorities that represent the population of the United States of America increases, healthcare organizations lack adequate representation of this growing population. The U.S. Census Bureau predicts by

2050 that the population of minority citizens in the America will represent more than one-third of the population. Healthy People 2010 push for cultural understanding by health care workers.

Therefore, it is important to continue to examine this arena and develop policies to embrace the increase of minority health care workers (Palmer

2003). Although there is a lack of workforce diversity in many positions in a health care organization including doctors, nurses, dentists, allied health, and pharmacists; the minority health care manager is often overlooked.

Therefore, the paper will focus specifically on

minority health care managers. The paper explores the past, present, and future of health care management workforce and compares it to numbers represented by other higher education positions: doctors, nurses, dentists, allied, and pharmacists. The paper will also examine the barriers that exist to enter the health care management field by diverse individuals.

Because health care management is still overly represented by Caucasian males, diversity, in this paper, will include white females and males and females of U.S. Census described minority sectors.

Study Design: The paper will analyze and pulltogether various databases and published information to demonstrate the need for increased diversity in health care management.

This paper will give future researchers ideas of subsequent studies that can be conducted to both tackle the problem of lack of diversity and the consequences it has in a health care organization.

Population Studied: The paper will focus on the corporate social responsibility that health care organizations have to their communities, and future representative communities, to ensure a vital, productive health minority workforce.

Conclusions: The paper demonstrates that lack of diversity in the health care workforce affects patient satisfaction, health outcomes, health behaviors, culturally sensitive information, language barriers, health literacy, discrimination, and racial disparity.


The role of minority health care manager will have significant impact on the strategic planning of the organization. It is important for managers and higher executive individuals to understand the importance of diversity for not only the patient population, but also their own population of health care workers. It will be important for them to embrace changes that will affect the organization positively. Overall, the paper will examine the issues mentioned in the abstract and represent a niche in the literature concerning health care workforce diversity and corporate social responsibility.

• Exploring the Relationship of Body Mass

Index and Workforce Participation

Jun Tang, M.S., Teresa Waters, Ph.D.

Presented By: Jun Tang, M.S., Research Data

Analyst, Preventive Medicine, University of

Tennessee Health Science Center, 66 N. Pualine

St. Suite 633, Memphis, TN 38105, Phone:

(901)448-5900, Fax: (901)448-7041, Email: jtang@utmem.edu

Research Objective: To describe the relationship between Body Mass Index (BMI) and workforce participation and to investigate the influence of demographic and socioeconomic characteristics on this relationship using population-based Medical

Expenditure Panel Survey Data.

Study Design: The working status of each individual in the 2004 sample was classified into one of two groups: continuous working versus not continuous working. BMI was classified into underweight, normal weight, overweight and three levels of obesity. Four separate logistic regressions were estimated to explore the association between body weight and workforce participation. The base model examined workforce participation as a function of BMI classification only. The augmented model controlled for demographic and socioeconomic characteristics in addition to BMI. In order to explore whether the workforce participation-BMI relationship might differ by sex, two additional logistic regressions, for male and female respondents, were also estimated.

Population Studied: Responses from 15,884 adults surveyed in the U.S. Medical Expenditure

Panel Survey 2004 who provided complete information regarding variables of interest were analyzed.

Principle Findings: In the base model, underweight and obese individuals had lower odds of workforce participation compared to normal weight individuals. In the full model that adjusted for demographic and socioeconomic factors, underweight and Class III obesity were associated with lower odds of working, with odds ratios (95% confidence interval) of 0.498 (0.497

- 0.5) and 0.947 (0.945 - 0.949), respectively, while overweight, Class I and Class II obesity were associated with higher odds of working

(relative to normal weight), with odds ratios of

1.13 (1.128 - 1.131), 1.099 (1.098 - 1.1), and 1.065

(1.064 - 1.067) respectively. The results for the male-only model were similar to the full model.

However, the results for the female-only model were slightly different: Class I and Class III obesity were positively associated with workforce participation with odds ratio of 1.089 (1.088 -

1.091) and 1.038 (1.035 - 1.04) respectively, while

Class II obesity and overweight were marginally or unrelated to workforce participation, with odds ratios of 0.993 (0.991 - 0.995), and 0.999

(0.998 - 1.001), respectively. Consistent with the overall augmented model, underweight women

had a significantly reduced odds of work force participation, with an odds ratio of 0.503 (0.501 -

0.505).

Conclusions: While underweight and obese individuals have lower odds of workforce participation, these differences appear to be driven heavily by socio-demographic factors.

After controlling for major socio-demographic factors, we found that, in general, BMI levels were actually positively associated with probability of working.


Economic theory suggests that non-normal weight levels (underweight, obese) might serve as a disability limiting workforce participation.

Our results, however, suggest that at most, only the extremes of the BMI distribution

(underweight, highest levels of obesity) were associated with reduced work probability. Our results also suggest that obesity trend in the U.S. may actually be slightly amplified in the U.S. workforce, leading to significant increases in health care costs over time.

•

The Distribution of International Medical

Graduates (IMGs) in US: The interplay of

Poverty, Rurality and Length of Practice

Xingyou Zhang, Ph.D., Martey Dodoo, Ph.D.,

Stephen Petterson, Ph.D., Andrew Bazemore,

M.D., M.P.H., Robert Phillips, Jr., M.D., M.S.P.H.

Presented By: Xingyou Zhang, Ph.D., Health

Geographer/Biostatistician, The Robert Graham

Center: Policy Studies in Family Medicine and

Primary Care, American Academy of Family

Physicians, 1350 Connecticut Avenue, N.W.,

Suite 201, Washington, DC 20036, Phone: 202-

331-3360, Fax: 202-331-3374, Email: xzhang@aafp.org

Research Objective: In the United States, international medical graduates (IMGs) have become a significant component of the US physician work force (23%). Compared to US medical graduates (USMGs), IMGs have distributed preferably to a critical supply for the rural areas, health professional shortage areas

(HPSA) and medically underserved Areas

(MUA). But little is known about what kind of communities these IMGs practice in at small geographic level. The purpose of this study is to systematically examine the census tract level neighborhoods where IMGs are located.

Study Design: We linked the geocoded 2006

AMA masterfile with US 2000 Census tract poverty data and USDA Economic Research

Service (ERS) census tract level rurality data.

We categorized census into 2 poverty and 3 rurality groups: low poverty neighborhoods which are census tracts with less than 20% population under poverty level, high poverty neighborhoods which are census tract with 20% or more population under poverty level; metropolitan urban neighborhoods with 2000

Rural-Urban Commuting Area Codes (RUCA)1-3, small city neighborhoods with RUCA 4-6, small town and rural neighborhoods with RUCA 7-10.

We compared the geographic distributions of

IMGs with different GME graduation years

(before 1996, 1996-2000, 2001-20005) for physician types (US-born vs foreign-born, primary care vs specialist). We also compared the distribution of IMGs with that of USMGs.

Population Studied: 314,784 US physicians who provide patient care and have geocodable office addresses in 2006 AMA master file.

Principle Findings: IMGs are less likely to practice in small cites/towns and rural areas

(large rural areas). 11.4% IMGs practice in large rural areas while 13.2% USMGs in these areas

(Fisher exact test: P<0.0001). US-born IMGs tend to practice in low poverty neighborhoods, and foreign-born IMGs are more likely to practice in high poverty neighborhoods. Newer

IMG physicians are more likely to practice in rural, high poverty neighborhoods.


IMGs are essential to health care access, particularly in both high poverty and rural areas.

This should be considered amidst calls to expand allopathic schools. In addition to successful policies for IMG recruitment such as the J-1 Visa program, policymakers should consider how to not only attract, but retain IMGs in these areas.

General Posters

• An Advanced Clinical Training Program for

Nursing Assistants

Nicole A Andreoli, M.S., Nicole A Andreoli, M.S.,

Sylvia Williams, R.N., M.A., Andrea Gowie

Presented By: Nicole A Andreoli, M.S., Research

Associate, Nerken Center for Research, Parker

Jewish Institute, 271-11 76th Avenue, New Hyde

Park, NY 11040, Phone: 718-289-2100 x4549, Fax:

718-289-2345 Email: nandreoli@parkerinstitute.org

Research Objective: The highly publicized national nursing shortage has been well documented in professional journals, labor force reports and daily newspapers. However, contrary

to prior belief, the shortage is not limited to registered nurses; there is a deficit in the numbers of working certified nursing assistants and licensed nursing professionals as well. A major problem with retaining a nursing staff is the high level of job dissatisfaction. Many find the physical, mental and emotional demands of the work environment too taxing. Additionally, nursing staff have often cited lack of knowledge and education as reasons for their dissatisfaction. A CNA training program was implemented with the objectives: to expand

CNAs’ knowledge of medical procedures; augment their skillset through classroom and clinical training; provide training necessary to maintain employment in a nursing home and provide training in skill areas that will support career advancement. A significant benefit of this program would be that CNAs will possess improved skills and tools to deliver better patient care in the health care industry, thereby leading to increase job satisfaction.

Study Design: The advanced clinical training program was structured to give recognition to the CNAs as having a very important role and to train participants to become better providers to their recipients. The 12-week program which focused on integrating the CNAs’ experience, their professional personal relationship with the resident, resident’s family and daily involvement with the patients. The curriculum consisted of the most common and serious signs, symptoms, and behavioral manifestations associated with six biological systems: cardiovascular, neurological, skeletal, respiratory, endocrine and integumentary) and the role of the CNA in their management. Instruction included a 6 ½ hour training day, including both didactic, clinical and lab sessions.

Population Studied: Upon curriculum completion, CNAs were asked to complete as satisfaction survey.

Principle Findings: The satisfaction survey gathered information regarding attitudes and feelings of the participants towards the training program. Of the 28 participants, 90% were very satisfied with the overall usefulness of the program. Eighty percent were very satisfied with reaching their career goals. 86% agreed that the program was very useful in helping with their current position. Similarly, a high proportion of program participants believe this program should continue in the future (80%). To improve the program, the participants suggested a longer training period and more class time. Other programs the participants expressed an interest in include: LPN, RN, EKG and Pharmacy

Technician.

Conclusions: Employment of CNAs is expected to grow faster than average in response to an emphasis on rehabilitation and long-term care needs of a rapidly growing elderly population.

Subnormal job dissatisfaction can have negative ramifications for the very people they are trying to help.


By providing education, training, and recognition, CNA’s will feel better equipped to perform their jobs causing their satisfaction to improve exponentially. Job satisfaction increases also have organizational benefits, not only do employees perform better, but they tend to be less afflicted with absenteeism and turnover.

Funding Source: Department of Health

•

Increasing Medication Compliance Through

Telemedicine Technology

Nicole A Andreoli, M.S., Lorraine Breuer, M.A.,

Diane Marbury

Presented By: Nicole A Andreoli, M.S., Research

Associate, Nerken Center for Research, Parker

Jewish Institute, 271-11 76th Avenue, New Hyde

Park, NY 11040, Phone: 718-289-2100 x4549, Fax:

718-289-2345 Email: nandreoli@parkerinstitute.org

Research Objective: Medication compliance is a significant problem for the elderly. A recent study noted that for chronic-disease management and prevention, medication adherence is 50%. Estimates indicate that 25% of elderly do not take prescription medications at all, while an additional 25% take medication, although it typically involves skipped doses and under and overdosing. Poor compliance is associated with drug interactions, hospitalizations, discomforts, care dissatisfaction, inadequate disease prevention, and death. This unique study attempts to utilize telemedicine as an aid in medication compliance, with the ultimate goal being to minimize the risks and consequences associated with incorrect medication use.

Study Design: A programmable, electronic medication dispenser was implemented to increase medication compliance in the homecare setting. The medication dispenser was preprogrammed to dispense each individual’s medication dosage following a given schedule.

The dispenser beeps at the appropriate timepoint and dispenses only those medications to be taken at that time. If the medication is not

taken from the pill dispenser within 30 minutes, the system sends an alert to the central monitoring center so that the homecare nurse can take follow-up actions.

Population Studied: Twenty-five residents were enrolled, receiving the medication dispenser.

Participants were randomized into control and experimental groups. However, several constraints impeded the quality of control group data. For example, nurses working with the control group ---- who did not receive the dispenser ---- were not willing to report residents had incorrect or missed doses, thereby deliberately concealing noncompliance.

Therefore, the control group was excluded from the study.

Principle Findings: Number of days enrolled in the study ranges from 72-136 (M=103.25

SD=21.60). There was a total of 665 observations, including alerts of medication compliance, noncompliance, low battery (N=7) and a jammed dispenser (N=16). Compliance rates range from 4-144 correct medication dosages (M=59.8) Non-compliance rates range from 1-54 incorrect dosages (M=20.37) Variability is due to differences in the number of observations, as not all participants were enrolled simultaneously. Results indicate that participants using this telemedicine device took the correct dosage at the time indicated 72% of the time, and were noncompliant 24.5% of the time. However, a selection bias exists. Since participants self-selected into this program, their motivations, lifestyle and desire to be prescription-compliant may differ significantly from those who decided not to participate.

Conclusions: Medication nonadherence is a serious but potentially correctable cause of treatment failure, drug-related complications, hospitalization and death among elderly patients. Reasons for nonadherence include complex medication regimens, age-related disease and disability, cognitive impairment and misunderstanding of medication use. This study indicated that residents adhered to medication dosages 72% of the time, as compared to previous estimated compliance rates of 50%, demonstrating that telemedicine can aid in increasing medication compliance.


This information is based on preliminary data but nonetheless suggests that further investigation in this area is worthwhile.

Additionally, dialogue should occur between caregivers and patients to ensure that the prescription regime is understood and could be followed, as it is an important step in preventing unnecessary interactions and ailments.

Funding Source: NYS Department of Health

•

Utilizing Clinical Looking Glass® for

Improving the Quality of Care of HIV Infected

Patients in a Network of 10 Community

Health Centers

Asif Ansari, M.D., Sara O. Briller, Ph.D., M.P.H.,

Robert S. Beil, M.D., Bruce Soloway, M.D.,

FAAFP, Arthur E. Blank, Ph.D., Peter A. Selwyn,

M.D., M.P.H.

Presented By: Asif Ansari, M.D., ECRIP Fellow,

Family and Social Medicine, Montefiore Medical

Center, 111 E 210 St, Bronx, NY 10467, Phone:

(732) 713-5067, Fax: (718) 798-9837 Email: asansari@montefiore.org

Research Objective: To create a cohort of HIV+ patients within Montefiore Medical Group II

(MMGII), a network of 10 community health centers serving a population of 128,512 (2006) patients in the Bronx, NY. To determine which patients in our cohort are on HAART (Highly

Active Anti-Retroviral Therapy) and opportunistic infection prophylaxis, and to perform these tasks accurately in a more time-efficient manner. This was done utilizing Clinical Looking Glass®

(CLG®), a sophisticated application in healthcare intelligence and outcomes analysis, developed at Montefiore Medical Center.

Study Design: We compared cohort building using billing information to cohort building derived through CLG®. CLG® integrates clinical and administrative datasets, allowing the creation of a unique set of patients based on an array of user-inputted parameters.

Population Studied: HIV positive patients within MMG II. These patients are cared for by the CICERO program, a multi-disciplinary team specialized in providing care to HIV positive individuals in a community setting.

Principle Findings: The use of CLG® for cohort building yielded clean, comprehensive and timely data, superior to that derived through the billing data. Prior to 2006 an HIV+ patient list derived from billing data was created. A chart abstractor, requiring four months, supplemented clinical information pertinent to QI. CLG® performed this task instantaneously with the added capability of statistical and epidemiological analyses. Information obtained from CLG® was used to detect variations from clinical protocols prompting timely notification to healthcare providers, and possible remediation.

Additionally, CLG® yielded a consistently larger

cohort as compared to that captured by using administrative data. Using administrative

(billing) information systems yielded 767 patients in 2005 as compared to 976 patients derived through the CLG® for the same time period (2005). The ease of data analysis enabled the following QI approaches: Patients on ARV /

HAART. Using CLG® we created a list of HIV medications. We delineated a sub-cohort of patients that were on HAART and subsequently reviewed patients who had detectable viral loads.

This prompted clinical intervention, if so warranted. Opportunistic infection prophylaxis.

Using CLG® we created a list of patients not on clinically indicated prophylaxis based on CD4 counts. This also prompted possible clinical intervention.

Conclusions: The use of CLG® is superior in all respects to the use of administrative data for the creation of a designated population of HIV positive patients within our network. CLG® captured patients that were not originally included in our cohort using the prior method of analyzing billing data. This made for a more comprehensive panel of patients. The application can be used to track and analyze intermediate points along the patient care continuum allowing medical practitioners and administrators to create remediation strategies for failing patients before those failures manifest as morbidity or mortality.


The use of CLG® provides a quick and reliable method of collecting patient information. CLG® provides instantaneous information to individual

Health Centers and clinicians for hands-on and continuous quality improvement work. Future uses will include other parameters such as patient retention.

Funding Source: Empire Clinical Investigator

Research Program (ECRIP)

•

Models of Mentoring and Job Satisfaction:

Assessment of Linear and Nonlinear

Relationships

Mary K Anthony, Ph.D., R.N., John M. Clochesy,

Ph.D., R.N., F.A.A.N., FCCM

Presented By: Mary K Anthony, Ph.D., R.N.,

Kerley Scholar Visiting Professor, School of

Nursing, University of North Carolina Charlotte,

9201 University City Boulevard, Charlotte, NC

28223, Phone: (704) 687-7736, Email: manthony@kent.edu

Research Objective: Mentoring is one of the most important relationships a novice nurse can have in transitioning to ICU, enhancing satisfaction and decreasing turnover. As part of the larger demonstration project to retain ICU nurses, the purpose of this study is to assess the congruence between nurses’ perceived importance and actual experience of key mentoring functions and its relationship to job satisfaction.

Study Design: A descriptive comparative design using survey methodology is used. Four cohorts of RN n = 58 novice nurses were hired into a 6 month mentored ICU orientation program at a major university hospital. Each novice nurse was assigned a mentor who met criteria for assuming a mentoring role. The 8- dimension

Fowler mentoring survey was distributed to novice nurses at approximately 3 and 6 months after hire. For each item, respondents were asked to rate both the importance and the extent that the mentoring function actually occurred.

Job satisfaction was assessed at 6 months using four subscales of the McCloskey-Mueller Job satisfaction survey. Data is reported on nurses from 3 of the 4 cohorts-data on cohort 4 will be completed in February, 2007- and who completed both the mentoring survey at 3 months and the satisfaction survey at 6 months n = 26.

Population Studied: The average age of nurses was 26.5 years, 88.5% were female, 80.8% were white, and 7.7% had worked with a mentor in a job outside of nursing.

Principle Findings: For the 8 mentoring functions- personal and emotional guidance, coaching, advocacy, career development, role modeling, strategies and systems advice, learning facilitation, and friendship-, congruence between the importance and actual occurrence of the mentoring function was calculated using the difference between the two scores. The relationship between the difference scores and job satisfaction -with coworkers, interaction, praise and recognition and control- were assessed. Preliminary exploration suggested that only the correlation between job satisfaction and learning facilitation was linear. For the other mentoring-satisfaction relationships, eta correlations were substantially higher and curve estimation indicated that the relationship between mentoring congruence and job satisfaction was quadratic and statistically significant-R2 and Beta. For all mentoring dimensions importance was rated higher than actual and was greatest among career facilitation, strategies and systems advice, and learning facilitation.

Conclusions: In general, when nurses rated the mentoring they actually experienced as greater than importance, satisfaction was low. However when there was a small to moderate discrepancy and nurses rated importance of mentoring greater than the actual, satisfaction was the highest. Finally, when the discrepancy was high: nurses’ perceived importance of mentoring was higher than experienced, job satisfaction was low. We will evaluate whether these finding hold when we assess the relationship of importance and actual mentoring at 6 months with satisfaction at six months.

Implications for Policy, Practice or Delivery: If particular aspects of early mentoring can be identified as being important to future satisfaction, then the opportunity exist for targeted interventions to be implemented that can improve nurse satisfaction and retention in

ICU where shortages are projected to worsen.


• Factor Structure of the Outcomes of Early

Mentoring Experiences

Mary K. Anthony, Ph.D., R.N., John M. Clochesy,

Ph.D., R.N., F.A.A.N., FCCM

Presented By: Mary K. Anthony, Ph.D., R.N.,

Kerly Scholar Visiting Professor, School of

Nursing, Unviersity of North Carolina at


Charlotte, NC 28223, Phone: 704-687-7736,

Email: manthony@kent.edu

Research Objective: Mentoring is one of the most important relationships for a new professional nurse. Important roles of mentoring have been identified however the outcomes of mentoring have had little empirical evaluation.

As part of the larger demonstration project to retain ICU nurses, the purpose of this study is to explore the factor structure of the benefits of mentoring.

Study Design: A methodological design is used in exploring the factor structure of the benefits scale of the Fowler mentoring survey. The survey consists of three parts: 39 items for 8 roles of mentoring, 29 items assessing benefits and 21 items assessing costs of mentoring. In the larger study, each novice nurse was assigned a mentor who met criteria for assuming a mentoring role. The Fowler mentoring survey was distributed to novice nurses at approximately 3 and 6 months after hire. Data from the 3 month survey is presented.

Population Studied: Fifty-eight nurses in 4 cohorts were enrolled in the study. Of the fortyfive who returned surveys at 3 months, the average age of nurses was 27.5 years, 77.8% were female, 84.4% were white, 73.3% had a BSN, and

11.1% had worked with a mentor in a job outside of nursing.

Principle Findings: A principal component extraction with varimax rotation yielded a five factor solution. Eignenvalues from the initial extraction were 15.4 for Factor 1 and 3.08 for

Factor 2. These two factors accounted for 63.8% of the variance. Factors 3, 4, and 5 had eigenvalues less than 2 and accounted for a total of 15% of the variance. Factor 1, alpha reliability of .97, consisted of 16 items with loadings ranging from .59 to .90. The underlying construct suggested that items were related to the successful socialization to the ICU and included a strong learning component, emotional support and relational network building. Of those 16 items, 4 had mixed loadings on Factor 2. Factor 2, alpha reliability of .88, consisted of 5 items with loadings ranging from .62 to .75 and was related to professional esteem. Factors 3 through 5, consisted of 2-3 items within each factor and were related to future potential benefits such as promotion, increased work responsibilities and helping others to achieve.

Conclusions: The five factor structure is empirically suggestive but the 2 factor structure is theoretically and empirically strong. At 3 months, new nurses viewed outcomes of mentoring as successful integration and socialization into knowledge driven ICU environments and building of professional esteem. Although the sample size was small,

Zeller and colleagues report that a sample size of

25 will produce a stable factor structure. When data collection is complete for the fourth cohort in February, 2007, the factor structure of benefits will be compared at 3 and 6 months.


Instrumentation to assess benefits of mentoring across time is important to the mentoring process early in the experience as well as longer term. Roles and benefits of mentoring are dynamic and matching them at any particular point in time is most likely to have the greatest impact on effectiveness and satisfaction.


• Impact of Hospital Formularies on

Fluoroquinolone Prescribing in Emergency

Departments

Sherrie Aspinall, Pharm.D., M.Sc., Joshua

Metlay, M.D., Ph.D., Judith Maselli, M.S.P.H.,

Ralph Gonzales, M.D., M.S.P.H.

Presented By: Sherrie Aspinall, Pharm.D., M.Sc.,

Clinical Pharmacy Specialist, Center for Health

Equity Research and Promotion, VA Pittsburgh

Healthcare System, University Drive C,

Pittsburgh, PA 15240, Phone: 412-688-6000

815364, Fax: 412-688-6527 Email: sherrie.aspinall@va.gov

Research Objective: The purpose of this study was to examine factors associated with fluoroquinolone prescribing for adults seeking care for acute respiratory infections (ARIs) in emergency departments.

Study Design: Randomized, controlled trial

Population Studied: Adults seeking care for acute respiratory infections in emergency departments at eight Veterans Affairs Medical

Centers and seven non-federal hospitals across the U.S.

Principle Findings: An antibiotic was prescribed at 66% of the 2483 eligible ARI visits.

Fluoroquinolones accounted for 14% (237/1646) of the total antibiotic prescriptions. At hospitals with at least one unrestricted fluoroquinolone on formulary, the average fluoroquinolone prescription rate was 17%; compared with a 6% prescription rate at hospitals with fluoroquinolone access restricted by the hospital formulary (p < 0.0001). In multivariable analyses, the factors associated with increased fluoroquinolone prescription rates were hospital formulary status, admission to the hospital, and the diagnoses of acute bronchitis, acute exacerbations of chronic bronchitis, and pneumonia.

Conclusions: Hospital formulary policies appear to represent a potentially important target for influencing outpatient drug prescribing in emergency departments.

Implications for Policy, Practice or Delivery: It is important for local policy makers to consider the impact of hospital formulary restrictions on patterns of outpatient antibiotic prescribing, which then can influence patterns of resistance.

Funding Source: AHRQ, Department of

Veterans Affairs

• Hospital and Market Factors Asssociated

With Guideline-Compliant Antibiotic Use for

Community Acquired Pneumonia

George Avery, Ph.D., M.P.A.


Assistant Professor, Health and Kinesiology,

Purdue University, 800 West Stadium Avenue,

West Lafayette, IN 47907, Phone: (765) 496-

3330, Fax: (765) 496-1239 Email: gavery@purdue.edu

Research Objective: This study was designed to examine hospital- and market-level factors associated with guideline-appropriate use of antibiotics to treat community-acquired pneumonia.

Study Design: Data was obtaine from a merger of variables from the 2005 American Hospital

Association Annual Survey, data reported in

2004 as part of the Hospital Quality Alliance

Quality Compare program, and data from the

2000 US Census Summary file 3, aggregate to the Health-Service Are level.

Population Studied: 1500 US hospitals with data in the American Hospital Association 2005

Annual Survey and the 2004 Hospital Alliance

Quality Compare dataset.

Principle Findings: Hospital based case management was associated with lower rates of timely and appropriate antibiotic usage. JCAHO accreditation and higher ratios of residents/bed were associated with lower rates of blood culture utilization and timely antibiotic use. Private nonprofit hospitals reported higher rates of appropriate and timely antibiotic usage, and the percentage of the market population that was white and/or urban was associated with greater rates of appropriate antibiotic utilization and use of blood cultures.

Conclusions: Market-and hospital-level factors are identifiable as having an impact on guideline- appropriate use of antibiotics. Results may be consistent with the existence of racial disparities in access to quality hospital care.


Assumptions that JCAHO accreditation and case management use are consistent with high quality care are called into question.

• Factors Affecting Physicians Information

Technology Use

Jong-Deuk Baek, Ph.D., Carleen H.Stoskoph,

Sc.D., Yunho Jeon, Ph.D.

Presented By: Jong-Deuk Baek, Ph.D., Graduate

Assistant, Health Services Policy and

Management, University of South Carolinz, 800

Sumter, Columbia, SC 29208, Phone: 803-777-

2772, Fax: 803-777-1836 Email: baekj@mailbox.sc.edu

Research Objective: To investigate impacts of physicians’ perception, individual factors, organizational factors, and health care system factors on physicians’ information technology use.

Study Design: This study utilized secondary data sets: 1) the 2000-2001 Community Tracking

Study (CTS) Physician Survey; 2) the 1998-1999

CTS Physicians Survey. For physicians’ IT use, the dependent variable, seven variables were measured in the 2000-2001 CTS Physician

Survey and this study created a composite score based on factor loadings from a principal component analysis. Four categories of predictors were considered: 1) physicians’ perception of IT, 2) socio-demographical and clinical variables, 3) organizational variables, and

4) health care system variables. As for the physicians’ perception, two variables were used to create a summated scale for physicians’ perceived usefulness. Age, gender, income, and race were considered as physicians’ sociodemographical variables. Primary care physician, authority, specialty, communication with patient, and communication with other providers were included as clinical variables. As for organizational variables, practice ownership and practice type were included. Perceived competitiveness, proportion of revenue from managed care contracts, proportion of revenue from Medicare, and proportion of revenue from

Medicaid were included as health care system variables. A multiple regression technique was employed to investigate adjusted impacts of factors on physicians IT use. SUDAAN procedures were used to obtain population estimates.

Population Studied: The unit of analysis is physicians randomly selected from 60 medical communities in the United States through the

CTS sampling design. The combined sample has

8,527 physicians.

Principle Findings: Physicians’ perception of usefulness was the strongest determinant of physicians IT use (ß=0.403, p < .0001). Female physicians showed less IT use (ß =-0.043, p <

.0001). As for clinical variables, specialty

(OBGYN ß=-0.037, p < .03), authority in business decisions (ß=-0.030, p < .0091), communication with patients (ß=0.028, p

<0.006), and communication with other providers (ß=0.032, p < 0.0001) were found to be significant. Practice type as an organizational factor was significant. All other types practitioners showed significantly greater utilization of IT than solo practitioners. Perceived competitiveness (ß=0.23, p <0.018) and managed care dependency (ß=0.036, p < .0007) were found to be predictors of physicians’ IT use.

Conclusions: Various factors are required to successfully adopt and utilize IT. Physicians are the major players that make IT adoption and utilization decisions. Therefore, not only factors related to physicians’ individual perception of IT, such as perceived usefulness, perceived easy of use, and compatibility, but also factors related to situations where individual physicians are delivering medical care must be considered.


This study provided a framework that consisted of Individual-level (physicians’ sociodemographical and clinical variables), organizational-level, and health care system-level factors. With this framework, the limitation of previous studies that focused on perceptions only can be overcome. Interventions for physicians’ IT adoption and implementation should be designed more realistically considering situational variables as well.

• Nationally Representative Health Related

Quality of Life Weights for Self-Reported

Health Status

Nathan A. Barleen, Bryan E. Dowd, Ph.D., Daniel

W. Russell, Ph.D., Stephen Joel Coons, Ph.D.,

Patrick W. Sullivan, Ph.D.,

Presented By: Nathan A. Barleen, Ph.D. candidate, Health Policy and Management,

University of Minnesota, 420 Delaware St. SE,

MMC 729, Minneapolis, MN 55455, Email: barl0050@umn.edu

Research Objective: The objective of this study was to produce nationally representative Health

Related Quality of Life (HRQOL) weights for selfreported health status: excellent, very good, good, fair, or poor.

Study Design: The study used recently developed U.S. time-trade-off-derived HRQOL weights corresponding to the EQ-5D health states and the EQ-5D health status measure data from the 2000 and 2002 Medical Expenditure

Panel Survey (MEPS) to construct HRQOL weights for self-reported health status, by a series of demographic variables.

Population Studied: The study intended to provide HRQOL weights representative of the

U.S. population. It is limited to the U.S. adult,

non-institutionalized population to match the data available in the MEPS.

Principle Findings: Mean and median HRQOL weights are presented for the five self-reported health status categories. Overall HRQOL weights are presented as well as HRQOL weights broken down by demographic variables.

Censored least absolute deviation regression results are also presented representing HRQOL weights adjusted for demographic variables.

Conclusions: Nationally representative HRQOL weights for self-reported health status facilitate the use large national surveys for conducting cost-utility analyses to evaluate health policies.


Many large national surveys collect information on self-reported health status, but no other information from which health related quality of life could be generated. These surveys often collect information on health insurance status, public program participation, health-care utilization, unmet needs, and other policy relevant variables. Nationally representative

HRQOL weights allow researchers to utilize large national surveys to conduct cost-utility analyses.


• An Application of Latent Class Cluster

Analysis in Outcomes Research: Identifying

High Cost Insomnia Patients

Onur Baser, M.S., Ph.D., Kathleen Foley, Ph.D.

Presented By: Onur Baser, M.S., Ph.D., Senior

Economist, Outcomes Research, Thomson

Medstat, 777 East Eisenhower Parkway, Ann

Arbor, MI 48104, Phone: 734-646-7991, Email: onur.baser@mac.com

Research Objective: Latent class cluster analysis has an obvious advantage over traditional analysis because it does not rely on assumptions of linear relationships between covariates, normal distribution for dependent variables or error terms and homogeneity that are often violated in practice. Despite its enormous potential, application of these models to outcomes research is limited. In this paper, we will apply latent class cluster model to identify high cost insomnia patients.

Study Design: Different numbers of clustered models are run and the best one is chosen according to Bayesian Information Criterion

(BIC). For the selected model, parameters and marginal latent probabilities for each latent variable are calculated. We also provide plots of the latent probabilities for the variables of interest. Bootstrapped standard errors are reported.

Population Studied: Market Scan data were used to identify high cost insomnia patient.

Patients were selected if they were diagnosed with insomnia or filled a prescription for a sleep aid during 2002 and 2003 (N=319,183).

Principle Findings: Based on the BIC, a four cluster model was selected. According to the model, 11% of the patients are identified as highcost patients with the mean annual expenditure of $45,358. Older individuals made up a greater proportion of patients with high medical costs.

61% of the high medical cost group was female.

Patients with high medical costs have the highest prevalence of medical conditions and lowest prevalence of mental health disorders.

Comorbid conditions were evenly distributed among the high cost patients.

Conclusions: Latent Class cluster analysis is an ideal method for identifying groups of patients with similar characteristics, when little information about potential characteristics exists apriori. Other techniques, such as multinomial logit, assume this knowledge exists apriori and yield biased results for case-mix analyses in outcomes research.


Latent class modeling provides a powerful way of identifying latent segments for whtih parameters in a speficied model differ and are easy to apply with existing softwares.

• Using Propensity Score Matching

Techniques for Average Treatment Effect:

Application to Triptan Use

Onur Baser, M.S., Ph.D.

Presented By: Onur Baser, M.S., Ph.D., Senior

Economist, Outcomes Research and

Econometrics, Thomson-Medstat, 777 East


Phone: 734-332-4246, Email: onur.baser@thomson.com

Research Objective: Propensity score matching technique has become popular approach to estimate average treatment effect. There are several techniques available in the literature and none of them priori superior to others. In this paper we applied recently proposed technique to choose among different types of propensity score models.

Study Design: Recently following procedure suggested for evaluating different types of propensity score matching techniques: a.

Calculate two sample t-statistics for continuous

variables and chi-squared tests for categorical variables b. Calculate the mean difference as a percentage of the average standard deviation c.

Calculate the percent reduction bias in the means of the explanatory variables initially and after matching d. Use the Kalmogorov-Smirnow test to compare the treatment and control density estimates for explanatory variables e. Use the same test to compare the density estimates of the propensity scores of control units with those of the treated units.

Population Studied: Data for this retrospective health care claims analysis originated from the

Medstat MarketScan Commercial Calims and

Encounters Database from 2001 to 2004.

Individuals age 12 and older, had diganosis of migraine, had at least one prescription for a triptan or had at least six months of continuous enrolment preceding the first triptan prescription or had at least 12 months continuous enrolment following the index event or eligible for medical and drug benefits during the 18-month study period included in the study.

Principle Findings: We applied nearest neighbor, radius, mahalanobis, kernel and stratified matching. According to criterias applied, kernel matching was distinctively better than the others. It estimated the treatment effect as $868. This was 41% less than the unmatched difference, 42% or 32% less than the amount obtained wrongly chosen method of radius matching or Mahalanobis matching, respectively.

Conclusions: This paper prestnes a case study, involving the effect of triptan use on health care expenditures in an effort to highlight how different types of propensity score matching techniques have substantial effects on the magnitude of treatment effect. The choice matters, and no single method is priori superior to the others.


Investigators should look at several criteria to choose among the different types of matching techniques and identify the technique best suited to their dataset.

•

The Effect on Employment Outcomes of

Second- vs. First-Generation Antipsychotic

Drugs in Schizophrenia

Marion Becker, Ph.D., M. Scott Young, Ph.D.,

Ronald J. Diamond, M.D.

Presented By: Marion Becker, Ph.D., Professor,

Mental Health Law and Policy, University of

South Florida, 13301 Bruce B Downs Boulevard,

MHC 2735, Tampa, FL 33612, Phone: (813) 974-

7188, Fax: (813) 974-9327 Email: becker@fmhi.usf.edu

Research Objective: This study examined the link between antipsychotic medication type, physical and behavioral health service use, and paid employment outcomes for Florida Medicaid beneficiaries with a diagnosis of schizophrenia

Study Design: This retrospective secondary data analysis used descriptive statistics and multivariate (regression analysis) to examine treatment outcomes for 10,330 continuously enrolled Florida Medicaid recipients during

FY01-03. Administrative databases were used to identify demographic characteristics, health services use, involuntary psychiatric examinations, arrests, and employment status.

Population Studied: The study sample included all beneficiaries meeting the following eligibility criteria: (1) were between the ages of 18 and 61 during FY 99-00; (2) were enrolled in Medicaid for at least 34 months of the 36 month study period, including 12 months prior to and 24 months after the index medication date used to determine continuous antipsychotic drug use;

(3) had a diagnosis of schizophrenia in FY 99-

00, as indicated by at least one inpatient or outpatient claim containing an ICD-9-CM code of 295. before the start of medication; (4) were not enrolled in a Medicaid managed care plan; and (5) were not living in a nursing home.

Principle Findings: Over half (58.3%) received second-generation antipsychotic (SGA) medication only; slightly less than one third

(31.7%) received first-generation antipsychotic

(FGA) medication only; and 10% combination

SGA and FGA therapy. Findings show that individuals receiving FGA medications had the lowest rate of psychiatric hospitalizations, the fewest crisis stabilization unit (CSU) or emergency room (ER) visits, and were least likely to require residential substance abuse treatment.

Patients on combination therapy had the highest rates of hospitalizations, CSU or ER visits, and residential treatment service utilization. The highest rates of paid employment over the study period were among persons taking SGAs. Over one-fifth (23.2%) had at least one quarter of paid employment, compared to 16.8% for those taking FGAs. Only 0.4% of persons on combination therapy met this employment criteria.

Conclusions: Although service use and cost findings in this study challenge the short-term advantage of SGAs we did find a statistically significant increase in quarters of paid employment for persons receiving SGAs.


Several studies including the recent CATIE research have evaluated the cost-benefit of SGAs relative to FGAs with mixed results. However, prior research has been limited to direct medical costs and devoted little attention to paid employment outcomes that may be an important contributor to QoL outcomes for persons with schizophrenia. Future studies should combine administrative data with such measures to improve our ability to assess the true value of different types of antipsychotic medication.

Funding Source: Eli Lilly and Company

•

Racial/Ethnic Disparities in Patient

Perceived Quality of Hospital Care

Rhonda BeLue, Ph.D., Kelly D. Taylor, M.S.

Presented By: Rhonda BeLue, Ph.D., Assistant

Professor, Health Policy & Administration, The

Pennsylania State University, 119a Henderson

Building, University Park, PA 16802, Phone: (814)

865-6898, Fax: (814) 863-2905 Email: rzb10@psu.edu

Research Objective: The objectives of this study are to assess racial and ethnic differences in perceptions of overall quality of care for hospital visits by: measures of patient-centeredness, patient socio-demographics and characteristics of the health care facility in Blacks, Whites and

Hispanics. Racial and ethnic disparities exist in multiple domains of quality of care including disparities in, quality of care received and experiences with patient-centered care.

Furthermore, it has been shown that Blacks and

Whites are often treated at racially homogeneous facilities that are either largely White or Black.

Blacks receive care at facilities which, 1) provide more charity care, 2) have higher percentage of revenue from Medicaid; and have physicians that are, 1) are more likely to practice in low-income neighborhoods and 2) are less likely to be board certified in their primary specialty. Physicians treating mostly white patients were more likely to indicate that they could confidently provide quality care and access referrals to specialty care, and ancillary services.

Study Design: The HCAHPS survey is composed of 27 items which measure important aspects of the hospital experience including: communication with doctors and nurses, responsiveness of hospital staff, cleanliness and quietness of the hospital, pain control, communication about medicines, hospital bed size, teaching status and geographic location, patient perceived overall quality and patient demographic characteristics. Generalized Linear

Mixed Models run using SAS Proc Mixed are employed to evaluate predictors of overall perceived quality of hospital care. An Oaxaca ----

Blinder decomposition analyses is also presented to show the separate effects of patient socio-demographic factors, hospital contextual factors and race on overall perceived quality of care.

Population Studied: The 2005 CAHPS of Health

Plans Hospital Survey (HCAHPS®) is used to explore racial and ethnic differences in perceived quality of hospital visits in adults age 18 -65.

Principle Findings: Global ratings of quality of hospital care are similar for Blacks and Whites.

Compared to Blacks and Whites, Hispanics report higher satisfaction, are more likely to recommend the hospital to others and were more satisfied with care from providers and their overall hospital experience, despite reporting worse overall health. Blacks are more likely than

Whites or Hispanics to be hospitalized in a teaching hospital and at larger bed size hospitals.

Conclusions: Variations in reports of the characteristics of the health care setting and quality of care provided should be further explored to determine in-depth what factors contribute to higher perceived quality of care for different patients.


Patient’s satisfaction with care can effect their treatment. Improved understanding of the nuances of satisfaction, particularly among differing patient groups regarding the practice setting, characteristics of the care provider, and quality of care has important implications for hospital’s efforts at continuous quality improvement.


•

Effects of Mental Illness, Age, Gender,

Personal Healthcare Provider Relationship, and Medical Insurance Status on Healthcare

Access in an Underserved Homeless Shelter

Population in two Midwestern Rural

Communities: A Multivariate Analysis

Chris Benejam, B.A. candidate, Lori Harmon,

Linda Owens, Ph.D., Ralph Benejam, M.D.

Presented By: Chris Benejam, Bachelor's degree candidate, premed student, Augustana College,

Box 139, 639 38th Street, Rock Island, IL 61201,

Phone: (309) 343-3355, Fax: (309) 344-9383

Email: chris_sbc4@hotmail.com

Research Objective: Although attention has been directed to disparities in healthcare access among people who are poor and homeless in urban areas of the United States, relatively little research has been published about healthcare access among the poor and homeless in rural areas. The objective of the current study is to examine the impact of mental illness, age, gender, personal healthcare provider relationship, and medical insurance status on healthcare access in an underserved homeless population in a two-county rural area in the

Midwest.

Study Design: Forty residents of two homeless shelters in west-central Illinois were surveyed by trained volunteers during a medical outreach screening project.

Population Studied: Forty residents of two homeless shelters of two rural communities of west-central Illinois.

Principle Findings: Regression analysis showed that the model accounted for about one third of the variance in healthcare access. Mental illness was the variable most highly associated with healthcare access, with those who indicated that they suffered from a mental health problem having less access to health care. Age was also significantly related to access, with older people having less access. The insurance indicator approached significance, suggesting that those with medical insurance coverage have more access to healthcare. Finally, gender and having an ongoing personal healthcare provider relationship were not significantly related to healthcare access.

Conclusions: Mental illness and age are significant variables in determining healthcare access in rural homeless populations.


Health care access issues in underserved homeless rural populations may involve multiple demographic variables that may need to be studied independently from those affecting homeless people living in urban environments.

• Utilizing Out-of-Pocket Health Care

Expenditures to Total Income Ratios to

Assess Disparate Financial Burdens for Rural

Residents

Kevin Bennett, M.S., Ph.D.

Presented By: Kevin Bennett, M.S., Ph.D.,

Assistant Professor, Family & Preventive

Medicine, University Of South Carolina School of

Medicine, 3209 Colonial Drive, Columbia, SC

29203, Phone: 8034343611, Email: kevin.bennett@palmettohealth.org

Research Objective: Out-of-pocket expenditures are important to examine because of their potential impact upon the patient. These expenditures represent the portion of the health care expenses that the patient is directly responsible for, and includes co-payments, coinsurance, deductibles, over the counter remedies, and other care not covered by insurance. Changes in out-of-pocket expenses can have a substantial impact upon health care utilization and health care outcomes. One method to assess financial burden is to examine the ratio of out-of-pocket spending to total income, which highlights the relative impact expenditures have upon those of different income and utilization levels. Expenditures and income vary by several demographic characteristics, such as age, race, and location of residence. The purpose of this analysis is to determine if rural residents spend more out-ofpocket on health care expenditures, as a proportion of their total income, than urban residents, taking into account demographic and behavioral characteristics.

Study Design: Analyses were performed at the family level, with the demographic characteristics of the reference person of the family used as a proxy for the family as a whole. Family income, health care expenditures, and out-of-pocket expenditures were calculated by summing all family members. Out-of-pocket spending does not include premiums, only expenses such as copayments, coinsurance, or services not covered by insurance. Each family was assigned to one of several subgroups, according to race, place of residence (MSA vs. Non-MSA), and insurance status. The ratio of out-of-pocket expenditures to total income was calculated for each individual and subgroup. All analyses weighted and performed using SAS v 9.1. Future analysis will utilize regression models to determine the impact of several factors in the out-of-pocket spending to total income ratio.

Population Studied: This analysis utilized the

2004 Full Year Consolidated Data File from the

2004 Medical Expenditure Panel Survey (MEPS).

Principle Findings: In 2004, families spent nearly 3% of their total income on out-of-pocket health care expenditures. Rural residents spent more out-of-pocket as a percent of their income

(3.6%) compared to urban residents (2.6%).

This trend held true among those with insurance, those without insurance, and within racial categories. Whites tended to have a higher out-of-pocket to income ratios than African

Americans or other races, even within rural residents and insurance status.

Conclusions: Based upon previous work by this author and the subgroup analysis, it appears that rural residents experience a greater out-of-pocket health care expenditure to total income ratio, indicating a higher financial burden. Future analyses (to be concluded by May 2007), which include regression modeling, will help identify those factors most associated with high out-ofpocket spending to total income ratios.


This disparate burden is important to recognize so that policy decisions can be made to help rural residents better afford their health care.

These findings are especially relevant for consumer-directed healthcare plans offered to rural residents. These plans need to be altered to address this increased financial burden to enhance their effectiveness, and to reduce potential impact upon healthcare utilization.

• Can a Short Health Promotion Program be

Effective in Engaging and Retaining Elderly

Adults in Health Promotion Activities?

Nancy Borkowski, D.B.A., John Abdirkin, M.D.,

Seok-Ho Song, Ph.D.

Presented By: Nancy Borkowski, D.B.A.,

Associate Professor and Dean of Academic

Affairs, Academic Affairs, South University, 1760

North Congress Avenue, West Palm Beach, FL

33409, Phone: 561-697-9200, Fax: 561-697-9944

Email: nborkowski@southuniversity.edu

Research Objective: To test whether Healthy &

Vital, a multifaceted short health promotion program, is effective in engaging and retaining older people in health promotion activities, and to determine if links between health behaviors and health outcomes (perceived and objective) may be conceptualized.

The Healthy & Vital program, developed by the the Netherlands Association for Applied

Scientific Research (TNO) Prevention and

Health, consists of physical exercises and health education, and has been shown (1) to increase physical activity in elderly; (2) to increase knowledge on health and disease; (3) to reduce feelings of loneliness; and (4) to have a number of favorable physiological effects.

Study Design: A community-based crosssectional trial. The intervention group participated in structured 30-minute weekly educational sessions and 30-minute weekly Tai

Chi exercise sessions over a 10-week period. The two interventions, i.e., physical exercise and health education, were conducted at senior centers located in Miami-Dade County that receive funding from the State of Florida Area

Agency on Aging.

Population Studied: One hundred twenty-eight community residents aged 65 and older who use the services and/or programs of senior centers funded by the State of Florida Area Agency on

Aging.

Principle Findings: ANTICIPATED RESULTS: It is hypothesized that the intervention group will show improvement in all of the study variables examined. Results will be measured using both subjective self-perceived and objective physiological measurements. Statistical tests will be used to analyze the data, using subjects as their own controls and using a separate control group. NOTE: data collection completed on

November 30 and is currently being analyzed.

OUTCOME MEASURES: Age, gender, length of involvement in the program, perceived health, restriction of everyday activities, balance, range of motion and muscle strength, knowledge of the risk factors for heart disease and proper nutrition for a healthy diet, blood pressure, cholesterol and glucose levels at entry to trial and after 12-weeks.

Conclusions: Data collection completed on

November 30 and is currently being analyzed.


Lack of physical activity, along with poor nutrition, are important contributors to many of the most important chronic diseases for older

Americans, including heart disease, diabetes, colon cancer, and high blood pressure. In an era of tightening health care dollars and an increased focus on general medicine and prevention, it is imperative that older adults become actively involved in their own health care. The importance of developing and sustaining positive health behavior in elderly adults cannot be underestimated. As such, one goal of the Miami-Dade County Mayor’s

Initiative on Aging is to foster healthy lifestyles among the elderly and reduce the risk of disease with the assistance of public-private partnerships. As part of this initiative, an exploratory study was conducted to measure the effects of two interventions, i.e., physical exercise and health education, on seniors’ overall health and well-being.

Funding Source: Private and Public Sources

• Indianapolis Discovery Network for

Dementia (IDND)

Malaz Boustani, M.D., M.P.H., Stephanie

Munger, B.S., Youcef Sennour, M.D., Ann Hake,

M.D., Rebecca Evans, M.D., Noll Campbell, M.D.

Presented By: Malaz Boustani, M.D., M.P.H.,

Regenstrief Institute, Inc, 1050 Wishard

Boulevard, RG 6, Indianapolis, IN 46202, Phone:

317-630-7200, Fax: 317-287-3798 Email: mboustani@regenstrief.org

Research Objective: To develop a local and diverse network of dementia researchers, clinical providers, and policy makers who are interested in improving the care for patients with dementia in Indianapolis.

Study Design: The Network uses the Complex

Adaptive System theoretical framework and the

Reflective Adaptive Process to facilitate and sustain effective interactions among its members.

Principle Findings: The Network was established in February of 2006 and it includes

37 active members representing geriatrics, neurology, psychiatry, pathology, neuropsychology, social psychology, nursing, social work, primary care, geriatric pharmacy, health services research, epidemiology, pharmaceutical industry, Alzheimer advocacy, state policy makers, health administration, and biostatistics. These members are affiliated with

12 local organizations. The network uses two types of communication among its members.

The first is a three hour face-to-face meeting that includes all members and is held every two to three months. The second is a project-based workgroup meeting that focuses on a specific task and includes a segment of the network members. Over the past 6 months, the network was able to build a web-based resource center, completed 4 full-day educational seminars on cognitive impairment in a hospital setting, successfully received funding to test a research enrollment process that uses the local

Alzheimer’s Association help line, facilitated the submission of two NIH applications, tested a new group interaction method called

‘‘consultancy’’ and has been able to maintain a

66% attendance rate with an average of three meetings attended per member.

Conclusions: Building a local interdisciplinary

‘‘think-tank’’ network in dementia would facilitate conducting various collaborative research, educational and quality improvement programs that meet the local research, clinical, and community needs relevant to dementia.


Despite substantial quality improvement efforts, numerous best practice guidelines, and excellent clinical and basic research activities over the past three decades, the Institute of Medicine (IOM) identified sub-optimal health care quality, compromised patient safety, and waste in our current health care system. The IOM recommended the need for system thinking and integrated, productive, locally sensitive collaboration among the various members of the local community, health care systems and research organizations. Such collaboration will ensure that 21st century American health care systems deliver safe, effective, patient-centered, timely, efficient, and equitable care.

• Impact of a Statewide Quality Improvement

Initiative in Improving the Management of

Pediatric Splenic Injuries in Washington State

Stephen Bowman, Ph.D., M.H.A., Sam R. Sharar,

M.D., Linda Quan, M.D.

Presented By: Stephen Bowman, Ph.D., M.H.A.,

Epidemiologist, Washington State Department of Health, Office of EMS and Trauma System,

PO Box 47853, Olympia, WA 98504-7853, Phone:

(360) 236-2873, Fax: (360) 236-2829 Email: smbowman@u.washington.edu

Research Objective: Evidence suggests that

90% of children with traumatic spleen injuries can be successfully managed non-operatively. In

Washington State, significant inter-hospital variation in pediatric spleen management led to the development and implementation of a statewide quality improvement initiative in 2002.

We evaluated pediatric splenic injury management before and after the implementation of a statewide quality improvement initiative.

Study Design: Retrospective cohort study using data from the Washington Trauma Registry for years 1999-2001 (pre-intervention) and 2003-

2005 (post-intervention). Multivariable regression was used to control for patient and hospital characteristics.

Population Studied: Children ages 0-14 years who were hospitalized with a traumatic (noniatrogenic) splenic injury were included.

Principle Findings: Splenectomies were more common, occurring in 13.6% of children, in the pre-intervention period, compared to 7.8% in the post-intervention period (p=.027). After adjusting for patient, injury and hospital characteristics, children remained less likely to receive a splenectomy in the post-intervention

period than in the pre-intervention period (OR

0.39, 95% CI 0.19, 0.82). Children cared for at pediatric trauma hospitals were less likely to receive splenectomy in both the pre-intervention and post-intervention periods, compared to children treated at general trauma hospitals

(p<.001). Splenectomy remained less common among children treated at pediatric-designated hospitals (OR, 0.21; 95% CI, 0.08-0.58) than among children treated in general trauma hospitals after controlling for intervention period.

Conclusions: The statewide quality improvement initiative was associated with a reduction in the rate of splenectomy in both pediatric and general trauma hospitals.

However, general trauma hospitals remained more likely to perform splenectomies than hospitals with pediatric trauma designation.

Implications for Policy, Practice or Delivery: In an organized trauma system, statewide quality improvement initiatives may be effective strategies to reduce clinical care variability.

Continued monitoring and focused education may lead to further adoption of spleenconserving management, resulting in decreased post-splenectomy morbidity, mortality and care cost.

• Productivity Costs due to Cancer Deaths:

Application of the Human Capital Model

Cathy Bradley, Ph.D., Robin Yabroff, Ph.D.,

Martin Brown, Ph.D.

Presented By: Cathy Bradley, Ph.D., Professor,


University, 1008 E Clay Street, Richmond, VA

23298, Phone: 804-828-5217, Fax: 804-828-1894

Email: cjbradley@vcu.edu

Research Objective: To apply the human capital model to estimate and project the value of lost productivity from wages and unpaid care giving that is associated with early death due to cancer.

Given inherent differences in labor supply and care giving responsibilities, we estimate cost separately for women and men in the United

States from 2000 through 2020.

Study Design: We used national death certificate data in the U.S. from 1999-2003 and

Census population estimates from the same period to calculate age-specific mortality rates for all cancers, and separately for 16 cancers in men and 18 cancers in women. These mortality rates were applied to population estimates and projections to calculate person years of life lost

(PYLL). From the Bureau of Labor Statistics, we obtained age and gender specific full and parttime employment rates and mean and median wages. Because unpaid caregiver time is vital to the well-being of families, we estimate the time adults spend care giving from responses to the

Current Population Survey and the Health and

Retirement Survey. Estimates were projected through the year 2020, separately for men and women for all cancers and by tumor site. A sensitivity analysis was performed on all key assumptions in the model.

Population Studied: The Unitest States population in years 2000 through 2020.

Principle Findings: In all years, PYLL were greatest for deaths from lung, female breast, colorectal, prostate, and pancreas cancers, reflecting age-specific mortality rates and life expectancy. In the year 2000, the human capital costs of cancer deaths in men and women were approximately $127 billion and by the year 2020, this cost is expected to be $304 billion------an increase of 2.4 fold. Given the emphasis the human capital method places on earned income, persons in the age groups 45 through 60 years experienced the greatest losses. The cost of deaths from breast cancer however occurs in younger age women. The cost of breast cancer death begins to steeply increase at age 35 to 40 years to $1.1 billion (annual costs in 2000) and peaks at age 50 to 55 years ($3.1 billion annual costs in 2000). The cost of lung cancer death in men and women, in contrast, peaks in ages 55 to

59 years ($7.2 billion annual costs in 2000).

Conclusions: These assessments can be used to determine the relative benefit of future programs that invest in cancer prevention, treatment, and control.


Polices aimed to reduce the human capital costs attributable to cancer mortality will have the greatest impact if they are targeted to lung and female breast cancer.

Funding Source: NCI

• The 2006 National Healthcare Quality

Report: Overview of Findings

Paul Jeffrey Brady, M.D., M.P.H., Karen Ho,

M.H.S.

Presented By: Paul Jeffrey Brady, M.D., M.P.H.,

Medical Officer, Center for Quality Improvement

& Patient Safety, Agency for Healthcare Research

& Quality, 540 Gaither Road, Rockville, MD

20850, Phone: 301-427-1322, Fax: 301-427-1341

Email: jeff.brady@ahrq.hhs.gov

Research Objective: The National Healthcare

Quality Report (NHQR) is an annual snapshot of the quality of the U. S. health care system. The

NHQR continues to be the broadest analysis of the quality of healthcare undertaken in the U.S. and aims to help policymakers, government program managers, employers, health care executives and insurers determine how to prioritize, plan and implement advances in health care delivery.

Study Design: The report tracks the health care system through 211 quality measures, including

40 core measures. These represent performance in four key areas: effectiveness of care, patient safety, timeliness, and patient centeredness. The report also analyzes quality and access to care by clinical conditions, including cancer, diabetes, end-stage renal disease, heart disease, and respiratory diseases; and for nursing home and home health care.

Population Studied: Most measures in the

NHQR cover the civilian, non-institutionalized

U.S. population. Some measures are appropriate for specific groups defined by age and gender.

Nursing home measures are specific to residents of these facilities.

Principle Findings: The 2006 NHQR shows the

U.S. health care system is missing important chances to help Americans avoid disease or serious complications. The report documents missed opportunities in colorectal cancer screenings, obesity counseling, asthma management, screenings for diabetes complications, pneumonia vaccines for the elderly and other areas. Overall, meanwhile, the quality of care of the U.S. health care system continues to improve at about 3 percent a year.

That’s the same rate of improvement that has been identified in the previous two years’ reports. The greatest gains in the 2006 reports were seen in hospitals, which improved by 7.8 percent. The quality of care of ambulatory services improved by 3.2 percent.

Examples of specific findings from the 2006

NHQR include: Only 58 percent of obese adults reported being counseled about exercise. Only

37 percent of overweight children and teens ages

2-19 reportedly are told they are overweight by a health care professional. Only 27 percent of people with asthma were given a disease management plan. Only 49 percent were told how to change their environment and 40 percent were given a controller medication. Only 48 percent of adults with diabetes received all three recommended screenings ---- blood sugar tests, foot and eye exams ---- to prevent disease complications.

Conclusions: Four themes emerged from the

2006 NHQR: (1) Most measures of quality are improving, but the pace of change remains modest. (2) Quality improvement varies by setting and phase of care. (3) The rate of improvement accelerated for some measures while a few continued to show deterioration. (4)

Variation in health care quality remains high.


Findings in the 2006 NHQR report suggest that ongoing emphasis on the delivery of clinical preventive services and also the use of care management plans for high morbidity conditions like asthma and diabetes are key areas for further improvements in quality. Given that most of these services are delivered in the ambulatory setting, collaborative efforts such as the

Ambulatory Care Quality Alliance are wellpositioned to support quality improvement.


• Increasing Natural Supports in Assertive

Community Treatment Services

David Branding, Ph.D, Joanne Rackow, M.S.W.,

Joe Hebel, M.S.W., Ed LaFramboise, M.S.W.,

John Moran, M.S.W., Christine Gebhard, M.P.A.

Presented By: David Branding, Ph.D, Director of

Quality Improvement, Quality Improvement,

Northern Lakes Community Mental Health, 105

Hall Street, Suite A, Traverse City, MI 49684,

Phone: (231) 935-3645, Fax: (231) 935-3082 Email: dave.branding@nlcmh.org

Research Objective: The research objective was to increase the percent of individual plans of service where natural supports were addressed and recruited using consumer input to educate service providers.

Study Design: A two-year A-B group design employing a service recipient focus group methodology was used to develop regional training content.

Population Studied: Adults with serious mental illness receiving assertive community treatment

(ACT) services as well as the clinical interdisciplinary teams that serve them.

Principle Findings: Overall performance toward the research objective was evidenced by observational data collection and monitoring.

The percent of ACT individual plans of service where natural supports were addressed increased almost 20% and the performance gain was maintained within three percentage points for two subsequent measurement periods of six months each. The percent of ACT recipient individual plans of service where natural

supports were actually recruited to support the person’s desired outcomes increase almost 60% over four measurement periods of six months each.

Conclusions: The project demonstrated that performance across a large, rural, geographically dispersed service delivery system could be systematically improved over time as well as suggested that empowering participants; in this case people with mental illness and other disabilities, to fully participate in the improvement initiative may have strengthened the treatment effect. This may be a critically important performance improvement capacity for behavioral health and other disabilitycompetent health care service systems focused on transformation to more recovery-oriented service delivery models.


The implications of these findings transcend federal policy, public behavioral health service delivery as well as professional evaluation and research practices. First, the current federal policy directive toward developing clearly articulated recovery-based systems of behavioral health care as described in the Report of the

Surgeon General were supported. As a concept, recovery, or the process of living a satisfying, hopeful, contributing life despite the limitations of mental illness, is exemplified in this project as persons with mental illness were valued for their

‘lived experience’ and the benefits that ascertaining those experiences in aggregate through focus groups had for improving a regional service delivery system as well as the resulting outcomes of the project. Further, the very performance targets of increasing natural supports is related to key recovery concepts; specifically that recovery is often clearly expressed through developing reciprocal relationships, and that by actively planning for the development and strengthening of those relationships, recovery can be facilitated. Finally, while community based participatory research has been described as an emerging model aimed at enhancing the relevance and value of research by key stakeholders, there have been few studies of people with significant disabilities such as serious mental illness being meaningfully involved in research projects from conceptualization through treatment design, monitoring, evaluation and analysis. Given the historic features of control and paternalism associated with public behavioral health services, both community based participatory research and recovery challenge the notion that people with mental illness should be viewed solely as the passive recipients of specialized services and further suggests the opportunity to involve people with significant disabilities in more rigorous project designs be pursued.

Funding Source: Michigan Dept. of Community

Health

• A Comparative Study of the Centers for

Medicare and Medicaid Services (CMS)

Recommendations and Existing Gulf Coast

State Laws for Nursing Home Disaster

Preparedness and Response

Lisa Brown, Ph.D., Kathryn Hyer, Ph.D., LuMarie

Polivka-West, M.S.P.

Presented By: Lisa Brown, Ph.D., Assistant

Professor, Aging and Mental Health, University of South Florida, 13303 Bruce B. Downs

Boulevard, MHC 1441, Tampa, FL 33612, Phone:

(813) 974-0098, Fax: (813) 974-1968 Email: lmbrown@fmhi.usf.edu

Research Objective: Poorly developed and executed disaster plans, uninformed evacuation decision-making, the isolation of nursing homes outside of the emergency operations in some states, and generally inadequate response by providers contributed to the deaths of more than

70 nursing home residents during the 2005 hurricane season. To identify gaps and limitations in the existing systems and to better understand the implications of the recommendations proposed by Centers for

Medicare and Medicaid Services (CMS), we conducted a comparative study of the proposed recommendations and the existing laws that govern preparation, evacuation, and recovery efforts in eight Gulf Coast States.

Study Design: The recommendations suggested by CMS were used to provide a framework within which we could examine general emergency plans, sheltering in place, and provisions for evacuation of nursing homes. A cross-source analysis was conducted to determine discrepancies between current regulations, state association guidelines, facility documents, and facility experiences.

Population Studied: This study included a review of both the CMS draft survey and certification documents Emergency

Preparedness and Response Health Care

Provider After Action Reporting Form and

Emergency Preparedness and Response Plan, the disaster materials of the Gulf State nursing home associations, and the DHHS’ Office of

Inspector General (OIG) report on CMS’ regulatory role in Nursing Home Emergency

Preparedness and Response during Recent

Hurricane.

Principle Findings: Consistent with Federal requirements, all eight states required that each

NH facility have a written disaster plan.

However, not all NH disaster plans were written at the same level of detail, which, in large part, reflects the specificity of existing state laws and prior experience with hurricanes. Just as individual nursing home disaster plans vary from facility to facility and state to state, state laws also vary greatly, and few specify elements to be contained in the plan, the need for state-level interagency involvement in plan development, the state agency responsible for plan review and oversight, and the frequency of the plan review.

Only three states have regulations that address transportation of nursing home residents during a disaster. Although the regulatory language that defines the scope of responsibility varies, the

2004 and 2005 hurricane seasons revealed that some companies providing emergency transport services were unable to honor their contractual agreements with nursing homes. A problem with the draft CMS recommendations is that the nursing home is the proposed accountable entity for disaster transportation. Realistically, nursing homes cannot control the multiple contracts that a transportation vendor might have in place that would then cause a shortage of vehicles after a hurricane or other disaster.

Conclusions: Disasters require coordination among multiple levels of county and state government agencies, voluntary organizations, and the private sector, as well as help from other states during large-scale emergencies.


The proposed CMS regulations require disaster preparedness and emergency planning within nursing homes, but true preparedness requires more than regulation of nursing homes. The requirement for nursing homes to ‘‘coordinate’’ emergency plans with local and state agencies seems reasonable, but it creates a federal mandate holding nursing homes responsible for the actions of an entity that is not in their control.

Funding Source: Borchard Foundation Center on Law and Aging

• Blood Culture Contamination Rate: A

Performance Measure Significantly Impacted by Organizational Personnel Use

Stephen Bruno III, B.A., Frances Hardic, B.S.,

Fred Meier, M.D., James Schnebel, B.S.

Presented By: Stephen Bruno III, B.A., research associate, Pathology, University of Pittsburgh

School of Medicine, 5150 Centre Avenue, Cancer

Pav. #201, Pittsburgh, PA 15232, Phone: (412)

647-0797, Fax: Email: brunos@upmc.edu

Research Objective: 1) To determine the impact of blood culture contamination at a single, community hospital on both patient and institutional outcome measures, and 2) to determine root causes for blood culture contamination.

Study Design: Retrospective review of microbiology laboratory records and clinical medical records. Monthly microbiology laboratory records were examined retrospectively, and the following variables were recorded for each blood culture drawn: contamination status (yes/no), personnel type drawing the culture (RN/phlebotomist), site of draw (catheter/peripheral), and hospital location

(ED, ICU, etc.). Retrospective chart reviews were performed on samples of 60 patients with and without contaminated blood cultures (total n = 120). Clinical outcome measures recorded included: length of stay (LOS), number of additional blood cultures drawn after the index culture, and antibiotic administration 72 hours after the index culture was drawn (yes/no).

Institutional cost outcomes were estimated through collection of data related to patient charges: total hospital charges, total pharmacy charges, and total laboratory charges.

Population Studied: All (n = 46,499) patients with one or more blood cultures obtained during a 27-month time period at a single, community hospital in Pittsburgh, Pennsylvania.

Principle Findings: Data initially were analyzed descriptively, including calculation of monthly institutional contamination rates stratified by personnel type. Associations between blood culture contamination and other laboratory and clinical outcome variables were examined using the Chi-square test or the correlation coefficient as appropriate. Differences between means were examined using the Student’s t-test. Statistical significance was assumed at a p value of £ 0.05.

Monthly contamination rates varied from 1.4% to 3.0%. RN personnel consistently exhibited higher contamination rates (1.9%-4.9%) than phlebotomists (0.1-1.6%). Significant associations were found between blood culture contamination and site of draw, hospital location, and all clinical outcome measures.

Median total hospital, laboratory, and pharmacy charges were higher for patients with

contaminated cultures compared to matched patients without contaminated cultures.

Conclusions: Our institutional results confirm previously published findings showing contamination of blood cultures is associated with negative patient and institutional outcomes.

A significant factor affecting blood culture contamination rate is the type of personnel drawing the culture, which is dependent on administrative decision making.


Based on the existence of consistent evidence linking blood culture contamination rates with measurable outcome metrics and the identification of actionable factors related to low contamination rates, blood culture contamination rate should be considered as a possible performance measure for federal value based reimbursement purposes.

Funding Source: CDC

• Exploring the Need to Integrate Knowledge of Prostitution into Substance Abuse

Treatment Programs

Mandi Burnette, Ph.D., Emma Lucas, M.S.W.,

M.P.H., Mark Illgen, Ph.D., Susan Frayne, M.D.,

Julia Mayo, B.S., Julie Weitlauf, Ph.D.

Presented By: Mandi Burnette, Ph.D.,

Postdoctoral Fellow, Dept of Psychiatry, VA Palo

Alto MIRECC, Stanford Medical School, 795

Willow Rd, Menlo Park, CA 95025, Phone: 650-

493-5000 x27907, Email: burnette@stanford.edu

Research Objective: Arrest statistics indicate that as many as 85% of women and nearly 50% of men arrested for prostitution also test positive for substances (Craddock, 1994). However, actual rates of prostitution among individuals seeking substance use disorder (SUD) treatment remains unknown, since studies of prostitution often pre-select participants based on involvement in prostitution, rather than SUD.

Additionally, we know little about the associated features of men and women with SUDs who engage in prostitution. Yet data on the mental and physical health characteristics of individuals involved in prostitution could assist SUD treatment providers in the creating more comprehensive treatment plans. Information about how these individuals utilize health services is also important in order to be sure their treatment needs are met in the most efficient manner. We examined the prevalence and associated features of prostitution among a national sample of men and women seeking substance abuse treatment. Our aims were to 1) document rates of prostitution among individuals seeking SUD treatment, 2) examine whether prostitution was associated with higher rates of physical, sexual, and mental health problems, and 3) examine whether prostitution was associated with higher rates of health utilization among those with known SUD.

Study Design: All participants completed a structured interviewed at the time of entry into treatment. Questions assessed multiple domains of functioning including: prostitution, substance use (e.g., problem substances), physical, sexual (e.g., STDs, AIDS) and mental health (e.g., anxiety, depression, hallucinations, suicide) symptoms in the past 12 months, and health utilization (e.g., emergency, hospital, clinic, and mental health hospitalizations) in the past 12 months.

Population Studied: Participants were drawn from the National Treatment Improvement

Evaluation Study (Gerstein et al., 1997), a national multi-site longitudinal evaluation of

SUD treatment programs. We selected all men and women over the age of 18 who were not incarcerated at the time of entry into the study, resulting in a sample of 4,622 (n=1,609 women, n=3,013 men).

Principle Findings: Prostitution was surprisingly common among both men (19%) and women

(51%) seeking SUD treatment in our multi-site national sample. Furthermore, prostitution was significantly associated with poor sexual and mental health (e.g., STDs, AIDS, anxiety, hallucinations, suicide attempts) among women and men, and with physical health symptoms and depression in men. Prostitution was also significantly associated with having used emergency room and mental health services in the past year.

Conclusions: Ultimately, increased awareness of prostitution among SUD treatment providers and researchers is crucial in order to provide the most informed SUD treatment. Our findings suggest further research is needed to: a) examine lifestyle and associated characteristics among those involved in prostitution, and b) integrate this information into present SUD treatment modalities.


We hypothesized several potential mechanisms by which this information may be helpful to SUD treatment providers, including: relapse prevention planning, understanding and treatment of mental health symptoms, and prevention and understanding of treatment failure.

• Parental Perceptions of Care Coordination for Children with Special Health Care Needs

Christine Burns, Ed.M., M.B.A., Taran Kaur,

D.D.S., Heather Berry, B.S., Jessica Roesser,

M.D., Mark Orlando, Ph.D., Steve Sulkes, M.D.

Presented By: Christine Burns, Ed.M., M.B.A.,

Associate Executive Director, Pediatrics, Box

671, University of Rochester, 601 Elmwood Ave,

Rochester, NY 14642, Phone: 585-275-6681,

Fax: 585-275-3366 Email:

Christine_Burns@urmc.rochester.edu

Research Objective: Children with developmental/chronic disorders have special health care needs that require complex care provided by multiple specialists. Care is often fragmented, challenging parents in their coordination efforts. The purpose of this study was to (1) evaluate parent perception of effort in coordinating services for their children who have special health care needs (CSHCN), (2) evaluate how often and how much time parents spend on care coordination. (3) assess parental opinions on time and ease of using an Internet-based program for care coordination.

Study Design: The survey instrument consisted of four sections. The first section asked questions on demographic information and the remaining three sections identified the parent’s

(2) satisfaction with current care coordination and desire for help with the activities (3) average time spent performing care coordination activities and (4) opinions on whether a secure

Internet based program would change the amount of time spent on care coordination. The data were analyzed using SPSS-PC. Data analysis identified which variables predict and/or contribute to the likelihood of receiving care coordination services. Certain questions that address specific services or needs were scaled.

Families’ perceptions of ‘‘optimal’’ care coordination services and potential impact utilizing web-based tools were summarized using a numeric scale.

Population Studied: Using randomized selection from an established clinical database, surveys were mailed to 315 families of children with ASD (ICD9-CM 299.0), including

Asperger’s disorder or PDD NOS (ICD9-CM code 299.8) and to 100 families of children diagnosed with spina bifida (ICD9-CM 741).

Principle Findings: Families report significant time spent in care coordination with differences between the ASD and spina bifida groups.

Respondents also reported that a secure

Internet-based system for care coordination could decrease time spent coordinating care and parents were highly interested in using such a system. Respondents reported significant barriers in communication with providers in health care, financial and school settings and accessing information about community resources. Satisfaction with care coordination was associated with perceived need for care coordination assistance. Being involved in decision-making, receiving immediate responses to problems, and assistance with treatment plan implementation were highly valued.

Conclusions: Because considerable variability in models for care coordination continues to exist and the majority of programs have fragmented care coordination, patient and family participation must be increased to assure familycentered care. Parents desire a care coordination program that uses efficient webbased tools to effectively engage all systems of care for CSHCN. Improvement of care coordination will enhance health and functional outcomes of children with ASD and spina bifida.


Models of care delivery for children with chronic conditions must include effective care coordination that involves participation by consumers and families and utilizes efficient information exchange methodologies. Webbased tools hold promise for improving familycentered care.


• Using a Regional Health Information

Exchange to Enhance State Mandated

Newborn Hearing Screening and Intervention

Shelley Carter, R.N., M.P.H., M.C.R.P., Tracy

Smith, B.S., Maggie Gunter, Ph.D., Shelley

Carter, R.N., M.P.H., M.C.R.P.

Presented By: Shelley Carter, R.N., M.P.H.,

M.C.R.P., Sr. Research Associate, Lovelace Clinic

Foundation, 2309 Renard SE Suite 103,

Albuquerque, NM 87106, Phone: 505-262-7199,

Fax: 505-262-7598

Email: ShelleyC@LCFresearch.org

Research Objective: To create an electronic exchange process for newborn hearing screening and an intervention tracking system.

Study Design: In 2004, a consortium of private and public health care organizations in New

Mexico proposed and then acquired federal and local financial support to build an electronic exchange, New Mexico Health Information

Collaborative or NMHIC. One of the goals of the exchange was to move medical records between

organizations for patient care. From the beginning, collaborators recognized the potential for using an electronic exchange to report health events to public health officials in New Mexico’s

Department of Health, DOH. Collaboration and multiple interactions between NMHIC, a rural hospital, Taos Holy Cross and DOH led to conceptualizing and creation of an electronic exchange process for a newborn hearing screening and intervention tracking system.

Population Studied: Because early intervention for newborn children with hearing deficits affects their growth, development, and later school performance, the New Mexico state legislature requires all newborns to undergo hearing screening. Screening is successfully accomplished for most of NM’s 27,500 annual newborns, with 398 positive for screening abnormalities. However, prompt audiologic diagnosis and early intervention are often delayed since reporting and referral processes involve numerous, paper-based steps.

Principle Findings: Eight months into the development of NMHIC, staff at rural Taos Holy

Cross Hospital,THCH volunteered to engage in an electronic process for referring patients between practitioners. At month 10, DOH and

NMHIC met to discuss electronic exchange ideas. After 5 months of consideration, reporting newborn screening results was chosen. At month 18, NMHIC and DOH decided to integrated THCH and DOH efforts. Between month 19 and 22, processes were outlined and all possible participants identified. At month 23 all parties convened to discuss electronic reporting and referral software, which was created in the ensuing 2 months. Testing and implementation are planned for month 25 and

26. Ten individuals were directly and another 10 tangentially engaged in planning.

Conclusions: Developing multiple-entity health information exchanges requires numerous collaborators and 25 months to implement a change such as electronic reporting and referring of newborns with possible hearing abnormalities.

Implications for Policy, Practice or Delivery: It is difficult to move an HIE from conceptual to operational without strong community support and commitment. An essential element for success is for stakeholders to identify benefits and to become fully engaged in the ongoing process.


• Baseline and Time-Dependent Factors

Associated with Pain Severity Outcomes over

One Year among Women with Metastatic

Breast Cancer

Liana Castel, M.S.P.H., Ph.D., Benjamin Saville,

M.S., Venita DePuy, M.Stat, Amy Abernethy,

M.D., Katherine Hartmann, M.D., Ph.D.

Presented By: Liana Castel, M.S.P.H., Ph.D.,

NRSA Postdoctoral Fellow, Sheps Center for

Health Services Research, University of North

Carolina at Chapel Hill, 725 Martin Luther King

Jr. Boulevard., CB# 7590, Chapel Hill, NC 27599,

Phone: 919-215-7561, Fax: 919-640-1001 Email: liana@unc.edu

Research Objective: To describe event patterns for first report of severe pain (defined as a pain score of 7 or above on the Brief Pain Inventory

[BPI] 0-10 pain severity scale) over a year, identifying baseline and time-dependent clinical and demographic factors associated with differences in time to first reach a score of 7.

Study Design: We conducted a secondary analysis of data from a clinical trial that assessed pain over a year using the BPI at multiple assessments. We fit piecewise exponential models to identify predictors of event patterns in the data, structured by 80-day intervals to account for interval-censoring. We assessed the effects of covariates on within-interval probabilities of treatment failure (BPI severity score of 7 or greater) and concomitant cumulative survival (here ‘‘survival’’ means not reaching the treatment failure threshold of 7) for each interval.

Population Studied: The study population consisted of 1124 women with metastatic breast cancer and bone metastases who were enrolled in a clinical trial comparing two bisphosphonates in addition to standard treatment. All patients received standard treatment including bisphosphonates. Our analyses did not compare treatment arms, such comparisons having already been conducted elsewhere. The trial was conducted from October 1998 to January 2001 at

207 centers in North America, South America,

Europe, Australia, and South Africa.

Principle Findings: Increased probability of treatment failure for pain severity was associated with non-Caucasian race (hazard ratio [HR]=2.52,

95% CI=1.69-3.76), restricted performance status

(HR=1.73, 95% CI=1.13-2.64), and having undergone radiation therapy in a previous interval (HR=2.86, 95% CI=1.61-5.09).

Cumulative severe pain-free survival rates ranged from 0.787 in the first interval to 0.634 in the last

interval for non-Caucasian women, while these rates ranged from 0.901 to 0.832, respectively, for Caucasian women; thus the cumulative survival rate for Caucasians in the last interval was higher than the rate for non-Caucasian women in the first interval. Similar event patterns for survival over the 80-day intervals were observed with regard to performance status and previous radiation therapy.

Conclusions: Non-Caucasian race, restricted performance status, and radiation therapy were associated with pain severity experienced over time among women with metastatic breast cancer. Our findings on the effects of race on pain outcomes over time confirm existing evidence of cross-sectional differences by race.

Our findings on the effects of restricted performance status underscore the importance of measuring and using this variable to predict longitudinal pain outcomes. Even after adjusting for performance status (a proxy for disease severity), we found a strong temporal association between radiation therapy in a previous interval and increased pain in the next interval; the underlying reasons for this association should be explored further in light of existing evidence for radiation’s palliative benefit.


This study provides information that can be used in further development of guidelines and in clinical settings to identify women with metastatic disease who are at greatest risk for pain treatment failure. Long-term pain management strategies should take into account not only baseline risk factors such as race for worsening pain outcomes, but also the effects on pain of time-dependent factors, in particular changes in antineoplastic therapies and changes in performance status.


•

Effects of Antenatal Care Services on

Birthweight: Lessons from Turkey

Yusuf Celik, Ph.D., Mustafa Younis, D.R.P.H.,

M.A., M.B.A., Vanessa Lora, M.D., M.H.S.A.

Candidate

Presented By: Yusuf Celik, Ph.D.,

Assoc.Professor, School of Health, Hacettepe

University, Ankara-Turkey, Ankara, TR, Phone:

(90) 312 - 311 5506, Email: younis99@gmail.com

Research Objective: This paper is an attempt to examine the effects of antenatal care (ANC) utilization on birthweight. Cost-effectiveness based health sector reform requires careful estimation of costs and productivity of health interventions as well as the substitution possibility among health inputs. If the parameters of production function are known, policy makers can estimate the health outcome effects of various input-mix.

Study Design: The analysis is based on the data collected from ever-married women by Turkey

Demographic and Health Survey 2004 (TDHS).

Two-stage least squares (TSLS) and ordinary least squares (OLS) estimation procedures are used in this paper to estimate the effect of health care input, namely antenatal care visits, on birthweight. Since the utilization of medical care itself may be dependent on women’s expectation about the pregnancy outcome, the parameters estimated through OLS may underestimate the true productivity of the input.

Population Studied: Infant children and mothers in Turkey

Principle Findings: The estimated functions indicate that antenatal care, woman’s health status, and birth order are significant determinants in birthweight. The TSLS estimate of marginal productivity of ANC visits was about four times the marginal productivity estimate in the OLS model.

Conclusions: The sensitivity of the parameter estimates to model specifications and empirical procedures followed demonstrates the importance of selecting the right model from both theoretical and empirical point of view.


This funding will be used by policy makers to improve infant health and expectant mothers.

•

Mental Health Care Utilization in Female

Veterans: Do Women Underutilize the VA?

Sharmila Chatterjee, M.D., M.P.H., Sue Eisen,

Ph.D., Maria Montez-Rath, M.S., Kevin Sloan,

M.D., Amy Rosen, Ph.D.

Presented By: Sharmila Chatterjee, M.D.,

M.P.H., Health Services Research Fellow, Edith

Nourse Rogers Memorial Veterans Hospital,

Center for Health Quality, Outcomes and

Economic Research, 200 Springs Road (152),

Bedford, MA 01730, Phone: (781)687-2857, Fax:

(781)687-2227 Email: sharmcha@bu.edu

Research Objective: Evidence exists that female veterans underutilize VA health services compared to male veterans; however, little is known about what types of services female veterans underutilize. To address this knowledge gap, we used a national sample of patients utilizing VA services to examine gender differences in mental health utilization.

Study Design: The study used a cross-sectional observational design to analyze VA outpatient mental health utilization. The sample was divided into three age groups: <35, 35-54 and >55 years. We constructed three outpatient utilization categories: general mental health

(psychiatric and psychological) services, specialized substance abuse (SA) services, and specialized post-traumatic stress disorder

(PTSD) services. We created four illness categories based on disease prevalence in the

VA: Psychotic Disorders, Mood Disorders,

Substance Abuse (SA) and PTSD. We used logistic regression models to predict odds of use of each outpatient category vs. all others, controlling for co-morbidity using illness categories and including an interaction term of gender by age. Linear regression models were used to predict number of visits in each utilization category.

Population Studied: Veterans who received any healthcare in 1999-2000 associated with a mental health or substance abuse diagnosis

(ICD-9 codes 290-312.9 and 316-316.99)

(N=914,255). Women comprised 5% of the sample.

Principle Findings: Women veterans in all age categories had greater odds of using general mental health services than men (OR 1.1 [CI

1.06-1.19], 1.3 [CI 1.23-1.31], 1.1 [CI 1.03-1.11], for each age group). Diagnoses of substance abuse or PTSD significantly increased the odds of using

SA (OR 8.42 [CI 8.29-8.56]) or PTSD services

(OR 7.7 [CI 7.56-7.78]). We subsequently stratified the analyses by diagnosis. Among veterans diagnosed with SA (5.4% of women, 9.5% of men) or PTSD (19% of women, 18.4% of men), female veterans <35 and 35-54 were less likely than male veterans to use SA (OR .64 [CI .52-.79] and .76 [CI .70-.84], respectively) or PTSD services (OR .61 [CI .53-.69] and .60 [CI .56-.63], respectively). In veterans diagnosed with SA or

PTSD, gender had no significant effect on likelihood of using general mental health services. Across diagnostic groups, women veterans had a greater number of visits to general mental health services. Women with

PTSD had more visits to general mental health and fewer visits to PTSD services in comparison to men. In veterans diagnosed with SA, gender had no effect on number of visits to any service.

Conclusions: Female veterans were more likely than males to use general mental health, but less likely to use PTSD or SA services. Once using general mental health services, female veterans made significantly more visits than men. This effect persisted in female veterans diagnosed with PTSD, but not in females diagnosed with

SA.


The VA has established several centers for the treatment of PTSD in women veterans, but currently, services are not widely available.

Further research may be needed on integrating gender-appropriate SA and PTSD services into the general mental health services that are available, as untreated SA and PTSD may be affecting women’s use of general mental health services, in addition to contributing to adverse consequences for women.

