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PubMed2005

Bone-conducted sound: physiological and clinical aspects.

OBJECTIVE: The fact that vibration of the skull causes a hearing sensation has been known since the 19th century. This mode of hearing was termed hearing by bone conduction. Although there has been more than a century of research on hearing by bone conduction, its physiology is not completely understood. Lately, new insights into the physiology of hearing by bone conduction have been reported. Knowledge of the physiology, clinical aspects, and limitations of bone conduction sound is important for clinicians dealing with hearing loss and is the purpose of this review. DATA SOURCES: The data were compiled from the published literature in the areas of clinical bone conduction hearing, bone conduction hearing aids, basic research on bone conduction physiology, and recent research on bone conduction hearing from our laboratory. CONCLUSION: Five factors contributing to bone conduction hearing have been identified: 1) sound radiated into the external ear canal, 2) middle ear ossicle inertia, 3) inertia of the cochlear fluids, 4) compression of the cochlear walls, and 5) pressure transmission from the cerebrospinal fluid. Of these five, inertia of the cochlear fluid seems most important. Bone conduction sound is believed to reflect the true cochlear function; however, certain conditions such as middle ear diseases can affect bone conduction sensitivity, but less than for air conduction. The bone conduction route can also be used for hearing aids; since the bone conduction route is less efficient than the air conduction route, bone conduction hearing aids are primarily used for hearing losses where air conduction hearing aids are contraindicated.

Basilar Membrane↗
PubMed2006

The personal and scientific feud between Ernst Brücke and Josef Hyrtl.

OBJECTIVE: To describe the events surrounding the personal and professional feud between Josef Hyrtl and Ernst Brücke and its impact on early investigations into the function of the semicircular canals of the inner ear. DATA SOURCES: Published data in scientific journals and news media, documents at the Vienna Institute for the History of Medicine, published personal letters, and an interview with Brücke's great-grandson, Dr. Thomas Brücke. CONCLUSION: Although Hyrtl was instrumental in recruiting Brücke to the University of Vienna, the two professors soon became embroiled in a feud that persisted throughout their academic careers. The difference in approach of these two giants in their field is well illustrated by their views on the function of the semicircular canals of the inner ear. Based on their shape, Hyrtl concluded that they were important for directional hearing, whereas based on animal experiments, Brücke concluded that they were sense organs for equilibrium.

Anatomy, Comparative↗
PubMed2004

Severity of injury and mortality associated with pediatric blunt injuries: hospitals with pediatric intensive care units versus other hospitals.

OBJECTIVE: To a) compare in-hospital mortality rates for pediatric (age <13 yrs) patients with blunt injuries in the New York State Trauma Registry based on hospital type (dedicated pediatric intensive care unit [PICU] and designated trauma centers and noncenters that do not have a dedicated PICU) for the purpose of determining whether there is a reduction in mortality at a specialty hospital and b) determine the extent to which high-risk patients are admitted to specialty hospitals. DATA SOURCE: Inpatient data for the years 1994-1998 in the New York State Trauma Registry. STUDY SELECTION: A total of 8,180 pediatric inpatients who suffered blunt injury were selected to examine where patients were treated (PICU, regional trauma center without PICU, area trauma center without PICU, or noncenter without PICU) as a function of injury severity. DATA EXTRACTION: Data were extracted for inpatients aged <13 yrs who suffered blunt injury. DATA SYNTHESIS: The injury severity of inpatients treated at PICUs and regional centers without PICUs was significantly higher than at other hospitals. Risk factors that were independently related to survival of pediatric trauma inpatients were age <5 yrs, motor component of one to five, abnormal systolic blood pressure relative to age, and International Classification of Disease, Ninth Revision-Based Injury Severity Score. Of the total 136 deaths, 133 were among the patients <5 yrs old, motor score <6, and age-related abnormal systolic blood pressure. A total of 66.8% of these patients were treated at PICUs, and 9.9% were treated at regional centers without PICUs. No statistically significant differences in risk-adjusted mortality rates were found by hospital type, but rates at PICUs were lower than for other types of hospitals except for noncenters without PICUs, whose patients were considerably less severely injured. CONCLUSIONS: There is significant triaging of the most seriously injured pediatric trauma inpatients to PICUs, and there is evidence that this policy is effective.

