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Selected AbstractsMental Illness and Length of Inpatient Stay for Medicaid Recipients with AIDSHEALTH SERVICES RESEARCH, Issue 5 2004Donald R. Hoover Objective. To examine the associations between comorbid mental illness and length of hospital stays (LOS) among Medicaid beneficiaries with AIDS. Data Source and Collection/Study Setting. Merged 1992,1998 Medicaid claims and AIDS surveillance data obtained from the State of New Jersey for adults with ,1 inpatient stay after an AIDS diagnosis from 1992 to 1996. Study Design. Observational study of 6,247 AIDS patients with 24,975 inpatient visits. Severe mental illness (SMI) and other less severe mental illness (OMI) diagnoses at visits were ascertained from ICD,9 Codes. About 4 percent of visits had an SMI diagnosis; 5 percent had an OMI diagnosis; 43 percent did not have a mental illness diagnosis, but were patients who had been identified as having an SMI or OMI history; and 48 percent were from patients with no identified history of mental illness. Principal Findings. The overall mean hospital LOS was 12.7 days. After adjusting for measures of HIV disease severity and health care access in multivariate models, patients presenting with primary and secondary severe mental illness (SMI) diagnoses had ,32 percent and ,11 percent longer LOS, respectively, than did similar patients without a mental illness history (p<0.001 for each). But in these adjusted models of length of stay: (1) diagnosis of OMI was not related to LOS, and (2) in the absence of a mental illness diagnosed at the visit, an identified history of either SMI or OMI was also not related to LOS. In adjusted models of time to readmission for a new visit, current diagnosis of SMI or OMI and in the absences of a current diagnosis, history of SMI or OMI all tended to be associated with quicker readmission. Conclusions. This study finds greater (adjusted) LOS for AIDS patients diagnosed with severe mental illness (but not for those diagnosed with less severe mental comorbidity) at a visit. The effect of acute severe mental illness on hospitalization time may be comparable to that of an acute AIDS opportunistic illness. While previous research raises concerns that mental illness increases LOS by interfering with treatment of HIV conditions, the associations here may simply indicate that extra time is needed to treat severe mental illnesses or arrange for discharge of afflicted patients. [source] Use of Outpatient Care in Veterans Health Administration and Medicare among Veterans Receiving Primary Care in Community-Based and Hospital Outpatient ClinicsHEALTH SERVICES RESEARCH, Issue 5p1 2010Chuan-Fen Liu Objective. To examine differences in use of Veterans Health Administration (VA) and Medicare outpatient services by VA primary care patients. Data Sources/Study Setting. VA administrative and Medicare claims data from 2001 to 2004. Study Design. Retrospective cohort study of outpatient service use by 8,964 community-based and 6,556 hospital-based VA primary care patients. Principal Findings. A significant proportion of VA patients used Medicare-reimbursed primary care (>30 percent) and specialty care (>60 percent), but not mental health care (3,4 percent). Community-based patients had 17 percent fewer VA primary care visits (p<.001), 9 percent more Medicare-reimbursed visits (p<.001), and 6 percent fewer total visits (p<.05) than hospital-based patients. Community-based patients had 22 percent fewer VA specialty care visits (p<.0001) and 21 percent more Medicare-reimbursed specialty care visits (p<.0001) than hospital-based patients, but no difference in total visits (p=.80). Conclusions. Medicare-eligible VA primary care patients followed over 4 consecutive years used significant primary care and specialty care outside of VA. Community-based patients offset decreased VA use with increased service use paid by Medicare, suggesting that increasing access to VA primary care via community clinics may fragment veteran care in unintended ways. Coordination of care between VA and non-VA providers and health care systems is essential to improve the quality and continuity of care. [source] Employed Family Physician Satisfaction and Commitment to Their Practice, Work Group, and Health Care OrganizationHEALTH SERVICES RESEARCH, Issue 2 2010Ben-Tzion Karsh Objective. Test a model of family physician job satisfaction and commitment. Data Sources/Study Setting. Data were collected from 1,482 family physicians in a Midwest state during 2000,2001. The sampling frame came from the membership listing of the state's family physician association, and the analyzed dataset included family physicians employed by large multispecialty group practices. Study Design and Data Collection. A cross-sectional survey was used to collect data about physician working conditions, job satisfaction, commitment, and demographic variables. Principal Findings. The response rate was 47 percent. Different variables predicted the different measures of satisfaction and commitment. Satisfaction with one's health care organization (HCO) was most strongly predicted by the degree to which physicians perceived that management valued and recognized them and by the extent to which physicians perceived the organization's goals to be compatible with their own. Satisfaction with one's workgroup was most strongly predicted by the social relationship with members of the workgroup; satisfaction with one's practice was most strongly predicted by relationships with patients. Commitment to one's workgroup was predicted by relationships with one's workgroup. Commitment to one's HCO was predicted by relationships with management of the HCO. Conclusions. Social relationships are stronger predictors of employed family physician satisfaction and commitment than staff support, job control, income, or time pressure. [source] Public Health Emergency Preparedness at the Local Level: Results of a National SurveyHEALTH SERVICES RESEARCH, Issue 5p2 2009Elena Savoia Objective. To study the relationship between elements of public health infrastructure and local public health emergency preparedness (PHEP). Data Sources/Study Setting. National Association of County and City Health Officials 2005 National Profile of Local Health Departments (LHDs). Study Design. Cross-sectional. Principal Findings. LHDs serving larger populations are more likely to have staff, capacities, and activities in place for an emergency. Adjusting for population size, the presence of a local board of health and the LHDs' experience in organizing PHEP coalitions were associated with better outcomes. Conclusions. The results of this study suggest that more research should be conducted to investigate the benefit of merging small health departments into coalitions to overcome the inverse relationship between preparedness and population size of the jurisdiction served by the LHD. [source] The American Community Survey and Health Insurance Coverage Estimates: Possibilities and Challenges for Health Policy ResearchersHEALTH SERVICES RESEARCH, Issue 2p1 2009Michael Davern Objective. To introduce the American Community Survey (ACS) and its measure of health insurance coverage to researchers and policy makers. Data Sources/Study Setting. We compare the survey designs for the ACS and Current Population Survey (CPS) that measure insurance coverage. Study Design. We describe the ACS and how it will be useful to health policy researchers. Principal Findings. Relative to the CPS, the ACS will provide more precise state and substate estimates of health insurance coverage at a point-in-time. Yet the ACS lacks the historical data and detailed state-specific coverage categories seen in the CPS. Conclusions. The ACS will be a critical new resource for