•

Baseline Psychosocial Predictors of Six-

Month Weight Loss Outcomes among

Participants in a Clinical Trial of Diet-Based

Strategies

Alex Cho, M.D., George Jackson, Ph.D., M.H.A.,

Jennifer McDuffie, Ph.D., Jennifer Strauss, Ph.D.,

Jamilya Bolton, B.S., William Yancy, Jr, M.D.,

M.H.Sc.

Presented By: Alex Cho, M.D., Fellow, Durham

VAMC, VA Center of Excellence for Health

Services Research in Primary Care, 508 Fulton St

(152), Durham, NC 27705, Phone: (919) 286.0411 x5687, Email: alex.cho@duke.edu

Research Objective: Objective: The transtheoretical model of health behavior postulates that readiness to change is key to successful behavior change. However, what components make up this readiness is less clear.

In the setting of a diet-based weight loss program, we sought to describe possibly modifiable psychosocial factors -- such as selfdetermination, the idea that motivation be located within a person versus without -- that were associated with differences in weight loss outcomes.

Study Design: Methods: The LCKD-Orlistat

Trial is an ongoing 48-week clinical trial that randomizes participating obese Veterans Affairs patients to a low-carbohydrate, ketogenic diet or a low-fat diet plus a medication, orlistat. At baseline, participants were asked to complete a battery of instruments assessing selfdetermination, weight loss expectations, stress and response to stress, autonomy, social support, and worry, selected using an adapted health belief framework. Six-month data from the first 76 enrolled patients are included in this analysis. Linear regression models were calculated in stepwise fashion incorporating age, sex, race, and the psychosocial characteristics assessed at baseline.

Population Studied: Veterans Affairs patients at the Durham VA with BMI >30.

Principle Findings: The mean age of participants was 54 years. 69 percent were male;

51 percent were white and 44 percent African

American. Mean weight at baseline was 259 lbs; mean BMI, 37. Participants reported expecting to lose an average of 61 lbs, or 24 percent of their starting weight, by participating in this study. After six months, actual mean weight loss was 24 lbs, or 9 percent of starting weight. A final linear regression model found a significant negative association between weight loss and a measure of self-determination, the relative autonomy index (RAI), adjusted for response to stress, age, sex, and race (p = 0.04; r^2 = 0.24).

Baseline perceived stress, autonomy, social support, and weight-related worry were not associated with weight loss outcomes.

Conclusions: Conclusions: Successful weight loss has been found to be associated with a number of patient characteristics, not all of them modifiable. Here we made a deliberate attempt to study only those characteristics that could possibly be modified through co-interventions.

Contrary to prior research in this area, we found a significant negative association between a measure of self-determination and weight loss.

This may be due to the population studied

(veterans) and/or the influence of powerful others ---- including providers ---- in participants' lives. In addition, we observed unrealistic weight loss expectations, which is not uncommon among participants who are attempting lose weight.


The desirability of internalized motivation on the part of patients may need to be balanced against the effect -- at least short-term -- of the influence of powerful others, including providers. This effect is seen, for example, in studies of the value of even brief physician advice in smoking cessation. Even as consumer-directed trends take hold in healthcare, the importance of healthcare professionals in the arena of lifestyle change should not be underestimated.

Funding Source: VA

• Health Center Financial Performance:

National Trends and State Variation, 1998-

2004

Patricia Collins, M.P.H., Kaytura Felix Aaron,

M.D., Vanessa Watters, M.H.A., Leslie Greenblat

Shah, M.H.S.

Presented By: Patricia Collins, M.P.H., Doctoral candidate, Health Policy and Management,

Johns Hopkins Bloomberg School of Public

Health, 501 St. Paul Street, Apt 504, Baltimore,

MD 21202, Phone: (617)953-0590, Email: pcollins@jhsph.edu

Research Objective: For four decades, health centers have provided high quality, cost-effective primary healthcare to underserved populations.

The research objective of this study was to analyze national trends in health center patients, providers, and financial performance for 1998-

2004, and State-specific data for 2004.

Study Design: This study is a descriptive analysis of financial performance and other organizational data submitted by health center grantees to the Bureau of Primary Health Care's

Uniform Data System between 1998 and 2004.

Population Studied: The study sample included a nationally-representative group of 914 health center grantees.

Principle Findings: Between 1998 and 2004, health centers served increasing numbers of underserved patients, which include patients who were uninsured or on Medicaid, minorities, and patients at or below poverty level. The number of health center providers and patients increased; patient-to-provider ratios did not change significantly. Medicaid remained the single largest source of health center revenue, accounting for 36.4 percent of total revenue in

2004. Compared to Medicare, private insurance, and self-pay, Medicaid consistently reimbursed health centers at the highest rate per patient.

Federal and non-Federal grants to support care for the uninsured is one of many important sources of revenue. Financial challenges for health centers included increasing costs and varied or declining rates of reimbursement for services rendered. However, health centers became more self-sufficient over time, average net revenues increased, and operating margins were predominantly positive. Data on individual

States, with different numbers and types of health centers, varied widely in all of these categories.

Conclusions: Health centers rely on Federal and non-Federal grant support, in concert with the

Medicaid program, as major funding sources.

Continued financial stability will be contingent upon health centers’ ability to balance revenues with the cost of managing the vulnerable populations that they serve.


As evidenced by the analyses presented in this paper, health centers have continued their long and distinguished history of caring for the nation’s most vulnerable populations. Financial

viability is the ultimate fiscal goal of the health center program. However, health centers’ mission of caring for all patients, regardless of ability to pay, means the long-term financial stability of health centers depends on continued support in the form of Federal and State grants to cover the costs of the uninsured and ability to maximize revenue streams from various sources.

This study further illustrates that a robust

Medicaid program is crucially important to health centers. Medicaid’s consistent reimbursement, commensurate with the costs of health center services, has made it a cornerstone of centers’ financial stability. The results of this study indicate that continued Federal grant assistance for health centers, supported by the

President’s Health Centers Initiative, and the

Medicaid program play a major role in the effort to sustain health centers and improve access to quality care for vulnerable populations.

Funding Source: HRSA, Johns Hopkins Primary

Care Policy Center

• Building an Accountable Structure of

Patient Care: A QI Comparison to the Toyota

Production System Model

Gerard Cronin, B.S.I.M., Karen Hopcia, R.N.,

M.S., Bonnell Glass, R.N., M.S., Katrina Smith, ,

Brittany Whitford

Presented By: Gerard Cronin, B.S.I.M.,

Operations Coordinator, Patient Care Services,

Massachusetts General Hospital, White 13, 55

Fruit Street, Boston, MA 02114, Phone: (617)726-

1292, Fax: (617)726-7563 Email: gmcronin@partners.org

Research Objective: In healthcare, quality can be concentrated on individual effort and global hospital initiatives. However, many industries have adapted the revolutionary Toyota

Production System (TPS) approach to quality improvement. The purpose of this poster is to compare the newly established unit-based quality improvement program to the industry-based

TPS. Methods utilized by the industry-based TPS will be explored and compared to the needs of the GCRC’s quality improvement program. The objectives are to give brief background information on quality improvement in the health care industry as well as within Toyota and explain TPS and how it compares and contrasts with health care, and more specifically the GCRC.

Study Design: This study took place in a small clinical research setting within a well renowned

Boston hospital. The staff consists of approximately 32 full time employees, which include 22 registered nurses, clinical lab assistants, bionutrition staff, clerical staff, administration staff, and a research subject advocate. There are also clinical investigators and study coordinators who come to the GCRC to conduct their own research studies. The

GCRC currently conducts over 150 research studies in the five inpatient and two outpatient rooms on the unit. The patients who come to the

GCRC range in age, reason for participating, and the type of illness they experience, whether it is mental, emotional or physical.

Population Studied: Sprung from need, the

GCRC launched a QI initiative to identify major areas of improvement needed for efficient operations. This included the areas such as communication, reduction of waste, reduction of redundancy, streamlining processes, and examine portability of the practice. As a source of comparison, the Toyota Production System was researched thoroughly to determine the overall philosophy of the organization as well as some of the specific methods Toyota uses to be effective, efficient and sustainable.

Principle Findings: Through various small unitbased trials the GCRC revised lab slips, made IS changes, modified the scheduling system, and worked to bring about a number of improvements. The staff satisfaction survey, Staff

Perception in the Clinical Practice Environment, was used as well as the Investigator Survey Tool.

As a means of accountability, the GCRC uses quality and safety reporting through the use of a unit-based incident reporting system with followup. In addition, the GCRC’s RSA is currently developing a patient/subject feedback survey.

Conclusions: The outcome of this study was that the GCRC QI program compared favorably with specific aspects of the TPS. While each organization comes from very different industries, each approach is still quite similar in terms of the philosophy, values, structure, system, problem solving, and decision-making.

Examining a model outside health care, such as the Toyota model, proves to be useful when quality improvement is the goal of the organization. Despite differences in the product produced, the system and methods can still apply. In addition, the model can provide validation that the approach of the health care organization is one that is well established and successful.


The initiative of the GCRC’s QI program has experienced several positive outcomes thus far.

This includes the creation of six committee teams that should help build communication

between all staff members, solve problems quickly and effectively, and may also create an enduring mindset for change. This comes at an opportune time as the evolution of General

Clinical Research Centers into Clinical

Translational Science Awards Centers brings new challenges and uncertainties, both financial and structural. The initiation of a quality improvement program to help identify areas of opportunity to streamline processes, improve efficiencies, and to solve problems through focused teams could prove to be extremely helpful for this transition.

•

Economic Analysis of a Tailored Behavioral

Intervention to Improve Blood Pressure

Control in a Veteran Primary Care Sample

Santanu Datta, Ph.D., M.B.A., Eugene Z.

Oddone, M.D., M.H.S., Maren Olsen, Ph.D.,

Hayden B. Bosworth, Ph.D.

Presented By: Santanu Datta, Ph.D., M.B.A.,

Assistant Research Professor, General Internal

Medicine & HSR&D, Duke University & Durham

VAMC, 508 Fulton Street, HSR&D, Building 16,

Durham, NC 27705, Phone: (919) 286-6936,

Email: santanu.datta@duke.edu

Research Objective: To evaluate the effectiveness and costs of a nurse-administered behavioral intervention designed to improve adherence with prescribed pharmacalogical and non-pharmacological regimens shown to improve blood pressure (BP) control.

Study Design: Patients of 30 primary care providers from the Durham Veterans

Administration Medical Center (DVAMC) were randomized to receive the tailored behavioral education intervention (n=294) or control

(n=294). The behavioral intervention was administered by a nurse who telephoned patients within one week of randomization and then every two months for 24 months. At each call, the nurse delivered scripted information drawn from nine educational and behavioral modules including: hypertension knowledge, memory, social support, patient/provider communication, medication refill reminders, appointment compliance, health behaviors (diet, exercise, smoking and alcohol use), health literacy aids, and medication side effects. To ensure that the intervention information was standardized, the nurse used a database application, which contained predetermined scripts and tailoring alogrithms. There were no face-to-face meetings between the nurse and the patient. Patients randomized to usual care were contacted at six and 24 months to complete 30minute secondary outcome assessments.

Population Studied: Eight hundred-sixteen eligible DVAMC hypertensive patients were contacted; 190 refused and 38 did not meet inclusion criteria. We enrolled 588 patients in the study.

Principle Findings: The average behavioral intervention phone call lasted 3.2 (±2.5) minutes.

Among the control patients, BP control improved from 44% to 52.5% over the 24 months. For behavioral intervention patients, BP control improved from 44% to 64%, an absolute incremental increase of 12.5%. The direct behavioral intervention cost, consisting of nurse and computer costs, was $70.47 per patient per year. Taking nurse salary and fringe benefits range ($78,304-$90,558) and three sizes of patient cohorts that can be overseen by a nurse

(1120, 840, and 560 patients) into consideration for sensitivity analysis, the direct cost ranged from $61.36 to $162.83 per patient. If indirect costs are included, the total behavioral intervention cost was $112.02 per patient with a range of $97.48 to $258.92. If office space cost is considered it adds another $2.26 to $4.46 per patient. We also assessed overall inpatient and outpatient costs over the 24-months and found no statistically significant differences between the intervention and control group patients.

Conclusions: The study results suggest that a nurse-administered tailored behavioral intervention is highly effective in improving blood pressure control, can be implemented at low average cost per patient, and is not likely to increase overall health care resource utilization.


While the behavioral intervention cost per patient is low, it could be further reduced if a health educator was used instead of a nurse. A health educator may achieve similar effectiveness given that the education modules are already developed and their delivery is standardized. However, a health educator may be less knowledgeable about discussing medication and health issues with the patient.

Second, over the long run, if the observed improvement in BP control can be maintained, the intervention cost potentially could be mitigated by lower BP-related healthcare resource utilization. Third, our study shows that with low intensity guidance hypertensive patients can self-maintain BP control.

Funding Source: VA

• Changes in Insurance Status and Access to

Care in an Integrated Safety Net Healthcare

System

Michael Durfee, B.A., M.S.P.H. in progress,

Adrienne Welsh, M.S.P.H., Patricia Gabow, M.D.

Presented By: Michael Durfee, B.A., M.S.P.H. in progress, statistical research specialist, Health

Services Research, denver health, 777 Bannock

Street, MC8701, Denver, CO 80204, Phone: 303-

436-4076, Fax: 303-436-4035, Email: michaeljoshua.durfee@dhha.org

Research Objective: To describe the demographic characteristics of a cohort of uninsured patients, the frequency to which this uninsured cohort switches insurance status when returning for care and the type of access point (primary, urgent and specialty) for the continuously uninsured compared to those that became insured.

Study Design: A retrospective descriptive cohort study of outpatient administrative data sets for an urban safety net hospital located in Denver,

Colorado from 2000 to 2005.

Population Studied: A cohort of 77,361 uninsured outpatients receiving care in an integrated delivery system during calendar year

2000

Principle Findings: The majority of the uninsured cohort was Hispanic (56 percent) with a median age of 30 years. Over 62 percent of the cohort returned during the five year study period, with 52 percent of these returning patients switching insurance status at least once during this time. Medicaid served as the primary reimbursement source for the patients who attained insurance. The uninsured that have switched to insured status visit urgent care at a significantly lower rate and visit specialty care at a significantly higher rate than the continuously uninsured (p<0.001) when adjusting for year, age, race/ethnicity and, gender and degree of illness.

Conclusions: In an integrated safety net system, there is a high frequency of insurance status switching by the uninsured. Patients who switch to an insured status are more likely to visit specialty points of care at a higher rate and to visit urgent points of care at a lower rate than the continuously uninsured.


While there is much literature comparing how uninsured and insured patients access care, there is little assessing access for those who are inconsistently insured versus those who are uninsured. Increased access to non-urgent care for the inconsistently insured gives merit to programs intended to provide insurance, even for a short period of time, as often found in

Medicaid and SCHIP.

• Terrific Toys Totes Pediatric Satisfaction

Donna Ettel, Ph.D., Jack Mullarkey, B.S., Michael

Cerio, M.Ed., Wallace Ettel, Anna Schrippa,

George Leonard Ettel, III

Presented By: Donna Ettel, Ph.D., Adjunct

Professor, Honors College, USF, 4202 East

Fowler Avenue, Tampa, FL 33701, Phone: 727-

368-4966, Email: dettel@spchs.org

Research Objective: Health care providers serving children are faced with a diverse set of challenges which may impact patient satisfaction. The aim of this study is to gain a more comprehensive understanding of pediatric patients' quality judgements through an allinclusive, survey-based, needs assessment at a not-for-profit children's hospital in the southeastern United States.

Study Design: A multivariate analysis of variance (MANOVA) was performed to examine the level of patient satisfaction across clinical units. The independent variables were the six clinical units to which patients were admitted.

The dependent variables measured responses to three survey questions regarding the variety, quality, quantity, and access to games/toys/activities.

Population Studied: The sample was limited to a retrospective review of survey scores from patients discharged from the inpatient setting

(n=500). Data was analyzed from the past three fiscal years. Included surveys were completed by the patients or their immediate families.

Excluded participants included patients receiving care only in the emergency department and outpatient settings.

Principle Findings: There were a total of 500 medical records reviewed, of which significant differences in patients' quality judgements were established. Overall, patients were satisfied with the quality of food (80%) and the quantity of food (82%). However, the findings illuminate the lack of satisfaction with the quality, amount, and access to toys/games/and activities for these pediatric patients.

Conclusions: "Play has been a well-established curriculum component in early childhood education" (Bergen 2002). Playtime during hospitalization is key for the continued growth and development of children. Availability of everyday toys --bubbles, water toys, paper and

crayons-- are essential and may help staff gain insight into the ways children cope with the hospital experience.


This research will assist hospital leadership in implementing strategies which will promote satisfaction and which will ultimately improve the quality of care.

•

Pediatric Pain Management: Dearth

Evaders of Documentation

Donna Ettel, Ph.D., Matthew Minkoff, Jerrica

Farias, Daniel McInerney, Esther Cameron,

Kathleen Radomski

Presented By: Donna Ettel, Ph.D., Adjunct

Professor, Honors College, USF, 4202 East

Fowler Avenue, Saint Petersburg, FL 33701,

Phone: 727-368-4966, Email: dettel@spchs.org

Research Objective: Efficient pain management depends on a complete assessment of patients and their unique responses to pain. Disturbing literary findings suggest that problems regarding patients' pain management in the hospital setting have not been resolved. These findings led to an assessment of documentation practices by health care providers in a not for profit teaching hospital in the south eastern

United States.

Study Design: The data collection process included a concurrent review of inpatients' medical records. A multivariate analyses of variance (MANOVA) was conducted to compare interventions and pain management documentation across clinical units. The independent variables consisted of the clinical unit to which the patient was admitted. The dependent variables examined healthcare professionals adherence to documenting the patients' pain scores, locations, modifiers, quality, duration, and aggravating factors.

Population Studied: Medical records for patients admitted to the medical surgical areas at a children's hospital in the southeast United

States were reviewed concurrently.

Principle Findings: Significant differences in pain management documentation were identified among the 500 medical records.

Overall, the pain score was documented 81% of the time, however, there was minimal compliance for recording pain location (14.0%), pain location modifier (11%), pain quality (1%), pain duration (1%), and pain aggravating factors

(1%). These data imply that hospital medical professionals neglected to document pain information that could be central to pain treatment and reduction.

Conclusions: Pain score documentation fulfilled hospital standards 81% of the time.

Unfortunately, the remaining documentation elements were out of compliance.

Understanding innovative ways to further document pain location, modifiers, duration, and aggravating factors may significantly improve the health care experience for pediatric patients.


This information will be instrumental in identifying, designing, and implementing strategies to promote effective pain management documentation.

• Pain Management Documentation:

Transitioning From Paper to EMR

Donna Ettel, Ph.D., Kehsi Wilson, William

Johnson, Julianne Escoto, Megan Thuy Vu

Presented By: Donna Ettel, Ph.D., Adjunct,

Honors College, USF, 4202 East Fowler Avenue,

Tampa, FL 33701, Phone: 727-368-4966, Fax:

Email: dettel@spchs.org

Research Objective: Measurement of pain management documentation stands poised to play an increasingly important role in the growing push toward accountability among health care providers. Effective pain management relies on a comprehensive assessment of patients and their responses to pain. The variety of reasons for ineffective pain relief necessitates documentation of current pain management to understand efficiency and effectiveness. Providers serving children are faced with a myriad of challenges as they transition from paper to electronic medical records. To increase our understanding of pain management documentation and interventions in a newly acquired electronic medical record

(EMR), in order to develop a performance enhancement strategy to ultimately improve the quality of care for children at a not-for-profit pediatric hospital in the southeastern United

States. To increase our understanding of documentation practices of pain management and interventions in order to develop a performance enhancement strategy to ultimately improve the quality of care for children at a pediatric hospital in the Southeast.

Study Design: A multivariate analysis of variance (MANOVA) was conducted to examine compliance with pain management documentation in the EMR across clinical units.

The independent variables were the six clinical

units at the hospital. The dependent variables measured compliance with documentation of pharmacological pain interventions, nonpharmacological pain interventions; and documentation of the effectiveness of the pain intervention in the hospitals EMR.

Population Studied: There were a total of 500

EMRs retrospectively reviewed, and significant differences in pain management documentation were identified. The sample was limited to a review of inpatient medical records from dischaged patients September 1, 2005 through

August 31, 2006.

Principle Findings: There was only 10% compliance with documentation of nonpharmacological interventions and 15% compliance with pharmacological interventions.

Additionally, patient evaluation (post pharmacological interventions) for effectiveness only occurred 9% of the time.

Conclusions: It was chilling to note that healthcare professionals have neglected to perform and/or document pain interventions.

EMRs are considered one of the most critical technologies for health professionals as they improve the quality and safety of care.


This information will be instrumental in identifying, designing, and implementing strategies to promote effective pain management documentation in the EMR to ultimately, improve the quality and safety of pediatric practices.

• High School and HIT: A Study of Students’

Health Awareness

Donna Ettel, Ph.D., Daniel McInerney, George

Leonard Ettel III, Jerrica Farias, Michael Cerio,

M.Ed., Matthew Minkoff

Presented By: Donna Ettel, Ph.D., 6333 9th

Avenue North, Saint Petersburg, FL 33710,

Phone: 727-553-3673, Fax: 727-553-3666 Email: dettel@hsc.usf.edu

Research Objective: Electronic data have the potential to serve as a vast resource of information for children and adolescents as they enhance their knowledge and understanding of healthcare issues, but there is uncertainty about how they use this technology and the accuracy of the information they find. To address this, high school students were surveyed as to their access to health information and how this information affects their behavior.

Study Design: A questionnaire was developed to explore knowledge and utilization of health information technology across grade levels 9-12 at a private, Catholic high school. Experts in medical informatics and/or health policy reviewed the questionnaire prior to its distribution. The anonymous survey was administered to all students in grades 9-12

(n=705) at the same time. Student participation was optional. Descriptive statistics and multivariate analysis of variance (MANOVA) were used to compare trends across grade levels.

Population Studied: The anonymous survey was distributed under teacher supervision to all students in grades nine through twelve (n=705) at a private Catholic high school in the southeastern United States.

Principle Findings: Of the 705 students in attendance, 497 returned their surveys, representing a response rate of 70.5%. The school-wide internet access was used by 80% of the student population, and 90% had access to the school’s broadband applications. Access to the internet and broadband was also common at home. Survey results indicated that 42% searched for some type of health information and 43% investigated specific medical conditions or disease states. The upperclassmen were significantly more likely to perform these searches. Only 4.6% of students reported that they emailed their doctors.

Conclusions: These findings indicated that the majority of high school students utilized broadband internet at school and at home and that many students, particularly in the upper grade levels, sought information related to specific medical conditions. Few students corresponded with their physicians using email.


This information should be useful in designing and implementing strategies to promote access to health information by adolescents and to prepare them to engage in patient-centered healthcare.

• Costs of Conventional and Rapid HIV

Screening in Healthcare Settings

Paul G. Farnham, Ph.D., Angela B. Hutchinson,

Ph.D., M.P.H., Stephanie L. Sansom, Ph.D.,

M.P.P., M.P.H.

Presented By: Paul G. Farnham, Ph.D.,

Associate Professor, Economics, Georgia State

University, 14 Marietta Street, NW, Atlanta, GA

30303, Phone: (404) 651-2624, Fax: (404) 651-

4985 Email: pfarnham@gsu.edu

Research Objective: In 2006, the Centers for

Disease Control and Prevention expanded

recommendations for human immunodeficiency virus (HIV) screening in US health care settings.

An estimated 25% of those infected with HIV are unaware of their status and may unknowingly transmit HIV. An opt-out or streamlined strategy was recommended to reduce costs and increase screening rates. Providers may also use conventional or rapid HIV screening tests. We estimate screening costs in these scenarios so that providers can understand the costs of implementing different strategies.

Study Design: We estimate provider costs for three scenarios: (1) STD Setting, Opt-In Testing, in which a client consents to an HIV test and is given full client-centered prevention counseling;

(2) STD Setting, Opt-Out Testing, where the client is told an HIV test will be performed unless declined and is offered limited riskassessment pre-test counseling; and (3)

Emergency Room Setting, Opt-Out Testing, in which a client is told an HIV test will be performed unless declined and written information is provided. Measured costs include: (1) provider/staff time for pre-test counseling and specimen collection; (2) provider time for performing the test and cost of the test kits; and (3) provider/staff time for post-test counseling. Under conventional testing, all clients must return to the clinic for test results/counseling. Under rapid testing, clients receive results/post-test counseling at the initial visit; only those ‘‘likely infected’’ return for confirmatory results and follow-up counseling.

Confirmatory testing is required for those who test positive using either conventional or rapid screening tests.

Population Studied: Based on the populations who participated in various HIV counseling and testing demonstration projects and the HIV cost literature, we estimated actual costs, not charges, from input variables in these sources.

Principle Findings: The per-client provider costs for HIV screening and notifying uninfected and infected clients of their results using different tests/approaches in alternative settings are as follows: STD Clinic, Opt-In: Rapid Test: HIV-:

$32.92; HIV+: $91.28; Conventional Test: HIV-:

$20.09; HIV+: $69.38. STD Clinic, Opt-Out:

Rapid Test: HIV-: $28.02; HIV+: $86.38;

Conventional Test: HIV-: $15.19; HIV+: $64.48.

Emergency Room, Opt-Out: Rapid Test: HIV-:

$20.64; HIV+: $72.02; Conventional Test: HIV-:

$ 7.81; HIV+: $54.87.

Conclusions: Under both conventional and rapid testing, the costs for HIV-infected clients are higher than for uninfected clients due to confirmatory testing and longer post-test counseling sessions. Costs are higher for rapid vs. conventional testing due to the more expensive rapid test kits and, for those who are

‘‘likely infected,’’ the additional specimen collection and post-test counseling on both first and second visits. Opt-out costs are less than opt-in, given the reduced pre-test counseling associated with opt-out screening.


Using either conventional or rapid tests, opt-out procedures result in significant reductions in

HIV screening costs, given the reduced counseling costs. However, the costeffectiveness of providing results to clients under these alternative scenarios still needs to be determined through an analysis that includes test acceptance and receipt of results in the various settings.

Funding Source: CDC

•

Bridging the Cultural Gap in a Transatlantic

Best Practice Transfer Initiative

Eileen Finerty, R.N., Thomas Sculco, M.D., JeMe

Cioppa-Mosca, M.B.A., P.T., Sue KING, M.Sc.,

Jane Harrison, M.Sc., Peterson, Judge, Graziano

Presented By: Eileen Finerty, R.N., Infection

Control Manager, nursing, Hospital for Special

Surgery, 535 East 70th Street, New York, NY

10021, Phone: +1 212 606 1235, Email: finertye@hss.edu

Research Objective: Objective: To examine contextual and organizational culture differences between health care professionals in the United

Kingdom and the United States as part of a best practice transfer initiative. In 2000 the Hospital for Special Surgery, (HSS) partnered with four

British National Health Service trusts in

Southwest London to develop the Southwest

London Elective Orthopaedic Center (SWLEOC), a fifty bed elective orthopaedic hospital. Four outcome measurements were selected for implementation as part of this best practice knowledge transfer project: Physical

Rehabilitation, Infection Control, Pre-operative

Patient Education and Leadership. As the project began to take shape, it became evident that there were significant cultural differences between the

United States and British groups. Our goal was to understand these differences and elucidate common themes in order to facilitate a successful transfer.

Study Design: Study design:We conducted structured and informal meetings and group sessions with the UK team to explore differences in the national health and individual hospital

systems in order elucidate themes common to both. Didactic presentations combined with multiple, open-ended discussions and teambuilding sessions were conducted with participants from all SWLEOC health care disciplines including administrators, physicians, nurses, physical therapists, and ancillary staff.

Population Studied: Population studied:

Frontline administrators, physicians, nurses, physical therapists, dietitian, and ancillary workers.

Principle Findings: Principal findings:

Differences in the healthcare systems in the two countries included size, government mandates and restrictions, quotas, and hierarchy. Much of the healthcare provided in the UK is done in the home, and it was noted that the British seemed more sensitive to the issues of aging than US group. However, common themes began to emerge as the sessions progressed. These themes included a desire to achieve service excellence and provide quality patient care, concerns regarding change management, human resource challenges associated with transfer from the NHS to the SWLEOC facility, and team development. The team participated in role-playing exercises and created storyboards to drill down and explore issues such as negotiating transfer of benefits from the NHS to SWLEOC, selecting the best professional candidates for hire, information sharing, communication among team members, performance monitoring and reporting, and development of pathways for patient care.

Conclusions: Conclusions: Although the NHS, as a government managed system, presents some issues not represented in the United

States, there are challenges that are common to both cultures. Use of open ended discussion and small group interaction facilitated the development of a cohesive group of professional care givers and administrators for a new orthopaedic hospital. The center opened in

January 2004, and successful outcome measurements for length of stay, infection prevention, functional milestone achievement and pre-operative patient education have been published. The issue of transfer from the NHS to

SWLEOC, known as secondment, deserves further in depth examination as the UK moves forward in developing specialty centers with non-

NHS partners.


Implications: Cultural assessment was an important component of this best practice transfer project and should be considered for future endeavors.

Funding Source: The institutions involved

• Do Physicians who Plan to Retire Actually

Retire?

Gaetano Forte, B.A., Gaetano Forte, B.A.

Presented By: Gaetano Forte, B.A., Director of

Information Management, Center for Health

Workforce Studies, 7 University Place/Room

B334, Rensselaer, NY 12144-3458, Phone: (518)

402-0250, Fax: (518) 402-0252 Email: gjf01@health.state.ny.us

Research Objective: To examine the degree of correlation between physician’s stated plans to retire and their subsequent retirement behaviors.

Study Design: The Center for Health Workforce

Studies conducts an ongoing survey of all licensed physicians in New York State with the cooperation of the NYS Education Department.

Physicians in New York are required to reregister their licenses with the Education

Department every two years on a rolling basis. In the re-registration materials sent to each physician, a survey is included with questions related to sociodemographic characteristics, medical education and training, and practice patterns. Physicians are also asked to indicate whether they are retired, and beginning in 1999, the survey included an item asking whether the respondent plans to retire from patient care within the next 12 months. Over 175,000 surveys have been completed since the item was added.

The present study focuses on active patient care physicians and examines the correlation between plans to retire and retirement by since 1999.

Specifically, we examine the correlation between indicating that one will retire in the next 12 months and being retired 24 months later (at the time of the next observation).

Population Studied: Active patient care physicians practicing in New York between 1999 and 2006 who responded to at least two consecutive re-registration surveys and indicated that they were planning to retire on the first of the two surveys.

Principle Findings: The correlation between plans to retire and retirement varied across specialties, controlling for demographic variables, location of medical school, and other practice characteristics.

Conclusions: The correlation between plans to retire and subsequent retirement behavior varies greatly across specialties. Hence, researchers studying retirement for a specific specialty should be cautious in how they operationalize the variable.


After many years of worrying about having too many physicians, many analysts are pointing to future, and in some specialties current, physician shortages. To date most efforts to assess the adequacy of the current supply of physicians and to forecast supply levels in the future have focused on the pipeline of new physicians, including medical school capacity and graduate medical training. As a result, little attention has been paid to studying physician retirement rates that can have a significant impact on aggregate physician supply. Most forecasts of supply simply rely on historical retirement rates that may not be appropriate in the coming years.

Moreover, few studies have considered the methodological issues surrounding the measurement of retirement. In this paper we have examined one of those issues, being able to accurately anticipate retirement behavior among practicing physicians, advancing the field's understanding of the issue.

Funding Source: New York State Department of

Health (NYSDOH)

•

VA/HSR&D’s Quality Enhancement

Research Initiative

Joe Francis, M.D., M.P.H., Diane Hanks, M.A.

Presented By: Joe Francis, M.D., M.P.H., QUERI

Director, Veterans Affairs, Office of Research and

Development, 810 Vermont Avenue NW,

Washington, DC 20420, Phone: (202) 254-0289,

Fax: (202) 254-0460 Email: joe.francis@va.gov

Research Objective: To provide an overview of

VA/HSR&D’s Quality Enhancement Research

Initiative (QUERI) ---- quality improvement program that advances the implementation of evidence-based research into routine clinical practice. QUERI also is focused on national spread and sustainability of optimal quality interventions.

Study Design: The Quality Enhancement

Research Initiative (QUERI) healthcare quality improvement program targets nine diseases/conditions that were selected because of their high prevalence among veterans and burden on patients, family members, and the VA health care system: Chronic Heart Failure,

Diabetes Mellitus, HIV/Hepatitis, Ischemic

Heart Disease, Mental Health, Polytrauma and

Blast-Related Injuries, Spinal Cord Injury, Stroke, and Substance Use Disorders. The nine QUERI

Coordinating Centers, each focusing on a single condition, employ the QUERI process to create measurable, rapid, and sustainable improvements in quality of care and health outcomes. QUERI utilizes a six-step process to diagnose gaps in performance and identify and implement interventions to address them: oIdentify high-risk/high burden conditions; oIdentify best practices; oDefine existing practice patterns in VA and variations from best practices; oDevelop and implement interventions to promote best practices; oDocument outcome and system improvements; and oDocument improvements in Health-Related Quality of Life.

Population Studied: Veterans

Principle Findings: QUERI efforts have reduced readmission rates for veterans with chronic heart failure, increased rates of pneumonia and influenza vaccine for veterans with spinal cord injury, and increased access to effective opioidagonist therapy for veterans with opioid dependence. Other QUERI projects are focused on: improving the detection and treatment of post-stroke depression, implementing evidencebased management of alcohol misuse nationwide, implementing telemedicine interventions to improve insulin treatment regimens for veterans with diabetes, and promoting the successful rehabilitation, psychological adjustment, and community reintegration of men and women who have served in Iraq and Afghanistan and have suffered polytrauma and blast-related injuries.

Conclusions: QUERI impacts are improving the health and quality of life for veterans.


As QUERI groups conducted the projects that led to these significant impacts, they learned several valuable lessons that will enhance the uptake of evidence-based research, such as understanding organizational factors that influence the project, identifying key leaders and experts that can serve as clinical champions, collaboration and innovations in technology that will be addressed in the poster.

Funding Source: VA

• Late-Life Depression and Emergency

Medical Services Utilization

Bruce Friedman, Ph.D., M.P.H., Benjamin Lee,

M.P.H., Yeates Conwell, M.D., Rachel L.

Delavan, M.S., William H. Barker, M.D., Manish

N. Shah, M.D., M.P.H.

Presented By: Bruce Friedman, Ph.D., M.P.H.,

Associate Professor, Community and Preventive

Medicine, Unversity of Rochester, 601 Elmwood


(585) 273-2618, Fax: (585) 461-4532 Email:

Bruce_Friedman@urmc.rochester.edu

Research Objective: To examine the association between major depression and emergency medical services (EMS) use by older adults age

65+. Late-life major depression is associated with significant mental suffering and increased health services use. Depression may be associated with additional EMS use and associated healthcare expenditures. Alternatively, depressed persons may not receive the amount of EMS services they require.

Study Design: A prospective observational study. We examined EMS use during the two years after each person was screened for major depression using the MINI Major Depressive

Episode (MDE) module. EMS utilization data were obtained from a daily journal concurrently completed by each subject or a caregiver. An episode of EMS care and transport was defined as an ambulance trip that resulted in an emergency department visit the same day, or a hospital admission that same day or the next day. We employed logistic, Poisson, and ordinary least squares (OLS) regression to examine the association between major depression and EMS use, controlling for demographic factors, social supports, health insurance, and health and disability status.

Population Studied: 1,444 persons age 65+ that participated in the Medicare Primary and

Consumer-Directed Care Demonstration. Study participants resided in 19 counties in New York,

West Virginia, and Ohio, and were required to need or receive help with either 2+ activities of daily living (ADLs) or 3+ instrumental ADLs

(IADLs), and must have received recent significant healthcare services use

(hospitalization, admission to a nursing home, or receipt of Medicare home health care services within the previous twelve months or 2+ ED visits within the past six months). The sample had a mean age of 80.5 years, 70% were female, and 3% were non-white. 16% were identified as having major depression using the MINI-MDE.

Principle Findings: 528 (36.6%) of the study sample reported at least one episode of EMS care and transport during the subsequent 2 years. More persons with major depression

(43%) than without (35%) reported EMS use

(p=0.032). When other factors were controlled in a logistic regression model, this effect was no longer statistically significant (z=1.14; OR=1.20; p=0.258). Of the 526 subjects that had at least one episode of EMS care and transport, depressed older adults reported more EMS episodes (mean=2.10) than the non-depressed

(mean=1.68) (p=0.009). Major depression was significantly associated with more EMS episodes in both Poisson (z=1.99; p=0.047) and OLS

(t=2.08; p=0.038) regression models.

Conclusions: Our finding of more EMS episodes by persons with major depression that had at least one EMS episode is similar to study findings for other healthcare services. However, it is currently unknown whether these additional

EMS episodes are necessary to address symptoms of major depression, especially suicidal ideation, or whether they are

‘‘unnecessary’’ in the sense that they could be eliminated by ensuring proper depression treatment by primary care providers or mental health specialists.


Research is needed to determine the appropriateness of more EMS episodes by persons with major depression, and their potential implications for healthcare costs and their containment.


• A Study of Substance Abuse Treatment

Quality in Outpatient Drug Abuse Treatment

Clinics

Karen Friend, Ph.D., Karen Friend, Ph.D., William

Zywiak, Ph.D., Pamela Block, Ph.D., Charles

Neighbors, Ph.D.

Presented By: Karen Friend, Ph.D., Associate

Research Scientist, Decision Sciences

Institute/PIRE, 120 Wayland Avenue, Suite 7,

Providence, RI 02906, Phone: (401)751-

1314x2103, Fax: (401)751-1592 Email: kfriend@pire.org

Research Objective: Managed care has created major changes in the delivery of health care services for individuals with substance use problems. While based in a limited way on empirical studies of the effects of higher levels of care versus lower levels, these alterations have gone well beyond existing research guidance. As a result, we are essentially experiencing a series of large-scale, unplanned experiments on the treatment system. As treatment programs adjust to changes in the reimbursement environment, as well as the evolving needs of their clients, the ultimate survival of effective treatment services will depend upon documented evidence of the effects of best managerial practices.

The purpose of this presentation is to describe and provide preliminary organization-level data regarding our five-year NIDA-funded study called

‘‘Project EQUIP.’’ This investigation is designed

to help determine which components of organizational and treatment quality are associated with successful client outcomes.

Study Design: To this end, we are conducting comprehensive organizational assessments in twenty substance abuse treatment facilities. We are also recruiting 25 clients per site and following these individuals for one year.

Population Studied: To date, we have performed organizational assessments at nine diverse sites.

Principle Findings: One site predominantly serves clients having private insurance; the rest primarily serve publicly-paid clients. Five use clinicians who were on staff, whereas the other four rely upon fee-for-service clinicians. Four sites were part of larger umbrella organizations while five operated independently. Six of the facilities focus primarily on addictions, whereas the others also treat mental illness and/or offer case management. Only one has an on-site physician who prescribes medications, while the others either contract these services to an outside psychiatrist or simply advise clients to seek outside medical treatment. Three sites have a high case flow, whereas substance abuse treatment at the other sites has slowed markedly as facilities adjust to the changes in funding.

Conclusions: The sample of facilities represents a wide range of institutional environments, clinical capabilities, and client populations.


These differences in clinics, staff arrangements, payer mix, and related issues will provide rich data to help us understand how clinics can best utilize limited resources to maximize client outcomes. In turn, this study hopes to inform private insurers, their customers (e.g., large employers), and program directors on best organizational practices, thereby helping to bridge the gap between research and practice.


• Follow the Money: Spending on Chronic

Disease in OECD Countries

Bianca Frogner, B.A., Gerard Anderson, Ph.D.

Presented By: Bianca Frogner, B.A., Ph.D.

Candidate, Health Policy and Management,

Johns Hopkins Bloomberg School of Public

Health, 371 Homeland Southway Apt 1A,

Baltimore, MD 21212, Phone: 410-323-3904,

Email: bfrogner@jhsph.edu

Research Objective: To present health care spending data from thirty countries in the

Organization for Economic Co-operation and

Development (OECD) and then examine recent initiatives to prevent and treat non communicable chronic disease, which accounts for approximately 80 percent of health care spending in many industrialized countries.

Study Design: Perspective paper.

Population Studied: Thirty countries in the

Organization for Economic Co-operation and

Development (OECD) with a focus on non communicable chronic disease in the United

States, Australia, Germany, and England.

Principle Findings: In 2004, U.S. spending per capita was almost two and one half times the per capita spending of the OECD country. Despite much higher levels of per capita health care spending, the US had fewer practicing physicians, practicing nurses, and long-term care beds per 1,000 population than the median country in the Organization for Economic Cooperation and Development. A common factor that appears to be driving up health care spending in all countries is the growing cost and prevalence of non communicable chronic disease.

Conclusions: This paper shows that within industrialized countries, non communicable chronic disease accounted for 88 percent of deaths from all causes and 86 percent of all disability adjusted life years in 2005. Five common non communicable chronic diseases

(cancer, diabetes, respiratory disease, cardiovascular disease, and stroke) reflected twothirds of deaths from all causes in the U.S.,

Australia, England, and Germany. Worldwide, a single non communicable chronic disease, cardiovascular disease, was responsible for three times more deaths than the number of deaths from the combination of HIV/AIDS, TB, and malaria in 2005.

Implications for Policy, Practice or Delivery: If industrialized countries hope to control the rapid annual increase in their nation’s health care spending, then understanding and managing chronic disease will have to take center stage in that strategy. The industrialized countries that have been addressing the issue of preventing and treating non communicable chronic disease for several decades are going to need to turn their international aid attention and expertise to the growing cost and prevalence of non communicable chronic disease in low and middle income countries.

Funding Source: CWF

• Community Characteristics Affecting ED

Use by Medicaid Enrollees

Rongwei (Rochelle) Fu, Ph.D., Robert A Lowe,

M.D., Emerson T Ong, B.A., Paul B McGinnis,

M.B.A., Charles Gallia, Ph.D.

Presented By: Rongwei (Rochelle) Fu, Ph.D.,

Assistant Professor of Biostatistics, Department of Public Health & Preventive Medicine;

Department of Emergency Medicine, Oregon

Health & Science University, 3181 SW Sam

Jackson Park Road, # CB669, Portland, OR

97239, Phone: 503-494-6069, Email: fur@ohsu.edu

Research Objective: We previously reported a

10-fold variation in ED use by Oregon Health

Plan (OHP, Oregon’s Medicaid expansion program) enrollees in different communities.

This study sought to determine community characteristics that might explain this variation, after adjusting for patient characteristics.

Study Design: This is a historical cohort study using administrative data of the OHP enrollees.

Oregon’s Office of Rural Health divides Oregon into 130 primary care service areas (PCSAs), each of which constitutes a rational medical market area. Each OHP enrollee was assigned to one of the 130 PCSAs based on residence ZIP code. PCSA characteristics studied included ethnicity composition, rural/urban status, presence of hospital(s) in the PCSA, driving time to hospital, and two measures of primary care capacity: primary care doctors/1000 population

(PCDP); and adjusted capacity (estimated provider-hours available/estimate of hours needed based on population demographics) and eight other variables. Statistical analyses used a two-stage model with the first stage model at the patient level and the second stage at the community level. In the first stage, ED utilization rates for each PCSA, adjusted for patient characteristics (demographics, OHP eligibility category, and chronic medical conditions) were calculated from a zero-inflated negative binomial regression for 104 patient types. Then at the community level, a random effects model was used to determine the association between community characteristics and ED utilization. We present results for the commonest patient type (white females age 18-

40 without chronic illnesses, eligible for OHP through the Temporary Assistance to Needy

Families program and with managed care coverage); analyses for all 104 patient types yielded similar results.

Population Studied: The 555,219 OHP enrollees between 7/1/2003 and 12/31/2004.

Principle Findings: In the multivariable models, ethnicity composition, driving time to hospital, presence of rural/urban hospital(s), and the two primary care measures were significantly associated with ED utilization rate. Compared to

PCSAs with 0-75% of desired adjusted capacity, enrollees in PCSAs with 75-125% or 125-200% adjusted capacity had 0.13 (95% CI 0.05, 0.22) and 0.15 (95% CI 0.06, 0.26) less ED visits/person/year, respectively. For PCSAs with the nearest hospital > 30 minutes away, ED use was 0.12 visits/person/year (95% CI 0.04, 0.20) less than in those PCSAs with a hospital within

10-30 minutes driving time. Patients residing in

PCSAs with hospitals also showed higher ED use, with 0.11 and 0.23 more ED visits per person per year, respectively. Unexpectedly, communities with higher PCDP showed higher

ED use, after controlling for adjusted capacity and other variables in the model. For those

PCSAs with 0.5-1.0 PCDP, ED use was 0.14 visits more per person per year.

Conclusions: Within this Medicaid population,

ED utilization is determined not only by patient characteristics but by community characteristics.

Increased distance to the nearest ED creates a barrier to emergency care. The relationship between primary care capacity and ED use requires further exploration.


Understanding how community characteristics are associated with ED use may facilitate the design of community-level interventions that improve access to primary care and reduce reliance on EDs.

Funding Source: Collins Medical Trust

• Variation in Antibiotics Use for the

Prevention of Postoperative Infection among

Acute Care Hospitals in Japan

Kiyohide Fushimi, M.D., Ph.D., Shinobu Kamata,

M.M.A.

Presented By: Kiyohide Fushimi, M.D., Ph.D.,

Associate Professor, Health Care Informatics,

Tokyo Medical and Dental University, 1-5-45

Yushima, Bunkyo-ku, Tokyo, 1138519, JP, Phone:

81-3-5283-5788, Fax: 81-3-5283-5788 Email: kfushimi.hci@tmd.ac.jp

Research Objective: Unaccountable variation in clinical processes may impede the efficiency and the quality of inpatient care in acute care hospitals. Especially, variation in drug use has a large impact on the quality of health care and the mal-use of antibiotics is known to induce

antibiotic-resistant bacteria, potentially resulting in a huge loss of social health care resources.

Although the assessment of clinical process variation is expected to be of worth and scientific interest, the assessment of the variation among hospitals requires a large amount of costly clinical information. In Japan, the introduction of a lump-sum type payment system based on

Diagnosis Procedure Combinations (DPC) to inpatient care in many of acute care hospitals has enabled us to obtain daily-recorded fee-forservice (FFS) administrative data and to analyze the use of drugs in detail. In this research, we aimed to develop a method to assess variation in antibiotics use among acute care hospitals by using precise FFS administrative data, and to reveal potential relations between the variation and the quality of the care.

Study Design: FFS administrative data were collected from 67 acute care hospitals in Japan.

42 hospitals were university hospitals and the rest were teaching hospitals. The administrative data, which were required for the development and maintenance of Japanese case-mix system, consisted of hospital and patient profiles, diagnoses and procedures, service codes and quantity for procedures, drugs and materials on each hospital day. On average 20 service items were recorded per patient per day. 50 million service item records from 200 thousand admissions were collected, put into a data warehouse, and submitted to OLAP and statistical analyses. For analyses of antibiotics usage, daily doses of antimicrobial agents per patient after surgical procedures in each hospital were assessed. Relatively simple surgical procedures including those for uncomplicated appendicitis and inguinal hernia were selected for analysis to avoid the effects of difference in severity of cases among hospitals.

Population Studied: Patients admitted in 67 acute care hospitals in Japan

Principle Findings: A large clinical process database was constructed and the variation in clinical processes was successfully visualized and analyzed by OLAP method. Variation in antibiotics usage after uncomplicated simple surgical procedures was striking. Eight times difference in the cost for antibiotics was found due to the differences in the duration and the dose of administration and the selection of brands and generics. In some hospitals, third and forth generation antibiotics tended to be selected for prophylactic use after surgical procedures, implicating mal-compliance to the guidelines. The difference in antibiotics usage was not related to the severity of illness, patient characteristics, the length of hospital stay or outcomes.

Conclusions: Our results indicated that precise administrative data can be used for the assessment of clinical variation of inpatient care in acute care hospitals. We found unaccountable variation in antibiotics usage in acute care hospitals in Japan, potentially impeding the efficiency and the quality of the care.


The assessment of unaccountable variation in clinical practice can be used as one of the indicators for hospital benchmarking and the hospital reimbursement rates can be deflated by the estimated excess cost due to mal-practice.

Funding Source: The Ministry of Health,

Welfare and Labour of Japan

• Establishing the Frequency and Outcome of

Cervical Cancer Screening Failures in the

United States

Kim Geisinger, M.D., Dana M. Grzybicki, M.D.,

Ph.D., Richard Zarbo, D.M.D., M.D., Chris

Jensen, M.D., Stan Geyer, M.D., Stephen S.

Raab, M.D.

Presented By: Kim Geisinger, M.D.,

Email: kgeis@wfubmc.edu

Research Objective: Current initiatives in cervical cancer screening are focused on increasing pre-neoplastic lesion detection as a means to reduce cancer incidence. Cervical cancer screening has not been rigorously evaluated in a patient safety context in which all false negative and false positive failures have been linked to clinical outcomes. Our objective was to determine the frequency and clinical outcome of cervical cancer screening failures.

Study Design: We performed an observational, retrospective study of women who underwent cervical cancer screening in 4 American hospital systems (Western Pennsylvania Hospital,

University of Pittsburgh, University of Iowa

Healthcare, and Henry Ford Health System) from 1998 to 2005. We defined a screening failure as a 2-step or greater discordant Pap test and follow-up colposcopic biopsy diagnosis and conducted medical record reviews to determine consequences of failures. Consequences included delays in diagnosis, unnecessary repeat testing or treatment, anxiety, and morbidity or mortality as a result of a failed test. We measured the proportion of women who experienced a screening failure and the associated outcome, classified as a no harm, near miss, or harm event.

Population Studied: 1,646,580 women who had a Pap test.

Principle Findings: A total of 5,278 2-step or greater discrepancies were detected (0.321% of all Pap tests). Missed squamous cancers (1 in

187,786 Pap tests), glandular cancers (1 in

20,000 Pap tests), or high grade lesions (1 in

6,870 Pap tests) comprised 4.1% of all discrepancies. The majority of all failures, or 1 in

210 women who underwent Pap testing, had a false negative or false positive diagnosis of a low grade lesion or a significant difference in diagnostic grading. We detected harm, generally manifested as a repeat invasive or noninvasive test or diagnostic delay, in 70.8% and 63.9% of discrepancies involving high and low grade lesions, respectively. Failures were secondary to the Pap test and colposcopy steps in 41.8% and

59.2% of cases, respectively.

Conclusions: Cervical cancer screening practices trade-off excellent squamous carcinoma prevention with a high Pap test and follow-up biopsy discrepancy proportion resulting in a large number of women who experience low grade harm. It is unknown if screening protocols can maintain high levels of disease detection and cancer prevention with a reduction in diagnostic discrepancies.


We established baseline cervical cancer screening failure proportions and the harm associated with failure. We confirmed that cervical cancer screening is excellent at squamous carcinoma prevention and considerably less effective at preventing adenocarcinoma. Current screening practices result in a low level of harm for many women.


• Geographic Variation in Performance

Measures Across Primary Care Clinics: The

VA MI Plus Study

Joe Gerald, M.D., Ellen Funkhouser, M.S., Ph.D.,

Deborah A. Levine, M.S.P.H., M.D., Ed F. Tipton,

M.D., Joe K. Gerald, M.D., Catarina I. Kiefe,

Ph.D., M.D.

Presented By: Joe Gerald, M.D., Post-Doctoral

Fellow, Division of Preventative Medicine,

University of Alabama at Birmingham, 1717 11th

Avenue South MT 401, Birmingham, AL 35294,

Phone: (205) 934-6838, Fax: (205) 934-4888

Email: geraldj@uab.edu

Research Objective: MI Plus is a randomized, controlled trial of an Internet-delivered intervention to improve treatment of ambulatory post----myocardial infarction patients with multiple co-morbidities. To understand geographic variations in quality, we describe geographic variation in 6 performance measures before randomization.

Study Design: The unit of randomization and of measurement was the Community Based

Outpatient Clinic. Because CBOCs are located in relative geographic proximity to their VAMC, we aggregated the data at the VAMC level. We measured performance for each CBOC through electronic algorithms that extract data from the electronic health record at each facility. We validated our algorithms through manual abstraction of random samples using VISTA

Web, which provides access to the EHR anywhere within VA to authorized users. The 6 performance measures were indicated use of aspirin, beta blockers, and lipid lowering medications, A1C testing, documentation of smoking status, and, among smokers, cessation counseling. Numerators and denominators for these measures both ranged from less than 20 to over 800 at each VAMC. We compared the ranges in performance and report them as percent difference from minimum performance to maximum performance.

Population Studied: We recruited 163

Community Based Outpatient Clinics affiliated with 47 Veterans Affairs Medical Centers in the

United States and Puerto Rico.

Principle Findings: The electronic records of

23,592 patients contributed to this analysis.

Overall performance across all VAMCs was: lipid medications 88.4%, A1C 86.8%, smoking documentation 78.9%, beta blockers 72.5%, aspirin 67.6%, and smoking counseling 60.1%.

Variation across all 47 VAMCs was: lipid medications 17.3% (77.9% to 95.2%), beta blockers 20.5% (61.9% to 82.4%), aspirin 49.1%

(39.4% to 88.5%), A1C 83.9% (6.2% to 100%), smoking documentation 86.9% (11.5% to

98.4%), and smoking counseling 97.9% (0.0% to 97.9%). A1C testing, smoking documentation and counseling had modest variations within some of the 6 US census regions and substantial variation within others, with use of lipid medications and beta blockers having the least variation within all regions.

Conclusions: There is substantial variation in 3 of 6 performance measures, with least variation in prescribing patterns for indicated medications. This variation differed across regions of the U.S.


Implementation efforts for evidence based care

may require particular attention to regional patterns and differences.

Funding Source: VA

•

Who’s Getting Annual Interval

Mammograms?

Jennifer M. Gierisch, M.P.H., Suzanne C. O’Neill,

Ph.D., Barbara K. Rimer, Dr.P.H., Celette S.

Skinner, Ph.D., Jessica DeFranks, M.P.H.

Presented By: Jennifer M. Gierisch, M.P.H.,

NRSA Predoctoral Fellow in Health Services

Research, Lineberger Comprehensive Cancer

Center, University of North Carolina at Chapel

Hill, Campus Box #7295, Chapel Hill, NC 27599-

7295, Phone: 919-843-8088, Fax: (919) 966-1787

Email: gierisch@email.unc.edu

Research Objective: Annual mammography, as compared to biennial screening, may be the optimal schedule to reduce the burden of breast cancer, especially for women in their 40s.

Despite increases in overall screening, fewer than half of age-eligible women report adherence for obtaining two consecutive mammograms on the recommended schedule. While substantial research exists on predictors of mammography for women aged 50+, much less is known regarding annual mammography, especially for women in their 40s. This research will examine demographic characteristics, attitudes, and barrier types related to annual mammography and determine whether variables differ by age groups, 43-49, 50-59, 60-75.

Study Design: Analyses include 2219 respondents who completed baseline telephone surveys as part of a five-year annual mammography maintenance intervention and confirmed two previous mammography dates indicated by insurance records. Annual mammography was defined as having a second mammogram within 10 to 14 months of a previous mammogram. Barriers were grouped into 10 categories. We conducted multiple logistical regressions to estimate the odds of annual mammography for the entire sample and stratified by age groups.

Population Studied: Eligible participants were women members of the North Carolina

Teachers’ and State Employees’ Comprehensive

Major Medical Plan-SHP, aged 43-75, who: had screening mammogram approximately eight months before baseline; never had breast cancer; and were enrolled in SHP for two or more years.

Principle Findings: Overall, 45.5% of participating women were adherent to annual mammography. Annual mammography was less likely for those who: reported less comfortable finances, OR=.68 95%, CI=.57-.81; did not receive a mammography reminder in the past year,

OR=.66, CI= .56-.79; expressed 3+ barriers towards getting a mammography, OR=.41, CI=

.34-.51; expressed some dissatisfaction with their last mammogram, OR=.57, CI= .43-.74; believed getting mammograms was not completely under their control, OR=.81, CI= .65-.99; worked for pay, OR=.59, CI= .48-.72; were ambivalent about mammography, OR=.27, CI= .13-.56; and lived with 3+ people, OR=.54, CI= .43-.68. Annual mammography did not vary based on ethnicity, marital status, education, discomfort/pain during previous mammograms. Respondents endorsing the following barrier types reported lower rates of annual mammography: lack of knowledge/trust in mammography, too busy/ forgot mammogram, cost, competing priorities, and physician-related, healthcare system-related, and logistical barriers. Age stratified results also yielded significant differences among age groups. As compared to women in their 50s, women in their 40s were less likely to report annual mammography, OR=.32, 95% CI=.25-.42.

Other key variables differed by age groups.

Conclusions: Annual mammography rates remain low. With rare exception such as age, demographic variables and individual-level barriers did not differentiate women’s adherence status, while contextual variables predicted lower likelihoods of having annual mammograms.

These contextual variables suggest the demands of work and family negatively impact personal health behaviors. Further examination of contextual factors that influence mammography screening is needed to increase adherence to annual mammography.


Annual mammography interventions should focus on the kinds of modifiable barriers identified here. Specifically, ambivalence about screening for women in their 40s should be addressed along with systems-level changes to assure that age-eligible women receive regular reminders.

Funding Source: NCI, AHQR NRSA

• Early Evidence On Changing Consumer

Health Care Behavior Through HSA/High

Deductible Health Plans Coupled With

Wellness Promotion: The Regence Experience.

Joe Gifford, M.D., Jeff Robertson, M.D., Ralph

Prows, M.D.

Presented By: Joe Gifford, M.D., Chief Medical

Officer, Health Services, Regence BlueShield,

1800 Ninth Avenue, Seattle, WA 98101, Phone:

(206) 332-5146, Fax: (206) 292-9935 Email: jgifford@regence.com

Research Objective: A current policy initiative is to promote a more efficient health care marketplace by increasing the engagement of consumers in their own health care purchasing decisions by structuring benefit plans so that the majority of health care purchases are made from the consumer’s own account. A popular addition to these plans is an incentive program with financial or other rewards that promotes a variety of ‘‘wellness behaviors’’ through the use of

Health Risk Assessments and coaching programs. It’s an assumption of these initiatives that health care costs will be reduced by a consumer who is engaged both in the buying of health care services and in the maintenance of his/her own health. At Regence, a large regional

BlueCross BlueShield plan in the Northwest with

8,000 employees, not only do we offer these plans commercially, but we have offered them to our own employees for the last three years. The purpose of this study is to examine the claims history of the Regence employees who have chosen an HSA-high deductible plan and attempt to draw conclusions about the effect on health care cost trend of this cohort, and the cohort who did not choose such a plan.

Study Design: We begin by describing the context------both the choice of health care plans for

Regence employees and the ‘‘healthy lifestyles’’ environment that has been instituted from the

CEO down in the organization. We then perform an actuarial analysis of several cohorts over three years of claim history: the HSA/high deductible cohort, a comparison cohort with similar characteristics that did not choose such a plan, and the cohort that chose more traditional PPO plans.

Population Studied: The 8000 employees of

Regence, Inc, an insurer based in Portland,

Oregon, with employees in Oregon, Washington,

Idaho, and Utah.

Principle Findings: While the results of the analysis are not yet final due to required claims run-out for the study year 2006, preliminary estimates are that claims costs are significantly lower for the group that selected the HAS/high deductible plan. In addition, overall claim experience for the group is showing a significant reduction of trend from expected.

We also find that despite a highly favorable subsidy of the HSA/high deductible plan for most employees, those who chose the plan are still in a minority. We explore why this is so, and how future plan designs and educational campaigns may encourage more employees to choose these plans in the future.

Conclusions: A consumer-directed health plan

(CDHP) with high deductible and HSA, when coupled with a strong corporate culture of wellness promotion, can dramatically lower expected health care costs. There are, however, barriers to widespread adoption of these plans due to their complexity and certain misperceptions about them.


CDHP/HSA plans hold great promise for reducing health care costs and promoting healthy behaviors. The next generation of such plans will need to reduce their complexity and increase the subsidy for certain employee segments to leverage their potential power.

Policy implications for the regulatory environment of HSA plans are discussed.

Funding Source: Regence BlueShield

• Utilization of Air and Land Ambulance

Services

Patricia Gladowski, R.N., M.S.N.

Presented By: Patricia Gladowski, R.N., M.S.N.,

Medical Project Analyst, Healthcare Informatics,

Highmark BCBS, 120 Fifth Avenue, Suite P7205,

Pittsburgh, PA 15222-3099, Phone: 412-544-3195,

Fax: 412-544-0700 Email: patty.gladowski@highmark.com

Research Objective: The objective of this study was to investigate the utilization and cost of ground and air ambulance services and to evaluate appropriateness of service and patient outcomes, including diagnosis, admission, discharge, or death. Both land and air ambulance utilization was reviewed at an individual member level to determine apppropriateness based on claims data and outcomes with the intent to identify potential educational needs at the provider and member level.

Study Design: Using billing codes to indicate whether service was ground, rotary wing or fixed wing ambulance transport, we looked at the number of transports, liability for the member and for the insurer and outcomes. Some of the variables considered were age, diagnosis, admission, no admission, transport site pickup

(i.e., hospital, accident scene, other facility, etc.), outcomes (i.e., top diagnoses, admission diagnoses - primary and secondary, length of admission, death). We also looked at the differences in payment to participating

participating providers and facilities vs. nonparticipating in the insurance network.

Population Studied: Using 4 years of data, we compared utilization in 2003 through 2006, which consited of approximately 5000 air transports per year. Ground ambulance involved an average of appproximately 160,000 transports per year.

Principle Findings: The primary reasons for air transport for those admitted were not surprising in that myocardial infarction, circulatory and ventilatory problems, along with significant trauma were at the top of the list. In a given year, however, approximately 1/3 of the patient transported via rotary air wer not admitted.

Investigation into the reasons for no admission, included whether it was due to inappropriateness of air transport versus death.

Ground transport had similar reasons for transport at the top of the list. Individuals transported were grouped into age categories with children under 17 representing a large portion of rotary wing transports.

Conclusions: Generally, the utilizationof air amabulance has been found to be appropriate in order to provide a timely response to care; however, there are incidences where land ambulance may have been more appropriate.

Review of the data has also shown that in some cases where transport occurred between facilities, land transport may have been adequate. Also, when analyzing data for the use of land ambulance service, it has been found that some individuals utilize services at a very high level.


Review of the data has shown that in some cases where air or ground transport occurred, other means of transport or care may have been implemented with similar outcomes and lower costs. It is improtant for providers and lay individuals to be educated on appropriateness of transport in order to ensure adequate and cost effective care.

• Elderly Depression Remission and

Ambulatory Services Utilization

Susan Grantham, M.P.P., M.A., Ph.D. Candidate,

Eugenie Coakley, M.P.H., M.A., James Maxwell,

Ph.D.

Presented By: Susan Grantham, M.P.P., M.A.,

Ph.D. Candidate, Senior Consultant, JSI Research and Training Institute, 44 Farnsworth Street,


(617) 482-0617 Email: sgrantham@jsi.com

Research Objective: To determine whether there is an ambulatory services utilization offset for those who remit from depression - Those with depression use more health services

(mental health and general medical) overall than those without depression. The logic follows that if we more effectively treated depression,

"excess" use of services would decrease; however, such offsets have not been found in the literature. Given that relatively few people actually remit in health services studies

(approximately 30 percent), the large percentage of non remitters might obscure offsets occurring for those who remit. Depression history is another variable of interest, with the rationale that those with a more chronic course of depression may be less likely to change their utilization patterns than those without such a history.

Study Design: This study was a secondary analysis of data from a multisite, randomized control trial of depression, anxiety, and at-risk drinking in the elderly (PRISM-E study). Using a generalized estimating equation mixed model to account for repeated measures over time, the model determines whether remission status over a six month period of study engagement affects future utilization, controlling for previous utilization, physical functioning, and demographic factors. Utilization data is abstracted from Medicare claims and Veterans'

Affairs (VA) outpatient utilization files, and utilization is tracked for a period of 18 months, from 9 months pre-study to 9 months post-study enrollment.

Population Studied: Elderly persons with a primary care appointment in either a VA or non-

VA setting and who assessed positive for major depression, a sample of 593 subjects.

Principle Findings: Remission from major depression results in an offset for ambulatory mental health encounters but not for non-mental health ambulatory encounters, specialist encounters, diagnostic test encounters, or encounters with a "non-specific" diagnosis code.

Prior period utilization and physical functioning, controlling for demographic factors, predict future utilization. When stratified by depression history, remission is on the threshold of being a significant predictor of future utilization (p=.09) and physical functioning is not for the group with depression history. The group without depression history mimics the results for the overall sample.

Conclusions: Remission is not related to a general (non MH) ambulatory services offset,

except possibly for those with a depression history.


Continuing to think about mental health services and general medical services as separate silos of care may be inappropriate. Although the literature clearly demonstrates that those with depression use more services than those without, the policy issue is to understand whether this extra service use is "effective" (i.e., leads to better outcomes). For example, if the extra service use is successfully addressing physical conditions related to depression, the service use would be considered effective. Recent research has shown that a collaborative care primary care approach to managing depression improves physical functioning in the elderly.

Perhaps the pathway through which a utilization offset is found for mental health treatment is through improvements to physical functioning.

The models from this study showed that future utilization was influenced by even small improvements in physical functioning.

Funding Source: SAMHSA, VA, HRSA, CMS

•

Improving Influenza Vaccination in

Pregnant Women

Anthony Greisinger, Ph.D., Melanie Mouzoon,

M.D., Frances Smith, M.D., Anthony Greisinger,

Ph.D., Nancy Peterson, Ph.D., Paul Glezen, M.D.

Presented By: Anthony Greisinger, Ph.D.,

Executive Director, Kelsey Research Foundation,

5615 Kirby Drive, Suite 660, Houston, TX 77005,

Phone: (713) 442-1222, Fax: (713) 442-1228 Email:

Anthony.Greisinger@kelsey-seybold.com

Research Objective: Backgound: The ACIP recommends that pregnant women receive inactivated influenza vaccine because they are at high risk for complications of influenza infection.

However, U.S. vaccine coverage averages only

12.8%. Coverage at Kelsey-Seybold Clinic (KSC) was 3.5% in 1998-2002. Objectives: To describe the strategies adopted to improve influenza immunization coverage in pregnant women in a large health care organization.

Study Design: A retrospective electronic database search of two consecutive influenza seasons (2003/04 and 2004/05) was performed to estimate influenza immunization rates in pregnant women at KSC after implementation of three main strategies: 1) revision and adoption of standing orders for influenza vaccine administration in obstetric (OB) and general medicine practices and training of OB and immunization nurses on their use, 2) active physician and employee annual influenza immunization campaign through broadcast emails and notices with information on immunization in pregnancy, and 3) assessment of immunization rates in pregnant women for individual OB providers using a billing database, direct encouragement, and behavior modeling by the head of the OB department. In addition, educational updates on influenza vaccine in pregnancy were provided to obstetricians, nurses, and staff during quarterly meetings.

Population Studied: The ethnic diversity of patients at KSC mirrors that of Houston: 49% white, 25% African-American, 21% Hispanic, and

5% Asian. Kelsey-Seybold patients are 57% female and 43% male. The population in the study sample included 2,023 women pregnant during 2003/04 and 1,893 women pregnant during 2004/05. The mean age of vaccinated women was 29.4 years and for non-vaccinated was 29.8 years.

Principle Findings: Influenza vaccine coverage rates increased from 3.5% to 21.1% in 2003/04 and to 30.6% in 2004/05, when influenza vaccine was administered to 427 of 2,023 and

579 of 1,893 eligible pregnant women, respectively. The number of prenatal care visits was the most important predictor for receipt of influenza vaccine, with a linear relationship between higher number of visits and increased odds of receiving influenza vaccine. An important barrier to influenza immunization of pregnant women by their obstetrician was identified: no reimbursement to the physician or the patient by insurance plans that cover pregnancy as a bundled service, which does not include immunizations.

Conclusions: Influenza vaccination rates in pregnant women can be improved substantially with standing orders for immunization and promotion through vaccine advocates and active educational activities focusing on encouraging influenza immunization in patients and health care providers.


Higher rates of immunization could be achieved if immunizations were included as part of routine pregnancy care in health insurance plans.

Funding Source: National Institutes of Health

• Comparing Rates of Self-Reported and

Diagnosed Obesity

Krista Gronley, M.P.H., M.B.A., M.A.

Presented By: Krista Gronley, M.P.H., M.B.A.,

M.A., Project Mgr., Research, Care Management,

Blue Cross Blue Shield of Hawaii, 818

Keeaumoku Street, Honolulu, HI 96814, Phone:

808-948-6979, Fax: 808-952-7536 Email: krista_gronley@hawaii.edu

Research Objective: To compare the rates of obesity captured in administrative claims data, and grouped using Symmetry’s Episode

Treatment Grouper™, with the self-reported height and weight data from a member survey.

Study Design: A retrospective, descriptive analysis of administrative claims data and member surveys for calendar years 2002 through

2004. Administrative claims data was grouped using Symmetry’s Episode Treatment Grouper™ and all completed episodes for ETG 0048 (mild obesity), 0049 (morbid obesity with surgery) and

0050 (morbid obesity) were evaluated. Selfreported height and weight data from the member surveys were used to determine an estimate of the incidence of obesity in the population.

Population Studied: Enrollees in a large health plan in Hawaii with completed episodes of mild

(n=11,208) or morbid obesity with (n=249) or without surgery (n=3,154) in calendar years 2002 through 2004 and members who responded to a member satisfaction survey in 2002 through

2004(n=32,422 average responses 2002 through

2004).

Principle Findings: There were 11,208 unique members with episodes of mild obesity (ETG

0048) in 2002 through 2004, as determined by grouped administrative claims compared to member self-reported obesity (from member survey with a BMI between 30 and 40) of 12,151.

The grouped data showed 3,403 unique members with morbid obesity with (ETG

0049)or without surgery (ETG 0050) compared to 1,657 with a BMI above 40 reported on the member survey for the same time period.

The member survey had significantly more men self-reporting height and weight resulting in a

BMI of over 40 (28.5% average over 2002 through 2004) than the 3.52% found in the administrative claims data. Women also had a significant difference with only 7.7% having a diagnosis of morbid obesity (with or without surgery) but over 18% (on average for 2002 through 2004) self-reporting height and weight yielding a BMI of over 40. The average age of members with claims of obesity (ETGs 0048,

0049 and/or 0050) was 46.3 years.

Conclusions: There is a significant difference in the number of members with a diagnosis of obesity and the number of members selfreporting obesity. This may provide opportunities to work with the physician community to address the increasing incidence of obesity in the health plan’s population.


This study will identify members that could be targeted for weight management interventions, potentially improving the member’s overall quality of care and health outcomes.

• The Effect of State Medicaid Payment

Policies and Nursing Home Racial

Composition on the Risk of Hospitalization for Black and White Residents

Andrea Gruneir, M.Sc., Susan C. Miller, Ph.D.,

Zhanlian Feng, Ph.D., Orna Intrator, Ph.D.,

Vincent Mor, Ph.D.

Presented By: Andrea Gruneir, M.Sc., Graduate student, Community Health, Brown University, 2

Stimson Avenue, Providence, RI 02912, Phone:

(401)863-1275, Fax: (401)864-3489 Email:

Andrea_Gruneir@brown.edu

Research Objective: Our objective is to quantify the effect of state Medicaid nursing home (NH) payment policies and NH racial composition on the differential risk of hospitalization for White and Black NH residents.

Study Design: This is a cross-sectional study in which we linked data from multiple sources to describe and control for features of the resident,

NH, market, and state for the year 2000.

Resident data were obtained from Minimum

Data Set (MDS) assessments and from

Medicare inpatient claims. Facility data came from the On-line Survey, Certification, and

Reporting System (OSCAR) and aggregated resident descriptors derived from the MDS. Data from the Area Resource File was used to describe the NH market, which was defined as the county. Data on state policies were taken from a previously conducted survey of state

Medicaid offices. A multi-level model was used to estimate the effect of resident, NH, and state characteristics on the likelihood of being hospitalized as compared to remaining in the

NH. Multiplicative interaction terms were used to estimate differential race effects (White versus

Black).

Population Studied: The population of interest was long-stay NH residents in the continental

U.S. during the second quarter of 2000.

Analyses were restricted to free-standing NHs located in urban counties. The final sample consisted of 516,082 residents in 8,997 NHs.

Principle Findings: Nineteen percent of residents were hospitalized during follow-up and this differed between Black and White residents

(Black: 24.1%, White: 18.5%). The multi-level model revealed that contextual factors significantly affected individual risk of hospitalization. A higher concentration of Black residents in a NH was negatively correlated with resource availability as measured by the percent of Medicaid and private-pay residents. Further, as the concentration of Black residents in a NH increased so did risk of hospitalization, regardless of individual race; residents in NHs with the highest proportion of Black residents were 20% more likely to be hospitalized than residents in NHs with the lowest proportion of

Black residents. However, higher Medicaid payment rates were associated with a lower risk of hospitalization and the effect was strongly modified by race. A ten-dollar increase in per diem reimbursement was associated with a 4% decreased risk for White residents but a 22% decreased risk for Black residents. The presence of a NH bed hold policy increased the risk of hospitalization (AOR=1.4, 95% CI=1.1-1.7) but did not differ by race.

Conclusions: Black residents are disproportionately located in Medicaid-reliant, resource-poor NHs. Without resources for skilled staffing or support services, residents of these NHs are at increased risk for hospitalization. Residents of such NHs gain more benefit from increased Medicaid reimbursement because the NHs lack other sources of revenue (such as private pay residents).


The differential effect of the Medicaid rate by race and the strength of NH racial profile on risk of hospitalization illustrate the need to better support NHs that serve Medicaid populations in order to reduce racial disparities in NH care.

Funding Source: NIA

•

Redesigning Clinical and Lab Processes to

Improve Thyroid Gland Diagnostic Testing

Dana Grzybicki, M.D., Ph.D., Stephen S. Raab,

M.D., Daniel Sudilovsky, M.D., Ron Balassanian,

M.D., Janine Janosky, Ph.D., Colleen Vrbin, B.S.

Presented By: Dana Grzybicki, M.D., Ph.D.,

Email: grzybickidm@upmc.edu

Research Objective: Fine needle aspiration

(FNA) is the first line diagnostic test for patients with thyroid gland nodules. During a two year period (2003, 2004) at one institution, the sensitivity and specificity of thyroid gland FNA for the diagnosis of neoplasm is 70.2% and

67.0%, respectively. Errors result from poor samples and lack of standardization in many of the testing steps. Our objective was to determine whether work process redesign resulted in diagnostic error reduction for patients who underwent FNA evaluation of thyroid nodules.

Study Design: In this longitudinal nonconcurrent cohort study set in a university hospital system, we compared the diagnostic error frequency of a thyroid gland FNA service before and after implementation of error reduction initiatives consisting of adoption of a standardized diagnostic terminology scheme and an immediate interpretation service. These initiatives were designed using principles of standardized work and immediate feedback and involved adoption of a standardized diagnostic terminology scheme and creation of an immediate interpretation service that focused on reducing the number of definitive diagnoses being made on poor quality specimens.

Immediate interpretation also provided a feedback loop to assist radiologists in improving sampling quality. Outcome performance characteristics included false negative, false positive, non-interpretable specimen, and surgery rates and overall diagnostic accuracy.

Population Studied: A total of 2,424 patients who had a thyroid gland nodule and underwent an FNA.

Principle Findings: Following diagnostic terminology standardization, the false negative rate decreased from 41.8% to 19.1% (P = 0.006), the specimen non-diagnostic rate increased 5.8% to 19.8% (P < 0.001), the sensitivity increased from 70.2% to 90.6% (P < 0.001), and the surgery rate decreased from 23.6% to 19.9% (P =

0.021). Overall accuracy, as measured by the area under a receiver operating characteristic curve, increased from 0.693 to 0.806 (P = 0.05).

Compared to patients who did not have an immediate interpretation, those that did had a lower non-interpretable specimen rate (7.8% with and 23.8% without immediate interpretation, P < 0.001).

Conclusions: Process change led to significantly fewer diagnostic errors in patients who had a thyroid gland FNA. Fewer errors resulted in fewer unnecessary operative procedures and fewer unnecessary repeat FNAs.


The lack of standardized diagnostic terminology and the lack of immediate interpretation services contribute to the wide variability in the reported diagnostic accuracy of thyroid gland FNA.

Simultaneously targeting specimen procurement and interpretation by focusing on process, rather

than on individuals, is a means to improve accuracy. Our next goal is to disseminate these strategies of error reduction in larger practice settings and through different types of pathology and radiology practice groups.


• What is the Cost of Emergency Department

Utilization by Medicaid Enrollees?

Daniel Handel, M.D., M.P.H., K. John

McConnell, Ph.D., Neal Wallace, Ph.D., Charles

Gallia, Ph.D.

Presented By: Daniel Handel, M.D., M.P.H.,

Health Services Research Fellow, Emergency

Medicine, Oregon Health & Science University,

3181 SW Sam Jackson Park Road, Mail Code

CR114, Portland, OR 97329, Phone: 503-494-

9587, Fax: 503-494-4640 Email: handeld@ohsu.edu

Research Objective: Frequent use of the emergency department (ED) is assumed to be an important driver of healthcare costs for

Medicaid patients. We sought to quantify the absolute and percentage of total Medicaid expenditures associated with outpatient ED visits.

Study Design: This retrospective study used data on 589,903 individuals enrolled in Oregon’s

Medicaid program in 2002. ED expenditures were defined as Medicaid spending for hospital, physician, and ancillary services associated with any ED visit not resulting in an inpatient admission. Multivariate generalized linear models were used to assess the effect of demographic factors and eligibility status on ED expenditures. We estimated average monthly ED expenditures in absolute values and as a percentage of total medical expenditures.

Population Studied: Medicaid enrollees in the state of Oregon in 2002.

Principle Findings: Expenditures associated with ED visits at 58 hospitals averaged $12.17

(95% CI 12.05-12.30) per-member-per-month, representing 7% of total monthly expenditures.

Ancillary services (labs and diagnostic imaging) accounted for 35% of ED expenditures.

Multivariate analyses showed higher ED expenditures were associated with increasing age and single adults (e.g., without spouse or children). A large portion of spending for ED services was concentrated among a small group of heavy users: while 80% of enrollees had no

ED expenditures, 50% of all ED expenditures could be attributed to 11% of enrollees.

Conclusions: ED expenses are a small percentage of total medical spending by

Medicaid enrollees; a very aggressive and successful policy that cut ED expenditures by

25% would reduce Medicaid expenditures by less than 2% per year. Actual savings would be even smaller if reduced ED utilization were offset by increased spending at the primary care level.

Since the great majority of these patients do not use the ED in a given year, efforts to reduce ED expenditures may be best accomplished through targeting selected enrollees who have very high

ED expenditures, rather than attempting to decrease overall ED use.


We have shown that only a small percentage of

Medicaid enrollees use the Emergency

Department. In order to enact cost-saving measures, efforts by state agencies must be focused on this subset of the population.

• Improvement Coaching for Primary Care

Safety Net Providers: The NYC Health Dept's

Year One Experience

Jeff Harris, Ellen Cohen, Ph.D., Thomas Cozart,

Lynn Silver, M.D., M.P.H., Mary Bassett, M.D.,

M.P.H.

Presented By: Jeff Harris, Preventive Services

Advisor, Bureau of Chronic Disease Prevention &

Control, NYC Dept of Health and Mental

Hygiene, 2 Lafayette Street, 20th floor, New York,

NY 10007, Phone: 212-442-0020, Fax: 212-676-

2161 Email: jharris2@health.nyc.gov

Research Objective: Evaluate results of first-year implementation of Preventive Services Advisor

(PSA) program for quality improvement in diabetes management and chronic disease prevention, and use results to redesign program for second year.

Study Design: Two Preventive Services Advisors

(PSAs) were deployed to East/Central Harlem,

South Bronx, and Central Brooklyn. Following site recruitment, first year activities included registry installation, training in data analysis, and production of baseline data reports to assist planned care. PSAs also trained teams in selfmanagement support, facilitated clinical training for providers, and assisted practices to more effectively allocate limited resources. PSAs used quantitative and qualitative methods to assess program impact and success. Quantitative measurement strategy included seven diabetesrelated outcome measures and four process measures. Qualitative methods included surveys, diaries and monthly report submission.

Population Studied: Medical practices serving adult diabetes patients in three underserved areas of New York City which have high prevalence of diabetes.

Principle Findings: In year one, seven (7) ambulatory care practices were recruited for participation (3 Bronx, 3 Harlem, 1 Brooklyn).

Qualitative data highlight the importance of senior leadership support and chronicle the process of engaging the team, offering important lessons for expansion of program to new sites.

Use of diabetes registry allowed populationbased care at a level not attainable without it.

Self-management support was satisfying to both patients and providers, though practices struggled with delivery system design issues.

Conclusions: Ongoing senior leader support and involvement is essential. Installation and population of registry is a necessary precursor to planned care. PSA program has been redesigned to create discrete modules (such as registry installation; using a registry for planned care; and self-management support), with the requirement that practices commit to beginning the PSA program with task-oriented, deadlinedriven registry installation module.


Effective quality improvement coaching of medical practices requires that senior leader support be operationally defined. In this way, senior leaders, all of whom have competing priorities, can realistically determine if and when they can participate fully in the manner necessary to achieve program goals.

•

Disability Related Outcomes of Pulmonary

Rehabilitation for Women with COPD

Salwa Hassanein, Ph.D, Georgia L Narsavage,

Ph.D., A.P.R.N., F.A.A.N.

Presented By: Salwa Hassanein, Ph.D, Post

Doctoral, Nursing, Case Western Reserve

University, 2901 Van Aken Boulevard Apt #1, cleveland, OH 44120, Phone: 216-991-6176, Fax:

216-368-3542 Email: salwaewis@hotmail.com

Research Objective: Pulmonary Rehabilitation

(PR) programs have been shown to improve functional status and exercise performance, decrease dyspnea, and improve quality of life outcomes in individuals with Chronic Obstructive Pulmonary

Disease (COPD).The epidemiology of COPD has documented an increased prevalence in women over the last decade. Since 2000, women have exceeded men in the number of deaths attributable to COPD. ‘‘In 2002, over 61,000 females died compared to 59,000 males’’

(National Center for Health Statistics, 2002).

Purpose: This study’s aim was to determine in sample of women with COPD, which contextual factors, resources, and barriers identified on initial assessment, predict consistent attendance

(PR dose effect), and the disability-related outcomes during PR programs. A descriptive predictive design using retrospective record analysis was used.

Study Design: A descriptive predictive design using retrospective record analysis was used.

Population Studied: Records of 72 community dwelling women with COPD who completed the

PR program at an urban tertiary medical center from 2000 to 2005 were included.

Principle Findings: On average women were

58.5 + 10.11 years old with a Body Mass Index

(BMI) 31.4+ 9.9, FEV1 of 47.58% predicted

(SD=20.7), and a FVC % predicted of

66.73(SD=17.36), FEV1/FVC % mean ratio was

54.20% predicted (SD=18.87), and RV was

145.43% predicted (SD= 68.77), indicating that women included in the study had moderate to severe obstructive lung disease. PR program women attendance averaged 20 (+ 4.4) sessions out of 24 sessions.The contextual variables of not a current smoking (Beta= -.31); not having

Emphysema (Beta= -.36); lower FEV1 %( Beta=-

.44); and higher FVC% (Beta =.48) were significant predictors of attendance at PR. The fewer co-morbidities significantly predicted the dose of PR (Beta=-.25). Women attained a dose of PR greater than 83%. The greater the PR attendance, the better the predicted outcomes of metabolic level (Beta=.31) and dyspnea

(Beta=.29) (higher score = less dyspnea) in the last PR session.

Conclusions: An increasing number of women began smoking in the past half-century, paralleling a rise in COPD rates among women

(U.S. Department of Health and Human

Services, 2004). Pulmonary rehabilitation guidelines indicate that current smoking could prevent candidates from being enrolled in PR, but no previous evidence documented reasons to exclude smokers from rehabilitation. In the current study, women with COPD had a mean smoking history of 42.6 (+SD =37.9) pack years

(packs per day times number of years smoked).

These findings support the ability to identify factors that predict attendance at a PR program, the negative effects of current smoking, and that higher attendance (dose effect) as a positive mediator in improving in metabolic level and dyspnea.


Nurses should assess patients for risk for PR non-attendance or completion and address characteristics that can be changed; smoking cessation could become a requirement before initiating a PR program, and PR outcome measures should capture dyspnea and metabolic status.