Child↗
PubMed2004

Effective trauma center partnerships to address firearm injury: a new paradigm.

BACKGROUND: Firearm violence is the second leading cause of injury-related death. This study examined the use of local trauma centers as lead organizations in their communities to address firearm injury. METHODS: Three trauma centers in cities with populations less than 100,000 were linked with a university-based firearm injury research center. A trauma surgeon director and coordinator partnered with communities, recruited and directed advisory boards, established a local firearm injury surveillance system, and informed communities using community-specific profiles. Primary process and outcome measures included completeness of data, development of community-specific profiles, number of data-driven consumer media pieces, number of meetings to inform policy makers, and an analysis of problems encountered. RESULTS: Local trauma centers in smaller communities implemented a firearm injury surveillance system, produced community-specific injury profiles, and engaged community leaders and policy makers to address firearm injury. Community-specific profiles demonstrated consistent firearm suicide rates (6.58-6.82 per 100,000) but variation in firearm homicide rates (1.08-12.5 per 100,000) across sites. There were 63 data-driven media pieces and 18 forums to inform community leaders and policy makers. Completeness of data elements ranged from 57.1% to 100%. Problems experienced were disconnected data sources, multiple data owners, potential for political fallout, limited trauma center data, skills sets of medical professionals, and sustainability. CONCLUSION: Trauma centers, when provided resources and support, with the model described, can function as lead organizations in partnering with the community to acquire and use community-specific data for local firearm injury prevention.

Adolescent↗
PubMed2006

Biological data warehousing system for identifying transcriptional regulatory sites from gene expressions of microarray data.

Identification of transcriptional regulatory sites plays an important role in the investigation of gene regulation. For this propose, we designed and implemented a data warehouse to integrate multiple heterogeneous biological data sources with data types such as text-file, XML, image, MySQL database model, and Oracle database model. The utility of the biological data warehouse in predicting transcriptional regulatory sites of coregulated genes was explored using a synexpression group derived from a microarray study. Both of the binding sites of known transcription factors and predicted over-represented (OR) oligonucleotides were demonstrated for the gene group. The potential biological roles of both known nucleotides and one OR nucleotide were demonstrated using bioassays. Therefore, the results from the wet-lab experiments reinforce the power and utility of the data warehouse as an approach to the genome-wide search for important transcription regulatory elements that are the key to many complex biological systems.

Algorithms↗
PubMed2003

Utilization of home health services before and after the Balanced Budget Act of 1997: what were the initial effects?

OBJECTIVE: To estimate the impact of the Balanced Budget Act of 1997 (BBA), which changed the way Medicare reimbursed for home health services, on a range of home health utilization measures, and to examine whether particular subgroups of beneficiaries were differentially impacted in the post-BBA period. DATA SOURCES: Secondary data from the Centers for Medicare and Medicaid Services (CMS) Standard Analytic Files for the 1 percent sample of Medicare beneficiaries for fiscal years 1997 and 1999, linked with information from CMS eligibility, provider, and cost report files as well as the Area Resources File. STUDY DESIGN: Logistic regression was used to estimate the effects of being in the post-BBA period on the incidence of home health service use and ordinary least squares (OLS) regression was used to estimate the effects of being in the post-BBA period on the amount and type of use by home health service users. Interaction terms we reincluded for all the independent variables to assess whether the effect was disproportionate among particular beneficiary subgroups. PRINCIPAL FINDINGS: Results show a 22 percent decrease in the percentage using home health services post-BBA and a 39 percent decrease in the number of visits per user. Stronger reductions, though not very large, were found in the incidence of use for beneficiaries aged 85 and older, those in states with high historical Medicare home health use, and those with Medicaid buy-in. More intensive reductions in the number of services were found for those aged 85 and older, in high historical Medicare use states, nonwhites, females, those using for-profit agencies, and those treated for certain diagnoses. Less intensive reductions were associated with hospital-based agencies. CONCLUSIONS: This research demonstrates that public program expenditures can be sharply curtailed with financial incentives. As reimbursement shifts to a prospective payment system legislated by the BBA, utilization should be closely monitored, especially for vulnerable subgroups.

