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PubMed2003

Managed care organizational characteristics and health care use among children with special health care needs.

OBJECTIVE: To examine the relationship between features of managed care organizations (MCOs) and health care use patterns by children. DATA SOURCES: Telephone survey data from 2,223 parents of children with special health care needs, MCO-administrator interview data, and health care claims data. STUDY DESIGN: Cross-sectional survey data from families about the number of consequences of their children's conditions and from MCO administrators about their plans' organizational features were used. Indices reflecting the MCO characteristics were developed using data reduction techniques. Hierarchical models were developed to examine the relationship between child sociodemographic and health characteristics and the MCO indices labeled: Pediatrician Focused (PF) Index, Specialist Focused (SF) Index, and Fee for Service (FFS) Index, and outpatient use rates and charges, inpatient admissions, emergency room (ER) visits, and specialty consultations. DATA COLLECTION/EXTRACTION METHODS: The telephone and MCO-administrator survey data were linked to the enrollment and claims files. PRINCIPAL FINDINGS: The child's age, gender, and condition consequences were consistent predictor variables related to health care use and charges. The PF Index was associated with decreased outpatient use rates and charges and decreased inpatient admissions. The SF Index was associated with increased ER visits and decreased specialty consultations, while the FFS Index was associated with increased outpatient use rates and charges. CONCLUSION: After controlling for sociodemographic and health characteristics, the PF, SF, and FFS indices were significantly associated with children's health care use patterns.

Adolescent↗
PubMed2003

What new knowledge would help policymakers better balance investments for optimal health outcomes?

OBJECTIVE: Review the limitations in cross-sectoral health outcomes research and suggest a future research agenda. DATA SOURCES, STUDY DESIGN, DATA COLLECTION: Literature review and workshop discussion. PRINCIPAL FINDINGS: The research evidence that would aid public and private policy makers in answering the question the title poses is quite limited. CONCLUSIONS: Much more evidence from diverse disciplines is needed, and key areas are suggested. Criteria for progress by 2010 are proposed.

Evidence-Based Medicine↗
PubMed2004

Moving beyond the typologies of managed care: the example of health plan predictors of screening mammography.

OBJECTIVES: To develop a framework of factors to characterize health plans, to identify how plan characteristics were measured in a national survey, and to apply our findings to an analysis of the predictors of screening mammography. DATA SOURCE: The primary data were from the 1996 Medical Expenditure Panel Survey. STUDY DESIGN: Women ages 40+, with private insurance, and no history of breast cancer were included in the study (N = 2,909). We used multivariate logistic regression to estimate mammography utilization in the past two years relative to health plan and demographic factors. Health plan measures included whether there is a defined provider network, whether coverage is restricted to a network, use of gatekeepers, level of cost containment, copayment and deductible amounts, coinsurance rate, and breadth of benefit coverage. PRINCIPAL FINDINGS: We found no significant difference in reported mammography utilization using a dichotomous comparison of individuals enrolled in managed care versus indemnity plans. However, women in health plans with a defined provider network were more likely to report having received a mammogram in the past two years than those without networks (adjusted OR= 1.21, 95 percent CI = 1.07-1.36), and women in gatekeeper plans were more likely to report receiving mammography than those without gatekeepers (adjusted OR = 1.18, 95 percent CI = 1.03-1.36). Restricted out-of-network coverage, use of cost containment, enrollee cost sharing, and breadth of benefit coverage did not appear to affect mammography use. CONCLUSIONS: It is important to examine the effect of individual health plan components on the utilization of health care, rather than use the traditional broader categorizations of managed versus nonmanaged care or simple health plan typologies.

Adult↗
PubMed2004

Patient satisfaction, treatment experience, and disability outcomes in a population-based cohort of injured workers in Washington State: implications for quality improvement.