researchers. To use the new data to the best advantage, careful research will be needed to understand its strengths and weaknesses. [source] Effect of Evidence-Based Acute Pain Management Practices on Inpatient CostsHEALTH SERVICES RESEARCH, Issue 1 2009John M. Brooks Objectives. To estimate hospital cost changes associated with a behavioral intervention designed to increase the use of evidence-based acute pain management practices in an inpatient setting and to estimate the direct effect that changes in evidence-based acute pain management practices have on inpatient cost. Data Sources/Study Setting. Data from a randomized "translating research into practice" (TRIP) behavioral intervention designed to increase the use of evidence-based acute pain management practices for patients hospitalized with hip fractures. Study Design. Experimental design and observational "as-treated" and instrumental variable (IV) methods. Data Collection/Extraction Methods. Abstraction from medical records and Uniform Billing 1992 (UB92) discharge abstracts. Principal Findings. The TRIP intervention cost on average $17,714 to implement within a hospital but led to cost savings per inpatient stay of more than $1,500. The intervention increased the cost of nursing services, special operating rooms, and therapy services per inpatient stay, but these costs were more than offset by cost reductions within other cost categories. "As-treated" estimates of the effect of changes in evidence-based acute pain management practices on inpatient cost appear significantly underestimated, whereas IV estimates are statistically significant and are distinct from, but consistent with, estimates associated with the intervention. Conclusions. A hospital treating more that 12 patients with acute hip fractures can expect to lower overall cost by implementing the TRIP intervention. We also demonstrated the advantages of using IV methods over "as-treated" methods to assess the direct effect of practice changes on cost. [source] Revealing and Resolving Patient Safety Defects: The Impact of Leadership WalkRounds on Frontline Caregiver Assessments of Patient SafetyHEALTH SERVICES RESEARCH, Issue 6 2008Allan Frankel Objective. To evaluate the impact of rigorous WalkRounds on frontline caregiver assessments of safety climate, and to clarify the steps and implementation of rigorous WalkRounds. Data Sources/Study Setting. Primary outcome variables were baseline and post WalkRounds safety climate scores from the Safety Attitudes Questionnaire (SAQ). Secondary outcomes were safety issues elicited through WalkRounds. Study period was August 2002 to April 2005; seven hospitals in Massachusetts agreed to participate; and the project was implemented in all patient care areas. Study Design. Prospective study of the impact of rigorously applied WalkRounds on frontline caregivers assessments of safety climate in their patient care area. WalkRounds were conducted weekly and according to the seven-step WalkRounds Guide. The SAQ was administered at baseline and approximately 18 months post-WalkRounds implementation to all caregivers in patient care areas. Results. Two of seven hospitals complied with the rigorous WalkRounds approach; hospital A was an academic teaching center and hospital B a community teaching hospital. Of 21 patient care areas, SAQ surveys were received from 62 percent of respondents at baseline and 60 percent post WalkRounds. At baseline, 10 of 21 care areas (48 percent) had safety climate scores below 60 percent, whereas post-WalkRounds three care areas (14 percent) had safety climate scores below 60 percent without improving by 10 points or more. Safety climate scale scores in hospital A were 62 percent at baseline and 77 percent post-WalkRounds (t=2.67, p=.03), and in hospital B were 46 percent at baseline and 56 percent post WalkRounds (t=2.06, p=.06). Main safety issues by category were equipment/facility (A [26 percent] and B [33 percent]) and communication (A [24 percent] and B [18 percent]). Conclusions. WalkRounds implementation requires significant organizational will; sustainability requires outstanding project management and leadership engagement. In the patient care areas that rigorously implemented WalkRounds, frontline caregiver assessments of patient safety increased. SAQ results such as safety climate scores facilitate the triage of quality improvement efforts, and provide consensus assessments of frontline caregivers that identify themes for improvement. [source] Power of Tests for a Dichotomous Independent Variable Measured with ErrorHEALTH SERVICES RESEARCH, Issue 3 2008Daniel F. McCaffrey Objective. To examine the implications for statistical power of using predicted probabilities for a dichotomous independent variable, rather than the actual variable. Data Sources/Study Setting. An application uses 271,479 observations from the 2000 to 2002 CAHPS Medicare Fee-for-Service surveys. Study Design and Data. A methodological study with simulation results and a substantive application to previously collected data. Principle Findings. Researchers often must employ key dichotomous predictors that are unobserved but for which predictions exist. We consider three approaches to such data: the classification estimator (1); the direct substitution estimator (2); the partial information maximum likelihood estimator (3, PIMLE). The efficiency of (1) (its power relative to testing with the true variable) roughly scales with the square of one less the classification error. The efficiency of (2) roughly scales with the R2 for predicting the unobserved dichotomous variable, and is usually more powerful than (1). Approach (3) is most powerful, but for testing differences in means of 0.2,0.5 standard deviations, (2) is typically more than 95 percent as efficient as (3). Conclusions. The information loss from not observing actual values of dichotomous predictors can be quite large. Direct substitution is easy to implement and interpret and nearly as efficient as the PIMLE. [source] The Adequacy of Household Survey Data for Evaluating the Nongroup Health Insurance MarketHEALTH SERVICES RESEARCH, Issue 4 2007Joel C. Cantor Objective. To evaluate the accuracy of household survey estimates of the size and composition of the nonelderly population covered by nongroup health insurance. Data Sources/Study Setting. Health insurance enrollment statistics reported to New Jersey insurance regulators. Household data from the following sources: the 2002 Current Population Survey (CPS)-March Demographic Supplement, the 1997 and 1999 National Surveys of America's Families (NSAF), the 2001 New Jersey Family Health Survey (NJFHS), a 2002 survey of known nongroup health insurance enrollees, a small 2004 survey testing alternative health insurance question wording. Study Design. To assess the extent of bias in estimates of the size of the nongroup health insurance market in New Jersey, enrollment trends are compared between official enrollment statistics reported by insurance carriers to state insurance regulators with estimates from three general population household surveys. Next, to evaluate possible bias in the demographic and socioeconomic composition of the New Jersey nongroup market, distributions of characteristics of the enrolled population are contrasted among general household surveys and a survey of known nongroup subscribers. Finally, based on inferences drawn from these comparisons, alternative health insurance question wording was developed and tested in a local survey to test the potential for misreporting enrollment in nongroup coverage in a low-income population. Data Collection/Extraction Methods. Data for nonelderly New Jersey residents from the 2002 CPS (n=5,028) and the 1997 and 1999 NSAF (n=6,467 and 7,272, respectively) were obtained from