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Elliott S Fisher

Publications and source records attributed to Elliott S Fisher.

At least 19 recordsLinked to original sources
PubMed2007

Analysis of observational studies in the presence of treatment selection bias: effects of invasive cardiac management on AMI survival using propensity score and instrumental variable methods.

CONTEXT: Comparisons of outcomes between patients treated and untreated in observational studies may be biased due to differences in patient prognosis between groups, often because of unobserved treatment selection biases. OBJECTIVE: To compare 4 analytic methods for removing the effects of selection bias in observational studies: multivariable model risk adjustment, propensity score risk adjustment, propensity-based matching, and instrumental variable analysis. DESIGN, SETTING, AND PATIENTS: A national cohort of 122,124 patients who were elderly (aged 65-84 years), receiving Medicare, and hospitalized with acute myocardial infarction (AMI) in 1994-1995, and who were eligible for cardiac catheterization. Baseline chart reviews were taken from the Cooperative Cardiovascular Project and linked to Medicare health administrative data to provide a rich set of prognostic variables. Patients were followed up for 7 years through December 31, 2001, to assess the association between long-term survival and cardiac catheterization within 30 days of hospital admission. MAIN OUTCOME MEASURE: Risk-adjusted relative mortality rate using each of the analytic methods. RESULTS: Patients who received cardiac catheterization (n = 73 238) were younger and had lower AMI severity than those who did not. After adjustment for prognostic factors by using standard statistical risk-adjustment methods, cardiac catheterization was associated with a 50% relative decrease in mortality (for multivariable model risk adjustment: adjusted relative risk [RR], 0.51; 95% confidence interval [CI], 0.50-0.52; for propensity score risk adjustment: adjusted RR, 0.54; 95% CI, 0.53-0.55; and for propensity-based matching: adjusted RR, 0.54; 95% CI, 0.52-0.56). Using regional catheterization rate as an instrument, instrumental variable analysis showed a 16% relative decrease in mortality (adjusted RR, 0.84; 95% CI, 0.79-0.90). The survival benefits of routine invasive care from randomized clinical trials are between 8% and 21%. CONCLUSIONS: Estimates of the observational association of cardiac catheterization with long-term AMI mortality are highly sensitive to analytic method. All standard risk-adjustment methods have the same limitations regarding removal of unmeasured treatment selection biases. Compared with standard modeling, instrumental variable analysis may produce less biased estimates of treatment effects, but is more suited to answering policy questions than specific clinical questions.

Aged↗
PubMed2006

Creating accountable care organizations: the extended hospital medical staff.

Many current policies and approaches to performance measurement and payment reform focus on individual providers; they risk reinforcing the fragmented care and lack of coordination experienced by patients with serious illness. In this paper we show that Medicare beneficiaries receive most of their care from relatively coherent local delivery systems comprising physicians and the hospitals where they work or admit their patients. Efforts to create accountable care organizations at this level--the extended hospital medical staff--deserve consideration as a potential means of improving the quality and lowering the cost of care.

Delivery of Health Care↗
PubMed2006

United States' trends and regional variations in lumbar spine surgery: 1992-2003.

STUDY DESIGN: Repeated cross-sectional analysis using national Medicare data from the Dartmouth Atlas Project. OBJECTIVE: To describe recent trends and geographic variation in population-based rates of lumbar fusion spine surgery. SUMMARY OF BACKGROUND DATA: Lumbar fusion rates have increased dramatically during the 1980s and even more so in the 1990s. The most rapid increase appeared to follow the approval of a new surgical implant device. METHODS: Medicare claims and enrollment data were used to calculate age, sex, and race-adjusted rates of lumbar laminectomy/discectomy and lumbar fusion for fee-for-service Medicare beneficiaries over age 65 in each of the 306 US Hospital Referral Regions between 1992 and 2003. RESULTS: Lumbar fusion rates have increased steadily since 1992 (0.3 per 1000 enrollees in 1992 to 1.1 per 1000 enrollees in 2003). Regional rates of lumbar discectomy, laminectomy, and fusion in 1992-1993 were highly correlated to rates of discectomy, laminectomy (R2 = 0.44), and fusion (R2 = 0.28) in 2002-2003. There was a nearly 8-fold variation in regional rates of lumbar discectomy and laminectomy in 2002 and 2003. In the case of lumbar fusion, there was nearly a 20-fold range in rates among Medicare enrollees in 2002 and 2003. This represents the largest coefficient of variation seen with any surgical procedure. Medicare spending for inpatient back surgery more than doubled over the decade. Spending for lumbar fusion increased more than 500%, from 75 million dollars to 482 million dollars. In 1992, lumbar fusion represented 14% of total spending for back surgery; by 2003, lumbar fusion accounted for 47% of spending. CONCLUSIONS: The rate of specific procedures within a region or "surgical signature" is remarkably stable over time. However, there has been a marked increase in rates of fusion, and a coincident shift and increase in cost. Rates of back surgery were not correlated with the per-capita supply of orthopedic and neurosurgeons.