OBJECTIVE: To determine what aspects of patient satisfaction are most important in explaining the variance in patients' overall treatment experience and to evaluate the relationship between treatment experience and subsequent outcomes. DATA SOURCES AND SETTING: Data from a population-based survey of 804 randomly selected injured workers in Washington State filing a workers' compensation claim between November 1999 and February 2000 were combined with insurance claims data indicating whether survey respondents were receiving disability compensation payments for being out of work at 6 or 12 months after claim filing. STUDY DESIGN: We conducted a two-step analysis. In the first step, we tested a multiple linear regression model to assess the relationship of satisfaction measures to patients' overall treatment experience. In the second step, we used logistic regression to assess the relationship of treatment experience to subsequent outcomes. PRINCIPAL FINDINGS: Among injured workers who had ongoing follow-up care after their initial treatment (n = 681), satisfaction with interpersonal and technical aspects of care and with care coordination was strongly and positively associated with overall treatment experience (p < 0.001). As a group, the satisfaction measures explained 38 percent of the variance in treatment experience after controlling for demographics, satisfaction with medical care prior to injury, job satisfaction, type of injury, and provider type. Injured workers who reported less-favorable treatment experience were 3.54 times as likely (95 percent confidence interval, 1.20-10.95, p = .021) to be receiving time-loss compensation for inability to work due to injury 6 or 12 months after filing a claim, compared to patients whose treatment experience was more positive.

Aged↗
PubMed2006

Overcoming bias in estimating the volume-outcome relationship.

OBJECTIVE: To examine the effect of hospital volume on 30-day mortality for patients with congestive heart failure (CHF) using administrative and clinical data in conventional regression and instrumental variables (IV) estimation models. DATA SOURCES: The primary data consisted of longitudinal information on comorbid conditions, vital signs, clinical status, and laboratory test results for 21,555 Medicare-insured patients aged 65 years and older hospitalized for CHF in northeast Ohio in 1991-1997. STUDY DESIGN: The patient was the primary unit of analysis. We fit a linear probability model to the data to assess the effects of hospital volume on patient mortality within 30 days of admission. Both administrative and clinical data elements were included for risk adjustment. Linear distances between patients and hospitals were used to construct the instrument, which was then used to assess the endogeneity of hospital volume. PRINCIPAL FINDINGS: When only administrative data elements were included in the risk adjustment model, the estimated volume-outcome effect was statistically significant (p=.029) but small in magnitude. The estimate was markedly attenuated in magnitude and statistical significance when clinical data were added to the model as risk adjusters (p=.39). IV estimation shifted the estimate in a direction consistent with selective referral, but we were unable to reject the consistency of the linear probability estimates. CONCLUSIONS: Use of only administrative data for volume-outcomes research may generate spurious findings. The IV analysis further suggests that conventional estimates of the volume-outcome relationship may be contaminated by selective referral effects. Taken together, our results suggest that efforts to concentrate hospital-based CHF care in high-volume hospitals may not reduce mortality among elderly patients.

Aged↗
PubMed2006

Managed care market share and primary treatment for cancer.

OBJECTIVE: Increases in the market share of managed care are associated with decreases in expenditures in the fee-for-service sector. To understand utilization patterns responsible for such savings, we assessed whether increases in managed care market share were related to increases in receipt of equally effective but less costly primary cancer therapies. DATA SOURCES: Cancer registry data linked to Medicare administrative data for a population-based sample of fee-for-service Medicare beneficiaries 66 years and older who were diagnosed with breast or prostate cancer during 1993-1999. STUDY DESIGN: We used fixed-effects regression models to assess whether county-level increases in the market share of managed care were associated with differences in receipt of cancer therapies that are similar in effectiveness but vary in cost. PRINCIPAL FINDINGS: Increases in the market share of managed care were not associated with differences in the receipt of mastectomy versus breast-conserving surgery with radiation for women with early stage breast cancer (p=.47) or with the receipt of conservative therapy (versus surgery or radiation therapy) for men with local or regional prostate cancer (p=.30). CONCLUSIONS: Increases in the market share of managed care do not appear to influence the receipt of equally effective primary treatments for cancer in the fee-for-service sector.

Aged↗
PubMed2006

The effect of cuts in medicare reimbursement on hospital mortality.