public sources. The 2001 NJFHS (n=5,580 nonelderly) was conducted for a sample drawn by random digit dialing and employed computer-assisted telephone interviews and trained, professional interviewers. Sampling weights are used to adjust for under-coverage of households without telephones and other factors. In addition, a modified version of the NJFHS was administered to a 2002 sample of known nongroup subscribers (n=1,398) using the same field methods. These lists were provided by four of the five largest New Jersey nongroup insurance carriers, which represented 95 percent of all nongroup enrollees in the state. Finally, a modified version of the NJFHS questionnaire was fielded using similar methods as part of a local health survey in New Brunswick, New Jersey, in 2004 (n=1,460 nonelderly). Principal Findings. General household sample surveys, including the widely used CPS, yield substantially higher estimates of nongroup enrollment compared with administrative totals and yield estimates of the characteristics of the nongroup population that vary greatly from a survey of known nongroup subscribers. A small survey testing a question about source of payment for direct-purchased coverage suggests than many public coverage enrollees report nongroup coverage. Conclusions. Nongroup health insurance has been subject to more than a decade of reform and is of continuing policy interest. Comparisons of unique data from a survey of known nongroup subscribers and administrative sources to household surveys strongly suggest that the latter overstates the number and misrepresent the composition of the nongroup population. Research on the nongroup market using available sources should be interpreted cautiously and survey methods should be reexamined. [source] Development of an Algorithm to Identify Pregnancy Episodes in an Integrated Health Care Delivery SystemHEALTH SERVICES RESEARCH, Issue 2 2007Mark C. Hornbrook Objective. To develop and validate a software algorithm to detect pregnancy episodes and maternal morbidities using automated data. Data Sources/Study Setting. Automated records from a large integrated health care delivery system (IHDS), 1998,2001. Study Design. Through complex linkages of multiple automated information sources, the algorithm estimated pregnancy histories. We evaluated the algorithm's accuracy by comparing selected elements of the pregnancy history obtained by the algorithm with the same elements manually abstracted from medical records by trained research staff. Data Collection/Extraction Methods. The algorithm searched for potential pregnancy indicators within diagnosis and procedure codes, as well as laboratory tests, pharmacy dispensings, and imaging procedures associated with pregnancy. Principal Findings. Among 32,847 women with potential pregnancy indicators, we identified 24,680 pregnancies occuring to 21,001 women. Percent agreement between the algorithm and medical records review on pregnancy outcome, gestational age, and pregnancy outcome date ranged from 91 percent to 98 percent. The validation results were used to refine the algorithm. Conclusions. This pregnancy episode grouper algorithm takes advantage of databases readily available in IHDS, and has important applications for health system management and clinical care. It can be used in other settings for ongoing surveillance and research on pregnancy outcomes, pregnancy-related morbidities, costs, and care patterns. [source] Health Care Markets, the Safety Net, and Utilization of Care among the UninsuredHEALTH SERVICES RESEARCH, Issue 1p1 2007Carole Roan Gresenz Objective. To quantify the relationship between utilization of care among the uninsured and the structure of the local health care market and safety net. Data Sources/Study Setting. Nationally representative data from the 1996 to 2000 waves of the Medical Expenditure Panel Survey (MEPS) linked to data from multiple secondary sources. Study Design. We separately analyze outpatient care utilization and whether an individual incurred any medical expenditure among uninsured adults living in urban and rural areas. Safety net measures include distances between each individual and the nearest safety net providers as well as a measure of capacity based on local government and hospital health expenditures. Other covariates include the managed care presence in the local health care market, the percentage of individuals who are uninsured in the area, and local primary care physician supply. We simulate utilization using standardized predictions. Principal Findings. Distances between the rural uninsured and safety net providers are significantly associated with utilization. In urban areas, we find that the percentage of individuals in the area who are uninsured, the pervasiveness and competitiveness of managed care, the primary care physician supply, and safety net capacity have a significant relationship with health care utilization. Conclusions. Facilitating transport to safety net providers and increasing the number of such providers are likely to increase utilization of care among the rural uninsured. Our findings for urban areas suggest that the uninsured living in areas where managed care presence is substantial, and especially where managed care competition is limited, could be a target for policies to improve the ability of the uninsured to obtain care. Policies oriented toward enhancing funding for the safety net and increasing the capacity of safety net providers are likely to be important to ensuring the urban uninsured are able to obtain health care. [source] Application of Regression-Discontinuity Analysis in Pharmaceutical Health Services ResearchHEALTH SERVICES RESEARCH, Issue 2 2006Ilene H. Zuckerman Objective. To demonstrate how a relatively underused design, regression-discontinuity (RD), can provide robust estimates of intervention effects when stronger designs are impossible to implement. Data Sources/Study Setting. Administrative claims from a Mid-Atlantic state Medicaid program were used to evaluate the effectiveness of an educational drug utilization review intervention. Study Design. Quasi-experimental design. Data Collection/Extraction Methods. A drug utilization review study was conducted to evaluate a letter intervention to physicians treating Medicaid children with potentially excessive use of short-acting ,2 -agonist inhalers (SAB). The outcome measure is change in seasonally-adjusted SAB use 5 months pre- and postintervention. To determine if the intervention reduced monthly SAB utilization, results from an RD analysis are compared to findings from a pretest,posttest design using repeated-measure ANOVA. Principal Findings. Both analyses indicated that the intervention significantly reduced SAB use among the high users. Average monthly SAB use declined by 0.9 canisters per month (p<.001) according to the repeated-measure ANOVA and by 0.2 canisters per month (p<.001) from RD analysis. Conclusions. Regression-discontinuity design is a useful quasi-experimental methodology that has significant advantages in internal validity compared to other pre,post designs when assessing interventions in which subjects' assignment is based on cutoff scores for a critical variable. [source] Psychometric Properties of the Dutch Version of the Hospital-Level Consumer Assessment of Health Plans Survey® InstrumentHEALTH SERVICES RESEARCH, Issue 1 2006Onyebuchi A. Arah Objectives. To assess the reliability and validity of a translated version of the American Hospital-level Consumer Assessment of Health Plans Survey® (H-CAHPS) instrument for use in Dutch health care. Data Sources/Study Setting. Primary survey data from adults aged 18 years or more who were recently discharged from two multispecialty city hospitals in the Netherlands. Study Design. We used forward