Showing papers in "Medical Care in 2008"
TL;DR: Evidence supports reliability and validity of the G AD-7 as a measure of anxiety in the general population and can be used to compare a subject's GAD-7 score with those determined from a general population reference group.
Abstract: Background:The 7-item Generalized Anxiety Disorder Scale (GAD-7) is a practical self-report anxiety questionnaire that proved valid in primary care. However, the GAD-7 was not yet validated in the general population and thus far, normative data are not available.Objectives:To investigate reliability
2,730 citations
TL;DR: A 75-year legacy is reviewed by reviewing the series of national studies that have given to the form and function of health services research and examines the Behavioral Model through 40 years of considerable application and alteration.
Abstract: National health surveys have played an important role in the development of health services research. They have contributed to the advancement of concepts, methods, and the policy relevance of the field. One product of these surveys was the Behavioral Model of Health Services Use. This article documents a 75-year legacy by reviewing the series of national studies that have given to the form and function of health services research. It further examines the Behavioral Model through 40 years of considerable application and alteration.
809 citations
TL;DR: It is very unlikely that $50,000 per Quality-Adjusted Life-Year (QALY) is consistent with societal preferences in the United States.
Abstract: Background: In the United States, $50,000 per Quality-Adjusted Life-Year (QALY) is a decision rule that is often used to guide interpretation of cost-effectiveness analyses. However, many investigators have questioned the scientific basis of this rule, and it has not been updated. Methods: We used 2 separate approaches to investigate whether the $50,000 per QALY rule is consistent with current resource allocation decisions. To infer a lower bound for the decision rule, we estimated the incremental cost-effectiveness of recent (2003) versus pre-“modern era” (1950) medical care in the United States. To infer an upper bound for the decision rule, we estimated the incremental cost-effectiveness of unsubsidized health insurance versus self-pay for nonelderly adults (ages 21‐64) without health insurance. We discounted both costs and benefits, following recommendations of the Panel on Cost-Effectiveness in Health and Medicine. Results: Our base case analyses suggest that plausible lower and upper bounds for a cost-effectiveness decision rule are $183,000 per life-year and $264,000 per life-year, respectively. Our sensitivity analyses widen the plausible range (between $95,000 per life-year saved and $264,000 per life-year saved when we considered only health care’s impact on quantity of life, and between $109,000 per QALY saved and $297,000 per QALY saved when we considered health care’s impact on quality as well as quantity of life) but it remained substantially higher than $50,000 per QALY. Conclusions: It is very unlikely that $50,000 per QALY is consistent with societal preferences in the United States.
566 citations
TL;DR: Evidence of a moderate implicit “perceived patient compliance and race” stereotype is found among pediatricians, needed to explore whether physician implicit attitudes and stereotypes about race predict quality of care.
Abstract: Background:Recent reports speculate that provider implicit attitudes about race may contribute to racial/ethnic health care disparities.Objectives:We hypothesized that implicit racial bias exists among pediatricians, implicit and explicit measures would differ and implicit measures may be related to
280 citations
TL;DR: Efforts to support improvement of hospital outcomes can take advantage of risk-adjustment methods based on automated physiology and diagnosis data that are not confounded by information obtained after hospital admission.
Abstract: Objectives: To develop a risk-adjustment methodology that maximizes the use of automated physiology and diagnosis data from the time period preceding hospitalization Design: Retrospective cohort study using split-validation and logistic regression Setting: Seventeen hospitals in a large integrated health care delivery system Subjects: Patients (n 259,699) hospitalized between January 2002 and June 2005 Main Outcome Measures: Inpatient and 30-day mortality Results: Inpatient mortality was 350%; 30-day mortality was 406% We tested logistic regression models in a randomly chosen derivation dataset consisting of 50% of the records and applied their coefficients to the validation dataset The final model included sex, age, admission type, admission diagnosis, a Laboratory-based Acute Physiology Score (LAPS), and a COmorbidity Point Score (COPS) The LAPS integrates information from 14 laboratory tests obtained in the 24 hours preceding hospitalization into a single continuous variable Using Diagnostic Cost Groups software, we categorized patients as having up to 40 different comorbidities based on outpatient and inpatient data from the 12 months preceding hospitalization The COPS integrates information regarding these 41 comorbidities into a single continuous variable Our best model for inpatient mortality had a c statistic of 088 in the validation dataset, whereas the c statistic for 30-day mortality was 086; both models had excellent calibration Physiologic data accounted for a substantial proportion of the model’s predictive ability Conclusion: Efforts to support improvement of hospital outcomes can take advantage of risk-adjustment methods based on automated physiology and diagnosis data that are not confounded by information obtained after hospital admission
277 citations
TL;DR: Results demonstrate the intervention's potential to increase self-reported patient activation, retention, and attendance in mental health care for minority populations by facilitating patient-provider communication.