Funding Source: CWRU

• The Effect of Copayment on Patient

Compliance to Specialty Drug Therapy

Regimens for Multiple Sclerosis, Rheumatoid

Arthritis

Rochelle Henderson, M.P.A., Emily Cox, Ph.D.

Presented By: Rochelle Henderson, M.P.A.,

Outcomes Research Sr. Project Manager,

Research and Product Management, Express

Scripts, 13900 Riverport Drive, Maryland

Heights, MO 63043, Phone: (314)702-7653, Fax:

Email: rhenderson@express-scripts.com

Research Objective: Examine the relationship between patient persistency and member copayment and distribution channel for two specialty therapy classes: multiple sclerosis

(MS) and drugs used to treat inflammatory conditions (IC).

Study Design: Cross sectional analysis of retrospective prescription data targeting patients with a prescription claim for MS or IC in the index period of July 1, 2004 through December

31, 2004.

Population Studied: Clients included in the analysis offered integrated (Home Delivery and retail) pharmacy benefits within an employerbased market (i.e., no Medicare or Medicaid), and offered a subsidized prescription benefit.

Only those patients eligible for pharmacy benefits throughout the entire study period of

January 1, 2004 through December 31, 2005 were included in the analysis. Each member was followed for 365 days from the date of the first claim within the index period. If the date of member’s last prescription in the follow-up period plus the days supply was within 60 days of the 365 day follow-up period, the member was considered to be ‘‘persistent’’.

Cox regression was used to analyze the relationship between persistency and copayment categories, controlling for age, gender, type of pharmacy provider (i.e., retail or specialty pharmacy), formulary status, whether the member was a new user, and whether the member took multiple forms of medication.

Average copayment per prescription was calculated by dividing the total member copayment by the number of 30-day equivalent prescriptions and categorized into five groups:

<=$20, >$21-$50, >$50-$75, >$75-$150, >$150.

Principle Findings: Results from the Cox regression for the MS therapy class indicate that younger age, new users, or filling a prescription in a retail pharmacy increased the likelihood of discontinuing therapy. Members paying greater than $150 had 19% (95% CI: 1.03-1.37) greater odds of discontinuing therapy than those paying less than $20. For RA, results from the Cox regression indicate that being younger, a new user, female or filling a prescription in a retail pharmacy increased the likelihood of discontinuing therapy. Compared to those paying <=$20 per prescription, patients paying from $76-150 and >$150 had a 17% (95% CI:

1.01-1.34) and 13% (95% CI: 1.00-1.28) greater likelihood of discontinuation of therapy. Price elasticity of demand for non-specialty medications have been found to range from -

0.18 to -0.30; rates up to six times higher than those estimated for the therapy classes in this study, -0.05 to -0.08. The relationship between compliance and distribution channel (i.e., retail vs specialty) suggest that higher touch models of care as provided under specialty may positively impact patient compliance.

Conclusions: Patients taking specialty medication are sensitive to prices only at the highest copayment categories. The better compliance noted for those receiving their medications through a specialty pharmacy provider has important implications for improved quality of care for these patients requiring a higher level of support to treat their condition.


Several aspects of specialty medications are complex and require a higher level of patient support to aid patients in managing their conditions. The better compliance noted for those receiving their medications through a specialty pharmacy provider has important implications for improved quality of care.

Funding Source: Express Scripts, Inc

• Infertility and Decision Making for the Use of Complementary Alternative Methods: A

Focus Group

Laura Hollywood, R.N.C., C.N.M., D.N.Sc.(C),

Joyce Anastasi, R.N., LAc, Ph.D., D.N.P.

Presented By: Laura Hollywood, R.N.C., C.N.M.,

D.N.Sc.(C), Nursing Instructor, School of

Nursing, Seton Hall University, 23 Foley Road,

Warwick, NY 10990, Phone: 845-987-8292, Fax:

845-987-8292 Email: laa20@columbia.edu

Research Objective: To explore factors, which influence an infertile woman's decision- making concerning Complementary Alternative Medicine

(CAM) treatment options.

Study Design: Study Design

Qualitative focus group methodology was selected for this exploratory study. Focus groups were chosen to promote an open expression of the ideas of the participants. Following IRB approval three focus group sessions were held with 2-5 members each, between July 19, 2006 and August 3, 2006. All sessions were conducted at the Columbia University School of

Nursing and lasted 1 ¼ hours to 1 ¾ hours.

Participant Selection Recruitment consisted of advertisements placed in local NYC newspapers and flyers placed on bulletin boards in the

Columbia University School of Nursing and

Medical Center. A telephone number for the PI was included in the advertisements. During the phone contact potential participants were screened for inclusion criteria which included being a women between the ages of 25 and 45, who speak and read English, and have been diagnosed with infertility. There was no exclusion criteria. The participants were given a description of the study and focus group scheduling information. Procedures: Informed consent was administered to all participants.

The participants also completed a short demographic questionnaire. The PI led each focus group and an assistant was present to take notes. Ten open ended questions were repeated to each group to guide the discussion.

Focus group sessions were audio-taped and transcribed verbatim. The PI listened to the audio-tapes while reading the transcripts to ensure accuracy. The data was coded by hand to identify key themes identified including the frequency of the comments.

Population Studied: Ten women between the age of 31 ---- 44 years, who could speak and read

English, who were diagnosed with infertility, were enrolled.

Principle Findings: Seven themes emerged from analysis of the data. These included:

Health Cost/Insurance, Job/Employment, Health

Beliefs, Perceived Barriers, Perceived Severity of

Side Effects, Support Groups and Perceived

Need.

Conclusions: Cost was considered by many of the women a significant factor for decision making regarding infertility treatments. The impact of cost on decision-making was directly related to insurance coverage. Women without insurance coverage could not afford some of the treatments; they also had an increase in the sense of disappointment in treatment failures when paying out of pocket. 2. Women with inflexible job schedules found job/ employment was also a significant factor in decision making regarding treatment options. For those who felt that infertility treatments were their priority, job/employment concerns were not as important. 3. There were several sub-themes influencing health beliefs and decision-making regarding infertility treatments. Many women felt that the decision -making regarding treatment options involved both partners but some women made the decisions independently.

All the participants looked to family, friends, and coworkers for advice on treatment options and choosing a practitioner. The success of other women influenced them to consider treatment options. Those who had heard about CAM treatment options described them as being effective for treatment of infertility, increasing overall health, and having a positive impact on stress reduction and hormonal regulation. All agreed that lifestyle had a significant impact on fertility. 4. There were also several sub-themes influencing perceived barriers to CAM and decision-making regarding infertility treatments.

Barriers to CAM use related by the participants included lack of knowledge, and the practitioners’ belief in CAM. All The participants who used CAM providers strongly believed that they dealt more with the emotional and spiritual aspects of infertility. Many felt that the HCP's beliefs about CAM as well as openness of communication affected whether they would disclose their use of CAM. The importance of the length of potential effectiveness of treatment as a factor in decision making varied depending on the woman's personal situation and history.

Barriers to conventional infertility treatments included waiting times at infertility clinics. 5.

Perceived severity of side effects also varied in importance as a factor in decision making regarding infertility treatments depending on the woman's personal situation and history. 6.

Many of the women used support groups for information gathering and emotional support.

Perceived need also varied depending on the woman's personal situation and history. Need factors included maternal age, whether the woman had any children, how much the partner desired children and the success rate of the treatment being considered.


Infertility is a life altering experience for women.

Nurses and health care providers have an important role in the decision making process for treatment. It is important that health care providers keep women informed by providing accurate and reliable information on various aspects of care. Health care providers must be able to discuss CAM options, known side effects, as well as adverse reactions to help women fully understand the choices available to them. 2.

Understanding the emotional experience of the infertile women and their partners is important for nurses who often serve as emotional support for women and their partners. 3. A frequently recurring theme concerned the costs of conventional treatments for infertility and/or lack of insurance coverage. Insurance coverage for infertility varies greatly, and only 13 states have a mandate allowing for insurance coverage. This results in private insurance companies determining coverage and requiring many couples to self-pay for treatment Nurses are advocates for clients and need to speak out for equity in access to infertility care and inadequate funding on behalf of their clients. 4. Internet use for information gathering/ health information and support groups is common, yet the quality of health web sites vary. It is important that nurses and health care practitioners realize that many of today’s health care consumers are internet savvy and welcome the 24/7 availability.

Internet users need to be directed to credible sites or to classes for internet consumers, which expose consumers to reliable Web sites.

• Reducing Extended Stays in State

Psychiatric Hospitals

Sandra Howell, Ph.D., Maria Kontorinakis, M.A.,

Nancy Scotto-Rosato, Ph.D., Judith A. Lucas,

R.N., Ed.D., Rice Fuller, Ph.D., Sandra Howell-

White, Ph.D.

Presented By: Sandra Howell, Ph.D., Asst. Res.

Prof, Center for State Health Policy, Rutgers

University, 55 Commercial Avenue, 3rd Fl, New

Brunswick, NJ 08848, Phone: (732) 932-4657,

Fax: (732) 932-0069 Email: showell@ifh.rutgers.edu

Research Objective: Long stays in state psychiatric hospitals are not new, but with expanded housing and service options in the community, improved inpatient treatment modalities and administrative decisions curtailing stays, patients with severe mental illnesses are expected to have more timely discharge. A case study in New Jersey examined why individuals involuntarily hospitalized who no longer met commitment standards had lengths of stay that exceeded months and years. Clinical profiles of cases were examined as well as the policy, legal, economic, and organizational considerations that impede transitioning to the community.

Study Design: Using the state’s psychiatric hospital administrative database, a stratified random sample of short and long stay residents was identified. Each case was reviewed in interviews with the treatment teams.

Population Studied: Hospitalized and recently discharged residents of the state’s psychiatric hospitals (N=222) who met criteria for a diagnosis of schizophrenia or schizoaffective disorder and were 18 to 64 years of age were studied. All residents were no longer committable and were designated in an intermediate legal status between commitment and discharge.

Principle Findings: 26% of residents who have not meet commitment standards for one year or more are of special concern to policymakers, state administrators and advocates. While continued hospitalization is indicated on a conditional basis to protect well-being and improve functioning, opposing views see the use of an intermediate legal status as a holding pattern alleviating pressure to find appropriate outpatient housing and services. Four specific clinical groups and residents with a Megan’s Law history have lengths of stay that are 1.5 to 3.4 times as long as the population of individuals with comparable diagnoses. 15% of residents were resistant to discharge and had developed an institutional life style and disabling dependence on the hospital environment.

Beyond a lack of sufficient housing are the needed, but unavailable supports and services to manage psychiatric illnesses and medical problems of individuals in the community.

Refusals by housing providers, their rigid selection criteria and gate-keeping limit housing options. Residents with Megan’s Law history are seen as having an intractable barrier to housing.

Other bureaucratic obstacles exist for those with a comorbid diagnosis of mental retardation.

Conclusions: Delays in discharge are considerably complex and extend beyond the lack of available housing in the community and the psychiatric status of residents. The current environment of residences in the community does not fit many of the needs of specific clinical and legal subgroups of individuals with a schizophrenia spectrum disorder. A complex array of psychiatric, medical, social, financial and

organizational issues in the mental health services system contribute to extended stays.


The states, their psychiatric hospitals and outpatient mental health service system face unenviable challenges. Improving care and treatment is complicated by enormous deficits, limited resources and ongoing critical needs of the psychiatric community to provide asylum, acute and extended treatment, medical care, rehabilitation and a safety net for disadvantaged persons with a severe mental illness. Discharge decisions are based on a wide range of legal, organizational and social contingencies that require policy and practice changes.

Funding Source: NJ Department of Human

Services: Division of Mental Health Services

• The Effect of Market Competition on Real

Out-of-Pocket Premium of Medicare Managed

Care Plans

Chun-Chih Jim Huang, Ph.D., Mahmud Khan,

Ph.D.

Presented By: Chun-Chih Jim Huang, Ph.D.,

Senior Outcomes Research Associate, Outcomes

Measurement Programs, Medstar Research

Institute, 6495 New Hampshire Avenue, Ste 305,

Hyattsville, MD 20783, Phone: (301) 560-2920,

Fax: (301) 560-2974 Email: jim.huang@medstar.net

Research Objective: This study examines the factors affecting real out-of-pocket premium changes for Medicare managed care plans

(MMCs) in the United States. Specifically, the assumptions tested in the study were as follows:

(1) MMCs with higher competition in local markets tend to lower real out-of-pocket premium. (2) Competition among hospitals results in lower prices, which are passed on to purchasers in the form of lower health insurance premiums. (3) The premium level of Medigap may be positively correlated to the premium of

Medicare managed care plans.

Study Design: The prospective study was designed based on the assumption that competition and other factors in previous years affect the pricing of out-of-pocket premium and design of other benefit packages of MMCs in the new contract year. The real premium of the managed care contracts over the years was used as the dependent variable with various organizational, geographic, benefit attributes and the degree of market competition as independent variables. The analysis was conducted in three stages. At the first stage, a mixed-effect probit regression model was estimated to identify the factors explaining continuation or withdrawal of Medicare managed care contracts in a county. By selecting the sub-set of contracts that remained in the market, a second mixed-effect probit regression equation was estimated to explain whether the contract required out-of-pocket premium in the next contract year. Finally, a mixed-effect linear regression equation was estimated to explain the change in real premium over two consecutive years.

Population Studied: Contract-county level data for MMCs were obtained from various sources for the years 1999 to 2003 in the county. Private

Fee-For-Service, Program for All-Inclusive Care for the Elderly, and Health Care Prepayment

Plans were not included. Counties in Alaska and

Puerto Rico were not included, either, due to insufficient information. The sample consists of

5,618 observations and over the five years period of the study, 4,717 continued in the market.

Principle Findings: The results show that

MMCs provided by non-profit organization, with higher enrollees, higher Medicare payment rate and growth in their service counties have higher probability of continuing in the market during the next period. The analysis with contracts remaining in the market indicates that competition in the managed care insurance market tends to decrease the probability of charging out-of-pocket premium and reduce the level of premium when out-of-pocket premium is charged. Presence of one additional contract in the service area lowers the real premium by

1.73%. An inverse relationship was observed between the number of hospitals in the service county and the premium level. After controlling for the number of hospital-beds per thousand population, one extra hospital decrease real premium by 0.59%. No significant relationship was found between the premium levels of

Medicare managed care plans and supplemental fee-for-service plans in the service areas. The results also show a 1% increase in Medicare payment growth reduces the real premium by about 0.95%.

Conclusions: Three important conclusions of this study are: (1) higher degree of market competition reduce out-of-pocket premium for

Medicare managed care enrollees. (2) Higher number of hospitals in the service area creates the opportunity of selective contracting by

HMOs, which may explain the lower premium charged. (3) Premium levels of Medicare managed care plans do not affect the premium of supplemental fee-for-service plans.


To lower the cost of insurance, policy makers can encourage competition in the market for

Medicare insurance plans. Reimbursement from

Medicare can also reduce out-of-pocket premium but competitive environment is likely to be more effective in lowering the out-of-pocket expenses for Medicare beneficiaries. A number of other policy variables were also identified which affect the benefit design and premium levels of MMC plans.

• Reimbursement Program for Curbside

Consults for Medicaid Patients in North

Carolina

Charles Humble, M.S.P.H., Ph.D., Steven E.

Wegner, M.D., J.D., Alan Stiles, M.D., John

Feaganes, Dr.P.H., Lori Campbell, R.N., M.B.A.

Presented By: Charles Humble, M.S.P.H., Ph.D.,

Director, Analytic Services, AccessCare, 3500

Gateway Centre Boulevard, Ste 130, Morrisville,

NC 27517, Phone: 919-380-9962, Fax: 919-468-

8573, Email: chumble@ncaccesscare.org

Research Objective: The supply of pediatric sub-specialists to support local primary care providers caring for Medicaid clients across

North Carolina is limited and concentrated in the major medical centers. The project is designed to encourage consultation between primary care providers and these physician specialists with the goals of supporting care in patients’ medical homes and optimizing the use of patient time and provider resources.

Study Design: Pediatric Chairs participated in the development of the simple data collection form used to request reimbursement for distant consults. The Chairs then educated specialists regarding the program and encouraged them to accept ‘‘curbside consults’’ by phone or email.

Data collection was kept to a minimum at the request of participating departments, but includes the Reason for, Duration of, and Result of the consult, e.g., whether use of other services was avoided. Payments to specialists were tied to length of consult. Savings were estimated based on average costs of outpatient visits, emergency department visits and hospital admissions for Medicaid clients. We here describe early results from the program.

Population Studied: The program was implemented in the pediatric Infectious Disease clinics at each of three medical centers and in the Gastroenterology clinic at the fourth center.

Therefore, the population directly studied was comprised of the specialists in the participating clinics and the primary care physicians referring patients to them.

Principle Findings: After testing at one center, requests were collected over a 3 month period.

Sixty-seven requests for reimbursement were collected for 60 unique Medicaid enrollees.

Ages of patients ranged from 1 to 21 with a median age of 1 year. The most frequently mentioned Reason for the consult - with more than one answer allowed - was advice on a new problem (69%) although advice on an existing problem (24%) and interpretation of results

(21%) were also commonly cited. Seventy percent of consults were of brief duration (less than 15 minutes) with another 25% lasting 15 - 30 minutes. The remaining 3 calls took greater than

30 minutes to complete. There were no requests for consultation by email. Specialist-reported

Results of the consults (with more than one

Result allowed) were as follows: specialist consult avoided (54%), transfer between hospitals avoided (19%), emergency room visit avoided (10%) and hospitalization avoided

(10%). In only 15 of the 67 consults for Medicaid patients (22%) was mention made of referral for other care. Available self-reported data suggest greater than $40 saved for each dollar spent for consults. Updated results will be presented at the conference.

Conclusions: Available self-reported data suggest that curbside consults are having the desired effect of supporting primary care physicians in the medical home while obviating the need for many referral visits and avoiding costly services in the majority of cases. The program is being expanded to additional clinics and facilities.


Compensating specialists for curbside consults may lead to more patient-friendly care and more optimal use of specialist services.

Funding Source: North Carolina Foundation for

Advanced HealthCare Programs

• Drinking and Smoking Behavior among

Some University Students in Korea

Tae-Yoon Hwang, Ph.D., Jung-Jeung Lee, M.D.,

Ph.D., Pock-Soo Kang, M.D., Ph.D., Kyeong-Soo

Lee, M.D., Ph.D.

Presented By: Tae-Yoon Hwang, Ph.D.,

Assistant Professor, Department of Preventive

Medicine & Public Health, College of Medicine,

Yeungnam University, 317-1, Daemyeong-Dong,

Nam-Gu, Daegu, 705-717, KR, Phone: (53)620-

4374, Fax: (53)653-2061 Email: luke@ynu.ac.kr

Research Objective: This study examines the drinking behaviors and the relationship between drinking and smoking behaviors among some

Korean university students.

Study Design: A self-administered questionnaire survey was conducted in May, 2006 in a university in Gyeongsangbuk-Do, Korea.

Population Studied: A total of 1,163 students(715 male and 448 female) completed questionnaires, who were randomly selected

Principle Findings: The overall drinking and smoking rates for male subjects were 88.7% and

37.2%, and those for females were 83.5% and

2.2%, respectively. Among the male drinkers

39.9% smoked, while 16.0% of the male nondrinkers were smokers. As male drinkers drink more often, heavier amount per drinking episode, even on a binge, their smoking rate was high. The subjects reported there was positive reinforcement between drinking and smoking behaviors.

Conclusions: The drinking rate of students was relatively high, especially for male students drinking behavior was strongly correlated with smoking behavior.


Health promotion programs should be targeted at university students considering drinking and smoking behaviors simultaneously.

Funding Source: Yeungnam University, Korea

•

Racial and Socioeconomic Differences in

Diabetes Care Experiences

George Jackson, Ph.D., M.H.A., Morris

Weinberger, Ph.D., Natia S. Hamilton, B.A.,

David Edelman, M.D., M.H.S.

Presented By: George Jackson, Ph.D., M.H.A.,

Research Health Scientist, Center for Health

Services Research in Primary Care, Durham

Veterans Affairs Medical Center, 508 Fulton

Street (152), Durham, NC 27705, Phone: 919-286-

0411 x 7091, Fax: 919-416-5836 Email: george.l.jackson@duke.edu

Research Objective: Assess potential demographic and socioeconomic differences in the degree to which primary care Veterans Affairs

Medical Center (VAMC) patients report that experiences with the diabetes care system are consistent with the Wagner Chronic Care Model

(CCM).

Study Design: Cross-sectional mailed survey of

VAMC primary care patients with diabetes. The survey included the Patient Assessment of

Chronic Illness Care (PACIC), which measures components of the system for providing chronic illness care suggested by the CCM. Data were also collected on patient demographics, socioeconomic status, satisfaction, and health status. Multivariate logistic regression models were developed with outcome variables indicating high level of CCM concordance as measured by overall PACIC summary scores (i.e. overall fidelity to the CCM) and individual system components experienced by the patient: 1) patient activation; 2) delivery system design

(care teams)/decision support; 3) collaborative goal setting; 4) collaborative problemsolving/contextual counseling; and 5) followup/coordination. Explanatory variables included race, education level, non-VA health insurance status, income, whether the individual has a person with whom the veteran is close (proxy for social support), and whether the patient had difficulty obtaining VA benefits in the last year.

Population Studied: 296 randomly selected primary care patients with diabetes at a tertiary care VAMC received the survey. 201 surveys were returned (68% response rate).

Principle Findings: The final analyses included

176 patients: 41.5% non-white (36.9% African

American); 97.7% men; mean age 65.1; 21.6% less than high school education; 31.82% with no non-VA health insurance; 67.5% with income less than $30,000; 21.0% difficulty getting VA benefits in the last year; and 13.6% without someone to whom they feel close. Non-white veterans were more than twice as likely to indicate that their experience with the VAMC is in line with the CCM (Odds Ratio (OR) = 2.3;

95% confidence interval (CI) = 1.2-4.5). For individual components, non-white veterans were two and a half times more likely to report high levels of care follow-up (OR = 2.6; 95% CI = 1.2-

5.5). While other associations were all in the same direction, none were statistically significant. Veterans who had not completed high school were two and half times more likely to report that their experience with the VAMC is in line with the CCM (OR = 2.5; 95% CI = 1.04-

5.8). Statistically significant associations of similar magnitudes were also seen between veterans having less than a high school education and perceived care teams, collaborative goal setting, and collaborative problem solving.

Conclusions: Non-white veterans

(predominantly African American) and veterans with less than a high school education were approximately two and a half times more likely to report that the VAMC provides diabetes care suggested by the Wagner Chronic Care Model.

This includes reporting better self-management support.


There are racial and educational differences in reported chronic illness care experiences among

VA patients. Further study of potential reasons for these differences (e.g. differential expectations; intensified efforts to collaboratively address the needs of patients) will be an important part of efforts to reduce healthcare disparities.

Funding Source: VA

• Predictors of Use of Mental Illness and

Substance Abuse Treatment Services among

HIV/AIDS Patients

Yunho Jeon, Ph.D., Carleen H. Stoskopf, Sc.D.,

Jong-Deuk Baek, Ph.D.

Presented By: Yunho Jeon, Ph.D., Research

Assistant, Health Services Policy and

Management, University of South Carolina, 6

Doral Court, Columbia, SC 29229, Phone: 803-

777-2772, Fax: 803-777-1836 Email: jeon@sc.edu

Research Objective: The purpose of this study is threefold: first, to determine use of mental illness and substance abuse (MISA) treatment services; second, to investigate factors affecting access to MISA services among nationally representative sample of HIV patients with comorbid MISA problems; and third, to identify reciprocal causal associations among population characteristics, use of mental illness and substance abuse treatment services, and health related quality of life (HRQOL) as a health outcome.

Study Design: Using the three waves of HIV

Cost and Services Utilization Study (HCSUS), descriptive, bivariate, and multiple logistic regression analyses were performed to determine the association between the population characteristics and the use of MISA treatment services. To examine the causal relationship among the population characteristics, the use of MISA treatment services, and HRQOL, cross-lagged analyses with zero-inflated Poisson regression and multiple linear regression were used.

Population Studied: HIV patients with mental illness and/or substance abuse problems

Principle Findings: HIV patients with comorbid

MISA problems were more likely to use some

MISA treatment services than those with mental illness problem only or those with substance abuse problem only. In the multiple regression analyses indicated that those with higher education, more mental illness symptoms, more use of illicit drugs or alcohol, less social support were consistently more likely to visit MISA treatment services. The cross-lagged analysis showed that those with better physical health composite scores of the HRQOL were more likely visit the MISA treatment services at the follow-up, while those with worse mental health composite scores of the HRQOL were more likely visit the services at the follow-up.

Conclusions: Predisposing and enabling variables in vulnerable domains were important supplements to the traditional predisposing and enabling variables in predicting visits to MISA treatment services, and health needs of those with comorbid MISA problems were important factors in explaining the use of MISA treatment services. The use of MISA treatment services may not have a major impact on the HRQOL for

HIV patients with comorbid MISA problems at the follow-up, but the HRQOL was significantly associated with the use of MISA treatment services at the follow-up.


One of the most important things for treating people living with HIV is to detect the mental illness and substance abuse problems as soon as possible. A simple and accurate screening tool for the mental illness and substance abuse disorder is needed in the community health clinics and primary care facilities, and the efficient integration of HIV/AIDS treatment and the MISA treatment is also required.

• Importance of Nativity When Studying

Acculturation among Mexican-American

Women

Marilyn Johnson-Kozlow, M.A., Ph.D.

Presented By: Marilyn Johnson-Kozlow, M.A.,

Ph.D., Principal Investigator, Graduate School of

Public Health, San Diego State University, 9245

Sky Park Court #225, San Diego, CA 92123,

Phone: (619) 594-8827, Fax: (619) 594-0274

Email: mfjohnson@projects.sdsu.edu

Research Objective: Mexican-Americans comprise 60% of the Latino population and are the largest US minority group. Mexican-

Americans differ in acculturation and acculturation may affect healthcare disparities.

However, acculturation is a complex process and researchers (Hunt et al., 2004) have expressed concern that acculturation has not been welldefined, though measured extensively. Proxy measures of acculturation are commonly used and may include language preference,

citizenship, nativity, and length of residence.

Often defined as adopting and relinquishing certain behaviors, few measures directly determine the degree to which Mexican-

Americans engage in cultural practices or are attached to their ethnic heritage. However, the present analysis is based on these more direct measures of acculturation as well as language use, years of residency, and nativity. The objective of the current research was to investigate the relationship of nativity (US- vs.

MX-born) on various indices of acculturation.

Study Design: Secondary analysis of data obtained from the Fragile Families and the Child

Wellbeing (FFCW) Study was conducted. The

FFCW Study is ongoing and examines how policies and environments affect families and children in the US. In addition to several indirect measures of acculturation (i.e. language use), two items that more directly assessed acculturation were analyzed: (1) attachment to ethnic heritage and (2) engaging in cultural practices.

Population Studied: A population-based, national sample of Mexican-American women

(N=749) was studied.

Principle Findings: Among US-born, greater acculturation (i.e. speaking English) was associated with less attachment and engaging in cultural practices. For MX-born women, however, speaking English was associated with greater attachment and cultural practices.

Among US-born women, years living in the US had no relationship to use of the Spanish language, whereas the longer MX-born women lived in thethe more they spoke English. The effect of years spent in the US attachment to and practicing culture differed by nativity: among

US-born, greater years in the US was associated with greater cultural participation but less attachment. The opposite was observed among

MX-born women.

Conclusions: These results suggest that traditional language-based measures of acculturation differ from more direct measures of acculturation (cultural practice/attachment).

The relationship between these measures also differs as a function of nativity. Mexicans born in the US may go through a different acculturation process than those born in MX, in which years spent in the US is an important part of the acculturation process. Similar analyses should be conducted among Mexican-American men.


Acculturation of Mexican-Americans is a complex process and is likely to differ by nativity.

However, acculturation scales often include items assessing nativity, thus eliminating the possibility of analyzing the effect of nativity on acculturation processes. Longitudinal research on acculturation processes among Mexican-

Americans is limited but is needed in order to understand the processes underlying acculturation by nativity. Several indices of acculturation should be routinely collected in healthcare settings, including language use, nativity, practice of and attachment to culture, generational status, years spent in theand citizenship.


•

Identifying Opportunities to Improve

Chronic Wound Management

Katherine R Jones, R.N., Ph.D., Kristopher

Fennie, Ph.D.

Presented By: Katherine R Jones, R.N., Ph.D.,

Sarah Cole Hirsh Professor, Frances Payne

Bolton School of Nursing, Case Western Reserve

University, 10900 Euclid Avenue, Cleveland, OH

44106-4904, Phone: (216) 368-5979, Fax: (216)

368-3542 Email: katherine.jones@case.edu

Research Objective: Chronic wounds affect millions of people in the U.S., and are a particular problem for the elderly. Non-healing or slow healing wounds represent a major health burden and drain on resources. Although evidence-based clinical practice guidelines and systematic reviews are available to guide treatment decisions, healing rates have not improved. It is therefore essential to determine the clinical, organizational, and policy variables that should be addressed to improve overall healing rates.

Study Design: We conducted a retrospective review of closed medical records at 4 sites using a structured data abstraction tool and protocol.

Data categories included demographics, clinical and risk factors, wound and treatment characteristics, and outcomes. Descriptive and multivariate analyses were conducted.

Population Studied: The sample consisted of

400 subjects with at least one chronic ulcer.

Mean age was 72.7 years,60.6% were white,

56.5% were female, and 34.7% were married.

There were 114 pressure, 103 diabetic and 183 venous ulcers.

Principle Findings: There was varied adherence to guideline recommendations. More than 90% of subjects had documentation of ulcer size, location, exudate and necrosis, but few had documentation of edges, edema, shape, or epithelialization. Fewer than 50% had a moisture

management dressing or received nutritional support for malnourishment. Exudate was managed inappropriately more than 50% of the time, while debridement was performed appropriately just over half the time. Medicaid insurance was associated with nonhealing wounds. Care delivery processes varied widely across sites in terms of frequency of visits, order writing responsibility, and extent of documentation.

Conclusions: Many patient, clinical and organizational factors appear to be influencing wound healing outcomes. The extent to which clinician knowledge gaps, patient compliance, reimbursement policy, limited inventory, and care organization contribute to nonhealing or delayed healing needs further exploration.


Chronic wound healing could be improved, with resulting cost savings and improved patient quality of life, by bringing current wound care practices more in line with evidence-based practice recommendations.

Funding Source: BMS/ConvaTec

•

EHR-Based Physician Alerts Increase

Uptake of an E-Health Intervention for

Chronically-Ill Patients

J.B. Jones, M.B.A., Nirav R. Shah, M.D., M.P.H.,

Zahra Daar, M.S., Steve Schwartz, Ph.D., Walter

F. Stewart, Ph.D., M.P.H.

Presented By: J.B. Jones, M.B.A., Research

Associate, Geisinger Center for Health Research,

100 N. Academy Avenue, M.C. 30-03, Danville,

PA 17837, Phone: (570) 214-9322, Fax: (570) 214-

9451 Email: jbjones@geisinger.edu

Research Objective: A limitation of many ehealth interventions is that patient uptake is typically very low, in the range of 2%-5%. We describe the impact of several different strategies designed to motivate use of an e-health intervention among patients with chronic disease. Our objective was to determine whether an enrollment model in which the physician

‘‘prescribes’’ an e-health intervention would be more effective than traditional approaches to patient enrollment.

Study Design: 1,593 users of an electronic patient portal were invited to participate in a web-based self-management program. Patients were initially invited by a letter mailed to their home from the director of the clinic (not necessarily their primary care physician) where they obtain their primary care. The program was an interactive website designed to improve chronic disease self-management. We conducted a telephone survey of 30 patients to identify reasons for their non-enrollment; we subsequently designed an e-health ‘‘prescribing’’ program involving letters and emails sent to patients from their primary care physician (PCP) approximately every 2 weeks. In the first phase of the prescribing program, patients received 2 letters and 2 emails directly from their PCP. In the second phase of the prescribing program, patients received 2 additional letters and emails from their PCP and were offered a gift card as an enrollment incentive. Concurrent with the PCP communications, we developed an electronic health record (EHR) alert designed to encourage physicians to discuss the intervention with their patients during the course of an ambulatory encounter. A time-to-event model was used to assess the response (enrollment) rate associated with each series of communications.

Population Studied: E-portal users who had a diagnosis of diabetes, cardiovascular disease, or heart failure and who had a primary care physician in one of the Geisinger Clinic´s 41 community practice sites.

Principle Findings: The initial series of two letters and two emails from the clinic director resulted in an 11.6% response rate. Enrollment tapered dramatically after the final email and failed to increase in the absence of further communication. There was an additional 5.8% response to the initial series of PCP letters and emails. The second series of PCP letters and emails/gift cards resulted in an additional 6.1% response. Notably, all response curves were similar in shape, although the PCP letter with gift card produced a more rapid response than the

PCP letter alone. While a majority of physicians did not respond to the EHR-based alert, enrollment increased more than three-fold

(hazard ratio: 3.7, 95% CI 1.8-7.7) among patients whose physician discussed the intervention with the patient after receiving and acknowledging the alert.

Conclusions: Physician involvement in

‘‘prescribing’’ an e-health intervention is associated with a significant increase in patient adoption thereof. Our results also indicate that patients initially identified as non-responsive can be motivated to enroll in an intervention through the use of low-intensity but regular communication.


Given the potential for health benefits, we should move beyond the ‘‘junk mail’’ model typically used to encourage e-health participation and use a ‘‘prescribing’’ model which leverages existing

doctor-patient communication behaviors and is tailored to a patient’s needs and motivations.

Funding Source: RWJF, AHRQ

•

The Cost of Improving Health Related

Quality Life Through School-Based Health

Centers

Kathryn Keller, M.P.A., Terrance J. Wade, Ph.D.

Presented By: Kathryn Keller, M.P.A., Program

Officer, Program, The Health Foundation of

Greater Cincinnati, 3805 Edwards Road, Suite

500, Cincinnati, OH 45209, Phone: 513-458-6616,

Fax: Email: kkeller@healthfoundation.org

Research Objective: to determine the incremental cost of improving the health related quality of life of students that use a school-based health center

Study Design: Data collected in two longitudinal studies will be merged. The first measuring the health-related quality of life of students that use a school-based health center. The second measures the Medicaid expenses of Medicaid students that had access to a school-based health center.

Population Studied: Ohio students in grades K-

8.

Principle Findings: The analysis is still underway with findings due in March. Expected results will show the incremental cost to

Medicaid to increase the health-related quality of life of students that use a school-based health center. The results will include students in the general population, as well as students with asthma and mental health issues.

Conclusions: Students that use school-based health centers have improved health-related quality of life. However, Medicaid expenses and savings vary depending on health condition and services provided. The analysis will explore the cost for improving the health status of students that utilize a school-based health center.


School-based health centers provide comprehensive services and cannot sustain on service revenue. This analysis looks at the costs associated with increasing health status.

Understanding the costs associated with increasing health status can help policymakers determine their investment in sustaining schoolbased health centers.

Funding Source: The Health Foundation of

Greater Cincinnati

• Feasibility of a Feedback Initiative for

Facilitating Patient Engagement and

Physician-Patient Communications

Donna Kerney, Ph.D., Paul LeVine, M.P.H.

Presented By: Donna Kerney, Ph.D., Director,

Analytic Services, InfoMedics, Inc., 12 Gill Street,

Suite 2600, Woburn, MA 01801, Phone: 781-904-

4516, Fax: 781-938-5303 Email: dkerney@infomedics.com

Research Objective: This research was conducted to evaluate the extent to which a feedback initiative could be used to facilitate patient engagement in their care and foster positive, constructive dialogue between patients and physicians.

Study Design: Three different programs designed to allow patients to provide physicians with feedback about their experiences taking a prescription medication for a gastrointestinal condition, an ocular condition, and a neurological condition were implemented. In each program patients with that condition voluntarily completed surveys about their symptoms, the impact of symptoms on activities, and their satisfaction with their medications. Patients were also asked about their motivation for participating in the surveys and their interest in similar initiatives in the future. Surveys were completed via an automated telephone system. Upon a patient’s completion of the surveys, a report summarizing the individual patient’s responses to the condition-specific, clinically relevant questions was sent to the prescribing physician. In this analysis, survey responses from all patients are aggregated and reported.

Population Studied: Patients participating in one of three different patient-feedback programs.

Principle Findings: Data from 1,783 patients who participated in one of three programs for a gastrointestinal (51%), ocular (37%) or neurological condition (11%) were summarized.

While the specific questions asked of patients varied depending upon their individual conditions, the subject areas were quite similar and focused on symptoms and the degree of symptom relief provided by the medication.

Participants in the GI program reported reductions in symptom severity of at least 47% across all symptoms reported. Those in the ocular program reported an average score of 7.6

(on a scale of 0-10, where 0 is ineffective and 10 is very effective) in the effectiveness of the medication at relieving their eye symptoms

Seventy-seven percent of patients using the

neurological medication reported that they had

‘‘much better control’’ of their condition. Two additional questions were asked of all patients across all of these programs. Seventy-two percent of patients indicated that they chose to participate in the surveys either because they wanted to give their physician information (47%) or because their physician asked them to participate (25%). Similarly, patients demonstrated their considerable interest in these types of initiatives as indicated by the 82% of patients who indicated a willingness to be contacted in the future about similar initiatives.

Conclusions: Feedback from patients to physicians outside the office setting, in the form of a brief summary report, can provide valuable input to the physician about patients’ perceptions of treatment that otherwise may have been missed. The data can open points for discussion between physicians and patients, allowing the identification of areas of progress and those in need of improvement.

Implications for Policy, Practice or Delivery: A straightforward survey tool and feedback system is a feasible and well-received means for facilitating constructive dialogue between patients and physicians.

• Racial/Ethnic Differences in Patient

Functioning when Friends/Family are

Involved in Involuntary Psychiatric Emergency

Admissions

Eric Kessell, M.P.H., George J. Unick, M.S.W.,

M.A., Ph.D., Richard Patel, M.D., Martha

Shumway, Ph.D.

Presented By: Eric Kessell, M.P.H., Healthcare

Research Fellow, Palo Alto Medical Foundation

Research Institute, 795 El Camino Real, Palo

Alto, CA 94301, Phone: 650-853-4763, Fax: 309-

423-4789 Email: kesselle@pamfri.org

Research Objective: Persistent racial/ethnic disparities have been observed in the utilization of psychiatric emergency services (PES), and PES use is one indicator of failure in the public mental health system. This project explored racial/ethnic differences in factors related to psychosocial functioning in the events leading to

PES admissions.

Study Design: A retrospective, observational review of medical records and legal documents.

Study staff abstracted records from involuntary admissions to San Francisco’s public psychiatric emergency department from Jan 1, 2005 to

March 30, 2005. Chart data were used to calibrate Global Assessment Scale (GAS) scores.

GAS scores were predicted with multivariate regression; explanatory variables included gender, substance use, homelessness, racial/ethnic group (Asian, Black, Latino, White and other), friend/family involvement, and interactions between racial/ethnic group and friend/family involvement.

Population Studied: Admissions of patients to a public psychiatric emergency room in San

Francisco, CA.

Principle Findings: Among persons involuntarily admitted to PES, mean GAS scores were significantly lower for Black patients

(p<0.01) and Asian patients (p<0.01) than for white patients. Friend/family involvement was associated with higher GAS scores for white patients, but this effect was not observed for

Black patients (p<0.01).

Black patients had friend/family involvement in

26.4% (52/197) of admissions, which was not significantly different from admissions of white patients (27.4% (89/324)). Friend/family involvement was observed in significantly more admissions of Asian and Latino patients (Asian:

55.4% (62/112); Latino/a: 46.4% (39/84)) than of white patients.

Conclusions: Black and Asian patients tend to be admitted to PES at lower levels of psychosocial functioning than are white patients.

Having friends or family members involved with admission is associated with higher functioning for white patients, but for Black patients this effect was not observed. Admissions of Asian and Latino/a patients, but not Black patients, more frequently involve friends/family than do admissions of white patients.


Results suggest that, for Asian and Black patients, friends and family members may delay seeking emergency treatment until illness reaches greater severity. This suggests a greater burden of care on these patients’ families. Asian and Latino patients’ greater family involvement in admissions may suggest that broader support networks can be called upon following psychiatric crises. However, the treatment delay suggested by these analyses may warrant targeted efforts to increase friend/family integration into the public mental health system and to encourage earlier treatment for patients of color.

Funding Source: San Francisco Mental Health

Board

• Applying Human Factors Research to

Improve Operating Room Safety

Aileen Killen, Ph.D., R.N., David Jaques, M.D.,

Jennifer Edwards, Dr.P.H.

Presented By: Aileen Killen, Ph.D., R.N.,

Director, Perioperative Nursing, Nursing and

Patient Safety, Memorial Sloan Kettering Cancer

Center, 1275 York Avenue, New York, NY 10021,

Phone: 212-639-5929, Email: killena@mskcc.org

Research Objective: In May 2006, the authors' hospital opened a state of the art surgical suite, designed in both form (ergonomics) and function (human factors) to maximize patient and staff safety. Coinciding with the opening, all

OR staff received Human Factors training based on Crew Resource Management Techniques adapted from the aviation industry. The training emphasized teamwork and communication with the goals of promoting culture change, reducing hierarchical behaviors, and addressing interdisciplinary differences. A new technology called the Wall of Knowledge was implemented in each OR to improve situational awareness ---- ie, patient information and team members’ names were made visible to all members of the team. Prompts for briefings and debriefings were displayed. This poster will present work done to understand the successes and barriers to improving safety and culture. The hospital is also participating in a five site Human Factors

Demonstration Project and is conducting common baseline measurement with the other sites, each of whom is implementing related changes.

Study Design: Prior to the opening of the new

ORs and the commencement of Human Factors

Training, 237 members of the OR staff were asked to report their views on safety and teamwork in the OR, using the AHRQ Hospital

Survey of Patient Safety Culture. (Similar data collected at the other four institutions is not part of this poster.) Focus groups were conducted to probe more deeply into the results. Data are being used to motivate change and monitor improvement.

Population Studied: Surgeons, anesthesiologists, and nurses working at one major teaching and research hospital (n=237).

Identifying information allows comparison of responses by discipline, surgical team, and tenure.

Principle Findings: Baseline data show that surgeons, anesthesiologists, and nurses perceive that the safety is good in the OR and that staff support each other, but that several aspects of safety and teamwork should be improved.

Challenges of communication across disciplines, inconsistency in teamwork, and fear of repercussions were especially notable findings.

Results vary widely by discipline and by surgical team. Consistent with the literature, nurses experience less teamwork and have greater safety concerns than surgeons. Focus groups allowed exploration of possible solutions to these problems, and further changes are planned for this winter and spring.

Conclusions: The need for technology and training to improve safety and teamwork was borne out in baseline survey data. Since opening the new surgical suite, the work of the hospital has focused on improving coordination, cooperation, awareness, and communication.

There have been some successes and some barriers to complete implementation of the desired behaviors. Lessons learned and next steps will be shared.


Efforts to improve patient safety in the OR must consider differences between disciplines and set targets for measurable system changes to assure goals are met. Technology can facilitate teams achieving a safer environment, but organizational barriers must also be addressed.

Funding Source: Kimberly-Clark Health Care,

Safer Healthcare, and internal funding.

• Association Between Obesity and Attitudes,

Awareness and Knowledge Regarding Diet among Minority, Low-Income Parents

Tae Hyun Kim, Ph.D., EUN A HAN, Ph.D.

Presented By: Tae Hyun Kim, Ph.D., Assistant

Professor, Department of Health Administration,

Governors State University, 1 University Parkway,

University Park, IL 60466, Phone: (708)534-4033,

Email: t-kim@govst.edu

Research Objective: It is known that there has been a dramatic increase in obesity in the United

States. While obesity is increasing in both genders and among all population groups, several studies suggest that disparity in the prevalence of obesity exits. In order to provide the opportunity for actions and interventions designed for prevention and treatment of the disproportionate burden of obesity in minority, low-income populations, it is vital to assess the factors contributing to the disparities in obesity.

This study examines the association between obesity and attitudes, awareness and knowledge regarding diet among minority, low-income parents in an attempt to explain how these factors might affect the diets of their children.

Study Design: For this study, low-income is defined as at or below 185 percent of the Federal poverty thresholds since it is the cutoff for some government-sponsored food assistance programs. The primary data sources used for this study include the USDA’s 1994-96

Continuing Survey of Food Intakes by Individuals

(CSFII) and 1994-96 Diet and Health Knowledge

Survey (DHKS) which provide socioeconomic, demographic, health-related, and dietary intake data on households and their members, and information regarding diet and health attitudes, awareness, and knowledge. Obesity is defined as the condition of being very overweight and having a body mass index (BMI) of 30 or higher, based on self-assessed height and weight.

Attitudes, awareness and knowledge regarding diet are measured by perceived importance of dietary guidance, diet-health perceptions, and nutrient composition knowledge of the main meal planner in the household. A multivariate analysis, a combination of analysis of covariance

(ANCOVA) and least- squares means comparisons, are used to test the effect of obesity on each dependent variable (attitudes, awareness and knowledge scores) while adjusting for control variables.

Population Studied: U.S. Department of

Agriculture (USDA) obtains data on nutritional status and food intakes from a nationally representative households, including low-income households, in the United States. The sample for this study consists of low-income parents who participated in the USDA’s Food Surveys.

Principle Findings: The study will test if minority, low-income parents who are obese are less aware of diet-obesity relationships and are less likely to place importance on including nutrients and other dietary components needed for health in their diets.

Conclusions: The results of this study will support that a better understanding of parents’ diet and health attitudes, awareness, and knowledge is an important preliminary step in preventing and decreasing overweight and obesity in their children.


The results of this study will provide potential policy implications for developing programs that are designed to encourage positive health behavior changes to prevent obesity in minority, low-income parents and thus lead to positive nutrition benefits for their children.

• Organizational Culture, Job Satisfaction, and Turnover Intention among Nurses in

Korean Public Hospitals

Tae Hyun Kim, Ph.D., Tae Hyun Kim, Ph.D.





Fax: Email: t-kim@govst.edu

Research Objective: Nurses play an important role in providing quality care to patients and improving the performance of hospitals. It is important to identify key factors that might help keep nurses satisfied and improve their retention rates. The purpose of the study was to examine the relationship among organizational culture, job satisfaction, and turnover intention among nurses in public hospitals in Korea.

Study Design: Four types of hospital culture

(consensual, rational, developmental, and hierarchical) were assessed using an instrument developed originally for a Competing Values

Model (Quinn & McGrath, 1985). Job satisfaction was measured based on Tymon

(1988)’s study. Structural Equation Modeling

(SEM) was used to analyze the relationship among organizational culture, job satisfaction, and turnover intention.

Population Studied: Registered nurses employed in public hospitals located in Seoul and Kyounggi metropolitan area were chosen as the study population. An initial pilot survey was conducted in June 2005 and the revised self administered questionnaires were distributed during June and July 2005. The sample for this study consists of 527 nurses after excluding 33 participants because of missing data on key study variables.

Principle Findings: Overall, organizational culture appeared to be significantly associated with job satisfaction and turnover intention of nurses working in public hospitals. Specifically, consensual culture and rational culture were positively associated with job satisfaction. Unlike previous studies, however, rational culture exhibits a stronger influence on job satisfaction than consensual culture. In addition, structural equation model found that organizational culture had both direct influence on turnover intention and indirect influence through job satisfaction.

Conclusions: Findings provide evidence for the notion that organizational culture is significantly associated with job satisfaction and subsequent turnover intention of hospital nurses.


Management should address the importance of any preventive approach that promotes task oriented and human related climate in the work settings to improve job satisfaction of nurses and to reduce the likelihood of their turnover.

• Leadership Styles and Hospital Employees’

Job Satisfaction and Turnover Intention in

Korea

Tae Hyun Kim, Ph.D., Tae Hyun Kim, Ph.D.





Email: t-kim@govst.edu

Research Objective: As noted in the general industry, the leadership of CEO is expected to be important for the performance of hospitals.

Previous studies also suggest that CEO leadership characteristics may have effects on the extent of employees' job satisfaction and turnover intention. However, little research related to this subject has been done in hospital settings in Korea. This study explored the relationship between the leadership styles of hospital CEOs and employees’ job satisfaction and turnover intention in general hospitals.

Study Design: The relationship of hospital CEO leadership style to employees' job satisfaction was examined based on the Bass's (1985) leadership paradigm of transformational and transactional leadership. The Multifactor

Leadership Questionnaire (MLQ Form-5) was modified and used to measure the leadership styles of hospital CEOs. Transformational leadership measures included charisma, individual consideration, and intellectual stimulation. Transactional leadership measures were constructed by contingent reward and management by exception. Job satisfaction index was developed following Tymon (1988)’s study.

Three hypotheses were tested using multiple regression analysis.

Population Studied: Employees including staff physicians, nurses, administrators, technologists, and assistants in public hospitals were chosen as the study population. An initial pilot survey was administered in September

2005 and the revised self administered questionnaires were distributed and collected during September and October 2005. A total of

493 hospital employees agreed to participate in the survey and completed the questionnaires.

Principle Findings: Overall, the findings of this study were consistent with previous studies.

Measures of CEO leadership showed significant relationships with measures of employees’ job satisfaction and turnover intention.

Transformational leadership of hospital CEOs showed stronger and more positive relationships with the job satisfaction measures of their staffs than did the transactional style, while it showed a negative relationship with turnover intention.

Among the measures of transformational leadership, charisma showed most significant relationships with both job satisfaction and turnover intention.

Conclusions: Study results suggest that transformational leadership from hospital CEOs improves the job satisfaction of employees and reduce their turnover intention. Further, results indicate that CEOs with charisma may be most effective in improving subordinate employees’ job satisfaction and retention.


The findings of this study provide implications for hospital management. The implications provide insight into CEO's desirable role and for developing a strategy that can be implemented in hospital settings.

• Access Barriers for the Low-Income Elderly:

The Impact of Medicaid Prescription Drug

Utilization Management Policies on

Medication Nonadherence

Michelle Kitchman, M.H.S., Jeanne Lambrew,

Ph.D., Sara Rosenbaum, J.D., Robert Hirsch,

Ph.D., Jeff Crowley, M.P.H., Dana Gelb Safran,

Sc.D.

Presented By: Michelle Kitchman, M.H.S.,

Principal Policy Analyst, Medicare Policy Project,

Henry J. Kaiser Family Foundation, 1330 G Street,

NW, Washington, DC 20005, Phone: (202) 347-

5270, Fax: (202) 347-5274 Email: mkitchman@kff.org

Research Objective: The purpose of this research study is to examine the influence of drug utilization management policies on the likelihood of drug access problems among the low-income, insured elderly.

Study Design: Using a cross-sectional design, this study uses data from the 2003

Kaiser/Commonwealth/Tufts-New England

Medical Center National Survey of Seniors and

Prescription Drugs to assess the impact of prescription utilization management policies on access to medications for the low-income insured elderly population. Specifically, the

study examines the direct and interactive effects of 6 commonly used strategies to manage drug utilization and thereby contain drug spending: preferred drug lists, prior authorization for brand drugs, mandatory generic substitution, steptherapy, drug quantity limits, and cost-sharing.

The study also examines whether those exposed to a higher number of utilization management policies have a greater likelihood of drug access problems compared to those exposed to fewer policies. Drug access is measured using the following self-reported prescription drug nonadherence behaviors: not filling a prescription one or more times due to cost; skipping or taking smaller doses of prescribed medications to make them last longer; and a composite measure which captures any of the aforementioned behaviors.

Population Studied: The target population for this study is the non-institutionalized lowincome elderly with prescription drug coverage.

The analytic sample includes individuals who meet the following criteria:

Ages 65 and older as of May 2003 (when the survey was fielded); live in the community and have incomes less than 200% of the 2003 federal poverty level; have drug coverage thru

Medicaid; and take at least one prescription medication regularly. There are 2,379 survey respondents who met the criteria for inclusion in the study sample.

Principle Findings: Preliminary findings suggest that: specific utilization management policies such as preferred durg lists and prior authorization for brand drugs impact patients' ability to access needed medications; the interactions between certain utilization management policies may lead to greater access problems; the effect of utilization management policies on access varies depending on the nonadherence behavior examined; and the number of policies to which insured seniors are exposed does not predict problems in accessing needed medications.

Conclusions: Specific drug utilization management strategies, independently and in combination, appear to reduce access to prescription medications among the low-income elderly and serve as better predictors of patient drug non-adherence than the number of drug utilization management policies present.

Strategies to contain drug spending should be designed and monitored with particular attention to how they will affect vulnerable populations, especially the low-income elderly whose disproportionately high medical needs and severly limited resources put them at risk of drug access problems.


This research helps to further understanding of key factors related to benefit design that may affect access to prescription drugs and potentially other needed health care services for the low-income aged. Lessons from the

Medicaid experience about how this population is affected by such strategies have important immediate policy implications for Medicare, especially because data about dual eligibles' access experiences under the Medicare drug benefit are not likely to be available for some time. This study provides a baseline for policymakers and others to gauge how well the

Medicare drug benefit addresses issues of drug access and affordability for aged dual eligibles and offers potential lessons for designing a meaningful drug benefit that promotes rather than hinders access to needed medications.

• Federal Healthcare for American Indian and

Alaska Native Women Veterans

Josea Kramer, Ph.D, Stella Sarkisyan, M.S.W.,

M.P.H., Judith Harker, Ph.D., Elizabeth Yano,

Ph.D., M.S.P.H., Donna Washington, M.D.,

M.P.H.

Presented By: Josea Kramer, Ph.D, GRECC

Assoc. Director of Education, Geriatric Research,

Education and Clinical Center, Veterans Affairs,

16111 Plummer Street (11E), North Hills, CA

91343, Phone: (818)895-9311, Fax: (818)895-9519

Email: Josea.Kramer@med.va.gov

Research Objective: This study describes characteristics and utilization patterns of

American Indian and Alaska Native- AIAN- women to contribute to interagency planning for resource coordination between the Veteran’s

Health Administration ----VHA-and Indian Health

Service ----IHS-, which have executed a

Memorandum of Understanding to share resources.

Study Design: We identified women in the first systematic study of use of VHA and or IHS by

American Indian and Alaska Native -AIAN- veterans, conducting bivariate analysis of linked and merged centralized administrative data from

VHA National Patient Care Database and IHS

National Patient Information Reporting System for FY02 and FY03.

Population Studied: Female IHS-enrollees who were eligible and accessed services in VHA and or IHS.

Principle Findings: AIAN women represented 9

Percent -n equals 5,856-of the total AIAN population identified ----n equals 64,746-, exceeding the expected rate. The population had a mean age of 44-plus or minus 3- years, more than 150,000 encounters and more than 1,600 hospital discharges. Like all VHA veterans, hypertension -28 Percent- and diabetes -23

Percent- were the most frequently diagnosed outpatient diseases. Like other women veterans, rates for depression -24 Percent- and anxiety disorders -21 Percent- were higher than their male counterparts but substance abuse -8

Percent- and PTSD -5 Percent- were lower. Three user groups emerged: dual users -40 Percent-,

IHS-only users -36 Percent- and VHA-only users -

24 Percent-. Two-thirds of dual users were nonveterans who received care at the VHA mainly through sharing agreements -65 Percent- or as employees -21 Percent-. Types of care accessed varied by user group. VHA-only users were more likely to be treated for behavioral and mental health conditions -e.g., alcohol dependence, schizophrenia- than dual users or IHS-only users. Dual users were more likely to access diagnostic and mental health clinics in VHA and primary care in IHS. However, dual users were treated for some key conditions in both VHA and

IHS settings, including bipolar disorders, diabetes without complications, lung cancer, hip fracture and hypertension. AIAN women who received care in any VHA outpatient setting were as likely as other female veterans to be treated in a women’s clinic. Hospital discharges reflected organizational resources, with IHS-only users top discharge diagnosis related to pregnancy and child-birth.

Conclusions: AIAN women veterans have similar healthcare needs as other veterans. VHA is an important resource for providing mental health care and diagnostic services and IHS is an important resource for primary care and obstetrics. There is some overlap with dualusers.


VHA already provides care to about half the population of IHS-enrolled female veterans.

Expanding VHA care to other eligible female

AIAN veterans would not require new types of services. However, increasing the potential for dual use would require coordination of care as well as resources to avoid unnecessary duplication or fragmentation of care. At least ad hoc coordination of resources for dual users already occurs. Since the majority of these dual users are non-veterans, VHA planning should include the opportunity to expand beyond the basic mission of services to veterans to include revenue generating sharing agreements where capacity exists.

Funding Source: VA

• Financial and Nonfinancial Barriers to

Health Care for Uninsured Adults

Jeffrey Kullgren, M.D., M.P.H., Catherine

McLaughlin, Ph.D.

Presented By: Jeffrey Kullgren, M.D., M.P.H.,

Resident in Internal Medicine, Department of

Medicine, Brigham and Women's Hospital, 75

Francis Street, Boston, MA 02115, Phone: 517-

214-7366, Fax: 617-264-6346 Email: jkullgren@partners.org

Research Objective: Most policy proposals to improve access to care for the uninsured exclusively target financial barriers. Access to care, however, is a multifaceted concept, and it is not known to what degree the uninsured experience nonfinancial barriers to health care.

This study examines the extent to which both financial and nonfinancial barriers limit access in a geographically and ethnically diverse sample of low-income uninsured adults.

Study Design: Date come from a multi-site telephone survey conducted between August

2001 and August 2002. Respondents with health care utilization in the 12 months prior to time of survey were classified as having access problems if they reported no usual source of care, or unmet medical, surgical, or prescription drug needs. Respondents without utilization in the previous 12 months who reported using no health care for reasons other than being seldom or never sick, or who reported unmet medical, surgical, or prescription drug needs, were also classified as having access problems. Reasons for each access problem were elicited from each respondent. Reasons given were classified as relating to one of the 5 dimensions (affordability, accommodation, accessibility, acceptability, and availability) in the Penchansky and Thomas framework of access to care. For each dimension of access, multiple logistic regressions were conducted to identify associations between experiencing at least one barrier related to that particular dimension and a series of individual predisposing, enabling, and need factors.

Population Studied: 1,118 low-income uninsured adults enrolled in 3 different community-based access programs, located in one large rural area and two urban areas.

Principle Findings: Fifty-two percent of all respondents reported some kind of access problem in the previous 12 months. Affordability barriers most commonly limited access, but 26% of all respondents reported at least one nonaffordability barrier, and 48% of respondents with at least one affordability barrier also reported a non-affordability barrier. Of all nonaffordability barriers, problems related to the availability of care were slightly more common than problems with accommodation, accessibility, and acceptability. Being uninsured for the entire previous year was associated with having at least one affordability barrier and having at least one availability barrier. Chronic illness was associated with having at least one accessibility barrier, at least one accommodation barrier, and at least one affordability barrier.

Being male, an immigrant, chronically ill, or uninsured for the entire previous year were all independently associated with having at least one non-affordability barrier.

Conclusions: Financial problems most often limited access to care in our sample of lowincome uninsured adults, but nonfinancial barriers were common and more frequently limited access in certain subgroups.


We find that low-income uninsured adults who have difficulty accessing needed health care services experience multiple barriers across multiple dimensions of access. While replication of our findings in other populations is needed, our results suggest that policy initiatives targeting only financial barriers will be unlikely to fully remedy disparities in access and outcomes based on insurance status.


• Prescription Opiate Deaths among Older

Adults in Los Angeles County, 2000-2004:

Implications for Health Policy and Planning

Tony Kuo, M.D., M.S.H.S., Kathryn Martin,

M.P.H., Parinaz Lajevardi, B.S., Paul Simon,

M.D., M.P.H.

Presented By: Tony Kuo, M.D., M.S.H.S.,

Director, Office of Senior Health, Public Health,

County of Los Angeles, 3530 Wilshire Boulevard,

Ste. 800, Los Angeles, CA 90010, Phone: 213-351-

7341, Fax: 213-351-2713

Email: tkuo@ph.lacounty.gov

Research Objective: To examine the prevalence and characteristics of, and methods for identifying fatal poisonings due to the use of prescription opiates among older adults in a large, diverse urban population.

Study Design: We conducted a retrospective case review of fatal poisonings among older adults using standardized case definitions and death certificates matched to Coroner’s records for the period 2000-2004. Two trained independent reviewers distinguished between deaths caused by prescription opiates, heroin, and other substances, such as cocaine, sedatives, and antidepressants by standardized review of death certificates, Coroner’s investigator reports, and toxicology results.

Cases of death caused by prescription opiates and those caused by other substances were compared on socio-demographics, co-morbid health conditions, circumstances surrounding the fatal incident, and toxicology data using crude frequency tables and stratified analyses.

Trends were identified from age-adjusted mortality rates.

Population Studied: All cases of unintentional, suicide and undetermined poisonings for 2000-

2004 in Los Angeles County among residents ages 55 and older (n = 510).

Principle Findings: The 510 cases in the study group were on average 64 years of age at the time of death; 64% male; 48% non-Hispanic

White, 13% Hispanic, 16% Black, 3% Asian or other race categories; 63% single, divorced or widowed; and 47% who died at home. Of the 510 cases in the study group, 13% were caused by prescription opiates, 24% by heroin, 13% by cocaine, 4% by alcohol, 1% by amphetamines,

32% by other prescription or over-the-counter medications, and 13% were due to other poisonings such as cyanide and carbon monoxide. Although prescription opiates did not account for the greatest number of deaths in the study group, the age-adjusted mortality rates for this drug category demonstrated an increase of 168% from 0.42 per 100,000 residents in

2000 to 1.12 per 100,000 residents in 2004.

Although there were also increases in the ageadjusted death rates for cases due to other drugcategories (e.g., other prescription drugs, cocaine, and alcohol), changes in these rates were not as dramatic or consistent as the change in the prescription opiate age-adjusted death rate.

Conclusions: Matching death certificates to

Coroner’s records and toxicology reports enabled us to determine that deaths due to prescription opiates, although small in number, increased substantially in Los Angeles County from 2000 to 2004 among older adults. Our use of multiple data sources and a standardized

protocol for describing prescription opiate mortality is a potentially underutilized method for monitoring prescription drug-related deaths, as these data are generally not available from vital statistics alone.


Concerns about potential addiction to prescription opiates and rising prevalence of chronic pain syndromes among older adults in the United States highlight the importance of monitoring prescription opiate misuse. Better surveillance and response to prescription opiate morbidity and mortality will be critical for informing local health officials, policymakers, and healthcare providers about this growing problem in the aging population.

• Does State Medicaid Policy to Increase

Nursing Home Staffing Results in more

Restorative Care?

Alexandre Laberge, M.B.A., Bsc, P.T., Dr Robert

Weech-Maldonado, M.B.A., Ph.D., Dr Kathy

Hyers, Ph.D., Dr Zhou Yang, Ph.D.

Presented By: Alexandre Laberge, M.B.A., Bsc,

P.T., Student, Department of Health Services

Research, Policy and Management, University of

Florida, 3725 NW 110th Terrace, Gainesville, FL

32606, Phone: (352) 333 0784, Fax: Email: laberger5@comcast.net

Research Objective: Florida’s Medicaid used financial incentives and staffing mandates to increase direct patient care staffing in nursing homes during 2000 to 2002. This study examines whether the change in Florida’s

Medicaid policy increased nursing home staffing and whether that change increased restorative ambulation care. Restorative ambulation care helps maintain residents’ highest level of functional mobility and it is an important process of nursing home quality.

Study Design: The study is a retrospective observational cohort study that used facility level data from the 1999 and 2002 from the Minimum

Data Set (MDS) and the Online Survey

Certification and Reporting (OSCAR). A difference-in-differences model is used to assess the impact of the change in Florida’s Medicaid policy on nursing home quality of care. In the first stage, we examine the relationship between the change in Florida’s Medicaid policy and nurse staffing ratios. Nursing homes in

Pennsylvania are used as the control group, since there were no major changes in

Pennsylvania’s Medicaid policy affecting nursing home staffing between 1999 and 2002. The dependent variables for the first stage consist of

Certified Nursing Assistant (CNA), Licensed

Nurse Practitioner (LPN) and Registered Nurse

(RN) hours per patient day. The independent variables consist of dummy variables for the state of Florida and the year 2002, and a

Florida/year 2002 interaction variable. In the second stage, we analyze the relationship of nursing home staffing changes on restorative ambulation care. The dependent variable consists of the change in the mean number of days per week of restorative ambulation care between 1999 and 2002. The independent variables consist of the change in CNA, LPN and

RN hours per patient day between 1999 and

2002. The control variables for both stages consist of payer mix, ownership, system membership and mobility case mix.

Population Studied: All of the Florida and

Pennsylvania nursing homes certified by the

Center for Medicaid and Medicare (CMS) in

1999 and 2002 were included in the study.

Principle Findings: The study found that CNA staffing increased significantly by 0.33 hours per patient per day (p<0.001) and that RN staffing decreased by 0.07 hours per patient per day

(p<0.01) in Florida after the policy change.

However, the amount of restorative ambulation provided was not influenced by CNA, LPN or RN staffing changes.

Conclusions: Changes in Florida's Medicaid policy resulted in some unintended consequences; while CNA ratios increased, RN ratios decreased. However, results suggest that staffing changes had little impact on the amount of restorative care provided. One possible explanation is that nursing homes may place greater priority on other processes of care. More research is needed to determine if other processes of care are influenced by the amount of staff and if facilities that provide a lower amount of restorative care have poorer mobility outcomes.


This study was able to measure the relationship between a change in structure (staffing) and a change in the amount of a process provided.

This can assist Florida Medicaid to evaulate the effectiveness of its policy.

Funding Source: CWF

•

Racial Disparities in Patient-Physician

Racial Concordance

Nuha Lackan, Ph.D., Erin Carlson, M.P.H.,

Elizabeth Trevino, Dr.P.H., James Stimpson,

Ph.D.

Presented By: Nuha Lackan, Ph.D., Assistant


University of North Texas Health Science Center

School of Public Health, 3500 Camp Bowie

Boulevard, Fort Worth, TX 76107, Phone: 817-735-

5023, Fax: 817-735-0446 Email: nlackan@hsc.unt.edu

Research Objective: Patient-physician racial concordance has been associated with positive health outcomes including the use of preventive services and satisfaction with care. Patientphysician racial concordance may contribute to high-quality patient/provider encounters by removing barriers to open communication and establishing rapport and trust with providers.

The objective of this study is to investigate racial disparities in patient-physician racial concordance and identify correlates of racial concordance.

Study Design: This cross-sectional study examines data from the 2001 Commonwealth

Fund Health Care Quality Survey. Racial disparities in patient-physician racial concordance were examined using bivariate and multivariate analyses. Multivariate logistic regression analysis was used to identify correlates of patient-physician racial concordance. Three race-specific (Non-Hispanic

White, Black or Hispanic) multivariate logistic regression analyses were performed to identify disparities in correlates of patient-physician racial concordance.

Population Studied: The study population was a nationally-representative sample of 6,306 adults age 18 and older. The sample was 53.2% Non-

Hispanic White, 15.7% Black, 16.5% Hispanic and 14.5% of another racial or ethnic group. The mean age was 44.6 years, 39.0% were males,

50.1% were married, 61.4% had more than a high school education and 84.8% of the population had some type of insurance coverage.

Principle Findings: In both bivariate and multivariate analyses, racial disparities in patientphysician racial concordance were observed, with the highest rates of concordance for whites

(65.5%), followed by Blacks (21.2%), Hispanics

(20.2%), and Asian and Pacific Islanders (3.1%).

Other characteristics associated with racial concordance were older age (OR 1.17, 95% C.I.

1.12-1.21), female gender (OR 1.36, 95% C.I. 1.22-

1.53), being married (OR 1.31, 95% C.I.1.17-1.46), higher educational attainment (OR 1.12, 95% C.I.

1.07-1.18), having insurance (OR 1.91, 95% C.I.

1.49-2.46), and having been born in the United

States (OR 4.56, 95% C.I. 3.91-5.33).

Conclusions: Patient-physician racial concordance occurs at much lower rates for racial and ethnic minorities. Furthermore, our findings suggest that patient-physician racial concordance is associated with other established predictors of improved health outcomes (e.g. higher socioeconomic status, being married, having insurance). While factors such as socioeconomic status are difficult to change, patient-physician race concordance is a factor over which individual patients can exercise control.


Employing strategies to create concordant patient-physician dyads may be a plausible mechanism by which health disparities can be reduced. For this reason, educational, government, and workplace policies are needed to support and increase the number of racial and ethnic minority health care providers. Policies to enhance recruitment of minority physicians are important in expanding the number of concordant physicians available to growing minority populations.

•

Exercixe Level and Age as Related to Self-

Perceived Physical Health, Mental Health, and Social Health in Older Adults

Barbara Leach, Ph.D.

Presented By: Barbara Leach, Ph.D., Nursing

Instructor, Health Science, Rio Hondo College,

2630 Winrow Court, Rowland Heights, CA 91748,

Phone: (626)-201-2795, Email: drbarbaraleach@hotmail.com

Research Objective: Based on research that demonstrates that older adults do not experience universal deterioration, that they are capable of engaging in all types of normal activity and that exercise can be highly beneficial, the research objective of this study was to examine the relationship between older individuals' degree of regular exercise and their self-perceptions of their physical, mental and social health. In addition, the relationship between age and selfperceptions of these three aspects of health was examined.

Study Design: A descriptive design was used to determine the relationships among the study variables. There were five variables considered in this study. Exercise was one independent variable and it was divided into three impact levels: activity of daily living only (ADL), low impact level, and high impact level. Age was the second independent variable. The three dependent variables included self-perceptions of

physical health, self-perceptions of mental health, and self-perceptions of social health. A between-subject group comparison was made of self-perceptions of health between a group of older adults performing ADL activities only, a group of seniors engaging in low impact exercise, and a group of older adults performing high impact exercose. A cross-sectional design was utilized to collect the data at one point in time. Data was collected using the SF-36 Survey to examine self-perceptions of physical and mental health and the Texas Social Behavior

Inventory to examine self-perceptions of social health. The Physical Activity Questionnaire for the Elderly was used to examine exercise level.

Age was determined by a demographic questionnaire. Six hypotheses were tested: 1) exercise level is positively related to selfperception of physical health in older adults, 2) exercise level is positively related to selfperception of mental health in older adults, 3) exercise level is positively related to selfperception of social health in older adults, 4) age is negatively related to self-perception of physical health in older adults, 5) age is negatively related to self-perception of mental health in older adults, and 6) age is negatively related to selfperception of social health in older adults.

Population Studied: The population studied was older adults age 55 and older who were involved in various levels of physical activity. The activity levels included: (1) performing activities of daily living, (2) low impact activities such as leisure walking, gardening, or performing household chores, and (3) performance of high impact exercise such as swimming, tennis, or participation in a formal exercise program. The sample size included 224 participants who were recruited using quota sampling to obtain at least

70 participants per each strata. The quota for each strata was 70 participants 55-64 years of age, 70 participants 65-74 years of age, and 70 participants over 75 years of age. Participants were invited by the researcher to participate in the study after the research plan had been described. Inclusion criteria included: 1) male or female over age 55, 2) alert and oriented, 3) understands and speaks English, and 4) able to communicate via an interpreter if unable to comprehend or speak English. Exclusion criteria included the existence of a state of quadraplegia or a delusional or confused state in which loss of touch with reality has occurred. Participants were recruited from an adult day care center, a

YMCA, church, and walking group at a mall.

Personal acquaintances of the researcher were also recruited.

Principle Findings: Hypotheses 1 and 4 were supported: a small positive correlation exists between exercise and positive perceptions of physical health and a moderate negative correlation exists between age and selfperception of physical health. Hypotheses 2, 3, 5, and 6 concerning the relationship between exercise level and self-perceptions of mental and social health and between age and selfperceptions of mental and social health were not supported, and were rejected.

Conclusions: The subject population was representative of the general population of older adults, therefore the study findings can be generalized to the senior population as a whole in the United States. The ethnicity was fairly diverse with Caucasians representing a little over one-half and the remainng being either Hispanic,

African-American, or Oriental. The majority of the particpants were considered middle-class and approximately one-fourth were low-income and a fourth were in the upper-income bracket.

Hypotheses 1 and 4 were also supported by the literature but findings of this study differed from the findings in the literature for hypotheses 2 and 3. The literature supported the findings that exercise positively related to self-perceived physical health and that age negatively related to self-perceived physical health, as age increased, positive self-perceptions of health decreased.

Hypotheses 2 and 3 were not supported by this study in that exercise was not related to selfperceptions of mental health, in contrast to the opposite findings in the literature. Findings of this study for Hypothesis 5 and 6 were both supported and not supported by the literature: advancing age in the literature at times did negatively affect self-perceived mental and social health and at other times it did not. Four alternative explanations exist for this study's refuted hypotheses: social support may have played a major role in the positive evaluation of physical, mental and social health in the majority of the participants, religious beliefs and practices may have influenced the positve evaluation of physical, mental, and social health in the majority of participants, an inherent tendency to view things positively may also have promoted these positive evaluations, and the predominance of positive evaluations of selperceived health may be a conscious or unconscious effort on the part of the participant to deny the aging process. Several ageist assumptions were dispelled by this study. The majority of the participants did not feel powerless, dependent, anxious, miserable, or depressed. They also felt that they were not

unable or unwilling to change, isolated, or unproductive. The majority of participants also were soically active and confident, demonstrated health-promoting behaviors, had a low-incidence of age-related diseases, and were active in some form.


This study added to the knowledge base of theory in the field of Gerontology by exploring areas that have been minimally investigated.

The five variables have not been previously examined together. The literature focused on actual, measurable, physiological changes in physical functioning to determine physical health in seniors and did not investigate the effect of self-perceptions of health on the actual health status of older adults. This study focused on seniors' perceptions of their health, which did not always coincide with actual limitations identified. This discrepency could become a motivating factor for compliance with healthpromoting activity or exercise regimens in seniors. Studies on leisure activities conducted on older adults are rare. This study identified several types of exercise that older adults preferred. This is a beginning step to acquiring data concerning the preferred activities of seniors so that appropriate exercise regimens and activity programs can be developed and successfully implemented. Minimal information on social functioning or the self-perception of social health in seniors was found in the literature. This study provides responses to questions regarding various aspects of social health which adds to the limited amount of information availabe on this topic. Preferred social activities of older participants were also identified which will help when planning activity interventions for seniors. The positive selfimages of seniors provided in this study will help promote a more positive attitude and view of the older population by health care providers and the general population. These attitudes and views can then be incorporated into the course curriculum for students studying Gerontology and into programs developed and implemented for older adults. The health-promoting tendencies of seniors identified in this study can be used to help motivate participation in programs and practices that promote healthy life-styles. This in turn may help to decrease the anticipated increases in health care costs predicted for the near-future as a result of the expanding older adult population in the United

States. Several areas for future research were identified as a result of this study. One such area is older adults' perception of what good health is, which will aid in the process of detecting health care needs of seniors, planning and implementing interventions to deal with the need, and evaluating their effectiveness. In addition, research examing social health in seniors in necessary along with barriers that limit seniors' participation in exercise programs and various social activities.

•

Factors Influencing Early Smoking among

High School Students of Korea

Kyeong Soo Lee, M.D., Ph.D., Tae-Yoon Hwang,

M.D., Ph.D., Sang-Gyu Kim, M.D., Ph.D.

Presented By: Kyeong Soo Lee, M.D., Ph.D.,

Associate Professor, Prev. Med. and Publ.

Health, Yeungnam Univ., 317-1 Daemyeongdong, Nam-gu, Daegu, 705035, Phone: +82-53-

620-4375, Fax: +82-53-653-2061 Email: drkslee@ynu.ac.kr

Research Objective: The purpose of the study was to identify a proportion of high school students who have smoked and variables influenced their smoking.

Study Design: A questionnaire was administered to 920 students in 3 high schools in Daegu(metropolitan city) and 3 high schools in smaller cities than Daegu in Korea from Aug. to Sept., 2001 .

Principle Findings: Of total respondents, 11.8% had experience of smoking. Of those, 20.2% citied "curiosity," 9.0% cited "upon recommendation of friends" and 6.2% cited

"stress management" as the main reasons for their starting smoking. Separately, 53.1% citied

"smoking habit," 26.5% cited "stress management" and 8.2% cited "socializing" as the main reasons for continuing smoking. Of total former smokers, 68.4% said health was the main reason for quitting smoking. Of those who failed to quit smoking, 58.7% cited "lack of selfdependence" as the main reason for their failure.

When asked whether smoking students have a plan to quit smoking, 12.6% said, "I have no such a plan" and 26.6% said "I will quit smoking some day." Of total respondents, 10.8% were smoking. Of those, 13.8% started smoking in their early teens and 10.4% started smoking recently or not long time ago, showing no significant difference between the two groups.

By variables influencing smoking, smoking of family member(s) (p<0.01) and intent to smoke

(p<0.05) were significantly related to early smoking. According to a multivariate logistic regression analysis, higher levels of stress and

the presence of smoking family member(s) were significantly related to early smoking.

Conclusions: Amid growing number of early smokers, it is imminent to identify smoking among young people and factors influencing their smoking as part of the efforts to prevent early smoking and discourage smoking. In addition, education programs need to be developed to assist early smokers in quitting smoking and prevent smoking among elementary school students.

Funding Source: Korean Government

• A Review on the Use of Integrated Disease

Management Interventions

Karin Lemmens, M.Sc., Anna Nieboer, Ph.D.,

Robbert Huijsman, Ph.D., M.B.A.

Presented By: Karin Lemmens, M.Sc.,

Researcher, institute of Health Policy and

Management, Erasmus MC, P.O. Box 1738,

Rotterdam, NL, Phone: +31 104088541, Fax: +31

10 4089094 Email: k.lemmens@erasmusmc.nl

Research Objective: To evaluate the effectiveness of multiple interventions for COPD and asthma within the context of integrated disease management.

Study Design: The PubMed database and

Cochrane Library (January 1995 - May 2006) were searched for studies applying a comparative study design to measure the effectiveness of multiple interventions (patient, provider and/or organizational interventions) for patients with chronic obstructive pulmonary disease (COPD) and/or asthma. A quantitative analysis was performed on quality of life comparing multiple interventions versus a single intervention. Since several quality of life measures were used, the differences in minimal clinically important difference (MCID) is rated. A qualitative assessment of the effects of multiple intervention studies on outcomes was performed. A distinction was made based upon the combination of interventions, contents of the interventions and study quality.

Population Studied: The studies include adult

COPD and asthma patients participating in disease management programs consisting of multiple interventions.

Principle Findings: A total of 23 studies met the inclusion criteria. The studies identified were heterogeneous in terms of (combinations of) interventions, range of outcomes measured, study design and settings in which care was delivered. Fifteen studies targeted double interventions (patients and organization), and eight studies performed triple interventions

(patient, provider and organization).

Only three studies were eligible for quantitative analysis on quality of care. This analysis showed no significant effect of multiple versus single interventions on quality of life; however a positive trend was detected.

Overall, triple interventions incline towards more positive outcomes than double interventions. In particular, combining patient education, provider education with an active role of the pharmacist in monitoring led to improvements in patient outcomes. Studies in which patient knowledge and compliance was enhanced also showed improvements in quality of life.

Conclusions: Estimates of the effectiveness of multifaceted interventions are limited due to heterogeneity in results, resulting from the range of diverse outcomes measured, the diverge combination of interventions, the different study designs and the many different settings in which care was delivered. Multifaceted interventions targeting COPD and asthma patients do not or only produce small improvements in process and outcome indicators. Triple interventions showed more positive improvements, especially for interventions in which pharmacists can liaise with the patient and the provider, provide education and play an active role in patient monitoring.


Measuring at outcome as well as process levels contributes to a better understanding of how to improve the quality of care. The choice of indicators in the studies included in this review was frequently not related to the interventions that were evaluated. Therefore, it is suggested that outcome and process indicators are needed that are sensitive to the specific interventions and are associated with the expected changes in care. More research on the long-term effectiveness of the multifaceted intervention strategies is required, as the follow-up period in many of the studies in the present review was short. It was therefore unclear whether the effects of the interventions can be maintained in the long term.

Funding Source: PICASSO for COPD

• Use of Complexity Science Improved

Effectiveness of Organizational Interventions for Patients with Congestive Heart Failure

Luci Leykum, M.D., M.B.A., Valerie Lawrence,

M.D., M.Sc., Michael Parchman, M.D., M.P.H.,

Jacqueline Pugh, M.D., Polly Hitchcock-Noel,

Ph.D., Reuben McDaniel, Ed.D.

Presented By: Luci Leykum, M.D., M.B.A.,

Assistant Professor of Medicine, Medicine,

South Texas Veterans Health Care System /

University of Texas Health Science Center at San

Antonio, 7400 Merton Minter, Ambulatory Care

11C6, San Antonio, TX 78229, Phone: 210 949

3819, Fax: 210 567 4423 Email:

Leykum@uthscsa.edu

Research Objective: The science of complex adaptive systems (CAS), suggests that organizational interventions leveraging the ability of participants to learn, interact, self-organize, and co-evolve will lead to improved patient outcomes. A previous study demonstrated this finding in patients with Type II diabetes. We examined this relationship in a systematic review of organizational studies focused on patients with congestive heart failure (CHF).

Study Design: Eligible studies were randomized or controlled clinical trials identified by a search of Medline from 1989 through 2005 after testing a broad array of potential search terms. Eligible publications were independently reviewed and then abstracted by teams of reviewers with clinical and methodological expertise.

Two raters then independently evaluated each study to assess the extent to which the intervention incorporated one or more of these characteristics of a CAS: individuals’ capacity/ability to learn; interconnections between individuals; the ability of participants to self-organize; and the tendency of participants to co-evolve. The effectiveness of the outcomes of each study was then assessed by two independent raters on a scale of 0 (no effect),

0.5 (mixed results), and 1 (intervention effective) based on the number and significance.

We used Fisher’s exact test to test the significance of the relationship between each individual CAS characteristic, as well as total number of characteristics, and strength of outcomes.

Population Studied: Adults with congestive heart failure.

Principle Findings: 1741 potential studies were identified by the literature search, 79 were reviewed in detail and 31 met eligibility criteria. At least one characteristic of a CAS was utilized in all of the 31 studies. The most common intervention was to influence the patterns of interconnects between individuals through the addition of a nurse case manager. Eight studies reported no improvement in any endpoints, eight reported significant improvement, and the remainder reported mixed results.

There was a significant relationship between the number of characteristics and the strength of outcomes (p<0.001). Outcome effectiveness was significantly related to interventions affecting participants’ ability to learn (p=0.01), self-organize (p<0.001), and co-evolve

(p<0.001). Interventions focusing on the interconnections between participants were not significantly related to positive intervention effects.

Conclusions: The effectiveness of organizational interventions in improving outcomes for patients with CHF was significantly associated with the number of CAS characteristics utilized in the interventions. We observed a greater effect for interventions that promoted learning, and the ability of participants to self-organize and coevolve.


This study adds to the data suggesting that interventions which consider health care delivery systems to be CAS’s are more likely to significantly improve patient outcomes. The data also suggest that interventions with strategies targeting multiple CAS characteristics may be most effective in improving health outcomes. Further research should address how best to translate these theoretical constructs of complex adaptive systems into interventions that can more effectively be used to improve the outcomes of chronically ill patients across disease states.

Funding Source: VA

• Impact of Managed Care on the Provision of Diet & Exercise Counseling to People with

Chronic Conditions

Susan Lin, Dr.P.H.

Presented By: Susan Lin, Dr.P.H.,

Academy/NCHS fellow, Division of Health Care

Statistics, National Center for Health Statistics,

3311 Toledo Road, Hyattsville, MD 20782, Phone:

301-458-4798, Email: fth8@cdc.gov

Research Objective: Previous studies have shown evidence suggesting managed care improves the use of preventive services particularly screening and immunizations.

However, little is known about whether the provision of health behavior counseling during primary care encounters is affected by the extent of the practice’s involvement in managed care.

This study was designed to examine the impact of managed care on the provision of diet and/or exercise counseling to patients with chronic conditions in physician offices.

Study Design: This is a cross-sectional study of clinical preventive services using the data from the National Ambulatory Medical Care Survey

(NAMCS), a nationally-representative survey of visits to office based physicians excluding anesthesiologists, radiologists, and pathologists.

The analysis used primary care visits made by adult patients age 18 and older with any of three chronic conditions (diabetes, hypertension, or heart disease). To examine the impact of managed care, which was measured by the percentage of revenue from managed care contracts, logistic regression adjusting for patient, visit, provider and other practice characteristics variables was used.

