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Biomedical subjects

Susan L Ettner

Publications and source records attributed to Susan L Ettner.

At least 37 records · Page 2Linked to original sources
PubMed2005

Racial and ethnic disparities in access to physicians with HIV-related expertise.

OBJECTIVE: Professional medical associations recommend that physicians who treat patients with human immunodeficiency virus (HIV) have a measurable form of disease-specific expertise, such as high HIV patient volume or infectious diseases certification. Although it is known that racial/ethnic minorities generally have worse access to care than do whites, previous work has not examined disparities in the use of physicians with HIV-related expertise. DESIGN, SETTING, AND PARTICIPANTS: We linked data from a prospective cohort study of 2,207 persons with HIV receiving care in the United States with a cross-sectional survey of 404 physicians caring for them. Using multivariate analysis, we estimated the association of patient race/ethnicity with the experience and training of their physicians, controlling for health status, socioeconomic status, demographic characteristics, and geographic variation in provider supply. RESULTS: Compared with white patients, African Americans were less likely to have an infectious diseases specialist as a regular source of care (odds ratio [OR], 0.60; 95% confidence interval [CI], 0.37 to 0.95). Persons of Alaskan Native, American Indian, Asian, Pacific Islander, or mixed racial background were also less likely than whites to have an infectious diseases specialist (OR, 0.44; 95% CI, 0.23 to 0.83). Conversely, Latino patients had physicians whose HIV patient volume was, on average, 24% higher than the physicians of white patients (incident rate ratio, 1.24; 95% CI, 1.03 to 1.50). CONCLUSIONS: Some groups of racial/ethnic minorities are less likely than are whites to have infectious diseases specialists as a regular source of care. The finding that the physicians of Latino patients had relatively higher HIV caseloads suggests that this particular patient subpopulation has access to HIV expertise. Further work to explain racial/ethnic differences in access to physicians will help in the design of programs and policies to eliminate them.

Black or African American↗
PubMed2005

Quality improvement for depression in primary care: do patients with subthreshold depression benefit in the long run?

OBJECTIVE: Quality improvement programs for depression can improve outcomes, but the utility of including patients with subthreshold depression in quality improvement programs is unclear. The authors examined 57-month effects of quality improvement on clinical outcomes and mental health care utilization of primary care patients with depressive disorder and subthreshold depression. METHOD: In a group-level, randomized, controlled trial, 46 primary care clinics were randomly assigned to provide usual care or care with a quality improvement intervention that included provider training and other resources for either medication management (medications quality improvement) or evidence-based psychotherapy (therapy quality improvement). Among 1,356 enrolled depressed patients, 991 completed the 57-month follow-up interview (604 patients with depressive disorder and 387 with subthreshold depression). Outcomes measured at 57 months were presence of probable depressive disorder, unmet need for appropriate care (untreated probable disorder), and mental health care utilization in the prior 6 months. RESULTS: Among patients with subthreshold depression at baseline, those seen in clinics with quality improvement programs with special resources for therapy were less likely to have probable depressive disorder and unmet need for care at follow-up, compared with those seen in clinics that provided usual care. Among patients with depressive disorder at baseline, those seen in clinics with quality improvement programs with special resources for medication management were less likely to have unmet need for care at follow-up, compared with those seen in clinics that provided usual care. Patients with subthreshold depression at baseline seen in clinics with a quality improvement intervention were less likely at follow-up to have had a mental health visit (in primary care or specialty care, depending on the intervention) in the prior 6 months. CONCLUSIONS: Relative to usual care, quality improvement interventions improved 57-month outcomes (probable depression, unmet need, or both) for primary care patients with depressive disorder and subthreshold depression and lowered use of mental health visits for those with subthreshold depression. The results highlight the feasibility and utility of including patients with subthreshold depression in such programs.

Adult↗
PubMed2005

Do specialist self-referral insurance policies improve access to HIV-experienced physicians as a regular source of care?