OBJECTIVE: To determine if patients treated at hospitals under different levels of financial strain from the Balanced Budget Act (BBA) of 1997 had differential changes in 30-day mortality, and whether vulnerable patient populations such as the uninsured were disproportionately affected. DATA SOURCE: Hospital discharge data from all general acute care hospitals in Pennsylvania from 1997 to 2001. STUDY DESIGN: A multivariate regression analysis was performed retrospectively on 30-day mortality rates, using hospital discharge data, hospital financial data, and death certificate information from Pennsylvania. DATA COLLECTION: We used 370,017 hospital episodes with one of four conditions identified by the Agency for Healthcare Research and Quality as inpatient quality indicators were extracted. PRINCIPAL FINDINGS: The average magnitude of Medicare payment reduction on overall net revenues was estimated at 1.8 percent for hospitals with low BBA impact and 3.6 percent for hospitals with a high impact in 1998, worsening to 2 and 4.8 percent, respectively, by 2001. Operating margins decreased significantly over the time period for all hospitals (p<.05). While unadjusted mortality rates demonstrated a disproportionate rise in mortality for patients from high impact hospitals from 1997 to 2000, adjusted analyses show no consistent, significant difference in the rate of change in mortality between high-impact and low-impact hospitals (p=.04-.94). Similarly, uninsured patients did not experience greater increases in mortality in high-impact hospitals relative to low-impact hospitals. CONCLUSIONS: An analysis of hospitalizations in the Commonwealth of Pennsylvania did not find an adverse impact of increased financial strain from the BBA on patient mortality either among all patients or among the uninsured.

Aged↗
PubMed2006

Effects of compensation methods and physician group structure on physicians' perceived incentives to alter services to patients.

OBJECTIVE: To examine how health plan payment, group ownership, compensation methods, and other practice management tools affect physician perceptions of whether their overall financial incentives tilt toward increasing or decreasing services to patients. DATA SOURCE: Nationally representative data on physicians are from the 2000-2001 Community Tracking Study Physician Survey (N=12,406). STUDY DESIGN: Ordered and multinomial logistic regression were used to explore how physician, group, and market characteristics are associated with physician reports of whether overall financial incentives are to increase services, decrease services, or neither. PRINCIPAL FINDINGS: Seven percent of physicians report financial incentives are to reduce services to patients, whereas 23 percent report incentives to increase services. Reported incentives to reduce services were associated with reports of lower ability to provide quality care. Group revenue in the form of capitation was associated with incentives to reduce services whereas practice ownership and variable compensation and bonuses for employee physicians were mostly associated with incentives to increase services to patients. Full ownership of groups, productivity incentives, and perceived competitive markets for patients were associated with incentives to both increase and reduce services. CONCLUSIONS: Practice ownership and the ways physicians are compensated affect their perceived incentives to increase or decrease services to patients. In the latter case, this adversely affects perceived quality of care and satisfaction, although incentives to increase services may also have adverse implications for quality, cost, and insurance coverage.

Attitude of Health Personnel↗
PubMed2006

A cost analysis of the Iowa Medicaid primary care case management program.

OBJECTIVE: To determine the cost savings attributable to the implementation and expansion of a primary care case management (PCCM) program on Medicaid costs per member in Iowa from 1989 to 1997. DATA SOURCES: Medicaid administrative data from Iowa aggregated at the county level. STUDY DESIGN: Longitudinal analysis of costs per member per month, analyzed by category of medical expense using weighted least squares. We compared the actual costs with the expected costs (in the absence of the PCCM program) to estimate cost savings attributable to the PCCM program. PRINCIPAL FINDINGS: We estimated that the PCCM program was associated with a savings of US dollars 66 million to the state of Iowa over the study period. Medicaid expenses were 3.8 percent less than what they would have been in the absence of the PCCM program. Effects of the PCCM program appeared to grow stronger over time. Use of the PCCM program was associated with increases in outpatient care and pharmaceutical expenses, but a decrease in hospital and physician expenses. CONCLUSIONS: Use of a Medicaid PCCM program was associated with substantial aggregate cost savings over an 8-year period, and this effect became stronger over time. Cost reductions appear to have been mediated by substituting outpatient care for inpatient care.