Aged↗
PubMed2003

Chronic disease medication use in managed care and indemnity insurance plans.

OBJECTIVE: To evaluate the impact of managed care on the use of chronic disease medications. DATA SOURCE: Claims data from 1997 from two indemnity and three independent practice association (IPA) model managed care insurance plans. RESEARCH DESIGN: Cross-sectional analysis of claims data. DATA COLLECTION: Adult patients with diabetes mellitus (DM, n = 26,444), congestive heart failure (CHF, n = 7,978), and asthma (n = 9,850) were identified by ICD-9 codes. Chronic disease medication use was defined through pharmacy claims for patients receiving one or more prescriptions for drugs used in treating these conditions. Using multiple logistic regression we adjusted for patient case mix and the number of primary care visits. PRINCIPAL FINDINGS: With few exceptions, managed care patients were more likely to use chronic disease medications than indemnity patients. In DM, managed care patients were more likely to use sulfonylureas (43 percent versus 39 percent for indemnity), metformin (26 percent versus 18 percent), and troglitazone (8.8 percent versus 6.4 percent), but not insulin. For CHF patients, managed care patients were more likely to use loop diuretics (45 percent versus 41 percent), ACE inhibitors or angiotensin receptor blockers (50 percent versus 41 percent), and beta-blockers (23 percent versus 16 percent), but we found no differences in digoxin use. In asthma, managed care patients were more likely to use inhaled corticosteroids (34 percent versus 30 percent), systemic corticosteroids (18 percent versus 16 percent), short-acting beta-agonists (42 percent versus 33 percent), long-acting beta-agonists (9.9 percent versus 8.6 percent), and leukotriene modifiers (5.4 percent versus 4.1 percent), but not cromolyn or methylxanthines. Statistically significant differences remained after multivariate analysis that controlled for age, gender, and severity. CONCLUSIONS: Chronic disease patients in these managed care plans are more likely to receive both inexpensive and expensive medications. Exceptions included older medications partly supplanted by newer therapies. Differences may be explained by the fact that patients in indemnity plans face higher out-of-pocket costs and managed care plans promote more aggressive medication use. The relatively low likelihood of condition-specific medications in both plan types is a matter of concern, however.

Adult↗
PubMed2003

False positive mammograms and detection controlled estimation.

OBJECTIVE: To investigate the causes of false positive in mammograms. DATA SOURCES: Secondary data collected from extracts from computerized medical records from 1999 from five thousand patients at a single hospital in a medium-sized Southern city. STUDY DESIGN: Retrospective analysis of electronic medical data on screening and diagnostic mammograms. Detection-controlled estimation (DCE) was used to compare the efficacy of alternative readers of mammogram films. Analysis was also conducted on follow-up exams of women who tested positive in the first stage of investigation. Key variables included whether the patient had had a prior mammogram, age of the patient, and identifiers for the individual physicians. DATA COLLECTION/EXTRACTION METHODS: Hospital maintains electronic medical records (EMR) on all patients. Extracts were performed on this EMR system under the guidance of clinical expertise. Data were collected for all women who had mammograms in 1999. Random samples were employed for screening mammograms, and all data was used for diagnostic mammograms. PRINCIPAL FINDINGS: Study results imply that access to a previous mammogram greatly reduces the incidence of false positives readings. This has important consequences for benefit-cost, and cost-effectiveness analysis of mammography. Were previous mammograms always available, the results imply the number of false positives would decrease by at least half. The results here also indicate that there is no reason to believe this decrease in false positive would be accompanied by an increase in the number of false negatives. Other attributes also affected the number of false positives. Mondays and Wednesdays appear to be more prone to false positives than the other days in the week. There is also some disparity in false positive outcomes among the five physicians studied. With respect to detection-controlled estimation, the results are mixed. With follow-up data, the DCE estimator appears to generate reasonable, robust results. Without follow-up data, however, the DCE estimator is far less precise. CONCLUSIONS: Study results imply that access to a previous mammogram reduces by at least half the incidence of false positives readings. This has important consequences for benefit-cost, and cost-effectiveness analysis of mammography.