Abstract: Background:Evidence suggests that minority populations have lower levels of attendance and retention in mental health care than non-Latino whites. Patient activation and empowerment interventions may be effective in increasing minority patients’ attendance and retention.Objectives:This study develop
232 citations
TL;DR: QI efforts are effective at reducing antibiotic use in ambulatory settings, although much room for improvement remains, and strategies using active clinician education and targeting management of all ARIs may yield larger reductions in community-level antibiotic use.
Abstract: Background:Overuse of antibiotics in ambulatory care persists despite many efforts to address this problem. We performed a systematic review and quantitative analysis to assess the effectiveness of quality improvement (QI) strategies to reduce antibiotic prescribing for acute outpatient illnesses fo
229 citations
TL;DR: Results of the review of empirical studies that estimate causal relationships between health insurance and health care utilization and/or health outcomes consistently show that health insurance increases utilization and improves health.
Abstract: Background:No current consensus exists on the causal effect of gaining or losing health insurance on health care utilization and health outcomes.Objective:To systemically search and review available evidence of estimated causal effects of health insurance on health care utilization and/or health out
214 citations
TL;DR: Perceived racial discrimination in health care is much more prevalent for African Americans than for whites or Hispanics, and is associated with worse health both forAfrican Americans and for whites.
Abstract: Background:Despite the surge of recent research on the association between perceived discrimination and health-related outcomes, few studies have focused on race-based discrimination encountered in health care settings. This study examined the prevalence of such discrimination, and its association w
212 citations
TL;DR: Disparities in care for depression and anxiety among African Americans and Hispanics remain in primary care and quality improvement efforts are needed to address cultural and linguistic barriers to care.
Abstract: Common depressive and anxiety disorders are often under-diagnosed and under-treated, with disparities in detection and appropriate care noted in earlier studies of African Americans and Hispanics.1–4 Although some recent data on disparities in general health care, including care for depression, question whether disparities are large enough to merit policy focus,5 other data demonstrate disparities for at least some groups persist in mental health care.6 In this paper, we examine trends in disparities in recognition and treatment of common depressive and anxiety disorders for African Americans and Hispanics, as compared with whites, over a 10-year period.
Both depressive and anxiety disorders can be effectively treated with antidepressant medication and structured psychotherapies in either psychiatric or primary health care settings.7,8 During the past decade, treatment rates for depression have generally increased across primary and specialty care among all race/ethnic groups,9,10 with a significant increase in the use of antidepressants and a decline in psychotherapy.11 Some data suggest disparities in diagnosis and treatment combined across sectors have narrowed for minorities, although absolute rates of care have remained lower among nonwhites.11 Two recent studies have demonstrated that disparities in mental health care are worsening.6,12
To better understand mental health care disparities, the health care setting must be taken into consideration. Disparities may be different across primary care and psychiatric sectors for at least 2 reasons. First, changes in depression care differ by sector. Earlier studies note that although visits for depression doubled from 1985 to 1993–1994,12 much of the increase in antidepressant prescriptions was among psychiatrists.11,12 More recently, data from 1990 to 1992 compared with 2001–2003 found that overall treatment for mental disorders increased 2.6-fold in the primary care sector and 2.2-fold in psychiatric settings.13 Similarly, medication treatment for panic disorder increased from 1992 through 1999, and prescribing differences between psychiatrists and primary care providers narrowed over time.14 Second, mechanisms for disparities might differ across the 2 sectors. Ethnic minorities are far less likely to be seen in psychiatry than in primary care.1 Once minorities get to psychiatric care, lower rates of diagnostic accuracy may result in disparities. In primary care, disparities may result from failure to detect depression or anxiety in minority patients. In this article, we examine disparities in depression and anxiety care separately in psychiatric and primary care settings.