and backward translation procedures and a panel of experts to adapt the 66-item pilot H-CAHPS into a 70-item Dutch instrument. Descriptive statistics and standard psychometric methods were then used to test the reliability and validity of the new instrument. Data Collection. From late November 2003 to early January 2004, the survey was administered by mail to 1,996 patients discharged within the previous 2 months. Principal Findings. Analyses supported the reliability and validity of the following 7-factor H-CAHPS structure for use in Dutch hospitals: on doctor's communication, nurses' communication, discharge information, communication about medication, pain control, physical environment of hospital, and nursing services. The internal consistency reliability of the scales ranged from 0.60 to 0.88. Items related to "family receiving help when on visit,""hospital staff introducing self," and "admission delays" did not improve the psychometric properties of the new instrument. Conclusions. These findings suggest that the H-CAHPS instrument is reliable and valid for use in the Dutch context. However, more research will be needed to support its equivalence to the United States version, and its use for between-hospital comparisons. [source] The Impact of Medicaid Managed Care on Pregnant Women in Ohio: A Cohort AnalysisHEALTH SERVICES RESEARCH, Issue 4p1 2004Embry M. Howell Objective. To examine the impact of mandatory HMO enrollment for Medicaid-covered pregnant women on prenatal care use, smoking, Cesarean section (C-section) use, and birth weight. Data Sources/Study Setting. Linked birth certificate and Medicaid enrollment data from July 1993 to June 1998 in 10 Ohio counties, 6 that implemented mandatory HMO enrollment, and 4 with low levels of voluntary enrollment (under 15 percent). Cuyahoga County (Cleveland) is analyzed separately; the other mandatory counties and the voluntary counties are grouped for analysis, due to small sample sizes. Study Design. Women serve as their own controls, which helps to overcome the bias from unmeasured variables such as health beliefs and behavior. Changes in key outcomes between the first and second birth are compared between women who reside in mandatory HMO enrollment counties and those in voluntary enrollment counties. County of residence is the primary indicator of managed care status, since, in Ohio, women are allowed to "opt out" of HMO enrollment in mandatory counties in certain circumstances, leading to selection. As a secondary analysis, we compare women according to their HMO enrollment status at the first and second birth. Data Collection/Extraction Methods. Linked birth certificate/enrollment data were used to identify 4,917 women with two deliveries covered by Medicaid, one prior to the implementation of mandatory HMO enrollment (mid-1996) and one following implementation. Data for individual births were linked over time using a scrambled maternal Medicaid identification number. Principal Findings. The effects of HMO enrollment on prenatal care use and smoking were confined to Cuyahoga County, Ohio's largest county. In Cuyahoga, the implementation of mandatory enrollment was related to a significant deterioration in the timing of initiation of care, but an improvement in the number of prenatal visits. In that county also, women who smoked in their first pregnancy were less likely to smoke during the second pregnancy, compared to women in voluntary counties. Women residing in all the mandatory counties were less likely to have a repeat C-section. There were no effects on infant birth weight. The effects of women's own managed care status were inconsistent depending on the outcome examined; an interpretation of these results is hampered by selection issues. Changes over time in outcomes, both positive and negative, were more pronounced for African American women. Conclusions. With careful implementation and attention to women's individual differences as in Ohio, outcomes for pregnant women may improve with Medicaid managed care implementation. Quality monitoring should continue as Medicaid managed care becomes more widespread. More research is needed to identify the types of health maintenance organization activities that lead to improved outcomes. [source] Measuring the Quality of Diabetes Care Using Administrative Data: Is There Bias?HEALTH SERVICES RESEARCH, Issue 6p1 2003Nancy L. Keating Objectives. Health care organizations often measure processes of care using only administrative data. We assessed whether measuring processes of diabetes care using administrative data without medical record data is likely to underdetect compliance with accepted standards for certain groups of patients. Data Sources/Study Setting. Assessment of quality indicators during 1998 using administrative and medical records data for a cohort of 1,335 diabetic patients enrolled in three Minnesota health plans. Study Design. Cross-sectional retrospective study assessing hemoglobin A1c testing, LDL cholesterol testing, and retinopathy screening from the two data sources. Analyses examined whether patient or clinic characteristics were associated with underdetection of quality indicators when administrative data were not supplemented with medical record data. Data Collection/Extraction Methods. The health plans provided administrative data, and trained abstractors collected medical records data. Principal Findings. Quality indicators that would be identified if administrative data were supplemented with medical records data are often not identified using administrative data alone. In adjusted analyses, older patients were more likely to have hemoglobin A1c testing underdetected in administrative data (compared to patients <45 years, OR 2.95, 95 percent CI 1.09 to 7.96 for patients 65 to 74 years, and OR 4.20, 95 percent CI 1.81 to 9.77 for patients 75 years and older). Black patients were more likely than white patients to have retinopathy screening underdetected using administrative data (2.57, 95 percent CI 1.16 to 5.70). Patients in different health plans also differed in the likelihood of having quality indicators underdetected. Conclusions. Diabetes quality indicators may be underdetected more frequently for elderly and black patients and the physicians, clinics, and plans who care for such patients when quality measurement is based on administrative data alone. This suggests that providers who care for such patients may be disproportionately affected by public release of such data or by its use in determining the magnitude of financial incentives. [source] Case-Mix Adjusting Performance Measures in a Veteran Population: Pharmacy- and Diagnosis-Based ApproachesHEALTH SERVICES RESEARCH, Issue 5 2003Chuan-Fen Liu Objective. To compare the rankings for health care utilization performance measures at the facility level in a Veterans Health Administration (VHA) health care delivery network using pharmacy- and diagnosis-based case-mix adjustment measures. Data Sources/Study Setting. The study included veterans who used inpatient or outpatient services in Veterans Integrated Service Network (VISN) 20 during fiscal year 1998 (October 1997 to September 1998; N=126,076). Utilization and pharmacy data were extracted from VHA national databases and the VISN 20 data warehouse. Study Design. We estimated concurrent regression models using pharmacy or diagnosis information in the base year (FY1998) to predict health service utilization in the same year. Utilization measures included bed days of care for inpatient care and provider visits for outpatient care. Principal Findings. Rankings of predicted utilization measures across facilities vary by case-mix adjustment measure. There is greater consistency within the diagnosis-based models than between the diagnosis- and pharmacy-based