Algorithms↗
PubMed2003

Using claims data to examine mortality trends following hospitalization for heart attack in Medicare.

OBJECTIVE: To see if changes in the demographics and illness burden of Medicare patients hospitalized for acute myocardial infarction (AMI) from 1995 through 1999 can explain an observed rise (from 32 percent to 34 percent) in one-year mortality over that period. DATA SOURCES: Utilization data from the Centers for Medicare and Medicaid Services (CMS) fee-for-service claims (MedPAR, Outpatient, and Carrier Standard Analytic Files); patient demographics and date of death from CMS Denominator and Vital Status files. For over 1.5 million AMI discharges in 1995-1999 we retain diagnoses from one year prior, and during, the case-defining admission. STUDY DESIGN: We fit logistic regression models to predict one-year mortality for the 1995 cases and apply them to 1996-1999 files. The CORE model uses age, sex, and original reason for Medicare entitlement to predict mortality. Three other models use the CORE variables plus morbidity indicators from well-known morbidity classification methods (Charlson, DCG, and AHRQ's CCS). Regressions were used as is--without pruning to eliminate clinical or statistical anomalies. Each model references the same diagnoses--those recorded during the pre- and index admission periods. We compare each model's ability to predict mortality and use each to calculate risk-adjusted mortality in 1996-1999. PRINCIPAL FINDINGS: The comprehensive morbidity classifications (DCG and CCS) led to more accurate predictions than the Charlson, which dominated the CORE model (validated C-statistics: 0.81, 0.82, 0.74, and 0.66, respectively). Using the CORE model for risk adjustment reduced, but did not eliminate, the mortality increase. In contrast, adjustment using any of the morbidity models produced essentially flat graphs. CONCLUSIONS: Prediction models based on claims-derived demographics and morbidity profiles can be extremely accurate. While one-year post-AMI mortality in Medicare may not be worsening, outcomes appear not to have continued to improve as they had in the prior decade. Rich morbidity information is available in claims data, especially when longitudinally tracked across multiple settings of care, and is important in setting performance targets and evaluating trends.

Adolescent↗
PubMed2002

Does prospective payment really contain nursing home costs?

OBJECTIVE: To examine whether nursing homes would behave more efficiently, without compromising their quality of care, under prospective payment. DATA SOURCES: Four data sets for 1994: the Skilled Nursing Facility Minimum Data Set, the Online Survey Certification and Reporting System file, the Area Resource File, and the Hospital Wage Indices File. A national sample of 4,635 nursing homes is included in the analysis. STUDY DESIGN: Using a modified hybrid functional form to estimate nursing home costs, we distinguish our study from previous research by controlling for quality differences (related to both care and life) and addressing the issues of output and quality endogeneity, as well as using more recent national data. Factor analysis was used to operationalize quality variables. To address the endogeneity problems, instrumental measures were created for nursing home output and quality variables. PRINCIPAL FINDINGS: Nursing homes in states using prospective payment systems do not have lower costs than their counterpart facilities under retrospective cost-based payment systems, after quality differences among facilities are controlled for and the endogeneity problem of quality variables is addressed. CONCLUSIONS: The effects of prospective payment on nursing home cost reduction may be through quality cuts, rather than cost efficiency. If nursing home payments under prospective payment systems are not adjusted for quality, nursing homes may respond by cutting their quality levels, rather than controlling costs. Future outcomes research may provide useful insights into the adjustment of quality in the design of prospective payment for nursing home care.

Cost Control↗
PubMed2002

Nursing home case-mix reimbursement in Mississippi and South Dakota.