Adolescent↗
PubMed2006

Will choice-based reform work for Medicare? Evidence from the Federal Employees Health Benefits Program.

OBJECTIVE: . To examine the effect of premiums and benefits on the health plan choices of older enrollees who choose Federal Employees Health Benefits Program (FEHBP) health plans as their primary payer. DATA SOURCES: Administrative enrollment data from the Office of Personnel Management (OPM) and plan premiums and benefits data taken from the Checkbook Guide to health plans. STUDY DESIGN: We estimate individual plan choice models where the choice of health plan is a function of out-of-pocket premium, actuarial value, plan attributes, and individual characteristics. Plan attributes include plan structure (fee-for-service/preferred provider organization, point-of-service, or health maintenance organization), drug benefit structure, and whether or not the plan covers other types of spending such as dental services and diabetic supplies. The models are estimated by conditional logit. Our study focuses on three populations that currently choose FEHBP as their primary health care coverage and are similar to the Medicare population: current employees and retirees who are approaching the age of Medicare eligibility (ages 60-64) and current federal employees age 65+. Current employees age 65+ are eligible for Medicare, but their FEHBP plan is their primary payer. Retirees and employees 60-64 are not yet eligible for Medicare but are similar in many respects to recently age-eligible Medicare beneficiaries. We also estimate our model for current employees age 55 and younger as a comparison group. DATA COLLECTION METHODS: We select a random sample of retirees and employees age 60-64, as well as all current employees age 65+, from the OPM administrative database for the calendar year 2001. The plan choices available to each person are determined by the plans participating in their metropolitan statistical area. We match plan premium and attribute information from the Checkbook Guide to each plan in the enrollee's list of choices. PRINCIPAL FINDINGS: We find that current workers 65+, 60-64, and non-Medicare eligible retirees are sensitive to variation in plan premiums. The premium elasticities for these groups are similar in magnitude to those of the age 55 and under employee group. Older workers and retirees not yet eligible for Medicare are willing to pay a substantial amount for plans with open provider networks. The willingness to pay for open networks is significantly greater for these groups than for younger employees. Willingness to pay for open network plans varies significantly by income, but varies little by age within group. CONCLUSIONS: Our finding that older workers and non-Medicare eligible retirees are sensitive to plan premiums suggests that choice-based reform of Medicare would lead to cost-conscious choices by Medicare beneficiaries. However, our finding that these groups are willing to pay more for open network plans than younger employees suggest that higher risk individuals may migrate toward higher benefit, higher cost plans. Our findings on the relationship between income and willingness to pay for open network plans suggest that means testing is a viable reform for lowering Medicare program costs.

Adult↗
PubMed2001

The point of triangulation.

PURPOSE: To explore various types of triangulation strategies and to indicate when different types of triangulation should be used in research. METHODS: Reviews included literature on triangulation and multimethod strategies published since 1960 and research books specifically focusing on triangulation. FINDINGS: Triangulation is the combination of at least two or more theoretical perspectives, methodological approaches, data sources, investigators, or data analysis methods. The intent of using triangulation is to decrease, negate, or counterbalance the deficiency of a single strategy, thereby increasing the ability to interpret the findings. CONCLUSIONS: The use of triangulation strategies does not strengthen a flawed study. Researchers should use triangulation if it can contribute to understanding the phenomenon; however, they must be able to articulate why the strategy is being used and how it might enhance the study.

Humans↗
PubMed1997

Oral lichenoid drug eruptions.