models. The eight facilities were ranked differently by the diagnosis- and pharmacy-based models. Conclusions. Choice of case-mix adjustment measure affects rankings of facilities on performance measures, raising concerns about the validity of profiling practices. Differences in rankings may reflect differences in comparability of data capture across facilities between pharmacy and diagnosis data sources, and unstable estimates due to small numbers of patients in a facility. [source] The End of an Era: What Became of the "Managed Care Revolution" in 2001?HEALTH SERVICES RESEARCH, Issue 1p2 2003Cara S. Lesser Objective. To describe how the organization and dynamics of health systems changed between 1999 and 2001, in the context of expectations from the mid-1990s when managed care was in ascendance, and assess the implications for consumers and policymakers. Data Sources/Study Setting. Data are from the Community Tracking Study site visits to 12 communities that were randomly selected to be nationally representative of metropolitan areas with 200,000 people or more. The Community Tracking Study is an ongoing effort that began in 1996 and is fielded every two years. Study Design. Semistructured interviews were conducted with 50,90 stakeholders and observers of the local health care market in each of the 12 communities every two years. Respondents include leaders of local hospitals, health plans, and physician organizations and representatives of major employers, state and local governments, and consumer groups. First round interviews were conducted in 1996,1997 and subsequent rounds of interviews were conducted in 1998,1999 and 2000,2001. A total of 1,690 interviews were conducted between 1996 and 2001. Data Analysis Methods. Interview information was stored and coded in qualitative data analysis software. Data were analyzed to identify patterns and themes within and across study sites and conclusions were verified by triangulating responses from different respondent types, examining outliers, searching for disconfirming evidence, and testing rival explanations. Principal Findings. Since the mid-1990s, managed care has developed differently than expected in local health care markets nationally. Three key developments shaped health care markets between 1999 and 2001: (1) unprecedented, sustained economic growth that resulted in extremely tight labor markets and made employers highly responsive to employee demands for even fewer restrictions on access to care; (2) health plans increasingly moved away from core strategies in the "managed care toolbox"; and (3) providers gained leverage relative to managed care plans and reverted to more traditional strategies of competing for patients based on services and amenities. Conclusions. Changes in local health care markets have contributed to rising costs and created new access problems for consumers. Moreover, the trajectory of change promises to make the goals of cost-control and quality improvement more difficult to achieve in the future. [source] Quantifying Components of Drug Expenditure Inflation: The British Columbia Seniors' Drug Benefit PlanHEALTH SERVICES RESEARCH, Issue 5 2002Steven G Morgan Objective. To quantify the relative and absolute importance of different factors contributing to increases in per capita prescription drug costs for a population of Canadian seniors. Data Sources/Study Setting. Data consist of every prescription claim from 1985 to 1999 for the British Columbia Pharmacare Plan A, a tax-financed public drug plan covering all community-dwelling British Columbians aged 65 and older. Study Design. Changes in per capita prescription drug expenditures are attributed to changes to four components of expenditure inflation: (1) the pattern of exposure to drugs across therapeutic categories; (2) the mix of drugs used within therapeutic categories; (3) the rate of generic drug product selection; and (4) the prices of unchanged products. Data Collection/Extraction Methods. Data were extracted from administrative claims files housed at the UBC Centre for Health Services and Policy Research. Principal Findings. Changes in drug prices, the pattern of exposure to drugs across therapeutic categories, and the mix of drugs used within therapeutic categories all caused spending per capita to increase. Incentives for generic substitution and therapeutic reference pricing policies temporarily slowed the cost-increasing influence of changes in product selection by encouraging the use of generic drug products and/or cost-effective brand-name products within therapeutic categories. Conclusions. The results suggest that drug plans (and patients) would benefit from more concerted efforts to evaluate the relative cost-effectiveness of competing products within therapeutic categories of drugs. [source] Benefit-Cost Analysis of Addiction Treatment: Methodological Guidelines and Empirical Application Using the DATCAP and ASIHEALTH SERVICES RESEARCH, Issue 2 2002Michael T. French Objective. To provide detailed methodological guidelines for using the Drug Abuse Treatment Cost Analysis Program (DATCAP) and Addiction Severity Index (ASI) in a benefit-cost analysis of addiction treatment. Data Sources/Study Setting. A representative benefit-cost analysis of three outpatient programs was conducted to demonstrate the feasibility and value of the methodological guidelines. Study Design. Procedures are outlined for using resource use and cost data collected with the DATCAP. Techniques are described for converting outcome measures from the ASI to economic (dollar) benefits of treatment. Finally, principles are advanced for conducting a benefit-cost analysis and a sensitivity analysis of the estimates. Data Collection/Extraction Methods. The DATCAP was administered at three outpatient drug-free programs in Philadelphia, PA, for 2 consecutive fiscal years (1996 and 1997). The ASI was administered to a sample of 178 treatment clients at treatment entry and at 7-months postadmission. Principal Findings. The DATCAP and ASI appear to have significant potential for contributing to an economic evaluation of addiction treatment. The benefit-cost analysis and subsequent sensitivity analysis all showed that total economic benefit was greater than total economic cost at the three outpatient programs, but this representative application is meant to stimulate future economic research rather than justifying treatment per se. Conclusions. This study used previously validated, research-proven instruments and methods to perform a practical benefit-cost analysis of real-world treatment programs. The study demonstrates one way to combine economic and clinical data and offers a methodological foundation for future economic evaluations of addiction treatment. [source] Preventive HIV Vaccine Acceptability and Behavioral Risk Compensation among a Random Sample of High-Risk Adults in Los Angeles (LA VOICES)HEALTH SERVICES RESEARCH, Issue 6 2009Peter A. Newman Objective. To assess HIV vaccine acceptability among high-risk adults in Los Angeles. Study Setting. Sexually transmitted disease clinics, needle/syringe exchange programs, Latino community health/HIV prevention programs. Study Design. Cross-sectional survey using conjoint analysis. Participants were randomly selected using three-stage probability sampling. Data Collection. Sixty-minute structured interviews. Participants rated acceptability of eight hypothetical vaccines, each with seven dichotomous attributes, and reported post-vaccination risk behavior intentions. Principal Findings. Participants (n=1164; 55.7 percent male, 82.4 percent ethnic minority, mean age=37.4 years) rated HIV vaccine acceptability from 28.4 to 88.6; mean=54.5 (SD=18.8; 100-point scale). Efficacy had the greatest impact on acceptability, followed by