OBJECTIVE: To evaluate the effects of nursing home case-mix reimbursement on facility case mix and costs in Mississippi and South Dakota. DATA SOURCES: Secondary data from resident assessments and Medicaid cost reports from 154 Mississippi and 107 South Dakota nursing facilities in 1992 and 1994, before and after implementation of new case-mix reimbursement systems. STUDY DESIGN: The study relied on a two-wave panel design to examine case mix (resident acuity) and direct care costs in 1-year periods before and after implementation of a nursing home case-mix reimbursement system. Cross-lagged regression models were used to assess change in case mix and costs between periods while taking into account facility characteristics. DATA COLLECTION: Facility-level measures were constructed from Medicaid cost reports and Minimum Data Set-Plus assessment records supplied by each state. Resident case mix was based on the RUG-III classification system. PRINCIPAL FINDINGS: Facility case-mix scores and direct care costs increased significantly between periods in both states. Changes in facility costs and case mix were significantly related in a positive direction. Medicare utilization and the rate of hospitalizations from the nursing facility also increased significantly between periods, particularly in Mississippi. CONCLUSIONS: The case-mix reimbursement systems appeared to achieve their intended goals: improved access for heavy-care residents and increased direct care expenditures in facilities with higher acuity residents. However, increases in Medicare utilization may have influenced facility case mix or costs, and some facilities may have been unprepared to care for higher acuity residents, as indicated by increased rates of hospitalization.

Diagnosis-Related Groups↗
PubMed2004

Do drug-free workplace programs prevent occupational injuries? Evidence from Washington State.

OBJECTIVE: To evaluate the effect of a publicly sponsored drug-free workplace program on reducing the risk of occupational injuries. DATA SOURCES: Workers' compensation claims data from the Washington State Department of Labor and Industries covering the period 1994 through 2000 and work-hours data reported by employers served as the data sources for the analysis. STUDY DESIGN: We used a pre-post design with a nonequivalent comparison group to assess the impact of the intervention on injury risk, measured in terms of differences in injury incidence rates. Two hundred and sixty-one companies that enrolled in the drug-free workplace program during the latter half of 1996 were compared with approximately 20,500 nonintervention companies. We tested autoregressive, integrated moving-average (ARIMA) models to assess the robustness of our findings. PRINCIPAL FINDINGS: The drug-free workplace intervention was associated (p < .05) with a statistically significant decrease in injury rates for three industry groups: construction, manufacturing, and services. It was associated (p < .05) with a reduction in the incidence rate of more serious injuries involving four or more days of lost work time for two industry groups: construction and services. The ARIMA analysis supported CONCLUSIONS: The drug-free workplace program we studied was associated with a selective, industry-specific preventive effect. The strongest evidence of an intervention effect was for the construction industry. Estimated net cost savings for this industry were positive though small in magnitude.

Accidents, Occupational↗
PubMed2004

The lifetime distribution of health care costs.

OBJECTIVE: To estimate the magnitude and age distribution of lifetime health care expenditures. DATA SOURCES: Claims data on 3.75 million Blue Cross Blue Shield of Michigan members, and data from the Medicare Current Beneficiary Survey, the Medical Expenditure Panel Survey, the Michigan Mortality Database, and Michigan nursing home patient counts. DATA COLLECTION: Data were aggregated and summarized in year 2000 dollars by service, age, and gender. STUDY DESIGN: We use life table models to simulate a typical lifetime's distribution of expenditures, employing cross-sectional data on age- and sex-specific health care costs and the mortality experience of the population. We determine remaining lifetime expenditures at each age for all initial members of a birth cohort. Separately, we calculate remaining expenditures for survivors at all ages. Using cross-sectional data, the analysis holds disease incidence, medical technology, and health care prices constant, thus permitting an exclusive focus on the role of age in health care costs. PRINCIPAL FINDINGS: Per capita lifetime expenditure is USD $316,600, a third higher for females (USD $361,200) than males (USD $268,700). Two-fifths of this difference owes to women's longer life expectancy. Nearly one-third of lifetime expenditures is incurred during middle age, and nearly half during the senior years. For survivors to age 85, more than one-third of their lifetime expenditures will accrue in their remaining years. CONCLUSIONS: Given the essential demographic phenomenon of our time, the rapid aging of the population, our findings lend increased urgency to understanding and addressing the interaction between aging and health care spending.