Our examination of mental health care disparities is informed by the Institute of Medicine (IOM) report,15 where a disparity is defined as any difference in the use of health services after adjusting for preferences and health care needs. The IOM definition contrasts with measures of disparity based on unadjusted differences between groups,16 or measures based on adjustment for socioeconomic variables such as income.17 The IOM approach regards socioeconomic factors such as income or insurance as potential mediators of disparities in health care. For example, if Hispanics are more likely to be uninsured and uninsurance is associated with poor access, insurance mediates disparities of this group.18 Recent data suggest 1-year rates of depression are relatively similar across white,19 Hispanic,20 and black21 populations in the United States, suggesting that health care need should be similar across ethnic groups. Because racial/ethnic differences may exist in awareness and help-seeking for mental health conditions22 and recognition of depression/anxiety may lead to appropriate treatment,23 we examine both group differences in and the effect of diagnosis on treatment. We do not adjust for preferences, as the issue of how to best measure and control for preferences within the IOM framework has not been resolved.18
Using National Ambulatory Medical Care Study (NAMCS) data from 1995 through 2005, we examine trends in diagnoses and treatment of depressive and anxiety disorders by psychiatrists and primary care physicians, comparing visits by African American and Hispanic patients with white patients. We provide a more comprehensive, detailed examination of racial/ethnic disparities in mental health care than currently exists by: (1) including common anxiety disorders in addition to depression, because a large number of office visits record anxiety as a diagnosis,24 (2) including counseling and counseling referrals in addition to medication treatment, (3) examining racial/ethnic differences in specialty mental health settings separate from general medical settings, and (4) extending results through 2005. We hypothesize that diagnoses and treatment will increase over time and that racial/ethnic differences in diagnoses and treatment will persist but be reduced over time, especially in the primary care sector.
199 citations
TL;DR: These 2 measures should be considered first when selecting among adherence measures when using administrative prescription claims data: MPR and PDC had the highest predictive validity for hospitalization episodes and nonpharmacy cost.
Abstract: Objective:To compare the predictive validity of 8 different adherence measures by studying the variability explained between each measure and 2 outcome measures: hospitalization episodes and total nonpharmacy cost among Medicaid eligible persons diagnosed with diabetes.Research Design:This study was
TL;DR: Marginal variable ICU costs are relatively small compared with average total costs and are only slightly greater than the cost of a ward day.
Abstract: Objectives:To estimate the actual cost savings that could be achieved through reductions in intensive care unit (ICU) length of stay and duration of mechanical ventilation by determining the short-run marginal variable cost of an ICU and ventilator day.Research Design:Retrospective cohort study in a
TL;DR: Patients with lower socioeconomic status have higher rates of adjusted operative mortality than patients with higher socioeconomic status across a wide range of surgical procedures, and disparities in surgical outcomes are largely attributable to differences between the hospitals.
Abstract: Background:Although racial disparities in the quality of surgical care are well described, the impact of socioeconomic status on operative mortality is relatively unexplored.Methods:We used Medicare data to identify all patients undergoing 1 of 6 common, high risk surgical procedures between 1999 an
TL;DR: PHDS can be used reliably to identify women who suffer a major adverse outcome during the birth admission and have potential for monitoring the quality of obstetric care in a uniform and cost-effective way.
Abstract: Background:As maternal deaths become rare in many countries, severe maternal morbidity has been suggested as a better indicator of quality of care.Objective:To develop and validate an indicator for measuring major maternal morbidity in routinely collected population health datasets (PHDS).Methods:Fi
TL;DR: Braithwaite et al, in this issue of Medical Care, set out to deduce lower and upper bounds on the value Americans place on quality-adjusted life years by analyzing the implications of aggregate decisions that citizens of this country have made— to pay for the increase in the cost of medical care services since 1950; or have not made—to insure the uninsured.