Aged↗
PubMed2006

Regional variations in health care intensity and physician perceptions of quality of care.

BACKGROUND: Research has documented dramatic differences in health care utilization and spending across U.S. regions with similar levels of patient illness. Although patient outcomes and quality of care have been found to be no better in regions of high health care intensity, it is unknown whether physicians in these regions feel more capable of providing good patient care than those in low-intensity regions. OBJECTIVE: To determine whether physicians in high-intensity regions feel better able to care for patients than physicians in low-intensity regions. DESIGN: Physician telephone survey. SETTING: 51 metropolitan and 9 nonmetropolitan areas of the United States and a supplemental national sample. PARTICIPANTS: 10,577 physicians who provided care to adults in 1998 or 1999 were surveyed for the Community Tracking Study (response rate, 61%). MEASUREMENTS: The End-of-Life Expenditure Index, a measure of spending that reflects differences in the overall quantity of medical services provided rather than differences in illness or price, was used to determine health care intensity in the physicians' community. Outcomes included physicians' perceived availability of clinical services, ability to provide high-quality care to patients, and career satisfaction. RESULTS: Although the highest-intensity regions have substantially more hospital beds and specialists per capita, physicians in these regions reported more difficulty obtaining needed services for their patients. The proportion of physicians who felt able to obtain elective hospital admissions ranged from 50% in high-intensity regions to 64% in the lowest-intensity region (P < 0.001 for the relationship between intensity and perceived ability to obtain hospital admissions); the proportion of physicians who felt able to obtain high-quality specialist referrals ranged from 64% in high-intensity regions to 79% in low-intensity regions (P < 0.001). Compared with low-intensity regions, fewer physicians in high-intensity regions felt able to maintain good ongoing patient relationships (range, 62% to 70%; P < 0.001) or able to provide high-quality care (range, 72% to 77%; P = 0.009). In most cases, differences persisted but were attenuated in magnitude after adjustment for physician attributes, practice characteristics, and local market factors (for example, managed care penetration); the difference in perceived ability to provide high-quality care was no longer statistically significant (P = 0.099). LIMITATIONS: The cross-sectional design prevented demonstration of a causal relationship between intensity and physician perceptions of quality. CONCLUSION: Despite more resources, physicians in regions of high health care intensity did not report greater ease in obtaining needed services or greater ability to provide high-quality care.

Adult↗
PubMed2006

Is technological change in medicine always worth it? The case of acute myocardial infarction.

We examine Medicare costs and survival gains for acute myocardial infarction (AMI) during 1986-2002. As David Cutler and Mark McClellan did in earlier work, we find that overall gains in post-AMI survival more than justified the increases in costs during this period. Since 1996, however, survival gains have stagnated, while spending has continued to increase. We also consider changes in spending and outcomes at the regional level. Regions experiencing the largest spending gains were not those realizing the greatest improvements in survival. Factors yielding the greatest benefits to health were not the factors that drove up costs, and vice versa.

Acute Disease↗
PubMed2006

Veterans Health Administration patients' use of the private sector for coronary revascularization in New York: opportunities to improve outcomes by directing care to high-performance hospitals.