Adolescent↗
PubMed2004

The effect of benefits, premiums, and health risk on health plan choice in the Medicare program.

OBJECTIVE: To estimate the effect of Medicare+Choice (M+C) plan premiums and benefits and individual beneficiary characteristics on the probability of enrollment in a Medicare+Choice plan. DATA SOURCE: Individual data from the Medicare Current Beneficiary Survey were combined with plan-level data from Medicare Compare. STUDY DESIGN: Health plan choices, including the Medicare+Choice/Fee-for-Service decision and the choice of plan within the M+C sector, were modeled using limited information maximum likelihood nested logit. PRINCIPAL FINDINGS: Premiums have a significant effect on plan selection, with an estimated out-of-pocket premium elasticity of -0.134 and an insurer-perspective elasticity of -4.57. Beneficiaries are responsive to plan characteristics, with prescription drug benefits having the largest marginal effect. Sicker beneficiaries were more likely to choose plans with drug benefits and diabetics were more likely to pick plans with vision coverage. CONCLUSIONS: Plan characteristics significantly impact beneficiaries' decisions to enroll in Medicare M+C plans and individuals sort themselves systematically into plans based on individual characteristics.

Aged↗
PubMed2004

Hospice use by Hispanic and non-Hispanic white cancer decedents.

OBJECTIVE: To investigate rates of hospice use between Hispanic and non-Hispanic white Medicare beneficiaries diagnosed with cancer using data from a large, population-based study. DATA SOURCES: Secondary data from the linked SEER-Medicare database including the SEER areas of Los Angeles, San Francisco, and San Jose-Monterey, California, and the state of New Mexico. All subjects were Hispanic or non-Hispanic whites, aged 67 and older, had a cancer diagnosis of breast, colorectal, lung, or prostate cancer from 1991-1996, and died of cancer from 1991-1998. STUDY DESIGN: This study employed a retrospective cohort design to compare rates of hospice use between Hispanics and non-Hispanic whites across patient characteristics and over time. PRINCIPAL FINDINGS: Rates of hospice use were similar for Hispanics (39.2 percent) and non-Hispanic whites (41.5 percent). In a bivariate logistic regression model, Hispanics were significantly less likely to use hospice than non-Hispanic whites (OR 0.91; 95 percent CI 0.85-0.97). However, after adjusting for age, marital status, sex, educational attainment, income, urban versus rural residence, and type of insurance using multivariate logistic regression analysis, the estimated odds for being a hospice user among Hispanics is similar to the odds of being a hospice user among non-Hispanic whites (OR 1.05; 95 percent CI 0.98-1.13). Stratified analyses revealed significant differences between ethnic groups in the use of hospice by type of insurance and SEER area, indicating interactions between ethnicity and these variables. CONCLUSIONS: Our findings indicate similar rates of hospice use for Hispanics and non-Hispanic whites diagnosed with one of the four leading cancers. Additional studies from other national registries may be necessary to confirm these findings.

Aged↗
PubMed2004

Care following acute myocardial infarction in the Veterans Administration Medical Centers: a comparison with Medicare.

OBJECTIVE: To compare patients treated for acute myocardial infarction (AMI) in a Veterans Health Administration (VHA) facility to similar patients treated under Medicare. DATA SOURCES: Administrative data on 13,129 elderly male veterans hospitalized for AMI in a VHA facility between October 1, 1996, and September 30, 1999, and a matched set of male Medicare beneficiaries with AMI treated in a non-VHA facility during the same time period. STUDY DESIGN: We conducted a retrospective cohort study using propensity score methods to identify a matched set of male elderly AMI patients treated either in a VHA facility or in a non-VHA facility under Medicare. We compared the two groups of patients according to characteristics of the admitting hospital, distances traveled for care, the use of invasive procedures, and mortality. We assessed the robustness of our conclusions to biases arising from unmeasured confounders using sensitivity analyses. PRINCIPAL FINDINGS: VHA patients were significantly less likely than Medicare beneficiaries to be admitted to high-volume facilities (for example, 25 percent versus 46 percent in 1999, p<0.001) or facilities with the capability to perform invasive cardiac procedures. Compared to Medicare patients, VHA patients traveled almost twice as far to their admitting hospital. The VHA patients were significantly less likely to undergo coronary angiography or revascularization in the 30 days following their AMI (p<0.001 for all comparisons). Veterans treated in the VHA had significantly higher mortality at one-year in all years studied (for example, 35.2 percent versus 30.6 percent in 1999). The proportion of elderly VHA patients admitted to high-volume facilities increased and 30-day mortality rates decreased between 1997 and 1999. Using sensitivity analyses to assess possible effects of unmeasured confounders, we could explain some but not all of the observed mortality differences. CONCLUSIONS: We observed differences in the way care for AMI patients was structured, in the use of invasive therapies, and in long term mortality between patients treated in VHA hospitals and those treated in non-VHA facilities under Medicare. Future research should focus on explanations for the differences between the two systems and for the reduction in short-term mortality among VHA patients. Further study of these differences both between and within the systems of care may help identify cost-effective strategies to improve care in both sectors.