Population Studied: Primary care visits made by adults with chronic conditions

Principle Findings: Between 2001 and 2004, there were an estimated 364.9 million visits made by patients with diabetes, hypertension or heart disease to primary care providers. Overall

31% of these visits involved diet/nutrition counseling, only 19% involved both diet and exercise counseling, and 34% involved diet and/or exercise counseling. Controlling for visit duration, number of prior visits, size of the practice and other variables, the percentage of revenue from managed care contracts was positively associated with diet and/or exercise counseling during primary care visits. The odds of patients getting counseling on diet and/or exercise as documented were doubled when they were seen by physicians in a practice with higher percent (80% to 100%) revenue from managed care contracts as compared with those with less than 20%. Other variables associated with behavior counseling at patient visits include longer visit duration, use of nonphysician staff, and payment source from private insurance.

Conclusions: Congruent with the literature demonstrating the effect of managed care on screening and immunization, this study shows that more involvement in managed care appears to increase the odds of documented diet and/or exercise counseling when patients are seen in the office.


The study findings suggest that the managed care companies’ policies and incentives towards preventive services may directly affect physician behavior in delivering preventive care. Secondary prevention is integral to delay and prevent the progression of disease. Primary care providers have opportunities and responsibilities to integrate preventive services into routine care of chronic conditions. Further inquiry is needed to determine the effective counseling strategies that can be utilized in clinical settings to improve patient outcomes.

•

Dentist Practice Patterns Segmentation and

Management: Insights from a National

Health Insurance Database

Chun-Mei Lin, M.P.H., Chih-Ling Fang, M.P.H.,

Chinho Lin, Ph.D.

Presented By: Chun-Mei Lin, M.P.H., manager,

Health expenditure, Bureau of National Health

Insurance Southern Reagon Branch, 96, Kungyuan Road, Tainan, TW, Phone: 886-6-2244396,

Fax: 886-6-2244342 Email: melin@mail.nhisb.gov.tw

Research Objective: This study aims at providing an easy, efficient and practical alternative approach in patterns of dental practice segmentation. This will help the thirdparty payer to recognize and describe novel or unusual patterns of dental practice for adopting various strategies in order to prevent fraudulent claims and overcharges.

Study Design: This study uses knowledge discovery (or data mining) to segment the dentists’ profiles by carrying out clustering techniques based on the features of service utilization rates. It is a hybrid of the knowledge discovery, statistics and artificial neural networks

(ANN) methodology to extract the knowledge from the dental claim database. Second, the data envelopment analysis (DEA) is used to compute the efficient scores on the segmentation of dentists’ practice patterns. Finally, while the features and patterns of dentist practice were segmentation from anterior procedures, an indepth interview was conducted. We illustrate the detailed managerial guidance to support the third-party payer in the management of various patterns of dentist practice.

Population Studied: One year of national insurance dental claims data on 672 dentists’ profiles were used to generate six practicespecific clusters as the starting point for management.

Principle Findings: It draws a complete picture relating to the characteristics of dentists’ practice patterns by reducing the attributes space to a smaller number of dimensions. We also provide different managerial guidance for each cluster, and this provides a practical way of clustering the anomalies in dentists’ practice patterns.

Conclusions: The segmentation of dentists’ practice patterns with intelligible and accountable tools aimed at analyzing and modeling the formal relations between fraud

indicators and claim suspicious for solving the key question of the third-party payer interest-----how to spot fraudulent or abusive behavior in health care providers. The benefit of the study is that it not only efficiently and effectively detects health fraud and abuse with a cost containment system, but also determines the appropriate audit trails to deal with the abnormal dentist’s practice patterns. Therefore, the segmentation of dentists’ practice patterns coupled with sophisticated effective auditing strategies will prevent fraudulent claims, overcharges, and duplication of services and tests. The third-party payer can thus gradually reduce the inspection and personnel costs.


Effective segmentation of dentists’ practice patterns makes it easier to detect and investigate fraudulent claims. This segmentation framework is appropriate to place in the core of claim payment auditing system by extracting practice pattern rules, and applies them repeatedly against new claims submissions for detecting suspicious practice patterns and abuse.

•

An Examination of Hospitals Bankruptcy,

Closures and Economics Incentives

Li-Lin Sunny Liu, M.B.A., Kathryn Jervis, Ph.D.,

Mustafa Z. Younis, Dr.P.H., M.A., M.B.A., Dana

Forgione, Ph.D.

Presented By: Li-Lin Sunny Liu, M.B.A., PH.D.

Cadidate, Accounting, Florida International

University, 11200 SW 8th St., Miami, FL 33199,

Email: younis99@gmail.com

Research Objective: The cost containment implemented by the Center of Medicare and

Medicaid (CMS) over the last two decades has increased the number of financially distressed hospitals. The hospitals method and reaction to the cost containment might differ by the type of the hospital’s ownership and other economics and financial variable. We examined the relation between ownership status , economics incentives and hospitals; closure and financial distress.

Study Design: The study used discriminate analysis method to examine a sample of closed hospitals as treatment group and open hospitals as control group from Medicare Cost Report

(MCR) from the Center of Medicare and

Medicaid 9CMS). For the years 1997-1999.

Population Studied: Sample of U.S. hospitals from 1997-1999.

Principle Findings: There is a weak association between hospitals ownership and financial distress. However other financial and non financial variable has a strong effect on hospitals financial distress such as occupancy rate, profit margin, return on equity and debt level.

Conclusions: : Hospitals ownership is weekly correlated with financial distress, despite that for profit hospitals report higher profit margin than non profit hospitals (Younis & Frogione, 2005).

Managers and administrators need to adopt strategies to manage occupancy rate, staffing and financial ratio to stay solvent.


The government regulations and legislation in health care affect hospitals regardless to the type of their ownership, however, with the number of the insured exceed the population of the state of

California, hospitals need to adopt strategies to balance their charity care and solvency.

•

If You Built, Will They Come Back? The Use of PZB Model in Identifying Factors for

Patient's Revisit

Ying-Ying Lo, M.P.H., Ying-Ying Lo, M.P.H.,

Cheng-Ming Chien, M.A.

Presented By: Ying-Ying Lo, M.P.H., doctoral

Canadidate, Institute of Human Resource

Management, National Sun Yat-Sen University,

70 Lien-Lai Road., Kaohisung, TW, Phone: 011-

886-7-5252633, Fax: 011-886-7-5252630 Email: mbrendalo@gmail.com

Research Objective: Obese is one of the important risk factors that cause chronic diseases. Weight-reducing clinic is a safe option for weight-reducing services. Since weightreduction is not covered by the Taiwanese

National Health Insurance, it has become a popular business operation strategy for clinics and hospitals to generate revenue. This study focuses on the influence of gap between patient expected services and perceived services to patient’s revisits to weight-reducing services. In addition, it identifies the factors that affect patient’s revisits.

Study Design: Data of this cross-sectional study were collected by the use of a structured questionnaire based on Gap5 from PZB

(Parasuramam, Zeithaml and Berry) Model with modifications to include eleven paired measurements on expected services and perceived services, patient’s demographic information, and health status. This study hypothesized the larger discrepancy of expected services and perceived services the less likelihood for patients to revisit weight-reducing services. Student t test was used to compare the

discrepancy between revisiting group and nonrevisiting group for all measurements. Logistic regression was employed to identify the factors influencing patient’s decisions to revisit services.

Population Studied: On hundred samples were randomly selected from those who visit weightreducing services in a hospital in Taiwan from

January 1, 2006 to Nov 30, 2006 and divided into two groups by the frequency of visits.

Patients with equal or more than three visits were classified as revisiting patients.

Principle Findings: The results of this study illustrated that the gap between expected services and perceived services of all indicators are significantly different between two groups.

Those indicators include distance to patient’s home, physician’s explanation, weight-reducing method, valuing patient’s privacy, and physician’s professionalism, content of health education, safety of treatment, effectiveness of services, attitudes of health professionals, price, and convenience and rapidness of services.

Non-revisiting patients’ gap is significantly larger than that of revisiting patients. Of all indicators, price showed the largest gap between two groups. Safety of treatment showed the smallest gap between two groups. After controlling gender and age, factors related to patient’s revisit to weight-reducing clinic are content of health education, price, and attitudes of health professionals.

Conclusions: The result of the study demonstrates the discrepancy between expected services and perceived services is different between revisiting patients and non-revisiting patients. Especially, price of weight-reducing service is important to patient decisions to continue receiving services. Weight-reduction requires commitment and long-term efforts.

Generally, patients can obtain price information at the very beginning of services. Therefore, if quality of services can not satisfy patients’ expectation for monetary value at initiate service, patients will not have incentives to continuously receive services.


The findings highlight the discrepancy of patient’s expected monetary value and perceived monetary value for weight-reduction in clinical setting. The results suggest that patients assess services with monetary value; managers of clinics need to assure quality of services at the initial visit to satisfy patient expectation for the money spent, especially for the money spent on weight-reducing services that require commitments and long-term efforts.

• Patient-Centered Care and Chronic Illness:

What Should We Know About Treatments

Perceptions of Patients Who Live with Asthma

Christine Loignon, Ph.D., Nicole Leduc, Ph.D.,

Robert Sévigny, Ph.D., Christophe Bedos, Ph.D.

Presented By: Christine Loignon, Ph.D.,

Postdoctoral Researcher, McGill University, 3640

University, Montreal (Quebec), H3A 2B2, CA,

Phone: (514) 398-7203, 00059, Fax: (514) 398-

8242 Email: Christine.Loignon@McGill.ca

Research Objective: The objectives of this study were to explore a) perceptions of treatments among adults who live with asthma, b) their experiences and strategies of self-management and process of seeking for health care.

Study Design: This study was based on a qualitative comprehensive design using semistructured interviews. Data analysis of transcribed interviews, indexation and reduction of data with sofware qualitative analysis, developement and validation of interpretations were used to reach intern validity.

Population Studied: Asthmatics adults living in an urban aera who attended a self-management education program delivered by primary health care organisations. Our study comprise a purposive mixed sample of 24 adults who live with asthma.

Principle Findings: Individuals afflicted by asthma develop self-care practices who are related to perceptions of medication. Asthmatics patients who envisage medication as poison, experience more symptoms and meanwhile tend to defer recourse to health care.Underprivileged individuals with multiple chronic illness face precarious living conditions, social isolation, limited access to continuous health care and

‘‘non-compliant stigma’’ in their encounters with health care professionals.

Conclusions: Our findings point to the importance of developing health interventions and self-management programs that addres perceptions of treatment. Perceptions of medications have important impact on self management of chronic illness as well on the recourse and access to health care.


This study can contribute to the enhancement of chronic illness care interventions and to the development of health policies that could meet patient's needs and expectations especially for underserved patients.

Funding Source: Canadian Institute of Health

Research and Asthma Society of Canada

• Impact of Regression to the Mean on

Studying Interventions to Reduce Emergency

Department Use

Robert Lowe, M.D., M.P.H., Rongwei Fu, Ph.D.,

Briar Ertz-Berger, M.D.

Presented By: Robert Lowe, M.D., M.P.H.,

Director, Center for Policy and Research in

Emergency Medicine, Emergency Medicine,

Oregon Health & Science University, 3181 SW

Sam Jackson Park Road, CR114, Portland, OR

97239, Phone: 503-494-7134, Fax: 503-494-4640

Email: lowero@ohsu.edu

Research Objective: Studies have reported successful interventions to reduce emergency department (ED) use by "heavy users" (HUs).

Most studies compared ED use before vs. after an intervention but lacked a control group.

Therefore, this reduction might also be due to regression toward the mean. We sought to determine the extent of regression toward the mean without an intervention in HUs.

Study Design: This historical cohort study used administrative data from 11 EDs (affiliated with 5 hospital systems) in the Portland, Oregon Tri-

County area. We tracked individual patients using unique identifiers assigned by each hospital system and compared the number of

ED visits by each patient 1/1/2004-6/30/2004

(Period 1) vs. 7/1/2004-12/31/2004 (Period 2).

For HUs (defined as greater than or equal to 4

ED visits in Period 1), we compared the mean number of visits in Period 1 vs. Period 2. To evaluate the possibility that patients decreased visits to one ED but increased visits to other nearby EDs, we used 2 other approaches to defining individual patients that were not dependent on hospitals' identifiers, via unique combinations of gender + birth date and of gender + birth date + zip code. Paired t-tests were used to compare counts of visits in the 2 periods.

Population Studied: 419,676 visits to 11 hospital

EDs.

Principle Findings: There were 207,976 ED visits in Period 1 and 211,700 in Period 2, by patients with 315,433 unique identifiers. Mean ED visits/patient were 0.73 in Period 1 vs. 0.74 in

Period 2 (difference -0.013, 95% CI -0.018, -

0.008). Among HUs, mean visits fell from 5.4 to

2.1 (difference 3.3, 95% CI 3.2, 3.4). The number of HUs increased from 4,467 to 4,700.

Sensitivity analyses with other approaches to identifying individual patients yielded similar results.

Conclusions: "Heavy ED users" in this study reduced their ED use in half with no intervention

- a greater improvement than reported in some intervention trials - while the number of HUs in the community increased. Whether one calls this

"regression toward the mean" or "clinical improvement over time," it shows the need for a comparison group in studying interventions, or at least for statistical assessment of regression toward the mean.


Demonstration projects treating frequent ED users that report reduced ED use over time may be inadequate to justify expansion of these programs, unless an untreated control group is included in the study.


• Predictors of First-Line Chemotherapy

Treatment among Elderly Patients with Stage

IIIB/IV Non-Small Cell Lung Cancer (NSCLC)

Martin Marciniak, Ph.D., Martin Marciniak,

Ph.D., Doug Faries, Ph.D., Michael Stokes, M.S.,

Don Buesching, Ph.D., Craig Earle, M.D.

Presented By: Martin Marciniak, Ph.D.,

Outcomes Research Scientist, US Outcomes

Research, Eli Lilly and Company, DC 6831,

Indianapolis, IN 46285, Phone: 317-433-1455, Fax:

317-651-2313 Email: mdybelm2@lilly.com

Research Objective: Data regarding first-line chemotherapy treatment among advancedstaged NSCLC patients is lacking. The purpose of this analysis was to assess predictors of firstline treatment and treatment selection among elderly patients with Stage IIIB/IV NSCLC.

Study Design: Multivariate logistic regression models controlling for age, gender, cancer stage, race, comorbidity, SEER region, and an indicator for residence in a metropolitan area were estimated to identify predictors of first-line chemotherapy treatment. Odds ratios and confidence intervals for measuring the strength of the association of each factor with receiving first-line chemotherapy were reported. Among only those patients who received chemotherapy, similar logistic regression models were estimated to identify factors associated with receiving cisplatin/carboplatin and gemcitabine versus other first-line treatments and cisplatin/carboplatin and taxane versus other treatments.

Population Studied: Patients aged 65 years and older diagnosed with Stage IIIB/IV NSCLC in a

SEER cancer registry between 1997 and 2002

were identified and retrospectively followed in the SEER-Medicare database.

Principle Findings: Among elderly Stage IIIB/IV

NSCLC patients, those who were older (odds ratios [95% CI]: 0.57 [0.53-0.61] for patients aged

75 to 84 years, 0.20 [0.17-0.23] for patients aged

85 years or older relative to patients aged 65 to

74 years), those with more than one comorbidity

(0.57 [0.50-0.65), blacks (0.59 [0.52-0.67]), those in urban and rural areas relative to metropolitan areas (0.81 [0.73-0.90] and 0.65 [0.49-0.86], respectively), were less likely to receive chemotherapy treatment. Males were more likely than females to be treated (1.14 [1.06-1.22]), as were patients in the Northeast and South relative to patients in the West (1.24 [1.13-1.36] and 1.33 [1.20-1.47], respectively). Focusing on the sample treated with chemotherapy, factors associated with receiving doublet therapy with cisplatin/carboplatin and a taxane relative to another first-line treatment included older age

(0.64 [0.57-0.72] and 0.24 [0.16-0.35]), male gender (1.15 [1.03-1.29]), diagnosis at stage IV relative to IIIB (0.79 [0.70------0.88]), being black,

Hispanic or Asian relative to white (0.61 [0.48-

0.76]), (0.46 [0.31-0.69]), and (0.49[0.31-0.76], respectively), and living in the Midwest relative to the West (0.80 [0.69-0.94]). Factors associated with receiving doublet therapy with cisplatin/carboplatin and gemcitabine relative to another first-line treatment included older age

(0.30 [0.11-0.82] for patients aged 85 years and older relative to patients aged 65 to 74 years), being black relative to white (0.59[0.35-0.98]), and living in the Northeast relative to the West

(0.72 [0.53-0.98]).

Conclusions: Several factors were found to be associated with chemotherapy treatment following a diagnosis of Stage IIIB/IV NSCLC, including age, comorbidity, race, disease severity, and geographic region.


Our findings suggest that there may be regional and ethnic differences in the first-line treatment of Stage IIIB/IV NSCLC among elderly patients.

Funding Source: Pharmaceutical

•

Reoperation Rates Following Lumbar Spine

Surgery and Influence of Spinal Fusion

Procedures

Brook Martin, M.P.H., Sohail K. Mirza, M.D.,

M.P.H., Bryan A. Comstock, M.D., M.P.H., Darryl

T. Gray, M.D., Sc.D., William Kreuter, M.P.A.,

Richard A. Deyo, M.D., M.P.H.

Presented By: Brook Martin, M.P.H., Research

Scientist, General Internal Medicine, University of Washington, Box 359736, 325 Ninth Ave,

Seattle, WA 98104, Phone: (206) 744-1803, Fax:

(206) 744-9889 Email: bim@u.washington.edu

Research Objective: To determine the cumulative incidence of a reoperation following lumbar surgery for degenerative conditions and, for specific diagnoses, to compare the frequency of reoperation following fusion with that following decompression alone.

Study Design: Retrospective analysis of

Washington State hospital discharge registry.

Population Studied: Patients who underwent an inpatient lumbar surgery in Washington State for degenerative spine disorders in 1990-1993.

Principle Findings: Patients who had surgery in

1990-93 had a 19% cumulative incidence of reoperation during the subsequent eleven years.

Patients with spondylolisthesis had a lower cumulative incidence of reoperation after fusion surgery than after decompression alone (17.1% versus 28.0%, p=0.002). For other diagnoses combined, the cumulative incidence of reoperation was higher following fusion than following decompression alone (21.5% vs. 18.8%, p=0.008). After fusion surgery, 62.5% of reoperations were associated with a diagnosis suggesting device complication or pseudoarthrosis.

Conclusions: The likelihood of reoperation following a lumbar spine operation is substantial. For spondylolisthesis, reoperation is less likely following fusion than following decompression alone. For other degenerative spine conditions, the cumulative incidence of reoperation is higher or unimproved after a fusion procedure compared to decompression alone.


This finding highlights the importance of better defining the indications, efficacy, and safety of spinal fusion surgery. Patients considering lumbar surgery should be informed of the substantial risk of having an additional operation.

Funding Source: Other, National Institute of

Arthritis, Musckuloskeletal and Skin Diseases

(NIAMS)

• Are Lumbar Spine Reoperation Rates

Falling with Greater Use of Fusion Surgery and New Surgical Technology?

Brook Martin, M.P.H., Sohail K. Mirza, M.D.,

M.P.H., Bryan A. Comstock, M.S., Darryl T. Gray,

M.D., Sc.D., William Kreuter, M.P.A., Richard A.

Deyo, M.D., M.P.H.

Presented By: Brook Martin, M.P.H., Research

Scientist, Division of General Internal Medicine,

University of Washington, Boc 359736, 325 ninth

Avenue, Seattle, WA 98104, Phone: (206) 744-

1803, Fax: (206) 744-9889 Email: bim@u.washington.edu

Research Objective: To examine the cumulative incidence of second lumbar spine operation following an initial lumbar operation for degenerative conditions. We aimed to determine if the cumulative incidence of a second lumbar spine operation decreased in the

1990s following an increase in the rate of fusion surgery and the introduction of several newer fusion technologies.

Study Design: Retrospective cohort study using a Washington State hospital discharge registry.

Population Studied: Patient who underwent inpatient lumbar surgery in Washington State for degenerative spine disorders in 1990-1993

(n=24,882) or in 1997-2000 (n=25,209).

Principle Findings: Among patients who underwent surgery for lumbar degenerative disease, more than twice as many had a fusion procedure in the 1997-2000 cohort (19.1%) compared to the 1990-93 cohort (9.4%).

However, the four-year cumulative incidence of reoperation was higher in the 1997-2000 cohort compared with the 1990-93 cohort (14.0% versus 12.4%, p<0.001). Among fusion patients, those in the 1997-2000 cohort were approximately 40% more likely to undergo a reoperation within the first year when compared to fusion patients the 1990-1993 cohort. There was no difference in reoperation probability beyond one year.

Conclusions: A higher proportion of fusion procedures and the introduction of new spinal implants between 1993 and 1997 did not reduce reoperation rates.


These trends suggest the importance of better defining indications for lumbar surgery, and better demonstrating the efficacy and safety of surgical innovations.

Funding Source: Other, National Institute of

Arthritis, Musckuloskeletal and Skin Disease

(NIAMS)

• A Comparative Analysis of Hospitalizations and Medical Doctor Contacts in the United

States and Canada using Poisson and Logistic

Regression Modeling: Findings from the Joint

Canada/United States Survey of Health

Michael E. Martinez, M.P.H., M.H.S.A., Debra L.

Blackwell, Ph.D., Jane F. Gentleman, Ph.D.,

Claudia San Martin, Ph.D., Saeeda Khan, M.A.

Presented By: Michael E. Martinez, M.P.H.,

M.H.S.A., Epidemiologist, Division of Health

Interview Statistics, National Center for Health

Statistics, 3311 Toledo Road, Room 2332,

Hyattsville, MD 20782, Phone: 301-458-4758, Fax:

301-458-4961 Email: bmd7@cdc.gov

Research Objective: Canada and the United

States employ strikingly different approaches to financing medical care for their residents.

Canada has a single payer plan in which virtually all residents have government-sponsored health insurance coverage for physician visits and hospitalizations. In contrast, in the United

States, most funding for health care services comes from private health insurance providers.

Given these important differences between the

Canadian and the U.S. health care systems, the objective of this analysis is to compare the two countries with respect to hospitalizations and medical doctor contacts, using two different types of statistical modeling procedures.

We previously used logistic regression to estimate the odds of being hospitalized and of contacting a medical doctor during the past year for both Canadian and U.S. adults. These analyses were based on dichotomous dependent variables that indicated whether or not a hospitalization or doctor contact had occurred during the past 12 months. We now use Poisson regressions, thus incorporating the additional information inherent in actual counts of overnight hospitalizations and doctor contacts during the past year. We examine the extent to which the additional information contributes to our understanding of factors associated with these events.

Study Design: Results of logistic and Poisson regression models predicting overnight hospitalizations and medical doctor contacts using data from the Joint Canada/United States

Survey of Health (JCUSH) will be presented.

Population Studied: Non-institutionalized adults (18 years and older) who were not residing in either Canadian or United States territories and who had a working landline telephone were the target populations of the

JCUSH.

Principle Findings: Comprehensive health insurance was not associated with having one or more overnight hospitalizations during the past year in the U.S., but lacking comprehensive health insurance was negatively associated with

the total number of overnight hospitalizations in the U.S. In both countries, sex was associated with having one or more overnight hospitalizations, but it was not associated with the total number of overnight hospitalizations.

Depression was not associated with contacting a medical doctor one or more times during the past year in either country, but was positively associated with the total number of doctor contacts in both countries. Also, in the U.S., education and income were weakly associated with contacting a doctor one or more times, but were strongly associated with the total number of doctor contacts in the past year.

Conclusions: Using two types of regression models on the same data was useful in providing extra information that would have been missed only using logistic regression.


Data permitting evaluations of the Canadian and

United States health care systems are of increasing importance to policy makers in both countries. Comparable data are valuable in removing methodological limitations that interfere with cross cultural comparisons between two or more countries. Furthermore, more expansive research can be conducted on comparable data as methodological limitations are removed from the data collection and editing processes.

Funding Source: CDC

• Does Managed Care Help or Hinder Access for Children with Special Health Care Needs and Limited English Proficiency?

Mary Masland, Ph.D., Lonnie Snowden, Ph.D.,

Soo Kang Pak, Dr.P.H., Neal Wallace, Ph.D.

Presented By: Mary Masland, Ph.D., Research

Director, Center for Mental Health Services

Research, Univ. of California Berkeley, 2140

Shattuck Ave #409, Berkeley, CA 94720-7414,

Phone: 510-551-6689, Fax: 510-642-9812 Email: mmasland@berkeley.edu

Research Objective: To measure health care access for children with special health care needs

(SHCNs) and the effect of parent’s limited

English proficiency (LEP) on access in managed care settings.


2003 California Health Interview Survey (CHIS).

The study data set of 968,476 children (after weighting to simulate the California population) was obtained by selecting children, aged 0-11 years old, with special health care needs as identified using screener questions included in the survey. Dependent variables measured the continuity of care, delays in care and the amount of care received by children with special health care needs. Independent variables measured the parent's race/ethnicity and English language proficiency, and managed care characteristics

(requiring assignment to a primary care physician and requiring a referral to see a specialist) of the health plan in which the child was enrolled. Models also included interaction terms between parent’s English language proficiency and managed care characteristics, as well as a number of demographic and SES variables. Models with binomial dependent variables were estimated using logistic regression while models with continuous dependent variables were estimated using linear regression.

Population Studied: Children, ages 0-11 years, with special health care needs in California in

2003.

Principle Findings: Among children with

SHCNs, 54% were non-white and 17% had parents with limited English proficiency (LEP).

Children with LEP parents, controlling for race/ethnicity, had worse access across all measures (having a usual source of care, having treatment or prescriptions delayed or denied, number of visits in 12 months) compared to children with non-LEP parents. Models of assignment to a primary care physician (PCP) showed that, for children with LEP parents, assignment to a PCP reduced the odds of having a usual source of care. PCP assignment had no significant effect on delay/denial of care or the number of doctor visits in the past 12 months.

Models of requiring a referral to see a specialist showed that, for children with LEP parents, requiring a referral increased the odds of having a usual source of care, but also increased the odds of delay or denial of care. The referral requirement had no significant effect on the number of visits per child.

Conclusions: Children with SHCN whose parents are LEP experience significantly lower rates of health care access than their counterparts whose parents are not LEP.

Managed care characteristics, such as required assignment to a primary care physician or referral to see a specialist, had mixed effects on access for SHCN children with LEP parents.


Many states are increasing the portion of

Medicaid enrollees in managed care. Given the large portion of LEP families enrolled in

Medicaid, this policy change will move many LEP families into managed care thus potentially

reducing these children’s access to care, unless action is taken to remove the barriers for LEP families created by managed care systems.

These effects were found for children with special health care needs; they are likely to be even more pronounced for typical children without urgent health care needs.

Funding Source: Univ of California Program on

Access to Care

• Effect of Outpatient and Case Management on Psychiatric Crisis Use among Ethnic

Minority Children & Youth in California’s

Public Mental Health System

Mary Masland, Ph.D., Neal Wallace, Ph.D., Mary

Masland, Ph.D.

Presented By: Mary Masland, Ph.D., Research

Director, Center for Mental Health Services

Research, Univ. of California Berkeley, 2140

Shattuck Avenue, #409, Berkeley, CA 94720-

7414, Phone: 510-551-6689, Fax: 510-642-9812

Email: mmasland@berkeley.edu

Research Objective: To determine the effect of mental health outpatient and case management visits on the use of psychiatric crisis care among ethnic minority youth.

Study Design: We examined specialty mental health claims data for all Medicaid-enrolled children under 18 years old in California between

7/1/1998 and 6/30/2001. From the 3 study years, we selected clients who had their first outpatient or case management visit during the middle 185 days of the year. We considered this first outpatient/case management visit of the year to be the index visit. Our final sample consisted of 97,618 non-foster care and 13,694 foster care youth. The dependent variable was a specified as the probability of the child having a crisis visit during the 90-day period following his/her index outpatient or case management service. Independent variables indicated if the child received, during the 90 days after the index visit, any outpatient/case management service before a crisis visit or any outpatient/case management at all if no crisis occurred.

Interaction terms were entered between a child’s race/ethnicity and receipt of outpatient/case management in the 90 days following the index visit. We also controlled for receipt of other mental health services in the 90 days prior to the index visit, the child’s race/ethnicity, age, gender, diagnosis, and disability status. We included cross-sectional fixed effect dummy variables specifying the client’s county of residence, and longitudinal fixed effect variables indicating in which of the three fiscal years the client was observed. Linear probability models were estimated with robust standard errors to correct of heteroskedasticity. Separate models were estimated for foster care and non-foster care children.

Population Studied: All Medicaid children and youth, under 18 years old, using public specialty mental health services between 7/1/98 and

6/30/01 in California.

Principle Findings: African American children were more likely than whites, while Latinos and

Asians were less likely than whites, to have a crisis in the 90 days following the index outpatient/case management visit. African

American, Latino and Asian children who received follow-up outpatient or case management services in the 90 days after the index visit were significantly less likely to have a crisis compared to those that did not. The size of this effect was consistently larger for ethnic minority children. These ethnic differences were not found among the foster care sample.

Conclusions: Outpatient or case management services are a moderator of crises, but ethnic minority children are less likely to receive them.

However, when they do, these services appear to be more effective at reducing crises compared to their effectiveness for white children.


Ensuring that minority children receive outpatient and case management services early in their treatment episode can reduce their reliance on the crisis system for mental health care.


•

Relational Factors and Physicians'

Intentions to Leave Practice

Leah E. Masselink, B.A., Shoou-Yih D. Lee, Ph.D.,

Thomas R. Konrad, Ph.D.

Presented By: Leah E. Masselink, B.A., PhD

Student, Health Policy and Administration, UNC

School of Public Health, 1101 McGavran-

Greenberg, CB#7411, Chapel Hill, NC 27599-

7411, Phone: 919-843-XXXX, Fax: 919-966-6961

Email: leah_masselink@unc.edu

Research Objective: Physician turnover threatens continuity of care for patients and is a huge source of added expense for health care institutions. Existing studies have examined a wide variety of individual and practice characteristics as antecedents of turnover for physicians. However, few studies have examined the effect of relational factors on physicians’

intention of leaving practice. Are physicians who report better relationships with colleagues, staff and patients less likely to intend to leave their practices? This question is examined in this study.

Study Design: Data used in the study come from a cross-sectional, community-based

Physician Worklife Survey in 1996-97. Survey questions asked physicians to indicate their agreement with statements about relationships with colleagues, staff and patients and sociocultural climate in their practice settings on a 5point scale with response options ranging from

‘‘strongly agree’’ to ‘‘strongly disagree’’. The association between relationships with colleagues, relationships with staff, relationships with patients, and workplace integration and the expectation of leaving current practice within two years is analyzed using a multivariable logistic regression model.

Population Studied: A nationally representative sample of 2,326 generalists and sub-specialists in medicine and pediatrics.

Principle Findings: Workplace integration had a significant and negative relationship with expected departure from current practice; that is, higher degrees of workplace integration were associated with lower likelihood of leaving practice (OR=0.85; p<0.01). Relationships with colleagues, staff and patients had no significant association with expected departure from current practice. The joint effect of relationships with colleagues, staff and patients was also insignificant (p=0.86).

Conclusions: While workplace integration-----positive perceptions of workplace socio-cultural climate------had a strong negative relationship with expected departure, relationships with colleagues, staff and patients had no association with expected departure.


Physician turnover is an expensive problem for health care organizations. This study suggests that interpersonal relationships influence physicians’ intentions to leave practice, but the mechanisms by which they do so are unclear.

Further research examining these mechanisms can help employers and policymakers to foster positive workplace relationships and improve physician retention.

Funding Source: Department of Health Policy and Administration, UNC School of Public

Health

• Avoiding Surgery: Evaluating High Energy

Extracorporeal Shock Wave Therapy as a

Treatment for Plantar Fasciitis

Richard Mathis, Ph.D., Steve Martin, B.A.,

B.S.N., M.S.Ed., Shiela Keith, M.S.

Presented By: Richard Mathis, Ph.D., Sr.

Manager, Medical Policy Research &

Development, Medical Policy Research &

Development, BlueCross BlueShield of

Tennessee, 801 Pine Street, 2E, Chattanooga, TN

37402, Phone: (423) 535-5801, Fax: (423) 535-8149

Email: richard_mathis@bcbst.com

Research Objective: To determine if highenergy extracorporeal shock wave therapy

(ESWT) is an effective treatment for plantar fasciitis. If effective, this would indicate a need for BlueCross BlueShield of Tennessee's

(BCBST) Medical Policy to be changed from investigational to medically necessary, thereby making it eligible for coverage by our fully insured accounts. Published studies on shock wave therapy for this indication were conflicting or inconclusive.

Study Design: Multicenter Case Series.

Physicians and facilities were invited to participate in the study and enroll patients who met the inclusion criteria (see Population

Studied section below). Enrollees were administered pre and post-treatment surveys utilizing a Visual Analogue Scale (VAS) pain score. Surveys were collected and the data analyzed.

Population Studied: BlueCross BlueShield of

Tennessee covered members treated by participating physicians and facilities. Inclusion criteria were: ·Refractory heel pain for six months despite at least a minimum of two cortisone treatments unless contraindicated or three months of NSAIDS unless contraindicated; and

·Failure of x-rays or other appropriate imaging study to rule out any other potential cause; and

·Failed response to one or more conservative modalities after use for a minimum of six weeks

(i.e., physical therapy, casting, walking boots, night splints, over-the-counter orthotics, heel cup, or heel cushions, custom molded foot orthotics, trial of change to oxford or running shoe, or other by arrangement with the designated BlueCross BlueShield of Tennessee

Medical Director.)

Principle Findings: An evaluation of the intensity of pain, pre-and post-treatment, was conducted using a paired sample t-test on the type of pain (morning, resting, and active). Of the 54 participants who responded to the pre and post-survey responses, 36 registered at least

a 50% reduction in pain. This indicated a success rate of 67% using various criteria.

Conclusions: High-energy ESWT is an effective means of testing plantar fasciitis. This means that many treated with this modality should be able to avoid open surgery and the associated rehabilitation. BCBST's Medical Policy was changed to reflect a medically necessary determination provided certain medical appropriateness criteria are met (such as the failure of conservative treatment)


This study indicates the benefit of a health plan partnering with physicians and facilities to conduct a pilot study on a treatment where the published results are conflicting or inconclusive.

• Characteristics of Veterans Admitted to

Veterans Health Administration (VA)

Hospitals with Acute Myocardial Infarction

(AMI)

Kelly McDermott, M.A., Predoctoral, Charles

Maynard, Ph.D., Anne E. Sales, Ph.D., Elliott

Lowry, Ph.D., Stephan Fihn, M.D., M.P.H.

Presented By: Kelly McDermott, M.A.,

Predoctoral, Research Assistant, VA Puget Sound

HCS, Department of Veteran Affairs, 511 E. Roy

Street, #313, Seattle, WA 98102, Phone: 206-366-

5271, Fax: Email: kmcdermo@u.washington.edu

Research Objective: Unlike many other health care systems, most medical centers operated by the Department of Veteran Affairs (VA) do not routinely receive patients through the emergency medical system leading to not only a relatively low volume of patients with AMI, but also a substantial proportion of patients who present relatively late after symptom onset. Because of these circumstances, the outcomes of patients with the most serious form of AMI, ST-elevation myocardial infarction (STEMI), might be more similar to those of patients with non-STEMI

(NSTEMI) than in other systems of care. We sought to compare the characteristics and outcomes of patients with STEMI and NSTEMI who were admitted to VA facilities during FY04-

05.

Study Design: We performed a retrospective cohort study using a national 100% sample of inpatients discharged from VA facilities with a diagnosis of STEMI or NSTEMI using data from detailed, standardized abstracts of the medical record (External Peer Review Program) for patients admitted during FY04-05 and from national patient care databases.

Population Studied: A total of 12,243 patients were admitted to VA facilities with a discharge diagnosis of STEMI (n=2,231) or NSTEMI

(n=10,012) in FY04-05 excluding those transferred in from the community and those experiencing an AMI after hospitalization. In addition, only the first admission for each patient is included in this analysis.

Principle Findings: Patients with STEMI were younger (mean 65.6 vs. 69.4, p<0.001), were less likely to have coexisting conditions, and were less likely to have been on cardio-protective medications (aspirin, beta-blockers, ACE inhibitors, antiplatelet agents and lipid lowering medication) prior to admission. Patients with

STEMI were more likely to present to a surgerycapable hospital (57.8% vs. 52.9% p<0.001) and during night hours (21.1% vs. 16.9% p<0.001).

Although patients with NSTEMI were more likely to present more than 12 hours after symptom onset, a considerable proportion of both groups arrived after this optimal time for treatment. (37% vs. 52% p<0.001). Unadjusted mortality was similar for patients with STEMI and NSTEMI (in-hospital 8% vs. 7% p=0.169, 30day 10% vs. 11% p=0.789). However, patients with STEMI had a significantly higher likelihood of both in-hospital (OR=1.86 p<0.001) and 30day (OR=1.62 p<0.001) mortality after adjustment for age, presenting symptoms, medical conditions, biomarkers, time of arrival, and treatment.

Conclusions: Among the population of AMI patients admitted to VA facilities during FY04-05, there were notable differences in the characteristics of those with STEMI versus

NSTEMI. In adjusted analysis, patients with the more severe diagnosis of STEMI had a much higher likelihood of both in-hospital and 30-day mortality.


Understanding the patient characteristics and outcomes of the VA AMI population is essential for developing valid policies and appropriate interventions to improve the quality of care for patients with AMI in the VA.

Funding Source: VA

• Center for Information Dissemination and

Education Resources: A Unique VA/HSR&D

Resource for National Dissemination Aimed at Translating Research into Practice

Geraldine McGlynn, M.Ed., Diane Hanks, M.A.,

Karen Bossi, M.A., Laurel Nevinslong, M.S.

Presented By: Geraldine McGlynn, M.Ed.,

Director, VA Boston Healthcare System, Center

for Infromation Dissemination and Education

Resources, 150 South Huntington Avenue,


(857) 364-4511 Email: geraldine.mcglynn@va.gov

Research Objective: 1) To disseminate important findings and information from VA’s

Health Services Research and Development

Service (HSR&D) to policy makers, managers, clinicians, and researchers throughout the

Veterans Health Administration (VHA), as well as the larger health care community, and 2) To support and promote the use of evidence-based research in decision-making to improve the health and care of veterans.

Study Design: HSR&D created and funded the

Center for Information Dissemination and

Education Resources (CIDER) as a unique, national resource center to plan, develop and implement activities and products that provide an informational bridge between the developers of new knowledge and information (the researchers) and the users of that knowledge and information (policy makers, managers, and clinicians). Each CIDER activity, event, and product is designed to identify and promote effective and efficient strategies that will improve the organization and delivery of health care to veterans at both the patient and system levels.

CIDER’s primary target audience for products and publications are senior managers and policy makers, whose decisions directly impact the system-wide operations of VHA, the largest integrated healthcare system in the country.

CIDER also produces other activities and products that target the broader VA management and healthcare community. The poster will describe the CIDER process, several key activities, products and impacts.

Examples include: 1) Publication Briefs ---- synopses of current journal publications based on research conducted by VA/ HSR&D researchers ---- written for senior management to make them aware of new findings that could affect clinical practice. 2) The Cyber Seminars

Program employs state-of-the art, web-based conferencing technology enabling dynamic interaction among participants at multiple sites nation-wide. This Program has allowed many of the VA Quality Enhancement Research Initiative

(QUERI) Centers to share knowledge that improves our understanding of the processes involved in implementing evidence into practice.

3) State-of-the-Art Conferences (SOTA) identify what we know about important health care topics, gaps in our knowledge, and methods for developing strategies to close those gaps. 4)

Enhancing and improving the web and webbased technologies, as well as targeted electronic dissemination that increase the uptake of evidence.

Population Studied: Managers/Decision

Makers

Principle Findings: Busy VHA managers and policy makers want accessible, accurate, and timely research evidence/information to inform their decision-making. CIDER works to meet this need by developing and disseminating Briefs on important HSR&D findings to VA Senior

Managers; conducting both live and on-demand

Cyber Seminars for targeted groups; planning, facilitating and disseminating products from

SOTAs on topics of importance to veterans’ health care; creating forums for dialog and collaboration between researchers and managers; and working to continuously enhance the impact and uptake of HSR&D research findings.

Conclusions: Translating research into practice is not a ‘‘one size fits all’’ process. CIDER employs multiple methods to disseminate important health services research findings to specifically targeted VA stakeholders to improve patient care and system performance.


Targeting VA managers and policy makers with accessible, accurate, and timely research evidence and information enables them to make evidence-based decisions that improve the cost, quality and outcomes of VA care.

Funding Source: VA

•

Case Study How to Increase the Value of

Administrative Data

Sofia Medvedev, Ph.D., Samuel Hohmann,

Ph.D., Michael Oinonen, Pharm.D., M.P.H.

Presented By: Sofia Medvedev, Ph.D., Program

Support Analyst, Clinical Information

Management Services, University HealthSystem

Consortium, 2001 Spring Road, Suite 700, Oak

Brook, IL 60523, Phone: 630-954-4890, Fax: 630-

954-5879 Email: medvedev@uhc.edu

Research Objective: o To describe the use of line item billing data in conjunction with normalized UB-92 administrative discharge data oTo illustrate how performance improvement opportunities can be identified with integrated data oTo delineate important implications of combining the data

Study Design: Retrospective cross-sectional analysis of UB-92 administrative discharge data and high-impact line item billing data were used

to count the discharges. Population based rates were generated and compared.

Population Studied: Inpatients and outpatients who received invasive cardiology procedures in calendar year 2005 from more than 100 hospitals using the database at the University

HealthSystem Consortium (UHC).

Principle Findings: There were wide variation among hospitals of total PTCA procedures, for example, one hospital performed higher proportion of total PTCA procedures on outpatients (36%) than the rest of UHC member hospitals combined (9%). Fewer outpatients were prescribed statins (a cholesterol-reducing drug) than inpatients, although there was considerable variation among hospitals. The amount of statins prescribed for PTCA outpatients was less than half the amount prescribed for PTCA inpatients. There was considerable variation in physician practice related to implanting coronary artery stents, whether bare metal or drug-eluting. Patterns of use of CK and CKMB laboratory tests among inpatients and outpatients were similar among hospitals. Outpatients were less likely to have 4 or more coronary artery stent implants. The age distribution of patients also showed wide variation.

Conclusions: Analysis has shown variation in the use of these clinical resources by care setting, physician, and patient demographics.

Some of the variation can be addressed with operational strategies (e.g., standardizing physician preference items), while others require a better understanding of the source of the variation, including validation of data collection. This insight can lead to the development of profiles of resource use by setting, patient cohort, physician, etc.


There are many implications of combining clinical resource utilization information with standard hospital discharge administrative data.

These include the ability to ensure effective revenue capture, to apply evidence-based medicine to practice, to compare performance against national benchmarks and hospitals exhibiting best practices, to pursue performance improvement opportunities (clinical and operational), and to educate clinicians on appropriate use of the data.

Funding Source: UHC

•

Patient Centered Decision Making in Using

High Risk Treatment in Multiple Sclerosis

Management

Linda Moore, Ed.D., M.S.N.

Presented By: Linda Moore, Ed.D., M.S.N.,

Associate Professor of Nursing, School of

Nursing, UNC Charlotte, College of Health &

Human Services, 9201 University City Boulevard,

Charlotte, NC 28223, Phone: (704) 687-7964,

Fax: (704) 687-6017 Email: lmoore@uncc.edu

Research Objective: Patient centered shared decision making for treatment of Multiple

Sclerosis, MS, is a dynamic process for this chronic progressive, debilitating, incurable disease. Engaging patients in decisions to begin, continue, or stop potentially lethal FDA approved treatments hoping to reduce disease progression and/or improve quality of life without affecting longevity, epitomizes decisional complexity and uncertainty. For MS patients who initiated the chemotherapy (Novantrone), the purpose of this study was to assess patient perceptions and expectations of chemotherapy related to actual clinical changes.

Study Design: A one group interrupted time series design was used to identify patterns of change in quality of life and symptoms.

Participants were assessed over time at baseline,

3 weeks after chemotherapy every 3 months with each dosage for maximum of two years. The 59 item Functional Assessment of Multiple

Sclerosis, FAMS, was used to assess the 7 dimensions of quality of life including: mobility, symptoms, emotional well being, contentment, thinking/fatigue, family, social well being. An additional investigator developed MS symptom visual analogue scale provided data pre and post chemotherapy. Participants were asked to comment about treatment aspects qualitatively.

Population Studied: Of twenty subjects enrolled, the age range was 20 to 60 years with a majority being Caucasian females. The approximate time since diagnosis ranged from 1 year for the very aggressive form of relapsing remitting, RRMS, to over 10 years for secondary progressive, SPMS. The majority of participants had RRMS with frequent exacerbations occurring as often as every 6-10 weeks or MRI scans indicating aggressive demyelination.

Principle Findings: Data for the expectations and perceptions of treatment have just been completed with reported findings regarding reasons for continuing or discontinuing high risk treatment that does not alter longevity or cure. Majority of those discontinuing chemotherapy did so because they saw no physical or mental improvement in their clinical status, even though they acknowledged the absence of exacerbations. Others discontinued

due to the new evidence of increased risk of the medication

Conclusions: Clinically, both from neurological assessment and MRIs, the drug has been found to be beneficial, but there was no data prior to this study on patient’s perceived expectations, benefits, or adverse effects that would contribute to the complex decision of agreeing with medical recommendations for a high risk treatment modality that had uncertain outcomes either from long term benefits or from long term side effects.


Health care providers need to be consciously aware of patient perceptions and expectations continuously during this on going difficult decision of therapy with uncertain benefits, and uncertain short and long term effects. While these participants verbally could state that the goal of treatment was to maintain the current quality of life, there was evidence from the findings that expectation was to improve the disease process and make them better. Patient preferences for adhering to recommended therapy is a shared decision making, dynamic process, especially when the long term effects can lead to potentially new terminal illnesses.

Funding Source: Serono Pharmaceuticals

• Per-Patient-Per-Month Drug Costs in

Medicare Part D Protected Classes

Lisa Mucha, Ph.D., Neal Masia, Ph.D., Kirsten

Axelsen, M.S.

Presented By: Lisa Mucha, Ph.D., Lead

Researcher, Outcomes Research, Thomson

Medstat, 150 Cambridge Park Drive, Cambridge,

MA 02140, Phone: 617-492-9331, Fax: 617-492-

9365 Email: lisa.mucha@thomson.com

Research Objective: The objective of this study was to estimate per patient per month (PPPM) costs of medications in the six Medicare Part D protected classes based on findings among

Medicare and dual eligible beneficiaries with drug coverage prior to enactment of the benefit.

Study Design: Data were from the Thomson

Medstat Marketscan Medicare and Medicaid claims databases. Costs were aggregated within each class, including patient-paid and plan-paid amounts. These costs provided the numerators for the PPPM calculations. Denominators were defined as the aggregated patient months for only those individuals who filled a drug within a particular class. Drugs covered under Part B were excluded.

Population Studied: The study sample was constructed by identifying patients who were enrolled either in Medicare or dually in Medicare and Medicaid in 2004.

Principle Findings: The classes where generic formulations were available (antidepressants and anticonvulsants) showed lower PPPM costs

($45.31 and $50.97, respectively). The costliest class was the antiretrovirals ($1,028.13) for dual eligible patients including those age 64 and under. Among the dual eligibles over 65, immunosuppressants were the costliest

($657.72). In the Medicare group, the cost of immunosuppressants ($814.86) was substantially higher than the other five classes.

The PPPM cost over all 6 classes for Medicare was $54.75, for dual eligibles it was $157.99, and

$116.35 for all patients.

Conclusions: The presence of high cost drugs in a class may lead to concern that protecting that class would mean an increased burden on Part

D. However, as as the results of this study show, actual drug claims reveal a differential by age and also by whether the patient was a dual eligible or eligible only for Medicare. Also, there is likely a mitigating presence of lower costs drugs, whether they are generic formulations or simply lower cost branded drugs within most classes. PPPM costs were not uniformly high among all the protected classes. The claims data in this study allowed a ‘‘real world’’ check of how much the protected classes may impact the finances of Part D.


There are differences within the classes between the dual eligible and Medicare patients, and also within the dual eligibles by age. This is an important message to policy makers that a change to the structure of the protected classes in Part D may have differential effects across and also within classes by Medicare solo or dual eligibility.

Funding Source: Pfizer, Inc.

• Exploring the Relationships Between

Dementia-Care, Quality Indicators and Patient

Outcomes

Daniel Murman, M.D., M.S., Elizabeth Dobie,

M.P.H., George Divine, Ph.D., Jennifer Elston

Lafata, Ph.D.

Presented By: Daniel Murman, M.D., M.S.,

Academic Physician (Neurologist), Department of Neurological Sciences, University of Nebraska

Medical Center, 982045 Nebraska Medical

Center, Omaha, NE 68198-2045, Phone: (402)

559-4086, Fax: (402) 559-9213 Email: dlmurman@unmc.edu

Research Objective: Little is known about the impact of receiving recommended dementia care on patient outcomes. We derived 23 quality indicators from evidence-based and expertopinion recommendations for ambulatory dementia care, including dementia assessment, psychosocial intervention, pharmacologic treatments, and co-morbid disease management. We examined the relationships between receiving recommended dementia care and three patient outcomes (i.e. quality of life, satisfaction with care, and costs of care).

Study Design: Cross-sectional design examining outcomes in patients with dementia after two years of care. Receipt of quality indicators was determined from administrative data, mailed caregiver survey responses and medical record chart abstraction. Caregivers rated the patient’s quality of life (Euroqol EQ5D score) and their satisfaction with the patient’s health plan

(CAHPS 2.0) in a mailed survey. Costs of the patient’s care were determined from administrative data and log transformed for statistical modeling. Mean differences in outcome measures were compared for those receiving or not receiving each quality indicator, using generalized estimating equations (GEE) that adjusted for provider clustering and five covariables (Dementia Severity Rating Scale,

Neuropsychiatric Inventory Questionnaire,

Charlson Co-morbidity Index, age and marital status). Significant GEE differences are reported

(p<0.05)

Population Studied: 326 subjects met inclusion criteria for a caregiver survey of which 178 completed the survey. Inclusion criteria included

ICD-9 code for dementia, chart abstraction evidence of dementia diagnosis, two year enrollment in managed-care health plan with pharmacy rider prior to 2005, a visit to dementia care physician during observation period, alive at time of survey, and permission of primary physician to contact patient. We report on the

178 survey respondents here, with the following characteristics: 57% female; 35% black; and mean age 77.5 years.

Principle Findings: In multivariable GEE models of quality of life scores, receipt of recommended care was associated with significantly higher scores for use of memantine for moderate to severe dementia and lipid testing in patients with co-morbid conditions. Significantly lower scores were associated with a referral to community resources and receipt of quality indicators for advanced directives and assignment of an alternative decision maker. In GEE models of satisfaction with the health plan, significantly higher satisfaction was seen in those receiving annual mental status examinations, patient and caregiver education, community resource referral, and lipid testing in high risk patients. In

GEE models of cost of care, significantly higher costs were associated with receipt of the advanced directive quality indicator, and significantly lower costs were associated with receiving diagnostic lab tests, annual functional assessments, annual HbA1c monitoring of diabetics, and lipid testing of high risk patients.

Conclusions: Multiple, dementia-care, quality indicators are associated with important outcomes in ambulatory dementia patients.

Future studies should explore further the impact of receiving recommended dementia care on patient outcomes, using larger samples, longitudinal designs and by combining individual indicators into a summary score


Further research is needed before the impact of improving adherence to evidence-based and expert opinion recommendations for ambulatory dementia care can be determined, including the use of dementia-care, quality indicators in payfor-performance programs

Funding Source: Alzheimer's Association

•

Implementation of a Medication

Reconciliation Process in the Division of

Primary Care Internal Medicine Clinics

Claudia Nassaralla, M.D., Ph.D., James M

Naessens, M.P.H., Sc.D., Rajeev Chaudhry,

M.D., M.P.H., Melanie Hansen, R.N., Sidna

Scheitel, M.D., M.P.H.

Presented By: Claudia Nassaralla, M.D., Ph.D.,

PGY3, Internal Medicine, Mayo Clinic, 200 First

Street Sw, Rochester, MN 55905, Phone: 507-529-

0956, Email: nassaralla.claudia@mayo.edu

Research Objective: This prospective study was designed to evaluate the causes of medication list inaccuracy, and implement interventions to enhance the overall accuracy of medication lists.

Study Design: This study was an extension of the initial benchmark study to encompass 5

PCIM outpatient clinics housed in the same facility. The study setting was the division of primary care internal medicine which consisted of 5 clinics with 32 staff physicians, 6 fellows and

95 residents. The study took place over 8 months with one multi-intervention. Prior to the intervention, baseline data was collected and

analyzed assessing the completeness and correctness of medication documentation in the electronic medical record. Completeness is defined as including medication name, dose, frequency and route, which was assessed by reviewing the medication list available in the electronic medical records (EMR) of randomly selected patients from a pool of all patients seen in the clinics during the study periods.

Correctness is defined as having no discrepancy between the documented medication list and the medications the patient is actually taking at home which was assessed by calling the patients at home. The intervention consisted of: 1) communicating the results of the baseline data collection to staff physicians and LPNs; 2) defining what constitutes a complete medication list to all physicians and LPNs; and 3) providing personalized feedback of baseline measures to

LPNs. A second data collection was undertaken 1 month after the intervention to re-assess the accuracy of medication lists. Medication lists are defined as accurate when they are complete and correct.

Population Studied: A subset of the adult population of the City of Rochester who are patients of the Primary Internal Medicine Clinic outpatient at Mayo Clinic.

Principle Findings: Completeness of individual medication items improved from 76.5%

(baseline) to 84.7% (post intervention).

However, the completeness of the entire medication lists only improved from 20.4% to

45.1%, p<0.001. The major causes of incomplete documentation of medication lists prior to implementing intervention was the lack of frequency (15.4%) and route (8.9%) of medication items within a medication list. In addition, documentation of over-the-counter and

‘‘as needed’’ medications was often incomplete.

The correctness of the entire medication lists improved from 29.5% to 48.1%, P<0.001.

However, the correctness of individual medication items worsened from 89.1% to

61.9%, p<0.001. The major causes of incorrectness in a medication list were due to misreporting of medications by patients or failure of clinicians to update the medication list when changes were made.

Conclusions: We found it easier to improve completeness than correctness of a medication list. The improvement of completeness of a medication list can be accomplished by giving personalized feedback to the LPNs who are responsible to initially create a preliminary note with the patient’s medication list. However, to improve the correctness of medication lists it is necessary to have an active participation of patients.


An increasing number of patients with multiple medical problems are being cared for in the outpatient setting. The complexity of these patients poses a challenge for primary care physicians to maintain the quality and continuity of patient care, while minimizing medication errors. Updated and accurate medication lists would greatly minimize drug-related morbidity and improve patient health outcome.

• Pneumonia Management: Comparing the

Hospitalists and the General Teaching Teams

Kimtuyen Nguyen, B.S., Denise Hodo, B.A.,

Stephen Goggans, M.D.

Presented By: Kimtuyen Nguyen, B.S., medical student, Internal Medicine, Medical College

Georgia, 1300 Warren Hites Drive, Apt. C104,

Augusta, GA 30901, Phone: (404)542-9534, Fax:

Email: knguyenmd@students.mcg.edu

Research Objective: The primary aim of this study was to compare adherence to guidelines regarding pneumonia management put forth by the Joint Commission on the Accreditation of

Healthcare Organizations, Infectious Disease

Society of America, and the Advisory Committee on Immunization Practices between nonacademic hospitalists and traditional General

Medicine teaching teams in an academic medical center.

Study Design: We obtained information from the Quality Management office of a 478-bed adult academic hospital on patients who were discharged between Jan 1st 2005 and Dec 31st

2005 with the principal diagnosis of pneumonia.

All patients cared for by the hospitalists and a random sample of patients cared for by the teaching teams were included in the study. All information was extracted through chart review by the Quality Management office and the researchers. Five guidelines were analyzed, including appropriate pneumococcal vaccine, flu vaccine, antibiotic treatment, smoking cessation counseling, and stable discharge criteria. In addition to guideline compliance, length of stay and mortality rate observed from the two groups were also recorded and compared.

Population Studied: Our patients were mostly from the small city of Augusta, Georgia. The median age of the patients for both groups was

58 with a range of approximately 75. The median number of comorbidities for our patient was two with the teaching teams having a wider range of

nine vs. four for the hospitalists. Approximately

45% of the patients were white and 52% were males. Patients in the study at admission had a median number of pneumonia severity index between 72 and 84.

Principle Findings: Sixty-five patients were treated by the hospitalists and 161 by the academic physicians. A composite adherence score ranging from 0 to 5 for each guideline appropriately followed was created for each patient. On average, the hospitalists and the teaching teams adhered to 3.4 and 3.5 out of five guidelines, respectively, a difference that was not statistically significant. When the guidelines were looked at individually, however, general medicine teaching teams were better at providing appropriate pneumococcal and flu vaccine with 45% adherence vs. 27% (p = 0.014) and 81% adherence vs. 42% (p = 0.007), respectively. There were no significant differences in adherence to the other individual guidelines. In regards to mortality and length of stay, after controlling for pneumonia severity index, there was no significant variation in mortality rate, but general teaching teams on average kept patients four days longer with a borderline significant p value of .0512.

Conclusions: In our setting, there was no significant difference in overall quality of care for hospitalized patients with pneumonia. General teaching teams provided appropriate pneumococcal and flu vaccinations significantly more often than nonacademic hospitalists.

Patients cared for by hospitalists had a shorter length of stay with no negative effect on stability at discharge.


Implementing a hospitalist program, as a single intervention, does not necessarily guarantee improved quality of care. Additional measures should be considered to ensure guideline compliance.

• Assessing the Preference in the Direction of the Internal Patient Flow in Rural Japan

Hisateru Ohba, Master of Medical Science,

Takumi Tanikawa, M.Med.Sc., Katsuhiko

Ogasawara, Ph.D., Tsunetaro Sakurai, Ph.D

Presented By: Hisateru Ohba, Master of

Medical Science, , Medical Informatics,

Hokakido University Graduate School of medicine, N15 W7, Sapporo, 060-8648, JP,

Phone: +81-11-706-6017, Fax: +81-11-700-5608

Email: hohba@cc.hirosaki-u.ac.jp

Research Objective: The objective of this study is to assess the direction preference of the patient flow between secondary medical care areas (SMCAs) to clarify the characteristics of the patient flow in the Hokkaido, Japan and to identify the characteristics of the PI in comparison to the outflow rate.

Study Design: The survey data of 79,814 inpatients and 1,408,724 outpatients in Hokkaido in May 2000 were used. The ‘‘Preference Index of migration (PI)’’ developed by Roberto Bachi was applied to evaluate the patient flow. Two central SMCAs (Sapporo and Kamikawa-Chubu) of 21 SMCAs were chosen as the target area of analysis.

Population Studied: The National Health

Insurance Patients; inpatients: 79,458 people, outpatients: 1,402,231 people (except the patients who had a check-up with medical institutions outside Hokkaido)

Principle Findings: The inflow areas (PI>100) of

Sapporo indicated a large distribution, while that of Kamikawa -Chubu was distributed in the neighboring SMCAs. There were no outflow areas (PI>100) for Sapporo. Three outflow areas for Kamikawa-Chubu were found in the neighboring three SMCAs. The outflow areas determined by PI>100 were different from those obtained by the outflow rate (5%). We found that the PI was not always in proportion to the outflow rate.

Conclusions: This study indicate that many patients in whole area visit the Sapporo SMCA, the patients in the noththern area visit the

Kamikawa-Chubu SMCA, and the PI reflect the patient migration in neighboring SMCAs in comparison to the outflow rate.


The PI will become a useful index to design the

Medical Care Plan because it is able to objectively analyze the preference for each direction of the patient flow and to establish the patient migration areas.

•

Proxy Decision Making for Those with

Intellectual Disabilities: Approving Periodic

Dental Care

Fredrick Orkin, M.D., M.B.A., S.M., Kathleen M.

Fisher, R.N., Ph.D., Michael J. Green, M.D., M.S.,

Vernon M. Chinchilli, Ph.D., Anand

Bhattacharya, B.P.T.

Presented By: Fredrick Orkin, M.D., M.B.A.,

S.M., Adjunct Professor, Anesthesiology, Yale

University, 400 Weekeepeemee Road,

Woodbury, CT 06798-1621, Phone: 203 405-1084,

Fax: 203 263-4939 Email: fredrickorkin@yahoo.com

Research Objective: 1. Identify the relative importance of factors in proxy decision making for a vulnerable population, individuals with intellectual disabilities, ID, for common preventative health care, periodic comprehensive dental care; 2. identify decision making patterns among subjects in use of specific factors; and 3. relate decision making patterns to subjects demographic characteristics.

Study Design: In a one hour interview, each agency director completed an anonymous survey regarding demographic and work characteristics, and a simulation exercise. The latter involved 20 hypothetical ID clients described on individual cards using 6 factors, at several factor levels, suggested in focus groups and a mailed survey.

Content of each card was set by a factorial experimental design. Each subject ranked the cards in order of their likelihood of approving the care. Conjoint analysis transformed each subjects rankings into factor utilities, from which percentage contribution, or importance, of each factor in the decision was computed. We used cluster analysis to identify common decision making patterns based on subjects utilities, and

Kruskall Wallis test and contingency table analysis to relate decision making patterns to subjects demographic characteristics.

Population Studied: 50 directors of agencies randomly selected from 262 licensed agencies providing residential services, including health care, for persons with ID in a large northeastern state.

Principle Findings: Subjects were middle aged, with mean 48 y and 95 pct CI 45 to 51, 62 pct female, with substantial experience with ID: mean years working with MR 22, 95 pct CI 18 to

25; mean years in decision making role 11, 95 pct

CI 9 to 14. Whereas 58 pct had a college degree,

30 pct had a masters and 8 pct a doctoral degree. 52 pct made health care decisions for clients at least monthly. Overall, subjects rankings weighted the importance of Quality of

Life, 24 pct; Individuals Wishes, 23 pct; Family

Input and Individuals Age, both 18 pct; Extra

Cost to Agency beyond reimbursement, 13 pct; and Functional Status, 3 pct. Underlying these group weightings were discrete decision making patterns: 4 subgroups of 8 subjects, or 16 pct each, weighted importance as 43 to 57 pct for

Quality of Life, Individuals Wishes, Family Input, or Individuals Age, while 14 subjects, or 28 pct, weighted Family Input 26 pct and Individuals

Wishes 32 pct, and only 4 subjects, or 8 pct, emphasized Extra Cost, weighting it 50 pct.

Subjects demographic characteristics did not discriminate among decision making patterns.

Conclusions: In this simulation, agency directors responsible for preventative health care decisions, such as dental care, for individuals with ID relied heavily on factors relating to the well being and autonomy of the individual and wishes of the family. Only a small minority of directors relied on factors unrelated to the individual with ID.


That several disparate decision making patterns were used suggests that more explicit guidance is needed.

Funding Source: NINR

•

Proxy Decision Making for Those with

Intellectual Disabilities: End of Life Care

Fredrick Orkin, M.D., M.B.A., S.M., Kathleen M.

Fisher, R.N., Ph.D., Michael J. Green, M.D., M.S.,

Vernon M. Chinchilli, Ph.D., Anand

Bhattacharya, B.P.T.

Presented By: Fredrick Orkin, M.D., M.B.A.,

S.M., Adjunct Professor, Anesthesiology, Yale

University, 400 Weekeepeemee Road,

Woodbury, CT 06798-1621, Phone: 203 405-1084,

Fax: 203 263-4939 Email: fredrickorkin@yahoo.com

Research Objective: 1. Identify the relative importance of factors in proxy decision making for a vulnerable population, individuals with intellectual disabilities, or ID, for withholding medical treatment, Scenario B1, and aggressive medical treatment, Scenario B2, at end of life; 2. identify decision making patterns among subjects in use of specific factors; and 3. relate decision making patterns to subjects demographic characteristics.

Study Design: In a one hour interview, each agency director completed an anonymous survey regarding demographic and work characteristics, and simulation exercises. The latter involved 20 hypothetical ID clients described on individual cards using 8 factors, at several factor levels, suggested in focus groups and a mailed survey.

Content of each card was set by a factorial experimental design. Subjects were randomly allocated to rank the cards in order of their likelihood of withholding or approving the care.

Conjoint analysis transformed each subjects rankings into factor utilities, from which percentage contribution, or importance, of each factor in the decision was computed. We used cluster analysis to identify common decision making patterns based on subjects utilities,

Mann Whitney U test to compare mean utility values by scenario group, and Kruskall Wallis test

and contingency table analysis to relate decisionmaking patterns to subjects demographic characteristics.

Population Studied: 50 directors of agencies randomly selected from 262 licensed agencies providing residential services, including health care, for persons with ID in a large northeastern state.

Principle Findings: Subjects were middle aged, with mean 48 y and 95 pct CI 45 to 51, 62 pct female, with substantial experience with ID: mean years working with MR 22, 95 pct CI 18 to

25; mean years in decision making role 11, 95 pct

CI 9 to 14. Whereas 58 pct had a college degree,

30 pct had a masters degree and 8 pct a doctoral degree. 52 pct made health care decisions for clients at least monthly. B1 and B2 groups were similar, except that a higher proportion of subjects allocated to Scenario B1 had moderately or very strong religious faith: P eq 0.005. Overall, subjects rankings weighted the importance of

Individuals Wishes, 31 pct for Scenario B1 and 32 pct for B2; Family Input, 15 and 14 pct;

Prognosis, whether care would likely add 6 months life, 10 and 15 pct with P eq 0.043 for difference; Quality of Life, both 11 pct; Extra Cost to Agency beyond reimbursement, 12 and 9 pct;

Individuals Age, both 9 pct; State Regulations, 8 and 6 pct; and Functional Status, 3 and 4 pct.

Underlying these group weightings were several discrete decision making patterns, but subjects demographic characteristics did not discriminate among patterns.

Conclusions: In this simulation, agency directors responsible for health care decisions, including end of life care, for individuals with ID relied heavily on factors relating to the well being and autonomy of the individual and wishes of the family. Prognosis was weighted modestly but significantly more when deciding whether to aggressively treat rather than withhold medical treatment at the end of life.


That several disparate decision making patterns were used suggests that more explicit guidance is needed.

Funding Source: NINR

• The Impact of the Accreditation Process on

Organizational Culture and Quality Practices in Primary Health Care Organizations

André Paccioni, Ph.D., Claude Sicotte, Ph.D.

Presented By: André Paccioni, Ph.D., Postdoctoral researcher, Center for Interdisciplinary

Research in Rehabilitation of Greater Montreal,

6300, Darlington avenue, Montreal, H3S 2J4,

CA, Phone: (514) 576-0246, Email: andre.paccioni@umontreal.ca

Research Objective: To describe and understand the effects of the accreditation process on the organizational culture, defined as a managerial philosophy, and on quality management practices in two community healthcare centers in Montreal, Canada.

Study Design: A combined qualitativequantitative approach pre and post-accreditation was used. The qualitative component included two group interviews and 35 semi-structured interviews with key informants, as well as nonparticipative observations and document analyses. As for the quantitative component, a structured questionnaire was distributed to all employees of both organizations at the pre and post-accreditation phases. An integrative analytical model was used to analyze the effects of the accreditation process in a sequential manner, first on organizational culture changes and then quality management practices changes.

Population Studied: The survey was based on a pre (n=178) and post (n=150) questionnaires addressed to all employees from support services to managers including all clinicians

(Mds, RNs, social worker, etc). The interviews were conducted with managers such as the focus groups.

Principle Findings: Results of the qualitative analysis show that the accreditation process promoted the emergence of team-consultation mechanisms and the strengthening of the participation of representatives on the different professional groups. The accreditation process made clearer organizational problems that, until then, were perceived as sources of inter-service conflict. One of the main objectives of the accreditation process was to improve the evaluation of user satisfaction. Self-evaluation was probably a key moment of collective expression of expectations on the part of both caregivers and professionals. It also provided managers with the opportunity to witness another way of being attentive to their subordinates’ suggestions, in order to foster human resources development while keeping organizational contingencies in mind. Said contingencies concern the organizational integration of constant improvement, given the unstable context of health-system restructuring in Quebec as illustrated by the creation of, among other things, the Centers for Health and

Social Services. As for the quantitative data, they show that the accreditation process has but little impact on employees’ perception of the values

conveyed within the organization. This result suggests that the foundations and objectives of the accreditation process are poorly understood and integrated by most of those not directly involved in it

Conclusions: Pre and post-accreditation results did not showed any significant differences between the two primary health care organizations in terms of respondents’ perception of their respective organizations’ organizational culture, or of their quality management practices. Both organizational cultures were rather hierarchical, indicating that the accreditation process is an external and bureaucratic control mechanism


Results suggest that the quality management practices must compose with the plural culture of the organization by treating the problems according to several approaches.

Funding Source: CIHR

• Practice Facilitation, Properties of a

Complex Adaptive System and Outcomes of

Primary Care for Patients with Type 2

Diabetes

Michael Parchman, M.D., M.P.H., Jacqueline

Pugh, M.D., Raquel Romero, M.D., Walter

Calmbach, M.D.

Presented By: Michael Parchman, M.D., M.P.H.,

Associate Professor, VERDICT Research Center,

South Texas Veterans Health Care System, 7400

Merton Minter Boulevard (11C6), San Antonio,

TX 78229-4404, Phone: 210-617-5314, Fax: 210-

567-4423 Email: parchman@uthscsa.edu

Research Objective: Prior research has characterized primary care clinics as a complex adaptive system. (CAS) Practice facilitation is an intervention that leverages CAS properties by creating time for learning and reflection among members of the clinic, fostering relationships, and encouraging them to develop change strategies that take into account their unique environment, resources and culture. The purpose of this study is to examine the effect of a practice facilitation intervention on control of

A1c, blood pressure (BP) and lipids as well as patient self-care behaviors among patient with type 2 diabetes seen in primary care clinics.

Study Design: A pre-post study in 5 primary care clinics. Each clinic received an average of 12 visits by a trained practice facilitator over a 7 month period of time. (December 2005 to June

2006)

Population Studied: The study was conducted in 5 diverse, autonomous primary care clinics.

Approximately 40-50 patients with type 2 diabetes were recruited to participate in each clinic. Patients completed pre and postintervention surveys and had their medical records abstracted for dates and values of A1c,

BP and lipid levels. Of the 237 patients who agreed to participate, 166 returned the initial survey and 162 of those returned the follow-up survey one year later.

Principle Findings: A surprising diversity of strategies was undertaken by different clinics in an effort to improve risk factor control among their patients with type 2 diabetes including: implementing a diabetes registry, group clinic visits, initiation of point-of-care testing for A1c and lipids, placing all patients with diabetes in blue colored charts with a diabetes flow sheet on the outside front cover, a change in officer routine in recording and acting on BP results, a telephone recall system for patients not seen in

3-6 months, and a re-organization of clinic staff and diabetes education programs. Across all 5 clinics, there was no significant change in A1c or

LDL-cholesterol values pre and post-intervention.

There was a significant decline in systolic blood pressure values. (p=0.03) However, when examining only those patients with poor control of A1c, BP or lipids prior to the intervention, there was a significant improvement in each risk factor post-intervention. There was also a significant improvement in patient-reported medication adherence (p=.009) and self-care activities (p<.001) for all patients.

Conclusions: Practice facilitation is an intervention that is feasible in primary care clinics, leverages the CAS properties of the clinic, and may be effective in improving outcomes of care for patients with type 2 diabetes.


Primary care clinics are unique setting where one-size-fits-all approaches are unlikely to produce a consistently positive result. The design of interventions to improve patient outcomes in primary care clinics must take into consideration the underlying fundamental properties of the system: that of a CAS.

Funding Source: National Institute of Diabetes,

Digestive, Kidney Disorders (NIDDK)

•

Health Behaviors of Older Chinese Adults

Living in New York City

Nina Parikh, Ph.D., M.P.H., Marianne C. Fahs,

Ph.D., M.P.H., Donna R. Shelley, M.D.

Presented By: Nina Parikh, Ph.D., M.P.H.,

Senior Research Associate, Brookdale Center on

Aging, Hunter College, CUNY, 425 East 25th

Street, New York, NY 10010, Phone:

212.481.4807, Fax: 212.481.3791 Email: nparikh@hunter.cuny.edu

Research Objective: Older immigrants present a growing challenge to policy makers concerned with optimal resource allocation to promote healthy aging in urban neighborhoods. Little is known about health risks in Chinese Americans, the largest Asian immigrant group in the U.S., since most previous research has aggregated this population, masking important health disparities that exist among specific Asian subgroups. This paper examines the health behaviors, including current smoking status, physical activity, alcohol use, and body mass index (BMI) of older Chinese adults by using population-based data

Study Design: We analyzed individual-level data from the New York City Chinese Health Study

(NYC CHS). The CHS is the largest populationbased household sample of Chinese residents aged 18-75 living in two distinct communities in

NYC. The sample was based on representative households, and individuals within households were selected as eligible sample participants using a complex multi-stage systematic stratified sampling design. Sample data were weighted to account for unequal probabilities of sample selection and non-response. The overall response rate of the CHS baseline survey was

57.8%. Trained bilingual interviewers conducted in-person household-based interviews in English,

Mandarin, Cantonese, and Fukinese with 2,537 respondents, and comprehensive information was obtained from the survey instrument across several domains, including health behaviors, health care utilization, employment, smoking knowledge and attitudes, acculturation, and demographic factors and SES.

Population Studied: The analytical sample included 517 respondents from the NYC CHS who were aged 55 and older.

Principle Findings: Logistic regression modeling was used to assess the association between demographic, socioeconomic status, acculturation, and health characteristics and selected health behaviors. Of particular interest were measures of acculturation, which overall, did not have an independent effect on the health behaviors of older Chinese adults, except for women and alcohol consumption, and men and physical exercise. Differences by gender were demonstrated for alcohol consumption controlling for other factors. The paper presents further results of descriptive and multivariate analyses of the relationship of social, economic, and cultural factors to selected health indicators including physical activity, obesity, alcohol consumption, and smoking status.

Conclusions: As immigrant populations age, it becomes increasingly important to understand and address the complexity of social determinants of healthy urban aging. Moreover, acculturation may not play as large a role in promoting healthy behaviors among older adults compared with their younger counterparts.


Limited research on older immigrant populations not only highlights the need for additional studies examining the health status and behaviors of these groups, but also requires a better understand of the relationship between acculturation and health of this vulnerable population. Findings will help inform preventive medicine practice in identifying and developing effective disease risk assessment strategies and targeting culturally-informed health promotion initiatives among older immigrant populations.

Funding Source: NCI

• Efficacy of a Referral Lipid Clinic for

Difficult to Treat Dyslipidemia Patients

Brian Peek, Pharm.D., Joy B. Evans, Pharm.D.,

Antoine Al-Achi, Ph.D., Angela Porter, Pharm.D.,

Angela Pentecost, Pharm.D.

Presented By: Brian Peek, Pharm.D.,

Coordinator, Research and Development,

Research/Pharmacy, Asheville VAMC, 1100

Tunnel Rd, Asheville, NC 28805, Phone: (828)

298-7911 x15525, Fax: (828) 299-5907 Email: brian.peek@med.va.gov

Research Objective: Assess the effectiveness of a consult driven, multidisciplinary clinic's management of difficult to treat dyslipidemia patients.

Study Design: Retrospective chart review of patients referred for dyslipidemia management.

Lipid profiles including total cholesterol, LDL-C,

HDL-C, and triglycerides were recorded. In addition the number of visits, medication profiles and adverse events of treated patients were collected. A gain score value was collected to assess lipid parameter difference between beginning and end of study period for each of the lipid components. This study was approved by the facility’s IRB and R&D committees.

Population Studied: Patients referred via an electronic consult for focused dyslipidemia

treatment were evaluated for inclusion. One hundred twenty-three male patients and two women met study criteria. Mean age was 63.9 years with 25% greater than 71 years old. All patients had not meet lipid treatment goals with usual care at referral and 47 % had reported adverse events to dyslipidemia medications.

Principle Findings: A mean LDL reduction of

29.8% was observed with p<0.0001, and 73.2% of patients met their LDL goal. Mean triglyceride reduction was 30.9%. An average of 2.64 visits corresponding to 19.26 weeks, was required to reach goal.

Conclusions: Inability to reach lipid treatment goals is common, and is complicated by comorbid conditions, and frequent reports of adverse events. This study demonstrates that focused multidisciplinary management can achieve treatment goals in elderly, difficult to manage patients failing therapy with usual care.


Difficult to treat dyslipidemia patients can efficiently reach goals in a referral based lipid clinic. Referral criteria can be adjusted to select the most appropriate patients to receive focused care. Multidisciplinary clinicians with specialized knowledge provide a cost effective mechanism to treat patients requiring intensive and frequent interventions. This approach may be used to assist health care systems meet performance standards for lipid management.

Funding Source: VA

• Hispanics Perceptions about Internet

Health Information: Implications for

Healthcare Providers

Ninfa Pena-Purcell, Ph.D., C.H.E.S.

Presented By: Ninfa Pena-Purcell, Ph.D.,

C.H.E.S., Visiting Assistant Professor,

Department of Health Studies, Texas Woman's

University, P.O. Box 425499, Denton, TX 76204,

Phone: 940-898-2863 or 915-433-0825, Fax: 940-

898-2859 Email: npurcell@mail.twu.edu

Research Objective: To investigate Hispanics’ perceptions about Internet health information.

Study Design: A secondary data analysis utilizing the Impact of the Internet and

Advertising on Patients and Physicians, 2000-

2001 survey.

Population Studied: Hispanic and non-

Hispanic White adults >18 years of age.

Principle Findings: Hispanics (29.3%) compared to Whites (36.2%) were less likely to access Internet health information in the past year. A higher proportion of Hispanic females

(30%) than Hispanics males (23.6%) used this resource. Hispanics compared with Whites reported less agreement that Internet health information improves understanding of their condition and treatment (Hispanics M = 1.65;

Whites M = 1.50) and gives confidence to speak with their physician (Hispanics M = 1.67; Whites

M = 1.47). Unlike their White cohorts (M = 2.68)

Hispanics (M = 2.25) were more likely to agree that health information found on the Web helped them take care of their health. Appraisal of

Internet health information between Hispanics and Whites was comparable: they agreed information was easy to find (Hispanics M = 197;

White M = 1.94) and they had concerns regarding reliability (Hispanics M = 2.01; Whites

M = 2.13). The odds for using Internet health information were increased for Hispanic females

(OR = 1.223, p < .05) compared to Hispanic males. Access to this resource decreased among Hispanics earning middle (OR = .262, p

< .001) and low (OR = 1.103, p .521) income compared to those with higher salaries.

Conclusions: Findings from this study suggest that Hispanics view Internet health information positively; however, the physician-patient relationship is not greatly affected.


Public health efforts are needed to increase use of Internet health information among Hispanics over the age of 18. Consideration must be given to increasing health literacy and computer skills.

Programs addressing this concern must be culturally relevant with attention given to linguistic barriers. Strategies to reduce digital disparities among Hispanics will likely help them become empowered and educated consumers thus favorably impacting their health outcomes.


• Modeling Recent Victimization and

Depression in Homelessness

Brian Perron, M.S.S.W., David Pollio, Ph.D.,

David Gillespie, Ph.D.

Presented By: Brian Perron, M.S.S.W., Doctoral candidate, Social Work, Washington University,

One Brookings Drive, St. Louis, MO 63130,

Phone: 314/255-7262, Fax: Email: beperron@wustl.edu

Research Objective: To test the influence of victimization on depressive symptoms among homeless persons with serious mental illness.

Study Design: Victimization is a common problem among homeless, seriously mentally ill populations. Previous research has suggested

that recent victimization is negatively associated with service use, and is differentially impacted based on variables such as age and mental illness. However, research to date has not modeled relationships among victimization, mental illness, and mediating factors. This study tested a model in a homeless service-using population, hypothesizing that recent victimization will be associated with increased recent depressive symptoms with perceived safety as a partial mediating factor. The hypothesized model was initially tested for the entire sample using structural equation modeling (SEM). Depression was measured by total symptoms reported during the previous two months using items from the Diagnostic

Interview Survey and Psychiatric Epidemiology

Research Interview. Victimization reflects the sum of five different types of victimization for the same period. Perception of safety was measured using items from the Lehman Quality of Life

Instrument. Subsequently, the model was tested using an SEM multiple group framework against five different variables (age, gender, homeless duration, substance use disorder, and psychotic disorder) hypothesized to influence the parameter estimates of the model.

Population Studied: Data for this study were derived from the Access to Community Care and

Effective Services and Supports (ACCESS) program. ACCESS was an 18-site, five-year project intended to improve individual functioning, quality of life, and housing outcomes for homeless persons with serious mental illness. The total analytic sample size was 12,909.

Principle Findings: Approximately 42% of the subjects reported at least one form of victimization. The overall model exhibited a good fit with the data (RMSEA=.032, GFI=1.0).

As hypothesized, victimization was positively associated with depression (ß = .06, p <.001) and negatively associated with perception of safety (ß = -.27, p < .001). Perception of safety was negatively associated with depression (ß = -

.33, p < .001). The model explained approximately 13% of the variance in depression.

The multiple group analyses revealed that the influence of victimization on depression was the greatest among women with substance use disorders (ß = .13, p < .001) and/or a psychotic disorder (ß = .12, p < .001). The positive effect of perceived safety on depression was substantially higher for persons with a psychotic disorder (ß = -.39, p < .001) compared to those without a psychotic disorder (ß = .27, p < .001).

Conclusions: This study supports the hypothesized model; victimization influences depressive symptoms, with perceived safety as a partial mediator. The effect of victimization appears strongest for women with a substance use or psychotic disorder.


Service providers should assess for recent victimization when providing services for homeless adults with serious mental illnesses.

Differential responses to victimization suggest the need for assessment, particularly for vulnerable women, and the potential for tailored interventions focusing on increasing either the perception of, or actual, safety for the homeless population.


• Victimization in Adolescent African-

American Substance Abuse Treatment

Clients: Prevalence, Associations, and

Implications for Treatment Planning

Brian Perron, M.S.S.W., Heather Gotham, Ph.D.,

Dong Cho, Ph.D.

Presented By: Brian Perron, M.S.S.W., Doctoral candidate, Social Work, Washington University,

One Brookings Drive, St. Louis, MO 63130,

Phone: 314/255-7262, Fax: Email: beperron@wustl.edu

Research Objective: Victimization is a traumatic life event that seriously challenges an individual’s resources and can negatively impact developmental processes in adolescents. Prior studies of adolescents have reported that victimization is associated with problems such as psychopathology, substance use, suicidality, physical aggression, and delinquent behavior.

Long-term consequences of victimization have also been described in the literature. The purpose of this study was to examine the prevalence of victimization among an understudied treatment population, African-American adolescents, and explore its associations with other clinical and psychosocial problems.

Study Design: Data for this study were derived from a larger treatment outcome study on substance abuse treatment in a large Midwestern city using a standardized clinical assessment called the Global Appraisal of

Individual Needs (GAIN). The GAIN contains scales and survey items related to eight domains: demographics, substance use, physical health, risk behaviors, mental health, environment, legal, and vocational. Victimization was measured by the General Victimization Scale

(GVS). The GVS is a 15-item scale based on dichotomous items (1=yes, 0=no). Four items ask whether respondents ever experienced four different types of victimization; four items reflect concern about future victimization ---- one item for each type of victimization; seven items ask about traumagenic factors, which are the circumstances surrounding victimization. Data were summarized using descriptive statistics.

Bivariate associations were tested using chisquare tests, from which effect sizes were computed.

Population Studied: This study included 259 participants who self-identified as African-

American. 84% were male, ranging in age from

12 to 17 years (Mean = 14.96, SD = 1.16).

Principle Findings: Half of participants reported lifetime victimization and one-quarter reported victimization during the past 90 days. The age of first abusive incident ranged from 4 to 17 years.

The most common type of victimization was being attacked with a weapon, which 45% of the participants reported. 22% reported being struck or beaten, 15% reported emotional abuse, and

4% reported being forced into sexual acts. 27% reported at least one type of victimization, and

22% reported two types. Past 90-day illegal activity, gang involvement, and conduct disorder exhibited the strongest associations with victimization. Contrary to prior research, gender was not related to prevalence or severity of victimization. Also, substance use disorders or recent substance use was not associated past

90-day, lifetime, or different types of victimization.

Conclusions: This study revealed that a high rate of victimization among African American adolescents in substance abuse treatment. The strongest correlates with victimization were measures of behavioral problems.