Health insurance policies that require prior authorization for specialty care may be detrimental to persons with HIV, according to evidence that having a regular physician with HIV expertise leads to improved patient outcomes. The objective of this study is to determine whether HIV patients who can self-refer to specialists are more likely to have physicians who mainly treat HIV. The authors analyze cross-sectional survey data from the HIV Costs and Services Utilization Study. At baseline, 67 percent of patients had insurance that permitted self-referral. In multivariate analyses, being able to self-refer was associated with an 8-12 percent increased likelihood of having a physician at a regular source of care that mainly treats patients with HIV. Patients who can self-refer are more likely to have HIV-experienced physicians than are patients who need prior authorization. Insurance policies allowing self-referral to specialists may result in HIV patients seeing physicians with clinical expertise relevant to HIV care.

Adult↗
PubMed2005

Impact of patient race on receiving head CT during blunt head injury evaluation.

OBJECTIVES: Prior evidence suggests that physicians may alter process of care based on race/ethnicity. The objective of this study was to determine whether race/ethnicity predicts whether a patient receives computed tomography of the head (head CT) during evaluation of blunt head injury. METHODS: This was a nonconcurrent cohort study set in an emergency department of a Level 1 trauma center in a university medical center. Consecutive patients presenting with blunt head injury from January 2000 to December 2000 were enrolled. The main outcome measure was whether or not a patient received head CT during evaluation of blunt head injury. RESULTS: The unadjusted probability of receiving head CT was similar among minority (33.9%; 95% confidence interval [CI] = 30.0% to 38.1%) and non-Hispanic white patients (36.4%; 95% CI = 33.5% to 39.3%). After adjusting for important clinical and socioeconomic predictors, minority patients had a probability of receiving head CT 0.84 times as high as that of non-Hispanic whites, but this result was not statistically significant (95% CI = 0.67 to 1.09). CONCLUSIONS: Minority and non-Hispanic white patients may not have significantly different rates of receiving head CT during evaluation of blunt head injury. A multicenter prospective study is necessary to confirm these preliminary findings.

Adult↗
PubMed2005

Do the incentives in 3-tier pharmaceutical benefit plans operate as intended? Results from a physician leadership survey.

BACKGROUND: Three-tier pharmaceutical benefit systems use graded co-payments to steer patients toward "preferred" formulary medications. OBJECTIVES: To evaluate physicians' knowledge of formularies and out-of-pocket costs in such systems, as well as their perceived responsibility for helping patients manage out-of-pocket costs. STUDY DESIGN: Self-administered written survey. METHODS: Physician leaders participating in the California Medical Association Leadership Conference were surveyed. RESULTS: A total of 133 responses were received from 205 participants (65% response rate). Physicians reported that they were often unaware of patients' out-of-pocket costs at the time of prescribing. Fifty-nine percent of physicians reported that they never or seldom were aware of patients' "preferred" (lower cost) formulary options when prescribing, and 70% never or seldom were aware of patients' out-of-pocket costs when prescribing. Although 88% of physicians agreed that it is important that patients' out-of-pocket costs for prescription drugs are managed, only 25% strongly or somewhat agreed that it is their "responsibility" to help. Instead, 69% of physicians believed that it is the responsibility of the pharmacist to be familiar with patients' out-of-pocket costs. Physicians reported that they receive phone calls from pharmacists concerning formulary issues after 18.6% of the prescriptions they write. CONCLUSIONS: Physician leaders reported that they often do not possess the knowledge to assist patients in managing out-of-pocket costs for prescription drugs and they depend on pharmacists to communicate patient preferences in making prescribing decisions. As a result, price preferences are communicated indirectly, likely less efficiently, rather than intentionally when prescribing decisions are made.

Data Collection↗
PubMed2004

Linking hospital discharge and death records--accuracy and sources of bias.