OBJECTIVE: We sought to quantify Veterans Health Administration (VA) patients' utilization of coronary revascularization in the private sector and to assess the potential impact of directing this care to high-performance hospitals. METHODS: Using VA and New York State administrative and clinical databases, we conducted a retrospective cohort study examining residents of New York State who were enrolled in the VA and underwent either coronary artery bypass graft (CABG) surgery or percutaneous coronary intervention (PCI) in 1999 or 2000 (n=6562) in either the VA or the private sector. We first calculated the proportion of revascularizations obtained in the VA and the private sector. We then identified the private sector hospitals in which these men obtained revascularizations and determined potential changes in mortality and travel burden associated with directing private sector care to high performance hospitals. RESULTS: VA patients in New York were much more likely to undergo revascularization in the private sector than in VA hospitals: 83% of CABGs (2341/2829) and 87% of PCIs (4054/4665) were obtained in the private sector. Private sector utilization was distributed evenly across high- and low-mortality hospitals. Directing private-sector CABG surgery to high-performance hospitals could have reduced expected mortality by 24% (from 2.3% to 1.7%) and would only increase median travel time from 21 to 30 minutes. The benefit of redirecting PCI care is minimal. CONCLUSIONS: For high-mortality procedures that veterans frequently obtain in the private sector, like CABG, directing care to high-performance hospitals may be an effective way to improve outcomes for veterans.

Angioplasty, Balloon, Coronary↗
PubMed2005

Variation in the tendency of primary care physicians to intervene.

BACKGROUND: Research has documented dramatic variation in health care spending across the United States that has little relationship to health outcomes. Although high-spending areas have more physicians per capita, it is not known whether this disparity fully explains the differences in spending or whether individual physicians in high-spending regions have a greater tendency to intervene for their patients. We sought to measure the tendency of primary care physicians to intervene across regions that differ in their levels of local health care spending. METHODS: We used data from the Community Tracking Study Physician Survey, a telephone survey of a nationally representative sample of 5490 primary care physicians who provided care to adults in 1998-1999 (response rate 59%). Local health care spending in physicians' communities was determined by assigning each participating physician to 1 of 306 US hospital referral regions. The tendency of physicians to intervene was measured by evaluating their responses to 6 clinical vignettes in which they were asked how often they would order a test, referral, or treatment for the patient described. RESULTS: In 5 of the 6 vignettes, physicians in high-spending regions were more likely to recommend interventions than those practicing in low-spending regions. For example, for a 35-year-old man with back pain and foot drop, physicians in high-spending regions would recommend magnetic resonance imaging 82% of the time, compared with 69% for physicians in low-spending regions (P<.001). For a 60-year-old man somewhat bothered by symptoms of benign prostatic hypertrophy, physicians in high-spending regions would make a urology referral 32% of the time, while those in low-spending regions would do so only 23% of the time (P<.001). Our findings that physicians in high-spending regions have a greater tendency to intervene persisted in analyses stratified by physician specialty (family/general practice vs internal medicine). CONCLUSION: Varying rates of health care spending across the United States reflect the underlying tendency of local physicians to recommend interventions for their patients.

Adult↗
PubMed2005

Racial trends in the use of major procedures among the elderly.

BACKGROUND: Differences in the use of major procedures according to patients' race are well known. Whether national and local initiatives to reduce these differences have been successful is unknown. METHODS: We examined data for men and women enrolled in Medicare from 1992 through 2001 on annual age-standardized rates of receipt of nine surgical procedures previously shown to have disparities in the rates at which they were performed in black patients and in white patients. We also examined data according to hospital-referral region for three of the nine procedures: coronary-artery bypass grafting (CABG), carotid endarterectomy, and total hip replacement. RESULTS: Nationally, in 1992, the rates of receipt for all the procedures examined were higher among white patients than among black patients. The difference between the rates among whites and blacks increased significantly between 1992 and 2001 for five of the nine procedures, remained unchanged for three procedures, and narrowed significantly for one procedure. We examined rates of CABG, carotid endarterectomy, and total hip replacement in 158 hospital-referral regions (79 hospital-referral regions for black men and white men and 79 for black women and white women) with an adequate number of persons for each procedure. We found that in the early 1990s, whites had higher rates for these procedures than blacks in every hospital-referral region. By 2001, the difference between whites and blacks (both men and women) in the rates of these procedures narrowed significantly in 22 hospital-referral regions, widened significantly in 42, and were not significantly changed in the remaining hospital-referral regions. At the end of the study period, we found no hospital-referral region in which the difference in rates between whites and blacks was eliminated for men or women with regard to any of these three procedures. CONCLUSIONS: For the decade of the 1990s, we found no evidence, either nationally or locally, that efforts to eliminate racial disparities in the use of high-cost surgical procedures were successful.