side effects and out-of-pocket cost. Ten percent would decrease condom use after vaccination. Conclusions. Findings support development of social marketing interventions to increase acceptability of "partial efficacy" vaccines, behavioral interventions to mitigate risk compensation, and targeted cost subsidies. [source] Translating Research into Practice Intervention Improves Management of Acute Pain in Older Hip Fracture PatientsHEALTH SERVICES RESEARCH, Issue 1 2009Marita G. Titler Objective. To test an interdisciplinary, multifaceted, translating research into practice (TRIP) intervention to (a) promote adoption, by physicians and nurses, of evidence-based (EB) acute pain management practices in hospitalized older adults, (b) decrease barriers to use of EB acute pain management practices, and (c) decrease pain intensity of older hospitalized adults. Study Design. Experimental design with the hospital as the unit of randomization. Study Setting. Twelve acute care hospitals in the Midwest. Data Sources. (a) Medical records (MRs) of patients ,65 years or older with a hip fracture admitted before and following implementation of the TRIP intervention and (b) physicians and nurses who care for those patients. Data Collection. Data were abstracted from MRs and questions distributed to nurses and physicians. Principal Findings. The Summative Index for Quality of Acute Pain Care (0,18 scale) was significantly higher for the experimental (10.1) than comparison group (8.4) at the end of the TRIP implementation phase. At the end of the TRIP implementation phase, patients in the experimental group had a lower mean pain intensity rating than those in the comparison group ( p<.0001). Conclusion. The TRIP intervention improved quality of acute pain management of older adults hospitalized with a hip fracture. [source] A Self-Report Measure of Clinicians' Orientation toward Integrative MedicineHEALTH SERVICES RESEARCH, Issue 5p1 2005An-Fu Hsiao Objective. Patients in the U.S. often turn to complementary and alternative medicine (CAM) and may use it concurrently with conventional medicine to treat illness and promote wellness. However, clinicians vary in their openness to the merging of treatment paradigms. Because integration of CAM with conventional medicine can have important implications for health care, we developed a survey instrument to assess clinicians' orientation toward integrative medicine. Study Setting. A convenience sample of 294 acupuncturists, chiropractors, primary care physicians, and physician acupuncturists in academic and community settings in California. Data Collection Methods. We used a qualitative analysis of structured interviews to develop a conceptual model of integrative medicine at the provider level. Based on this conceptual model, we developed a 30-item survey (IM-30) to assess five domains of clinicians' orientation toward integrative medicine: openness, readiness to refer, learning from alternate paradigms, patient-centered care, and safety of integration. Principal Findings. Two hundred and two clinicians (69 percent response rate) returned the survey. The internal consistency reliability for the 30-item total scale and the five subscales ranged from 0.71 to 0.90. Item-scale correlations for the five subscales were higher for the hypothesized subscale than other subscales 75 percent or more of the time. Construct validity was supported by the association of the IM-30 total scale score (0,100 possible range, with a higher score indicative of greater orientation toward integrative medicine) with hypothesized constructs: physician acupuncturists scored higher than physicians (71 versus 50, p<.001), dual-trained practitioners scored higher than single-trained practitioners (71 versus 62, p<.001), and practitioners' self-perceived "integrativeness" was significantly correlated (r=0.60, p<.001) with the IM-30 total score. Conclusion. This study provides support for the reliability and validity of the IM-30 as a measure of clinicians' orientation toward integrative medicine. The IM-30 survey, which we estimate as requiring 5 minutes to complete, can be administered to both conventional and CAM clinicians. [source] Imputation of SF-12 Health Scores for Respondents with Partially Missing DataHEALTH SERVICES RESEARCH, Issue 3 2005Honghu Liu Objective. To create an efficient imputation algorithm for imputing the SF-12 physical component summary (PCS) and mental component summary (MCS) scores when patients have one to eleven SF-12 items missing. Study Setting. Primary data collection was performed between 1996 and 1998. Study Design. Multi-pattern regression was conducted to impute the scores using only available SF-12 items (simple model), and then supplemented by demographics, smoking status and comorbidity (enhanced model) to increase the accuracy. A cut point of missing SF-12 items was determined for using the simple or the enhanced model. The algorithm was validated through simulation. Data Collection. Thirty-thousand-three-hundred and eight patients from 63 physician groups were surveyed for a quality of care study in 1996, which collected the SF-12 and other information. The patients were classified as "chronic" patients if they reported that they had diabetes, heart disease, asthma/chronic obstructive pulmonary disease, or low back pain. A follow-up survey was conducted in 1998. Principal Findings. Thirty-one percent of the patients missed at least one SF-12 item. Means of variance of prediction and standard errors of the mean imputed scores increased with the number of missing SF-12 items. Correlations between the observed and the imputed scores derived from the enhanced models were consistently higher than those derived from the simple model and the increments were significant for patients with ,6 missing SF-12 items (p<.03). Conclusion. Missing SF-12 items are prevalent and lead to reduced analytical power. Regression-based multi-pattern imputation using the available SF-12 items is efficient and can produce good estimates of the scores. The enhancement from the additional patient information can significantly improve the accuracy of the imputed scores for patients with ,6 items missing, leading to estimated scores that are as accurate as that of patients with <6 missing items. [source] How Much Is Postacute Care Use Affected by Its Availability?HEALTH SERVICES RESEARCH, Issue 2 2005Melinda Beeuwkes Buntin Objective. To assess the relative impact of clinical factors versus nonclinical factors,such as postacute care (PAC) supply,in determining whether patients receive care from skilled nursing facilities (SNFs) or inpatient rehabilitation facilities (IRFs) after discharge from acute care. Data Sources and Study Setting. Medicare acute hospital, IRF, and SNF claims provided data on PAC choices; predictors of site of PAC chosen were generated from Medicare claims, provider of services, enrollment file, and Area Resource File data. Study Design. We used multinomial logit models to predict PAC use by elderly patients after hospitalizations for stroke, hip fractures, or lower extremity joint replacements. Data Collection/Extraction Methods. A file was constructed linking acute and postacute utilization data for all medicare patients hospitalized in 1999. Principal Findings. PAC availability is a more powerful predictor of PAC use than the clinical characteristics in many of our models. The effects of distance to providers and supply of providers are particularly clear in the choice between IRF and SNF care. The farther away the nearest IRF is, and the closer the nearest SNF is, the less likely a patient is to go to an IRF. Similarly, the fewer IRFs, and the more SNFs, there are in the patient's area the less likely the patient is to go to an IRF. In addition, if the hospital