Abstract: for coverage recommendations to the National Health Service 2 ; some observers have inferred that explicit criteria such as £30,000 per QALY may be used to guide these recommendations. 3 The World Health Organization has proposed that developing countries might use a cost-per-QALY threshold of 3 times the per-capita gross domestic product to guide their health care resource allocations. 4 Despite widespread use elsewhere in the world, cost-effectiveness analysis has gained only limited traction in the United States as an explicit guide to clinical practice, insurance coverage, and policy decisions. It seems that Americans do not have the inclination to focus on the fact that even in the wealthiest country in the world, resources are limited, and not all beneficial health services can be provided to everyone who might potentially benefit from them. Rationing among health services occurs largely by default and not by design. In the United States, cost per QALY is sometimes cited as part of the justification for guidelines for clinical practice or preventive services, and a decade ago a panel was convened by the US Public Health Service to provide guidance to practitioners of cost-effectiveness analysis. 5 However, despite the attention given to cost-effectiveness analysis in medical journals, The Centers for Medicare and Medicaid Services have avoided explicit use of cost-effectiveness criteria in coverage decisions, and it is unclear to what degree cost-effectiveness is used to guide coverage decisions in the private sector. 6 Because cost per QALY is not used in any systematic or consistent way in the United States, it should not be surprising that there is no consensus as to the appropriate value of cost per QALY that should guide health care decisions and policies. The number $50,000 per QALY has become a mythical benchmark for cost per QALY in this country, although it is impossible to trace its origins. Some authors of cost-effectiveness studies refer to this number when reporting subgroup analyses or sensitivity analyses 7 ; these kinds of statements should not be interpreted as endorsements of a $50,000 per QALY threshold, but rather as a convenient way of representing the conclusion that the intervention in question is good value for money even under pessimistic assumptions. With that interpretation, the reference to the $50,000 threshold could be interpreted as an implied lower bound on the value of a QALY. Braithwaite et al, in this issue of Medical Care, 8 set out to deduce lower and upper bounds on the value Americans place on quality-adjusted life years by analyzing the implications of aggregate decisions that citizens of this country have made—to pay for the increase in the cost of medical care services since 1950; or have not made—to insure the uninsured. They argue that because the gains in life expectancy since 1950 have been bought at an estimated average cost of $183,000 per year of life expectancy gained, on average Americans must be willing to pay at least that much for a year of life. When optimistic imputations of quality of life gains are also considered, the implied lower bound on the value of a QALY drops to $109,000. The number drops below $100,000 when they
TL;DR: Primary care patients have distinct preferences for CRC screening tests that can be linked to test attributes, and Tailoring screening recommendations to patients’ preferences may increase screening adherence.
Abstract: Background:Incorporating patients’ preferences into colorectal cancer (CRC) screening recommendations has been identified as a potential mechanism for increasing adherence. This study used conjoint analysis to describe variation in CRC screening preferences among racially/ethnically diverse primary
TL;DR: Findings suggest that physician self-referral arrangements and independent diagnostic testing facilities seem to be contributing to this greater use of advanced imaging, especially for MRI and PET.
Abstract: Background:Recent reports by the Medicare Payment Advisory Commission have highlighted sharp increases in the use of advanced diagnostic imaging procedures among the Medicare fee-for-service population. Little research has examined whether such trends also exist among persons with generous private i
TL;DR: The 3-item Care Transitions Measure closely approximates the 15-item instrument and may be attractive to purchasers and health care organizations that want to assess quality in this area while minimizing cost and response burden.
Abstract: Background: The Institute of Medicine has identified care transitions as a priority area for performance measurement. Objectives: To examine the performance of the Care Transitions Measure (CTM) in more diverse populations and to introduce a 3-item CTM. Research Design: Cross-sectional study with purposive sampling of traditionally underserved populations. Confirmatory factor analyses, internal consistency reliability analyses, and differential item function tests were performed to explore the stability and performance of the 15-item CTM. Regression assessed the ability of the 3-item CTM to predict the 15-item CTM total score. Analysis of variance tests were conducted to explore CTM performance in different populations with respect to health and demographics. Subjects: A total of 225 patients age 18‐90 who were hospitalized in the past 12 months and were African American, Hispanic American, or rural-dwelling. Measures: CTM-15, CTM-3, age, gender, education, and health status. Results: Mplus confirmatory factor analysis supported the CTM-15 factor structure in more diverse population (Comparative Fit Index CFI 0.954). The 3-item CTM explained 88% of the variance in the 15-item CTM score. Differential item function analysis did not reveal any differential item difficulty by age, gender, education, self-rated health, or group (African American, Hispanic American, and rural-dwelling). Conclusions: Following endorsement by National Quality Forum, findings support use of the CTM in national public reporting efforts. The 3-item CTM closely approximates the 15-item instrument and may be attractive to purchasers and health care organizations that want to assess quality in this area while minimizing cost and response burden.