Aged↗
PubMed2005

Publicly reporting comprehensive quality and cost data: a health care system's transparency initiative.

BACKGROUND: Transparency in health care, including the public reporting of health care results, is an expanding and unstoppable phenomenon. Health care systems have an opportunity to: (1) be proactive and accountable for the care they provide, (2) help patients learn more about their condition as a supplement to understanding the performance measures, and (3) use public reporting to foster process of care and outcome improvement initiatives. An overview is provided of the first 22 months of a transparency initiative at Dartmouth-Hitchcock Medical Center (DHMC). LAUNCHING THE TRANSPARENCY INITIATIVE: An interdisciplinary operations group works with the various clinical programs--both providers and patients--to identify what quality and cost measures are most desired by patients and what measures are the focus of the clinical program's internal measurement and reporting processes. The measures are presented on the DHMC Web site, with access to additional resources, such as clinical decision aids. DISCUSSION: A variety of factors are important to the transparency initiative--senior leaders' perceptions, risk management issues, resources required for the design and maintenance of the initiative, and developing both methodological protocols and technical systems.

Benchmarking↗
PubMed2005

New York's statistical model accurately predicts mortality risk for veterans who obtain private sector CABG.

OBJECTIVE: To determine whether patients' use of the Veterans Health Administration health care system (VHA) is an independent risk factor for mortality following coronary artery bypass grafting (CABG) in the private sector in New York. DATA SOURCES: VHA administrative and New York Department of Health Cardiac Surgery Reporting System (CSRS) databases for surgeries performed in 1999 and 2000. STUDY DESIGN: Prospective cohort study comparing observed, expected, and risk-adjusted mortality rates following private sector CABG for 2,326 male New York State residents aged 45 years and older who used the VHA (VHA users) and 21,607 who did not (non-VHA users). DATA COLLECTION METHODS: We linked VHA administrative databases to New York's CSRS to identify VHA users who obtained CABG in the private sector in New York in 1999 and 2000. Using CSRS risk factors and previously validated risk-adjustment model, we compared patient characteristics and expected and risk-adjusted mortality rates of VHA users to non-VHA users. PRINCIPAL FINDINGS: Compared with non-VHA users, patients undergoing private sector CABG who had used the VHA were older, had more severe cardiac disease, and were more likely to have the following comorbidities associated with increased risk of mortality: diabetes, chronic obstructive pulmonary disease, cerebrovascular disease, peripheral vascular disease, and history of stroke (p<.001 for all); a calcified aorta (p=.009); and a high creatinine level (p=.003). Observed (2.28 versus 1.80 percent) and expected (2.48 versus 1.78 percent) mortality rates were higher for VHA users than for non-VHA users. The risk-adjusted mortality rate for VHA users (1.70 percent; 95 percent confidence interval [CI]: 1.27-2.22) was not statistically different than that for the non-VHA users (1.87 percent; 95 percent CI: 1.69-2.06). Use of the VHA was not an independent risk factor for mortality in the risk-adjustment model. CONCLUSIONS: Although VHA users had a greater illness burden, use of the VHA was not found to be an independent risk factor for mortality following private sector CABG in New York. The New York Department of Health risk adjustment model adequately applies to veterans who obtain CABG in the private sector in New York.

Aged↗
PubMed2005

Bereaved family member perceptions of quality of end-of-life care in U.S. regions with high and low usage of intensive care unit care.