This study underscores the importance of comprehensive assessments in substance abuse treatment settings. One example of this is the need for assessing trauma and victimization separately from traumatic stress disorder, as diagnostic criteria for traumatic stress disorder alone do not overlap with victimization, nor necessarily identify those who may need help most. Also, the high risk and problem behaviors associated with victimization in this sample suggest the need to assist adolescents in identifying potentially threatening situations and developing strategies for minimizing risk of future victimization.

Funding Source: CSAT

• The Design of Performance Measures to

Improve Healthcare Quality

David Persaud, Ph.D.

Presented By: David Persaud, Ph.D., Associate

Professor, Health Services Administration,

Dalhousie University, 5599 Fenwick Street,

Halifax, Nova Scotia, B3T1R2, CA, Phone: (902)

494-1308, Fax: (902) 4494-6849 Email: d.persaud@dal.ca

Research Objective: To develop a performance management system that would enable healthcare managers to utilize information obtained from performance measures to modify healthcare activities and processes with the aim of improving health outcomes.

Study Design: Performance measures at the program, hospital, and system level from several countries were studied to determine if there were mechanisms in place to utilize feedback from measurement to improve care.

Population Studied: Performance measures that reflect populations at the program, hospital, and system level were assessed.

Principle Findings: We found that performance measures generally measure access to health care services or the quality of these services with the overarching intent of performance measurement being to improve the health status of the population. These measures can either inform on the activities performed in health care facilities (process measures) or the outcomes of these activities (outcome measures). But because of their intuitive appeal and the increased need for accountability, the recent trend has been to put more effort into assessing health outcomes rather than processes of care.

However, the greatest benefit of measuring health care performance is to improve the quality of services provided in terms of effectiveness and efficiency. This occurs when performance measurement serves to change activities that can result in improved outcomes. Unfortunately, it was observed that the vast majority of program, organizational and system level performance measures do not allow for the timely identification and improvement of the activities responsible for the outcomes being assessed. They are not linked to obvious processes which can be altered in an attempt to improve outcomes. This means that performance measures are generally not actionable ---- an important premise of performance measurement. This leaves an obvious gap between performance measurement

and the improvement in quality that measurement is meant to initiate.

Conclusions: We have developed a performance management system called systematic outcome mapping (SOM) that closes the loop between measurement and quality. This is a dynamic process that enables the continuous assessment of activities implicated in outcomes being measured. Linkages between processes and outcomes are delineated by utilizing combinations of evidence-based medicine, consensus conferences, Delphi techniques, and stakeholder input. Logic models and fishbone diagrams are then used to map the defined linkages. Instrument panels monitor the outputs and outcomes with the aim of comparing them to pre-determined benchmarks. When measures are outside of the ranges specified by the benchmarks, the a-priori mapped out processes are modified or changed with the intent of improving outcomes.


There is a need to develop performance measures that are actionable in order to fulfill the quality aspect of performance measurement and make it a management system rather than just a measurement system. The system developed in this study does that and can be used to improve healthcare delivery and the outcomes of care.

•

Coordinated Care in the Treatment of

Chronic Illnesses: The Importance of Primary

Care

Stephen Petterson, Ph.D.

Presented By: Stephen Petterson, Ph.D., Senior

Health Policy Researcher, Robert Graham

Center, American Academy of Family Physicians,

1350 Connecticut Avenue, N.W., Suite 201,


Fax: Email: SPetterson@AAFP.org

Research Objective: A growing body of research documents the efficacy and efficiency of coordinated care among health professionals in the treatment of chronic illnesses. Despite these findings, there is little systematic study of current patterns, in particular the extent of coordination among primary care and specialist physicians.

This study develops and estimates models to understand the extent to which health care is

‘‘shared’’ across a variety of both acute and chronic illnesses.

Study Design: Data is from the 2002 and 2003

Medical Expenditure Panel Survey, which includes longitudinal information about all medical events and the specialty of providers over a two-year period. The sample consists of

We define primary care providers as physicians in general practice, internal medicine, family medicine and pediatricians. Specialist physicians are defined as non-primary care physicians. We distinguish among three types of episodes: treatment over the course of a calendar year a) solely by primary care physicians, b) solely by specialist physicians and c) by a combination of primary care and specialist physicians. The study is restricted to persons reporting treatment for one or more of the following conditions: Mental disorders

(n=3133), Diabetes (n=2643), Heart Disease

(n=2805), Cancer (n=1929), Pulmonary

Conditions (n=4157), Kidney Disease (n=598),

Arthritis (n=3243), Hypertension (n=4711),

Cerebrovascular Diseases (n=338), Trauma

(n=3680), Back Problems (n=2100), and

Infectious Diseases (n=1494).

Population Studied: Adult non-institutionalized civilian population in the United States with treatment for a variety of medical conditions (see above).

Principle Findings: For the medical conditions examined in this study, we find relatively low levels of care where treatment is provided by both primary care and specialist physicians.

Rates of shared care vary from a low of 7% for hypertension to 24% for heart diseases.

Typically, a large proportion of patients receive care exclusively from primary care providers (e.g. treatment for diabetes, pulmonary conditions, hypertension and infectious diseases) or from specialists (e.g. cancer, and kidney diseases).

Finally, for certain broad category of illnesses such as mental disorders and heart disease, there is no clear predominance of either specialists or primary care providers.

Conclusions: The relative importance of primary care providers and specialists differ predictably in the treatment of certain broad groups of conditions. Still, even for conditions amenable to greater collaboration--e.g. mental health disorders or diabetes--there are very low levels of shared care.


Arguably, the future of medicine will embrace models of coordinated care for chronic illnesses in which specialists and primary care providers work together to provide cost-effective treatment.

The results of this study, particularly the overall low levels of share care, show that we are long way from this ideal. Further work is necessary to better understand factors that foster shared care; in turn, policies are required to encourage health

systems and physicians to develop, when appropriate, collaborative models of medical treatment .

Funding Source: Robert Graham Center

• Human Capital in the Nursing Workforce and Its Impact on Patient Outcomes

Ciaran Phibbs, Ph.D., Ann Bartel, Ph.D., Pat

Stone, R.N., Ph.D., Nancy Beaulieu, Ph.D.

Presented By: Ciaran Phibbs, Ph.D., Health

Economist, Health Econmics Resource Center,

VA Medical Center (152), 795 Willow Road,

Menlo Park, CA 94025, Phone: (650) 493-5000 x22813, Fax: (650) 617-2639 Email: cphibbs@stanford.edu

Research Objective: There is an emerging evidence base on the effect of nurse staffing levels on patient outcomes in acute care hospitals and increased interest in mandating nurse staffing ratios. But this focus on staffing levels ignores two important characteristics of the nursing workforce: skills and stability.

Guided by the theory of human capital, the primary purpose of this project is to move beyond analyses of nurse staffing levels and to provide a comprehensive econometric analysis of the impact of the skill level and the stability of the nursing workforce on nursing-sensitive patient outcomes.

Study Design: This is a longitudinal study using data from Veterans Affairs (VA) hospitals for the fiscal years 2003 through 2006. This project will first examine the relationship between nurse staffing and patient outcomes, and then add human capital variables to examine how they mediate the relationship between nurse staffing and patient outcomes. Measures of human capital are being derived from the VA’s

Personnel and Accounting Integrated Data

(PAID) system, which contains payroll data including employee qualifications, and employment history. Patient outcome variables were derived from the discharge abstract files.

All variables are being aggregated by month for each inpatient unit at each VA facility. Human capital variables include not only staffing (hours per patient day and skillmix) but also night and weekend staffing, certifications, tenure, employment status, stability of the provider team. Nursing sensitive patient outcomes were derived using the Agency for Healthcare

Research and Patient Safety Indicators software.

The outcomes being analyzed include those that there is previous evidence as being sensitive to nursing care delivery.

Population Studied: The initial analyses are being conducted using data from the VA’s medical (n=114) and surgical (n=98) intensive care units. The analysis will be extended to all

VA inpatient units.


This study will extend the literature on the relationship between nurse staffing and patient outcomes by using monthly data from each inpatient unit of the hospital. In contract, most previous studies have used annual data for all inpatients. The results should extend our knowledge on the relationship between nurse staffing and patient outcomes. A unique feature of our project is that we will be able to study nursing teams. For example, we can compare the impact on patient outcomes of a unit nursing staff that has worked together as a team for many months or years with a team that has been intact for a shorter period of time. A finding that the former staff is more productive (i.e. better patient outcomes) would indicate that hospitals should consider implementing teambuilding interventions and mechanisms to keep teams together. Our analysis will also enable us to compare the productivity of teams that are composed of regular full-time RNs with teams that have temporary nurses as members.


•

Pay for Performance and Incentives for

Quality Improvement

Christine Pierce, M.S.N., Judith J. Baker, Ph.D.,

C.P.A.

Presented By: Christine Pierce, M.S.N., Partner,

The Resource Group, P.O. Box 373, Richfield, OH

44286, Phone: (330) 659-2324, Fax: (330) 659-

2999 Email: cpierce@consultresourcegroup.com

Research Objective: Pay for performance is designed to reward providers for reporting their results according to predetermined outcome criteria. Also known as value-based purchasing, pay for performance consists of purchaserdefined quality measures for which health care providers supply their data and are in turn rewarded for their performance. This survey explores the current status of Medicare quality initiatives and that agency’s progression toward aligning financial reward with provider outcomes.

Study Design: The historic evolution of

Medicare quality initiatives, including demonstrations, for both the hospital and physician office settings was constructed within

a worksheet format. Major changes and additions to the programs were trended.

Population Studied: The unit of review was the quality program components

Principle Findings: Although still in its relative infancy, health care quality management is growing increasingly sophisticated with a focused attempt to align payment and performance. The Centers for Medicare and

Medicaid Services (CMS) lead their Quality

Improvement Roadmap with the following vision statement: The right care for every person every time, and acknowledge that the best way to help health care providers deliver high-quality, efficient care is to pay for it. Evolving Medicare quality initiatives and demonstration projects support this premise. For example, hospital providers are currently required to conform to a structured quality reporting program or else be financially penalized under Medicare’s inpatient prospective payment system (IPPS) via a reduction in the Medicare Annual Payment

Update. In the outpatient setting a physician quality reporting system, linked to a payment incentive, has been mandated for 2007 by the

Tax Relief and Health Care Act of 2006.

Medicare’s Hospital Compare program is one current example of a consumer-focused product that has been built upon voluntary reporting of hospital outcomes. Performance transparency will grow as an important component of provider marketing as consumer-driven health care continues to expand.

Conclusions: Pay for performance has been implemented in some settings as a new payment strategy for Medicare. In these cases it is beginning to replace the current system that tends to reward service utilization and high-cost complex procedures. It is still too early to fully assess outcomes and their implications.

Challenges to implementation include defining and quantifying the outcome criteria and managing the data with what are often inadequate provider information systems.


Health care providers must be aware of the evolving trends in quality management and, in order to preserve financial viability, they must develop systems and processes that will facilitate achieving and reporting specific performance outcomes.

Funding Source: Centocor, Inc.

•

The Effects of Consumer-driven Health Care on Cost and Utilization

Christine Pierce, M.S.N., Judith J. Baker, Ph.D.,

C.P.A.

Presented By: Christine Pierce, M.S.N., Partner,

The Resource Group, P.O. Box 373, Richfield, OH

44286, Phone: (330) 659-2324, Fax: (330) 659-

2999 Email: cpierce@consultresourcegroup.com

Research Objective: Rising healthcare premiums for employers have spurred the need for an insurance approach beyond that of historic managed care plans. Economically engaging patients in their healthcare decisions is an evolving trend that seeks to alleviate some of the employer burden and promote consumer responsibility for resource selection and consumption. This study explores the current status of consumer-directed health care products and the implications for employers, consumers and health care providers.

Study Design: The historic evolution of consumer-driven health care products was constructed within a timeline format and the related legislative and regulatory changes were superimposed. A worksheet was developed to illustrate the current variety of available products including cost, benefits detail, consumer eligibility and participation, as well as other impacts.

Population Studied: The unit of analysis was the individual consumer-driven product.

Principle Findings: Initiatives in this realm have grown significantly over the last four years. A summary of findings follows. The category of consumer-driven health care now includes a wide variety of approaches toward applying principles of consumerism to health care, ranging from health savings accounts to disease management programs, resulting in cost savings and changes in utilization. Legislative and regulatory changes have supported the growth of consumer-driven health care and furthered acceptance among employers and employees across the United States. As recently as

December, 2006, favorable health savings account legislation was signed in to law as part of the Tax Relief and Health Care Act of 2006.

Conclusions: The intent of consumer-driven health care products is two-fold: decreasing employer health benefit costs while encouraging better educated employees to make higher quality health decisions toward improved health care outcomes. Although the impact on costs and utilization are readily measurable, clinical outcomes evaluation is in its infancy and will continue to shape this trend as it matures.


Employers, consumers and health care providers must be made aware of the options and ongoingly evaluate the results in order to better

select economical health insurance approaches that also produce quality outcomes. Additionally policy makers must consider the potential need for regulatory and legislative changes to support such initiatives.

Funding Source: Centocor, Inc.

• Measuring Lead Screening in Children

Enrolled in Medicaid

Donna Pillittere, M.S., Dana Rey, M.P.H., Rich

Mierzejewski, M.S., Philip Renner, M.B.A., Sarah

Scholle, M.P.H., Dr.P.H.

Presented By: Donna Pillittere, M.S., Director,

Quality Measurement, National Committee for

Quality Assurance (NCQA), 2000 L Street, Suite

500, Washington, DC 20036, Phone: (202) 955-

1736, Fax: (202) 955-3599 Email: pillittere@ncqa.org

Research Objective: To explore the potential for a performance measure to assess lead screening in children enrolled in Medicaid. Despite recommendations from the Centers for Disease

Control and Prevention (CDC) to screen children enrolled in federal health care programs, health plan data show that most children enrolled in

Medicaid do not receive lead screening.

Study Design: Observational study conducted in six health plans. Using administrative and medical record data, children who turned two years of age during the measurement year were identified. Determination was made whether these children had been screened for elevated lead levels during the measurement year.

Population Studied: Six health plans participated in the study by providing patientlevel administrative and medical record data. The enrollments of these plans included Medicaid members, with membership across several geographical regions of the U.S., and ranged in size from 16,000 to over 720,000 members.

Principle Findings: Prevalence of children who turned two years of age during the measurement year varied among plans based on the plans’ enrollment with a range from about 24 to 43 children 2 years of age per 1,000 members.

Medicaid plan performance how that there is variation between plans and quite a bit of room for improvement. Screening rates range from 35 to 82 percent using the administrative method and from 49 to 84 percent using the hybrid method (administrative supplemented by medical record review). With respect to the amount of screenings children received, most children received one and only one screening, though of the children who received screenings, across plans, there were between 17 and 39 percent of children who received more than one.

With respect to gender of children at first lead screening, of those children who had been tested, male children tended to have slightly higher rates with a range of about 51 to 53 percent over female children with a range of 47 to 49 percent across the 3 plans. With respect to age of children at first lead screening, of those children who had been tested from the eligible population, a first lead screening test occurred most often between the ages of 13-18 months (54 percent). Across plans, 2.07 percent of children who were screened and who had blood level results in their medical record showed levels of >

10 µg/dL. These numbers are higher that the

U.S. prevalence which has been found to be 1.6

% (1999-2002). (Rischitelli et al.)

Conclusions: This study showed low rate of lead screening in children enrolled in Medicaid. In addition, elevated lead levels were found to be higher than the US prevalence.


Measurement of lead screening is feasible. The existence of standardized metrics may provide and opportunity for national benchmarking and potential for improvement.

Funding Source: CDC

• Differentials in Survival Rates and Triage to

Trauma Centers between Elderly and Non-

Elderly Following Motor Vehicle Crashes in

Florida

Etienne Pracht, Ph.D., Barbara Langland-Orban,

Ph.D., David J. Orban, M.D., Lewis Flint, M.D.

Presented By: Etienne Pracht, Ph.D., Assistant

Professor, Health Policy and Management, USF,

COPH, 13201 Bruce B. Downs Boulevard, MDC

56, Tampa, FL 33612-3805, Phone: (813) 974-

7609, Fax: (813) 974-6741 Email: epracht@health.usf.edu

Research Objective: The elderly (65 years and older) have historically been an important segment of the Florida population. Older age is associated with reduced physiologic reserve and greater comorbidities, underscoring the need for special consideration of the elderly in a medical setting. This may be particularly true in the case of trauma such that elderly trauma patients may not initially present as a trauma alert. The objectives of this research are (a) to identify time trends in trauma and trauma related fatality rates between elderly and non-elderly patients hospitalized following a traffic crash; (b) to determine whether seriously injured elderly

patients are triaged to designated trauma centers (DTCs) following a MVC at rates similar to non-elderly patients; and (c) to differentiate survival rates among elderly and non-elderly trauma patients who are hospitalized following a crash.

Study Design: Descriptive methods are used to construct a profile of hospitalized motor vehicle accident victims in Florida based on location, type of accident, comorbidities, severity, and mortality with a focus on age using statewide hospital data. Multivariate logistic regression methods are then used to model the odds of being transported to a DTC.

Population Studied: All seriously injured adults, ages 18 and over, hospitalized in Florida from

1991 to 2005.

Principle Findings: Trends indicate that MVC related trauma hospitalizations increased significantly during the decade from 1991 to

2000 while leveling off thereafter. MVC trauma related fatality rates among the elderly were substantially higher, measured both in terms of a proportion of injured and per 10000 people, in each year studied. Furthermore, elderly trauma patients have lower survival rates at all levels of severity when compared with the non-elderly population. Surprisingly, elderly MVC related trauma victims are significantly less likely to be triaged to a DTC even after controlling for patient demographic characteristics, distance, the type of accident, and the severity of the primary injury.

Conclusions: The findings suggest the need to implement strategies to reduce occurrence of

MVCs involving the elderly, to improve access to trauma centers by providing a DTC in the six

Florida regions that currently lack a trauma center, and to reassess emergency medical systems triage criteria and protocols to integrate the special needs of the elderly and improve triage decision making.


The Florida experience is important as it has the potential to direct other states’ policy decisions to prevent and appropriately triage MVC injuries among the elderly.

• The Application and Outcomes of a

Comprehensive Performance Improvement

System

Jan Pringle, Ph.D., Lois Edmondston, B.S.,

Anthony Snow

Presented By: Jan Pringle, Ph.D., 3401 Fifth

Avenue, Falk Clinic, Room 454, Pittsburgh, PA

15213, Phone: (412) 647-4304, Email: lae19@pitt.edu

Research Objective: The University of

Pittsburgh’s School of Pharmacy (UPSOP) has been developing a comprehensive performance improvement system that involves substance use disorder providers regularly collecting information from clients during and even following treatment, receiving reports based upon the data collected, and learning how to use the reports to make indicated clinical/programmatic changes.

Study Design: Residents: All current residents are required to complete a monthly form which summarizes their status in each area being studied; education, abstinence, employment, and criminal justice involvement. The data are entered into an Access database. Reports are produced and given to program representatives monthly, quarterly, and annually. Post-

Discharge: Discharged clients are contacted monthly until 6 months post-discharge. The interview concentrates on the status of the following aspects of their recovery: employment, housing, criminal justice involvement, and abstinence. Data are entered into an Access database. Reports are produced and given to the program representatives monthly.

The reports are used by the program to continually monitor the progress of the residents and determine any areas where clinical/programmatic changes may be necessary. All forms were developed through a collaboration of UPSOP and program leadership.

Population Studied: UPSOP has been applying this system to a ¾ way house program located in Pittsburgh, Pennsylvania with notable success.

A ¾ way house provides men who are involved in the local criminal justice system with a safe, sober, and supportive environment to begin recovery while attending outpatient treatment.

The program objectives are to help the residents continue their recovery plan by participating in outpatient treatment, 12-step meetings, 5MC aftercare meetings, life skills training, and sober recreational activities and to help the residents reintegrate into their community with permanent stable housing and independent living skills.

Principle Findings: The results of the application of this comprehensive performance improvement system were as follows: Results from the most recent interview of residents currently in the program indicate 52.4% of the residents are employed or actively seeking employment, 97.4% have no probation/parole violations, 90.5% have had no relapse, and

85.7% are currently enrolled in or have completed an educational program. At 6 months post-discharge, clients interviewed reported 95.7% reside in stable housing, 88.1% have not relapsed, 91.5% have no probation/parole violations, and 42.6% are employed.

Conclusions: The presentation or poster will discuss how the program used the data to make specific programmatic changes to improve overall performance, and the role of the UPSOP in providing ongoing technical assistance and mentoring.


This approach can be applied to other similar programs in order to better meet the needs of clients by enhancing program services via a realtime data collection and reporting system.

Funding Source: PA Department of Health,

Bureau of Drug and Alcohol Programs (BDAP)

• Clinician Perceptions of an Electronic

Medical Record in the Emergency Department

Tanjala Purnell, M.P.H., B.S., Ann McAlearney,

Sc.D., Deena Chisolm, Ph.D.

Presented By: Tanjala Purnell, M.P.H., B.S.,

Research Assistant, Center for Innovation in

Pediatric Practice, Columbus Children's Hospital

Research Institute, 700 Children's Drive,

Building J1401, Columbus, OH 43205, Phone:

614-355-3613, Fax: 614-722-3544 Email:

PurnellT@pediatrics.ohio-state.edu

Research Objective: Understanding factors associated with clinician acceptance and satisfaction with new clinical information technology is important to developing effective implementation plans. The objectives of this study are to measure clinician perceptions of the recently implemented Epic eChart electronic medical record system in the Columbus

Children’s Hospital Emergency Department and to determine how user perceptions change over time.

Study Design: Physicians and nurses from the emergency department were recruited to complete an online survey at three points in time

6 weeks, 12 weeks, and 6 months post implementation. This abstract presents results from the first time period. Potential predictors of satisfaction studied include perceived usefulness, perceived ease of use, and attitudes toward using technology, as well as user demographics and general attitudes toward clinical and CIT. Bivariate relationships between satisfaction and each potential predictor were assessed using the chi-square test.

Population Studied: Thirty physicians and nurses currently working in the emergency department were recruited using email solicitation. 81 percent of study participants were female, and 59 percent were younger than age 40. An additional 30 clinicians from the emergency department and urgent care clinic where the Epic system has been installed will be included in the study’s final analysis.

Principle Findings: Overall, 38.5 percent of participants agreed that they were completely satisfied with system reliability and functionality and would recommend use of Epic to clinicians at other pediatric institutions. Satisfaction levels were significantly correlated with users’ primary roles, perceived ease of use, and general attitudes toward CIT. 60 percent of nurses but only 25 percent of physicians agreed that they were completely satisfied with both functionality and reliability and would recommend the system to other clinicians. Participants who agreed that

CIT makes health care safer and more efficient with only limited disruptions in workflow or care scored higher on satisfaction than those who disagreed. Higher perceived ease of use scores were also associated with higher satisfaction scores.

Conclusions: Only 40 percent of users were completely satisfied with initial reliability and functionality of the system and would recommend use to clinicians at other pediatric institutions, suggesting continued opportunities for improvement. Subsequent data collections will determine whether this improves over time.

Perceived ease of use and attitudes about CIT were significantly correlated with satisfaction levels; yet, age and gender were not.


Health care organizations must place emphasis on improving general attitudes about CIT and undertake efforts to reduce or eliminate barriers associated with perceived ease of use prior to implementation in order to improve clinician acceptance and satisfaction rates. Physicians may also require special attention. Our results suggest that concerns about age as a barrier to

CIT acceptance may be overstated in ambulatory settings.

Funding Source: Columbus Children’s Research

Institute

•

The Association Between Local Nursing

Home Bed Supply and Transition to

Institutional Residence Following Hip

Fracture

David C. Radley, M.P.H., Daniel J Gottlieb, M.S.,

Elliott S. Fisher, M.D., M.P.H., Anna NA

Tosteson, Sc.D.

Presented By: David C. Radley, M.P.H., PhD

Candidate, Dartmouth Medical School, Center for Evaluative Clinical Sciences, HB 7251,

Hanover, NH 03766, Phone: 603.653.0832, Fax:

Email: david.radley@dartmouth.edu

Research Objective: Nursing home residence following hip fracture is costly and may not reflect patient care preferences at the end-of-life.

Our goal was to determine the relationship between local nursing home bed supply and institutional residence among persons with hip fracture.

Study Design: Persons with hip fracture were identified from MedPar claims files; the

Minimum Dataset (MDS) was used to record institutional residence prior to and at 6 months following fracture; Online Survey Certification and Reporting (OSCAR) data were used to measure the regional supply of nursing home beds at the hospital referral region (HRR) level.

Nursing home bed supply was adjusted to account for regional differences in age distribution. The primary exposure was local nursing home bed supply, measured as the ratio of beds per 1000 HRR residents to the national average. The primary outcome was nursing home residence at 6 months following hip fracture. People who died in a nursing facility prior to 6 months were considered to be residents. Sub-analyses evaluated 6-month and

1-yr mortality. Multivariate analysis was used to adjust for patient age, sex, race, comorbidity,

Medicaid status, type of fracture and repair, acute hospital length of stay, and regional demographic characteristics.

Population Studied: We studied Medicare beneficiaries with an incident hip fracture in

2000. Excluded persons were: enrolled in a

Medicare HMO, under the age of 65, hospitalized for hardware removal or repair of a previous hip fracture, and those who resided institutionally 30 days prior to their fracture and whose fracture appeared related to trauma or metastatic bone cancer. We analyzed data for

65,299 people.

Principle Findings: Age-adjusted nursing home bed supply varied 6-fold between regions with lowest and highest relative capacities. Observed nursing home residence at 6 months postfracture was 11% overall and showed a small, but significant, degree of variation across quintiles of nursing home bed supply: q1(9.5%), q2(10.8%), q3(11.1%), q4(11.9%) q5(10.9%). This trend remained after multivariate analysis. Relative to persons residing in the lowest quintile of nursing home bed supply, those residing in regions with a higher supply of nursing home beds were more likely to be institutionalized at 6 months following their fracture: q2(OR=1.21: 95%CI 1.11-

1.31), q3(OR=1.28: 1.18-1.39), q4(OR=1.37: 1.26-

1.48), q5(OR=1.24: 1.15-1.35). Nursing home residence was less likely among females

(OR=0.67: 0.63-0.71) and blacks (OR=0.84: 0.76-

0.94), while increasing age (OR=1.04 per year:

1.04-1.05), Medicaid enrollment (OR=1.34: 1.25-

1.43) and longer acute length of stay (OR=1.02 per day: 1.02-1.03) were associated with higher likelihood of institutional residence. There was no increased risk of death among persons residing in regions with smaller nursing home bed supplies.

Conclusions: Nursing home residence following hip fracture is more common in regions with higher supplies of nursing home bed supply, though this effect is attenuated in the regions with the highest capacities. There is no survival benefit in regions where there is a greater supply of nursing home beds.


While these findings suggest a small degree of supply-induced utilization of institutional nursing home care, it may more important to focus further research on the effects of nursing home capacity on cost and quality-of-life.

Funding Source: NIA

• Factor Structure of Four Scales to Measure

Outcomes of Patient-Centered Nursing Care

Laurel Radwin, Ph.D., R.N., Howard Cabral,

Ph.D, M.P.H.

Presented By: Laurel Radwin, Ph.D., R.N.,

Yvonne L. Munn Nurse Researcher, Yvonne L.

Munn Center for Nursing Research,

Massachusetts General Hospital, 275 Cambridge

Street, POB430, Boston, MA 02114, Phone: 617-

726-1018, Fax: Email: lradwin@partners.org

Research Objective: Evaluate the factor structure of four scales measuring outcomes of patient-centered nursing care (N-PCC).

Study Design: Desired health outcomes

(DHOs) of N-PCC, described by acutely ill cancer patient participants in a previously reported qualitative study, provided the basis for the development of four scales. Scale items were generated from the qualitative data and literature. Experts assessed the items for content validity; content validity was also assessed

through cognitive interviews with cancer patients. Pilot testing based on data from 66 cancer patients and using multitrait/multi-item analysis methods provided preliminary acceptable assessments of the scales’ convergent and discriminant validity (previously reported). Trust in Nurses (5 items), Cancer

Patient Optimism (4), Fortitude (4), and

Authentic Self-Representation (3) Scales were examined using confirmatory factor analysis in a new, larger sample. Goodness of fit statistics for evaluation were comparative fit index (CFI, criterion>.95), Tucker-Lewis Index (TLI,>.95), root mean square error of approximation

(RMSEA, <.06) and the standardized root mean square residual (SRMR, <.08). Cronbach’s alphas were calculated to assess the scales’ reliabilities.

Population Studied: Patient participants were recruited over an 18-month period from an inpatient hematology-oncology unit at New

England’s largest safety net hospital (N=178).

The majority were male (51.1%). The sample was diverse: 56% White; 28% African

American/Black; 1% Asian; 1% indigenous

American; 9% multiple race; 5% other race or the data were missing;11% Hispanic. Nearly 15% were non-English speaking at home. Mean age

58.4 years (sd=13.4). Nearly 30% did not complete high school, 33% had a h.s.diploma,

14% some college, and 25% completed college or beyond.

Principle Findings: The first model tested specifying ‘‘Desired Health Outcomes’’ as a single latent variable and the four scales as manifest variables did not fit the data. Four models were tested then with each scale as a latent variable with items as manifest variables.

Fit statistics were acceptable for the Authentic

Self-Representation Scale: CFI=1.0; TLI=1.0,

RMSEA<.001; SRMR<.001. A four item Trust in

Nurses Scale best fit the data: CFI=.99 TLI=.98,

RMSEA=.07, SRMR=.02.

Fit statistics indicated that the specified items for the Cancer Patient Optimism and Fortitude

Scales were different than originally conceptualized. Conceptual and statistical considerations offered by exploratory factor analyses guided respecification of the models.

The new Cancer Patient Optimism Scale (4 items) fit statistics were acceptable: CFI=.96;

TLI=.88, RMSEA=.15, SRMR=.04. The second scale was titled Cancer Patient Distress (4 items): CFI=.96; TLI=.89, RMSEA=.13,

SRMR=.04. Cronbach’s alphas for the scales were acceptable, ranging from .71 to .82.

Conclusions: Fit statistics indicated that four scales representing latent variables each with three or four items representing manifest variables resulted in models with better fit than a single model with one abstract latent factor and four distinctive manifest variable scales.


The IOM’s reports on quality have emphasized desired health outcomes as well as patientcentered care. These scales provide metrics to measure outcomes of patient-centered care that patients have identified as important, as well as extending the scope of nursing care quality measurement beyond the typically used adverse nurse sensitive events.


• Health Care Resource Utilization by

Caregivers of Dementia Patients in Virginia

Ateequr Rahman, M.B.A., Ph.D.

Presented By: Ateequr Rahman, M.B.A., Ph.D.,

Associate Professor, School of Pharmacy,

Shenandoah University, 1775 N. Sector Court, winchester, VA 22601, Phone: 540-678-4365, Fax:

540-665-1283 Email: arahman@su.edu

Research Objective: It has been estimated that between 2.2 to 3 million people in the country provide regular assistance to patients with dementia. Many are husbands or wives of the older people and are, themselves, limited in the activities they can perform. Caregivers also include other relatives such as daughters, daughter in laws, sisters and brothers, nieces, nephews, cousins and grandchildren, as well as friends and acquaintances. Various studies have reported elevated levels of depression and other health care problems among caregivers, but the causes and health consequences of burden are not always clear. The objective of this research was to determine if reported health care services utilization of caregivers significantly differed in terms of selected socio-demographic variables.

This study further studied the impact of care giving on the overall health care resource utilization of caregivers.

Study Design: A descriptive non-experimental design-utilizing survey instrument was used in this study. The population consisted of a nonrandom sample of caregivers of cognitively impaired persons in Virginia.

Population Studied: The investigators secured the subjects mailing lists by contacting the local community and church organizations. The caregivers received booklet-form survey containing demographic information sheet and

health care utilization scale. The inclusion criteria in the study were that the impaired person and the caregiver lived or used to live in a single shared household or the caregiver was directly responsible for providing care. That the caregiver had primary responsibility for the impaired person and that the caregivers did not receive financial compensation for their services

Principle Findings: A total of 110 questionnaires met the inclusion criteria. The data were entered and analyzed using the statistical package SPSS for windows, version 12.0. Research questions were tested using multivariate analysis of variance at an a priori alpha level of 0.05.

Female caregivers utilized more health care services than males. Caucasians utilized more health care services than other races (R2 = 0.32).

Married caregivers utilized more health care services than non-married (R2 = 0.21). Physician office visits, counseling, hospitalization and diagnostic services were the significant health care services utilized (R2 = 0.29).

Conclusions: Significant differences were observed in various socio-economic variables of caregivers as it relates to health care services utilization. By accurately measuring and identifying health needs and health care services utilization of the caregivers, it might be possible to more effectively address the special needs of caring for a dementia patient.


The knowledge gained through this study could serve as a base for development of specific interventions guided by patterns of health care utilization and health needs identified. These intervention or prevention techniques could be used to assist caregivers in maintaining their own health. This preliminary study may lay the groundwork for subsequent studies that examines the relationship between various sociodemographic factors and health care utilization of the caregivers of dementia patients.

Funding Source: Shenandoah University

• Feeding Tubes Insertion among Persons with Advanced Cognitive Impairment: Race

Matters

Ramona Rhodes, M.D., M.P.H., Orna Intrator,

Ph.D., Susan Mitchell, M.D., M.P.H., Vince Mor,

Ph.D., Joan Teno, M.D., M.S.

Presented By: Ramona Rhodes, M.D., M.P.H.,

Assistant Professor, Center for Gerontology and

Healthcare Research, Brown Medical School, 2


401-863-3635, Fax: 401-863-1742 Email:

Ramona_Rhodes@brown.edu

Research Objective: Previous research found a higher prevalence of feeding tubes among

African Americans, AA. Our goal is to examine whether incidence of feeding tube insertion differs between AA and white nursing home residents with dementia.

Study Design: Secondary analysis of the national repository of the 2000 Minimum Data

Set merged with Medicare Part A and B claims to examine the incidence of feeding tube insertion.

Persons were followed up for one year to determine whether there was a procedure code and/or physician billing indicating the insertion of feeding tube. Nine months survival status was monitored for persons who had a feeding tube inserted. Two multivariate models were estimated using GEE to adjust for clustering of

NH residents within hospital service areas since most feeding tubes were inserted in the hospital.

One multinomial logistic regression of one year feeding tube insertion incidence, controlling for death, and one logistic regression of 9-months mortality following feeding tube insertion were performed. All models tested the association of race, while adjusting for age, gender, ADL, CPS score, urban location, and length of stay.

Population Studied: AA and white NH residents age 65 and older, insured by Medicare, with advanced dementia, and without a feeding tube based on MDS assessment closest to April 1,

2000.

Principle Findings: Among the 62,916 NH residents 9.2 percent were AA, 76.4 percent were female, mean age 84.5 years. The incidence of feeding tube insertion was 100/1000 for AA NH residents compared to 28/1000 for White NH residents, p value less than 0.001. Even after adjustment for the above variables, AAs were more likely to have a feeding tube placed -- AOR,

2.9; 95 percent CI, 2.6 ---- 3.3 -- within nine months of baseline MDS assessment. Despite the increase rate of feeding tube insertion, we did not find evidence that AAs AAs were more likely than Whites to survive over a 9 months period following feeding tube placement -- AOR, 0.95,

95 percent CI, 0.8 ---- 1.2. The majority, or 69.3 percent, of feeding tubes were inserted during an acute care hospital stay.

Conclusions: AA are nearly three timely as likely to have a feeding tube inserted compared to whites. We did not find a clinically significant survival advantage with this increased rate of feeding tube insertion.


Future research should examine the roles that patient preferences, physician/patient communication, and cultural differences play in

making the decision to pursue insertion of feeding tubes and other more aggressive treatment modalities in African Americans with advanced disease states. Interventions can then be designed to enhance advanced care planning practices and physician/patient communication that is evidence-based, culturally sensitive, and improves the quality of life for patients and families of diverse ethnic backgrounds.

Funding Source: NIA

• Strategic Clustering and Product

Differentiation by Alcohol Vendors

David Ridley, Ph.D., Paul A. Zandbergen, Ph.D.

Presented By: David Ridley, Ph.D., Assistant

Professor, Health Sector Management, Duke

University, 1 Towerview Drive, Durham, NC

27708-0120, Phone: (919) 660-3784, Email: david.ridley@duke.edu

Research Objective: For decades the rationale for alcohol control policy has been the relationship between location of alcohol vendors and consumption. We examine location decisions of alcohol vendors.

Study Design: We compare clustering by on-site alcohol vendors (bars and restaurants) to off-site alcohol vendors (liquor and grocery stores). We use the difference in L-functions to estimate clustering.

Population Studied: We use precise location data from five cities for on-site alcohol vendors, off-site alcohol vendors, and public elementary schools.

Principle Findings: Bars exhibit the highest degree of clustering, followed by restaurants that sell alcohol, liquor stores, and offsite vendors excluding liquor stores.

Conclusions: The results support the extensive theoretical literature on clustering which indicates that vendors cluster more in markets with more differentiated products. Furthermore, we demonstrate that in contrast to the existing empirical literature, the proper measurement of clustering requires a comparison of clustering in multiple industries.


Theory suggests that proximity of alcohol vendors tends to increase competition.

Competition in alcohol markets might not be socially desirable, however, if it takes the form of lower prices and more lenient carding.

Funding Source: NIAAA

• Variation in Surname Analysis and

Geocoding in the Identification of Hispanic

Members in an HMO

Debra P. Ritzwoller, Ph.D., Anna Sukhanova,

M.S., Bridget Gaglio, M.P.H., Fabio Almeida,

M.S.W., Diego Osuna, M.D., Melanie Stopponi,

M.P.A.

Presented By: Debra P. Ritzwoller, Ph.D., Health

Economist, Clinical Research Unit, Kaiser

Permanente, 10065 E. Harvard Avenue #300,

Denver, CO 80231, Phone: 303-614-1317, Fax: 303-

614-1305 Email: debra.ritzwoller@kp.org

Research Objective: In order to address racial and ethnic disparities in both health care and in the delivery and receipt of behavioral health interventions, researchers and policy makers need information regarding the racial and ethnic mix of their target populations. In the absence of self-report data, research suggests that surname analysis combined with geocoded census data may provide accurate and efficient means of inferring race/ethnicity across health plan membership. The purpose of this paper is to use the ‘gold standard’ of self-report to examine the variation in surname analysis, geocoding, and the combination of surname and geocoding in the identification of Hispanic members of an

HMO.

Study Design: Using data derived from three behavioral interventions, we examined the agreement of race/ethnicity from selfidentification with the member’s Spanish surname match, and with geocoded data that provided estimates of the overall proportion of

Hispanic population in the member’s census tract. We employed the Generally Useful Ethnic

Search System (GUESS) to identify members with Spanish/Hispanic surnames. We then computed measures of sensitivity, and specificity.

Population Studied: The analyses employed data from three interventions currently underway at Kaiser Permanente Colorado: a tailored smoking reduction project, and a lifestyle behavior intervention, named Viva Bien, which targeted postmenopausal Latina women with type 2 diabetes at risk for CHD, and a Internetmediated program to enhance consumption of fruits and vegetables Making Effective

Nutritional Choices titled MENU.

Principle Findings: Of the 593 contacted regarding the smoking reduction study who responded to the Hispanic self-identification question, 44 self-identified as Hispanics, 25 mapped to the surname software, for a

sensitivity of 57% and a specificity of 96%. Only

15% of those self-identified as Hispanics lived in a census tract with reporting a Hispanic population of > 50%. Of the 1,188 female members who were contacted for the Viva Bien study and provided self identification of race/ethnicity, 177 self-identified as Hispanic, 139 mapped to the surname software, for a sensitivity of 79% and a specificity of 95%. Forty percent lived in a census tract with reporting a

Hispanic population of > 50%. Of the 466

Menu members who were contacted and responded to the Hispanic self-identification question, 134 self-identified as Hispanic, 122 mapped to the surname software for a sensitivity of 91%, an a specificity of 89%. Less than 5% lived in a census tract with reporting a Hispanic population of > 50%.

Conclusions: While the sensitivity of the surname identification varied greatly across the three target populations, the specificity remained quite high. The proportion of self-identified

Hispanics living in moderately or heavily

Hispanic areas was relatively low and variable.


Contrary to recent publications, our findings suggest that the sensitivity of a surname identification system may vary greatly, especially in a more integrated region, and in an insured population. Adding a census tract flag indicating that > 50% of the population is Hispanic does not always improve sensitivity or specificity of the surname system. More research is needed to better understand the optimal uses and limitations surname identification and geocoding for inferring the racial/ethnic composition of health plans.

Funding Source: NCI, NHLBI

• The Effects of Certificate of Need

Regulation on Hospital Costs

Dr. Patrick Rivers, Ph.D., M.B.A., Myron D.

Fottler, Ph.D., M.B.A.

Presented By: Dr. Patrick Rivers, Ph.D., M.B.A.,

Associate Professor & Director, Health Care

Management, Southern Illinois University, 1365

Douglas Drive -MC 6615, Carbondale, IL 62901-

6615, Phone: (618) 453-8842, Fax: (618) 453-7020

Email: privers@siu.edu

Research Objective: This study examines the impact of Certificate of Need Regulation (CNR) on Hospital Costs (HC).

Study Design: We applied a modified structureconduct-performance paradigm to a nationwide sample of American hospitals to investigate the impact of CNR on HC. For the investigation, we used secondary data from four sources: the

Centers for Medicare and Medicaid Services

(CMS), American Hospital Association (AHA),

Interstudy, and Area Resource Files (ARF).

Population Studied: Data from a panel of 2,168

U. S. short-term general, nonfederal hospitals operating during the period 1999-2003 were analyzed.

Principle Findings: Results of our analysis indicate that the existence of a CNR program was not related to hospital costs, the stringency of the CNR program was positively and significantly related to HC.

Conclusions: Implications drawn from these results include the inability of CNR to contain hospital costs as many would assume or expect, and the possibility that CNR may actually increase hospital costs, while reducing competition.


Since the purpose of CNR legislation is to contain or reduce such HC, we may conclude this policy initiative did not achieve its stated objectives during the above recent period. As a consequence of the inability of CNR laws to contain HC, many states in the U.S. are attempting to refine their CNR to better address the nature and causes of HC inflation.

Funding Source: Southern Illinois University

Carbondale

• Development of a Master Patient Index within the New Mexico Health Information

Collaborative

Scott Robinson, M.A., M.P.H., Tracy Smith, B.A.,

Herbert T. Davis, Ph.D., Eva Lydick, Ph.D.

Presented By: Scott Robinson, M.A., M.P.H.,

Senior Research Associate, Health Services

Research Division, Lovelace Clinic Foundation,

2309 Renard PL NW, Albuquerque, NM 87106,

Phone: (505)262-7835, Fax: (505)262-7598 Email:

Scott@lcfresearch.org

Research Objective: Healthcare in the US is delivered in a fragmented manner that promotes service duplication and errors related to missing information. Patients potentially suffer waste and harm, while healthcare dollars are spent inefficiently. Considerable current initiatives are on-going to connect medical care practitioners with patient information which already exists in electronic health information silos. New Mexico

Health Information Collaborative, NMHIC, was created as a 3-year project, with financial support from AHRQ and community partners. A major

first step in developing this exchange was creation of an MPI or record locator service to match patient identitifiers from multiple information sources to a single patient.

Consultation with stakeholders indicated that a false positive, FP, error which returned the wrong patient's record was greater than a false negative, FN, error which failed to retrieve all a single patient's records. This particular project developed and tested a Master Patient Index,

MPI, capable of returning healthcare records for a single individual whom has utilized different healthcare systems.

Study Design: Numerous methods of linking records were considered. The final methodological selection uses a probabilistic name-matching algorithm that is a Root Mean

Square, RMS, of three commonly used scores, social security number, SSN, gender and date of birth, DOB. SSNs, DOB and gender were scored on an exact match while a RMS of 0.8 was used for name-matching. A decision tree based on these elements provided the ultimate link no-link decision.

Population Studied: This utilized health plan members in New Mexico from two major health plans.

Principle Findings: To test the algorithm, two health databases were used. The first database, with approximately 96,000 subscribers was used as the index database. A random sample of

40,000 patients in the second database was used as the incoming data. These two databases were selected as there is a reasonable overlap in their service populations. This created almost 4 billion comparisons, which were too much to manually review. We used a cut-off score of .76 on the RMS as true matches very rarely had an

RMS score below that threshold. As a result

116,204 cases required manual review. A second independent reviewer adjudicated all of the115 disagreements reducing the disagreements to 16

FN and no FP matches out of 4 billion comparisons. This resulted in essentially 100 percent sensitivity and specificity.

Conclusions: The MPI developed for NMHIC had adequate performance characteristics for use in a regional healthcare information exchange.


The development of a MPI can help in areas such as continuity of care, reduction of healthcare costs due to decreased repeated procedures and aid in public health research.


• Progress in Reducing Disparities in

Mammography Use among U.S. Women Ages

40 to 64 Years, by Race, Ethnicity, Income and Health Insurance, 1993-2005

Susan Sabatino, M.D., M.P.H., Ralph Coates,

Ph.D., Robert Uhler, M.A., Nancy Breen, Ph.D.,

Florence Tangka, Ph.D., Kate Shaw, M.S.

Presented By: Susan Sabatino, M.D., M.P.H.,

Medical Officer, Division of Cancer Prevention and Control, Centers for Disease Control and

Prevention, 4770 Buford Highway (MS K-53),

Atlanta, GA 30341, Phone: (770)488-8372, Fax:

(770)488-4759 Email: SSabatino@cdc.gov

Research Objective: Our objective was to examine progress towards reducing disparities in mammography use by race, ethnicity, income and insurance, and by combinations of these characteristics.

Study Design: This cross-sectional analysis compared self-reported mammography use within two years using the 1993 and 2005

National Health Interview Surveys (NHIS). NHIS provides nationally representative samples of the civilian, non-institutionalized U.S. population.

For each year, we calculated the age-adjusted proportions of women screened by race, ethnicity, income, and health insurance, and by combinations of these factors. We used general linear contrasts to test for differences within year. To examine changes in disparities over time, we subtracted the proportions of women screened in 1993 from those in 2005 after agestandardizing the yearly rates to the 2000 U.S.

Census. We calculated 95% confidence intervals around these differences using general linear contrasts, and confidence intervals that excluded zero were considered statistically significant. We used multinomial logistic regression to adjust for age, race, ethnicity, income, insurance, education, region and duration of U.S. residence.

We presented results as predicted marginals within year, and used general linear contrasts to test for differences among groups. SUDAAN was used in all analyses.

Population Studied: Women ages 40-64 years

(n=4,167 in 1993, n=7,434 in 2005). uninsured women remained far below national goals.

Principle Findings: In 2005, uninsured women reported the lowest mammography use (38.3%

[95%CI 34.9, 41.9%]). Disparities by insurance status were not reduced between 1993 and 2005.

Screening increases occurred among lowincome, uninsured women (6.9 percentage points [0.0, 13.8]), but not among middle-

income, uninsured women (-6.7 percentage points [-21.7, 8.2]). In 2005, low-income women had lower use than high-income women (55.0%

[52.7, 57.4] vs. 79.1% [77.0, 81.0] in 2005), despite greater gains over time. Compared with white women, disparities for American Indian/Alaska

Native women in 1993 were eliminated, and disparities for Asian women emerged. No disparities were seen for African-American women compared with white women. Hispanic women were less likely than non-Hispanic women to report screening in 2005 (58.1% [53.7,

62.3] vs. 69.0% [67.6, 70.4]).

Conclusions: For many groups, screening use increased from 1993 to 2005. For some, disparities were reduced or eliminated. However, mammography use among low-income and


Continuing efforts are needed to reduce disparities and to maintain parity where they have been eliminated. Increased efforts are particularly needed to address the persistent and considerable disparity for uninsured women.

•

Uninsured Rates for Workers: Minority

Considerations

Timothy Sahr, M.P.H., M.A., M.Div., ThM,

William D Hayes, Ph.D., Gilbert Nestel, Ph.D.

Presented By: Timothy Sahr, M.P.H., M.A.,

M.Div., ThM, Director of Research, Health Policy

Institute of Ohio, 37 West Broad Street, Suite

350, Columbus, OH 43215, Phone: (614) 224-

4950, 308, Fax: (614) 224-2205 Email: trsahr@healthpolicyohio.org

Research Objective: The research objective was to examine uninsured rate influences for working

Ohioans factoring for race.

Study Design: The study utilized a statewide employment and coverage survey, the 2004

Ohio Family Health Survey (OFHS). The OFHS is a complex designed random-digit dial stratified survey, weighted to county level representation. The sample size for the survey was 39,953. Examining uninsured rates to demographic characteristics for workers, logistic regression was used to analyze the relative odds for being uninsured, factoring for race, gender, educational attainment, self-reported health status, and size of employing firm. The total of the subpopulation included in the study was

23,499 adults ages 18 and older.

Population Studied: The population studied is

Ohio workers ages 18 and older. The sample frame included the total non-institutionalized

Ohio population, with survey over-sampling for minorities and rural county residents. The subpopulation studied were those reporting working at least 1-week prior to being surveyed.

Principle Findings: While working minorities are disproportionately uninsured in Ohio, factors that traditionally influence coverage rates such as poor education, young age, being single, working part-time, and poverty pose a greater relative risk threat to Ohio’s white male population.

Additionally, these higher relative risk rates vary according to geographic influences and changes in employment characteristics.

Conclusions: The relative odds for being uninsured vary according to many demographic characteristics. Examining race, while minority workers proportionately have higher uninsured rates, white male workers experience a higher relative risk for becoming uninsured if they are poorly educated, single, impoverished, work parttime, or report having poor to fair health status.


Beyond descriptive analyses, when considering policies and programs for increasing access to health care coverage, policy makers should examine populations using risk rate calculations.

Such calculations give useful insights to potential risks certain populations may have for becoming uninsured.

• Uninsured Rates and Firm Sizes in Ohio

Timothy Sahr, M.P.H., M.A., M.Div., ThM,

William D Hayes, Ph.D., Gilbert Nestel, Ph.D.,

Charles Betley, M.S., Michael Wiggins

Presented By: Timothy Sahr, M.P.H., M.A.,

M.Div., ThM, Director of Research, Health Policy

Institute of Ohio, 37 West Broad Street, Suite

350, Columbus, OH 43215, Phone: (614) 224-

4950, 308, Fax: (614) 224-2205 Email: trsahr@healthpolicyohio.org

Research Objective: To examine associations between employing firm size and uninsured rates for working Ohioans, accounting for select demographics.

Study Design: The study uses the 2004 Ohio

Family Health Survey, a complex designed random-digit dial stratified survey weighted to county level representation. The sample size for the survey was 39,953, with a proxy sample of

15,447 children. Examining recodes of reported firm sizes for those reporting working at least 1week prior to being surveyed, analyses was performed to determine clustering of uninsured rates for workers, accounting for educational attainment, job status (full-time or part-time), race, gender, age, marital status, family

composition, and self-reported health status.

The total of the subpopulation included in the study was 23,499 adults ages 18 and older.

Population Studied: The survey frame included the total non-institutionalized Ohio population, with survey over-sampling for minorities and rural county residents. The subpopulation studied were respondents who reported working at least 1-week prior to being surveyed who were older than 18 years of age.

Principle Findings: The size of the employing firm is statistically associated with uninsured rates in Ohio -- smaller firms have much higher uninsured rates than larger firms. Demographic factors also influence uninsured rates across all firm sizes, but particularly for small and medium firm employees. Particularly, those who are independently employed (self-employed with no employees) and working for small firms (<50 employees) who reported poor educational attainment, younger ages, being a minority, being single or divorced, impoverished, and in poor to fair health had significantly higher uninsured rates. Additionally, in many instances those not working, accounting for these demographics, had better coverage rates than those who were independently employed or working for small firms.

Conclusions: Ohio workers who are independently employed or working for small firms have significantly higher uninsured rates than do workers in larger firms. In many instances, the independently employed and small firm workers have higher uninsured rates than do those not working. Demographics influenced uninsured rates for workers, particularly for independent and small firm workers.


The recent emphases upon policy makers to decrease the uninsured rates within states by requiring employers to offer insurance should take into consideration the uninsured dynamics for the independently employed or small firm workers who currently makeup over 45% of

Ohio’s working uninsured. Incentives, assistance, or coverage buying power needs to be addressed to enable small firms and independent workers to participate in an employer-based health insurance market.

•

Variation in the Use of Neuraminidase

Inhibitors in the Treatment Of Influenza

Kathy Schulman, M.S., Xue Song, Ph.D.,

Nianwen Shi, Ph.D.

Presented By: Kathy Schulman, M.S., Lead

Researcher, Outcomes & Econometrics,

Thomson Medstat, 125 CambridgePark Drive,

Cambridge, MA 02140, Email: kathy.schulman@thomson.com

Research Objective: Use of antiviral medications is recommended for the control of seasonal and pandemic influenza. US and

European public health agencies have concluded that neuraminidase inhibitors are complementary to vaccines and should be used in an influenza pandemic for treatment of index cases and for influenza prophylaxis in public safety workers, essential service providers and key decision makers. The objective of the current study was to profile the use of neuraminidase inhibitors.

Study Design: The study was based on a retrospective analysis of health insurance claims data in the 2000 ---- 2005 flu seasons using the

Thomson Marketscan® databases. Patients were required to be continuously enrolled for at least 3 months prior to and one month after the date of influenza diagnosis (index date). We excluded patients who 1) had pneumonia on the index date, or 2) were hospitalized on the index date, or 3) were pregnant on the index date, or 4) received an NI more than 1 day before or after the diagnosis of influenza, or 5) received an NI without a diagnosis of influenza. A total of

262,944 patients met all eligibility requirements,

47,901 of whom received an NI.

Population Studied: Influenza patients less than 65 years of age with employer sponsored insurance, 65 years of age or older with employer sponsored supplemental insurance, or patients of any age who were recipients of state Medicaid programs.

Principle Findings: Overall, the percentage of influenza cases receiving a NI rose from 8.2% during the 2000-2001 season to 39.1% in 2004-

2005. Use of an NI was highest in the commercially insured population (30.0%) and lowest among patients with Medicaid (4.0%).

Patients with HMO coverage received an NI less frequently (20.6%) than did patients with indemnity style plans (30.2%). Use of an NI was highest in the southern and north central regions of the US (36.5%, 24.7%) and lowest in the western and northeastern US (14.5%, 14.4%).

Patients in rural areas were more likely to receive an NI than their urban counterparts (27.3% vs.

15.6%). This was especially true for Medicaid patients (14.1% vs. 1.9%). Adults, ages 18-64, were most likely to use an NI (24.6%), followed by teens (20.5%), children ages 6-12 (14.5%),

and seniors (12.1%). Children under the age of 5 were least likely to receive an NI (8.7%).

Conclusions: The use of neuraminidase inhibitors for patients with influenza varies considerably by payer, region, plan benefit design, and age. Although this variation may reflect differences in physician practice pattern or patient preference, it may also represent barriers to access.


Variation in the use of neuraminidase inhibitors to treat patients with influenza may suggest that some communities will be better prepared than others during an influenza pandemic. Lack of access to an NI especially among the urban poor may exacerbate the impact of pandemic influenza. Understanding the factors that drive disparity in access may lead to improvements in pandemic preparation.

•

Developing an Evidence-Based Typology of

Public Health Systems: A Qualitative Analysis

F. Douglas Scutchfield, M.D., Michelyn

Bhandari, Dr.P.H., M.P.H., Nikki Lawhorn,

M.P.P., Ashley McCarty, B.S., Glen Mays, Ph.D.,

M.P.H., Sharla Smith, M.P.H.




Management, Health Services Research and

Policy College of Public Health, 121 Washington

Ave, Room 105, Lexington, KY 40536-0003,

Phone: (859) 257-5678 X82024, Fax: (859) 257-

2821 Email: scutch@uky.edu

Research Objective: Utilizing the typology of public health systems structure and composition identified in the quantitative phase of this study, this qualitative phase seeks to build on those findings by 1) Gathering information on how different types of local health departments allocate public health responsibilities and resources among key governmental and nongovernmental actors; 2) Identify the political, economic, institutional, and socio-cultural forces that shape the structure and operation of public health delivery systems; 3) Assess how system structure and composition influences the availability and effectiveness of essential public health services in states and communities.

Study Design: The qualitative phase of this study is based on findings from a longitudinal survey of local public health department directors conducted in 1998 and 2006. The surveys assessed local public health systems composition, coordination, and performance with respect to the twenty core public health activities. Survey data were also linked with secondary data on local public health department characteristics and resources obtained from the 1997 and 2005 NACCHO

National Profiles of Local Health Departments.

Hierarchical cluster analysis was used to group local public health agencies into seven clusters based on their composite system typology score.

The seven clusters represent the relative strengths and weakness of agencies across three domains: differentiation, integration, and centralization.

Population Studied: Two agencies were selected from each of the seven clusters to participate in qualitative interviews designed to further examine quantitative findings. Of the two agencies selected from each cluster, one agency represents an agency that had a stable composite score between 1998 and 2006; the second represents an agency that had a change in their composite score.

Principle Findings: The quantitative phase of the study found increases in both the availability and perceived effectiveness of core public health activities. This phase of the study explores the underlying drivers of change including the role of assessment activities and increased funding and whether observed changes are real or perceived.

In addition, quantitative findings suggested a change in the degree of interaction/contribution of organizational partners since 1998. The qualitative phase of the study identifies the array of organizations contributing to local public health activities and explores the nature and intensity of interaction among the major organizational participants including the barriers and facilitators that affect interaction with other contributors across the following areas: political/governmental, policy/programmatic, economic, institutional/organizational culture, leadership characteristics/style, population health needs, risks, and geographic/proximity.

Findings on the impact of this interaction on overall system performance will be presented.

Conclusions: The results of this study will suggest how to improve the performance of local health departments. Using knowledge gained from this research, the organization, resources, and management of public health systems can be improved.


In-depth analysis of individual organizations within each cluster of the public health system typology will increase understanding of the different approaches local health departments use to organize and deliver public health

services. These findings will enable policymakers and key stakeholders to understand the relative strengths and weaknesses of these alternative approaches and the political, economic, and institutional contexts in which these approaches appear to function best.


•

Development, Dissemination, and

Utilization of Public Health Systems Research

Resources

F. Douglas Scutchfield, M.D., Nikki Lawhorn,

M.P.P, Ashley McCarty, B.S., Michelyn Bhandari,

Dr.P.H., M.P.H., Allison Amrhein, M.P.H.




Management, University of Kentucky College of

Public Health, 121 Washington Ave, Room 105,

Lexington, KY 40536-0003, Phone: (859) 257-

5678 X 82024, Fax: (859) 257-2821 Email: scutch@uky.edu

Research Objective: This study examined descriptive records of datasets and instruments for inclusion in a Public Health Systems

Research (PHSR) subset of the Health Services and Sciences Research Resources (HSRR) database maintained by the National Library of

Medicine (NLM) and seeks to 1) disseminate information about the PHSR subset and related research to the PHSR research community; and

2) facilitate utilization of this resource by PHSR researchers.

Study Design: We reviewed existing HSRR datasets and related PHSR literature to create a

PHSR subsection of the HSRR database. The

PHSR subset contains data resources which address key areas of PHSR including: access to and utilization of public health services; systems assessment; workforce development; finance/spending; and program and policy planning. After creation of this PHSR dataset, mini-grants were awarded to post-doc or junior faculty within three years of their terminal degree who proposed secondary data analysis projects using a database found in the PHSR subset.

A survey of known PHSR researchers was conducted to determine awareness, utilization, and value of the PHSR subset.

Population Studied: The population studied included databases currently available in the

HSRR database and other public health databases that were identified as potentially useful to PHSR researchers. In addition, we were able to determine the type of databases that have utility for junior faculty based on their use of this resource and ascertain the value of this product by those currently doing PHSR.

Principle Findings: 122 databases and survey instruments have been tagged PHSR in the

HSRR database. Of those, approximately 110 originated from the HSRR database. The remaining 12 were identified through various methods, including literature review and collaboration with leading public health organizations and agencies. The majority of databases tagged PHSR met criteria for multiple areas, the most common being access to and utilization of public health services and systems assessment and evaluation.

Nearly 100% of the funded mini-grant proposals utilized the 12 datasets that were newly identified. Mini-grant topics include public health partnerships, performance standards, preparedness and capacity, and public health practice enhancement.

Conclusions: Development of the PHSR section of the HSRR database has strengthened the capacity to conduct public health systems research, as evidenced by the nearly exclusive use of newly identified datasets in the mini-grant projects. While the HSRR database already contained useful information for PHSR, the addition of PHSR specific databases has increased activity in the field and highlights the need for maintainence and further identification of PHSR datasets/instruments.


The PHSR subset is vital to the continued growth and development of the discipline. Increasing access to and awareness of PHSR resources should be an important part of the agenda for continued development of the PHSR field.

This project furthers that goal by providing the opportunity for mini-grant recipients to present their research results at a PHSR conference in

April 2008 and submit papers for publication in a peer-reviewed journal supplement.

Dissemination of the mini-grant findings will increase awareness of the PHSR database, attract new researchers to the field, and enhance the data resources which are necessary to further develop the discipline.


• Heart Disease among Noninstitutionalized

Elderly Medicare Beneficiaries

Ravi Sharma, Ph.D.

Presented By: Ravi Sharma, Ph.D., 1650

Research Boulevard, Rockville, MD 20850,

Phone: 301-738-3589, Email:

RaviSharma@Westat.com

Research Objective: To assess the factors affecting the likelihood of reporting recent heart disease.

Study Design: We tracked all noninstitutionalized non-decedent elderly (aged

65 or over) Medicare beneficiaries with hypertension in 2003 or 2004 using the

Medicare Current Beneficiary Survey. We compared beneficiaries who report some type of heart disease the previous year with those who do not. We conducted a multivariate (logistic) analysis to assess the factors that influence the likelihood of reporting recent heart disease. We also compared healthcare utilization and costs of various subgroups.

Population Studied: All community-dwelling non-decedent elderly Medicare beneficiaries with hypertension in 2003.

Principle Findings: Most of the beneficiaries with hypertension who report heart disease for which treatment is sought in 2004 have two or less distinct forms of heart disease. Poor health in 2003 raises the risk of reporting some type of heart disease in 2004. Blacks and Hispanics are less likely to report heart disease in 2004, whereas older cohorts are more likely than their younger counterparts. Using logistic regression, we model the likelihood of reporting heart disease in 2004 after controlling for heart disease during the baseline period, pre-existing heart disease, measures of health status, selected comorbidities, age group and ethnicity.

The incidence of heart disease the previous year has a dominant positive impact on the likelihood of having heart disease in 2004 However, an indication of pre-existing heart rhythm problems, congestive heart failure, or other heart problems reduces the likelihood of recent heart disease.

Poor baseline health status, either self-reported or measured by limitations of ADLs and mobility limitations, also raise the likelihood. Having diabetes or pulmonary disease raises the likelihood. In contrast, Blacks and Hispanics are less prone to report recent heart disease.

Relative to those in age group 65 to 74, members of older age groups are more likely to have heart disease in 2004. Those who report some type of heart disease in 2004 are more likely to

(intensively) utilize major healthcare services in

2003 (the year prior to the incidence or diagnosis of heart disease) than those who do not. As a result, they have considerably higher total healthcare expenditures in 2003, costs that tend to remain higher than baseline.

Conclusions: Poor health in 2003, pre-existing coronary heart disease, and old age raise the likelihood of reporting heart disease in 2004.

The latter outcome is foreshadowed by an increase healthcare utilization and costs in the baseline year (2003). Surprisingly, Blacks and

Hispanics are less likely to report current year heart disease, suggesting disparities in diagnosis and treatment.


Elderly Medicare beneficiaries with hypertension who display any of the above risk factors should be closely monitored to avoid the incidence of

(and/or the development of additional forms of) heart disease. A heart disease management program may be cost-effective for this at-risk population.

Funding Source: CMS

•

Depression Increases the Risk of

Hospitalization in Geriatric Home Care

Patients

Thomas Sheeran, Ph.D., M.E., Amy L. Byers,

Ph.D., M.P.H., Martha L. Bruce, Ph.D., M.P.H.

Presented By: Thomas Sheeran, Ph.D., M.E.,

Assistant Professor, Geriatric Psychiatry, Weill

Cornell Medical College, 21 Bloomingdale Road,

White Plains, NY 10605, Phone: 914-997-8640,

Fax: 914-682-6979 Email: ths2007@med.cornell.edu

Research Objective: This study evaluated the association between depression and hospitalization risk among elderly home care patients. Hospitalization for older adults receiving home healthcare services is a clinically significant and costly outcome. Not only is hospitalization among the most expensive healthcare costs for Medicare, it also is associated with increased risks for functional decline and patient mortality. Previous studies have reported that depression predicts hospitalization in other populations. We examined whether depression is associated with increased risk of hospitalization among older adults receiving home healthcare services. Given evidence implicating depression in the risk of mortality, depression among home healthcare’s medically ill and disabled patient population may increase the risk for hospitalization.

Study Design: Participants were a representative sample of elderly patients admitted over a 2-year period to a not-for-profit Medicare-certified home health agency in Westchester County, New

York. In-home research interviews were conducted and agency administrative/utilization

data was obtained. Specifically, data came from

SCID, Charlson Comorbidity Index, MMSE, assessment of ADLs and IADLs, and agency administrative/utilization data.

Population Studied: The population consisted of a representative sample of 477 elderly patients admitted over a 2-year period to a not-for-profit

Medicare-certified home health agency. Eligibility criteria included: age > 65 years; Englishspeaking; non-aphasic; not severely hearing impaired; and non-demented. The Cornell

Institutional Review Board approved this protocol.

Principle Findings: Logistic regression models first tested the effect of depression on hospitalization, and then the interaction between depression and length of stay on likelihood of hospitalization. Controlling for medical and cognitive status, the interaction between depression and length of stay on hospitalization was statistically significant (p=0.013). Patients who suffered from depression were at higher risk for hospitalization than other patients during the first six weeks of receiving home health services.

The risk associated with depression diminished the longer patients remained in care.

Conclusions: Depression was found to be associated with hospitalization.


Our group has found that depression is highly prevalent in older home healthcare patients, and detection and management of depression in home care is feasible and effective. Because hospitalization is so costly to patients and payors, and since hospitalization rates are included in CMS outcome indicators, these findings highlight the value of placing greater priority on treating geriatric depression. The findings also suggest that increased reimbursement for mental healthcare by CMS could decrease adverse outcomes and improve patient care.


• Perceptions about Behind-the-Counter

Availability of Pseudoephedrine

Chih-Wen Shi, M.D., M.S.H.S., Theodore

Ganiats, M.D.

Presented By: Chih-Wen Shi, M.D., M.S.H.S.,

Assistant Adjunct Professor, Department of

Family and Preventive Medicine, UC San Diego,

9500 GilmanDrive, M/C-0807, La Jolla, CA

92093, Phone: 6195435489, Fax: 6195435996

Email: cwshi@ucsd.edu

Research Objective: Recent federal legislations has mandated pharmacies to move pseudoephedrine (PSE) products from over-thecounter to behind-the-counter. We undertook a qualitative study that explored the public’s perceptions about this new policy.

Study Design:

Ninety participants comprising of physicians, patients, and pharmacists responded to questions about perceived advantages and disadvantages of this policy, its influence on the treatment for a common cold, barriers to implementation, and personal impacts.

Qualitative content analysis was performed through the immersion and crystallization process to identify emerging themes and salient topics.

Principle Findings: Advantages included more opportunities for pharmacist counseling, decreased access to pseudoephedrine by minors, less likelihood for misuse to occur, and less shoplifting. Disadvantages included rising prices for other cold remedies, less consumer autonomy, and more pharmacy workload.

Implementation barriers involved lack of consolidated purchase data between various pharmacies as well as discrepancies between store versus pharmacy hours of operation.

Impact on treatment of colds consisted of substitution with other over-the-counter remedies and frequent clinic visits for prescription drugs.

Conclusions: This exploratory study suggested actions that might improve the desired effect of the pseudoephedrine legislation: 1) establishing a universal system of linking purchase data among various pharmacies, 2) reducing the discrepancy between pharmacies’ and stores’ hours of operation, 3) providing additional support to help the pharmacy staff adapt to their new regulatory roles, 4) enhancing public awareness about the policy, and 5) studying the economic effects of this policy on the costs of cold remedies and health care expenditures.

• Disparity in Anti-Diabetic Drug Use in the

United States: Evidence from the Medical

Expenditure Panel Survey (MEPS)

Lizheng Shi, Ph.D., M.S.Pharm., Eric K Liao,

M.H.A., Mahmud Khan, Ph.D.

Presented By: Lizheng Shi, Ph.D., M.S.Pharm.,

Assistant Professor, Health Systems

Management, Tulane University, 1440 Canal

Street Suite 1900, New Orleans, LA 70112,

Phone: 504-988-6548, Fax: 504-988-3783 Email: lshi1@tulane.edu

Research Objective: Use of a combination therapy, either more than two oral anti-diabetic agents or combination of insulin and an oral agent, has been suggested for the response to glycemic control failure in patients with type 2 diabetes. This study aims to evaluate the utilization pattern of anti-diabetic drugs for diabetic patients by gender and race to determine the degree of disparity in the use of monotherapy and combination therapy (i.e., use more than 2 oral anti-diabetic agents or combination of oral and insulin).

Study Design: In this retrospective database study, use of anti-diabetic agents was extracted from the Prescribed Medication File. The MEPS obtained information on health status of surveyed individuals through a number of structured questionnaires including SF-12 physical component summary (PCS) and mental component summary (MCS) scores as well as

EQ-5D utility score. ANCOVA model has been used to examine the associations between use of monotherapy or combination and health status by race and gender.

Population Studied: A national sample of

Americans with diabetes was selected from the full sample of Medical Expenditure Panel Survey of 2002-2003 using ICD-9 CM code: 250.xx.

Principle Findings: Fewer female patients used a combination therapy than male patients

(p<0.0001). Only 4% of female patients used combination therapy compared to about 10% of male patients. Among the non-whites 9% were under combination therapy compared to about

6% for whites (p<0.0001). However, health status (SF-12 PCS score, SF-12 MCS score and

EQ-5D utility score) remained more or less similar for gender and race after controlling for mono- or combination therapy in the ANCOVA models.

Conclusions: There were some differences by gender and race in the utilization pattern of antidiabetic agents for adults with diabetes. This preliminary analysis using the MEPS data set was limited by cross-sectional study design and lack of lab results to ascertain the degree of glycemic control.


Health disparity issues need to be addressed to improve medication use for prompt response to loss of glycemic control in care for diabetes patients.

•

Rural Populations: Are they at Increased

Risk for In-Hospital Mortality?

Claudia Steiner, M.D., M.P.H.

Presented By: Claudia Steiner, M.D., M.P.H.,

Senior Research Physician, Center for Delivery,

Organizations and Markets, Agency for

Healthcare Research and Quality, 540 Gaither

Road, Rockville, MD 20854, Phone: (301) 427-

1407, Email: claudia.steiner@ahrq.hhs.gov

Research Objective: Rural areas face different health care challenges than urban areas.

Information on the quality of health care services for rural residents (20% of the US population) is sparse. Our objective was to study whether inhospital mortality across several important clinical conditions differs between residents of rural areas and large urban areas, and whether any differences are related to the rural or urban location of the hospital.

Study Design: National estimates of riskadjusted hospital mortality were calculated for residents of urban and rural areas overall, and by hospital location. Risk-adjustment variables include age, gender, age-gender interaction, and

APR-DRGs specific to each condition. Rates are expressed per 1000 discharges. The urban-rural classification for patients and hospitals was based on the new OMB definitions of Core-

Based Statistical Areas. Metro areas were divided into large and small metro areas using Urban

Influence Codes. Final designations were large/small urban, large/small rural (counties with no town greater than 10,000 residents).

Population Studied: Data are from the

Healthcare Cost and Utilization Project's

Nationwide Inpatient Sample (7 million discharges from a representative sample of 20% of US community hospitals) linked to the State

Inpatient Databases for 2002. All in-patient admissions for six conditions (AMI, CHF, GI hemorrhage, hip fracture, pneumonia, stroke) as measured by the Agency for Healthcare Research and Quality's Inpatient Quality Indicators were selected.

Principle Findings: The number of discharges for each condition varied: 292,070 for hip fracture; 501,477 for GI hemorrhage; 528,733 for stroke; 628,922 for AMI; 1,116,749 for CHF; and

1,280,880 for pneumonia. Residents of small rural areas (the most remote) had 30% higher adjusted hospital mortality rates than residents of large urban areas for CHF, hip fracture and stroke (48 per 1000 discharges, 34 per 100, and

132 per 1000 respectively), 14% higher for AMI

(98 per 1000), but no significant differences for

GI hemorrhage (30 per 1000) or pneumonia (81 per 1000). Among small rural areas residents, adjusted hospital mortality rates for AMI, CHF and stroke were 25%, 49% and 18% higher

respectively for patients treated at rural hospitals than for those treated at large urban area hospitals. Stroke patients from small rural areas treated at urban area hospitals maintained a

20% higher adjusted hospital mortality rate compared to residents of large urban areas. In contrast, AMI and CHFpatients from small rural areas treated at urban area hospitals showed an adjusted in-hospital mortality rate that was no different than residents of large urban areas.

Findings for residents of large rural areas were similar to those of small rural areas.

Conclusions: : Findings suggest that rural areas residents are at higher risk for in-hospital mortality for 4 of 6 conditions as compared to urban area residents. Treament for these conditions (AMI, CHF, hip fracture and stroke) can include more advanced technological care.

Treatment at urban area hospitals elliminates this rural disparity for all but stroke patients.


While urban area hospitals may have the broader resources for providing care, urban hospital care may not be available to all rural area residents, especially the most remote. There are opportunities to augment the breadth and depth of care in rural hospitals, but it remains unanswered whether such efforts would decrease in-hospital mortality.


•

The Reliability of an Organizational

Assessment of Substance Abuse Clinics

Based upon the Malcolm Baldridge Model

Robert Stout, Ph.D., Karen Friend, Ph.D., William

Zywiak, Ph.D., Pamela Block, Ph.D., Charles

Neighbors, Ph.D.

Presented By: Robert Stout, Ph.D., Senior

Scientist, Decision Sciences Institute/PIRE, 120

Wayland Avenue, Suite 7, Providence, RI 02906,

Phone: (401)751-1314x2101, Fax: (401)751-1592

Email: stout@pire.org

Research Objective: Many studies of treatment organizations have relied upon questionnaires to administrators or clinicians. This approach, however, has the drawback that there is no check on the validity of these self-reported data. Project

EQUIP, a 5-year NIDA-funded study of organizational factors associated with drug abuse client outcomes in 20 clinics, uses an organizational assessment procedure based upon the Malcolm Baldridge model. This model combines interviews, archival data, and observational data to draw a comprehensive understanding of organizational functioning.

One of the challenges in applying this model is establishing that ratings made by research staff about an organization are of adequate reliability.

Study Design: In clinical research, reliability is often determined using a pool of subjects drawn for that specific purpose. The cost of on-site assessments, however, generally makes it infeasible to use such an approach in organizational studies. Because of this limitation, it is often necessary to gather reliability and validity data in the same sample.

To maximize the reliability of the organizational ratings, the following methods are being employed. (1) For each key construct in the model, multiple indicator items have been developed and subjected to revision after feedback from a panel of researchers and clinicians. (2) Each item is rated by at least three independent raters; only those items having acceptable inter-rater agreement will be used in computing scale scores. (3) The mean rating across the judges will be used for each item.

Rater training included simulated interviews with experts who have served as clinical administrators, and a pilot study in a site that was not used in the final investigation. Methods such as these have proved successful in medical studies employing expert judges making complex diagnoses.

Population Studied: This poster describes data from nine clinical facilities recruited to date.

Principle Findings: Our version of the Baldridge contains eleven key ratings: Competitive

Environment, Strategic Challenges,

Modernization Challenges, Performance

Improvement Process, Clinical Quality

Improvement, Clinical Performance, Clinical

Coordination, Public Responsibility/Citizenship,

Strategy Deployment, Patient/Customer

Relations, and Information Management. The results showed that, for the sample of clinics for which adequate organizational assessment data are available, rates of exact agreement (on a 5point scale) ranged from 50% to 88% with a mean of 71%; mean agreement within one category is 99%. The categories with highest reliability were competitive environment and clinical coordination; modernization challenges was the least reliable.

Conclusions: We conclude from these preliminary data that the Malcolm Baldridge process produces ratings of reliability adequate for research needs.


Researcher ratings help to avoid some potential biases inherent in self-reports from informants drawn from within the organizations being

assessed. As ratings become more widely used in organizational studies, it is critical that attention be paid to all possible ways to maximize reliability.


• Latent Constructs Measured by a

Questionnaire Developed to Assess Clients’

Perception of the Quality of Head Injury

Rehabilitation Service Delivery

Bonnie Swaine, Ph.D., Clément Dassa, Ph.D.,

Anne Kone, M.Sc., Claire Trempe, M.Sc ., Louise

Demers, Ph.D., Elisabeth Dutil, M.Sc.

Presented By: Bonnie Swaine, Ph.D., Associate

Professor, School of Rehabilitation, Fac of

Medicine, University of Montreal, C.P. 6128 Succ.

Centre-ville, Montreal, H3C 3J7, CA, Phone: 514-

343-7361, Fax: 514-343-2105 Email: bonnie.swaine@umontreal.ca

Research Objective: The goal is to present preliminary results from an exploratory factor analysis using questionnaire responses collected during the 1st phase of data collection of a study to develop and validate a tool to measure the perception of quality of rehabilitation services for persons with a head injury (HI). The specific study objective was to determine the latent constructs measured by the 61-item questionnaire.

Study Design: Cross-sectional study. Exploratory factor analysis (EFA) was used to identify the latent constructs (or factors) that best explain the variance in sets of questionnaire items.

Exploratory principal axis factor, with oblimin rotations, was used to identify the most relevant sub-scales (and most conceptually meaningful factors), based on the factor patterns, communalities and accounting for the variance.

Population Studied: Questionnaire responses were collected during individual interviews conducted prior to discharge with 334 adults with a HI who had received publicly funded rehabilitation services at one of 13 facilities (e.g. acute care, rehabilitation and social reintegration centers) across the province of Quebec, Canada.

Respondents had a mean age of 40.5 years (+

16.6) and the majority were male (76 %). They had HIs ranging in severity from mild to severe; the mean Glasgow Coma Scale score was 9.7 (+

4.1).

Principle Findings: EFA was unable to specify a unique solution; factors were not interpretable when we attempted to produce factors reflecting the 5 dimensions of care upon which the tool was originally developed. Three potential subscales were however identified explaining 29 to 39.4% of the variance. The internal consistency of the subscales varied from 0.72 to

0.90 (Chronbach’s alpha). A one-factor solution was found for items forming an ‘Ecosystemic approach’ subscale (n= 9). Two-factor solutions were retained for items relating to ‘Quality of service providers’ (technical qualities n= 19; human qualities n=10) and to Service organisation (organisation of services n= 9, availability of services n= 4). The remaining items do not appear to form meaningful factors.

Conclusions: The perception of the quality of HI rehabilitation appears to be a complex multidimensional construct. EFA identified 3 potential subscales within the 61-item questionnaire to assess clients’ perceptions of different aspects of the structure and process of

HI rehabilitation programs. Results were somewhat expected given that the data collection process is ongoing (total n=610).


Assessing clients’ perception of quality of the care they receive is important to consider when evaluating the performance of rehabilitation programs. Current research on the questionnaire should provide, to those interested in improving the quality of care of persons with HI, a tool having the potential to be an important complement to evaluations currently conducted as part of the accreditation process of rehabilitation programs for persons with HI. The tool should provide important information to program managers about whether to maintain or modify processes of care (related to factors measured by the tool: service provider quality, overall treatment approach and organisational performance) to better address the needs of this significant patient population.

Funding Source: Fonds de la recherche en santé du Quebec (FRSQ) & Canadian Institutes of Health Research

• Rural-Urban Differences in Preventable

Hospitalizations among Community-Dwelling

Dementia Patients

Joshua Thorpe, M.P.H., Ph.D., Courtney Van

Houtven, Ph.D., Betsy Sleath, Ph.D., R.Ph.,

Elizabeth Clipp, Ph.D., R.N.

Presented By: Joshua Thorpe, M.P.H., Ph.D.,

Assistant Research Professor, Duke University,

DUMC 3322, Durham, NC 27710,

Email: joshua.thorpe@duke.edu

Research Objective: Compared to urban communities, rural areas have fewer available health care providers and offer a narrower range

of health services. Alzheimer’s patients and their informal caregivers living in rural communities, therefore, may face significant barriers to obtaining timely and effective medical care for the patient. One indicator of access to outpatient care is hospitalizations for ambulatory care sensitive conditions (ACSC). ACSC hospitalizations are hospital admissions for conditions where "good outpatient care can potentially prevent the need for hospitalization, or for which early intervention can prevent complications or more severe disease" (AHRQ

2004). We explored rural-urban differences in risk for potentially preventable hospitalizations in a particularly vulnerable, and rapidly expanding, population ---- veterans with dementia residing in the community.

Study Design: Medicare and VA inpatient claims were linked to data from the 1998

National Longitudinal Caregiver Survey (NRI-95-

218; E. Clipp, PI). The final sample consisted of

1,189 community-dwelling older male veterans with dementia, and their co-residing female informal caregivers. We used the Andersen

Behavioral Model of Health Service use

(BMHSU) to identify care-recipient, caregiver, and community factors driving urban-rural differences in preventable hospitalization. Rural-

Urban Commuting Area (RUCA)codes were used to classify care-recipients into 3 categories of rurality: (1) urban; (2) large rural; (3) small/isolated rural areas. Inpatient claims were used to identify care-recipients with an inpatient claim indicating a potentially preventable hospitalization over the one-year tracking period for each veteran. To disentangle the effects of rurality from other BMHSU factors, variables were entered into a logistic regression model in the following stages: (1) rurality alone, (2) rurality

+ predisposing factors, (3) rurality + predisposing + underlying medical need, and finally (4) rurality + predisposing + underlying medical need + enabling factors.

Population Studied: 1,189 community-dwelling male veterans with dementia and their coresiding informal caregivers. Veterans less than

65 years of age, those with no VA outpatient visits in the previous year, and those who died or entered a nursing home anytime during the 12 month period were excluded.

Principle Findings: 189 of the 1,189 veterans

(15.9%) had a potentially preventable hospitalization over the one year period. Overall, dementia patients living in more isolated rural areas more likely to have had a preventable hospitalization compared to those in urban areas (23% versus 15%; unadjusted odds ratio

[OR]=1.80; p<.01). The addition of predisposing factors did not eliminate the disparity (OR=1.85; p<.01), nor did controlling for underlying medical need (OR=1.84; p=.01) and enabling factors (OR=1.87; p<.01).

Conclusions: Rural veterans with dementia were more likely to be hospitalized for a potentially preventable condition, and this disparity was could not be explained by differences in caregiver, care-recipient, or community factors.


Dementia patients living in rural areas may face particular challenges in receiving timely, effective ambulatory care.

Funding Source: AHRQ, American Foundation for Pharmaceutical Education.

• Explicit Incentives for Quality in Breast

Cancer Care: Physician Reports from the Los

Angeles Women’s Health Study

Diana Tisnado, Ph.D., Jennifer Malin, M.D.,

Ph.D., Danielle Rose-Ash, Ph.D., May Tao, M.D.,

Patricia Ganz, M.D., Katherine L. Kahn, M.D.

Presented By: Diana Tisnado, Ph.D., Adjunct

Assistant Professor, Division of General Internal

Medicine and Health Services Research, David

Geffen School of Medicine, UCLA, 911 Broxton

Plaza, Box 951736, Los Angeles, CA 90095-1736,

Phone: 310-794-0711, Fax: 310-794-0732 Email: dtisnado@mednet.ucla.edu

Research Objective: Health care quality is of concern nationally, and health care structural arrangements have been evolving rapidly to respond to increasing financial pressures and demands to enhance quality. These changes have been shown to impact primary care delivery, yet little is known about how these new organizational and financial arrangements affect the delivery of breast cancer care.

Study Design: Cross-sectional, observational study of physician self-reported financial arrangements from a survey of breast cancer care providers. Physicians were asked whether they were subject to explicit incentives for quality

(i.e., receipt of additional income for scoring well on (a) patient satisfaction surveys or (b) other measures of quality) within 12 months prior to the survey. We examined the prevalence, correlates and predictors of such incentives.

Covariates included practice characteristics

(managed care involvement, practice type, size), and physician characteristics (age, specialty, ownership interest, volume). Descriptive analyses were performed including comparisons of categorical variables using Chi-squares. We

performed multivariable logistic regression analyses to predict use of explicit incentives controlling for other covariates, weighted for non-response and clustering of physicians within office.