from which the patient is discharged has a related IRF or a related SNF the patient is more likely to go there. Conclusions. We find that the availability of PAC is a major determinant of whether patients use such care and which type of PAC facility they use. Further research is needed in order to evaluate whether these findings indicate that a greater supply of PAC leads to both higher use of institutional care and better outcomes,or whether it leads to unwarranted expenditures of resources and delays in returning patients to their homes. [source] Risk Segmentation Related to the Offering of a Consumer-Directed Health Plan: A Case Study of Humana Inc.HEALTH SERVICES RESEARCH, Issue 4p2 2004Laura A. Tollen Objective. To determine whether the offering of a consumer-directed health plan (CDHP) is likely to cause risk segmentation in an employer group. Study Setting and Data Source. The study population comprises the approximately 10,000 people (employees and dependents) enrolled as members of the employee health benefit program of Humana Inc. at its headquarters in Louisville, Kentucky, during the benefit years starting July 1, 2000, and July 1, 2001. This analysis is based on primary collection of claims, enrollment, and employment data for those employees and dependents. Study Design. This is a case study of the experience of a single employer in offering two consumer-directed health plan options ("Coverage First 1" and "Coverage First 2") to its employees. We assessed the risk profile of those choosing the Coverage First plans and those remaining in more traditional health maintenance organization (HMO) and preferred provider organization (PPO) coverage. Risk was measured using prior claims (in dollars per member per month), prior utilization (admissions/1,000; average length of stay; prescriptions/1,000; physician office visit services/1,000), a pharmacy-based risk assessment tool (developed by Ingenix), and demographics. Data Collection/Extraction Methods. Complete claims and administrative data were provided by Humana Inc. for the two-year study period. Unique identifiers enabled us to track subscribers' individual enrollment and utilization over this period. Principal Findings. Based on demographic data alone, there did not appear to be a difference in the risk profiles of those choosing versus not choosing Coverage First. However, based on prior claims and prior use data, it appeared that those who chose Coverage First were healthier than those electing to remain in more traditional coverage. For each of five services, prior-year usage by people who subsequently enrolled in Coverage First 1 (CF1) was below 60 percent of the average for the whole group. Hospital and maternity admissions per thousand were less than 30 percent of the overall average; length of stay per hospital admission, physician office services per thousand, and prescriptions per thousand were all between 50 and 60 percent of the overall average. Coverage First 2 (CF2) subscribers' prior use of services was somewhat higher than CF1 subscribers', but it was still below average in every category. As with prior use, prior claims data indicated that Coverage First subscribers were healthier than average, with prior total claims less than 50 percent of average. Conclusions. In this case, the offering of high-deductible or consumer-directed health plan options alongside more traditional options caused risk segmentation within an employer group. The extent to which these findings are applicable to other cases will depend on many factors, including the employer premium contribution policies and employees' perception of the value of the various plan options. Further research is needed to determine whether risk segmentation will worsen in future years for this employer and if so, whether it will cause premiums for more traditional health plans to increase. [source] Improving Care for Minorities: Can Quality Improvement Interventions Improve Care and Outcomes For Depressed Minorities?HEALTH SERVICES RESEARCH, Issue 2 2003Controlled Trial, Results of a Randomized Objective. Ethnic minority patients often receive poorer quality care and have worse outcomes than white patients, yet practice-based approaches to reduce such disparities have not been identified. We determined whether practice-initiated quality improvement (QI) interventions for depressed primary care patients improve care across ethnic groups and reduce outcome disparities. Study Setting. The sample consists of 46 primary care practices in 6 U.S. managed care organizations; 181 clinicians; 398 Latinos, 93 African Americans, and 778 white patients with probable depressive disorder. Study Design. Matched practices were randomized to usual care or one of two QI programs that trained local experts to educate clinicians; nurses to educate, assess, and follow-up with patients; and psychotherapists to conduct Cognitive Behavioral Therapy. Patients and physicians selected treatments. Interventions featured modest accommodations for minority patients (e.g., translations, cultural training for clinicians). Data Extraction Methods. Multilevel logistic regression analyses assessed intervention effects within and among ethnic groups. Principal Findings. At baseline, all ethnic groups (Latino, African American, white) had low to moderate rates of appropriate care and the interventions significantly improved appropriate care at six months (by 8,20 percentage points) within each ethnic group, with no significant difference in response by ethnic group. The interventions significantly decreased the likelihood that Latinos and African Americans would report probable depression at months 6 and 12; the white intervention sample did not differ from controls in reported probable depression at either follow-up. While the intervention significantly improved the rate of employment for whites and not for minorities, precision was low for comparing intervention response on this outcome. It is important to note that minorities remained less likely to have appropriate care and more likely to be depressed than white patients. Conclusions. Implementation of quality improvement interventions that have modest accommodations for minority patients can improve quality of care for whites and underserved minorities alike, while minorities may be especially likely to benefit clinically. Further research needs to clarify whether employment benefits are limited to whites and if so, whether this represents a difference in opportunities. Quality improvement programs appear to improve quality of care without increasing disparities, and may offer an approach to reduce health disparities. [source] Expanding the Andersen Model: The Role of Psychosocial Factors in Long-Term Care UseHEALTH SERVICES RESEARCH, Issue 5 2002Elizabeth H Bradley Objective. To examine a prevailing conceptual model of health services use (Andersen 1995) and to suggest modifications that may enhance its explanatory power when applied to empirical studies of race/ethnicity and long-term care. Study Setting. Twelve focus groups of African-American (five groups) and white (seven groups) individuals, aged 65 and older, residing in Connecticut during 2000. Study Design. Using qualitative analysis, data were coded and analyzed in NUD-IST 4 software to facilitate the reporting of recurrent themes, supporting quotations, and links among the themes for developing the conceptual framework. Specific analysis was conducted to assess distinctions in common themes between African-American and white focus groups. Data Collection. Data were collected using a standardized discussion guide, augmented by prompts for clarification. Audio taped sessions were transcribed and independently coded by investigators and crosschecked to enhance coding validity. An audit