BACKGROUND AND OBJECTIVE: The aim of this study was to develop and apply an automated linkage algorithm to 10 years of California hospitalization discharge abstracts and death records (1990 to 1999), evaluate linkage accuracy, and identify sources of bias. METHODS: Among the 1,858,458 acute hospital discharge records with unique social security numbers (SSNs) from 1 representative year of discharge data (1997), which had at least 2 years of follow-up, 66,410 of 69,757 deaths occurring in the hospital (95%) and 66,998 of 1,788,701 of individuals discharged alive (3.7%) linked to death records. Linkage sensitivity and specificity were estimated as 0.9524 and 0.9998 and positive and negative predictive values as 0.994 and 0.998 (corresponding to 400 incorrect death linkages among out-of-hospital death record linkages and 3,300 unidentified record pairs among unlinked live discharges). RESULTS: Based upon gold standard linkage rates, discharge records for those of age 1 year and older without SSNs may have 2,520 additional uncounted posthospitalization deaths at 1 year after admission. Gold standard comparison for those with SSNs showed women, the elderly, and Hispanics and non-Hispanic Blacks had more unlinked hospital death records, although absolute differences were small. The concentration of unidentified linkages among discharge records of traditionally vulnerable populations may result in understating mortality rates and other estimates (i.e., events with competing hazard of death) for these populations if SSN is differentially related to a patient's disease severity and comorbidities. CONCLUSION: Because identification of cases of out-of-hospital deaths has improved over the past decade, observed improvements in patient survival over this time are likely to be conservative.

Adolescent↗
PubMed2004

Accommodating ethnic diversity: a study of California hospice programs.

BACKGROUND: Studies have confirmed ethnic disparities in the use of hospice services and identified barriers that minorities face in accessing care. OBJECTIVES: We sought to determine whether hospices provide services that might affect minority participation. RESEARCH DESIGN: We surveyed California hospices to determine whether programs use diverse health care providers and volunteers, offer translation, diverse spiritual care, or outreach materials and whether they plan to expand such services. Linking the data to the California Office of Statewide Health Planning and Development annual home care and hospice survey and 2000 US Census, we used multivariate linear regression to evaluate the relationship of program characteristics (profit status, size, chain/freestanding status, urban/rural location, and proportion of nonwhite residents) to services that might affect minority participation. SUBJECTS: One hundred of 149 programs that we surveyed responded. RESULTS: Many programs offer translation (81%), diverse providers (63%) and volunteers (64%), and culturally diverse spiritual services (52%). Few (21%) were conducting outreach, but 23/25 programs expanding services reported plans to improve outreach. In multivariate models adjusted for program size, chain status, profit status, urban/rural location, proportion of nonwhite residents, we found that larger hospices and those in ethnically diverse zip codes were more likely to offer such services. Larger hospices are more likely to report expanding such services. CONCLUSIONS: Many hospices are making efforts to accommodate ethnically diverse patients, but a substantial number are not. Culturally appropriate care and outreach should be addressed in efforts to improve the acceptability and experience of hospice care among minorities.

California↗
PubMed2004

Hospice admission practices: where does hospice fit in the continuum of care?

OBJECTIVES: To evaluate selected hospice admission practices that could represent barriers to hospice use and the association between these admission practices and organizational characteristics. DESIGN: From December 1999 to March 2000, hospices were surveyed about selected admission practices, and their responses were linked to the 1999 California Office of Statewide Health Planning and Development's Home and Hospice Care Survey that describes organizational characteristics of California hospices. SETTING: California statewide. PARTICIPANTS: One hundred of 149 (67%) operational licensed hospices. MEASUREMENTS: Whether hospices admit patients who lack a caregiver; would not forgo hospital admissions; or are receiving total parenteral nutrition (TPN), tube feedings, radiotherapy, chemotherapy, or transfusions. RESULTS: Sixty-three percent of hospices restricted admission on at least one criterion. A significant minority of hospices would not admit patients lacking a caregiver (26%). Patients unwilling to forgo hospitalization could not be admitted to 29% of hospices. Receipt of complex medical care, including TPN (38%), tube feedings (3%), transfusions (25%), radiotherapy (36%), and chemotherapy (48%), precluded admission. Larger program size was significantly associated with a lower likelihood of all admission practices except restricting the admission of patients receiving TPN or tube feedings. Hospice programs that were part of a hospice chain were less likely to restrict the admission of patients using TPN, radiotherapy, or chemotherapy than were freestanding programs. CONCLUSION: Patients who are receiving complex palliative treatments could face barriers to hospice enrollment. Policy makers should consider the clinical capacity of hospice providers in efforts to improve access to palliative care and more closely incorporate palliation with other healthcare services.