OBJECTIVES: To identify, from amongst drugs reported as causing lichenoid drug eruptions, those affecting the oral mucous membranes and to review the clinical, histological and immunological features of such oral lichenoid drug eruptions in comparison to oral lichen planus, amalgam contact lesions and lichen planus-like eruption in graft-versus-host disease (GVHD). DATA SOURCES: Ovid Medline data searches on CD-Rom were carried out for the years 1966-1996 to identify reports of oral lichenoid drug eruptions and their clinical, histological and immunological features. Articles retrieved were examined for further appropriate references in the period 1940-1996. DATA EXTRACTION AND SYNTHESIS: Each paper was critically examined for evidence of a clinically verifiable lichenoid drug-eruption affecting the oral mucous membranes and the effects of subsequent drug withdrawal. Available clinical, histological and immunological features were recorded. The papers examined were too diverse in nature to permit a structured criticism. The extracted data have been tabulated where appropriate. CONCLUSIONS: The reports of oral lichenoid drug eruptions are considerably fewer than those of cutaneous eruptions and fewer drugs have been reported as causing oral rather than cutaneous lichenoid eruptions. Histology and immunology cannot be used reliably to differentiate lichenoid drug eruptions from idiopathic lichen planus, amalgam contact lesions and lichen planus-like eruption in GVHD. Lichenoid drug eruptions may also show some histological characteristics of oral discoid lupus erythematosus. An accepted protocol agreed by a number of international centres would permit the gathering of substantial information on LDE and could lead to a greater understanding of the mechanisms involved.

Dental Amalgam↗
PubMed2002

Primary care cancer and diabetes complications screening of black women with type 2 diabetes.

PURPOSE: To determine the frequency with which Black women with type 2 diabetes receive routine primary health care screening for cancer and diabetes complications. DATA SOURCES: Pilot study data from a convenience sample of 21 Black women (mean age 46.8 years) with type 2 diabetes. CONCLUSIONS: Cancer screening consisted of Pap smear, mammography, and colon cancer screening consistent with current American Cancer Society recommendations. Ninety percent reported having had a Pap smear, 86% mammogram and 33% colon cancer screening. Diabetes complications screening was based on the American Diabetes Association care recommendations. Fifty-five percent received screening eye exams, 40% were screened for renal proteinuria, and 50% received foot examinations and diabetes foot care instruction. IMPLICATIONS FOR PRACTICE: This sample of mid-life, Black, educated, working women with type 2 diabetes utilize healthcare services and have high rates of primary care cancer screening. Rates of diabetes complications screening are less than optimal. Because Black American women suffer disproportionately high rates of diabetes and related complications, it is imperative that they receive quality diabetes care in an effort to improve health outcomes and decrease premature mortality.

Adult↗
PubMed2005

EverCare nurse practitioner practice activities: similarities and differences across five sites.

PURPOSE: To examine the similarities and differences in the performance and frequency of performance of EverCare nurse practitioner (NP) practice activities at demonstration sites in five states. This study builds upon a previous study in which the development and testing of the EverCare Nurse Practitioner Role and Activity Scale (ENPRAS) was conducted. DATA SOURCES: A Background Data Sheet and the ENPRAS, a 99-item tool that encompasses six role subscales-Collaborator, Clinician, Care Manager/Coordinator, Counselor, Communicator/Cheerleader, and Coach/Educator, were completed by 127 EverCare NPs at demonstration sites in five states (Georgia, Maryland, Massachusetts, Colorado, and Florida). CONCLUSIONS: Performance of NP activities across the demonstration sites in five states was generally consistent, with significant differences only in the amount of time spent on activities associated with the Collaborator and Coach/Educator roles. Overall, EverCare NPs spent more time on Clinician and Communicator/Cheerleader role activities than on activities associated with the other roles. EverCare NP patient caseload was positively related to frequency of performance of the Clinician and Care Manager/Coordinator roles. IMPLICATIONS FOR PRACTICE: EverCare NPs provide proactive primary care to long-stay nursing home residents. The observed consistency reflects a strong centrally directed practice model. The identified roles and activities of the EverCare NP are consistent with previous studies and reports focused on the roles and activities of NPs who provide care to nursing home residents in other models of care delivery. Policy makers, healthcare providers, and the public should take these findings into account when considering a national model of care for this population. Future studies should examine the effect of variations in performance of activities on resident-specific and setting-specific outcomes.

Adult↗
PubMed2003

Community needs and strengths assessments as an active learning project.