Population Studied: Medical oncologists, radiation oncologists and surgeons practicing in

Los Angeles County identified by a populationbased cohort of women with breast cancer identified by the cancer registry (76% response rate, n=348).

Principle Findings: Overall, 23 percent of respondents reported being subject to explicit incentives for quality. Bivariate results indicate that physicians’ reported use of explicit incentives for quality in their main practices varied significantly by level of managed care involvement, practice type, size, and physician ownership interest. In bivariate analysis, use of explicit incentives for quality increased monotonically with level of managed care involvement, and physicians from the largest practice types reported the highest prevalence of explicit incentive use, likely due to confounding with group-model HMO practice type. In multivariable analyses, group-model HMO practice type was more likely to be associated with reported use of incentives for quality as compared with solo practice type, controlling for physician age, gender, breast cancer volume, ownership interest, reimbursement type, and practice size and type (p<0.0001).

Reimbursement based on capitation was positively, significantly associated with explicit incentives for quality (p<0.02). Physician age, gender, volume, and specialty type were not significantly associated with use of explicit incentives for quality.

Conclusions: Use of explicit incentives for quality among breast cancer care providers in

Los Angeles County was modest, and primarily associated with a high level of managed care involvement: affiliation with a group-model

HMO or managed care arrangements involving capitated payments. Use was rare among fee-forservice providers and those in smaller size practices with low managed care involvement.


Most cancer care providers in Los Angeles

County outside of group model HMOs are not subject to explicit financial incentives based on quality of care indicators. Further research is needed to determine whether such incentives change breast cancer care and outcomes, and what if any associations exist between implicit financial incentives (e.g., capitation or fee-forservice reimbursements) and performance on quality indicators.


Research Program

• Physician Self-Reported Financial Incentives in Breast Cancer Care: Results from the Los

Angeles Women’s Health Study

Diana Tisnado, Ph.D., Danielle Rose-Ash, Ph.D.,

Jennifer Malin, M.D., Ph.D., May Tao, M.D.,

Patricia Ganz, M.D., Katherine L. Kahn, M.D.

Presented By: Diana Tisnado, Ph.D., PhD,

Division of General Internal Medicine and

Health Services Research, David Geffen School of Medicine, UCLA, 911 Broxton Plaza, Box

951736, Los Angeles, CA 90095-1736, Phone: 310-

794-0711, Fax: 310-794-0732 Email: dtisnado@mednet.ucla.edu

Research Objective: Health care quality is of concern nationally, and health care structural arrangements have been evolving rapidly to respond to increasing financial pressures and demands to enhance quality. These changes have been shown to impact primary care delivery, yet little is known about how evolving organizational and financial arrangements affect the delivery of breast cancer care. We sought to better understand how physicians characterize their own financial incentives to perform various practices and services.

Study Design: Cross-sectional, observational study of physician self-reported financial arrangements from a 2004 survey of breast cancer care providers. Physicians were asked to describe their overall, individual financial incentives with respect to selected clinical practices and services pertinent to breast cancer care (n=8 for medical oncologists; 6 for radiation oncologists; 3 for surgeons). For example, medical oncologists were asked to describe their individual financial incentives regarding the use of office-based parenteral chemotherapy.

Respondents were asked to indicate whether on balance, incentives favor reducing the practice or service, expanding it, or neither. We examined the prevalence of self-reported incentives to reduce or expand each practice or service.

Descriptive analyses were weighted for physician survey non-response.

Population Studied: Medical oncologists

(n=111), radiation oncologists (n=66) and surgeons (n=171) practicing in Los Angeles

County, identified by a population-based cohort of women with newly diagnosed breast cancer

identified by the cancer registry (76% physician response rate, n=348).

Principle Findings: Self-reports of implicit financial incentives to reduce or expand practices or services varied by specialty type and item. For example, among medical oncologists, rates of incentives either to reduce or expand practices or services ranged from 42% for office-based chemotherapy to 16% for use of in-dwelling venous catheter. Among radiation oncologists, rates ranged from 21% for CT-based treatment planning to 14% for stereotactic radiosurgery.

Among surgeons, rates ranged from 11% for hospitalization to 6% for patient enrollment in clinical trials. Among medical oncologists who reported any incentives, incentives to expand services were reported for 4 out of 8 items (e.g., office-based chemotherapy) and incentives to reduce services were reported for 2 of 8 items

(e.g., referral to other cancer care providers).

Among radiation oncologists who reported any incentives, 4 of 6 services examined were associated with incentives to expand services.

Among surgeons who reported any incentives, incentives were equally likely to be associated with service reduction (e.g., hospitalization) as with more service use (e.g., clinical trial enrollment).

Conclusions: The majority of physicians delivering specific cancer treatments in Los

Angeles County reported perceiving no overall personal financial incentives to reduce or expand the practices or services studied. However, notable proportions of physicians did report financial incentives either to reduce or expand performance of certain practices and services.

Among those, incentives were more often reported to favor expanding the practice or service.


Further research is needed to determine whether such incentives change breast cancer care and outcomes, and what if any associations exist between implicit financial incentives (e.g., capitation or fee-for-service reimbursements) and performance on quality indicators.

Funding Source: Other Govt, California Breast

Cancer Research Program

• Mapping Your Community's Health

Shiloh Turner, M.P.A., Mark Carrozza, M.A.,

Andrew Bazemore, M.D., M.P.H.

Presented By: Shiloh Turner, M.P.A., Director,

Health Data Improvement, Program, The Health

Foundation of Greater Cincinnati, 3805 Edwards

Rd., Ste. 500, Cincinnati, OH 45209, Phone:

513.458.6608, Fax: 513.458.6610 Email: sturner@healthfoundation.org

Research Objective: The research objective is to graphically combine, analyze, and display information in ways that promote understanding and improvement of health and healthcare.

Study Design: Health Landscape is an interactive web atlas that educates health professionals, policy makers, academic researchers and planners on how to geographically depict health data. There is no cost to use the site. Health Landscape is a collaborative effort of the Health Foundation of

Greater Cincinnati, the Robert Graham Center, and the University of Cincinnati. There are three primary components to the site: Community

Health View, Primary Care Atlas, and the Health

Center Mapping Tool. This poster will describe each module as an innovative platform that public health and social service providers can use to identify needs in their community, evaluate their programs' effectiveness, and influence policy change.

Population Studied: Primary care physicians; general population

Principle Findings: By using the Health

Landscape platform, one is able to determine whether they reside in a physician shortage area, what would happen if medical residency programs were removed from a given area, and map a variety of national, state, and local health survey data to determine needs of a given population.

Conclusions: Having the ability to map health data adds a new dimension to data analysis and dissemination.


Health Landscape allows users to pictorially communicate complex health data to policy and other decision makers with a single map.

Funding Source: The Health Foundation of

Greater Cincinnati

• Dissemination of Toyota Production System

(TPS) Methods to Improve Quality and

Patient Safety in Cervical Cancer Screening

Colleen Vrbin, B.S., Carey Andrew-JaJa, M.D.,

Dana M. Grzybicki, M.D., Ph.D., Gloria Carter,

M.D., Stephen S. Raab, M.D.

Presented By: Colleen Vrbin, B.S.,Email: vrbincm@upmc.edu

Research Objective: Errors in cervical cancer screening occur in several of the phases of testing, including the sampling and

cytotechnologist screening phases. We previously showed that TPS practice redesign of a single clinician’s office and the cytology lab reduced Pap test errors. TPS redesign affects all areas of work and creates safer processes that involve the continuous flow of specimens with improvement in hand-off communications and quality feedback. Our goal was to determine if

TPS process redesign could be implemented widely across a group of clinicians and multiple lab personnel to improve cervical cancer screening patient safety.

Study Design: We performed a one-year nonconcurrent interventional cohort study that included 5384 case and 5442 control women who had a Pap test procured by 1 of 5 clinicians. We implemented a continuous flow, one-by-one process in the cervical cancer screening practices of 4 gynecologists and 1 nurse practitioner. For each Pap test, the clinicians used a TPS checklist that allowed the clinician to focus on every step of Pap test procurement. We assigned a unique cytotechnologist to screen the Pap tests from every clinician, and the cytotechnologists provided immediate feedback regarding specimen adequacy and abnormal results to each clinician. To evaluate adequacy, we measured pre (control) and post (case) implementation proportion of Pap tests with unsatisfactory and absent endocervical transformation zone component (ETZC) interpretations. We also measured the proportion of women with missed and detected cervical intraepithelial neoplasia (CIN) and with a missed squamous intraepithelial lesion (SIL).

Population Studied: 10,826 women who had a

Pap test.

Principle Findings: After the intervention, the mean proportion of Pap tests lacking a transformation zone component decreased from

17.3% to 15.1% (P = .001) and the proportion of unsatisfactory Pap tests decreased from 1.3% to

0.9% (P = .008). The case group of women showed a 113% increase in newly detected CIN following a previous benign Pap test procured the previous year (P = .004), indicating a missed

SIL in the previous year. The case group of women also showed a 16% increase in detected

CIN.

Conclusions: Disseminating TPS methods across a group of clinicians and cytotechnologists resulted in improved sampling and fewer false negative diagnoses. TPS redesign resulted in improved communication between the cytology lab and the clinicians and an increased focus on work safety. Initiatives that target the entire testing pathway help to improve patient safety.


TPS methods effectively may be disseminated across multiple cervical cancer screening practices to improve patient safety. TPS work redesign appears to be particularly suited for lab testing processes that involves numerous steps of highly focused work and frequent hand-offs.

Funding Source: Jewish Healthcare Foundation

• Positive Health Effects of Social Capital:

Evidence from the Changing Rural Societies in China

Hongmei Wang, Ph.D., Mark Schlesinger, Ph.D.

Presented By: Hongmei Wang, Ph.D., Assistant


UNMC, 984350 Nebraska medical Center,

Omaha, NE 68198-4350, Phone: (402)559-9413,

Fax: (402)559-7259 Email: wxiaohan2002@yahoo.com

Research Objective: This study employs longitudinal data from rural China to examine the changes in social capital from 2002 to 2004 and its association with changing health status.

The results of this study assist us in understanding the causal effects of social capital on health by establishing the temporal sequence.

The findings are also helpful to formulate relevant health policies that focus on the social determinants of health.

Study Design: This paper adopts multivariate ordered logistic regression and linear regression, adjusting for survey design effects, for main analyses. The outcome variables include a 5point scale self-reported general health, a 3-point scale self-reported mental health measure, a continuous Value Analog Scale measure of general health, and a continuous Mental Health

Inventory measure of mental health. Social capital is measured both at individual level and village level based on 10 questions measuring trust and mistrust. A trust index and a mistrust index were constructed separately and both measures were aggregated at village level. A rich set of variables including demographic, health risk measures, social economic factors, and sanitary measures were controlled in the models.

Population Studied: The analyses focus on rural residents in 22 villages in China who are 15 years to 85 years old. The data employed is from a stratified random sample in the household survey of the Harvard Rural Mutual Healthcare

Project. The final longitudinal sample consists

of 4937 subjects interviewed in both year 2002 and 2004.

Principle Findings: (1) Measured as interpersonal trust, individual-level social capital changes substantially over time while villagelevel social capital maintains stable for most of the villages over the two years. (2) Individuallevel trust is associated with a person’s demographic and social economic status, whereas the only age is associated with individual-level mistrust significantly. (3)

Individual trust at the baseline is positively associated with improved health status two years later. However, individual mistrust appears to have opposite effects on general health and mental health. Mistrusting people tend to have worse mental health status but better general health status. (4) Village-level social capital doesn’t seem to have consistent long-term health effects.

Conclusions: The empirical results suggest that community-level social capital does not change dramatically in a relatively short period of time in rural China. However, this does not rule out the possibility of community changes under substantial external efforts such as implementing large-scale public programs.

Individual-level trust can vary with the changes in demographic factors and social economic status.

The study results suggest that individual social capital can be changed in a relatively short period and can be more effective on changing an individual’s health compared to community level social capital.

•

Mississippi State Gender Disparity in

Mortality

Xueyuan Wang, M.P.H., Peggy A. Honoré,

D.H.A.

Presented By: Xueyuan Wang, M.P.H., Research

Assistant, Office of Science, MS Department of

Health, 571E Woodrow Wilson, Jackson, MS

39215, Phone: (601)576-7772, Fax: (601)576-7497

Email: Xueyuan.Wang@msdh.state.ms.us

Research Objective: The purpose of this study was to examine for mortality gender trends and disparities in the State of Mississippi, especially in three leading causes of death (heart disease, stroke and cancer) over the 15- year period 1990-

2004. Investigation for gender bias due to the mortality was also an objective of the study.

Study Design: The Mississippi Department of

Health’s online health query system-Mississippi

Statistically Automated Health Resource System

(MSTAHRS) was used to access age-adjusted mortality and population data by gender in 9 age groups (birth to 15, 15-24, 25-34, 35-44, 45-54, 55-

64, 65-74, 75-84, and 85 and older). Independent

T-tests were used to compare the mortality mean over time. Gender bias was calculated by using the excess mortality rate between gender.

Regression models were used for the trends over time analysis.

Population Studied: Total population of the state of Mississippi.

Principle Findings: Over the 15-year period, the overall male mortality rate was significant higher than the female rate (p=0.002). When examining the top three leading causes of death, both heart disease and cancer mortalities for males were significantly higher than females rates, while the stroke mortality difference was not statistically significant. The trends over time analysis showed a significant decrease for both males and females in overall mortality, heart disease mortality and stroke mortality. Cancer mortality for males decreased significantly while there was no significant change for females. The gender bias as a result of the overall higher male morality rate equated to more than 80,000 male deaths between 1990-2004. The population age gaps began with the 15-24 age groups and enlarged consistently through the next 7 age groups.

Conclusions: The significant disease in overall mortality, heart disease and stroke mortalities for both males and females could indicate the effectiveness of health education and promotion in the state. Although mortalities for males have decreased significatly since 1990, the rates are still higher than females. Since the population gender gap was observed to begin at the 15-24 age group, this may suggest and support the gender disparities could be associated with factors (i.e., socio-economic, environmental, etc.)after birth.


This study is relevant for state-wide policy making where knowledge related to the impact of health gender bias and disparity could be considered when designing and funding public health and social service programs.

• Mississippi Public Health Districts

Overweight or Obese and Diabetes

Prevalence Spatial Analysis

Xueyuan Wang, M.P.H., Marinelle Payton, M.D.,

Ph.D., M.S., M.P.H., Peggy A. Honoré, D.H.A.

Presented By: Xueyuan Wang, M.P.H., Research

Assistant, Office of Science, MS Department of

Health, 571 E Woodrow Wilson, Jackosn, MS

39215-1700, Phone: (601)576-7772, Fax: (601)576-

7497 Email: Xueyuan.Wang@msdh.state.ms.us

Research Objective: The aim of this study is to determine whether or not there are district disparities in the prevalence of overweight or obesity and diabetes among the nine public health districts in Mississippi.

Study Design: Age-adjusted overweight or obese and diabetes prevalence rates by district were selected from the 2005 Mississippi

Behavioral Risk Factor Surveillance Survey

(BRFSS) Report, an ongoing, state-based telephone survey. ArcView was used for districts spatial analysis. The top three overweight or obese prevalence districts were selected and compared with the top three diabetes prevalence districts.

Population Studied: The total sample size was

5,257. Of them, 64 did not response to their county of residence.

Principle Findings: The analysis showed that

District 1, 7 and 8 (ranked high to low, respectively) had the highest rates of overweight or obesity prevalence rates. District 7, 2 and 9

(ranked high to low, respectively) had the highest rates of diabetes.

Conclusions: The findings showed a disparity among public health districts in Mississippi in prevalence of overweight and diabetes. Of all districts compared, District 7 was found to have a direct association with diabetes and overweight or obesity prevalence rates.


This study is relevant for state-wide policy making regarding health program planning and design and for strategies to maximize funding for public health and social service programs.

• Examination of Enabling Services Users at

Community Health Centers Serving Asian

Americans, Native Hawaiians, and Pacific

Islanders

Rosy Chang Weir, Ph.D., Heidi Park Emerson,

Ph.D., Winston Tseng, Ph.D.

Presented By: Rosy Chang Weir, Ph.D., Senior

Research Associate, Association of Asian Pacific

Community Health Organizations, 300 Frank H.

Ogawa Plaza, Suite 620, Oakland, CA 94612,

Phone: 510-272-9536, x107, Fax: 510-272-0817

Email: rcweir@aapcho.org

Research Objective: Enabling services are believed to substantially improve health access and outcomes for underserved minority patients according to provider perspectives at community health centers and may represent important mediators for reducing health disparities.

However, there is no solid evidence to support these claims, as data on enabling services is currently lacking. The purpose of this project is to better understand the nature of enabling services and the impact of these services on health care of underserved Asian Americans and

Pacific Islanders at community health centers.

Study Design: The study compared the characteristics of Users and Non-Users of enabling services at three community health centers serving predominantly Asian Americans and Pacific Islanders located in Hawaii, New

York, and Washington. We determined whether patients who had a medical visit in June 2004 had received any enabling services in the previous year. Quantitative data was collected on patient demographics, ICD-9 diagnosis and enabling services encounters. The standardized categories of enabling services included case management assessment, treatment, and referral services, financial counseling, health education, interpretation services, outreach services, transportation, and other services.

Population Studied: Asian Americans, Native

Hawaiians, and Pacific Islanders

Principle Findings: Preliminary analyses indicated that Enabling Service (ES) Users were more likely to be non-white, older, female, and uninsured compared to ES Non-Users (p<.05).

ES Users also had a higher incidence of chronic conditions whereas Non-Users had a higher incidence of acute conditions. Further analysis indicated that patients with chronic conditions were less likely to use financial counseling (17%) than patients with acute conditions (22%). It is not known whether ES Non-Users had received an enabling service prior to implementation of the study, and other factors may contribute to the differences observed.

Conclusions: This study has been able to show differences in characteristics of patients who use enabling services compared to those who do not. Enabling services are critical to the delivery of care at community health centers that serve diverse and vulnerable populations. These services are likely to prevent acute episodes and promote better management of chronic diseases.

Implications for Policy, Practice or Delivery: It is necessary to obtain better data on enabling services, especially at health centers that disproportionately serve diverse and underserved populations who often rely on these services for access to care. Although enabling services are important to the care at community health

centers, these services are currently underfunded and not reimbursed. More research is needed to examine how enabling services improve quality of care and reduce health disparities. The services should be further studied and tailored to specific AAPI populations and health conditions.

For example, health outcomes for specific diseases, such as diabetes, the most common chronic condition observed in this study, should be further analyzed in future studies. The research results demonstrating the value of enabling services can be used to advocate for adequate reimbursement of these services and contribute to reduction of health disparities.

•

Mapping Medically Underserved Asian

American and Pacific Islander Counties in the

United States: A National Analysis

Rosy Chang Weir, Ph.D., Winston Tseng, Ph.D.,

Jeffrey Caballero, M.P.H.

Presented By: Rosy Chang Weir, Ph.D., Senior

Research Associate, Association of Asian Pacific

Community Health Organizations, 300 Frank H.

Ogawa Plaza, Suite 620, Oakland, CA 94612,

Phone: 510-272-9536, x 107, Fax: 510-272-0817

Email: rcweir@aapcho.org

Research Objective: Asian Americans and

Pacific Islanders (AAPIs) have historically faced multiple social and racial/ethnic health disparities in the United States. However, little national health care data on AAPIs exist and no studies to date have examined medically underserved health service areas for AAPIs. This project seeks to address this gap and utilizes the

Geographic Information Systems (GIS) approach to assess and identify the major medically underserved AAPI areas at the county level across the United States.

Study Design: The methods for this study included (1) conducting a literature and data search on AAPI health and GIS, (2) prioritizing available and relevant AAPI specific data and indicators, (3) developing a Medically

Underserved AAPI County (MUAC) index adapted from the BPHC MUA index (i.e., poverty and primary care physician to patient ratio) and incorporated key AAPI specific county indicators

(i.e., limited English proficiency and AAPI population), (4) determining the indicator weights based on BPHC’s MUA index weights and existing literature for each the MUAC index indicators, (5) conducting GIS analysis to identify and assess severity level of MUAs by county, (6) conducting GIS analysis to identify and assess severity level of MUACs at the county level, (7) assessing social demographic and health characteristics of MUAC counties identified to validate the underserved designation, and (8) comparing similarities and differences nationally between MUAs and MUACs at the county level.

Population Studied: Asian Americans, Native

Hawaiians, and Pacific Islanders

Principle Findings: Based on our Medically

Underserved AAPI County (MUAC) Index, 266 counties were identified across the nation, representing 12% of all counties. 138 (52%)

MUAC counties were not designated as BPHC medically underserved counties. Of these 138 counties, 20 (14%) had an AAPI population of

10,000 or greater, and 29 (21%) counties had an

AAPI population of 5,000 or greater. The top five

MUAC counties with an AAPI population of

10,000 or more included: Philadelphia, PA,

Suffolk, MA, Merced, CA, Fresno, CA, and San

Francisco, CA. The top 5 MUAC counties with an AAPI population of 100,000 or more included: San Francisco, CA, Kings, NY,

Alameda, CA, New York, NY, and Queens, NY.

Conclusions: This project provides a preliminary assessment of counties across our nation most needing expanded community health services for underserved AAPIs. Medically Underserved

Asian American and Pacific Islander

Communities (MUACs) are spread out across our nation in both urban and rural regions and in major and small AAPI concentration areas.


This project provides a national county level assessment and identified major Medically

Underserved Asian American and Pacific

Islander Counties (MUAC) that require expansion of health centers to provide adequate access to care for AAPIs. The project also contributes to Presidential and Congressional

Initiatives to improve the participation of underserved AAPIs in federal programs and to expand the number of people served by community health centers. These results can address and prioritize health center expansion areas for medically underserved AAPIs. Overall, this project is of critical importance with health systems implications and has a long-term goal of furthering national efforts to reduce ethnic/racial health care disparities for all.

Funding Source: DHHS, Office of Minority

Health

•

Impact of Commuting Distance on Nursing

Staffing of a Rural Hospital

Ronald Wiewora, M.D., M.P.H., Mary Weeks,

R.N., Melissa Ransom, SRN

Presented By: Ronald Wiewora, M.D., M.P.H.,

Chief Medical Officer, Glades General Hospital,

Health Care District, 1201 S. Main Street, Belle

Glade, FL 33434, Phone: 561-996-6571 ext. 400,

Fax: 561-996-2898 Email: rwiewora@hcdpbc.org

Research Objective: The objective of this study was to assess the impact of commuting distances on the nursing staff of an isolated, rural hospital.

Study Design: A retrospective study of personnel records was performed in December

2006.

Population Studied: The population studied was the professional nursing staff (RNs and

LPNs) of Glades General Hospital.

Principle Findings: 103 professional nurses

(RNs and LPNs) were employed by Glades

General Hospital in December 2006. 30 of these nurses lived in the Glades area (Belle

Glade, Pahokee and South Bay; called the "local nurses") and commuted less than 10 miles to the hospital for work. The remaining 73 nurses

("non-local nurses") commuted distances ranging from 30 miles to 77 miles. The average commuting distance in this group was 45 miles.

The average time for this commute was 60 minutes. Nurses working in areas with call-back duties (Operating Room) tended to live closer to the hospital than nurses in areas working shifts without call-back responsibility ( such as Med-

Surg).

Conclusions: Glades General Hospital relies heavily on professional nurses who do not reside in the community. Policies need to be adapted to attract and retain this group of nurses.


Long commute times necessitated change in three areas: 1. Work start hours were flexed to allow accomodation for child care arrangements.

2. Fatigue was monitored as a patient safety issue. 3. Salaries needed to be adjusted to keep up with rising costs of gasoline.

• Medicare Part D Prescription Drug Benefit and Administrative Burden in Care of Dual

Eligible Psychiatric Patients

Josh Wilk, Ph.D., Joyce West, Ph.D., Donald Rae,

M.A., Maritza Rubio-Stipec, Sc.D., Jennifer Chen,

B.S., Darrel Regier, M.D., M.P.H.

Presented By: Josh Wilk, Ph.D., Director,

Workforce Studies, American Psychiatric

Institute for Research and Education, American

Psychiatric Association, 1000 Wilson Boulevard.,

Arlington, VA 22209, Phone: 703-907-8618, Fax:

703-9071087 Email: jwilk@psych.org

Research Objective: 1) Systematically quantify the amount of administrative burden of psychiatrists and their staff related to prescription drug administration as part of the

Medicare Part D plan among a large, national sample of Medicare and Medicaid ‘‘dual eligible’’ psychiatric patients; and 2) Evaluate and identify the association between Part D Prescription

Drug Plan (PDP) features, patient characteristics, and setting factors with increased administrative burden.

Study Design: A national survey was conducted among a sample of 5,833 psychiatrists randomly selected from the AMA Physicians Masterfile.

64% responded to the survey, reporting clinically detailed data on one systematically selected dual eligible patient and on features and experiences of their caseload.

Population Studied: Although this study only examined patients of psychiatrists, this group is of particular interest since psychiatrists treat the majority of the nation's individuals receiving treatment for schizophrenia and others with the most severe forms of mental illnesses. Most of these patients are on clinically complex medication regimens.

Principle Findings: Psychiatrists and their staff spent an average of 47 minutes (S.E. = 8.5 min.) of administrative time per one hour of direct patient care with dual eligible patients in the

Medicare Part D program. Several PDP plan features were associated with increased administrative time including prior authorization

(53 minutes per hour direct patient care, p<.05), preferred drug formularies (52 minutes, p<.05), and plans with dosing limits (65 minutes, p<.01).

Several medication access problems were also significantly related to increased administrative burden including problems accessing clinically indicated refills (46 minutes, p<.05) and problems with medication being stopped due to administrative issues (52 minutes, p<.01).

Multiple linear regression using administrative burden calculated as a percentage of total patient care time found that when controlling for all other standard factors, step therapy or ‘‘failfirst’’ policies (p=.01), preferred drug formularies

(p=.05), problems accessing medication refills

(p=.01), and patient problems with co-payments

(p=.005) resulted in significantly more administrative burden for psychiatrists. In fact, step therapy policies resulted in a nearly 10% increase in administrative burden compared to

PDP plans without these policies.

Conclusions: There was significant concern regarding the transition of Medicare and

Medicaid ‘‘dual eligible’’ patients, a high-risk,

high-cost vulnerable population to Medicare Part

D, and the effects of this large policy shift on the administrative burden that would be placed on psychiatrists treating these patients. Results of this study indicate that several features of PDPs and as well as access problems related to the implementation of Part D have resulted in significant increases in administrative burden for psychiatrists. In many cases, for every one hour of direct patient care, there is nearly one hour of administrative time for the psychiatrists and his or her staff compared to PDPs without these policies.


Given the increased vulnerability of this population and their need for intensive clinical care, the increased administrative burden produced by Part D implementation and PDP policies is a possibly significant risk to the quality of care of these patients as a result of diminished time attending to patients’ other medical and psychosocial issues.

Funding Source: American Psychiatric Institute for Education and Research (APIRE)

•

Economic Evidence of Complementarity and Substitution between Complementary and Alternative Medicine and Mainstream

Medicine in the United States

Tom Xu, Ph.D.

Presented By: Tom Xu, Ph.D., Assistant

Professor, Family & Community Medicine, Texas

Tech University Health Sciences Center, 3601 4th

Street, MS 8161, Lubbock, TX 79430-8161, Phone:

(806)743-6983, Fax: (806)743-1292 Email: tom.xu@ttuhsc.edu

Research Objective: This paper estimated the own-price and income elasticity of visits to complementary and alternative medicine (CAM) providers and its cross-price elasticity with visits to mainstream medicine (MSM) providers among adults in the United States.

Study Design: The Medical Expenditure Panel

Survey 1996 and 1998 were used. A two-stage estimation was conducted. The first stage used a bivariate probit model to examine the determinants of the likelihood that an individual used MSM and/or CAM. The second stage estimated own-price, cross-price and income elasticities of CAM and MSM visits among users.

Population Studied: US adults

Principle Findings: It was found that the ownprice elasticity for MSM was about -0.09 among users of only MSM. The own-price elasticity for

CAM was about -0.35 among users of only CAM.

Among users of both MSM and CAM, the ownprice elasticities of MSM and CAM were -0.10 and -0.29, respectively. The cross-price elasticity of CAM and MSM visits was 0.07, indicating economic substitution. Income elasticities were near zero for both MSM and CAM visits.

Conclusions: The results implied that consumers are more responsive to price changes in CAM than in MSM visits. These findings are consistent with the observations that CAM use is less prevalent than MSM and more an ‘‘elective’’ approach for patients.


The economic substitution between CAM and

MSM poses challenges in health care market regulations and taxations. Although the efficacy and effectiveness of many CAM types are still under debate, policy-makers and insurance plans have to face the reality of the expansion of CAM market in many developed countries.

Funding Source: NIH/NCCAM

• Coping Strategies and Stressors in

Hemodialysis Patients

Shu-Chuan Jennifer Yeh, Ph.D., Hsueh-Chih

Chou, R.N., M.B.A.

Presented By: Shu-Chuan Jennifer Yeh, Ph.D.,

Associate Professor, Institute of Hospital &

Health Care Administration, National Yang-Ming

University, 155, Sec. 2, Li-Nong Street, Taipei,

11211, TW, Phone: 886-2-2826-7346, Fax: 886-2-

2820-6252 Email: syehboston@gmail.com

Research Objective: This study uses a large sample to investigate the stress related to undergoing hemodialysis and the relationship between these stresses and ESRD patients’ coping strategies.

Study Design: We used the Hemodialysis

Stressor Scale and the Jalowiec Coping Scale to interview 2642 HD patients (mean age = 57;

53.5% female). The Hemodialysis Stressor Scale measures the level of stress related to following stressor subscales daily activity, physical condition, dependency on medical staff, fluid & food restriction, role ambiguity, blood vessels, and reproduction. The Jalowiec Coping Scale identifies the use of the following coping strategies: problem-oriented, emotion-oriented, seeking support, avoidance, and isolated thoughts. Data were analyzed using Hierarchical

Linear Modeling.

Population Studied: 2642 hemodialysis patients

Principle Findings: HD patients facing daily activity were positively associated with using

emotion-oriented, avoidance, and isolated thoughts as coping styles and negatively related to seek support from professionals. The higher the perceived stress in relation to physical symptoms, dependency on medical staff, and blood vessel, the more the patients used emotion-oriented, support seeking, avoidance, and isolated thoughts to cope. Patients facing fluid & food restriction and role ambiguity were found to be positively associated with emotionoriented, avoidance, and isolated thoughts coping strategies. Patients facing stress from reproduction were positively associated with emotion-oriented, avoidance, and isolated thoughts only. HD patients seldom use problemoriented strategy to ease their stresses. Support seeking was another least used coping strategy in our patients.

Conclusions: The most commonly used coping strategies in our patients were emotion-oriented, avoidance, and isolated thoughts. Choice of coping strategy depended upon types of stressor.


The association between coping strategies and stress can be positive, negative, or neither.

Regardless of type of stress, understanding how

HD patients employ coping strategies assists clinicians to intervene some education or management programs to faciliate patients' adjustment.

Funding Source: National Science Council of

Taiwan

• The Effect of Hurricane Katrina on

Hospitals Staffing & Services in New Orleans,

Louisiana

Mustafa Younis

Presented By: Mustafa Younis, Chair,

Department of Health Policy & Management,

Stempel School of Public Health, Florida

International University, 11200 SW 8th St.,

Miami, FL 33199, Email: younis99@gmail.com

Research Objective: review of the effect of

Hurricane Katrina on hospitals located in New

Orleans metro area before and after the Katrina disaster. The effects of the hurricane on health care services, along with recommendations for future natural disasters, are presented and discussed.

Study Design: Descriptive statistics were used as the basis of discussion.American Hospitals

Associations (AHA) Annual Survey and Medicare

Cost Report (MCR) data were used to draw comparison of hospitals services pre-post

Katrina.

Population Studied: 90% of the hospitals in

New Orleans.

Principle Findings: While over 50% of hospitals in New Orleans closed since Katrina and the numbers of hospitals, physicians, nurses, and other health care providers in the surrounding metro area declined, the residents of New

Orleans have suffered higher incidence rates of mental and physical illnesses. Therefore, we could not conclude that the number of bed available per populations is appropriate in post

Katrina.

Conclusions: Due to the close of safety net hospitals such as (Charity hospitals, which had over 1000 bed) and other health care services, we conclude the city is in desperate need for help from the federal, state and local government to maintain the safety net hospitals. Furthermore, due to the mental effect and financial impact on the city residents, many individuals are delaying needed preventive and primary health care visits.


Preparing for natural disaster and other man made crisies (Boi-Terr) is in need for review by policy maker. Hurricane Katrina was a wake up call for the country.

• State Implementation of a Bioterrorism

Preparedness Programs

Mina Zadeh, M.P.H., doctoral student

Presented By: Mina Zadeh, M.P.H., currently a doctoral student, Program Analyst/Team Leader,

Office of Inspector General, US Department of

Health and Human Services, 61 Forsyth Street,

SW, Suite 3B80, Atlanta, GA 30303, Phone: 404-

562-7739, Fax: 404-562-2994 Email: mina.zadeh@oig.hhs.gov

Research Objective: To evaluate the Centers for

Disease Control and Prevention’s (CDC) early implementation of the CHEMPACK project.

Study Design: CDC established the CHEMPACK project to assist State and local health departments in protecting communities against the deadly effects of potential nerve agent releases. Because nerve agent exposure requires rapid treatment, the CHEMPACK project places nerve agent antidotes in communities throughout the country in advance of an event.

In 2003, CDC established CHEMPACK as a pilot in three locations. In 2004, CHEMPACK was made available to all 62 Bioterrorism

Cooperative Project Areas (the 50 States; the

District of Columbia; the cities of Chicago, New

York, and Los Angeles; Puerto Rico; the U.S.

Virgin Islands; and the 6 Pacific Basin jurisdictions), referred to hereafter as States.

State participation in the CHEMPACK project is voluntary.

Population Studied: For this study, we interviewed officials from CDC and six States about early CHEMPACK implementation, particularly roles and responsibilities, as well as barriers in sustaining the project. We also reviewed CDC and State CHEMPACK documents.

Principle Findings: We determined that CDC has opportunities to strengthen CHEMPACK deployment. Details regarding the findings will be provided at a later time.

Conclusions: We determined that CDC has opportunities to strengthen CHEMPACK deployment. Details regarding the findings will be provided at a later time.


The research results can fall under the following conference theme: "Quality: Measuring and

Improving Quality" conference theme. The research/evaluation results address: (1) creating national standards for measurement and reporting of health care quality and safety, (2) local and regional efforts to measure and improve quality, and (3) improvement and safety. CHEMPACK effectiveness hinges on deployment------nerve agent drugs need to be distributed and administered quickly to save lives. We recommended that CDC take a more active role in planning for CHEMPACK deployment by undertaking several activities.

Funding Source: Department of Health and

Human Services

• "Magnetism" Job Satisfaction and Intent to

Leave in Hospital Nurses

George Zangaro, Ph.D., Meg Johantgen PhD, RN

Presented By: George Zangaro, Ph.D., Executive

Assistant, Navy Medicine Support Command,

U.S. Navy, 8901 Wisconsin Ave T-18, Bethesda,

MD 20889, Phone: 301-295-0329, Fax: 301-295-

2374 Email: gazangaro@nmetc.med.navy.mil

Research Objective: Many hospitals are aspiring to be designated as ‘‘magnet’’ hospitals, reflecting an environment of excellence in nursing practice that has been associated with better patient and nurse outcomes. This study examined nurse perceptions of these forces in their organization in relation to their job satisfaction, workload, and desire to quit.

Study Design: Using a secondary data analysis of a survey distributed to staff registered nurses at 3 large military hospitals, the concepts of the

Price and Mueller Turnover model were mapped to 6 of the 14 forces of Magnetism. Multivariate analyses examined the relationship among the forces and reported satisfaction.

Population Studied: Anonymous surveys were distributed to a convenience sample representing both military and civilian staff registered nurses. Of the nearly 1200 staff nurses, a total of 496 usable questionnaires were returned for a 42% response rate.

Conclusions: As organizations struggle to maintain nursing staff and improve quality, it is unclear how the magnet movement is influencing the work environment of nurses.

While work loads are perceived as high, nurses are generally satisfied. Communication and peer support appear to be important aspects of these environments.

Principle Findings: A majority of nurses agreed that they were satisfied with their job (58%) and that the organization inspired their best job performance (54%). However, 20% agreed that the workload was too heavy and 22% desired to leave the present organization. In logistic regression after controlling for tenure, military status, and gender, nurses who perceived poor communication in an organization were significantly more likely to leave the organization.

Peer support has the strongest association with job satisfaction.


Hospital organizations are moving toward implementing the magnet hospital concepts, yet the influence on the work environment for staff nurses is less clear and must be studied. Better measures of workload must be developed so that variation across hospitals, units, shifts, and patient populations can be understood.

Funding Source: TriService Nursing Research

Program

• What are the Factors Related to Being an

Internet User for Medical Information?

Yan Zhang, Ph.D., Betsy Jones, Ed.D., Mary

Spalding, M.D., Mike Ragain, M.D., Rodney

Young, M.D., Dannen Mannschreck, M.D.,

Presented By: Yan Zhang, Ph.D., Assistant

Professor, Family and Community Medicine,

Texas Tech University Health Sciences Center,

3601 4th Street MS 8161- Room 1C165D,

Lubbock, TX 79430, Phone: (806)743-6984, Fax:

(806)743-1292 Email: yan.zhang@ttuhsc.edu

Research Objective: This study was to explore the factors related to internet usage for medical information among the primary care clinic patients in West Texas rural areas.

Study Design: The survey was conducted in the

West Texas area that is served by the campuses of TTUHSC in Lubbock, Amarillo, El Paso and

Odessa. A convenience sample was drawn from nine clinics that serve low-income populations.

The estimated average number of monthly patients seen in the nine clinics is 4920, and this project targeted to reach 40% (1968) of the patients. Participation was voluntary. Pregnant women and persons under age 18 were excluded from participation. Surveys were distributed to the patients at an on-going basis during a 6-week period in Winter 2006. At the end of the data collection a total of 2036 completed forms were received. Internet usage responses were complete for 1890 subjects. Survey questions were adapted from BRFSS and CAHPS that included information on demographics, selfrated general health, health insurance status, etc.

Logistic regressions were conducted to explore the factors related to being an internet user for medical information. This study was approved by the Institutional Review Board of Texas Tech

Health Sciences Center

Population Studied: The mean age of subjects was 46.4 years (SD=16.28), with 74% (1408) of them women; 26.8% (487) of them had a highest education level less than high school, and 53.3%(960) of subjects reported themselves as Hispanic/Latino origin.

Principle Findings: Of 1890 subjects, 699 (37%) reported having used the internet for medical information. Among the internet users, the primary use of the internet was to request more health information (30.4%, 208/685) followed by using the internet to purchase health supplies

(13.4%, 92/687). The following factors were found related to internet usage: (1) Those covered by Medicaid (OR=.588, 95%CI=.372-

.929) and those who didn’t have insurance

(OR=.488, 95%CI=.316-.754) were less likely to use the internet, compared to private insurance holders. (2) Respondents who agreed that they had been able to take care of themselves without doctor’s help (OR=1.945, 95%CI=1.190-3.181) were about 2 times more likely to use the internet, compared to those who strongly disagreed that they had been able to take care of themselves without a doctor’s help. (4) Those who reported more worried days (OR=1.015,

95%CI=1.002-1.028) were more likely to use the internet than those who had fewer worried days.

Age, education level, and Hispanic Origin were also found significantly related to internet usage.

Conclusions: Private health insurance users, patients with higher health confidence levels, younger people, patients with higher education levels, and those of non-Hispanic origin are more likely to use the internet for medical information.


Only a little more than one third of the patients used the internet. Promoting health/medical information through websites or other on-line resources might not be the most effective way to reach a majority of patients in rural areas.

•

An Exploration of Complementary and

Alternative Medicine Usage among Primary

Care Patients

Yan Zhang, Ph.D., Betsy Jones, Ed.D., Mary

Spalding, M.D., Mike Ragain, M.D., Rodney

Young, M.D., Dannen Mannschreck, M.D.

Presented By: Yan Zhang, Ph.D., Assistant

Professor, Family and Community Medicine,

Texas Tech University Health Sciences Center,

3601 4th Street MS 8161- Room 1C165D,

Lubbock, TX 79430, Phone: (806)743-6984, Fax:

(806)743-1292 Email: yan.zhang@ttuhsc.edu

Research Objective: This study explored the factors related to complementary and alternative medicine (CAM) usage among the primary care clinic patients in West Texas rural areas.

Study Design: The survey was conducted in the

West Texas area that is served by the campuses of TTUHSC in Lubbock, Amarillo, El Paso and

Odessa. A convenience sample was drawn from nine clinics that serve low-income populations.

The estimated average number of monthly patients seen in the nine clinics is 4920, and this project targeted to reach 40% (1968) of the patients. Participation was voluntary. Pregnant women and persons under age 18 were excluded from participation. Surveys were distributed to the patients at an on-going basis during a 6-week period in Winter 2006. At the end of the data collection period, 2036 completed forms were received. Complementary and alternative medicine usage responses were complete for

1873 subjects. Survey questions were adapted from BRFSS and CAHPS that included information on demographics, self-rated general health, health insurance status, etc. Logistic regressions were conducted to explore the factors related to CAM use. This study was approved by the Institutional Review Board of

Texas Tech Health Sciences Center.

Population Studied: The mean age of subjects was 46.4 years (SD=16.28), with 74% (1408) of them women; 26.8% (487) of them had a highest education level less than high school, and 53.3%(960) of subjects reported themselves as Hispanic/Latino origin.

Principle Findings: Of 1890 subjects, 694 (37%) reported having used some form of CAM.

Among the CAM users, the main types of CAM were Chiropractor (33.2%, 223/672) followed by

Massage Therapist (28.7%, 199/660) and

Herbalist (13.5%, 87/644). The following factors were found related to CAM use: (1) Those who had discussed the use of alternative medicine with their physicians were 46 times likely to use

CAM (OR=46.20, 95%CI=27.05-78.89) than those who had not discussed it with their physicians. (2) Those covered by Medicaid

(OR=.55, 95%CI=.332-.922) and those covered by other insurance (OR=.63, 95%CI=.40-.99) were less likely to use CAM compared to those who had private insurance. (3) Those who rated their heath care providers more highly (OR=.918, p=.020, 95%CI=.855-.987) were less likely to use

CAM compared to those who rated care services lower. (4) Those living in Odessa (OR=.481, p=.015, 95%CI=.267-.865) were less likely use alternative medicine compared to those living in

Amarillo. Gender, education level, and Hispanic

Origin were also found significantly related to

CAM use.

Conclusions: Patients who discussed CAM with their physicians, private health insurance users, patients with higher rating of their health care providers, females, patients with higher education levels, and those of non-Hispanic origin are more likely to report having used CAM.


CAM use is limited among primary care patients in rural areas with a little more than one third of them having reported some types of use.

Physicians’ opinion might influence patients’ choice of CAM. Primary care physicians may want to learn more about CAM in order to make appropriate recommendation to their patients.

Student Posters

• Women’s Status and Child Nutrition: Does

Social Structure Matter in India?

Sunitha Ambatt Sankaran, Pursuing Ph.D.,

Irudaya Rajan, Ph.D.

Presented By: Sunitha Ambatt Sankaran,

Pursuing Ph.D., Research Scholar, Economics,

Centre for Development Studies,, Prasanth

Nagar Road, Ulloor, Thiruvananthapuram - 695

011, Kerala, India, Thiruvananthapuram, 695 011,

IN, Phone: +91-471-2442481,2448901, Fax: +91-

471-2447137 Email: sunitha@cds.ac.in

Research Objective: First, is women’s status an important determinant of child nutritional status? Second, if so what are the pathways in which it operates? How do the the specific social structure in India explains the link between women's status and child nutrition.

Study Design: National family health survey of

Inda which represent more than 90 per cent of the population of the country is the data sources.

UNICEF (1998)and Engle et al (1999) framwok for causes of child under-nutrition.

Population Studied: Women in India and children who are staying with their mothers.

Principle Findings: Women's status does influences child nutritional status.Social structure does seems to have influence on defining women's status and this in turn influences child nutritional level differently in different social structure.

Conclusions: The peculiar social structure of

India asssumes different status to its women in terms of decision making, asset holding, social and economic status etc. This differential status of women, manifest diffferently on the level of child nutrition.


Improving women status in terms of decision making power, asset holding and social and economic dimentions is extreemly need to improve the child nutrition level. Since the pathways are different in different social groups a wholistic approach in this manner will not bring the desired outcome, insted initiatives to improve women's status must be differently initiated in different social groups.

• Labor Market Outcomes of Teen Mothers:

Evidence from Georgia

Djesika Amendah, Ph.D Candidate, M.Phil, M.A.

Presented By: Djesika Amendah, Ph.D

Candidate, M.Phil, M.A., Ph.D Candidate,

Department of Economics, Georgia State

University, Andrew Young School of Policy

Studies, 14 Marietta Street NW, Suite 535D,

Atlanta, GA 30303, Phone: 404 605 7000, Fax:

404 651 4985 Email: damendah1@student.gsu.edu

Research Objective: The United States has the highest rate of teenage childbearing among industrialized countries, even though this rate has been declining in the last decade.

Conventional wisdom suggests that teenage childbearing is a life-altering event associated with a series of negative impacts on both mothers and children. Earlier research claimed that teenage childbearing causes the mothers to be more likely to earn lower income and less likely to finish high school and participate in the labor market. More recent studies find that these effects are only small and temporary. The purpose of this research is to contribute to this debate by analyzing the effect of teenage childbearing on the mother’s employment and earnings in the state of Georgia.

Study Design: I use a sample of pairs of sisters one of whom is a teenage mother while the other is a non-teen mother. I use panel data analysis with family fixed effects to compare labor market participation and earnings of pairs of sisters.

Population Studied: The sample used for this study is combined from three administrative datasets obtained from the Georgia Department of Labor and the Daprtment of Human

Resources: a birth subset of Vital Statistics collected in collaboration with the CDC; an employment dataset compiled from the unemployment insurance files; and a welfare dataset compiled from the application for public cash assistance files. The birth data cover the years 1994 to 2002, the labor dataset, the years

1990 to 2003, and the welfare dataset, the years

1990 to 2005. The labor and welfare datasets offer quarterly information. I use the welfare dataset because it is the only one that allows me to identify sisters. At the time of their first birth, the teen mothers’ ages varied between 14 and 17, while their sisters’ ages varied between 18 and

25. The sample size is 2,736 person-quarters.

Principle Findings: Preliminary results indicate that teen mothers are 0.7% more likely to work than their sisters, although this difference is not statistically significant. Teen mothers between their 18th and 24th birthdays earn 14% less than their sisters. This earning difference disappears when all the teen mothers are at least 24 years old. They then earn 45% more than their sisters, a result that is statistically significant at the 10% level of confidence.

Conclusions: The impacts of teenage childbearing on the adult mother’s labor market participation and earnings appear small and temporary. Teen mothers are somewhat more likely to be employed during the first five years after they turn 18, but they earn less than their sisters. However, when all teen mothers are at least 24 years old, they seem to earn more than their sisters.

Implications for Policy, Practice or Delivery: If teenage childbearing does not have persistent negative consequences on the adult mother’s employment, then, with respect to labor activity, teenage mothers are not different from other women from similar backgrounds. Thus, if labor market outcomes are deemed a major concern, current dollars aimed at reducing teen pregnancy may be better spent addressing problems preexisting to teenage pregnancy such as poverty and poor education.

• The Diffusion of Human Papillomavirus

DNA Testing among Medicaid Beneficiaries in Florida

Rebecca Anhang Price, M.S.

Presented By: Rebecca Anhang Price, M.S.,

Ph.D. Candidate, Department of Health Care

Policy, Harvard University, 180 Longwood

Avenue, Suite 113, Boston, MA 02115, Phone:

(617)432-3371, Email: ranhang@fas.harvard.edu

Research Objective: Cervical cancer screening is indicated for more than 100 million women in the United States, but is underutilized by those of lower education and income, and those who live in rural areas. The FDA initially approved a new form of cervical cancer screening, DNA testing for carcinogenic strains of human papillomavirus (HPV), in 2000. This study investigates how quickly HPV test use has diffused across a population with low screening rates; whether the introduction of the HPV test is associated with higher screening rates among those previously unscreened or underscreened; and how appropriate and inappropriate use of the test has evolved during its initial years on the market.

Study Design: Medical claims data for the period July 2001 through June 2005 were obtained for beneficiaries of Florida Medicaid. In keeping with clinical guidelines, HPV test use is deemed appropriate if used in conjunction with a Pap smear for primary screening in women age

30 and older, or if used subsequent to a Pap smear result of atypical squamous cells of uncertain significance in women of any age.

Multivariate logistic regression models assess differential diffusion of HPV test use across urban/rural counties, provider specialty, proportion of provider’s patients on Medicaid, and patient age and race.

Population Studied: 336,009 women, ages 21 through 64, eligible for Florida Medicaid through

AFDC and enrolled in Medicaid for at least 12

consecutive months between July 2001 and June

2005.

Principle Findings: Preliminary results suggest that few women on Florida Medicaid received an

HPV test between 2001 and 2004, although this proportion increased substantially over the time period. Black women were significantly less likely than White or Hispanic women to receive any type of screening for cervical cancer; however, women of all ethnicities had similar rates of HPV testing.

Conclusions: Introduction of a new cervical cancer screening technology did not substantially alter screening practices of women on Florida

Medicaid. Preliminary analyses do not provide evidence of disparities in HPV test use across racial or ethnic groups. Further analyses will assess appropriate vs. inappropriate use of HPV testing; explore rates of HPV testing in previously unscreened women; and examine determinants of differential diffusion of HPV test use across provider types and patient characteristics.


Findings will inform cervical cancer prevention policy.

Funding Source: Foundation for Informed

Medical Decision Making

• Religiosity/Spirituality in Young Women

Receiving Treatment for Eating Disorders

Michele Athay

Presented By: Michele Athay, Predoctoral

Fellow, Center for Evaluation and Program

Improvement, Vanderbilt University, Peabody

#151, 230 Appleton Place, Nashville, TN 37203,

Phone: (615) 343-2704, Email: michele.athay@vanderbilt.edu

Research Objective: Increasing evidence suggests that cultural factors such as spiritual and religious beliefs and practices have an important impact on both physical and mental health yet it is a factor often left out of eating disorder treatment outcome literature. Exploring religious and spiritual beliefs as they manifest and change throughout an individual’s course of treatment provides insight into the role of faith in the process of recovery and maintenance of that recovery upon transition from a treatment facility into independent living. Additionally, spiritual and religious beliefs and practices are important in understanding the micro and mesosystems in which individual is embedded.

The purpose of this study is to specifically investigate religiosity/spirituality as a factor potentially impacting the transition of young women from a faith-based residential treatment facility into independent living. Issues specifically addressed included: Quantitative exploration of the relationship between measures of eating disorder symptomology and religiosity/spirituality; Use of qualitative data to better understand the role that religious and spiritual practices and beliefs play in the manifestation of eating disorders; Quantitative investigation of whether ratings of religiosity/spirituality and the presence of eating disorder symptomology differed according to length of time within the treatment facility

This study is part of a larger research project aimed at identifying factors associated with successful transition from residential care into independent and self-sufficient living. These findings will be integrated into a Transitional

Care Program being developed to help facilitate the transition for young women exiting a treatment facility.

Study Design: This study will analyze data from self-report measures on eating disorder symptomology and religiosity/spirituality collected at a single point in time.

Instruments used for this study: 1. The Eating

Disorder Examination Questionnaire which assesses frequency of behavioral features of eating disorders as well as severity of aspects of the psychopathology of eating disorders by

Fairburn and Beglin, 1994. The Brief

Multidimensional Measure of

Religousness/Spirituality, 1999, which is part of the General Social Survey, a random national survey of the National Data Program for the

Social Sciences by Fetzer Institute, 2003.

Analysis tools and procedures: Data from the standardized measures will be analyzed utilizing correlation and regression statistical procedures with SPSS 14.0 software, 2006.

Population Studied: Mercy Ministries of

America, founded in 1983, is a non-profit, faithbased residential program for females, ages 13-

28, who are struggling with problems such as eating disorders, chemical addictions, unplanned pregnancy, depression, and abuse.

The females who come to Mercy Ministries typically stay in the residential setting for an average of 6-9 months, free of charge, where they receive intensive biblical counseling that addresses issues that put the female in need of residential care. There are currently 3 homes located in the United States, which have about

150 females entering the program each year.

Selection of participants: As part of ongoing research for development and implementation of

a Transitional Care Program, all current residents, ages 13-28, in Mercy homes, N = 90, will complete a packet of selected measures during January, 2007.

Principle Findings: Data collection is currently underway and will be completed in January 2007, so that there will be five months to analyze the data and prepare the presentation.

Conclusions: Although this study has not yet been completed, several hypotheses are being tested. First, the scores from the MMRS will differ between individuals who are self-reported to have eating disorders and those who do not.

This may point to a unique role that faith plays in the course of eating disorders. Second, that there will be a relationship between scores on the MMRS and EDE-Q, indicating a possible relationship between eating disorder symptomology and religiosity/spirituality. This would confirm conclusions drawn by the few studies that have been conducted concerning faith and eating disorders. Third, the length of time residing within the treatment facility will correlate with the scores on both the EDE-Q and the MMRS, suggesting that over the course of treatment, recovery can be partially described by lowered levels of eating disorder symptomology and increasing levels of religiosity/spirituality.


Implications: Focusing on the religious and spiritual side of an individual may serve as a natural support to the facilitation of recovery and positive coping mechanisms, much in the same way that a family or therapist can. The researchers hope that the findings from this study will provide valuable information to be integrated into the curriculum of the Transitional

Care Program currently being developed, to be implemented in January 2007, to facilitate young women in their transition from the residential program into independent living. The extent to which religiosity/spirituality plays a role in the maintenance and recovery from eating disorders may be critical in determining the extent to which it should be a focal point in the curriculum of the Transitional Care Program and for the successful transition of young women into independent living.


• The Impact of Nursing Unit Turnover on

Nurse Satisfaction, Medication Errors, and

Patient Satisfaction

Sung-Heui Bae, M.P.H., Bruce Fried, Ph.D.

Presented By: Sung-Heui Bae, M.P.H., Doctoral

Student, Health Policy and Administration,

University of North Carolina at Chapel Hill,

McGavran-Greenberg Hall, CB #7411, Chapel

Hill, NC 27599-7411, Phone: (919) 265-4805, Fax:

(919)966-6961 Email: sbae@email.unc.edu

Research Objective: Nurse turnover has reached critical levels and recent research suggests that turnover accompanied by the nursing shortage may compromise healthcare quality. Ongoing instability in the nursing workforce raises questions about the impact of turnover on nurse morale and effectiveness, cost containment efforts, and the continuity and quality of patient care. Although turnover is thought to lower the quality of care, empirical research on the impact of nurse turnover on outcomes is lacking. Those few studies that have examined the impact of turnover have measured the aggregate organizational impact of turnover, which does not permit assessment of the specific social and behavioral mechanisms associated with poor outcomes. Turnover and organizational characteristics typically vary by nursing unit. Therefore, examining turnover at the nursing unit level is key to understanding the relationship between turnover and outcomes.

The purposes of this study are (1) to examine the relationship between registered nurse turnover and patient and nurse outcomes; and (2) to assess how this relationship may be mediated by key organizational factors.

Study Design: This study uses data from the

Outcomes Research in Nursing Administration

(ORNA-II), a longitudinal, causal modeling study examining the relationships among external environmental characteristics, hospital characteristics, nursing unit characteristics, staffing, work environment and organizational and patient outcomes. A particular advantage of these data is that turnover was measured for an appropriate period of time prior to measuring the outcome variables, thus providing the opportunity to draw conclusions about causality.

With the nursing unit as the unit of analysis, the dependent variables include nurse job satisfaction, patient satisfaction, and medication errors measured by the number of medication errors reported on the nursing unit divided by the number of patient days. The crude nursing unit turnover rate for the given period is the primary independent variable. Factors hypothesized to mediate the impact of turnover on outcomes include the nature and complexity of the work (i.e., task environment) and the unitspecific impact of turnover on relational coordination activities.

Population Studied: The sample includes 286 general medical-surgical nursing units in 146 randomly selected US general hospitals. Data were collected for the periods January 2003-June

2003, and January 2004-June 2004.

Principle Findings: Nursing unit turnover rates ranged from 0 to 1.03 (mean=0.1263). Number of unit level medication errors ranged from 0 to

49 (mean=3.7). Continued analysis will explore specific relationships among nursing unit turnover, nursing unit characteristics, and nurse and patient outcomes.


Although we have an implicit sense that turnover is associated with poorer outcomes, this study will provide insight into the dynamics of the turnover-outcome relationship, and how this relationship is moderated by unit level factors identified conceptually by organizational researchers. The study will contribute to a limited body of knowledge on the consequences of nursing turnover, and provide healthcare managers with information about the types of nursing units most at risk of poor outcomes related to turnover.

•

Exacerbation Events and Healthcare Costs for Medicare-Eligible Patients with Chronic

Obstructive Pulmonary Disease (COPD) by

Initial Medication Regimen

Christopher Blanchette, M.A., Manabu Akazawa,

M.P.H.

Presented By: Christopher Blanchette, M.A.,

Manager, Global Health Outcomes,

GlaxoSmithKline, 5 Moore Drive, 17.1178, RTP,

NC 27709, Phone: 919-483-1988, Email: christopher.m.blanchette@gsk.com

Research Objective: To compare the effects of initial medication regimens on exacerbation events (COPD-related hospitalizations and/or emergency department visits) and COPD-related costs for Medicare-eligible patients with COPD in a Medicare-eligible managed care population.

Study Design: A historical cohort study and a propensity-matched comparison was made as a sensitivity analysis. Exacerbation events were assessed using Cox-proportional hazards regression models controlling for baseline factors and pre-index events as well as in unadjusted models with a propensity-matched sample. Healthcare costs were assessed using a generalized linear model (GLM) to adjust for baseline characteristics and pre-index utilization and costs as well as in unadjusted models with the propensity-matched sample.

Population Studied: Commercially insured patients aged 65 years and older, with COPDrelated medical costs (ICD-9-CM = 490, 491,

492, 496), 18 months of continuous enrollment

(12 months pre and 6 months post), and at least one prescription claim (index) for ipratropium

(IPR) or fluticasone propionate/salmeterol (FSC)

500/50 between 01/2001, and 08/2003 were assessed.

Principle Findings: 1,051 patients were identified; IPR (n=952) and FSC (n=99). EVENTS

- Compared with IPR, FSC was associated with a significantly lower risk of COPD-related event

(HR 0.547 [95%CI 0.301-0.995]). COSTS -

Compared to IPR, the FSC cohort had lower medical (-$464) and total (-$14) costs and higher pharmacy costs (+$260). However, cost differences were not significantly different between the groups with the exception of pharmacy costs, which may be due to a higher compliance rate by the FSC group. Results from the sensitivity analysis with the propensity-scorematched sample of 194 were similar.

Conclusions: Compared to the IPR cohort, the

FSC cohort was 45% less likely to have an exacerbation event and had lower or similar medical costs. FSC is a more cost-effective initial maintenance therapy than IPR for the Medicare population.


Accurate healthcare technology assessment for formulary decision making requires access to

Medicare part D claims.

Funding Source: GlaxoSmithKline

•

African American Knowledge of Kidney

Disease: Results from the First National

Study

Teri Browne, M.S.W., Amy D. Waterman, Ph.D.,

Elisa H. Gladstone, M.P.H., Brian M. Waterman,

M.P.H.

Presented By: Teri Browne, M.S.W., Doctoral candidate, School of Social Service

Administration, University of Chicago, 4400 W.

Lake Ave #108B, Glenview, IL 60026, Phone:

773-368-6429, Fax: 708-344-6127 Email: teri@uchicago.edu

Research Objective: Kidney disease is an

African American public health crisis. The first survey of African Americans about kidney disease was conducted by the National Kidney

Disease Education Program (NKDEP), of the

National Institutes of Health, to determine this population’s knowledge and behaviors related to kidney disease.

Study Design: Using random-digit dialing, 2,039

African Americans were surveyed from seven states (GA, MD, OH, MS, LA, MO, TN) about their knowledge and behaviors related to kidney disease.

Population Studied: 2,039 African American adults from seven states (GA, MD, OH, MS, LA,

MO, TN)

Principle Findings: Even though almost half

(43.7%) of the African-Americans surveyed had a risk factor for kidney disease (including hypertension, diabetes, or a family history of kidney disease), only 2.8% reported that kidney disease was a top health concern for them. Less than half of surveyed respondents knew the correct definition of kidney disease (48.6%), knew a test to diagnose kidney disease (39.5%), and knew that African-Americans were at higher risk for kidney disease (18.1%). Few understood the relationship between hypertension, diabetes, and kidney disease; less than 15% mentioned that kidney disease could be a negative consequence of unmanaged diabetes (13.6%), hypertension (12.1%), or a family history of kidney disease (2.4%). African Americans who were objectively at risk for kidney disease did not always perceive themselves to be at higher risk:

75% of African Americans with risk factors for kidney disease did not perceive themselves to be at higher risk. Only 37.4% of African-Americans had ever been tested specifically for kidney disease.

Conclusions: This study indicates that kidney disease is not currently perceived as an important health problem for African-Americans, that they may not understand fundamental information about kidney disease, and that they are not taking action to prevent kidney disease.


As the first national study of this topic, the conclusions are important in creating public health interventions to address this urgent problem and can help the nephrology team in targeting programs to most effectively reach this audience.

Funding Source: NIDDK

•

Race and Ethnic Disparities in Diabetes

Care and Monitoring

Melissa Butler, Pharm.D., M.P.H.

Presented By: Melissa Butler, Pharm.D., M.P.H.,

Student, DPOP, UNC-CH, 801 Woodcroft

Parkway, Apt 1403, Durham, NC 27713, Phone:

919-724-7947, Email: melissab@unc.edu

Research Objective: To determine if there are differences in recommended diabetes care monitoring in patients with diabetes by race and ethnicity.

Study Design: Retrospective, cross-sectional, multivariate, logistic regression analyses using nationally representative data from 2002-2004 were conducted using the Andersen Behavioral

Model of Health Services Use. Race-stratified analyses were also used to examine racial/ethnic variation of enabling, predisposing, and need variables with the receipt of recommended diabetes monitoring.

Population Studied: Uninstitutionalized, black, white, and Hispanic adults aged 18 or older who reported having diabetes were included in this analysis.

Principle Findings: Pupil dilation was positively associated with increasing age, having insurance, fair to good health, pupil dilation in previous years, and blood pressure, A1C, and foot checks. Being male, not getting necessary medical care, making less than $25,000 a year, and having less than a high education were negatively associated with having pupils dilated.

Foot examinations were more likely if respondents lived in a MSA, had an A1C, pupil dilation, and were being treated for diabetes with diet, oral medications, and insulin. Blacks, exercisers, and older respondents were less likely to have foot exams. A1C test were less likely in blacks and older adults. Diabetes-related eye disease, fair to good health, use of medications, cholesterol tests, pupil and foot exams, and being able to make decisions with providers were positively associated with A1C tests. Unlike the other forms of monitoring, many respondents did not know if they had had an AIC test.

Respondents were more likely to have had all three tests if they lived in a MSA, were older, had eye disease, fair to good health, cholesterol checks, and were treated with medications, diet, and insulin. Blacks, people with less than a high school education, and people who believed they could overcome illness without medical professional help were less likely to have had all three tests. In the race-stratified analyses different variables contributed to receipt of diabetes care monitoring. Hispanics who reported they could overcome illness without medical professionals were less likely to receive diabetes monitoring, as were black males and whites with less than a high school education.

Conclusions: There were no racial differences in receipt of pupil dilation exams; however blacks were less likely to receive foot exams and A1C tests. Need variables were associated with

receipt of all types of diabetes monitoring. The enabling variable MSA was associated with foot care which may indicate a concentration of podiatrists in urban areas. Other enabling variables, income and insurance, were associated with receipt of pupil dilation exams.

Age,a predisposing variable, was positively and negatively associated with receipt of services.

The only other predisposing variable that made an impact on diabetes monitoring was education.


Different interventions are needed to increase utilization of diabetes care monitoring between racial groups as there are different variables contributing to use of services. Not knowing if services, eg. A1C tests, have been received indicates need for more education.

•

Hispanic Ethnicity and Public Clinic Use as

Predictive Factors of Emergency Department

Utilization

Erin Carlson, M.P.H.

Presented By: Erin Carlson, M.P.H., Graduate

Research Assistant, Health Management and

Policy, University of North Texas Health Science

Center, 3500 Camp Bowie Boulevard, Fort

Worth, TX 76107, Phone: (402) 305-3144, Fax:

(817) 735-0446 Email: ecarlson@hsc.unt.edu

Research Objective: This study investigates

Hispanics’ receipt of care at public clinics and the impact of use of public clinics as a usual source of care among Hispanics on their use of the emergency department (ED).

Study Design: The 2005 National Health

Interview Survey (NHIS) provided data for analysis. An NHIS adult sub-sample (n=31,428) containing information on public clinic utilization was merged with the core file

(n=98,649) containing information on ED utilization, ethnicity, and other variables.

Analyses were restricted to non-Hispanic whites,

Hispanics, and African-Americans. Univariate analyses provided descriptive statistics. Bivariate analyses examined associations among predictor variables. A multivariate ordinal logistic regression model predicted the number of times respondents reported using the ED in the past year. Model covariates included Hispanic ethnicity, birthplace, clinics as usual source of acute and preventive care, and controlled for uninsurance, income level, race, and health status.

Population Studied: The nationally representative clustered random sample included 56,972 non-Hispanic whites, 23,642

Hispanics, and 13,603 African-Americans. Over four-fifths of the sample respondents had coverage and over half reported no source of preventive care.

Principle Findings: Of Hispanics, 31.8% reported no health coverage, 68.4% reported no source of preventive care, and 46.6% reported annual household incomes less than $20,000.

Hispanic ethnicity was significantly associated with public clinic use for preventive (p=<.0001) and acute care (p=<.0001). Nearly one-third

(29.4%) of Hispanics reported that a public clinic was their usual source of acute care, compared with 15.7% of non-Hispanics. Of those who used clinics for preventive care,

32.0% were Hispanic. Using clinics as a usual source of acute care and the number of times presenting in the ED in the past 12 months were significantly related (p=.0006).

In the logistic regression model, the significant predictors of ED use were clinic as a usual source of acute care (p=.011), income (p=<.001), and health status (p=.006).

The odds of presenting at the ED 2 or more times in the past 12 months versus less than 2 times significantly increased by 2.57 times for persons whose usual source of preventive care was a public clinic (p=.012, CI=1.23, 5.37).

Conclusions: Hispanic ethnicity, foreign birthplace, and lower incomes were each significantly associated with clinic use. Hispanics were more than twice as likely as non-Hispanics to rely on clinics for care. Persons who sought preventive care at clinics were over twice as likely to present at the ED than those who sought care elsewhere, perhaps implying that those who seek preventive care from a safety net source, rather than forego preventive care, can be diagnosed with health problems that require more specialized levels of care than what a public clinic can provide. Findings also confirmed that lower incomes among Hispanics may influence the forces that drive ED use, such as a lack of insurance and primary care, that can result in preventable, emergent conditions.


Policies targeting expanding access for

Hispanics should take into account lower incomes and need for safety net care for the uninsured who have conditions requiring care beyond that offered at public clinics.

•

Regulating Hospital Mission: A

Longitudinal and Quasi-Experimental

Assessment of State Community Benefit Laws

Wendy L. Chen, M.H.S.

Presented By: Wendy L. Chen, M.H.S, Doctoral student, Department of Health Policy and


Chapel Hill, 1101 McGavran-Greenberg Hall,

Chapel Hill, NC 27599-7411, Phone: (503)780-

4693, Fax: (919) 966-6961 Email: wchen@email.unc.edu

Research Objective: The growth of under and uninsured populations increased burden on state and federal governments to finance health care, and the corporatization of health care have raised concerns about whether not-for-profit

(NFP) hospitals are fulfilling their communityoriented mission. While local tax authorities, the

Internal Revenue Service, and Congress have stepped up their efforts to scrutinize the behavior of NFP hospitals, state governments have taken the lead in forcing NFP hospitals to meet their obligations that come with a tax exemption. Starting in the early 1990, an increasing number of states have instituted laws to regulate not-for-profit hospitals’ provision of community benefit services in exchange for their tax advantage. Little research has examined the effectiveness of these state community benefit laws and the contingency factors that influence

NFP hospitals’ compliance with these regulations. This study addresses two questions:

(1) Are state community benefit laws effective in promoting NFP hospitals’ provision of services that are aimed to promote community health status? (2) What are the conditions that facilitate or inhibit NFP hospitals’ response to the laws?

Study Design: This study employs a pre-post quasi-experimental design to compare ownership and state differences in NFP hospitals’ willingness to participate in community benefit activities before and after the implementation of the laws. Longitudinal panel data on all private hospitals in California, Texas and Florida participating in the AHA and state annual hospital surveys between 1991 and 2002 are used. Hospitals in California and Texas, where community benefit laws have been instituted, are the study group; hospitals in

Florida, where such a law does not exist, constitute the comparison group. Community benefit services were assessed in the programmatic, financial and special population areas. Contingency factors include hospital size, managed care participation, system/network status, and market competition. Analysis is based on the linear probability and the difference-in-difference-in-difference models.

Population Studied: A total of 7,099 hospitalyear observations representing private hospitals in California, Texas and Florida.

Principle Findings: State community benefit laws positively affect the provision of community benefit services in NFP hospitals. In California, the law elevates the averaged percentage of community service provision in NFP hospitals by a magnitude of 0.044 (p=0.061) after 1994, compared to the pre-law period. In Taxas, NFP hospitals provided more uncompensated care at an average of $5,495 per bed (p<0.001) during

1997-2002,, compared to the pre-law period.

Compared to Florida, the difference in charity care between NFP and FP hospitals increased by

$2,377 per bed (p=0.019) and reached an average of $3,970 per bed (p<0.001) during

1997-2002. Hospital size and market competition facilitate NFP hospitals’ response to the laws. The effects of other contingency factors are inconsistent across states and service areas.

Conclusions: Results indicate that state laws are effective in promoting NFP hospitals provision of community benefit services. How the laws are crafted also makes a difference. The California law includes a list of sample programs beneficial to the community at large. NFP hospitals in

California respond to such rhetoric by increasing the variety of community oriented services available to its target communities; no difference is seen in financial contributions. The Texas law stipulates strict financial rules. In response,

Texas NFP hospitals divert resources away from community oriented programs to expand their financial contributions to bad debt, charity and uncompensated care. Certain organizational and environmental contingencies, such as hospital size, have significant influences on how

NFP hospitals respond to the laws. Further research is needed to explore such contingency effects in order to inform the design and implementation of state community benefit laws.


State community benefit laws are an effective means to influence NFP hospitals’ community benefit behaviors. However, for states contemplating the use of similar laws, attention should be paid to the stipulations of the law according to the needs of communities and the strengths of NFP hospitals in order to achieve optimal policy effectiveness.


• Methodology Employed in Cost-of-Illness

Studies in the United States: A Systematic

Review

Gerd Clabaugh, M.P.A., Marcia Ward, Ph.D.

Presented By: Gerd Clabaugh, M.P.A., student,

Department of Health Management and Policy,

University of Iowa, 6027 Redbud Court, Des

Moines, IA 50131-1630, Phone: 515-210-2900, Fax:

Email: gerd-clabaugh@uiowa.edu

Research Objective: We undertake a systematic review to examine the methods used by researchers in developing cost-of-illness studies.

This review aims to categorize the approaches that the published literature uses in terms of perspective, scope, components of care analyzed in the literature, datasets, and valuation approaches used. It draws conclusions regarding the adequacy of current COI research methods and makes recommendations on improving them.

Study Design: A systematic review of the cost of illness literature is conducted to determine how researchers deal with direct medical costs in their analyses. The online bibliographic information service HealthSTAR (which incorporates Medline) was used to search for

COI studies in the research literature published during the period 2000-2004. The search strategy used the term ‘‘cost of illness’’ as a

MeSH (medical subject heading) term.

Population Studied: Research studies published in the period 2000-2004 and categorized in the

HealthSTAR bibliographic information service.

Principle Findings: The HealthSTAR literature search identified references to 650 articles. The abstract review resulted in the identification of

170 of these for the more detailed review. This process identified 52 articles that met all criteria of COI studies. We identified 197 components of care analyzed across the 52 articles. Private insurance or employer-claims datasets comprised the largest source of utilization and cost information among the studies. Nearly half of the 52 articles (24) represent the capturing of costs from the perspective of society. 19 articles represent the perspective of either employer or insurance-based health care. A wide variety of illnesses are studied in the COI literature. The most frequent illness studied in the COI articles that met our inclusion criteria was arthritis (6 articles). Respiratory diseases, urinary diseases, and Alzheimer’s disease were the subject of 3 articles each.

Conclusions: Analyzing cost of illness presents useful opportunities for communicating with the public and policymakers on the relative importance of disease and illness. Our research indicates that many COI studies have focused exclusively on a subset of total health care expenditures. Without well-accepted standards to guide researchers in their execution of these studies, policymakers and the general public must be wary of the data sources and methods used in their calculation. Specifically, oDisclosure of perspectives used in guiding the study ---- Understanding the perspective from which costs are captured is critical to a clear understanding of cost of illness. oInclusion, whenever possible, of all affected components of care ---- Analyses limited to only a few components of care will under-estimate the cost of illness for the conditions under study and limit generalizability of the findings. oIdentification of the components of care analyzed ---- Researchers must clearly articulate those particular health care cost segments included in their analysis. A standard language for components of care should be created and data elements matched against these to ensure clarity in identification of cost categories. oDescription of data sources ---- This will enable future researchers to replicate and improve on the analysis of COI studies by understanding what the data used represent. oUse, whenever possible, of publicly-available datasets ---- This will permit other researchers to replicate the findings, will enhance generalizability, and will facilitate understanding of the data elements used in the analyses. oIdentification of costs captured ---- Costs of care come in a wide variety of forms, including out-of-pocket, insurancebased reimbursement, charges, indirect costs, etc. Studies should also clearly articulate whether the cost data used represent the actual cost of delivering care, dollars exchanged for the provision of care, or simply provider charges which may be subject to inflating (such as for cardiac surgery) or discounting (such as in preferred provider arrangements). oDisclosure of the year reflected in the utilization data and in its valuation - This is important for interpreting findings when patterns of treatment change over time. Also, the year that costs were valued is important when comparing findings across studies using different years, so that inflation factors can be appropriately applied and discounting can be employed. oDescription of the strategy for using primary and secondary diagnosis data - Where diagnostic data are used, studies should declare how they have dealt with the use of primary and secondary diagnoses in capturing cost information. In particular, were cases limited to utilization where the specific

ICD-9 codes were listed first or was a broader inclusion rule used?


Standards to guide the methodology of COI studies will aide interpretation of findings and comparison of results across studies and diseases. At the very least, as listed above, researchers should be mindful of their responsibility to disclose pertinent details of their methods to permit others to understand and replicate their results. With the increasing popularity of COI studies, standardization of methods becomes more critical to permit policymakers and the general public to better understand our investment in health care, and to drive decisions about future insurance benefits, efforts in curbing and controlling disease and illness, and development of programs to improve the health of the population.


•

Use and Perceived Effectiveness of Herbs by U.S. Adults

Margaret Cushman, M.S.N., M.S., Ph.D.

Presented By: Margaret Cushman, M.S.N.,

M.S., Ph.D., doctoral candidate, College of

Nursing and Health Sciences, University of

Massachusetts Boston, (home) 75 Shore Drive,

Freeport, ME 04032-0000, Phone: (207) 865-

4684, Fax: Email: mcushman@jhu.edu

Research Objective: The study examines the predisposing, enabling, and health status determinants of U.S. adults on their herb use, and whether they differ by health condition; and describes the utilization of conventional and other CAM health services by herb users overall and for various conditions.

Study Design: The study is a secondary data analysis of the NHIS 2002 and its Alternative

Health Supplement. Data are analyzed using logistic regression and structural equation modeling (SEM), guided by a framework based on Andersen’s Model of Health Behavior.

Population Studied: The target population is

US adults 18 and over, and the specific subpopulation of individuals reporting use of herbs

(n=7,566). Of those ever using herbs, 5,787 reported use of herbs in the prior 12 months of which 3,315 reported using herbs to treat a health condition.

Principle Findings: The SEM model has been constructed and data analysis and testing of model estimation are underway, on this full-time doctoral dissertation project. Results of the analysis and findings will be available well in advance of the June Research meeting.


Herb use is among the most popular complementary and alternative therapies, and the fastest growing. Knowledge of the variables that contribute to herb use among U.S. adults can aid health practitioners in anticipating use.

Knowledge concerning patterns of concomitant use of conventional and CAM health service with herb use can inform health policy and future health services research.

• Nuclear Medicine Scientists in the USA - A

Cross Sectional Study

Ajita De, M.A., M.Phil, M.S., Paul Wing,

D.Engin., Ms. Margaret Langelier, M.S.

Presented By: Ajita De, M.A., M.Phil, continuing

MS in Health Policy, Management & BEhavior,

Graduate Research Assistant, Center for Health

Workforce Studies, 7 University Place/Room 334,

Rensselaer, NY 12144-3458, Phone: 518-402-0250,

Fax: 518-402-0252 Email: de_ajita@yahoo.com

Research Objective: To learn about scientists working in the field of Nuclear Medicine Science

(NMS) in the U.S.

Study Design: Cross-sectional.

Population Studied: Nuclear Medicine

Scientists (NMSs) actively working in the U.S. in

2006.

Principle Findings: - 83% of the NMSs were male and 17% were female compared to 49% and 51%, respectively, in the general population.

- Asian/Pacific Islanders were over-represented whereas Black/African Americans and Hispanics were under-represented. Non-Hispanic Whites were slightly over represented compared to the general population and American Indians/Alaska

Natives were slightly under-represented in this workforce. - 29% of active NMSs were born outside the U.S. - 59% of active NMSs held doctoral degrees. - 28% worked primarily in academic medical centers and 24% worked in hospitals/medical centers. - The main branches of science included Physics, Pharmacy,

Chemistry, Computer Science/ Engineering, some combinations of these four, and other. -

46% of the NMSs worked in research and development. Among these scientists 63% worked in radiopharmaceutical development. -

The roles of the NMSs varied from basic science and applied research to technical and administrative support and combinations of these roles. - The mean annual salary of the active NMSs in 2006 was $123,800, and the median was $108,000. Many of those in the salary ranges above $150,000 were working

more than one job. - The NMSs held a variety of different certifications, depending in part on their branch of science.

Conclusions: This study shed light on this small but essential component of the Nuclear

Medicine workforce that is seldom studied in a formal way. NMS is a critical foundation for the practice of nuclear medicine, and NMSs play central roles in the design and development of nuclear medicine equipment, tools, and techniques. They are a very diverse group of highly paid intellectuals coming from different branches of science and playing a wide range of roles in nuclear medicine. NMS encompasses a myriad of research activities and scientific roles.

The interdisciplinary nature of nuclear medicine science research and clinical nuclear medicine services are evident from the survey responses.

A number of issues face NMSs in the future.

There is no standard pathway for entry into the

NMS field. No standard licensure process exists for the NMSs. Funding for NMS, which is highly dependent on the Federal government, is fragile.


NMS is a critical foundation for the entire field of nuclear medicine. The way the field of nuclear medicine is evolving makes the seminal contributions of NMSs very crucial, since they are among the key determinants of the direction and pace of future change. They play major roles in generating the scientific and technological breakthroughs that lead to the new cameras and diagnostic and therapeutic procedures currently transforming the field of medical imaging.

The information and insights provided by this study inform planners, policy makers, and educators interested in ensuring that nuclear medicine science flourishes in the future. The poster will also include some recommendations applicable to the NMSs individually as well as collectively.

Funding Source: Society of Nuclear Medicine

• Breast Abnormalities: Identification of

Barriers to Follow Up and Treatment

Following Mammography

Ruth DeBoard, M.S., Ph.D. in progess

Presented By: Ruth DeBoard, M.S., Ph.D. in progress U of AZ, Assistant Clinical Professor,

Family Nurse Practitioner, School of Nursing,

Northern Arizona University, 8650 Laramie Rd.,

Flagstaff, AZ 86004, Phone: 928-380-1959, Fax:

928-523-7171 Email: Ruth.DeBoard@nau.edu

Research Objective: 1.To identify the characteristics of women who do not return for follow up and treatment following abnormal mammography. 2. To determine the point at which women depart from recommended follow- up and treatment following abnormal mammography. 3. To identify the personal, financial and organizational barriers possibly affecting diagnosis and cancer follow- up and treatment after screening.

Study Design: Quantitative data collection and statistical analysis through participant survey at baseline, two, four and six months at multiple sites in urban and rural Arizona is proposed.

Data will be collected through federally and state funded screening programs, community health centers and women’s health clinics. Bi- lingual

Promotoras, lay health workers, will be oriented in each location and will participate in data collection. Subjects will be invited to participate in the study at the time of screening, then incorporated into the study based upon confirmed abnormal mammography results.

Population Studied: Cognitively intact, adult women, who have confirmed abnormal results following mammography. The population served largely constitutes underserved women in

Arizona who are uninsured/ underinsured and seek breast cancer screening through state and federally funded early detection programs, community health centers and women’s health clinics. Outreach includes women of diverse ethnicity: African American, Native American,

Alaskan Native, Hispanic, Asian, and Caucasian residents; migrant working women; young and elderly. Invitation to participate in the study is at the time of screening. Inclusion is based upon confirmed abnormal mammography results.

Principle Findings: In progress. This poster illustrates the conceptual framework guiding this research: the Healthcare Utilization Model developed by Andersen and Aday. This model is useful in analysis of factors associated with patient utilization of healthcare services to include: predisposing characteristics, enabling resources and need. This model also explores contextual variables, such as role of environment: healthcare system and external environment; and provider related factors: provider and community enabling factors, which affect personal health choices and utilization of breast cancer screening services.


There is a dearth of research and knowledge related to the women who depart from recommendations for follow- up and treatment after abnormal mammography. The result is a deficiency in understanding of the women’s characteristics, points at which they depart from

recommendations for follow up and treatment, and identification of the possible personal, financial or organizational barriers to continued access to care. It cannot be assumed that women who disappear and do not follow recommendations for follow- up have false positive mammograms. In fact, this scarcity of knowledge likely constitutes a loss of precious screening dollars, delayed treatment resulting in later entry into the health care system with advanced stage disease and more expensive care, as well as poorer health outcomes resulting in exacerbation of health disparity.

Gaining clarity on this significant number of women in Arizona may help to identify indicators for women at risk for non completion of cancer screening voluntarily begun. This information may contribute to making breast cancer screening procedures more efficient and cost effective, improving health outcomes, reducing health disparities and may have implications for other health screening programs for women.

• Ethics in Canadian Health Technology

Assessment: A Descriptive Review

Deirdre DeJean, B.A., B.Sc.

Presented By: Deirdre DeJean, B.A., B.Sc.,

Graduate Student, Health Research

Methodology Programme, McMaster University,

1200 Main St W, Hamilton, L8N 3Z5, CA, Fax:

905 297-9838 Email: deirdre.dejean@mail.mcgill.ca

Research Objective: Health technology assessment investigates the implications of the introduction and use of a particular technology through the examination of five types of outcomes: safety, efficacy and effectiveness, psychological, social and ethical considerations, organizational and professional implications, and economic issues. Essentially, HTA endeavors to provide research information on the impacts of interventions present and forthcoming in health care. An increasing number of studies indicate that ethical implications are neglected in HTA reports, but no study to date has examined how they are incorporated into HTA when they are included.

The purpose of this descriptive review is to characterize the strategies used to incorporate ethically relevant information into Canadian health technology assessment reports published from 1997-2006.

Study Design: Descriptive review. Quantitative descriptive features of the health technology assessment reports are summarized. Methods of qualitative description were used to develop a comprehensive review of ethics content captured in the reports.

Population Studied: Health technology assessment reports in English and French were collected from the 6 Canadian HTA agencies that currently advise government agencies: Agence d'évaluation des technologies et des modes d'intervention en santé, Alberta Heritage

Foundation for Medical Research, Canadian

Agency for Drugs and Technologies in Health,

Institute for Clinical and Evaluative Sciences in

Ontario, Technology Assessment Unit of the

McGill University Health Centre, and the Ontario

Medical Advisory Secretariat.