Caregivers↗
PubMed2004

Socioeconomic status and health: a micro-level analysis of exposure and vulnerability to daily stressors.

This study examines the interconnections among education--as a proxy for socioeconomic status--stress, and physical and mental healthy by specifying differential exposure and vulnerability models using data from The National Study of Daily Experiences (N = 1,031). These daily diary data allowed assessment of the social distribution of a qualitatively different type of stressor than has previously been examined in sociological stress research--daily stressors, or hassles. Moreover, these data allowed a less biased assessment of stress exposure and a more micro-level examination of the connections between stress and healthy by socioeconomic status. Consistent with the broad literature describing socioeconomic inequalities in physical and mental health, the results of this study indicated that, on any given day, better-educated adults reported fewer physical symptoms and less psychological distress. Although better educated individuals reported more daily stressors, stressors reported by those with less education were more severe. Finally, neither exposure nor vulnerability explained socioeconomic differentials in daily health, but the results clearly indicate that the stressor-health association cannot be considered independent of socioeconomic status.

Adult↗
PubMed2003

Charity for the dying: who receives unreimbursed hospice care?

OBJECTIVES: Many deaths occur among persons without insurance coverage for hospice care. We examined the patient and agency characteristics associated with receiving unreimbursed hospice care in a national survey. RESULTS: We examined the receipt of unreimbursed care using the 1998 National Home and Hospice Care Survey (NHHCS) discharge dataset. Overall, only 3% of hospice patients received unreimbursed care. Because 98% of older adults are eligible for Medicare, we stratified multivariate analysis on age greater or less than 65 years. Among persons less than 65 years of age, younger, nonwhite persons were more likely to receive unreimbursed care, as were persons with cancer. Agencies providing unreimbursed care to persons over the age of 65 years were more likely to be not-for-profit and freestanding. CONCLUSION: Recipients of unreimbursed hospice care are demographically similar to the uninsured, and whether uninsured persons receive unreimbursed hospice care depends on clinical and agency organizational factors related to the motivation to provide unreimbursed care.

Age Distribution↗
PubMed2002

Contribution of major diseases to disparities in mortality.

BACKGROUND: Mortality from all causes is higher for persons with fewer years of education and for blacks, but it is unknown which diseases contribute most to these disparities. METHODS: We estimated cause-specific risks of death from data from the National Health Interview Survey conducted from 1986 through 1994 and from linked vital statistics. Using these risk estimates, we calculated potential years of life lost and potential gains in life expectancy related to specific causes, with stratification according to education level and race. RESULTS: Persons without a high-school education lost 12.8 potential life-years per person in the population, as compared with 3.6 for persons who graduated from high school (ratio, 3.5; P<0.001). Ischemic heart disease contributed most (11.7 percent) to the difference according to education in potential life-years lost (with all cardiovascular diseases accounting for 35.3 percent). All cancers accounted for 26.5 percent, including 7.7 percent due to lung cancer; other lung diseases and pneumonia contributed 10.1 percent of the total, whereas human immunodeficiency virus (HIV) disease accounted for none of the difference according to education. The pattern of disparities according to level of income was similar to that according to level of education. Blacks and whites lost 7.0 and 5.2 potential life-years per person, respectively, as a result of deaths from any cause (ratio, 1.35; P<0.001). Cardiovascular diseases accounted for one third of this disparity, in large part because of hypertension (15.0 percent); HIV disease (11.2 percent) contributed almost as much as ischemic heart disease (5.5 percent), stroke (2.8 percent), and cancer (3.4 percent) combined; trauma and diabetes mellitus accounted for 10.7 percent and 8.5 percent, respectively. CONCLUSIONS: Although many conditions contribute to socioeconomic and racial disparities in potential life-years lost, a few conditions account for most of these disparities - smoking-related diseases in the case of mortality among persons with fewer years of education, and hypertension, HIV, diabetes mellitus, and trauma in the case of mortality among black persons. These findings have important implications for targeting efforts to reduce existing disparities in mortality rates.