The Community Needs and Strengths Assessment Project (CNSAP) incorporated development of needs and strengths assessment research into an undergraduate Community Health course as an active learning project--one of seven principles for effective practice in undergraduate education. Community needs and strengths assessments prove useful to health educators primarily in planning programs and promoting effective public relations. Assessments also help to identify and diagnose health problems and to evaluate programs. Through the CNSAP students completed a process health educators use to identify gaps between current and required programs and to prioritize assets and resources based on community needs and strengths. The CNSAP focused on mastery of four skills required for completing a needs and strengths assessment: identifying data sources, conducting primary data collection from a target audience, analyzing data and prioritizing identified needs and strengths, and abstracting information concisely. The project, which included substantial community involvement, helped students identify needs and strengths necessary for addressing community health problems and concerns.

Adult↗
PubMed2003

Productivity losses from injury in China.

OBJECTIVE: To examine the productivity losses and costs of injury and disease in China using an improved approach. METHODS: Potentially productive years of life lost (PPYLL) were calculated for injury and four major disease groups (respiratory, cardiovascular, infectious, neoplastic). DATA SOURCES: The mortality data are from the 1999 National Health Statistics Report and the morbidity data from the 1998 Second National Health Service Survey Report. RESULTS: Injuries caused an annual PPYLL of 12.6 million years, more than for any disease group. The estimated annual economic cost of injury is equivalent to US dollars 12.5 billion, almost four times the total public health services budget of China. Motor vehicle fatalities accounted for 25% of the total PPYLL from all injury deaths. CONCLUSION: Injury control and prevention programs merit priority to reflect the social and economic burden of injury in China.

Accidents, Traffic↗
PubMed1996

Estimating the prevalence of drug misuse in Dundee, Scotland: an application of capture-recapture methods.

STUDY OBJECTIVES: To apply capture-recapture methods to provide an estimate of the prevalence of opiate and benzodiazepine misuse in Dundee, Scotland. DESIGN: A four sample capture-recapture method using data from both statutory and non-statutory data sources to estimate drug misuse prevalence in Dundee between January 1990 and December 1994. PARTICIPANTS: Users of benzodiazepines or opiates residing within Dundee. RESULTS: Altogether 855 drug misusers were identified from various sources within Dundee; many were identified from more than one source. Using this data, the estimated unknown population was 1702, giving a total population of 2557 (95% confidence interval (CI) 1974, 3458) who misuse benzodiazepines or opiates. This represents a prevalence of 28.8 (95% CI 22.3, 39.0) per thousand. CONCLUSIONS: Capture-recapture techniques can be applied to statutory and non-statutory agency data to produce an estimate of at least certain sections of the drug misusing population. However, it is important to recognise the limitations of this methodology and in future to seek to combine a range of approaches to the problem of estimating prevalence rather than sticking rigidly to any single approach.

Adolescent↗
PubMed2004

Patient and disease profile of emergency medical readmissions to an Irish teaching hospital.

OBJECTIVE: To determine whether there was a relationship between coded diseases at the time of hospital discharge, a pattern of ordering investigations, and hospital readmission in a major teaching hospital. DESIGN: Systematic review of data relating to emergency medical patients admitted to St James' Hospital Dublin between 1 January and 31 December 2002. DATA SOURCES AND METHODS: Data on discharges from hospital recorded in the Hospital In-Patient Enquiry (HIPE) system. The value of HIPE data in describing the relationship between the pattern of resource utilisation, diagnostic related groups, and hospital readmission has not previously been examined. RESULTS: Of 5038 episodes recorded among 4050 patients admitted, the number of readmissions was up to 15. Age and male gender were factors associated with readmission, and readmitted patients remained in hospital for longer. No particular test request predicted readmission, but computed tomography of the brain was associated with a reduced readmission rate. Discharge diagnostic related group coding at first discharge predicted readmission-codes related to heart failure, respiratory system, alcohol, malignancy, and anaemia. CONCLUSIONS: It was found that clinical coding using the HIPE database strongly predicted hospital readmission. It may be argued that early hospital readmission reflects unsatisfactory patient care, alternatively that many readmissions are not preventable, representing either new events in elderly patients with chronic illnesses and frequent co-morbidity or related to social factors. The utility of specific interventions, in patients at high risk for hospital readmission, could be explored.

Adult↗