Health technology assessment reports published from 1997-2006 were identified through the HTA

Database. All reports identified, including full reports and brief publications, were collected to reflect the full range of HTA products that are produced and disseminated by agencies.

Principle Findings: The six Canadian HTA agencies aspire to incorporate ethics into their assessments: agency mandates list the assessment of ethics specifically, relevant concepts such as equity, or the broader impacts of the technology. Of the 694 reports, however, only 11 percent acknowledge ethics, 6 percent report on legal issues relevant to ethics, 2 percent incorporate values, and 2 percent include the discussion of principles.

Some of the ethical issues addressed include access to the technology, equity, the four principles, lightening the economic burden on community, reinforcing prejudices in society, and discriminating against particular groups

(e.g., age, sex, ethnicity).

Strategies for incorporating ethics into the assessment include: having an ethicist on the research team, reviewing the literature for ethical analyses or qualitative research describing patient preferences, or conducting interviews and mail surveys to capture patient and provider perspectives. Analyses vary in depth from substantive discussions of ethical issues to the superficial acknowledgment of issues or simply the statement that ethical analysis is needed.

Conclusions: Canadian HTA agencies are not fulfilling their mandates to include the ethical assessment of health technologies. The methods for incorporating ethical issues into

HTA in Canada vary greatly. A more systematic and transparent approach needs to be developed.


Health technology assessment is increasingly criticized for its neglect of ethical and social

issues. A more comprehensive approach to

HTA will require the development of guidelines for the ethical assessment of health technologies.


Research

• Impact of State Funded Recovery Oriented

Residency Training on the Delivery of

Recovery Oriented Services to Patients

Jonathan Delman, J.D., M.P.H., Ds.C. (pending)

Presented By: Jonathan Delman, J.D., M.P.H.,

Ds.C. (pending), Executive Director, Consumer

Quality Initiatives, 132 Kemble St., Roxbury, MA

02119, Phone: 617-427-0505, Fax: Email: jdelman@cqi-mass.org

Research Objective: In 2002, the President’s

New Freedom Commission on Mental Health released a report (Transforming Mental Health

Care in America), stating that the system must

‘‘…move forward as quickly and efficiently as possible to achieve a more competent and expanded workforce necessary to ensure the full opportunity for recovery, resiliency, and wellness for all Americans with mental illnesses.’’ To address this concern, the Massachusetts

Department of Mental Health (‘‘DMH’’) funds several medical schools to educate and train residents to utilize recovery-oriented, client centered, and evidenced based practices.

This mixed methods study was initiated by DMH

(Dr. Foti), in collaboration with Consumer

Quality Initiatives, Inc. (J. Delman, M.

Goodman), in order to assess the degree to which residents in such education/training programs are providing recovery-oriented and client-centered services. As an exploratory study without a comparison group, the findings will generate hypotheses regarding associations with resident and training program characteristics and the degree to which residents are providing services with a recovery, client centered focus.

Study Design: To assess the degree to which residents are offering recovery-oriented client centered services, we decided to examine the patient perspective. Thus, a survey instrument

(RESI-1) was developed based the Recovery

Enhancing Environment Measure (‘‘REE’’), and adapted for this study to reflect the treatment activities of psychiatric residents. The survey consists of 19 quantitative questions, three openended questions and a series of demographic regarding the patient interviewed. We’re also identifying which of the 4 training programs the patient’s resident is part of.

Population Studied: The subjects are adults diagnosed with a serious mental illness who are being treated at a DMH operated services program (day treatment, clinic) by a resident or intern of DMH’s Psychiatry Residency or

Psychology Internship/Fellowship Training

Program. To be a candidate for an interview, that person must have met with a resident/intern at least 2 times. Prior to collection of the data, the investigators received

IRB approval from DMH Central Office Research

Review Committee.

Principle Findings: The final report will be a mixed methods assessment of the degree to which DMH residency/training programs in the aggregate are teaching residents/interns to have a recovery-focus, based on the perspectives of consumers being treated by the residents/interns. Based on all data, we hope to generate hypotheses about the effects of key aspects of the training programs on resident performance in relation to recovery orientation and client-centeredness. We will also assess the

RES-1 for internal reliability and concurrent criterion validity.

•

Development and Testing of a Satisfaction

Measurement Instrument for Integrated

Long-Term Care

Gail Dobell, Doctoral Candidate

Presented By: Gail Dobell, Doctoral Candidate,

Graduate Student, Social and Behavioral

Sciences, University of California, San Francisco,

1815 Portola Rd, Woodside, CA 94062, Phone:

650-529-1797, Fax: same Email: gaild@onlok.org

Research Objective: Consumer satisfaction is recognized as an important indicator of quality in long-term care. Research on consumer satisfaction with long-term care has largely focused on the nursing home setting with limited attention to home and community-based care delivery. As more elders begin receiving care in home and community-based settings, proven methods for assessing the satisfaction of care recipients are needed. This study reports on the development and testing of the Consumer

Satisfaction Measurement Instrument (ConSat) for frail elders receiving services from an integrated home and community-based longterm care program.

Study Design: The research team reviewed existing satisfaction measurement instruments and conducted patient and provider focus groups to identify the domains of satisfaction relevant to the population. Observation of

service delivery, cognitive interviews, and expert panel review were used to confirm the preliminary instrument. Data from 339 in-person interviews was used to analyze the psychometric characteristics of the instrument.

Population Studied: State certified nursing home eligible elders living in the community enrolled in one of nine PACE (Program of Allinclusive Care for the Elderly) programs located in CA, CO, MA, NY, OR, SC, TX, and WA. PACE programs provide integrated medical and social services using a Medicare and Medicaid capitated payment system. The participant sample was limited to cognitively capable persons as determined by the Short Portable

Mental Status Questionnaire (SPMSQ) (Pfeiffer,

1975) and performance on a short series of screening items.

Principle Findings: Preliminary results indicate that the three core domains of satisfaction: interpersonal processes of care, technical competency, and system adequacy capture the experience of care for frail elders receiving the

PACE model of home and community-based care. Six of eight services exceeded a Cronbach’s alpha score of .70, four exceeded .80, considered high for group comparisons of this content. Two services did not meet the acceptable reliability criterion.

Conclusions: Results show evidence of ConSat instrument validity and reliability. Further research should be conducted to test the psychometric properties of the instrument using a mixed mode data collection methodology: mailed, telephone, and in-person interviews.


Using an appropriately designed instrument, frail elders receiving home and community-based long-term care services are capable of reporting satisfaction with service delivery. Satisfaction information can be used to guide both internal quality improvement efforts and external regulation of home and community-based longterm care providers. Best practice and measurement standards for this population and for home and community-based care settings may be appropriate as part of an overall effort to improve long-term care service delivery.

Funding Source: the California HealthCare and

Archstone foundations and Agency for Health

Care Research and Quality

•

Post Acute Care Use for Older Adults after

Hospitalization for a Cardiac Event

Mary Dolansky, R.N., Ph.D., Shirley M. Moore,

Ph.D., Fang Xu, M.S., Alfred Rimm, Ph.D.

Presented By: Mary Dolansky, R.N., Ph.D., postdoctoral student, nursing, case western reserve university, 19101 Euclid Ave, Cleveland, OH

44106, Phone: 216-368-0568, Email: mary.dolansky@case.edu

Research Objective: Adults over the age of 65 comprise over half of the admissions for a cardiac event (coronary artery bypass surgery

[CABS], acute myocardial infarction [AMI], intracoronary interventions [ICI], and heart failure

[HF]). Acute cardiac events reduce cardiac function and contribute to declines in physical function. To facilitate recovery, post-acute care

(PAC) is available and includes skilled nursing facility care (SNF), intermediate rehabilitation facility care (IRF) and home healthcare (HHC).

Although there are Medicare reimbursed cardiac rehabilitation (CR) services available in outpatient facilities 4-6 weeks after a cardiac event, there are no CR services available during

PAC. In addition, PAC patients are less likely to attend out-patient CR and therefore do not receive the documented benefits of CR.

Understanding the current use of PAC and the characteristics of older cardiac patients that use

PAC after a cardiac event is important in order to establish the need to deliver CR services during

PAC.

Study Design: This population-based study is a cross-sectional secondary analysis of the

Medicare Part A database (Medicare Provider

Analysis and Review, MedPAR file). The specific aims were to 1) identify the proportion of older adults discharged to PAC after a hospitalization for a cardiac event; 2) determine demographic

(age, race, gender) and disease factor

(comorbidity, cardiac event type) differences between older adults discharged to home compared to SNF, IRF or HHC; and, 3) use logistic regression models to evaluate the effects of hospital factors (length of stay in hospital, hospital reimbursement), demographics (age, race, gender), and disease factors (comorbidity) relative to PAC use.

Population Studied: The population included adults 65 years of age and older with a hospital diagnosis of CABS (N=89,359), AMI

(N=170,797), ICI (N=185,485), and HF

(N=1,311,989).

Principle Findings: Approximately half of the older adults after CABS, AMI, and HF used PAC; whereas only 5% of ICI patients used PAC. For all cardiac event types less than 3% of older adults used IRFs. The majority of CABS patients used

HHC; the majority of AMI and HF used SNF.

Older adults that used PAC compared to those

who did not were older, female, had more comorbidity, and had longer length of stay. For

AMI and HF patients, whites were more likely to use PAC (SNF and HHC) than blacks and other minorities.

Conclusions: The study provides national PAC trends for older adults hospitalized for a cardiac event. The under-utilization of PAC services by

African Americans and other minorities needs to be further addressed. Since a substantial numbers of older adults after a cardiac event used PAC and these patients are least likely to receive CR, the current CR model needs to be reevaluated.


The delivery of CR services into PAC (safe endurance training, education on risk factor modification, and survival management) may be an opportunity to improve the recovery of older adults after a cardiac event and make effective use of scarce health care resources. In addition, factors found to be related to PAC will assist in the

Funding Source: NIH K12

•

Prevalence and Correlates of Stimulant

Medication Use by U.S. Adults

David Dore, Pharm.D., Kate L. Lapane, Ph.D.

Presented By: David Dore, Pharm.D., Postdoctoral Fellow/Ph.D. Student, Center for

Gerontology and Health Care Research, Brown

Medical School, Box G-S121, 6th Floor,

Providence, RI 02903, Phone: 401-863-7345, Fax:

401-863-7912 Email: david_dore@brown.edu

Research Objective: Clinicians and researchers now recognize the burden of attention deficit hyperactivity disorder (ADHD) in adults.

Clinicians prescribe stimulants, including methylphenidate and amphetamines, as first-line therapy to treat symptoms of ADHD. Recent reports highlight cardiovascular risks associated with use of these medicines. Little data exist describing the prevalence and correlates of methylphenidate or amphetamine use in adults, especially among those with cardiovascular disease or risk factors. Moreover, researchers and providers know little about the public health impact of amphetamine-related adverse effects.

The objective of this study was to quantify the use of stimulant medications among U.S. adults and to identify correlates of therapy.

Study Design: We conducted a cross-sectional study using a representative sample of noninstitutionalized civilian U.S. adults. We used

Markov chain Monte Carlo multiple imputation with a single chain and a non-informative prior distribution to estimate values of missing data.

We used multivariable logistic regression to derive estimates of the association of demographic and clinical characteristics with the use of methylphenidate or amphetamines. All estimates accounted for the complex probability sampling design of the survey to represent the general U.S. population experience.

Population Studied: We derived our sample from the National Health and Nutrition

Examination Survey (NHANES) covering years

1999-2002. Eligibility criteria included all participants, greater than 17 years of age, who completed the Mobile Examination Clinic portion of the survey.

Principle Findings: The sample consisted of

10,568 respondents representing approximately

206 million U.S. adults 18 years or older.

Twenty-five respondents, representing an estimated 752,257 U.S. adults, used methylphenidate or an amphetamine-based product in the 30 days prior to their interview.

Overall, users were younger than non-users and more likely to be male, non-Hispanic White, have more education, and higher income. The estimated prevalence of stimulant use was

0.42% among males and 0.32% among females.

The reported prevalence of ADHD among users was 4.9% compared with 0.2% among nonusers (AOR 3.75; 95% CI 0.56------25.3). Stimulant use was associated with a lower prevalence of congestive heart failure (AOR 0.44; 95% CI

0.05------4.25), prior myocardial infarction (AOR

0.31; 95% CI 0.04------2.42), and prior stroke (AOR

0.24; 95% CI 0.02------3.48). Use of methylphenidate or amphetamines was associated with a higher prevalence of hypertension (AOR 1.61; 95% CI 0.40------3.56), and use of antidepressants (AOR 4.47; 95% CI

1.41------14.2), benzodiazepines (AOR 4.28; 95% CI

1.12------16.4), and other anti-insomnia medications (AOR 2.47; 95% CI 0.69------8.94).

Conclusions: Despite increasing awareness of adult ADHD, the prevalence of stimulant medication use among U.S. adults is rare. Use of stimulants may be inversely related with a history of cardiovascular disease. The rare use of stimulants among U.S. adults limits the power of this study. Additionally, NHANES collects data by self-report and may underestimate the prevalence of stimulant use and its correlates.


Prescribers appear to be using stimulants judiciously; however, it is unclear whether high concomitant medication use increases risk of stimulant-related adverse effects.


• Psychiatric Crisis Services as the Entry

Point into the Public Mental Health System for Ethnic Minority Children and Youth

Kya Fawley, M.S.W., Neal Wallace, Ph.D., Mary

Masland, Ph.D., Kya Fawley, M.S.W.

Presented By: Kya Fawley, M.S.W., Graduate

Student Researcher, Center for Mental Health

Services Research, Univ. of California Berkeley,

2140 Shattuck Avenue #409, Berkeley, CA

94720-7414, Phone: 510-643-9625, Fax: 510-642-

9812 Email: kfawley@berkeley.edu

Research Objective: To determine whether ethnic minority youth are more likely to enter mental health treatment through psychiatric emergency services compared to their white counterparts, controlling for foster care status.

Study Design: We examined specialty mental health claims data for all Medicaid-enrolled children under 18 years old in California between

7/1/1998 and 6/30/2001. We selected only children and youth who had any crisis visits, subject to certain constraints (only clients who had experienced their first crisis visit at least 3 months after the beginning of the fiscal year were selected in order to avoid censoring of the data). Our final sample consisted of 16,843 nonfoster care youth and 3,267 foster care youth.

Taking the first crisis visit of the year as the index visit, we observed the client’s use of non-crisis mental health services 90 days before the index visit. The dependent variable measured the probability of the child receiving any type of nonemergency mental health service prior to the index crisis visit. Independent variables were the child’s race/ethnicity, age, gender, diagnosis, and disability status. Also included were crosssectional fixed effect dummy variables for county of residence and longitudinal fixed effect variables indicating in which of the three fiscal years the client was observed.

Linear probability models were estimated with robust standard errors to correct of heteroskedasticity. Separate models were estimated for foster-care and non-foster care children.

Population Studied: Medicaid children and youth, under 18 years old, using public specialty mental health services between 7/1/98 and

6/30/01 in California.

Principle Findings: Among children not in foster care, African American, Latino and Asian children were significantly less likely than white children to have received any mental health care during the 3 months prior to their first crisis visit.

There were no statistically significant differences between Native American and white children.

Among children in foster care, there were no statistically significant racial/ethnic differences in pre-crisis receipt of mental health services.

Conclusions: For African American, Latino and

Asian non-foster care children, compared to white children, psychiatric crises are more likely to occur in isolation without any prior contact with the specialty mental health care system.

These ethnic differences were not found among children living in foster care.


Minority crisis users were more likely than their white counterparts to be new to the mental health treatment system, or to be disengaged from treatment, with the emergency encounter acting as their pathway into care. The literature identifies obstacles to care for minorities

(cultural differences in defining personal distress, mistrust of the mental health system and providers, lack of culturally and/or linguistically matching providers) which channel minority children into crisis care. Systematic mental health screening and referral practices for foster care children appear to have reduced racial/ethnic disparities in treatment entry pathways. Mental health screening of non-foster care Medicaid children, as well as efforts to build trust between providers and minority communities and to respond to differing cultural styles and language needs, may reduce these disparities.


•

Explaining Government Responsiveness to

HIV/AIDS in Sub-Saharan Africa

Ashley Fox, M.A.

Presented By: Ashley Fox, M.A., Sociomedical

Sciences, Columbia University Mailman School of Public Health, 57 W106th St, Apt. 6A, New

York, NY 10025, Phone: 917-779-8006, Fax:

Email: amf2116@columbia.edu

Research Objective: To assess why similarlysituated countries in sub-Saharan Africa have responded to HIV with varied levels of aggressiveness.

Study Design: Utilizing Mill’s Method of

Agreement, this research matched countries on

HIV prevalence, inequality, health systems capacity and GDP per capita in order to identify the variables that explain countries’ differential responsiveness in fighting HIV. Policy responsiveness is measured as the timing and

magnitude of domestic spending devoted to HIV prevention and treatment initiatives. Public opinion data were analyzed to assess the public’s concern over HIV and appraisal of the government’s response.

Population Studied: Countries were selected for this comparative case study through on an iterative process of matching ideas with evidence and cases in an effort to derive a theory that can be generalized to a larger number of cases.

Principle Findings: Despite similar levels of HIV prevalence, economic development, and health systems capacity, South Africa, Botswana,

Namibia and Zimbabwe have differed in their responses to HIV, with Botswana and South

Africa engaging in aggressive preventive policy responses while Namibia and Zimbabwe behave as policy laggards in their funding of HIV prevention and treatment programs. Partisan ideology and political competition were found to make the critical difference in policy aggressiveness. Incumbent parties that are anti-

Western in their ideology have been less likely to devote funding and attention to standard policy recommendations of international health institutions. However, when facing political competition from a pro-Western opposition party, previously unresponsive countries have become more aggressive, engaging in internationally-accepted policy responses. One of the main findings of this research is that, despite government rhetoric, South Africa has not actually lagged far behind other African countries in its response to HIV in terms of the timing and resources devoted to stem the spread of HIV.

Furthermore, analysis of public opinion data from South Africa demonstrates that the primary constituents of the African National Congress government are supportive of the government’s response to HIV.

Conclusions: A proactive government response is necessary to stem the spread of HIV/AIDS in sub-Saharan Africa. Yet, even governments with relatively well developed health system infrastructures and soaring HIV rates have differed in the level of aggressiveness of their response to the HIV epidemic. An active political competition in the context of an unresponsive government may increase responsiveness; however, in the context of an otherwise responsive government, political competition may lessen the aggressiveness of its response.


International institutions, donors and Western

NGOs working in African countries should take seriously the impression that their programs represent a Western disease model and the domestic political ramifications of their work.

•

Long-Term Care Market Competition and

Nursing Home Dementia Special Care Units

Andrea Gruneir, M.Sc., Kate L. Lapane, Ph.D.,

Susan C. Miller, Ph.D., Vincent Mor, Ph.D.

Presented By: Andrea Gruneir, M.Sc., Graduate

Student, Community Health, Brown University, 2


(401)863-1275, Fax: (401)863-3489 Email:

Andrea_Gruneir@brown.edu

Research Objective: Our objectives are 1) to quantify the effect of competition from other long-term care (LTC) providers on the odds of a nursing home (NH) reporting a dementia special care unit (SCU), and 2) among those

NHs with an SCU, to quantify the effect of competition on mean acuity on the SCU.

Study Design: This is a cross-sectional study in which we defined the LTC market as the county.

Data on NHs was obtained from the On-Line

Survey, Certification, and Reporting System

(OSCAR). Market data was obtained from the

Area Resource File and a listing of assisted living facilities (ALFs). For each NH, LTC market competition was measured by: the NH's share of beds, the presence of another NH SCU, the presence of ALFs, the presence of dementia care in ALFs, and the presence of home health in the market.

Population Studied: We included all freestanding NHs in urban counties in the state of

Texas during the year 2004. The final sample included 942 NHs in 122 counties.

Principle Findings: Competition from another

NH-based SCU was associated with the presence of an SCU in a NH (AOR: 3.2; 95% CI:

1.6-6.4) but there were no associations with other measures. Of NHs with an SCU, only presence of an ALF was associated with mean

SCU acuity. Average SCU acuity was higher for

NHs located in counties with an ALF than for those in counties without (ß: 1.5; 95% CI: 0.3-

2.7).

Conclusions: A NH's investment in specialized dementia care is influenced by the behavior of nearby NHs but not yet by other forms of LTC.

Meanwhile, competition from ALFs seems to result in a different profile of SCU users.


People with dementia make up the largest group of long-stay NH residents so attracting these individuals has been an important part of NH marketing. In the past, dementia SCUs were a

competitive edge against other NHs because they attracted lower acuity, private-pay residents.

However, non-institutional LTC alternatives, especially ALFs, appeal to a similar market and their proliferation raises questions about their impact on the NH industry. Further development of our understanding on this issue is vital for long-term care planning.

Funding Source: NIA

• Prenatal Maternal Stress and Birth Weight

Margaret L. Holland, M.S., Peter Veazie, Ph.D.,

M.S., Harriet Kitzman, R.N., Ph.D.

Presented By: Margaret L. Holland, M.S., graduate student, Dept. Community and

Preventive Medicine/Health Services Research

Division, University of Rochester, 601 Elmwood


585-273-2548, Email: margaret_holland@urmc.rochester.edu

Research Objective: Low birth weight (LBW) is a significant problem for blacks, leading to worse health outcomes throughout life and disparities between blacks and whites in the US. Many risk factors have been identified, but the incidence of

LBW continues to rise. I have identified potential stresses that may contribute to LBW in low income black women: financial, mental health, neighborhood crime rate, and mental and verbal abuse. These are all potentially mediated by social support. Although these stresses have been previously reported in the literature, no studies were found that explored the relative importance of the stresses in relation to each other.

Study Design: The Nurse-Family Partnership

(NFP) collected data on 1139 women in

Memphis, TN during pregnancy (less than 29 weeks) from 1990 to 1991. These women were primarily black (92%), unmarried (98%), poor

(85% at or below the federal poverty level), young (mean years of age 18.1, SD = 3.2) and with low education (mean years of education is

10.3 yrs, SD=1.9). For this study, I use the 2 NFP comparison groups, but exclude whites (47 subjects), those who had diabetes (2 subjects), and those who were married (12 subjects), and those with a previous miscarriage to result in a sample size of about 600. I use linear regression to estimate the contribution of each type of stress and the interaction of social support.

Using Monte Carlo simulation, I estimate a power of 80 to 95% using the False Discovery

Rate method to account for multiple comparisons. The actual power is dependent on the combination of factors found to be significant.

Population Studied: Black, unmarried, young pregnant women in Memphis, TN.

Principle Findings: The stresses that are found to be significant and the impact of social support on those stresses will be reported, along with the relative importance of each significant stress.

Conclusions: Although psychosocial stress has previously been found to increase the incidence of LBW, the details of what types of stresses contributed have not been thoroughly explored.

These data allow a unique opportunity to explore specific sources of stress, including neighborhood factors, social support, maternal mental health, abuse, and financial concerns within an at-risk group. This study focuses entirely on low-income, unmarried, black women, which may not allow generalization to other populations, but does provide a clear indication of the factors affecting a group in need of intervention.


By identifying the specific sources of stress and their relative impacts, appropriate interventions can be designed to focus on the most critical stresses and reduce the incidence of LBW.


• Predictors of Chiropractic Utilization Within the U.S. Over-65 Population

Meghan Hufstader, Ph.D Candidate, Teresa

Waters, Ph.D.

Presented By: Meghan Hufstader, Ph.D

Candidate, Student, Health Science

Administration, University of Tennessee Health

Science Center, 847 Monroe Avenue, Suite 205K,

Memphis, TN 38163, Phone: 901-338-9983, Fax:

Email: mhufstad@utmem.edu

Research Objective: To investigate predictors of chiropractic utilization within the U.S. over-65 population

Study Design: Data from the 2003 Medical

Expenditure Panel Survey (MEPS) was used to examine the impact of race, ethnicity, gender, education, income, and diagnosis of osteoarthritis on use of chiropractic services among the elderly. Potential predictors in the model were chosen based on current literature.

The impact of health insurance was not considered, since most of the population 65 and older is covered by Medicare. A significance level of 0.05 was used throughout the analyses.

Population Studied: Over-65 individuals in the

United States.

Principle Findings: Being a minority dramatically reduced the likelihood of chiropractic utilization. Relative to white persons,

Asians and blacks were 92 % (odds ratio 0.08) and 97 % (OR 0.03) less likely to use these services. Hispanics were also far less likely to use chiropractic services relative to non-Hispanics

(OR 0.22). Osteoarthritis was a significant predictor of chiropractic utilization with a 22% increase in utilization when compared individuals without osteoarthritis. Low income

(125-200 % of federal poverty line [FPL]) and poor (<=100 % of FPL) individuals were slightly more likely than high income (> 400 % of FPL) to use chiropractic services, with odds ratios of

1.03 and 1.05, respectively, while near poor

(through 125 % of FPL) and middle income

(200-400% of FPL) were significantly less likely to use these services, with odds ratios of 0.73 and 0.74, respectively. Educational attainment was a significant predictor of use, with high school graduates 30% more likely than non high school graduates to utilize chiropractic services.

Age was a negative predictor of use in the 65 and older population, with a decrease in utilization of approximately 3% per year of increased age.

Conclusions: Current chiropractic use in the US elderly is heavily concentrated in the white, non-

Hispanic population. Females, individuals with a high school or greater education, and those with higher incomes are generally more likely to use chiropractic services.


There is some evidence that chiropractic use is associated with decreased overall healthcare costs in a non-elderly population. Recognizing the potential benefits of chiropractic services,

Medicare expanded its coverage in this service area in 2005. Our results suggest that many

Medicare beneficiaries who might benefit from chiropractic services are not receiving these services. Further research investigating barriers and facilitators to chiropractic use, especially among minority patients, is needed to determine whether specific changes might enhance use.

•

Predictors of Children's Use of

Psychotropic Medication

Sarah Hurley, M.A.

Presented By: Sarah Hurley, M.A., Health

Science Administration, University of Tennessee

Health Science Center, 847 Monroe Avenue,

Memphis, TN 38103, Phone: 901-251-4950, Fax:

901-251-5018 Email: sarah.hurley@youthvillages.org

Research Objective: Concern over psychotropic medication use in children has grown in recent years. Effectiveness, side-effects, and effects of long-term use are issues frequently raised by parents and other child advocates. This study examined the likelihood of psychotropic medication use in children, comparing those whose parents also use such medication and those whose parents do not. Demographic factors, insurance status, and mental health diagnosis in both children and parents were also investigated for their role in explaining children’s use of psychotropic medication.

Study Design: Data from Panel 7, collected in

2002 and 2003, of the Medical Expenditure

Panel Survey were used for this study. All youth age 25 and under who were identified as a son, daughter, grandson, granddaughter, niece, or nephew were selected. Sample size was 5,829.

Data from parents and other adults in the household were then matched to each child’s record. Logistic regression was employed to investigate the relationship between psychotropic medication use in children and a variety of independent variables including parental use of psychotropic medication, mental health status of children and parents, insurance and poverty status, and demographics.

Population Studied: This study examined a representative sample of all children living within

US households during 2002 and 2003. While children in foster care were included in the population, those living in long-term residential settings, including residential treatment centers, group homes, psychiatric facilities, were not included.

Principle Findings: Approximately 10 percent of the children in the sample were reported to have a mental health diagnosis, while 7.8 percent of them were identified as having a prescription for psychotropic medication. Age and sex were significant predictors of psychotropic medication use, with usage more likely in older children and males. Black children were less likely to use these medications, but other minorities and

Hispanics more likely to receive psychotropic medication. Children at lower income levels were less likely to use psychotropic medications, as were those without insurance for at least part of the study period. Mothers’ mental health diagnoses were associated with higher likelihood of psychotropic medication use in children, while psychotropic medication use in mothers was associated with lower use in children.

Conclusions: This study provides important information about the characteristics of US children who use psychotropic medication.

While demographics play an important role in describing this group of children, the mental health status of parents is also a critical element in understanding which children receive psychotropic medication. Further investigation into the nature of the relationship between parental mental health and psychotropic medication use in children is warranted.

Implications for Policy, Practice or Delivery: A more complete understanding of the factors influencing psychotropic medication use in children is essential to discussions of the appropriateness of the level of use within the population. Disparities in the use of these medications by race and ethnicity, income level, and insurance status may be of concern to policymakers. In addition, the relationship between parental mental health status and children’s use of psychotropic medication that was demonstrated in this study could have significant impacts on the screening and assessment processes for prescribing psychotropic medication to children.

•

The Return on Investing Additional Tax

Dollars into The National Institutes of Health:

A Case Study Examining Whether Increased

NIH Funding Correlates with Increased Phase

I Testing of New Pharmaceuticals

Gretchen Jacobson, Ph.D., Gerard F. Anderson,

Ph.D.

Presented By: Gretchen Jacobson, Ph.D., 20

Snows Court, NW, Washington, DC 20037,

Phone: 202-707-1686, Email: gjacobso@jhsph.edu

Research Objective: This study aims to quantify the return from investing additional dollars into the National Institutes of Health (NIH) on pharmaceutical research and development

(R&D), by evaluating the impact of an additional billion dollars on the number of new drugs each year entering Phase I clinical trials. The study also aims to determine how the return on investment, as define above, varies across individual Institutes of the NIH.

Study Design: The comprehensive dataset needed to meet this objective was constructed by combining data from many sources on NIH funding, counts of drugs beginning clinical trials between 1983 and 1999, industry research spending, insurance coverage, drug sales, counts of drugs in later stages of R&D, perceived medical need for disease treatments, indicators for FDA incentives, and the number of companies involved in developing each drug.

The drugs were grouped into disease categories corresponding to each Institute, which resulted in drugs targeting diseases with the majority of their research funding coming from the same

NIH Institute were grouped together. The primary model was a log-linear model of the counts of drugs and cumulative Congressional appropriations for NIH, discounted 3% annually.

Sensitivity analyses were done using with four other forms of NIH funding: (1) using a discount rate of 5% rather than 3%, (2) using annual appropriations rather then cumulative appropriations, (3) excluding administrative and training grant appropriations from the total appropriations, and (4) using non-AIDS research appropriations. The study also examined the sensitivity of the findings to insurance coverage, industry research spending, pharmaceutical sales revenue, potential competing pharmaceuticals, FDA drug development incentives, and the companies involved in developing each drug.

Principle Findings: This study found that, during the 1980s and 1990s, each additional billion dollars in cumulative Congressional NIH appropriations resulted in an average of 5.3 new drugs ($188.7 million/drug) entering Phase I clinical trials across all disease categories. The number of new drugs entering Phase I clinical trials per billion dollar increase in NIH funding varied markedly across Institutes, ranging from

23.8 ($42.0 million/drug) for NIAMS, to less than 1 (>$1 billion/drug) when NIMH, NIDA, and NIAAA were combined. Modeling showed that, in the 1980s and 1990s, the time lag between increases in cumulative Congressional appropriations and increases in new drugs entering Phase I clinical trials was estimated to be 11.1 years, averaging across Institutes, with wide variation in time lags across Institutes, ranging from 18 years for NIDDK to 4 years for the combination of NIMH, NIDA, and NIAAA.

Conclusions: Increases in cumulative NIH funding correlates strongly with return in terms of new drugs entering Phase I clinical trials.


The wide variation in the return across individual

Institutes raises questions about the most effective way to allocate NIH funding to maximize impact on pharmaceutical research and development by disease categories.


•

Factors Contributing to Excess Deaths by

Unintentional Injuries among Florida's

Uninsured Children

Lilyan Kay, M.S., M.P.H.

Presented By: Lilyan Kay, M.S., M.P.H., Doctoral student, Nursing instructor, Applied

Anthropology, University of South Florida, 4202

East Fowler Ave, SOC107, Tampa, FL 33611,

Phone: (813) 831-9739, Email: lkay@cas.usf.edu

Research Objective: To determine factors related to excess deaths by unintentional injuries, which were discovered to occur among uninsured children in Florida. It was found that in 2002 these children died at approximately twice the rate as those who had Medicaid.

Reference: 2005 Chartbook: Childhood Injury in

Florida, 2002: A report on hospital care and prevention information. University of South

Florida Division of Child Health Outcomes

Study Design: The proposed study will begin in early 2007. It will use a mixed methods design to determine factors related to these excess deaths, using Agency for Health Care

Administration (AHCA) data on inpatients, ambulatory patients, and emergency room patients available through the Florida

Department of Health. The AHCA databases contain de-identified information on age, race/ethnicity, county, payer status, and diagnoses. Data on inpatients for 2005-2006, ambulatory patients for 2004-2005, and emergency room patients for 2005 will be analyzed to determine whether the types of unintentional injuries leading to death differ significantly among the two populations: (1) children who have no insurance and (2) children insured by Medicaid, the null hypothesis being that they do not. A model to test for significance will account for other factors known to be significantly related to type of injury, such as age. Determining whether there were differences in the types of injuries suffered by these two groups of children will be basic in guiding the search for factors related to the excess deaths. This knowledge will also be instrumental in generating questions for the interview questionnaires, which will comprise the qualitative component of the study. Semistructured interviews will be conducted with mothers of children who have suffered unintentional injuries, who were either uninsured or covered by Medicaid. These interviews will include questions on preventive and episodic health care practices, access to health and social services, family and neighborhood support systems, employment, transportation, schools, churches/spirituality, educational attainment, housing and specific events related to the injury.

Questions specific to the issue of health insurance will be included, to discover the reasons why children remain without health insurance. Additionally, there will be interviews of health care personnel who care for injured children, uninsured and on Medicaid, who function at various levels of the health care system. These will include first responders, primary care practitioners, school nurses and hospital staff, both emergency and inpatient.

Population Studied: Florida children who are uninsured and on Medicaid


This study is intended to uncover reasons for excess deaths among uninsured children, and by doing so inform policy and practice so that future deaths can be prevented. Many if not most of these children are eligible to be insured in the Florida KidCare program. Discovering what specific barriers to enrollment have been, particularly in this group of children who were very likely at high risk for injury, would be instrumental in surmounting them. The question of whether there were issues before, during or after emergency room visits with regards to disparate medical treatment of uninsured children is critical. And there are other factors that can only be discovered by listening to those who have experienced these events. In its 2005 Annual Report to the State

Legislature, the Florida Child Abuse Death

Review Team recommended that the Florida

Statutes be amended to provide for the review of all deaths of children, not solely those due to neglect or abuse as is currently the case, noting that Florida’s criteria for review are ‘‘significantly more restrictive than any other state in the nation’’2. The aim of this study is to identify factors related to unintentional injuries among uninsured children, who experience significantly greater mortality from this cause than other children. Thus, the proposed study would contribute significantly to this endeavor.

Funding Source: AHRQ Health services research dissertation grant application under review

• Knowledge and Practices of Pregnant

Women, Role of Lady Health Workers'

Interpersonal Communication

Rukhsana Khan, M.B.B.S.,M.P.H., Amjad

Chaudry, M.B.B.S., M.P.H.

Presented By: Rukhsana Khan, M.B.B.S.,M.P.H.,

Lecturer, Biostatistics, University Of Limpopo,

P.O Box 214 Medunsa ,0204, Pretoria, ZA,

Phone: +27 12 521 5032, Fax: +27 12 560 0172

Email: rukhsana_khan@hotmail.com

Research Objective: (a)Assess knowledge of

Lady Health Workers(LHWs) regarding antenatal care (b) Assess level of awareness of pregnant women served by LHWs (c)Compare knowledge of LHW trainers, LHWs and pregnant women to measure the gaps. (d)Explore community’s opinion regarding antenatal care

Study Design: Descriptive, Cross sectional

Population Studied: a) Lady Health workers attached to 05 selected health centres in a union council of district Islamabad(Pakistan). b)

LHVs(Lady Health Visitors) who train these

LHWs in these centres c) Pregnant women in community who are served by these health workers.

Principle Findings: (a) Different variables selected from the syllabus of LHWs were used to measure the gaps in knowledge. Highest scores were obtained by LHVs, followed by LHWs, and then by pregnant women.This difference was tatistically significant pvalue .000 (b) Mean scores of LHWs varied with education. Those with higher education scored better in all areas except one, but this difference in the knowledge was not statistically significant p value 0.12 c)

When respondents in community were asked about the importance of ANC 96.4% mothers gave a positive response. On further inquiry

41.4% thought it is helped them to know the health and position of foetus in womb, 21.4% said it is good for mothers health. Detection of complications and timely treatment was considered important by29% of women

Conclusions: (a) Services provided by LHWs were having a positive impact on the beliefs and practices of women and children from rural and low socio-economic background

(b) Deficient interpersonal communication of

LHWs was either due to faults in the curriculum or teaching skills of the trainers.


(a)LHWs and their trainers lacked knowledge in certain areas. It may have serious clinical consequences as well as undermining the professional reputation of National Programme for family planning and primary health care. (b)

Training component especially that of IPC of

LHWs has to be strengthened. It would ensure that the Program’s intended health benefits and impact reaches all of the served population

•

Do Policies Reduce Expenditure Per Day's

Supply of Drug Therapy

Jennifer Kibicho, M.A., B.A.

Presented By: Jennifer Kibicho, M.A., BA, Ph.D

Candidate, Economics, Wayne State University,

615 W. Hancock #201, Detroit, MI 48201, Phone:

313-832-0214, Fax: 313-577-9564 Email: ak3241@wayne.edu

Research Objective: Michigan Medicaid program implemented the following policies to curb rising prescription drug costs: 1) a preferred drug list (PDL) with supplemental manufacturer rebates in February 2002, 2) joint purchasing arrangement (JPA) with Vermont in February

2003, 3) maximum allowable cost (MAC) for pharmacy reimbursement in November 2003, and 4) Michigan multi-state purchasing arrangement (MMSPA) with seven other states in May 2004. The study seeks to quantify the impact of each policy on expenditure per day’s supply of prescription drugs (EDS), and identify the most effective policy in reducing expenditures.

Study Design: The study analyzed 60 months of claims data (29 months pre-policy and 31 months post-policy) relating to cardiovascular prescriptions for dual eligible beneficiaries 65+ years. It employs a microeconomic theoretical framework based on two concepts: policies increase the relative price of non-preferred to preferred drugs and secondly, the economic assumptions of a rational, fully-informed and financially responsible consumer may not apply to the pharmaceutical industry. Regression analysis with standard errors corrected for autocorrelation using the Newey-West estimator was used to test the above objectives.

Population Studied: Beneficiaries 65 years and older, dually eligible for both Medicaid and

Medicare with positive prescription drug expenditures for cardiovascular related conditions.

Principle Findings: The PDL, JPA and MMSPA did not significantly impact EDS. MAC policy was the most significant policy in reducing EDS through reduction in the cost of generics. Finally, the generic to brand ratio stabilized after MAC policy yet EDS increased following implementation of MMSPA. The study had the following limitations: supplemental manufacturer rebates and administration expenses were omitted from the analysis, and the post-policy period was not long enough for the impact of policies to be fully evaluated.

Conclusions: Some of the cost containment policies were successful in shifting prescribing patterns towards use of more generics

(increased from 30% pre-policy to 52% postpolicy), causing EDS to fall by 9%. PDL policy caused generic prices to rise perhaps due to increase in demand while brand-name products

fell (since high-cost brand-name manufacturers opted not to participate in the program), though the net effect on EDS was not statistically significant. Purchasing arrangements did not significantly impact EDS.


Findings have important implications for the newly implemented Medicare Modernization

Act. The finding that JPA & MMSPA did not significantly impact EDS suggests that reduction in the Medicaid population following transfer of dual eligibles to Medicare will not affect the daily cost of drug therapy, though supplemental manufacturer rebates will decline. The Act specifically prohibits the federal government from negotiating prices directly with manufacturers and is silent on reference pricing.

The findings from the study suggest that

Medicare prescription drug plans (PDPs) would save costs considerably by implementing MAC or reference pricing. Finally, the finding that EDS increased after MMSPA raises the question of whether there is a limit to cost containment and if diminishing returns to policy apply. A costbenefit analysis may assist in future policy design especially in the current era of multiple cost-containment strategies.

Funding Source: Graduate Teaching Assistant

Fellowship and Blue Cross Blue Shield Student

Award 2006/2007 Academic Year

•

Understanding Medicare Changes:

Overcoming Enrollment Obstacles for Part D and Extra Help

Ann Marie Kopitzke, M.P.A., Karen Karlowicz,

Ed.D., R.N.

Presented By: Ann Marie Kopitzke, M.P.A.,

Graduate Teaching/Research Assistant, College of Health Sciences - PhD, Old Dominon

University, PO Box 6285, Norfolk, VA 23508,

Phone: 757-489-8712, Fax: Email: amkopitz@odu.edu

Research Objective: Determine the number of contacts that resulted in enrollment or application in Medicare Part D and Extra Help from educational efforts

Study Design: 1-year longitudinal case study

Population Studied: Medicare beneficiaries eligible to apply for Extra Help or to enroll in Part

D

Principle Findings: 32.5% of Medicare beneficiaries screened enrolled in a Part D plan

56% of Medicare beneficiaries screened were eligible and applied for the Extra Help assistance. Multiple contacts (an average of 3 per individual) and methods (presentation, faceto-face and telephone) were necessary to overcome obstacles to application or enrollment.

Conclusions: Multiple contacts were necessary to clarify and assist Medicare beneficiaries in understanding both the Extra Help and Part D portions of the Medicare Modernization Act.

The low-income and asset based eligibility limited the number of applicants eligible for

Extra Help. The number of plans and numerous factors involved in choosing a Part D plan required three or more (on average) encounters before a plan was selected for enrollment.

Educational strategies used to inform the

Medicare population were helpful, yet confusion still exists regarding Part D plans and the Extra

Help benefit.

Implications for Policy, Practice or Delivery: In assisting Medicare beneficiaries individualized attention is the best method for helping them to apply or enroll. The number of people available to educate and assist with the process must be increased as well as funding provided to agencies that are successfully aiding Medicare beneficiaries with this complex process.

Funding Source: Senior Services of

Southeastern Virginia/ABC Grant

• Comparing Different Stakeholders’

Perceptions about Important Dimensions of

Performance to Consider when Evaluating

Neurotrauma Service Corridors

Marie-Eve Lamontagne, Ph.D. candidate, Bonnie

R. Swaine, Ph.D., André Lavoie, Ph.D., Anne-

Claire Marcotte, M.A.

Presented By: Marie-Eve Lamontagne, Ph.D. candidate, Student, School of rehabilitation,

Université de Montréal, Bureah H-044, CHA,

1401 18ème rue,, Québec, G1J 1Z4, CA, Phone:

(418) 2624-089, Fax: (418) 649-5733 Email: marie-eve.lamontagne@umontreal.ca

Research Objective: To report and compare the perceptions of clinico-administrative team members working in three types of organizations

: acute care, rehabilitation facilities and Health and social service agencies, HSSA, within neurotrauma service corridors with regards to the importance of 16 dimensions of performance included in the Global and Integrated Evaluation

Model of Performance of Health Services,

EGIPSS' model.

Study Design: Phase 1. Clinico-administrative teams were each provided with a questionnaire listing 16 performance dimensions included in the EGIPSS model and asked to grade their

importance on a 100-point scale, 0 indicating not at all important and 100 indicating extremely important. Phase 2. As part of an ongoing province-wide accreditation process of neurotrauma service corridors, mandated by the

Provincial Ministry of Health and Social Services,

MHSS, nine discussion groups were organised each regrouping 5 to 12 key informants from each of the three types of organizations providing care within 15 different neurotrauma service corridors. During these discussions groups, a consensus technique, TRIAGE, was use to determine the groups’ perception with regards to the important dimensions of performance to include in a performance evaluation. Results from both phases were compiled and compared

Population Studied: Phase 1.Clinicoadministrative team from 35 organisations, working within one of the 15 neurotrauma service corridors for moderate/severe traumatic brain injury across the province of Québec, Canada.

Each team, included two managers, a coordinator, a physician, and another clinician.

Participants working in HSSAs answered the questionnaire individually. Phase 2. Two representatives, a coordinator and manager, from each facility within the service corridor.

Principle Findings: The individual perception of clinico-administrative teams regarding the importance of dimensions of performance varied across organisations; grades of importance differed by at least 20 % for approximately 50 % of the performance dimensions, e.g. efficacy, efficiency, and quality of services. However, a consensus among participants was readily obtained during discussion groups. According to the clinico-administrative teams, continuity of care and accessibility of care appear to be the most important dimensions to consider in the evaluation of the performance of service corridors. Volume of services seems to be the least important to participants.

Conclusions: Working within the same corridor of services does not guarantee a shared and common understanding of what should be considered when evaluating the performance.

The importance of the dimensions of performance varies slightly among different clinico-administrative teams who actually work together inside neurotrauma service corridors.

Implications for Policy, Practice or Delivery: It is essential to develop a shared and common perception of the important performance dimensions before implementing a performance measurement system within a complex continuum of services. This research involved clinico-administrative teams in the process of identifying the dimensions of importance. As such, the planning and the implementation of such as system by the MHSS should be facilitated.


Research; PRISST programm of research funding in neurotrauma

•

Influence of Health Beliefs on Health and

Breast Cancer Screening Practices among

Older Women from Appalachian Kentucky

Corinne Leach, M.S.

Presented By: Corinne Leach, M.S., Doctoral

Candidate, Graduate Center for Gerontology,

University of Kentucky, 900 S. Limestone, 306

Wethington Health Sciences Building, Lexington,

KY 40502, Phone: (859)806-0757,

Email: corinne.leach@uky.edu

Research Objective: This dissertation sought to understand how older, rural women from an underserved area of Appalachian Kentucky develop knowledge and beliefs about health, cancer in general and, in particular, breast cancer, over the life course and how beliefs shape the use of health and cancer screening services.

Study Design: Grounded theory was used to explore underlying beliefs and meanings in an indepth and contextualized manner. Participants were interviewed approximately three times each due to the in-depth nature of the interview guide.

Questions assessed the perceived availability of health resources, health and cancer beliefs, knowledge of cancer and breast cancer screenings, and mammography, self-breast exam, and clinical breast exam thoughts and behaviors. After transcription, each interview underwent coding and thematic analysis using

NVivo 7 qualitative analysis software.

Population Studied: Using theoretical and snowball sampling, 20 women ages 65 and older without a history of cancer diagnosis participated in the study. Approximately one-third of participants were originally recruited through the county senior center and through "Commodities

Day" where individuals 150% below the poverty line are eligible to receive food once a month at the local fairgrounds. The other two-thirds of the sample were referred to the study by someone who already participated. All women lived in the same rural Appalachian county in Kentucky designated as a ‘‘distressed county’’ by the

Appalachian Regional Commission (ARC) due to

high unemployment rates, high poverty rates, and low per capita income.

Principle Findings: Having a physician recommend the screening, having someone in their lives who was diagnosed with breast cancer, and regularly visiting a doctor appeared to most significantly impact when and why each woman began receiving mammograms.

Although all women reported knowing about the importance of self-breast exams, many women reported not being consistent with its use.

Reasons for not doing self breast exams include cultural barriers, such as not feeling comfortable touching themselves, and other barriers, such as not wanting to find a lump while alone, not feeling competent in being able to find a lump, and time constraints.

Conclusions: Even among very low income women, most appear to receive yearly mammograms. However, since women were originally recruited from Commodities Day they are already part of a system. Many women still exist who do not receive screenings but are much more difficult to reach. A surprisingly higher number of women report not being consistent with self breast exams despite speaking about the importance of doing them at least once a month.


Current cancer education programs are missing essential information about this population of women, with many rural women continuing to underutilize screening services. In order to increase early detection behaviors, additional studies that focus on rarely or never screened women are needed in order to gain a better understanding of how rural women perceive cancer and how these perceptions and beliefs are formed throughout one’s lifetime.


•

Child and Adolescent Health Disparities in

Rural Communities: A Literature Review

Daniel Leland, B.A., Craig Anne Heflinger, Ph.D.

Presented By: Daniel Leland, B.A., Pre-Doctoral

Research Fellow, Human and Organizational

Development, Vanderbilt University, Peabody

#151 - 230 Appleton Place, Nashville, TN 37203-

5721, Phone: (615) 343-1652, Fax: (615) 322-7049

Email: daniel.e.leland@vanderbilt.edu

Research Objective: To synthesize the extant research literature on disparities in health status and health care for children and adolescents living in rural areas.

Study Design: Three databases in psychology i.e., PsychINFO, sociology i.e., Sociological

Abstracts, and medicine i.e., PubMed were searched to collect articles. To ensure the literature was recent, articles must have been published since 2000. The search was conducted using a hierarchical approach. 5,305 articles were found using the search: health disparities. 380 articles were found when rural was added to the search string. Incorporating children and adolescents to the search resulted in 33 articles. Lastly, 25 articles were returned when the search terms care and status were added.

Population Studied: The population of interest for this literature review was children and adolescents living in rural communities. About one in five of all U.S. children and adolescents live in rural areas.

Conclusions: A pervasive problem in the literature is a lack of consistency about the definition of rurality. A consensus is needed as to what is to be considered rural and what is not.

An overwhelming majority of these studies are descriptive in nature. As aforementioned, relatively few studies used data from residents in metropolitan or suburban settings to compare findings.

Principle Findings: Preliminary findings from the review have revealed mixed conclusions.

Almost 1 in 3 children does not have health insurance coverage for all or part of the year, with a disproportionate number of these children living in rural areas. Researchers found that insurance status, ethnicity, and income correlated with greater access. Moreover, the researchers posited that the strongest determinant of child access to care was the impact of the child’s impairment on family functioning. Several studies found that, compared to their urban counterparts, rural agencies have lower funding levels, lack of medical specialists, limited access to grant funding, difficulty recruiting staff, lack of transportation, vast geographic area to cover for services, smaller hospitals with limited budgets, and at times fragmented services, and scarce resources. Conversely, one study using urban influence codes, suggested that rurality had a minimal impact on health care access and utilization. Urban and rural residents were as likely to have had at least one visit to a health care provider. Thus, the rural physician supply was considered adequate, despite having fewer physicians than urban communities.

Implications for Policy, Practice or Delivery: In general, the review demonstrates the need for

research to improve in this area and offers some suggestions regarding the future of rural children and adolescent health disparities research.

Researchers should devise innovative approaches to ease the burden of rurality on health care. These approaches must provide quality health care and services to our nation’s rural children and adolescents. Additional implications for research and policy decisions regarding the future of rural health care will also be discussed.


• Barriers to Help-Seeking for Alcohol

Problems among People with Self-Perceived

Need for Help

Chunyu Li, M.S., Kenneth Connor, M.D., Bruce

Friedman, Ph.D.

Presented By: Chunyu Li, M.S., PhD candidate, community and preventive medicine, university of rochester, 601 Elmwood Avenue Box 644, rochester, NY 14642, Phone: (585)275-9794, Fax:

(585) 461-4532 Email: chunyu_li@urmc.rochester.edu

Research Objective: To describe reasons for not getting help for alcohol problems among people with self-perceived need, and to examine whether the reasons differ by age, gender, race and income.

Study Design: The National Epidemiologic

Survey on Alcohol and Related Conditions

(NESARC) (2001-2002), a survey of a nationally representative sample of the noninstitutionalized U.S. household population, was analyzed. Self-perceived need was defined by a

‘‘yes/no’’ question: ‘‘Was there ever a time when you thought you should see a doctor, counselor, or other health professional or seek any other help for your drinking, but you didn’t go?’’

Dummy variables were generated for each of 27

‘‘yes/no’’ questions directly about reasons for not getting help among people with self-perceived need of help for alcohol problems. The percentage of people with each reason was ordered in general and compared between younger and older adults, women and men, whites and non-whites, people with an annual household income of less than $30,000 and those with more than that. The Pearson Chisquare test and logistic regression were employed in the analysis.

Population Studied: 1078 participants were identified as having self-perceived need of help for alcohol problems but not getting help (93.0% adults aged 18-64, 64.3% men, 62.5% white).

23.0% were identified in the last 12 months.

66.5% were not diagnosed with alcohol problems.

Principle Findings: The top five reasons for not getting help among people with self-perceived need were ‘‘Thought I should be strong enough to handle it alone’’ (40.3%), ‘‘Thought the problem would get better by itself’’ (32.1%),

‘‘Didn’t think drinking problem was serious enough’’ (19.2%), ‘‘Stopped drinking on my own’’ (18.7%), and ‘‘Too embarrassed to discuss it with anyone’’ (18.7%). The order of the top five reasons differed by age, gender, race and income. Among the top five reasons, self-stigma

(‘‘Too embarrassed to discuss it with anyone’’) was more likely to be reported among men

(OR=1.47, p=0.02) and whites (OR=1.34, p=0.08) and ‘‘Thought I should be strong enough to handle it alone’’ was more likely to be reported among men (OR=1.63, p<0.01), whites

(OR=1.40, p=0.01), and richer people (OR= 1.21, p=0.07).

Conclusions: Among people with self-perceived need of help for alcohol problems, the most important reason for not getting help is

‘‘Thought I should be strong enough to handle it alone.’’ Reasons varied by age, gender, race, and income.


Help-seeking has been found to affect recovery from alcohol problems. Self-perceived need is fundamental for seeking help. Few studies have explored barriers to seeking help for alcohol problems among people with self-perceived need for help. Most studies on barriers to help-seeking for alcohol problems have examined the differences in population characteristics between patients treated in treatment clinics and untreated patients in the community. This study provides potentially useful information for interventions to enhance help-seeking for alcohol problems.

• Effectiveness of a Health Promotion Nurse

Intervention in Reducing Suicidal Ideation in the Elderly

Chunyu Li, M.S., Yeates Conwell, M.D., Bruce

Friedman, Ph.D., Andrew Dick, Ph.D.

Presented By: Chunyu Li, M.S., Ph.D. candidate, community and preventive medicine, university of rochester, 601 Elmwood Avenue Box 644, rochester, NY 14642, Phone: (585)275-9794, Fax:

(585) 461-4532 Email: chunyu_li@urmc.rochester.edu

Research Objective: To evaluate whether a health promotion nurse (HPN) intervention is more effective than usual care in reducing suicidal ideation (SI) among disabled community-dwelling elderly, and to explore potential mediators and moderators.

Study Design: A prospective randomized controlled trial conducted at two sites (New York and West Virginia/Ohio) in 1998-2002 with patients recruited from primary care practices.

The HPN intervention involved monthly home visits, medication management, collaborative goal setting, health behavior change, disease self-management, a depression intervention, and special office conference visits. Suicidal ideation was defined as answering ‘‘yes’’ in the last year to at least one of the questions in the Paykel et al. (1974) scale. The Chi square statistic and student’s t-test were used to compare the HPN and the control (care as usual) groups.

Generalized Estimating Equations (GEE) were utilized to account for autocorrelation across each individual over time. Potential mediators

(depression, hopelessness, life satisfaction, selfrated health, and physical health status), and potential moderators (study site, baseline SI, and time) were tested.

Population Studied: 467 cognitively intact, community-dwelling, disabled Medicare beneficiaries age 65+ with recent significant healthcare use were followed for up to two years.

Interviews were conducted at baseline, 12 months, and 22 months.

Conclusions: Findings suggest that the HPN intervention is more effective than usual care in reducing SI, but not effective in preventing SI.

Improvements in self-rated health may result in reduced SI among the elderly.

Principle Findings: The 467 patients had a mean age of 79.1 years, 25.3% were male, and

2.1% were nonwhite. At baseline the proportion of patients reporting SI did not differ significantly between the HPN (n=238) (27.0%) and Control

(n=229) (30.1%) groups (p=.46). Of the 133 patients with SI at baseline, 28.1% remained so at 12 months in the HPN group as compared with 50.7% in the Control group (p<0.01). Of the

333 patients without SI at baseline, 9.8% had SI at 12 months in the HPN group as compared with 11.2% in the Control group (p=0.72). Based on the GEE model, the rate of no SI at follow-up in the HPN group was higher than in the control group (OR=1.47, p=0.07). Among patients with

SI at baseline, the rate of no SI at follow-up was higher in the HPN group than the control group

(OR=1.92, p=0.07). Among those without SI at baseline, the rate of no SI at follow-up was not significantly different between the HPN and control groups. The effect of HPN on SI did not differ by study site and time. Self-rated health was found to mediate the effect of HPN on SI.


Suicide is a serious public health problem among persons age 65+. SI is a risk factor for completed suicide; its reduction may lead to fewer suicides. If the results of the present study can be replicated, provision of HPN interventions may be useful in reducing SI and suicides among Medicare beneficiaries with disabilities living in the community.

•

Does Physician Recognition of Depression

Differ by Race/Ethnicity among the Elderly?

Chunyu Li, , Bruce Friedman, Ph.D., Andrew

Dick, Ph.D., Kevin Fiscella, M.D., Yeates Conwell,

M.D.

Presented By: Chunyu Li, 601 Elmwood Avenue

Box 644, Rochester, NY 14642, Phone: (585)275-

9794, Email: chunyu_li@urmc.rochester.edu

Research Objective: To evaluate whether physician recognition of depression differs by race/ethnicity among Medicare beneficiaries.

Study Design: The Medicare Current Beneficiary

Survey (MCBS) data for 2001-2003 were analyzed. Physician recognition was assessed by patient self-report to the following: ‘‘Since a year ago, did a doctor tell you that you had a mental or psychiatric disorder, including depression?’’

Screening for depression was conducted using the Patient Health Questionnaire (2-item)

(having depressed mood and/or anhedonia).

Racial/ethnic groups included non-Hispanic whites, non-Hispanic blacks, Hispanics, and others. The Chi square statistic and student’s ttest were used to compare characteristics across racial/ethnic groups among people who screened positive for depression. Logistic regression was utilized to examine whether physician recognition differed by race/ethnicity among people who screened positive for depression, controlling for age, gender, marital status, number of children, rural/urban status, annual household income, education, health insurance, functional status, number of chronic conditions, and usual source of care. All estimates were adjusted by sampling weights and study design effects.

Population Studied: There was a total of 30,568 person-years among Medicare beneficiaries aged

65 or older in 2001-2003. A total of 3,877 (12.7%) person-years screened positive for depression.

Of these, 77.1% of them were non-Hispanic

whites, 19.0% were 85 year or older, and 37.7% were males.

Principle Findings: A higher proportion of minorities screened positive for depression than non-Hispanic whites (Chi2= 33.58, p<0.01).

Among those who screened positive for depression, Physicians were more likely to recognize non-Hispanic whites (Chi2=6.82, p<0.01). In a bivariate logistic regression model, non-Hispanic blacks (OR=0.60, p=0.007) and others (OR=0.52, p=0.061) were less likely to be identified by physicians compared with non-

Hispanic whites. No significant difference was found between Hispanics and non-Hispanic whites (OR=1.06, p=0.68). In a multivariate logistic regression model, similar differences were found, and age, income, marital status, functional status and having usual source of care were found to contribute to physician recognition.

Conclusions: The results indicated that physician recognition of depression differs by race/ethnicity among the elderly who screened positive for depression.


Depression is a significant public health problem among the elderly. The disparities found in this study may result from differences in patient helpseeking for depressive symptoms, physician’s ability to recognize depressive symptoms across culture, and/or patient-provider relationships and communication. Further analyses will be done to explore whether there are differences in diagnosis and/or treatment of depression across racial/ethnic groups among people with depression. We can then examine whether such differences are due to patient-physician communication or to physician recognition.

Such findings will facilitate development of targeted interventions to address these disparities.

•

Changes in Patient Safety Indicators after

Critical Access Hospital Conversion

Pengxiang Li, M.A., John E. Schneider, Ph.D.,

Marcia M. Ward, Ph.D.

Presented By: Pengxiang Li, M.A., Student,

Health Management and Policy, The University of Iowa, 5229 Westlawn, Iowa City, IA 52242,

Phone: (319)335-8713, Email: pengxiangli@uiowa.edu

Research Objective: To examine the impact of

CAH conversion on hospital patient safety

Study Design: We employed quasi-experimental designs that use both control groups and pretests. The hospital-year was the unit of analysis. Patient safety indicators (PSIs) were computed from Iowa State Inpatient Databases

(SIDs) using Agency for Healthcare Research and Quality (AHRQ) quality indicators software.

Four PSIs were available for all 89 Iowa rural hospitals across 8 years with the AHRQrecommended denominator >= 30 cases: PSI-5

(foreign body left in), PSI-6 (iatrogenic pneumothorax), PSI-7 (infections due to medical care), and PSI-15 (accidental puncture or laceration). We included two additional PSIs that had fairly large denominators for most hospitals to measure a broader scope of patient safety:

PSI-2 (death in low-mortality DRGs) and PSI-3

(decubitus ulcer). We built two composite PSIs, which are the weighted average of four PSIs and six PSIs. The weights are based on the frequency of the numerator of each PSI in our sample.

CAH status was extracted from the Iowa

Hospital Association. Case-mix variables were extracted from Iowa SIDs. Market variables came from the area resource file (ARF). We employed two multiple regression approaches. Using median splits from 8-year data of 89 Iowa rural hospitals, we developed binary variables for each

PSI, where 1 equals poorer performance and 0 equals better performance. We used GEE logit to examine the association between CAH conversion and the likelihood of poor performance for a hospital in a year. We also used random-effects tobit models to assess the effects of CAH conversion on continuous measures of PSIs. The models were adjusted for case-mix, market variables, and year dummy variables. Sensitivity analyses were used to examine the robustness of the findings.

Population Studied: Secondary data on hospital patient safety indicators (PSIs), hospital CAH status, patient case-mix, and market variables, for 89 Iowa rural hospitals during 1997-2004.

Principle Findings: CAH conversion in Iowa rural hospitals was associated with better performance of risk-adjusted rates of iatrogenic pneumothorax, selected infections due to medical care, accidental puncture or laceration, and composite score of four PSIs. The odds ratios of poor performance in CAH hospitals compared to rural PPS hospitals are 0.30 (CI:

0.14-0.64) for PSI-6, 0.29 (CI: 0.15-0.56) for PSI-

7, 0.40 (CI: 0.24-0.67) for PSI-15, and 0.49 (CI:

0.31-0.80) for composite score of four PSIs.

CAH conversion had no significant impact on the observed rates of death in low-mortality

DRGs, foreign body left during procedure, riskadjusted rate of decubitus ulcer, or composite

score of six PSIs. The sensitivity analyses showed that our findings were robust.

Conclusions: CAH conversion in rural hospitals is associated with enhanced patient safety performance related to indicators for relatively prevalent infections and injuries.


We speculate that the most likely mechanism linking CAH conversion and improved quality performance is the change in payment mechanism from prospective to cost-based.

Enhancement of financial resources may have contributed directly to an expansion in quality enhancement activities and infrastructure. The

Medicare Rural Hospital Flexibility Program of

1997 appears to have attained its objective to improve quality of care for previously financially vulnerable rural hospitals.


•

Does Better Managed Care Quality Reduce

Disenrollment in the New York State

Children’s Health Insurance Program

(SCHIP)?

Hangsheng Liu, M.S., Charles E. Phelps, Ph.D.,

Peter J. Veazie, Ph.D., Andrew W. Dick, Ph.D.,

Jonathan D. Klein, M.D., M.P.H., Laura P. Shone

Dr.P.H., M.S.W., Peter G. Szilagyi, M.D., M.P.H.,

Presented By: Hangsheng Liu, M.S., Doctoral

Candidate in Health Services Research & Policy,

Community and Preventive Medicine, University of Rochester, 601 Elmwood Ave, Box 644,

Rochester, NY 14642, Phone: (585)275-0165, Fax:

Email: Hangsheng_Liu@urmc.rochester.edu

Research Objective: In recent years, SCHIP retention has been a focus of both state governments and the research community.

Despite the fact that most states use managed care plans to provide services to low-income children in SCHIP, the effect of quality of care on disenrollment remains unclear. We examined whether higher quality measures in managed care plans were associated with lower disenrollment from SCHIP in New York.

Study Design: The study was based on a NY statewide cohort of children who enrolled in

SCHIP in 2001 and were followed up for about 15 months. Quality of care was measured using seven Consumer Assessment of Health Plans

Survey (CAHPS) scores and three Health Plan

Employer Data and Information Set (HEDIS) scores, according to the 2002 NY Quality

Assurance Reporting Requirements data. Based on the 2001 and 2002 NY SCHIP universal billing files, we defined voluntary disenrollment as being disenrolled from SCHIP for at least two consecutive months. We excluded disenrollment due to change in residence, switching to

Medicaid or being over the age limit for SCHIP.

A theoretical model was derived from the satisfaction literature, and a discrete-time survival model was applied.

Population Studied: A total of 1995 low-income children enrolled in 29 managed care plans were included.

Principle Findings: Among children with bettereducated parents, the probability of disenrollment was reduced by 31% for those in plans with an average CAHPS score above the third quartile. Similarly, among children with special care needs, those in plans with an average HEDIS score above the third quartile were 33% less likely to disenroll. Larger plans and plans with more competitors showed a lower disenrollment rate, and this effect primarily appeared during the annual recertification period. The risk of disenrollment for plans with commercial product lines was more than 60% lower compared to those without, and this effect mainly existed during the first several enrolled months. Non-profit plans did not demonstrate any significant difference in disenrollment compared to for-profit plans. The annual recertification generated 17-fold greater disenrollment compared to other time periods.

During the recertification period, children with special care needs were more likely to disenroll, and plan outreach activity decreased the risk of disenrollment. Finally, younger children and children with unemployed parents were more likely to leave the program.

Conclusions: Higher quality of care measured by CAHPS and HEDIS scores substantially reduces disenrollment in the NY SCHIP program, especially among children with special care needs and those with better-educated parents. The disenrollment rate was higher in smaller plans and in plans without commercial product lines or with fewer competitors.


Since prior studies have found that most children who disenroll become uninsured, the state government could support efforts to improve retention and reduce the number of uninsured through emphasizing CAHPS or

HEDIS measures. This would be particularly effective among the most vulnerable children with special healthcare needs. Special attention should be paid to smaller plans and plans with only Medicaid or SCHIP product lines.

Increasing plan outreach activities during the

annual recertification period could also help improve the retention in SCHIP.

Funding Source: AHRQ, NYS DOH, David and

Lucile Packard Foundation

• Living with Traumatic Brain Injury: A

Narrative Analysis of a Survivor’s

Photographs and Interview

Laura Lorenz, M.A., M.Ed.

Presented By: Laura Lorenz, M.A., M.Ed.,

Doctoral Candidate, Health Policy Concentration,

The Heller School for Social Policy and

Management, 56 Chase Road, Marlboro, MA

01752, Phone: 508-624-0555, Email: llorenz@brandeis.edu

Research Objective: To gain an understanding of lived experience with traumatic brain injury.

Study Design: In October 2005 the author carried out an exploratory study ‘‘Facilitators and

Barriers to Recovery from Traumatic Brain Injury:

Through the Lens of Photovoice,’’ intended to inform a dissertation proposal, and recruited one respondent. The author and respondent met three times, to: 1) discuss the project and go over the informed consent form, 2) sign the consent form and pick up the camera, and 3) discuss the respondent’s photographs. She was asked to take photographs of living with TBI and facilitators and barriers to recovery from her perspective using a disposable camera with 27 exposures. She finished her camera in three weeks and met with the author a week later to discuss her pictures. They discussed the photographs in the order in which they were taken. The author analyzed the resulting qualitative data (photographs and interview text) using a narrative analysis method inspired by

Elliot Mishler (2004), to see ‘‘the basic story parts, in temporal order: an initial problem, action to deal with it, and a resolution.’’

Population Studied: This case-centered study had one adult traumatic brain injury (TBI) respondent. As specified in the protocol, she had a cognitive level of at least seven on the Ranchos

Los Amigos Cognitive Level Scale (one being lowest and ten being highest), and she had received her injury four years prior to the study.

Principle Findings: The respondent was purposeful in completing the study assignment.

She told the researcher what each photograph meant for her, why she had taken it, and how she had settled on or created the image. Some study photographs were symbolic, others were representational. The author’s narrative analysis grouped 15 of the respondent’s photographs and interview excerpts into the plot categories problem, action, and resolution. The data and analysis reveal this respondent’s challenges living with TBI, her compensation strategies, her gradual improvement over time, and her sense of inner pride and hope for the future.

Conclusions: A major question when considering narrative analysis methods is: What is narrative? For this study, narrative is the series of photographs and interview text generated by the respondent. Rich et al (2002) and others have referred to a series of respondent images

(video) and text as a visual illness narrative. For this TBI respondent, four years after her injury, her series of images (photographs) and text could be called a visual healing narrative.


TBI affects at least 1.4 million people in the U.S. each year. An estimated 5.3 million Americans are living with disabilities resulting from TBI, and another 80,000 to 90,000 people join their numbers annually. Research that provides a deeper understanding of the TBI patient’s perspective can provide clinicians and others with valuable insights into the lives of TBI survivors and facilitators and barriers to recovery and rehabilitation from their point of view.

Funding Source: Heller Alumni Fund

• Beyond Brain Drain: Trends in Nursing

Education, Recruitment and Migration in the

Philippines

Leah E. Masselink, B.A.

Presented By: Leah E. Masselink, B.A., PhD

Student, Health Policy and Administration, UNC

School of Public Health, 1101 McGavran-

Greenberg, CB#7411, Chapel Hill, NC 27599-

7411, Fax: 919-966-6961 Email: leah_masselink@unc.edu

Research Objective: The Philippines has a long history as a supplier of human resources, especially nurses, to countries in the developed world. Exporting nurses has been a longstanding economic strategy for the Philippine government. Because of its link with migration opportunities, nursing has also become a second career for other professionals, especially physicians. As a result, recent years have seen unprecedented growth in the demand for nursing education in the country. This study explores the policy context and consequences of these trends for education, recruitment and migration of nurses in the Philippines.

Study Design: Data were collected via qualitative interviews of key informants in the

Philippines. Interview topics included antecedents of the recent growth of nursing education, ‘‘second course’’ nursing education for physicians, and school strategies and government policies for managing recruitment and migration of nurses. Supplemental information was gathered from Philippine newspapers, presentations given at a private hospital administrators’ conference, and publications provided by interviewees.

Population Studied: Deans and administrators at 7 nursing schools in Manila, Iloilo City, and

Bacolod City; a ‘‘second course’’ nursing program alumnus; representatives of the

Philippine National Institutes of Health, the

Department of Health, and the Philippines

Overseas Employment Administration.

Principle Findings: The number of nursing schools in the Philippines has grown explosively, from 40 schools in the 1980s to 470 documented programs in 2006. As the number of programs has grown, some schools have also sought rapid, drastic expansions in enrollment.

The Philippines has also seen a movement of physicians into ‘‘second course’’ nursing education. The effects of this trend are being felt throughout the country, particularly as physicians leave their posts in public hospitals and rural areas to work abroad as nurses.

Demand for medical education has declined, and some nursing schools have opened special programs that allow physicians to pursue nursing education while continuing to practice as physicians.

Conclusions: While the migration of health professionals from developing countries to developed countries is typically framed as ‘‘brain drain’’, the Philippines is a unique case: nursing education has become a large and growing industry in the Philippines because of its link with migration opportunities. Nursing schools have responded to demand by increasing enrollment and accommodating second-career nursing students, particularly physicians. In this context, nursing leaders in the Philippines are struggling to maintain quality education and a sense of public service in a profession increasingly governed by business interests and individual aspirations for overseas employment.


US and other developed countries’ policies of importing nurses from developing countries can have unintended consequences, such as the explosive growth of the nursing education industry and the depletion of the physician workforce in the Philippines. Future policies should include efforts to address these implications of overseas nurse recruitment for sending countries.

Funding Source: UNC University Center for

International Studies, Sheps Center for Health

Services Research, Department of Health Policy and Administration

• A Review Tool to Improve Emergency

Management Plans in Rural Hospitals

TaQuesa McClain, M.B.A., M.A.., B.S.

Presented By: TaQuesa McClain, M.B.A., M.A..,

B.S., Graduate Research Associate, SC Rural

Health Research Center, USC-Arnold School

Public Health, 220 Stoneridge Dr Ste 204,

Columbia, SC 29210, Phone: 803-315-6841, Fax:

803-233-8193 Email: quesamcclain@aol.com

Research Objective: The purposes of the study were to (1) develop an Emergency Preparedness

Assessment Protocol (EPAP) for rural hospitals and (2) test the instrument’s utility by conducting a case study in a small, rural hospital in South Carolina. The intended outcome was to provide small, rural hospitals with a reliable protocol for assessing their emergency management and disaster plans.

Study Design: Developed from a comprehensive literature review, the emergency preparedness assessment protocol tool focused on (a) policies and procedures implementation,

(b) hospital staff readiness and (c) dissemination of information to key stakeholders. The EPAP was applied to a 90-bed hospital in rural South Carolina

Population Studied: Emergency Preparedness policies of a rural hospital in South Carolina.

Principle Findings: The strengths observed were senior management staff was National

Incident Management System (NIMS) IS-700 certified. The hospital developed a local implementation of the national Hospital

Emergency Incident Command System (HEICS) plan, which outlines the chain of command, logistics, and responsibilities of the hospital and first responders. Quarterly preparedness drills include an introduction to bioterrorism; mass casualty and avian flu pandemic table top exercises; and the use of personal protective clothing, such as powered air purifying respiratory (PAPr’s). However, use of the EPAP revealed weaknesses in the hospital’s emergency and disaster plans. The hospital’s plan lacked a detailed chain of command for transporting the elderly and disabled nursing home patients at an adjacent facility owned by the hospital. Another gap revealed by the EPAP assessment was the

omission of volunteer support staff from the communication chain. Since many hospital services (information desk, switch board, gift shops) are handled by volunteer staff it is imperative that they are included in the emergency contingency plan.

Conclusions: Due to the various local and state agencies involved in public safety, a coordinated plan must be developed and implemented.

Communication and dissemination of information are two of the major concerns associated with hospital emergency preparedness plans. While these issues are not exclusive to rural hospitals, they can be exacerbated due to additional barriers rural communities face.


Rural hospitals should utilize an emergency preparedness assessment tool to assist with essential response efforts for all first responders and public safety/health agencies. These plans hopefully will improve the overall individual, community, and essentially the public’s health.

Funding Source: RWJF Summer Research

Practicum (SCRIPT)

•

Examining Relationships: Associations between Organizational Characteristics and

Medicaid Reimbursements

Joseph McCombs, B.A., B.S., Tricia J. Johnson,

Ph.D., Diane M. Howard, Ph.D., Ronald O. Neff,

M.S.

Presented By: Joseph McCombs, B.A., B.S.,

Student, Health Systems Management, Rush

University, 1076 N Paulina Apt. 3R, Chicago, IL

60622, Phone: 718-864-2251, Email: joseph_mccombs@rush.edu

Research Objective: Illinois is examining methods to cost effectively provide health insurance coverage to its uninsured population.

The reimbursement methodology used by the state Medicaid program was last updated in

1992. Since this time, a series of targeted add-on payments have been used to increase reimbursement for specific types of providers and services instead of increasing the base DRG for every provider. The state government has placed much of its attention on expanding enrollment in Medicaid as a way to provide coverage for the uninsured, but the cost of using the current system is not clear. Little is known about the effectiveness of or impact of

Medicaid’s reimbursement system on Illinois hospitals. Hospital providers in Illinois are a critical component of the Medicaid program, receiving over 61% of the total Medicaid reimbursement. By introducing methods to reduce hospital expenditures or eliminate wasteful spending by Medicaid will have a substantial effect the Illinois healthcare system.

This study examines whether Medicaid reimbursement is associated with not only hospital costs, but also hospital characteristics including bed size, type of institution, payer mix, network affiliation, geographic location and teaching status.

Study Design: This was a cross-sectional study of the relationship between Medicaid reimbursement and hospital costs. Hospital-level data on costs, paid claims, and characteristics were provided primarily by the Illinois

Department of Health and Family Services for

July 2004 to June 2005 for all hospitals in the state. The Illinois Department of Public Health

(IDPH) and the Illinois Hospital Association

(IHA) were used to supplement data on hospital characteristics.

Population Studied: All Illinois hospitals will be analyzed.

Conclusions: If results show that no relationship exists between provider characteristics and Medicaid reimbursement, this study will provide a basis for dialogue between healthcare leaders and state policymakers. This could allow policy makers to take steps to improve the reimbursement structure within the Medicaid system.

If there is no relationship between Medicaid reimbursement and hospital costs healthcare leaders and policy makers should reevaluate the reimbursement structure to become more appropriately allocated. If, on the other hand, a positive relationship between Medicaid reimbursement and hospital costs is found, then other approaches will be needed to increase funding for the state Medicaid program.


Designing a system that fairly reimburses health care providers for care to Medicaid-covered individuals is critical. Equitable Medicaid reimbursement will facilitate access to timely and appropriate care for Medicaid beneficiaries.

An equitable system will also help position

Medicaid to expand its rosters to incorporate more enrollees. To do this, Illinois must uncover those hospitals that are receiving significantly higher reimbursements and examine whether these reimbursements are based on financially sound and reasonable methods based on need or eligibility.

• Comprehension of Health Plan Language for Denial of Benefit Claims

E. Kiernan McGorty, J.D., M.A.

Presented By: E. Kiernan McGorty, J.D., M.A.,

Graduate Student, Psychology, University of

Nebraska - Lincoln, 4661 Hope Valley Road, Apt.

G, Durham, NC 27707, Phone: 919-475-7646,

Fax: Email: kmcgorty@yahoo.com

Research Objective: The present study explored consumers’ comprehension of employersponsored health plan documents, which are governed by the disclosure requirements and civil enforcement mechanisms of the Employee

Retirement Income Security Act, and consumers’ propensity to appeal denied healthcare benefits.

Study Design: Over the internet, participants read either original or redrafted versions of medical necessity and claims procedure clauses.

Participants either read plan documents without a priori knowledge or knowing they have been denied coverage. Participants were tested on their comprehension of the clauses, completed a health literacy test, and reported their personal health history and insurance status. Participants were randomly assigned to a weak or strong claim condition and were told the Health Plan had denied them care that they had requested.

They took part in a simulated appeals process and assessed their satisfaction with the Health

Plan.

Population Studied: Employees (N = 93) from around the country and undergraduate students

(N = 117) at the University of Nebraska-Lincoln completed the study.

Principle Findings: Participants completed a comprehension test to demonstrate their understanding of the medical necessity and claims procedure clauses. The mean overall comprehension accuracy score indicated that respondents made slightly more correct responses than incorrect responses. On average, 52.57% of participants’ responses were hits, 33.66% were misses, and 13.77% were do not know answers. An ANOVA with the comprehension test as the dependent variable revealed no main effect for the drafting of the clauses, F(1, 202) = .01, p = .91.

An ANOVA with the propensity to appeal as the dependent variable revealed a main effect for claim, F(1, 193) = 74.11, p < .001, such that participants in the strong claim condition (M =

3.82, SD = 1.02) were more likely to appeal the denial than participants in the weak claim condition (M = 2.56, SD = 1.04). There was no correlation between comprehension and propensity to appeal for participants in the strong claim condition, r(100) = .09, p = .39.

However, in the weak claim condition, the more participants understood the medical necessity and claims procedure clauses the less likely they were to appeal a denied benefit, r(109) = -.21, p <

.05. The more participants felt the Health Plan was procedurally fair and the more participants were satisfied with the Health Plan, the less likely they were to appeal the denied claim, r(209) = -

.27, p < .001.

Conclusions: After reading medical necessity and claims procedure clauses, consumers demonstrated poor comprehension of their rights and responsibilities regarding denied healthcare benefits. Redrafting of the clauses did not improve their comprehension. In the weak claim condition, better comprehension did lead to more appropriate appeal decisions.

Participants also were less likely to challenge denied benefits when they were satisfied with the

Health Plan’s appeal process.


Findings from this study have implications for improving the comprehensibility of health plan documents and reducing unnecessary healthcare expenditures by improving patient satisfaction with their health plans, reducing the number of frivolous lawsuits over plan coverage, and decreasing the administrative costs for sponsoring plans.

• Moving the Healthcare Sector Forward: The

Role of Health Information Technology

Doug Melton, B.A., M.P.H.

Presented By: Doug Melton, B.A., M.P.H., P.O.

Box 1574, Pittsboro, NC 27312, Phone: (919) 260-

1568, Fax: Email: dougmelton04@yahoo.com

Research Objective: The objective of this research is to identify the promises of health information technology particularly using an electronic health record (EHR) system and to also examine the most likely function of health information technology to achieve nationwide adoption

Study Design: observational study design was used to compare current use of health IT in clincial settings throughout the state to those found in emprical research in other states.

Variables that were observed were estimated cost of technology, type of health services delivery, and patient use.

Population Studied: Data was obtained from a

North Carolina statewide health informatics

project composed of providers and other health care organizations.

Principle Findings: Results indicate that health information technology can improve the quality of care for consumers of health by transforming the health sector from paper-based to computerbased patient health records. Primary results found that health care organizations and providers were more likely to use electronic health records if physician buy-in was present and the

Conclusions: The first and most likely function of health information technology to become adopted by health organizations nationwide is electronic prescribing. Optimal use and rewards of health information technology adoption will not be achieved until questions about the financial barriers of information technology investment and data transfer standards are further explored.


The health care sector has been slow to adopt

EHR systems because there are still many unanswered questions about the financing and economic incentives for providers who choose to invest in these systems. The overarching barrier to nationwide health information technology adoption is due the architectural impediments of interoperability. Future research must demonstrate the business case for small group practices to adopt health technology systems in order for widespread use of EHR outside of major health systems

• Examining Factors Associated with

Childhood ADHD Diagnosis and Medication

Use in a Multivariate Context with a California

Focus

Sepideh Modrek, B.A., Steve Hinshaw, Ph.D.,

Susan Stone, Ph.D., Brent Fulton, Ph.D.

Presented By: Sepideh Modrek, B.A., AHRQ Pre-

Doctoral Research Fellow, Petris Center/ Health

Services and Policy Analysis, UC Berkeley, 2150

Shattuck Avenue, Suite 525, Berkeley, CA 94704,

Phone: (510) 643-4100, Fax: Email: smodrek@yahoo.com

Research Objective: This study describes the association between child- and family-level characteristics and whether a child is diagnosed with ADHD and is taking medication for the condition. The study also describes the association of ADHD diagnosis and medication use with a state's supply of pediatricians, child psychiatrists, and psychologists as well as its education policies. Lastly, it describes how

California’s ADHD diagnosis and medication rates compare to other states using both crude rates and rates that are adjusted for states’ differing child and family characteristics.

Study Design: The data are from the 2003

National Survey of Children's Health

(NSCH) and logistic regression models are used to estimate the associations between ADHD diagnosis and medication use and child-, family-, and state-level characteristics.

Population Studied: Nationally representative sample of children aged 4-17.

Principle Findings: The study confirms that

ADHD diagnosis and medication use are associated with child and family characteristics, but also shows that diagnosis is associated with a state’s supply of pediatricians, child psychiatrists, and psychologists as well as its education policies. Twenty-three states’ crude diagnosis rates are higher than California’s rate; however, when these rates are adjusted for differing child and family characteristics, no state is statistically higher. However, California’s medication rate remains low even when these variables are accounted for.

Conclusions: These results show that child and family characteristics as well as state-level health provider supply and education policies are associated with ADHD diagnosis and medication rates. California’s low medication rate may be due to its higher use of complementary and alternative medicines.


Both demographic and state level policy's


•

Menopause Transition and Female Labor

Supply

Mercy Mvundura, Ph.D. candidate, MA, B.Sc.

Presented By: Mercy Mvundura, Ph.D. candidate, MA, B.Sc., Ph.D candidate,

Economics, Georgia State University, 14 Marietta

Street, N.W., Atlanta, GA 30303, Phone: (202)

386-2176, Email: mercymvu@hotmail.com

Research Objective: Women in midlife experience menopause which signifies the end of menstrual cycles. Previous researchers have argued that menstrual cycles have non-trivial, negative consequences on some women’s health, lifestyles, and labor market behavior. The end of these reproductive cycles (menopause) should bring relief for these women. However, another body of literature asserts that menopause is associated with poor health for some women and so may have a negative effect

on labor market outcomes. The objective of this study is to explore the effect of the transition from premenopause to postmenopause on women’s labor market behavior.

Study Design: Panel data methods (fixed effects) are used in regressions where the labor market outcomes of interest are labor force participation and full time employment for women who were employed. The key explanatory variables are the reproductive stages, i.e. premenopause, perimenopause, surgical menopause, or natural postmenopause. I also include interaction terms for the menopause stage and hormone use.

Population Studied: The paper uses data from the National Longitudinal Survey of Young

Women, a survey of civilian, noninstitutionalized women residing in the US. I use five waves of the survey with biennial data from

1995 to 2003. There are 14,633 person year observations. The analysis includes women aged between 42 and 52 years in 1995.