Black People↗
PubMed2002

Insurance coverage, medical conditions, and visits to alternative medicine providers: results of a national survey.

BACKGROUND: In 1997, patients made an estimated 629 million visits to complementary and alternative medicine (CAM) providers; however, little is known about factors associated with visits to CAM providers. OBJECTIVE: To examine the effect of insurance coverage on frequency of use of CAM providers. METHODS: We conducted a nationally representative, random household telephone survey of 2055 adults. MAIN OUTCOME MEASURE: The number of visits made to CAM providers. RESULTS: An estimated 44% of the US population used at least 1 CAM therapy in 1997. Of those using CAM, 52% had seen at least 1 CAM provider in the last year. Among those who used a CAM therapy, factors independently associated with seeing a provider were having been in the upper quartile of visits to conventional providers in the last year (adjusted odds ratio [AOR], 2.00; 95% confidence interval [CI], 1.33-3.01), female sex (AOR, 1.67; 95% CI, 1.17-2.38), and having used the therapy to treat diabetes (AOR, 5.20; 95% CI, 1.40-19.40), cancer (AOR, 2.99; 95% CI, 1.04-8.62), or back or neck problems (AOR, 1.51; 95% CI, 1.02-2.23). Factors independently associated with frequent use (. or = 8 visits per year) of a CAM provider were full insurance coverage of the CAM provider (AOR, 5.06; 95% CI, 2.45-10.47), partial insurance coverage (AOR, 3.26; 95% CI, 1.72-6.19), having used the therapy for wellness (AOR, 2.85; 95% CI, 1.63-4.98), and having seen the provider for back or neck problems (AOR, 2.26; 95% CI, 1.29-3.94). Conservative extrapolation to national estimates suggests that 8.9% of the population (17.5 million adults) accounted for more than 75% of the 629 million visits made to CAM providers in 1997. CONCLUSIONS: A small minority of persons accounted for more than 75% of visits to CAM providers. Extent of insurance coverage for CAM providers and use for wellness are strong correlates of frequent use of CAM providers.

Adult↗
PubMed2002

Cash and compassion: profit status and the delivery of hospice services.

OBJECTIVES: To evaluate the relationship of hospice profit status to patient selection and service delivery. DESIGN: We analyzed responses to the 1997 California Office of Statewide Health Planning and Development (OSHPD) annual home care and hospice survey. Outcomes included the percentages of patients with noncancer diagnoses, referred from long-term care, and with government payers; average length of stay (LOS); the intensity and skill mix of nursing services; and potential availability of chemotherapy and radiotherapy. Reduced models controlled for facility type, profit status, urbanicity, and patient-days. Complete models additionally controlled for patient gender, age, race/ethnicity, diagnosis, referral source, and primary reimbursement source. PARTICIPANTS: All 176 licensed California hospices in 1997. RESULTS: We report comparisons of for-profit and not-for-profit hospices as the absolute difference in percentage points between outcomes (e.g., a difference of 40% vs. 50% is reported as a 10 percentage point difference). In reduced models, for-profit hospices reported 17 percentage points more discharges with noncancer diagnoses, 15 percentage points more long-term care referrals, and 8 percentage points more patients with government payers. Average LOS did not differ by profit status. In reduced models, for-profit hospices delivered 0.20 more daily nursing visits on average; this difference was attributable to patient characteristics. The ratio of skilled to total nursing visits was 11 percentage points lower for for-profit hospices compared to not-for-profit hospices in reduced models (7 in complete models). Profit status was unrelated to the potential availability of chemotherapy and radiotherapy. CONCLUSION: For-profit hospices compared to not-for profit hospices serve a higher percentage of persons with noncancer diagnoses, residents of long-term care, and persons with government insurance. Differences in patterns of nursing services among hospices were related to patient characteristics. The potential availability of complex palliative services did not differ by profit status.