trail was maintained to document analytic decisions during data analysis and interpretation. Principal Findings. Psychosocial factors (e.g., attitudes and knowledge, social norms, and perceived control) are identified as determinants of service use, thereby expanding the Andersen model (1995). African-American and white focus group members differed in their reported accessibility of information about long-term care, social norms concerning caregiving expectations and burden, and concerns of privacy and self-determination. Conclusions. More comprehensive identification of psychosocial factors may enhance our understanding of the complex role of race/ethnicity in long-term care use as well as the effectiveness of policies and programs designed to address disparities in long-term care service use among minority and nonminority groups. [source] Physician Referral Patterns and Race Differences in Receipt of Coronary AngiographyHEALTH SERVICES RESEARCH, Issue 4 2002Thomas A. LaVeist Objective. This study addresses the following research questions: (1) Is race a predictor of obtaining a referral for coronary angiography (CA) among patients who are appropriate candidates for the procedure? (2) Is there a race disparity in obtaining CA among patients who obtain a referral for the procedure? Study Setting. Three community hospitals in Baltimore, Maryland. Study Design. We abstracted hospital records of 7,927 patients from three hospitals to identify 2,653 patients who were candidates for CA. Patients were contacted by telephone to determine if they received a referral for CA. Logistic regression was used to assess whether racial differences in obtaining a referral were affected by adjustment for several potential confounders. A second set of analyses examined race differences in use of the procedure among a subsample of patients that obtained a referral. Principal Findings. After controlling for having been hospitalized at a hospital with in-house catheterization facilities, ACC/AHA (American College of Cardiology/American Heart Association) classification, sex, age, and health insurance status, race remained a significant determinant of referral (OR=3.0, p<.05). Additionally, we found no significant race differences in receipt of the procedure among patients who obtained a referral. Conclusions. Our results demonstrate that race differences in utilization of CA tend to occur during the process of determining the course of treatment. Once a referral is obtained, African American patients are not less likely than white patients to follow through with the procedure. Thus, future research should seek to better understand the process by which the decision is made to refer or not refer patients. [source] A National Study of Efficiency for Dialysis Centers: An Examination of Market Competition and Facility Characteristics for Production of Multiple Dialysis OutputsHEALTH SERVICES RESEARCH, Issue 3 2002Hacer Ozgen Objective. To examine market competition and facility characteristics that can be related to technical efficiency in the production of multiple dialysis outputs from the perspective of the industrial organization model. Study Setting. Freestanding dialysis facilities that operated in 1997 submitted cost report forms to the Health Care Financing Administration (HCFA), and offered all three outputs,outpatient dialysis, dialysis training, and home program dialysis. Data Sources. The Independent Renal Facility Cost Report Data file (IRFCRD) from HCFA was utilized to obtain information on output and input variables and market and facility features for 791 multiple-output facilities. Information regarding population characteristics was obtained from the Area Resources File. Study Design. Cross-sectional data for the year 1997 were utilized to obtain facility-specific technical efficiency scores estimated through Data Envelopment Analysis (DEA). A binary variable of efficiency status was then regressed against its market and facility characteristics and control factors in a multivariate logistic regression analysis. Principal Findings. The majority of the facilities in the sample are functioning technically inefficiently. Neither the intensity of market competition nor a policy of dialyzer reuse has a significant effect on the facilities' efficiency. Technical efficiency is significantly associated, however, with type of ownership, with the interaction between the market concentration of for-profits and ownership type, and with affiliations with chains of different sizes. Nonprofit and government-owned facilities are more likely than their for-profit counterparts to become inefficient producers of renal dialysis outputs. On the other hand, that relationship between ownership form and efficiency is reversed as the market concentration of for-profits in a given market increases. Facilities that are members of large chains are more likely to be technically inefficient. Conclusions. Facilities do not appear to benefit from joint production of a variety of dialysis outputs, which may explain the ongoing tendency toward single-output production. Ownership form does make a positive difference in production efficiency, but only in local markets where competition exists between nonprofit and for-profit facilities. The increasing inefficiency associated with membership in large chains suggests that the growing consolidation in the dialysis industry may not, in fact, be the strategy for attaining more technical efficiency in the production of multiple dialysis outputs. [source] Practice Characteristics and HMO Enrollee Satisfaction with Specialty Care: An Analysis of Patients with Glaucoma and Diabetic RetinopathyHEALTH SERVICES RESEARCH, Issue 4 2003José J. Escarce Background. The specialist's role in caring for managed care patients is likely to grow. Thus, assessing the correlates of patient satisfaction with specialty care is essential. Objective. To examine the association between characteristics of eye care practices and satisfaction with eye care among working age patients with open-angle glaucoma (OAG) or diabetic retinopathy (DR). Subjects/Study Setting. A total of 913 working age patients with OAG or DR enrolled in six commercial managed care health plans. The patients were treated in 144 different eye care practices. Study Design. We used a patient survey to obtain information on patient characteristics and satisfaction with eye care, measured by scores on satisfaction subscales of the 18-item Patient Satisfaction Questionnaire. We used a survey of eye care practices to obtain information on practice characteristics, including provider specialties, practice organization, financial features, and utilization and quality management systems. We estimated logistic regression models to assess the association of patient and practice characteristics with high levels of patient satisfaction. Principal Findings. Treatment in a practice with a glaucoma specialist (for OAG patients) or a retina specialist (for DR patients) was associated with higher satisfaction, whereas treatment in a practice that obtained a high proportion of its revenues from capitation payments or in a group practice where providers obtained a high proportion of their incomes from bonuses was associated with lower satisfaction. Conclusions. Many eye care patients prefer to be treated by specialists with expertise in their conditions. Financial arrangement features of eye care practices also are associated with patient satisfaction with care. The most likely mechanisms underlying these associations are effects on provider behavior and satisfaction, which in turn influence patient satisfaction. Managed care plans and provider groups should aim to minimize the negative impact of managed care features on patient satisfaction. [source] | ||||||||||