OBJECTIVES: To compare the quality of end-of-life care of persons dying in regions of differing practice intensity. DESIGN: Mortality follow-back survey. SETTING: Geographic regions in the highest and lowest deciles of intensive care unit (ICU) use. PARTICIPANTS: Bereaved family member or other knowledgeable informants. MEASUREMENTS: Unmet needs, concerns, and rating of quality of end-of-life care in five domains (physical comfort and emotional support of the decedent, shared decision-making, treatment of the dying person with respect, providing information and emotional support to family members). RESULTS: Decedents in high- (n=365) and low-intensity (n=413) hospital service areas (HSAs) did not differ in age, sex, education, marital status, leading causes of death, or the degree to which death was expected, but those in the high-intensity ICU HSAs were more likely to be black and to live in nonrural areas. Respondents in high-intensity HSAs were more likely to report that care was of lower quality in each domain, and these differences were statistically significant in three of five domains. Respondents from high-intensity HSAs were more likely to report inadequate emotional support for the decedent (relative risk (RR)=1.2, 95% confidence interval (CI)=1.0-1.4), concerns with shared decision-making (RR=1.8, 95% CI=1.0-2.9), inadequate information about what to expect (RR=1.5, 95% CI=1.3-1.8), and failure to treat the decedent with respect (RR=1.4, 95% CI=1.0-1.9). Overall ratings of the quality of end-of-life care were also significantly lower in high-intensity HSAs. CONCLUSION: Dying in regions with a higher use of ICU care is not associated with improved perceptions of quality of end-of-life care.

Aged↗
PubMed2004

Use of hospitals, physician visits, and hospice care during last six months of life among cohorts loyal to highly respected hospitals in the United States.

OBJECTIVE: To evaluate the use of healthcare resources during the last six months of life among patients of US hospitals with strong reputations for high quality care in managing chronic illness. DESIGN: Retrospective cohort study based on claims data from the US Medicare programme. PARTICIPANTS: Cohorts receiving most of their hospital care from 77 hospitals that appeared on the 2001 US News and World Report "best hospitals" list for heart and pulmonary disease, cancer, and geriatric services. MAIN OUTCOME MEASURES: Use of healthcare resources in the last six months of life: number of days spent in hospital and in intensive care units; number of physician visits; percentage of patients seeing 10 or more physicians; percentage enrolled in hospice. Terminal care: percentage of deaths occurring in hospital; percentage of deaths occurring in association with a stay in an intensive care unit. RESULTS: Extensive variation in each measure existed among the 77 hospital cohorts. Days in hospital per decedent ranged from 9.4 to 27.1 (interquartile range 11.6-16.1); days in intensive care units ranged from 1.6 to 9.5 (2.6-4.5); number of physician visits ranged from 17.6 to 76.2 (25.5-39.5); percentage of patients seeing 10 or more physicians ranged from 16.9% to 58.5% (29.4-43.4%); and hospice enrollment ranged from 10.8% to 43.8% (22.0-32.0%). The percentage of deaths occurring in hospital ranged from 15.9% to 55.6% (35.4-43.1%), and the percentage of deaths associated with a stay in intensive care ranged from 8.4% to 36.8% (20.2-27.1%). CONCLUSION: Striking variation exists in the utilisation of end of life care among US medical centres with strong national reputations for clinical care.

Aged↗
PubMed2004

Should aspirin be continued in patients started on warfarin?

BACKGROUND AND OBJECTIVE: Clinicians frequently face the decision of whether to continue aspirin when starting patients on warfarin. We performed a meta-analysis to characterize the tradeoffs involved in this common clinical dilemma. DATA SOURCES: Multiple computerized databases (1966 to 2003), reference lists of relevant articles, conference proceedings, and queries of primary authors. STUDY SELECTION: Randomized trials comparing warfarin plus aspirin versus warfarin alone. Studies with target international normalized ratios (INRs) <2 were excluded. DATA EXTRACTION: Two reviewers independently extracted baseline data and major outcomes: rates of thromboembolism, hemorrhage, and all-cause mortality. DATA SYNTHESIS: Nine studies met the inclusion criteria. Of the five that enrolled patients with mechanical heart valves, four used the same target INR in both groups, while one used a reduced target INR for the warfarin plus aspirin group. Pooling the results of the first four studies demonstrated that combination of warfarin plus aspirin significantly decreased thromboembolic events (relative risk [RR], 0.33; 95% confidence interval [CI], 0.19 to 0.58), increased major bleeding (RR, 1.58; 95% CI, 1.02 to 2.44), and decreased all-cause mortality (RR, 0.43; 95% CI, 0.23 to 0.81) compared to warfarin alone. The one valve trial using a reduced INR in the warfarin plus aspirin group reported no difference in thromboembolic outcomes but found decreased major bleeding and a significant mortality benefit with combination therapy. Of the remaining trials, three evaluated a warfarin indication not routinely used in the United States (post-myocardial infarction), and the only trial that considered atrial fibrillation was terminated early due to inadequate enrollment. CONCLUSIONS: For mechanical heart valve patients, the benefits of continuing aspirin when starting warfarin therapy are clear. For other routine warfarin indications, there are not adequate data to guide this common clinical decision.