Aged↗
PubMed2004

Understanding employee awareness of health care quality information: how can employers benefit?

OBJECTIVE: To analyze the factors associated with employee awareness of employer-disseminated quality information on providers. DATA SOURCES: Primary data were collected in 2002 on a stratified, random sample of 1,365 employees in 16 firms that are members of the Buyers Health Care Action Group (BHCAG) located in the Minneapolis-St. Paul region. An employer survey was also conducted to assess how employers communicated the quality information to employees. STUDY DESIGN: In 2001, BHCAG sponsored two programs for reporting provider quality. We specify employee awareness of the quality information to depend on factors that influence the benefits and costs of search. Factors influencing the benefits include age, sex, provider satisfaction, health status, job tenure, and Twin Cities tenure. Factors influencing search costs include employee income, education, and employer communication strategies. We estimate the model using bivariate probit analysis. DATA COLLECTION: Employee data were collected by phone survey. PRINCIPAL FINDINGS: Overall, the level of quality information awareness is low. However, employer communication strategies such as distributing booklets to all employees or making them available on request have a large effect on the probability of quality information awareness. Employee education and utilization of providers' services are also positively related to awareness. CONCLUSIONS: This study is one of the first to investigate employee awareness of provider quality information. Given the direct implications for medical outcomes, one might anticipate higher rates of awareness regarding provider quality, relative to plan quality. However, we do not find empirical evidence to support this assertion.

Awareness↗
PubMed2005

The administrative control system of substance abuse managed care.

OBJECTIVE: This article searches for the dimensions of the administrative structures in outpatient substance abuse managed care that control the behavior of agency providers. It also ascertains how these dimensions, and several financial mechanisms, affect key aspects of the providers services: the average number of sessions of care that are delivered, the rate of completion of care, and the (estimated) rate at which clients control their substance use. DATA SOURCES: The data were collected in 1999 for this investigation. STUDY DESIGN: These data come from a nationally representative, cross-sectional sample of individual contracts between outpatient drug treatment providers and the Behavioral Health Managed Care Organizations (BHMCOs) that are empowered to regulate the delivery of services. Provider responses are analyzed here. DATA COLLECTION METHODS: Factor analyses at a contract level examine the structural dimensions of the control system. Multivariate analyses at the same level rely on generalized linear models to predict the dependent variables by the structural dimensions and financial mechanisms. FINDINGS: The factor analyses suggest that there are six multiple variable structural dimensions. The multivariate analyses suggest that the dimension that mandates follow-up of discharged clients tends to relate to more sessions of care and perhaps a higher rate of service completion. Most other dimensions are found to relate to fewer sessions of care, lower rates of service completion, or lower rates of control of substance abuse. No structural dimension relates to all dependent variables. Financial mechanisms evince varying relations to the sessions of care. They rarely relate to the other dependent variables. CONCLUSION: The results generally suggest that providers, payers, or policymakers might affect service provision by selecting BHMCOs that stress particular structural dimensions and financial mechanisms. However, managed care contracts most heavily rely on structural dimensions that restrict treatment sessions and fail to predict superior client outcomes.

Ambulatory Care↗