Aged↗
PubMed2002

Prescription of antipsychotic drugs by office-based physicians in the United States, 1989-1997.

OBJECTIVE: This study examined trends in the prescription of antipsychotic drugs in a nationally representative sample of physicians in nonfederal office-based clinical practice during the 1990s. METHODS: The authors analyzed physician-reported data from annual National Ambulatory Medical Care Surveys between 1989 and 1997 using weighted national estimates of physician visits during which antipsychotic drugs were prescribed. Prescription rates for antipsychotic drugs were compared between periods and among demographic, organizational, and clinical subgroups. RESULTS: Prescription of antipsychotic drugs in office-based practice increased significantly between 1989 and 1997. In 1989 antipsychotics were prescribed during 3.2 million office visits (.46 percent of all visits), compared with 6.9 million visits in 1997 (.88 percent). The atypical antipsychotics risperidone and olanzapine were the most widely prescribed antipsychotics in 1997. Risperidone was prescribed during 22.8 percent of all visits that involved prescription of an antipsychotic, and olanzapine during 17.1 percent. Psychiatrists were more likely than other physicians to prescribe an atypical agent (37.1 percent of visits involving prescription of an antipsychotic compared with 14.2 percent). Psychiatrists were also more likely than other physicians to schedule a follow-up visit after prescribing an antipsychotic (96.6 percent of visits compared with 73 percent). No evidence was found of a broadening of diagnostic indications for use over time. CONCLUSIONS: The rate of prescription of antipsychotic drugs among office-based physicians increased sharply during the 1990s after a nine-year decline. The increase was accounted for by growth in the use of atypical antipsychotics; the overall prescription rate of conventional agents did not change. Psychiatrists were more likely to prescribe atypical agents and to monitor more closely patients who were taking antipsychotics.

Drug Prescriptions↗
PubMedDate not supplied

How did the introduction of managed care for the uninsured in Iowa affect the use of substance abuse services?

Concerns about access under managed care have been raised for vulnerable populations such as publicly funded patients with substance abuse problems. To estimate the effects of the Iowa Managed Substance Abuse Care Plan (IMSACP) on substance abuse service use by publicly funded patients, service use before and after IMSACP was compared; adjustments were made for changes in population sociodemographic and clinical characteristics. Between fiscal years 1994 and 1997, patient case mix was marked by a higher burden of illness and the use of inpatient, residential nondetox, outpatient counseling, and assessment services declined, while use of intensive outpatient and residential detox services increased. Findings were similar among women, children, and homeless persons. Thus, care moved away from high-cost inpatient settings to less costly venues. Without knowing the impact on treatment outcomes, these changes cannot be interpreted as improved provider efficiency versus simply cost containment and profit maximization.

Database Management Systems↗
PubMedDate not supplied

The impact of managed care on the substance abuse treatment patterns and outcomes of Medicaid beneficiaries: Maryland's HealthChoice program.

The introduction of Medicaid managed care raises concern that profit motives lead to the undersupply of substance abuse (SA) services. To test effects of the Maryland Medicaid HealthChoice program on SA treatment patterns and outcomes, Medicaid eligibility files were linked to treatment provider records and two study designs were used to estimate program impact: a quasi-experimental design with matched comparison groups and a natural experiment. Patient sociodemographic and clinical characteristics were adjusted using multiple regression. Under managed care, there was a shift from residential, correctional-only, and detoxification-only treatment toward outpatient-only treatment. Among beneficiaries entering treatment, those enrolled in managed care organizations (MCOs) had similar utilization and outcomes to those in Medicaid fee-for-service; those enrolling in MCOs during treatment had longer and more intensive episodes and, as a result, better outcomes. Thus, the study disclosed no empirical evidence that health plans respond to capitation by reducing SA services.

Adolescent↗