TL;DR: Although mammography use increased for some groups between 1993 and 2005, low-income, uninsured women continued to have the lowest screening rates in 2005 and the disparity for this group was not reduced, resulting from possible declines in mammography even for uninsured women not in poverty.
Abstract: Objective:To examine current disparities in mammography use, and changes in disparities over time by race, ethnicity, income, insurance, and combinations of these characteristics.Research Design:Comparison of cross-sectional surveys of mammography use using the 1993 and 2005 National Health Intervie
TL;DR: Senior managers perceived patient safety climate more positively than nonsenior managers overall and across 7 discrete safety climate domains, and patterns of variation by management level differed by professional discipline.
Abstract: Background:Strengthening hospital safety culture offers promise for reducing adverse events, but efforts to improve culture may not succeed if hospital managers perceive safety differently from frontline workers.Objectives:To determine whether frontline workers and supervisors perceive a more negati
TL;DR: Racial/ethnic differences in service use may arise in part from different propensities to interpret emotional symptoms as reflecting one's mental health and then to seek professional intervention for emotional problems.
Abstract: Background:Studies of health service use for emotional problems show that the majority of those with disorders do not seek professional help. In addition, mental health service use is lower among members of minority communities, compared with non-Hispanic whites.Objective:To examine the role of self
TL;DR: This study shows 1 process by which practice climate translates into patient activation, and it is found that supportive interactions among practitioners and staff within primary care teams facilitate trust-building interactions between practitioners and patients.
Abstract: Background:Little is known about processes by which proactive primary care teams might activate their patients. We examine the role of trust in patient-physician relationships for translating practice teamwork into patient activation.Methods:Data were collected by surveys of adult enrollees and prim
TL;DR: These national data document lower rates of arthritis-related hip/knee surgeries for older black versus white adults age 65 or above, consistent with other national studies, however, utilization rates for black versuswhite under age 65 do not differ.
Abstract: Background Nearly 18 million Americans experience limitations due to their arthritis. Documented disparities according to racial/ethnic groups in the use of surgical interventions such as knee and hip arthroplasty are largely based on data from Medicare beneficiaries age 65 or older. Whether there are disparities among younger adults has not been previously addressed. Objective This study assesses age-specific racial/ethnic differences in arthritis-related knee and hip surgeries. Design Longitudinal (1998-2004) Health and Retirement Study. Setting National probability sample of US community-dwelling adults. Sample A total of 2262 black, 1292 Hispanic, and 13,159 white adults age 51 and older. Measurements The outcome is self-reported 2-year use of arthritis-related hip or knee surgery. Independent variables are demographic (race/ethnicity, age, gender), health needs (arthritis, chronic diseases, obesity, physical activity, and functional limitations), and medical access (income, wealth, education, and health insurance). Longitudinal data methods using discrete survival analysis are used to validly account for repeated (biennial) observations over time. Analyses use person-weights, stratum, and sampling error codes to provide valid inferences to the US population. Results Black adults under the age of 65 years report similar age/gender adjusted rates of hip/knee arthritis surgeries [hazard ratio (HR) = 1.43, 95% confidence interval (CI) = 0.87-2.38] whereas older blacks (age 65+) have significantly lower rates (HR = 0.38, CI = 0.16-0.55) compared with whites. These relationships hold controlling for health and economic differences. Both under age 65 years (HR = 0.64, CI = 0.12-1.44) and older (age 65+) Hispanic adults (HR = 0.60, CI = 0.32-1.10) report lower utilization rates, although not statistically different than whites. A large portion of the Hispanic disparity is explained by economic differences. Conclusions These national data document lower rates of arthritis-related hip/knee surgeries for older black versus white adults age 65 or above, consistent with other national studies. However, utilization rates for black versus white under age 65 do not differ. Lower utilization among Hispanics versus whites in both age groups is largely explained by medical access factors. National utilization patterns may vary by age and merit further investigation.