Anticoagulants↗
PubMed2004

Variations in the longitudinal efficiency of academic medical centers.

Recent studies have revealed dramatic differences among academic medical centers (AMCs) in the quantity of care provided to their patients. The implications, however, depend upon whether the additional resources provided by some centers lead to better results. This study describes the content, quality, and outcomes of care across AMCs that differ by up to 60 percent in the overall intensity of medical services delivered to patients with serious chronic illnesses. Efforts to reduce costs will require attention to supply-sensitive services (the frequency of hospital stays, physician visits, specialist consultations, diagnostic tests, and minor procedures) and should include a focus on the longitudinal efficiency of hospitals and medical staffs.

Academic Medical Centers↗
PubMed2004

Use of Medicare claims data to monitor provider-specific performance among patients with severe chronic illness.

This study illustrates that Medicare claims can be used to measure population-based, provider-specific rates of resource inputs, utilization, and Medicare spending. The target populations are seventy-seven cohorts of chronically ill Medicare enrollees who received most of their care from seventy-seven well-known U.S. hospitals. Striking variations are documented in resource inputs and use of services during the last six months of life. The patterns of care seen in the progression of chronic illness correlate highly with care received during previous periods. We believe that hospital-specific measures can be helpful in identifying providers with acceptable quality indices who are also relatively efficient in managing chronic illness.

Chronic Disease↗
PubMed2003

The implications of regional variations in Medicare spending. Part 1: the content, quality, and accessibility of care.

BACKGROUND: The health implications of regional differences in Medicare spending are unknown. OBJECTIVE: To determine whether regions with higher Medicare spending provide better care. DESIGN: Cohort study. SETTING: National study of Medicare beneficiaries. PATIENTS: Patients hospitalized between 1993 and 1995 for hip fracture (n = 614,503), colorectal cancer (n = 195,429), or acute myocardial infarction (n = 159,393) and a representative sample (n = 18,190) drawn from the Medicare Current Beneficiary Survey (1992-1995). EXPOSURE MEASUREMENT: End-of-life spending reflects the component of regional variation in Medicare spending that is unrelated to regional differences in illness. Each cohort member's exposure to different levels of spending was therefore defined by the level of end-of-life spending in his or her hospital referral region of residence (n = 306). OUTCOME MEASUREMENTS: Content of care (for example, frequency and type of services received), quality of care (for example, use of aspirin after acute myocardial infarction, influenza immunization), and access to care (for example, having a usual source of care). RESULTS: Average baseline health status of cohort members was similar across regions of differing spending levels, but patients in higher-spending regions received approximately 60% more care. The increased utilization was explained by more frequent physician visits, especially in the inpatient setting (rate ratios in the highest vs. the lowest quintile of hospital referral regions were 2.13 [95% CI, 2.12 to 2.14] for inpatient visits and 2.36 [CI, 2.33 to 2.39] for new inpatient consultations), more frequent tests and minor (but not major) procedures, and increased use of specialists and hospitals (rate ratio in the highest vs. the lowest quintile was 1.52 [CI, 1.50 to 1.54] for inpatient days and 1.55 [CI, 1.50 to 1.60] for intensive care unit days). Quality of care in higher-spending regions was no better on most measures and was worse for several preventive care measures. Access to care in higher-spending regions was also no better or worse. CONCLUSIONS: Regional differences in Medicare spending are largely explained by the more inpatient-based and specialist-oriented pattern of practice observed in high-spending regions. Neither quality of care nor access to care appear to be better for Medicare enrollees in higher-spending regions.

Aged↗