Principle Findings: Controlling for demographic, socio-economic, and health variables, I find that women in premenopause were less likely to be in the labor force than women in postmenopause and the difference was statistically significant. To test if the lesser labor force participation is due to premenopausal women having child care demands, I run the regression using the sample of women who do not have any children aged less than seven years and still find the same result. There was no significant difference in labor force participation between women in perimenopause, women who had surgical menopause and women who experienced natural post menopause. Women who had surgical menopause and who used hormones were more likely to be in the labor force. Women in both premenopause and perimenopause were less likely to work full time when compared to women who had experienced natural postmenopause. There was no difference in the decision to work fulltime between women who had experienced surgical menopause and women who had natural menopause. Using the sample of women without young children, I find that the signs of the coefficients remain unchanged. I also find that hormone use did not have any effect on the decision to work fulltime.

Conclusions: The findings suggest that, controlling for other relevant variables, labor force attachment increases as women move from premenopause to menopause. Hormone use was beneficial for women with surgical menopause because these women were now more likely to be in the labor force.


Among a generally healthy population, the transition to menopause is not disruptive to the decision to work. As women enter menopause, they are more likely to choose to work. Also among working women, those in menopause are more likely to work fulltime. Thus, menopause should not be viewed in the negative context as is seen in some literature where the emphasis focuses on the poor health associated with the transition. Furthermore, hormone use can be beneficial for women who have surgical menopause as it controls the menopause symptoms and makes them more likely to be in the labor force.

• Technical Efficiency and Quality Outcomes of Acute Care Hospitals: A Data Envelopment

Analysis Approach

Preethy Nayar, M.S., M.Phil., Yasar A. Ozcan,

Ph.D., M.B.A.

Presented By: Preethy Nayar, M.S., M.Phil.,

Doctoral Student, Health Administration,

Virginia Commonwealth University, 3412

Andover Hills Pl, Richmond, VA 23294, Phone:

(804) 346-0782, Email: nayarp2@vcu.edu

Research Objective: In an era of cost containment and resource constraints the U.S hospital industry is facing incentives to improve technical efficiency. Improvements in efficiency result in optimal resource utilization and it is hoped in improved organizational performance.

Hospital administrators thus, are increasingly concerned with assessment of their organizations' technical efficiency.Data

Envelopment Analysis is a non-parametric technique that assesses the relative efficiency of organizations, called as Decision Making Units.

DEA is a useful technique to assess organizational performance in terms of technical and allocative efficiency. However, little work has addressed quality issues, or included qualitative outcomes in DEA. While stressing technical efficiency are quality outcomes being compromised? Do hospitals that have a safety net role and bear a disproportionate share of uncompensated care burden perform poorly in terms of efficiency and quality as compared to their peers? The answers to these questions are far from resolved. The purpose of this study is to analyze the technical efficiency of acute care hospitals using outcome measures of quality in

the DEA and to examine the efficiency of safety net hospitals relative to their peers.

The research questions that this study attempts to address are: 1.How does the inclusion of quality outcomes as outputs in the DEA models impact the results of technical efficiency? 2.Do safety net hospitals that bear a disproportionate share of the uncompensated care burden in a community have worse outcomes in terms of efficiency as compared to their peers?

Study Design: The study design was crosssectional. Data for this study were extracted from secondary databases including the American

Hospital Association survey database for 2003; the HCFA database for FY2003; the Virginia

Health Information database and the CMS website www.cms.hhs.gov .

Population Studied: The sample included all non-federal acute care hospitals in the state of

Virginia in 2003. The unit of analysis is the nonfederal acute care hospital.

Principle Findings: The most significant finding of the analysis of the DEA models was that hospitals that were efficiently producing quantitative outputs: outpatient visits, adjusted discharges and training FTEs; were also efficiently producing the quality outputs: % pneumonia patients receiving oxygenation assessment, initial antibiotic timing and pneumococcal vaccination. Also, some of the inefficient and near-efficient hospitals with regard to quantitative outcomes were efficiently producing the quality outcomes. The findings of the study also indicate that safety net hospitals that may be considered to be at a disadvantage as compared to their peers due to their higher uncompensated care burden were performing as well or even better than their peers in terms of technical efficiency.

Conclusions: The evidence from this study indicates that quality outcomes were not being compromised by the efficient hospitals in the study. This indicates that the hospitals were behaving as not only quantity maximizing units, but as quality maximizing units as well. This is indeed heartening, especially in view of

Medicare’s Quality Initiative that seeks to reward high performing hospitals with bonuses.


This study represents a significant contribution to the DEA literature as no previous study has attempted to analyze quality outcomes as outputs in the technical efficiency analysis. It also has implications for policy because the findings indicate that a managerial focus on improving technical efficiency is not likely to compromise quality. With an increasing emphasis on quality by third party payers like

Medicare with pay for performance initiatives, the findings of this study are especially significant for policy makers and administrators alike, as the evidence is that hospitals can maximize both quality and quantity; and efficiency need not be at the expense of quality.

• Burden and Correlates of Anxiety and

Depression among Married Women in a

Developing Country Setting

Gul Nowshad, M.B.B.S, M.P.H., Syed M Shah,

M.B.B.S., M.P.H., Ph.D., Rashida Bano, M.P.H.

Presented By: Gul Nowshad, M.B.B.S, M.P.H.,

Graduate Research Assistant, Management,

Policy and Community Health, School of Public

Health, UT Houston, 7900 Cambridge Apt 24-

1G, Houston, TX 77054, Phone: (713) 791-9832,

Email: drgulnowshad@yahoo.com

Research Objective: The purpose of this study was to identify the prevalence of depression married women in the Northern Areas of

Pakistan and also to increase the knowledge of the factors that influence depression.

Study Design: Cross sectional study

Population Studied: A random sample of 900 married women aged 15 to 49 years was selected by stratified random sampling from a sampling frame in Ghizar district, with a total population of 121,280. Sample size was allocated proportionate to the size of each the villages.

Trained female interviewers conducted the survey and informed consent was signed by each study participant. Lactating and pregnant women are excluded as being a higher risk of suffering from depression. Information were collected from participants on sociodemographic variables, use of snuff, daily cigarette consumption, use of health care loss of pregnancy through household visits and the survey was completed in 2000. The instrument used to assess the anxiety and depression levels was the Aga Khan University Anxiety and

Depression Scale (AKUADS), an indigenous screening instrument developed in the local language (Urdu) for anxiety-depression syndromes. The questionnaire has 25 items, 13 psychological and 12 somatic. In comparison with available instruments in Urdu, comprising of either psychological or somatic items, this scale includes both, which increases its reliability for use as a screening instrument. This instrument has been validated using appropriate sample size. At a cut off score of 19 points

AKUADS has specificity of 81%, sensitivity of

74%, a positive predictive value of 63%, and negative predictive value of 88%. It has a higher predictive value than some of other available scales such as the self-reporting questionnaire.

This instrument has been used17 successfully to measure burden of mental stress and to evaluate effectiveness of community-based intervention to reduce anxiety and depression, a reliable indicator of mental illness in a community.

Principle Findings: We found that 308 (34%) out of 900 married women aged 15 to 49 had anxiety and depression. 629 participants

(69.9%) were illiterate. The prevalence of anxiety and depression decreased as the level of education increased. Women who worked in public and private sectors (2.3%) were less likely to have anxiety and depression. Prevalence of anxiety and depression increased with increase in duration of marital life and the number of children. Women who lost a pregnancy or used snuff or smoked cigarette were also more likely to have anxiety and depression. Women who had a household income of more than US dollars 90 or more per month and who had 2 or more than two earning members in family were less likely to have anxiety and depression.

Depressed women were also more likely to be smokers (AOR=4.07), snuff users (AOR=3.34) and lost a pregnancy in the past (AOR=1.42).

Women who had self-perception of good health were less likely to have anxiety and depression.

Conclusions: Education and employment are the mandatory tools; every woman in developing should have access to fight back the emotional stress.


Preventive strategies should include social policies aimed at increasing sex equality, eliminating poverty for population at risk like women.

•

Qualitative Study Participation of Clinicians

Selected by their Disparate Rate of Colorectal

Cancer Screening

Cathleen (Katie) O'Farrell, M.D., Laura Mae

Baldwin, M.D.

Presented By: Cathleen (Katie) O'Farrell, M.D.,

Research Fellow, Family Medicine, University of

Washington, 10602 9th Ave NW, Seattle, WA

98177, Phone: 206-245-6467, Email: ofarrell@u.washington.edu

Research Objective: Use qualitative interviews to determine what message components of a provider's reported conversations with patients are associated with that provider's measured colorectal cancer screening rate. Determine if participation rate is different for two groups of physicians with desparate colorectal cancer screening rates.

Study Design: Two provider groups have been identified - one group with very high colorectal cancer screening rates and one with very low colorectal cancer screening rates. Fifteen randomly selected physicians from each group will be interviewed. The interviewer will not know which group the physicians are in until after the interviews are transcribed and coded. Interview questions are based on the Theory of Planned

Behavior and also include probes regarding patient centered care behaviors,care processes, and involvement with health care teams.

Population Studied: All physician subjects will be from an integrated health maintenance organization where all their patients have similar benefits for preventative services and similar direct to patient information from their insurance provider. Performance measures are based on HEDIS criteria. Practice demographics will be compared.

Conclusions: Participation data and preliminary results will presented on the poster.

Principle Findings: Study interviews are ongoing at time abstract submitted.


This qualitative study will allow the researcher to shed light on the differences between providers who cause improvement in outcomes for colorectal cancer by increasing patient screening and providers who do not.

•

Strategic Planning of a Focus Group for a

Community Health Center in the Hampton

Roads Area

Karen Otero-Fisher, Clare Houseman, Ph.D.,

Kurt Heisler, Sariyamon Tiraphat, John Dool,

Zafer Pirim

Presented By: Karen Otero-Fisher, Student,

College of Health Services, Old Dominion

University, Norfolk, VA 23508, Phone: (757) 683-

3000, Email: solegrrl@hotmail.com

Research Objective: To determine stakeholders' views regarding a Community Health Center's image, focus groups among consumers, staff, and board members were held.

Study Design: Three groups answered a demographic survey in addition to small group focus group.

Population Studied: Three groups were constructed based on convienece sampling: consumers, staff, and board members. Each

group consisted eight people or less.

Questionaires with demographic information were filled in addition to the interview. Similar ideas and finding were placed on a table based on clinical, community, service, outcome, operation, and impact.

Principle Findings: All groups agreed that quality health care was provided by the center and that turnover was an issue due to costs, mainly the physicians. Staff turnover caused concerns regarding rescheduling and familiarity.

Costs and location of the clinic made it convenience for the consumers to use. Each grouping noted the availability of services regardless of insurance status. All focus groups commended the addition of a pediatric area, and of the center itself to the Hampton Roads area.

Conclusions: Similar and conflicting views were held by groups regarding issues including: aesthetic decorating, waiting time, transportation, comparison of services, etc.

Recommendations and additional planning to enhance the center was also provided by the grouping.


Preceptions and ideas from the stakeholders can be used as a reference source in the development and implementation of programs to improve the center's services and productivity.

•

Agreement between Patient Records and

Medicaid Claims in a Medical Practice-Based

Preventive Dental Program

Bhavna Pahel, B.D.S., M.P.H., R. Gary Rozier,

D.D.S., M.P.H., Sally C. Stearns, Ph.D.

Presented By: Bhavna Pahel, B.D.S., M.P.H.,

PhD candidate, Health Policy & Administration,

UNC School of Public Health, McGavran

Greenberg Hall, CB# 7411, Chapel Hill, NC

27599-7411, Phone: (919) 724-2239, Fax: (919)

966-6961 Email: talekar@email.unc.edu

Research Objective: In response to poor dental care access for low-income children, North

Carolina (NC) Medicaid now reimburses medical providers to provide preventive dental care. This care includes dental screening and risk assessment, fluoride therapy, counseling and dentist referrals as needed (‘‘Into the Mouths of

Babes’’ program, IMB). During the demonstration phase (1999-2002), physicians voluntarily completed patient encounter forms

(EF) to provide dental information not available in Medicaid claims submitted for reimbursement. This study links data from these two sources and assesses their agreement on frequency of IMB visits to determine their usefulness for program evaluation.

Study Design: The EF data are linked with NC

Medicaid claims from participating medical practices using patient identifiers in a multi-step match algorithm. Descriptive analyses compare frequency of IMB visits in EF and claims using percent agreement and weighted kappa statistics. A multinomial logit model with practice-level clustering examines predictors of the likelihood of a match between EF and claims

(match, unmatched EF or unmatched claims).

Population Studied: Medicaid-enrolled children

(birth through 35 months old) with one or more

IMB visits during 2000 through 2002 in practices (N=153) submitting 10 or more claims or EF.

Principle Findings: Of the 47,956 visits (30,790 children), 71% are a match, 15% are unmatched

EF and 14% are unmatched claims. Agreement on number of visits is 85% overall (weighted kappa=.66) and 87% of children have at least one match. Pediatric practices (PED) provide the majority of IMB visits (82.4%) and have the most matches. Health departments (HD) and family medicine practices (FAM) provide 11.7% and 5.9% of the IMB visits, respectively. FAM have more unmatched EF (30%) compared to both HD (20%) and PED (13%). The odds of both unmatched EF and unmatched claims relative to a match are 1.6 and 0.6 times greater, respectively, for HD than PED. The odds of unmatched EF relative to a match are 2.5 times greater for FAM than PED. Both, HD and FAM are more likely to have EF unmatched than claims compared to PED.

Conclusions: Substantial agreement between EF and claims on number of IMB visits suggests that patient records can supplement Medicaid claims data. The higher likelihood of unmatched

EF for HD may occur because timely submissions of Medicaid claims are less critical for their continued operation than for private practices. Inadequate record-keeping may account for the unmatched claims from HD.

Some FAM practices experimented with adoption longer than PED practices by completing EF without submitting claims, which may account for their unmatched EF.


Many states are instituting programs to expand access to pediatric preventive dental care in the medical setting. Overall, claims may be the most complete data set for assessing visit frequency. Yet claims lack important patient information and may be incomplete for health departments and family practices, important

healthcare settings for Medicaid clients. Results suggest that determination of the effectiveness of programs in increasing access to preventive care may be improved by combining claims data with other information sources.

Funding Source: NIDCR

• Comparison of Medication Adherence and

Health Care Costs after Converting from

Syringe Insulin to Pen Therapy in Medicaid

Type 2 Diabetes Patients

Manjiri Pawaskar, M.S., Rajesh Balkrishnan,

Ph.D., Fabian T. Camacho, M.S., Roger T.

Anderson, Ph.D.

Presented By: Manjiri Pawaskar, M.S., Teaching associate, Pharmacy administration, Ohio state university, 500 W 12th Avenue, Columbus, OH

43210, Phone: 614-247-8910, Email: pawaskar.1@osu.edu

Research Objective: Medication adherence and total health care costs for diabetes may vary according to the type of pharmacotherapy. The objective of this study was to compare medication adherence and the total health care costs in patients with type 2 diabetes who switched from insulin vial/syringe therapy to insulin pen therapy vs. those who continued with syringe therapy.

Study Design: A retrospective database analysis of the North Carolina Medicaid database from

September 24, 2001 to July 18, 2006.

Multiple linear regression models were used to predict the impact of switching therapy on the total health care costs and medication adherence using propensity scores as covariates. The adjusted means were calculated to determine the group differences across different outcomes.

Population Studied: The study involved patients with type 2 diabetes who enrolled in the North

Carolina Medicaid program from September 24,

2001 to July 18, 2006.Patients aged 18 years and above who maintained continuous Medicaid eligibility for entire 24 months follow up period were included in the study. Type 2 diabetic patients who switched from syringe to pen

(n=560) therapy were pair-matched with those who continued with syringe insulin (n=560) by age, total health care costs and diabetes related costs.

Principle Findings: The mean age of patients who switched from syringe to pen was 40.79

±17.88 years vs 41.73 ±16.79 years for syringe only group. The total health care costs was decreased substantially for patients who switched from syringe to pen (($10,366) compared to those who remained on syringe only ($13,840) (p<0.05). The hospital costs for patients with pen device were lower than those with syringe ($2,680.80 vs $4,339.33 respectively, p< 0.05). Patients who switched to pen device experienced decreased number of days on syringe (138 vs 220, p=0.01) while increased number of days on OAD (83 vs 67 respectively, p< 0.05). The syringe to pen group had significantly lower syringe adherence (0.38 vs

0.61, p <0 .0001) compared to syringe only group. We found decreased pen adherence in patients when compared to syringe adherence for control (0.42 vs 0.62, p<0.0001).

Conclusions: Patients with type 2 diabetes who switched from insulin vial/syringe to pen therapy experienced lower medication adherence compared to those who continued with syringe therapy. However, patients switched to pen device were associated with significant reduction in healthcare services utilization including hospitalizations, and reduced total health care costs.


The health care professionals should provide patient education and counseling regarding insulin pen use to improve medication adherence. The diabetes management program should be designed to improve patient awareness regarding insulin pen therapy.

•

Description of Approaches to Providing

Language Interpretation for Mental Health

Clients in California

Carol Peng, M.S.W., PhD student, Christine Lou,

M.S.W., Mary Masland, Ph.D., Lonnie Snowden,

Ph.D.

Presented By: Carol Peng, M.S.W., PhD student,

Graduate Student Researcher, Center for Mental

Health Services Research, UC Berkeley, 2140

Shattuck Avenue, #409, Berkeley, CA 94720,

Phone: (510)845-0844, Email: pengcj@berkeley.edu

Research Objective: To describe and assess the different approaches for language interpretation currently being implemented in California’s public mental health system.

Study Design: Gather information through the literature, conferences, and key informant interviews on the approaches for language interpretation in practice or being implemented in California’s public mental health system.

Assess approaches according to cost, availability, and adherence to national standards for interpreters in healthcare settings developed by

the National Council on Interpreting in Health

Care (NCIHC). These standards provide guidelines on issues such as accuracy, confidentiality, impartiality, cultural awareness, and professionalism.

Population Studied: California’s 57 public mental health systems

Principle Findings: Under Title VI of the Federal

Civil Rights Act of 1964, all state Medicaidfunded agencies, managed care plans, and hospitals are required to take adequate measures to ensure that health consumers receive free of charge equal access to services in the consumer’s primary or preferred language. In

1997, as part of a vigorous response to the Title

VI requirements ---- among the most systematic and conscientiously enforced in the nation ---- the

California Department of Mental Health mandated that each county mental health system provide a specific set of in-language services and linguistically capable staff or interpreters at key points of contact for all

‘‘threshold language’’ populations. The establishment of threshold languages is described by state officials as ‘‘the annual numeric identification, on a countywide basis, of

3,000 beneficiaries, or 5% of the Medi-Cal

(Medicaid) population, whichever is lower, whose primary language is other than English, for whom information and services shall be provided in their primary language.’’ California’s county public mental health systems prioritize hiring bilingual, licensed mental health providers for threshold populations. Shortages of such providers frequently necessitates the use of interpreters. There are several major approaches to providing interpretation: 1) staff interpreters,

2) contract interpreters, 3) employee language banks, 4) community interpreter banks, 5) telephonic and video services/remote consecutive interpretation, and 6) remote simultaneous interpretation. Preliminary research indicates that employee language banks and telephonic services are frequently used within California’s public mental health systems.

Hiring staff interpreters, a common practice in general health services, is less prevalent in

California’s public mental health care systems.

Access to trained, in-person interpreters is generally limited throughout the public mental health systems. In response to this need, the

California Department of Mental Health is planning an interpreter training pilot commencing in the first quarter of 2007. This training will later be available for purchase at the county level. Results of this implementation and other current practices will be reviewed by this research team.

Conclusions: Language barriers can be a major deterrent to accessing effective mental health care. Preliminary research indicates that systems are constrained by bilingual workforce shortages.

Counties have adopted various strategies for interpretation to address the need for appropriate language assistance. Utilized methods reflect available organizational and community resources as well as cost and efficacy considerations.


As the nation’s immigrant population increases,

California’s experience in implementing its threshold language access policy and specific measures such as interpreter services can provide valuable lessons for other states with burgeoning immigrant populations and concomitant service needs.


• The Impact of Racial Isolation: Residential

Segregation and Preterm Birth

Michelle Precourt Debbink, B.A.; M.D./Ph.D. expected 2012, Michael D. Bader, B.A., Cameron

Shultz, M.S.W.

Presented By: Michelle Precourt Debbink, B.A.;

M.D./Ph.D. expected 2012, Medical

Student/Graduate Student, Public Health Policy,

Health Management and Policy, University of

Michigan Medical School and School of Public

Health, 2358 Hilldale Dr., Ann Arbor, MI 48105,

Phone: 734-995-6820, Fax: 440-274-9659 Email: mdebbink@gmail.com

Research Objective: We evaluate the correlation between racial residential segregation, as measured by spatial analysis of the racial composition in census tracts, and preterm delivery in Michigan's metropolitan statistical areas.

Study Design: We create a hierarchical model to explore the correlation and relative impact of racial residential segregation, and specifically racial isolation, on preterm delivery. A distancebased measure of racial composition for each

Census tract (representing the racial isolation of communities within a Census tract) and neighborhood variables from the 2000 Census

(percent vacant housing, education level, median household income, percent unemployed, and number of children per household) comprise the tract-level variables, and maternal age and race

(as reported in Michigan vital statistics data from 2000) comprise the individual-level

variables. The hierarchical modeling analysis will be carried out using STATA 9 (College Station,

TX).

Population Studied: Women in Michigan

Metropolitan Statistical Areas (MSAs) with births recorded by the State of Michigan's Department of Community Health Vital Records in the year

2000.

Principle Findings: We expect to find that residential racial segregation (as measured by the spatial racial isolation of Census tracts) predicts preterm delivery. We expect this association to be negative (as segregation increases, gestational age decreases) for African

Americans. However, we hypothesize that segregation will offer a protective effect for

Caucasians. Previous studies looking at alternate parameters of segregation (e.g., dissimilarity index) have shown a predictive relationship that holds when external factors

(income and education) are controlled.

Conclusions: By using a distance-based measure of racial composition, we focus on the racial isolation of communities as a parameter of residential segregation. Our analysis furthers existing research regarding segregation and health by exploring the impact of this largelyunexplored parameter of segregation. We expect our findings to show that an important aspect of segregation leading to adverse outcomes for the

African American community is the racial isolation experienced by segregated communities, and not merely the concentration of poverty.


Racial disparities in preterm delivery persist despite clinical efforts to improve prenatal care, so evaluating nonclinical factors in preterm delivery may lead to improved policy and population-based solutions. The mechanisms by which social and neighborhood factors contribute to preterm delivery require further research, but continued evaluation of these influences may lead to a better understanding of the ways policy can be used to alter the isolating circumstances of residential segregation.

•

The impact of Organizational Factors and

Patients’ Needs on Enabling Services

Provided by Federally Qualified Health

Centers

Rajeshwari Punekar, M.P.H, Rebecca Wells,

Ph.D., Joseph J.Vasey, Ph.D.

Presented By: Rajeshwari Punekar, M.P.H,

Doctoral Student, Health Policy and

Administration, The Pennsylvania State

Univeristy, 15B N Henderson Building, University

Park, PA 16802-6500, Phone: (205)529-3063, Fax:

Email: rsp151@psu.edu

Research Objective: To identify organizational and patient population characteristics associated with the scope and volume of enabling services provided by Health Resource and Service

Administration’s (HRSA) -funded community health centers. Enabling services play a critical role in facilitating access to care for vulnerable populations. This research study was part of a broader investigation into factors affecting service provision by health centers.

Study Design: The primary source of data was the HRSA Uniform Data System based on annual reports by all federally funded community health centers. The unit of analysis was the health center. Separate lagged ordinary least squares regression modeling predicted scope and volume of enabling services in 2004 as a function of organizational and patient characteristics in 2003. The scope of enabling services was measured by the number of enabling services (e.g. transportation, case management, interpretation/translation) provided by the health center. The volume of enabling services was measured by total number of encounters each center reported for all enabling services combined. Organizational characteristics measured were size (number of staff); number of managed care contracts; net revenue per encounter; level of grant funding; staff caseload; and geographic location

(urban/rural). Patient characteristics included percentages of patients who were female; above

65 years of age; migrant; homeless; HIV-positive; needing interpreters; below poverty level; and uninsured.

Population Studied: 883 U.S. based community health centers operating in 2003 and 2004.

Principle Findings: Among organizational characteristics, number of staff and number of managed care contracts were positively associated with scope and volume of enabling services. Urban and suburban centers offered a broader scope of enabling services than did rural centers, but not different volumes. Staff caseload was negatively associated with scope of enabling services and grant revenue was negatively associated with volume of enabling services.

Among patient population characteristics, the percentages of patients who were migrant; homeless; and uninsured were positively associated with scope and volume of enabling services. The percentage of patients in poverty was positively associated with the scope of

enabling services, and the percentage of HIVpositive patients was positively related to volume of enabling services.

Conclusions: Health centers appear to be responding to patient needs by providing more enabling services when they serve more vulnerable populations. Larger centers also seem to be able to provide more enabling services. Contrary to popular assumptions, managed care was positively associated with enabling services. Surprisingly, higher levels of grant support were not associated with either.


To the extent that doing so does not undermine other goals, funders may want to encourage economies of scale. Although health center directors may currently see managed care contracts as financially necessary but unsupportive of enabling services, the current analysis suggests a different view. Results here indicate that managed care contracts may facilitate access for patients. Thus, managed care contracts may actually be beneficial for both centers and the patients they serve.

•

Gender, Age, and Geographic Variation in

Hospital Length of Stay among HIV-Infected

Adults in Louisiana

Anthony Santella, M.P.H., Dr.P.H.(c), Lizheng

Shi, Ph.D., Claudia R. Campbell, Ph.D., Patricia

Kissinger, R.N., M.P.H., Ph.D., Ramses Sadek,

Ph.D.

Presented By: Anthony Santella, M.P.H.,

Dr.P.H.(c), Doctoral Candidate, Department of

Health Systems Management, Tulane University

School of Public Health and Tropical Medicine,

1440 Canal Street, Suite 1900, New Orleans, LA

70112, Phone: 404-276-5961, Fax: 212-886-3271

Email: asantella@gmail.com

Research Objective: This retrospective study aims to evaluate the effect of predisposing

(demographic), enabling (organization), and need (evaluated health status) factors on

HIV/AIDS-related hospital length of stay from

1998 through 2003.

Study Design: The analyses were performed for the overall 6-year period and then repeated for each year of admission. The unit of analysis was hospital admission of a person living with

HIV/AIDS. Log-transformed length of stay (LOS) was fit on specified predictors and covariates using the ordinary least-squares approach. The predictor effects on the original scale were evaluated by back-transforming the regression parameters and using smearing estimators. The additivity assumption in the model was checked by testing for two-way interactions of the aforementioned demographic predictors with covariates. Throughout the analyses, a conventional level of alpha=0.05 was used for interpretation of results. When statistical tests were repeated for each year, the results were

Bonferroni-adjusted to control for the inflation of

Type-I error.

Population Studied: Inpatient hospital visit record data from 1998 through 2003 was abstracted from the Louisiana Hospital Inpatient

Discharge Database. International Classification of Diseases, Ninth Edition codes 042 (HIV-1 infection), V08 (asymptomatic HIV infection), and 795.71 (nonspecific serological evidence of

HIV) were used to select HIV/AIDS cases.

Principle Findings: From 1998 through 2003, a total of 8,888 inpatient visit records for 6,276 (71 percent) males and 2612 (29 percent) females were identified. Of the admitted patients, 32 percent were 18 to 34 years of age, 62 percent were 35-54, and 5 percent were older than 55 years. The patients were mostly urban residents

(89 percent). Records mostly represented either emergency (54 percent) or urgent visits (37 percent). The mean length of stay in hospital was 9 days (range 1-100 days) with average hospital charges of $22,000. About 40 percent of patients had AIDS Defining Illnesses.

Cumulative mortality over the 6-year period was

7.9 percent (n=57). On aggregate multivariable analysis, the length of stay for rural residents was on average 1.38 times longer than for urban residents (p=0.025). This effect was consistent for each year of analysis, although it failed to reach statistical significance after adjustment for multiplicity. Subjects gender and age category were found to be insignificant predictors for the length of hospital stay, controlling for other covariates in model. Other significant independent predictors of the length of stay in aggregate model were number of comorbid conditions, number of inpatient medical procedures, presence of AIDS Defining Illnesses, and source and type of admission, although effects of only the first two predictors were significant at each year of analysis.

Conclusions: This study shows that gender and age category of an HIV/AIDS patient are not significant predictors of HIV/AIDS-related LOS, however, the number of comorbid conditions and inpatient medical procedures are significant.


Future length of stay research should focus on mutable enabling factors (as opposed to immutable predisposing factors), which can

increase equitable access to healthcare services.

Researchers can also develop comorbidityadjusted risk adjustment methods to account for underlying differences in the patient populations.

• Beware of Your Assumptions: Differences along the Response Continuum in the

Behavioral Risk Factor Surveillance System

Karen Schneider, B.A., Ph.D. Candidate, Kate L.

Lapane, Ph.D.

Presented By: Karen Schneider, B.A., Ph.D.

Candidate, Graduate Student, PhD Candidate,

Community Health, Brown University, 121 South

Main Street, Box S-121, Providence, RI 02912,

Phone: 917-670-7837, Email:

Karen_Schneider@brown.edu

Research Objective: Response rates of national health surveys have steadily declined over the past decade. For the Behavioral Risk Factor

Surveillance System (BRFSS), the median response rate across states in 1994 was 70%; by

2004, it was 51%. Nonresponse bias threatens the quality of survey data and may bias estimates. To adjust for nonresponse bias,

BRFSS data include a weight based on the age, race, and sex distribution of a state or region.

This presumes that nonresponders are ‘‘missing completely at random’’ on all factors but age, race and sex; however, this assumption cannot be verified. Instead differences between early and late responders can be explored, and results from late responders can be extrapolated to nonresponders. Our study purpose is to compare differences between early and late responders in the BRFSS, the US’s largest population-based telephone health survey.

Study Design: The BRFSS is an annual randomdigit-dial survey of the adult civilian, noninstitutionalized population, sponsored by the

CDC and conducted in all 50 states. A dichotomous outcome was created using extreme values of the number of call attempts made to complete interview. Early responders were defined as completion in 1-2 calls, and late responders were defined as completion in 7+ calls. Independent variables included sociodemographic, behavioral and health care access variables. Cross-tabulations and logistic regression analyses were performed in SAS and

SUDAAN.

Population Studied: Individuals 18 years and older who participated in the 2004 Behavioral

Risk Factor Surveillance System (n=193,462).

Principle Findings: Number of call attempts varied from 3.4 to 6.6 by state. Late responders

(7+ calls) comprised 48% of the sample and were more likely to be: men (vs. women:

OR=1.35; 95% CI=1.30-1.41); 18-29 years (vs. 70+ years: OR=2.96; 95 CI=2.72-3.22); Hispanic (vs.

Non-Hispanic White: OR=2.14; 95% CI=1.99-

2.31); some/no high school (vs. college graduate/higher: OR=1.14; 95% CI=1.06-1.23); never married (OR=1.12; 95% CI=1.05-1.20) or widowed/divorced/separated (OR=1.10; 95%

CI=1.05-1.16) vs. married/partnered; uninsured

(OR=1.08; 95% CI=1.01-1.14) or insured with no usual provider (OR=1.11; 95% CI=1.04-1.19) vs. insured with usual provider; and living in a larger household (continuous: OR=1.05; 95% CI=1.03-

1.07).

Conclusions: Enhanced calling efforts were successful in increasing the representation of a variety of groups in the BRFSS. Without intensive callbacks, groups that are often the focus of health disparities research ---- undereducated, unmarried, uninsured, and Hispanic - would likely be underrepresented in the BRFSS.

Additionally, if differences along the response continuum follow the observed trend, the assumption that non-responders are similar to responders is probably violated.


BRFSS is executed on the state-level. States should be encouraged to follow callback procedures, as recommended by the CDC, to increase representativesness of survey sample and aid conversion of non-responders.

Interviewer training and supervision are particularly important in reducing or eliminating common sources of survey error. If such practices are not followed, then the validity of prevalence estimates, which are often used to track progress towards national and state

Healthy People 2010 goals, is questionable.

Survey error could result in misclassification of states and/or groups on attainment of target goals and result in wasted resources or lost opportunities in terms of public health interventions.

• Impact of Childhood Health and

Socioeconomic Status on Long Term Care

Utilization in Later Life

Monika Setia, M.A., France Weaver, Ph.D.

Presented By: Monika Setia, M.A., Ph.D.

Candidate & Graduate Assistant, Health Policy &


116 North Henderson, University Park, PA 16802,

Phone: 517-643-0975, Fax: Email: mzs187@psu.edu

Research Objective: The life course perspective theorizes that childhood conditions have lasting effects on health and socioeconomic status later in life. Our study expands this body of research by determining the impact of early life events on long term care utilization in later life. Specifically, the research examines whether poor health and low socioeconomic status during childhood increase the likelihood of long term care use in the elderly population.

Study Design: A cross sectional analysis is performed using logistic regression on two distinct dependent variables ---- the likelihood of any nursing home stay and the likelihood of formal (paid) home care use. For each type of long term care, two models are estimated. The first model assesses the total effect of poor health and low socioeconomic status in childhood by controlling only for demographic characteristics. The second model determines the direct effect of the childhood characteristics by controlling for present health and socioeconomic status that are determinants of long term care use and may have been impacted by childhood characteristics.

Population Studied: The analysis is conducted on a nationally representative sample of 70 and over individuals who were surveyed in 2004 as part of the Health and Retirement Study (HRS).

The analytic sample has 7,505 observations, with

9 percent reporting a nursing home stay and 4 percent using formal home care. The average age of the respondents is 78 years. Six percent report that they were in poor or fair health as a child and 11 percent report low socioeconomic status during childhood.

Principle Findings: Childhood health has a significant total effect on the probabilities of institutionalization and formal home care use in later life, while childhood socioeconomic status has no total effect. Individuals reporting good to excellent childhood health have an 8.7 percent probability of institutionalization compared to

11.1 percent for those reporting fair to poor health as a child. This corresponds to a relative differential of 32.3 percent. The probability of formal home care use is 4.2 percent for individuals with good to excellent childhood health compared to 6.5 percent otherwise. This corresponds to 62.7 percent higher likelihood of formal home care use for individuals with fair/poor childhood health. After controlling for current individual characteristics, there is no significant direct effect of childhood health and socioeconomic status on long term care use.

Conclusions: These results indicate that childhood health is related to long term care utilization in later life but that this effect is indirect through its impact on current individual characteristics. Further work is needed to understand the pathways through which childhood health may impact long term care use.


Health interventions and policies directed towards improving childhood health may indirectly affect health care utilization over the life span, including long term care use in later life.

• Home Health Care Financing and Service

Intensity: Dual Eligibles Before and After the

BBA

Huai-Che Shih, M.S., Helena Temkin-Greener,

Ph.D., M.P.H., Bruce Friedman, Ph.D., M.P.H.

Presented By: Huai-Che Shih, M.S., Doctoral

Candidate in Health Services Research and

Policy, Department of Community and

Preventive Medicine, University of Rochester,

601 Elmwood Avenue Box 644, Rochester, NY

14642, Phone: (585)275-9794, Fax: (585)461-4532

Email: huai-che_shih@urmc.rochester.edu

Research Objective: Medicare-Medicaid dual eligible beneficiaries are poorer, sicker, and cost

Medicare 60% more than non-dual enrollees.

The Balanced Budget Act (BBA) of 1997 changed the payment system for Medicare home health care (HHC) from cost-based to prospective reimbursement. Prior studies have observed the effect of BBA on number of visits and severity of

Medicare HHC users, as well as on distribution of payment sources. However, little is known about the effect of BBA on beneficiaries who are dually eligible for both Medicare and Medicaid.

We examined the changes in financing distribution and service intensity of HHC used by the dual beneficiaries to investigate the possible substitution between Medicare and

Medicaid as a result of BBA.

Study Design: We used Medical Expenditure

Panel Survey (MEPS) data from the pre-BBA

(01/1996-09/1997), Interim Payment System

(IPS) (10/1997-09/2000), and Prospective

Payment System (PPS) (10/2000-12/2003) periods. Financing distribution was measured by the proportion of HHC expenditures for each payment source. Service intensity was measured by the number of HHC visits per month, and patient case-mix was derived from the CMS-HCC risk-adjustment model. All estimates were adjusted for statistical sampling weights.

Population Studied: 8,178 patient-months

(MEPS home health events) of dual eligibles

aged 65 and older were identified from the entire

30,115 formal home health events available in

MEPS between 1996 and 2003.

Principle Findings: Medicare as a proportion of all HHC expenditures decreased from 59.5% in pre-BBA to 22.5% in IPS, and to 20.9% in PPS.

The share of Medicaid increased from 28.9% to

56.8%, and to 66.5% during the same period of time. For HHC visits primarily paid by Medicare, the number of visits increased from per-BBA

(14.28 visits) to IPS (16.10 visits; p=0.178) and declined with PPS (13.52 visits; p=0.074). In contrast, when the primary funding source was

Medicaid, the number of visits decreased from per-BBA (16.85 visits) to IPS (15.67 visits; p=0.331), and later significantly increased after

PPS (18.01 visits; p=0.041). We observed an increasing trend in risk score over time. Both

Medicare and Medicaid HHC followed this pattern, but a significant increase was only observed for Medicare HHC after PPS (from

0.720 to 0.921; P<0.001) and for Medicaid HHC after IPS (from 0.651 to 0.758; p=0.006).

Conclusions: Substantial shifts in financing distribution, number of visits and case-mix were observed in our study. We believe these changes were the result of HHC agencies responding to the financial incentives created by the BBA.

While the IPS put tighter constraints on payments and caused a reduction in Medicare

HHC, the PPS introduced a predetermined rate schedule that created incentives for agencies to provide fewer visits and/or select patients during that period.


These findings suggest that a substitution has occurred as result of BBA in HHC paid by

Medicare and Medicaid among dual beneficiaries. Further research is needed to investigate whether the combination of BBA effect has affected patient outcomes.

Funding Source: University of Rochester

• Home Health Care Utilization Patterns among Dual Eligible Beneficiaries: Before and

After the 1997 Balanced Budget Act

Huai-Che Shih, M.S., Andrew Dick, Ph.D., Bruce

Friedman, Ph.D., M.P.H., Helena Temkin-

Greener, Ph.D., M.P.H., Kathryn Votava, Ph.D.,

R.N.

Presented By: Huai-Che Shih, M.S., Doctoral

Candidate in Health Services Research and

Policy, Department of Community and

Preventive Medicine, University of Rochester,

601 Elmwood Avenue Box 644, Rochester, NY

14642, Phone: (585)275-9794, Fax: (585)461-4532

Email: huai-che_shih@urmc.rochester.edu

Research Objective: Transition probability models are commonly seen in cost-effectiveness analysis but are rarely used in studying health care utilization. To examine possible substitution between home health care (HHC) paid for by

Medicare and by Medicaid for dual eligible beneficiaries, we developed a transition probability model to evaluate the changes in utilization of HHC resulting from the Balanced

Budget Act (BBA) of 1997.

Study Design: We used the Medical Expenditure

Panel Survey (MEPS) data from the pre-BBA

(01/1996-09/1997), Interim Payment System

(IPS) (10/1997-09/2000), and Prospective

Payment System (PPS) (10/2000-12/2003) periods. The HHC utilization patterns were decomposed into three parameters: (1)

‘‘incidence’’ was estimated conditional on one year without any Medicare/Medicaid HHC use based on a logit model; then (2) ‘‘on-spell’’

(defined as consecutive months of HHC use) and (3) ‘‘off-spell’’ (months of no HHC use) were estimated based on a duration model. The transition probability model incorporated these three parameters and simulated how each individual changes his/her utilization status conditional on socio-demographic characteristics and policy (BBA) status.

Population Studied: Simulated dual eligible beneficiaries aged 65 and older (n=800; mean age=73.89, SD=6.88; 70.12% female; 44.12% nonwhite) followed for up to 96 months.

Principle Findings: 1) Medicare HHC:

Compared to the pre-BBA period, the IPS and

PPS periods were associated with lower incidence, and were shorter on-spell and longer off-spell. The PPS period had higher incidence, and was shorter on-spell and longer off-spell than the IPS period. 2) Medicaid HHC:

Compared to the pre-BBA period, the IPS period was associated with lower incidence, and was shorter on-spell and longer off-spell. The PPS period was associated with higher incidence, and was longer on spell and shorter off spell.

Conclusions: The adjusted prevalence derived from the transition probability model showed a substantial decrease in Medicare HHC utilization after IPS and a substantial increase in

Medicaid HHC utilization after PPS. However, compared to unadjusted prevalence, only the aforementioned increase and decrease were captured by the transition probability model.


Our findings suggest that the transition

probability model is useful in evaluating changes in health care utilization. However, uncertainties that resulted from a limited sample size and model assumptions (e.g., definition of home health spell) could compromise the sensitivity of the model estimation. More studies are needed to fully explore the potential of this approach for health services research.

Funding Source: University of Rochester

• The Operational and Financial Impact of an

Observation Unit in an Emergency

Department

Veronica Sikka, M.H.A., M.P.H., Ralph R. Clark,

M.D., Pawan Suri, M.D., Tania Arora, M.D.,

Joseph Ornato, M.D., Michael Gonzalez, M.D.

Presented By: Veronica Sikka, M.H.A., M.P.H.,


University, 12601 Hogan's Alley, Chester, VA

23836, Phone: 804-530-0950, Email: s2vsikka@vcu.edu

Research Objective: In February 2006, the VCU

Medical Center, an 820-bed urban academic medical center, opened its first ED observation unit (OU) for <24-hour observation care. This study compares the length of stay, volume, and financial differential in providing observation care in an ED OU versus admitting patients as inpatient observation with no dedicated observation unit.

Study Design: Nine months of data (May 2005

- October 2006)before and after the opening of the OU in February 2006 were analyzed in terms of LOS and volume. In terms of financials, only

5 months of complete data (September 2005 -

June 2006) pre and post were available. Data points analyzed were average and total direct, indirect, and variable costs & reimbursement, profit/loss, and payer mix.

Population Studied: VCU Medical Center- an urban academic medical center (inpatient versus emergency observation)

Principle Findings: In 9 months, the ED OU treated a total of 1,821 patients. The average length of stay in the ED OU was 14.7 hours compared to 21.9 hours in inpatient observation.

Upon addition of the ED OU, operational effects were also realized on the inpatient observation side. Volume decreased by 225 patients per month on average. Average LOS on the inpatient observation side also fell by 5 hours.

The average reimbursement and average margin was $112 and $43, respectively, higher with inpatient observation. Although the average total costs of the ED OU are slightly higher, there was no overall significant difference between the two observation options financially (p>0.05). The higher costs for ED observation and lower reimbursement could be attributed to start up costs and billing practices that are still being refined to realize the full charge capture potential. The lower average reimbursement and profit/loss could be attributed to the fact that the

ED OU had 10% more self pay/indigent patients compared to inpatient observation.

Conclusions: The ED OU has significant potential to decrease inpatient observation volume and LOS and increase inpatient capacity to absorb higher acuity, longer LOS patients.

Benefits of an ED OU include its dedicated resources and protocols to short-stay, observation care. Inpatient care usually involves higher fixed costs and greater resources dedicated to care for higher acuity patients.

These resources are not being utilized efficiently on inpatient observation patients who are generally lower acuity and have shorter LOS.

These results are currently being validated with a multi-site study comparing the ED OU and inpatient observation operationally and financially. Preliminary data reveal similar findings.


Resources are not being utilized efficiently on inpatient observation patients who are generally lower acuity and have shorter LOS. The recent

IOM report on the emergency medicine crisis highlights the importance of observation units in emergency medicine with minimal reference to its operational and financial benefits. These results will hopefully contribute to a better understanding of an EDOU's impact on an academic medical center. These findings are currently being validated with a multi-site study comparing the ED OU and inpatient observation operationally and financially in 5, regionally diverse, academic medical centers. Preliminary data reveal similar findings.

Funding Source: Emergency Medicine

Foundation

•

Risk for Hospitalization among of Black and

White Home Health Care Patients

Laura Smith, B.S., Vincet Mor, Ph.D.

Presented By: Laura Smith, B.S., Ph.D.

Candidate, Community Health - Epidemiology,

Brown University, 121 South Main St - Box G-

S121, Providence, RI 02903, Phone: 401-699-

4582, Email: laura_smith@brown.edu

Research Objective: To compare characteristics of Black and White home health (HH) patients.

To quantify the impact of HH patient race on risk for hospitalization, accounting for risks for other discharge outcomes.

Study Design: This is a cross-sectional study using data from the 2000 National Home and

Hospice Care Survey (NHHCS). A polytomous logistic regression was conducted to determine hospitalization risk, accounting for competing risks for death and admission to nursing home or other inpatient settings.

Population Studied: The population is a nationally representative sample of all patients discharged from home health agency care between October 1999 and September 2000.

Patients with any payer types and referral source are included. Exclusions: Patients with a length of stay over 2 years, individuals not in

Black/White racial categories (due to small sample sizes).

Principle Findings: More Black HH patients are under 65 years old (Black: 35.6%, CI: 27.2-44.1%;

White: 28.3%, CI: 25.0-31.8%), and less often married (Black: 23.1%, CI: 16.2-30.0%; White:

43.2% CI: 39.6-46.8%). Both groups tend to be female (64%). Medicaid was primary payer for more Black patients (Black: 15.8%, CI: 9.8-20.2%;

White: 7.1%, CI: 5.2-9.1) and more are dually eligible (Black: 11.4%, CI: 6.9-15.9%; White: 5.5%,

CI: 4.1-6.9). More Black patients were admitted for diabetes (Black: 12.4%, CI: 6.9-17.9%; White:

2.2%, CI: 2.2-4.4%) and White patients for pulmonary and orthopedic diagnoses. Black patients were slightly more likely to have no informal caregiver (not significant).

Black patients are less likely to receive care from hospital based agencies (Black: 33.1%, CI: 23.8-

42.3%; White: 53.7, CI: 50.1-57.3) and have longer

HH admission lengths (Black: 65.7 days, CI: 53.3-

78.1l; White: 41.8, CI: 38.6-45.0).

Regression findings, though not significant, suggest Black patients are more likely to be hospitalized (AOR: 1.15, CI: 0.65-2.0), less often die (AOR: 0.72, CI: 0.32-1.59) or are discharged to another inpatient setting (AOR: 0.57, CI:0.25-

1.27).

Conclusions: Small sample issues exclude strong conclusions. Black HH patients have characteristics (Medicaid as primary payer, dual eligibility) known to increase vulnerability to poor care and adverse outcomes. Lengths of stay and diagnoses suggest more Black patients receive care for chronic conditions. Residual confounding is likely, including differences in cultural preferences for care.


Racial disparities in health outcomes and access have been documented in many settings. Fewer studies have assessed disparities in HH care.

This study details demographic and clinical differences in Black and White HH patients.

While inconclusive, findings suggest that Black

HH patients may be at higher risk for poor outcomes.

Funding Source: NIA

• Non-Urgent ED Utilization in the Memphis

MSA

Stephanie Steinberg, Teresa M. Waters, Ph.D.,

Cyril Chang, Ph.D.

Presented By: Stephanie Steinberg, Research

Leader, Preventive Medicine, University of

Tennessee Health Science Center, 66 N. Pauline

- Suite 633, Memphis, TN 38103, Phone: (901)

262-7402, Email: scs@midsouth.rr.com

Research Objective: To examine the relationship between having a PCP for regular health care and the likelihood of frequent use of non-urgent ED visits over a twelve month period for a cohort of adult and pediatric patients, while controlling for potential cofounders such as comorbidity, socio-demographics, and health status.

Study Design: Adult and pediatric ED patients presenting for non-urgent conditions were surveyed regarding their reasons for seeking care in the ED, prior utilization, preferences for site of primary care, insurance and socioeconomic status. At least 150 patients from 10 different hospitals in Memphis, Tennessee were surveyed over a seven week period. Based upon the distribution of visits and prior ED utilization studies, frequent use was defined as four or more other visits within the previous year. A binary logistic model was used to determine the association between having a PCP and frequent non-urgent ED utilization.

Population Studied: Adult and pediatric emergency department patients with non-urgent diagnoses seeking care in ten urban and suburban hospitals in the Memphis MSA at peak hours (daytime, evening, weekday and weekends) were surveyed. Eligible patients were identified as non-urgent per each hospital/health system’s nurse triage protocols. Participating hospitals included eight non-profit adult hospitals (owned by three health systems), a public safety net hospital and a regional freestanding pediatric hospital.

Principle Findings: Of the 2,223 patients surveyed, 1,949 patients (89%) had 0-3 other ED visits within the past twelve months, and 234 patients (11%) had 4 or more other ED visits within the past twelve months (frequent users).

Individuals having a PCP were less likely to be frequent ED users for non-urgent care (odds ratio (OR) 0.63; 95% confidence interval 0.44 to

0.90). Characteristics independently associated with frequent non-urgent ED use were: 1) ED’s

24/7 hours of operation influenced decision to come (y/n) (OR 1.53; 1.02 to 2.29); 2) being low income (< $30,000/year) (OR 1.98; 1.15 to 3.43);

3) being employed (OR 0.50; 0.35 to 0.72); and

4) obtaining medical care ‘normally’ during the daytime (y/n) (OR 0.56; 0.36 to 0.88). The regression model met statistical test requirements for Homer and Lemeshow, Log

Likelihood and Deviance and Pearson tests for goodness-of-fit.

Conclusions: Results suggest that having a relationship with a PCP may reduce non-urgent

ED utilization. Only 45 percent of frequent nonurgent ED users had a PCP, even though 84 percent were insured. The frequent user population also strongly preferred obtaining care in the ED due to the 24/7 hours of operation.

This raises the issue of adequacy of available outpatient resources in the community to support the healthcare needs for this population.


Developing a relationship with a PCP may promote appropriate use of the emergency department, regardless of socioeconomic, insurance or health status. These findings have potentially significant financial and quality implications to hospital administrators and health care policy analyst as they attempt to address non-urgent ED use in conjunction with the health care needs of the poor and uninsured.

•

Rural-Urban Disparities in the Mental

Health Workforce in the State of Florida

Zoe N. Swaine, M.S., Robert G. Frank, Ph.D.

Presented By: Zoe N. Swaine, M.S., Graduate

Assistant, Department of Clinical & Health

Psychology, College of Public Health and Health

Professions, Florida Center for Medicaid and the

Uninsured, University of Florida, PO Box 100227,

Gainesville, FL 32610, Phone: (352) 273-5931,

Email: zoe@phhp.ufl.edu

Research Objective: The availability of health providers is an important aspect of access to healthcare. Recent work has shown that there is a lower supply of mental health specialists in rural communities, when compared with urban communities. However, no recent studies have evaluated the ratio of mental health providers per capita using accurate, up-to-date estimates of workforce size. The aim of the study was to characterize the distribution of the mental health workforce across the 67 counties of Florida.

Study Design: The relationship between county rurality, as measured by Urban Influence Codes

(UIC), and the availability of licensed psychologists, licensed mental health counselors, licensed marriage and family therapists, licensed clinical social workers and licensed psychiatrists in each Florida county

(measured as the ratio of provider per 100,000 capita) was examined. Hierarchical regression analysis was used to predict each of the five types of provider availability while controlling for age distributions, annual per capita income, and race/ethnicity in each county. Data on the 67

Florida counties were collected from several preexisting sources between August and September of 2005 (N = 67). Data was obtained from the

Florida Department of Health, the American

Medical Association, the Department of

Agriculture and the U.S. Census Bureau.

Population Studied: The population under study included all 67 counties in Florida.

Principle Findings: Rurality was significantly related to all provider availability ratios, accounting for between 3% and 10% of the variance in provider availability, over and above county characteristics. As rurality increased, provider availability decreased in all instances.

This disparity was most pronounced in psychiatrist availability, where rurality accounted for 10% of the variance in psychiatrist availability

(DR2 = .10, p < .001). Descriptive data revealed that 24% of counties had no psychiatrist. As a result the responsibility of prescribing psychotropic medication in these 17 counties falls on the shoulders of primary care physicians.

Thirty percent of Florida’s counties met criteria as Mental Health Professional Shortage Areas as defined the Bureau of Health Professions.

Conclusions: These results confirm the presence of rural-urban disparities in the distribution of the mental health workforce despite efforts of local, state and federal agencies to minimize the unmet need of those in more rural communities.


More needs to be done to address disparities in workforce distribution. Policy supporting the inclusion of mental health providers in primary care practices is vital to increasing access to mental health services in rural communities. In

addition the funding of training in rural issues in graduate programs in mental health would foster links to these communities and perhaps improve recruitment and retention in these areas.

• Rates of Prescription Drug Underutilization by the Medicare Population, 1996-2004

Tami Swenson, M.A.

Presented By: Tami Swenson, M.A., research fellow, School of Public Health, University of

Minnesota, 55 Willey Hall, 225 19th Avenue S,

Minneapolis, MN 55455, Phone: (612) 626-8492,

Fax: (612) 626-8492 Email: tswenson@umn.edu

Research Objective: This study examines crosssectional and longitudinal rates of prescription drug underutilization within the Medicare population and assesses the reasons for not acquiring the medication.

Study Design: The Medicare Current Beneficiary

Survey (MCBS) Access to Care module is used for the analysis. MCBS is a multi-purpose panel survey composed of four rotating cohorts interviewed over a four-year period. Survey instruments on access and self-reported health measures are administered during the fall interview round. Underutilization is defined as prescription medications not acquired by the beneficiary during the previous 12 months.

Reasons for prescription underutilization are divided into three groups. Cost-related reasons are that the survey respondent thought the medication would cost too much or the medication was not covered by insurance. Nonadherence reasons include the panelist thinking the medication was unnecessary, thinking the medication would not help the condition, fearing reactions to medication, preferring not to take medications, or feeling no need for the medication. Access reasons include not having a way to obtain the prescription, no convenient pharmacy, not able to get the medication in a timely manner, or not having time to get the prescription.

Population Studied: Community-dwelling,

‘‘always-enrolled’’ Medicare population from

1996 to 2004.

Principle Findings: Cross-sectional rates of underuse have increased from 3.0 percent of the community-dwelling Medicare population in

1996 to 4.4 percent or 1,714,995 Medicare beneficiaries in 2004. Longitudinal rates have a similar steady increase from 9.6 percent of the

1999 four-year cohort reporting any underutilizing prescription medications during the survey rotation period to 13.2 percent of the

2004 four-year cohort. The longitudinal rates, however, show that underutilization is an episodic occurrence with an average of 80 percent of those reporting any underuse having only one instance of unfilled prescription medications and no other underutilization during the four-year rotation period. Reasons for prescription underuse show that cost reasons are the predominant factor for underutilization,

56.6 percent on average for cross-sectional rates.

Longitudinal findings show large increases in the number reporting any cost-related reasons for underutilization, from 27.9 to 55.8 percent, and those reporting any non-adherence reasons from

29.0 to 37.7 percent from 1999 to 2004.

Conclusions: Previous studies of prescription medication underuse in the Medicare population have been primarily based on cross-sectional surveys and have assumed that reported underuse was a regular cost-saving practice rather than episodic. The longitudinal findings in this research, however, suggest that prescription medication underuse is typically an isolated event and related to expected predictors.

In addition, the findings suggest that nonadherence, access, and cost-related reasons for underuse may have different explanatory factors of underuse within the Medicare population.


The results from this study suggest that medication underutilization is not a static trait or permanent condition. Consequently, the practice of not filling a prescribed medication by the Medicare population may be more appropriately addressed as an episodic phenomenon in policy and clinical recommendations and should be more closely examined in relation to other types of underutilization, such as skipping doses.

• Prevalence Rates of Morbid Obesity in

Virginia

Sariyamon Tiraphat, M.S., Karen otereo, M.P.H.,

Anna Jeng, Sc.D.

Presented By: Sariyamon Tiraphat, M.S., student, Community and Environmental health,

Old dominion University, 1049 W 49 th Street,

Apt. 324, Norfolk, VA 23508, Phone: 757-489-

2418, Email: stira001@odu.edu

Research Objective: Several factors could contribute to the development of obesity including genetic, hereditary, environmental, metabolic, and eating disorders. However, the specific underlying causes of morbid obesity are still unclear. The identifying of a high-risk group

with morbid obesity to prevent an increased rate and plan useful prevention programs is the issue for consideration. The objective of this present study was to determine the numbers and rates of morbid obesity hospitalization in Virginia by age level, sex and race. The results of this study may assist public health officials or other interested parties in identifying high-risk groups with morbid obesity. The outcome may be useful for developing prevention plans or intervention programs for high-risk groups affected by morbid obesity in the state.

Study Design: Information on morbid obesity hospitalization in 2005 was obtained from the

Virginia Health Information (VHI) database. The records coded ICD-9-CM: 278.01 as the primary diagnosis of morbid obesity were analyzed and rates were calculated based on the U.S. Census

Bureau’s population estimate for the year 2005.

Population Studied: Morbid obesity hospitalization in Virginia 2005.

Principle Findings: 1.In 2005, there were 3,292 hospitalizations for morbid obesity in Virginia; morbid obesity hospitalization discharge annual rate was 4.5 per 10,000 persons. 2.Among the population, women suffer greater morbidity and mortality than men. The hospitalization rate among females was almost seven times higher than the male rate. 3.Working adults between 35-

59 years old have the highest rate and number of hospital discharges, whereas the number of hospital discharges among children younger than 5 years of age and the elderly more than 75 years was zero. 4.Considering the patient’s race,

African-Americans had a dramatically higher rate of hospital discharges compared to all other races , whereas Asians and Hispanics do not have a significant problem of morbid obesity.

Conclusions: 1.The most prevalence of morbid obesity was noticed in females. 2. The disease can be found at a young age (5- 19 years), but the highest incidence was found in working adults between 35-59 years old. 3.The prevalence of the disease varied by race with the highest rate in

African-Americans, whereas Asians had the lowest rate.

Implications for Policy, Practice or Delivery: 1.

Investigate the factors associated with morbid obesity among a specific target population group in Virginia. 2. Study the influence of lifestyle and traditional activity on morbid obesity in different culture.

•

Ambient Air Pollutants in Norfolk City

Sariyamon Tiraphat, M.S., Anna Jeng, Sc.D.


Old Dominion University, 1049 W 49 th Street,

Apt. 324, Norfolk, VA 23508, Phone: 757-489-

2418, Email: stira001@odu.edu

Research Objective: There is a growing concern that exposure to air pollution is associated with increased risk of respiratory morbidity and mortality. To avoid exposure the pollutant at a high level, it is most important to know the pattern and concentrations of the pollutant by time. However, there is limited information on average concentration and the temporal pattern of ambient air pollutants within a community. To lead systematic research on air pollution management at a regional level, this study is to examine pattern of ambient air pollutants in the target area.

Study Design: Hourly ambient air information of CO, NO, NO2, and SO2 for the 4-year period

2001 through 2004 recorded from an air monitoring station in Norfolk, Virginia was obtained from Virginia Department of Health

.We organized and categorized data by month, day, and hour and used SPSS software to calculate and compare mean concentrations of air pollutants in each specific level. Also, we determined and identified their patterns by plotting the graph.

Population Studied: Hourly ambient air information of CO, NO, NO2, and SO2 for the 4year period 2001 through 2004 in Norfolk,

Virginia

Principle Findings: 1.The months with the highest amount pollutants were November and

January with the average concentrations of pollutants average 0.6, 0.008, 0.0028 and 0.02 mg/cm3 of CO, SO2, NO and NO2, respectively; the months with the lowest concentration were

July, August, and September with average readings of Co, SO2, NO and NO2

at 0.107, 0.003, 0.002, and 0.013 mg/cm3, respectively. 2. The day with the lowest concentration of the pollutants was Sunday, whereas Monday, Tuesday, Friday and

Wednesday were found to have the highest concentrations of air pollutants studied. 3.The concentration trend increased and reached its highest value in the early morning hours 06: 00

AM - 07:00 AM, and subsequently decreased and reached its lowest value at 11:00 AM -4:00

PM. afterward, the concentration increased again and reached a high level at 7:00 PM-11:00 PM and later decreased and reached its lowest value at 3:00 AM.

Conclusions: The concentrations of air pollutants are vary by time, then it will be safe for vulnerable to keep away from exposure the pollutants in a high risk time.

Implications for Policy, Practice or Delivery: 1.

The results may be used by the state or other entities to make public policy decisions regarding air pollution management. 2. Future studies are recommended to examine relationships of these pollutants with respiratory disease and mortality in the regional population.

• Economic Evaluation of Cervical Cancer

Screening

Sariyamon Tiraphat, M.S., Henry Zhang, Ph.D.


ODU, 1049 W 49th Street, Apt. 324, Norfolk, VA

23508, Phone: 757-489-2418, Email: stira001@odu.edu

Research Objective: Worldwide, cervical cancer remains a critical public health problem that is third cancer in overall disease burden for women throughout the world .The majority of cervical cancers occur in women who have never been screened or who have not been screened within the past 5 years. Several alternative approaches to cervical cancer screening have been proposed to reduce the morbidity and mortality rates of this disease. However, there have been many debates about the potential effects, costs and outcomes of each screening approach. This paper is to compare screening strategies, based on cost effectiveness criteria.

Study Design: To obtain cost and effectiveness data variables, the researcher surveyed systematic medical literature reviews from medical databases including Medline,

ScienDirect and CINAHL as well as other information resources from, WHO and National

Cancer Institute websites. Average cost and lifeyear saved from relevant 8 research studies were considered. TreeAge Pro Healthcare module is used to build a decision tree based on four decision strategies and created a CEA table.

Strategies were considered to be dominated if they were more costly and less effective in term of life year saved or had a higher costeffectiveness ratio than an adjacent strategy.

Population Studied: Cervical cancer screening including Cytology-Based Screening(Pap Smear

Test),Visual inspection with acetic acid (VIA) screening, Human Papillomavirus Testing (HPV

Testing), HPV tests in combination with Pap tests.

Principle Findings: Compared with no screening, all strategies saved lives, at costs ranging from $655 to $3,858.36 per LYS.

Comparing each strategy with the next least expensive alternative, VIA screening is found the least expensive option and saved the greatest number of lives, with a cost of $655 per LYS.

Conclusions: VIA test is the most costeffectiveness screening.


VIA test may be considered by decision-makers as a dominant test for cervical cancer screening especially in less-developed countries that have limited costs.

•

A Decision Making Model for HealthIT

Carlos Torres, Darrell Burke, Ph.D., Ebrahim

Randeree, Ph.D., Mia Lustria, Ph.D.

Presented By: Carlos Torres, Student, 1468 Twin

Lakes Circle, Tallahassee, FL 32311, Phone: 850-

422-2285, Email: cisfast@comcast.net

Research Objective: In the United States, the adoption of new information systems by health care providers is moving at a slow pace. There are many reasons why health care providers have not converted their data to electronic format.

One of those reasons is the fact that health care providers lack the necessary knowledge needed to decide which information tools they need to integrate into their workplace. Therefore, health care providers need a decision making model to choose an effective and efficient information technology platform.

Study Design: Mixed method or survey

Population Studied: Physicians


Health care providers are now faced with the adoption new information technology systems for various reasons. This research study will aid on the development of a working model that health care providers can turn to when making decisions about which information technology will work best for their practice.

•

Medicare Part D: Understanding the

Process of Policymaking

Michael Tutty, M.H.A.

Presented By: Michael Tutty, M.H.A., Public

Policy Ph.D. Program, University of

Massachusetts Boston, 100 Morrissey

Boulevard, Boston, MA 02125, Phone: (508) 856-

4350, Fax: (508) 856-4456 Email: michael.tutty@umb.edu

Research Objective: On December 8, 2003 the

Medicare Prescription Drug Improvement and

Modernization Act of 2003 was signed into law by President George W. Bush. This legislation added outpatient prescription drug coverage to

Medicare that took effect on January 1, 2006.

How did adding prescription drug coverage to

Medicare get on the policy agenda? Why is this new benefit designed as it is? What is the likelihood of future Medicare Part D policy modification? This paper tracks the policymaking process for this legislation from policy formulation through policy implementation and the future outlook for modification to understand why and how

Medicare Part D became public policy.

Study Design: Policymaking is a cyclical process that starts with policy formulation. This phase has two distinct parts: agenda setting, where the problem is identified, and legislation development, where laws and regulations are passed. After the formal enactment of legislation, there is the policy implementation phase, where rules and polices are established and the law becomes operational. After the policy is implemented, its impacts are measured and evaluated. Depending on the results, the policy may be modified and a new policy formulation process starts. Each of these phases is influenced by the preferences and politics of those impacted by the policy. Based on an extensive literature review, this paper applies the policymaking model against the actions in which Medicare Part D was formulated and implemented, as well as highlights the process for future policy modification.

Population Studied: The populations studied are Medicare beneficiaries, along with the various actors in Medicare Part D policy development including physicians, pharmacies, health insurers, the pharmaceutical industry, and the politicians themselves.

Principle Findings: Health policymaking is not a linear, rational process. However, the process of adding prescription drug coverage to Medicare can be understood using the traditional policymaking model. Certain political events and actors aligned in 2003 to create a window of opportunity for legislation development to add prescription drug coverage to Medicare. Once passed, the Centers for Medicare and Medicaid

Services (CMS) began the implementation phase of policy development where the rules and procedures were established. On January 1,

2006 implementation turned to operation as millions of beneficiaries started to utilize the new benefits of Medicare Part D. With this, the outcomes and impact of Medicare Part D became visible and discussions of policy modification began.

Conclusions: Understanding the health policymaking process through which Medicare

Part D was created allows for insight into the limitations of this new benefit and its reliance on the free market to provide outpatient prescription drugs for Medicare beneficiaries.


Applying the health policymaking framework to

Medicare Part D creates an understanding of how a policy window opened to add prescription drug coverage to Medicare, why it was designed in the way it was, and how it will impact

Medicare beneficiaries and other groups.

Understanding the policy process by which

Medicare Part D was created also allows for a more robust future evaluation, as any health policy can only be fairly judged within the context in which it was made.

• Identifying Health Behaviors in Maritime

Union Members

Susan Tweed, M.S., R.N., Clare Houseman,

Ph.D., R.N., Stacey Plichta, Sc.D.

Presented By: Susan Tweed, M.S., R.N., Health

Educator for Sentara Healthcare, Health Services

Research, Old Dominion University, 3565

Norland Court, Norfolk, VA 23513, Phone: 757-

552-9297, Email: satweed@cox.net

Research Objective: The purpose of the study is to discover the knowledge, beliefs, and attitudes of members of the Hampton Roads Shipping

Association-International Longshoreman

Association (HRSA-ILA) regarding health behaviors and the union’s role in health promotion through participation in a focus group.

Study Design: Five focus groups were held at various locations with a total of 30 participants.

The knowledge, beliefs, and attitudes of longshoremen regarding healthy lifestyles were explored. Snowball sampling was used as the recruitment procedure for participants. All participants were active or retired HRSA-ILA members. Refreshments were provided and each participant was given a $25.00 gift certificate to a local store. A moderator’s guide was developed. The focus groups were facilitated in areas that were familiar to the participants either in their union local or in the benefits administration building. A tent card to record an anonymous name and a demographic

data sheet was provided to each participant. All focus groups were audio taped and transcribed by the researcher. All transcriptions were assessed for accuracy by two independent coders. The transcriptions were hand-coded using the constant comparative method.

Population Studied: Maritime union members of the Hampton Roads Shipping Association -

International Longshoremans Association

Principle Findings: Twenty-nine of the 30 participants completed a demographic profile.

Of these 22(76.8%)were African- American and

7(24.1%)White. The educational level showed

9(31.0) did not complete high school,

11(37.9%)had a high school or GED, 6(20.7)had some post high school, and 3(10.3%)college degree or higher. Marital status showed

2(6.9%)were single, 24(82.8%)married,

19(3.4%)divorced, and 2 (6.9%)widowed. The mean age was 58 with a standard deviation of

12.68. The mean years participants had worked in the union was 25 years with a standard deviation of 12.74. Behaviors reported were

7(24.1%)had used tobacco today,

10(34.5%)participate in sports regularly,

5(17.25)eat 5 servings of fruits and vegetables per day, 17(60.7%)get 30 min of moderate exercise 5 or more days/week, and 11(7.9%)are members of a gym. In regards to attitudes and beliefs

12(41.4%)believed that there was a likelihood of eating 5 servings of fruits and vegetables per day next week, 18(62.1%)believed that there was a likelihood of getting 30 min of moderate exercise

5 or more days next week. Five (17.2%)beleived that eating 5 servings of fruits and vegetables per day and 27(93.1%)getting 30 min of moderate exercise 5 or more days/week is beneficial.

Twenty-eight(96.6%)reported they had a safe place to walk or run. Several themes emerged from the focus groups with maritime union members. In the voices of the longshoremen:

Knowledge About Health - ‘‘…before my heart disease I never sit back and read ---- read about those different kinds of diseases but I wouldn’t know what to do because I ain’t no doctor but I would have kept a closer check on what was going on with my body but after the incident I read and check everything.’’ Eating - ‘‘…you may be out there for a long stretch and they say we really got to get this ship out of here - which means we are going to work through the meal ---- you don’t go eat at all and then you don’t want to take the chance of eating something that’s spoiled.’’ ‘‘…for meals you get in your car and drive off (the shipyard) and go to the fast food places and try to make a good choice. …(on the piers) they have a guy that sells food there but that’s no good - only fast food - hot dogs, hamburgers, cheeseburgers - ain’t no salads.’’

Sleep - ‘‘I might have to be up all night and you get home in the morning and the sun is up so you don’t want to go lay in bed. You sit on the couch for a little while and you start to doze off and then wake up and can’t go back to sleep and you don’t have enough energy to do anything... they will call me in a couple hours and I’ll go back in tonight.’’ Exercise - ‘‘…members can go down to the YMCA, the union pays for that … we can ride bikes, lift weights or whatever helps.’’

‘‘…(now, the) job is a whole lot easier and much more sitting and a lot more riding around and a lot less activity ---- you are wore out, you still go home wore out not muscularly just emotionally fatigued from being out there so long.’’ Stress -

‘‘…there is a constant push to get out ships on time and they pushing to not miss work ---- don’t miss out of your gang ---- work that is scheduled like ours they tell people working 35 hours working longshoreman is like working 50 hours any place else.’’ Inhibiting Factors: Job and

Balance -‘‘…when you go home and lay down...you may have every good intention in the world to get up and work out and fix a nice meal

- then you get a call that you have a ship at midnight that night and that drains any amount of energy you had so you just lay around knowing that you have to go in tonight.’’ Lack of

Routines - ‘‘.. you can’t really have structure, you know 8:00 to 12:00…go to the gym every other day then every Tuesday and Thursday do cardio then the rest of the time lift…it’s just that you don’t know when or where you’re going to be at what time.’’ Enhancing Factors ‘‘…healthy thinking will motivate you to really work even harder.’’ ‘‘…you have to adjust your lifestyle to what you learn and discover along the way. It’s a shame you don’t know what is going on when you are young ---- but nobody does.’’ Influence of

Families - ‘‘…my wife and daughter watch all things I eat ---- a couple of nights ago I tried to snitch a bowl of ice cream and my daughter walked in and just snatched it out of my hand and walked away…I started to say something to her but she was only trying to help me so I left it alone.’’ Peers - ‘‘I think everybody is more health conscious ‘cause it takes somebody to do something to motivate somebody else and then it just takes ---- you wonder why this guy is feeling good all the time and it kind of motivates others.’’ ‘‘…about four years ago every body would be getting a Philly’s steak and cheese and fries - now when we go to Mike’s I bet you at least half of them get a salad with grilled

chicken…a lot of guys are changing over but it’s hard ---- it’s a never ending battle.’’

Conclusions: Participants had good knowledge of healthy eating habits, importance of regular physical activity and its relationship to a healthy lifestyle. The work environment posed many obstacles that are difficult to overcome. Both positive and negative attitudes were expressed related to nutrition and physical activity. Being a maritime union member afforded many positive benefits such as livable wages and excellent health benefits. Participants provided many suggestions for interventions.


Findings from these groups will be used in the development of a survey on health behaviors to elicit attitudes and beliefs of a larger population of union members. The results will be used to develop targeted materials to be incorporated into a comprehensive health promotion program.

Funding Source: Sentara Healthcare

• Health Insurance Status and Emergency

Department Utilization of Young Adults in

Age Group of 19-29

Varun Vaidya, B.S. Pharm

Presented By: Varun Vaidya, B.S. Pharm,

Graduate Student, Health Sceince

Administration, University of Tennessee, 847

Monroe Avenue Suite 226, Memphis, TN 38163,

Phone: (901)448-1763, Email: vvaidya@utmem.edu

Research Objective: The constant growth of the uninsured population is a significant concern and a major challenge for the US health care system. The primary objective of this study is to investigate relationship of health insurance status and emergency department (ED) utilization in young adults (age group 19-29).

Study Design: This study utilized 2003 Medical

Expenditure Panel Survey (MEPS) data. All variables of interest (ED visits, Insurance status, demographic variables) were identified from the

‘house hold component' of MEPS. Multiple logistic regression analysis was used to estimate likelihood of visiting ED and being uninsured in various age categories.

Population Studied: Young adults in the age group of 19-29.

Principle Findings: 10.4 million Individuals in the age group 19-29 were identified not having health insurance coverage for the entire year.

Within uninsured population, young adults had higher ED utilization in terms of number of ED visits compared to other age groups, accounting for 35% of total ED visits in uninsured population. The young adults had a noticeably higher likelihood to visit ED compared to all other age groups. (OR: 1.383 CI: 1.381-1.384)

Inclusion of interaction effects between insurance status and age groups, demonstrated young adults with public insurance are more likely to visit ED than privately insured or uninsured young adults. (OR: 1.133 CI: 1.13-1.136)

Conclusions: This study found that the young adults in age group 19-29 have a significantly higher rate of uninsurance compared to all other age categories. The young adults utilize more ED in terms of number of visits relative to all other age groups. Strong interaction effects were observed between age categories and insurance status. Public insurance has a very high likelihood of ED visit across all age groups compared to the insured individuals. Uninsured tend to use less care across the board including

ED visits. However young adults and children use more ED care relative to insured adults.


Linking of the young adults to the medical homes could be one the effective ways to cut down the burden on heavily crowded EDs.

Extending Medicaid’s eligibility could be one of the possible ways to decrease number of uninsured individuals in young population but it might not be helpful in reducing the use of ED care

• Exploration of Predictors for Flu Shots among Asthmatics in Virginia

Soji Varghese, Masters, Mathew John, Masters

Presented By: Soji Varghese, Masters, Student,

Community Health, Old Dominion University,

Hampton Boulevard, Norfolk, VA 23529, Email: svarg003@odu.edu

Research Objective: Asthmatics are at high risk of complications due to influenza. The National

Asthma Education and Prevention program has identified influenza vaccination as one of the key factors essential for quality care in asthmatics. In spite of the availability of a safe and effective vaccine against influenza, there has been a gradual decrease in the immunization rates for flu among general population with only approximately only one third of asthmatics receiving a flu shot according to National Health

Interview Survey. This study examines the factors that may be associated with obtaining flu shots using the Anderson model of predisposing, enabling and need factors.

Study Design: Secondary data analysis of the

2002 Behavioral Risk Factor Surveillance System data for the state of Virginia. The BRFSS is conducted by CDC and is a self-reported data from retrospective, observational cross-sectional study.

Population Studied: All survey respondents of above 18 years of age who self identified as having asthma were included (n=450). Overall the group consisted of 29% males, 65.8%

Caucasians, more than 22% African Americans, others including Hispanics was nearly 12%.

Mean age of the participants was 55 years.

Principle Findings: Predisposing, enabling and need factors were all associated with obtaining a flu shot. Those who were older, had health care coverage and a person with a personal healthcare provider were more likely to obtain a flu shot as did those who rated their own health status as poor.

Conclusions: Implementation of door-to-door flu shot campaigns for asthmatics and organization of free clinics delivering flu shot for asthmatics are possible interventions for poor health care coverage and absence of a health care provider.


Public health policy of mandatory flu shot immunization of asthmatics.

•

Do Post-Operative Complications Vary by

Hospital Teaching Status?

Smruti Vartak, M.P.H., Marcia M Ward, Ph.D.,

Thomas E Vaughn, Ph.D.

Presented By: Smruti Vartak, M.P.H., Research

Assistant, Department of Health Management and Policy, University Of Iowa, 5229 Westlawn,

Iowa City, IA 52242, Phone: 319-335-8713, Email: smruti-vartak@uiowa.edu

Research Objective: To assess post-operative patient safety outcomes across teaching and non-teaching hospitals and to examine the relation of hospital and patient factors to patient safety outcomes.

Study Design: The Nationwide Inpatient Sample and American Hospital Association annual survey data were used for analyses. Patient safety indicators (PSI) developed by the Agency for Healthcare Research and Quality (AHRQ) were used to identify six post-operative PSIs.

The specific PSIs analyzed were ---- Post-operative hip fracture (PSI-08), Post-operative hematoma or hemorrhage (PSI-09), Post-operative physiometabolic derangement (PSI-10), Post-operative respiratory failure (PSI-11), Post-operative pulmonary embolism or deep vein thrombosis

(PSI-12), and Post-operative sepsis (PSI-13).

The study sample consisted of 646 acute care hospitals, divided into non-teaching (N=400), minor teaching (N=207) and major teaching hospitals (N=39). The unit of analysis was the patients. Associations between hospital teaching status and patient and hospital characteristics were determined using one-way

ANOVA and Pearson chi-square test.

Generalized estimating equation (GEE) regression models were used for multivariable analysis to adjust for clustering of patients within hospitals. Non-teaching hospitals were used as a reference group.

Population Studied: The study sample consisted of 646 acute care hospitals, divided into non-teaching (N=400), minor teaching

(N=207) and major teaching hospitals (N=39).

Principle Findings: Bivariate results showed higher observed PSI rates at major teaching hospitals. Results from multivariable analyses, after adjusting for hospital size, staffing variables, patient case mix, and other risk factors, showed that major teaching hospitals had significantly higher odds of post-operative pulmonary embolism or deep vein thrombosis and post-operative sepsis, lower odds of postoperative respiratory failure, and showed no difference for post-operative hip fracture, postoperative hematoma or hemorrhage, and postoperative physio-metabolic derangement. The results also showed that many of the patient and hospital characteristics were related to the postoperative PSI rates.

Conclusions: The present analysis found an inconsistent relationship between teaching status and post-operative patient safety event rates. Teaching status of the hospital was associated with numerous hospital and patient characteristics which mediate the relationship between teaching status and patient safety indicators.


The results do confirm that teaching hospitals perform more complicated procedures and do treat sicker patients. While these patient characteristics cannot and should not be changed, teaching hospitals may reduce postoperative complications by better assessing the risk for each patient and applying appropriate preventive measures. One other implication of the current findings for the complex relationship among hospital and patient characteristics is apropos to emerging pay-for-performance initiatives. Such initiatives must carefully take multiple patient characteristics along with

hospital structure into consideration so that incentives fairly reward appropriate quality indicators.


• Location, Location, Location: The

Distribution of Peritoneal Dialysis Services in the United States

Virginia Wang, M.S.P.H., Shoou-Yih Daniel Lee,

Ph.D.

Presented By: Virginia Wang, M.S.P.H.,

Doctoral Student, AHRQ/NRSA Predoctoral

Fellow, Department of Health Policy &

Administration, University of North Carolina-

Chapel Hill, CB #7411, Chapel Hill, NC 27599-

7411, Phone: (919) 593-2832, Fax: (919) 966-6961

Email: virginia.wang@unc.edu

Research Objective: The development of peritoneal dialysis (PD) offered the promise of a convenient, clinically effective, and less expensive alternative to hemodialysis (HD), the dominant form of renal therapy for end-stage renal disease

(ESRD). Studies demonstrated the apparent superiority of PD for ESRD patients, providers, and payers. In 1983, the Medicare program enacted a payment policy that would promote the use of PD. However, diffusion of PD has been limited. While six percent of US ESRD patients were newly treated with PD, Asian and

European countries reported up to 82 percent

PD incidence in 2003. Despite a significant preference for PD among patients and physicians, the low utilization of PD suggests that the provision of PD services in the US deserves greater scrutiny. This study examines the availability and distribution of PD services among dialysis facilities in the US and addresses the question: Are PD therapies available in areas where they are presumably needed most?

Study Design: This study uses national, longitudinal data on ESRD patients and provider organizations from the US Renal Data System and the Centers for Medicare and Medicaid

Services. Choropleth maps display the spatial distribution of PD service availability in the US between 1994 and 2003. Patterns of PD service availability over time are also examined in relation to ESRD incidence and prevalence rates, as well as patients’ locale, age, and employment demographics.

Population Studied: The study population includes all patients and outpatient dialysis facilities participating in the Medicare ESRD program between 1994 and 2003. Excluded from the analysis are inpatient dialysis and transplant only providers, as well as patients and facilities located outside the 50 US states.

Principle Findings: Overall, the numbers of facilities offering any form of PD services increased, but the proportion of US facilities offering PD services decreased from 54.7 percent

(n=1,387) in 1994 to 45.5 percent (n=2,016) of facilities in 2003. During the study period, the highest ESRD incidence and prevalence rates are found in the west and southwestern states, which have the fewest numbers of facilities offering any type of PD service. In contrast, the

Northeast has the highest proportion and the steadiest number of facilities with PD services, but the lowest ESRD prevalence rates in the country.

Conclusions: Location of PD service availability is not congruent with locations of ESRD patient populations.


Medicare’s near-universal provision of dialysis treatment to a growing population with ESRD in the current health care environment ---- marked by limited resources, inequalities in access, and growing concern about quality ---- makes dialysis an important area for research. When all societal costs are considered, PD may be less costly than

HD. Starting more patients on PD would not only curtail Medicare’s costs considerably, but would also better align ESRD care with patient preferences. By understanding how PD services are distributed over time, health planners and policymakers can determine the extent to which

PD is accessible to ESRD patients.


•

Erythromycin Prior to EGD for Acute Upper

GI Hemorrhage: A Cost-Effectiveness Analysis

Nathaniel Winstead, M.D., M.S., C. Mel Wilcox,

M.D.

Presented By: Nathaniel Winstead, M.D., M.S.,

Post Doctoral Fellow, Health Services Research

Training Program, University of Alabama-

Birmingham, 703 South 19th Street,

Birmingham, AL 35294, Phone: 205-996-2877,

Fax: 205-934-0777 Email: twinstead@uab.edu

Research Objective: Erythromycin is a potent stimulator of gastrointestinal motility. Recent studies have examined the use of intravenous

(IV) erythromycin to empty the stomach prior to esophagogastroduodenoscopy (EGD) for acute upper gastrointestinal (GI) hemorrhage. These studies have focused on clinical and endoscopic endpoints but cost-effectiveness of this intervention has not been evaluated.

Study Design: We performed a PUBMED search for studies evaluating the use of IV erythromycin prior to EGD for acute upper GI hemorrhage.

Three studies were located and outcomes data from these studies were used for costeffectiveness analysis. We also obtained costs for

IV erythromycin ($30.55) from the peer-reviewed literature, and charges for EGD ($400) and surgery ($15,000) from the 2006 Medicare fee schedule. When necessary, costs were converted to 2006 US dollars. Probabilities of need for second-look EGD were obtained from a pooled analysis of the available studies (0.176 with and

0.310 without). Probability of perforation and surgery was obtained from the medical literature

(0.0002). We created a decision-analysis tree using these probabilities and costs and performed cost-effectiveness analysis, one-way sensitivity analysis and Monte Carlo simulation using TreePlan software.

Principle Findings: One-way sensitivity analysis showed that a strategy of erythromycin prior to

EGD was cost-effective when the cost of EGD was greater than $226.70, cost of erythromycin was less than $53.58, probability of second-look

EGD with erythromycin was less than 0.24, and probability of second-look EGD without erythromycin was greater than 0.25. Because of uncertainty surrounding the point estimates of probability of second-look EGD and perforation, heterogeneity of costs of erythromycin, EGD, and surgery, we performed a Monte Carlo simulation using 1000 sampled data points. This simulation showed an average cost savings of $20.42 (95%

CI $19.50-$21.34) when erythromycin was given prior to EGD for acute upper GI hemorrhage.

Conclusions: Erythromycin prior to EGD for acute upper GI hemorrhage is cost-effective and results in modest cost savings.


Because of cost savings and potential of avoiding morbidity and mortality of additional, preventable procedures, IV erythromycin should be considered before EGD for acute upper GI hemorrhage.


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