TL;DR: Patients who felt they had sufficient time with their healthcare provider were more likely to be screened for CRC and receiving sufficient explanation of the healthcare processes by providers may improve screening rates.
Abstract: Background:Screening reduces incidence and mortality from colorectal cancer (CRC). Despite improved access, screening is suboptimal and disparate among minority groups. Quality of patient-provider communication may impact CRC screening.Objectives:We examined the relationship between patient-provider
TL;DR: Age continues to be a significant predictor of PCP registration in Nova Scotia even after controlling for the confounding effects of many new demographic, health service, and ecologic indicators.
Abstract: Background:Inequalities in access to palliative care programs (PCP) by age have been shown to exist in Canada and elsewhere. Few studies have been able to provide greater insight by simultaneously adjusting for multiple demographic, health service, and socio-cultural indicators.Objective:To re-exami
TL;DR: Among chronically ill patients, 3–4 days recall of PT/PP yield adherence estimates, which are practically as reliable and valid as longer intervals and which predict functional outcomes.
Abstract: Background
Patient Centered Communication (PCC) is associated with more appropriate treatment of depression in primary care. In part a function of patient presentation, little is known about other influences on PCC. We investigated whether PCC was also influenced by personality dispositions of primary care providers (PCPs), independent of patient presentation.
TL;DR: The findings indicate that military institutions should continue public education campaigns to de-stigmatize mental health problems and should make necessary changes in health delivery systems to gain the trust of military members.
Abstract: Background: Mental disorders constitute a significant public health problem in active military populations. However, very little is known about patterns of mental health service use in these populations. Objectives: The primary objective of this study was to examine the patterns and predictors of mental health service use in active Canadian Force members. Additional objectives included identification of barriers to service use. Design: A cross-sectional analysis was conducted using data from the Canadian Community Health Survey-Canadian Forces Supplement. Subjects and Measures: Participants were assessed for mood, anxiety, and substance use disorders using the World Health Organization's Composite International Diagnostic Interview. Those who met criteria for at least 1 disorder in the past year (n = 1220) were included in the analyses. Results: Of military members with a 12-month diagnosis, 42.6% used services in the past year. Predictors of service use included mental health indicators, gender, marital status, and military rank. Of military members who failed to use services, only a small percentage (3.5–16.0%) acknowledged a need for services. These members perceived a number of barriers to services, foremost among which was lack of trust in military health, administrative, and social services. Conclusions: Despite recent efforts to de-stigmatize mental health problems and treatments, unmet need for mental health services remains a significant problem in active militaries. Our findings indicate that military institutions should continue public education campaigns to de-stigmatize mental health problems and should make necessary changes in health delivery systems to gain the trust of military members.
TL;DR: The findings suggest that the association between RN staffing and skill mix and in-hospital patient mortality depends on whether the analysis is conducted at the hospital or unit level.
Abstract: Context:Nurse staffing is not the same across an entire hospital. Nursing care is delivered in geographically-based units, with wide variation in staffing levels. In particular, staffing in intensive care is much richer than in nonintensive care acute units.Objective:To evaluate the association of i
Journal Article•
TL;DR: The therapeutic misconception occurs when a research subject fails to appreciate the distinction between the imperatives of clinical research and of ordinary treatment, and therefore inaccurately attributes therapeutic intent to research procedures.
Abstract: Background.The therapeutic misconception occurs when a research subject fails to appreciate the distinction between the imperatives of clinical research and of ordinary treatment, and therefore inaccurately attributes therapeutic intent to research procedures. The therapeutic misconception is a seri
TL;DR: A cross-sectional analysis of all visits with an established primary care provider found no consistent association between blood pressure control, management of chronic conditions, and specific EHR components.
Abstract: Background:Electronic health records (EHRs) have been promoted as an important tool to improve quality of care. We examined the association between EHR components, a complete EHR, and the quality of care.Methods:Using data from the 2005 National Ambulatory Medical Care Survey and the National Hospit