Showing papers in "Medical Care in 2012"

Effectiveness-implementation Hybrid Designs: Combining Elements of Clinical Effectiveness and Implementation Research to Enhance Public Health Impact

Abstract: Objectives:This study proposes methods for blending design components of clinical effectiveness and implementation research. Such blending can provide benefits over pursuing these lines of research independently; for example, more rapid translational gains, more effective implementation strategies,

Systematic review of comorbidity indices for administrative data.

Abstract: Background:Adjustment for comorbidities is common in performance benchmarking and risk prediction. Despite the exponential upsurge in the number of articles citing or comparing Charlson, Elixhauser, and their variants, no systematic review has been conducted on studies comparing comorbidity measures

Prevalence and costs of co-occurring traumatic brain injury with and without psychiatric disturbance and pain among Afghanistan and Iraq war veteran VA users

Abstract: BACKGROUND:: Traumatic brain injury (TBI) is the "signature injury" in the Afghanistan and Iraq wars [Operation Enduring Freedom in Afghanistan (OEF)/Operation Iraqi Freedom (OIF)]. Patients with combat-related TBI also have high rates of psychiatric disturbances and pain. OBJECTIVES:: To determine the prevalence of TBI alone and TBI with other conditions and the average cost of medical care for veterans with these diagnoses. METHODS:: Observational study using national inpatient, outpatient, and pharmacy data from Veterans Health Administration (VHA) datasets. Costs are estimated from utilization related to care within the VHA system. Participants were all OEF/OIF VHA users in 2009. RESULTS:: Among 327,388 OEF/OIF veterans using VHA services in 2009, 6.7% were diagnosed with TBI. Among those with TBI diagnoses, 89% were diagnosed with a psychiatric diagnosis [the most frequent being posttraumatic stress disorder (PTSD) at 73%], and 70% had a diagnosis of head, back, or neck pain. The rate of comorbid PTSD and pain among those with and without TBI was 54% and 11%, respectively. The median annual cost per patient was nearly 4-times higher for TBI-diagnosed veterans as compared with those without TBI ($5831 vs. $1547). Within the TBI group, cost increased as diagnostic complexity increased, such that those with TBI, pain, and PTSD demonstrated the highest median cost per patient ($7974). CONCLUSIONS:: The vast majority of VHA patients diagnosed with TBI also have a diagnosed mental disorder and more than half have both PTSD and pain. Patients with these comorbidities incur substantial medical costs and represent a target population for future research aimed at improving health care efficiency. Language: en

The Use of Patient-reported Outcomes (PRO) Within Comparative Effectiveness Research: Implications for Clinical Practice and Health Care Policy

Abstract: Background:The goal of comparative effectiveness research (CER) is to explain the differential benefits and harms of alternate methods to prevent, diagnose, treat, and monitor a clinical condition or to improve the delivery of care. To inform decision making, information from the patient’s perspecti

Quality of data in perinatal population health databases: a systematic review

Abstract: BackgroundAdministrative or population health datasets (PHDS) are increasingly being used for research related to maternal and infant health. However, the accuracy and completeness of the information in the PHDS is important to ensure validity of the results of this research.ObjectiveTo compile and

A Pragmatic Framework for Single-site and Multisite Data Quality Assessment in Electronic Health Record-based Clinical Research

Abstract: Introduction: Answers to clinical and public health research questions increasingly require aggregated data from multiple sites. Data from electronic health records and other clinical sources are useful for such studies, but require stringent quality assessment. Data quality assessment is particularly important in multisite studies to distinguish true variations in care from data quality problems. Methods: We propose a “fit-for-use” conceptual model for data quality assessment and a process model for planning and conducting single-site and multisite data quality assessments. These approaches are illustrated using examples from prior multisite studies. Approach: Critical components of multisite data quality assessment include: thoughtful prioritization of variables and data quality dimensions for assessment; development and use of standardized approaches to data quality assessment that can improve data utility over time; iterative cycles of assessment within and between sites; targeting assessment toward data domains known to be vulnerable to quality problems; and detailed documentation of the rationale and outcomes of data quality assessments to inform data users. The assessment process requires constant communication between sitelevel data providers, data coordinating centers, and principal investigators. Discussion: A conceptually based and systematically executed approach to data quality assessment is essential to achieve the potential of the electronic revolution in health care. High-quality data allow “learning health care organizations” to analyze and act on

Impact of FDA drug risk communications on health care utilization and health behaviors: a systematic review.

Abstract: OBJECTIVE:: To review literature on the impact of The Food and Drug Administration (FDA) drug risk communications on medication utilization, health care services use, and health outcomes. DATA SOURCES:: The authors searched MEDLINE and the Web of Science for manuscripts published between January 1990 and November 2010 that included terms related to drug utilization, the FDA, and advisories or warnings. We manually searched bibliographies and works citing selected articles and consulted with experts to guide study selection. STUDY SELECTION:: Studies were included if they involved an empirical analysis evaluating the impact of an FDA risk communication. DATA EXTRACTION:: We extracted the drug(s) analyzed, relevant FDA communication(s), data source, analytical method, and main outcome(s) assessed. RESULTS:: Of the 1432 records screened, 49 studies were included. These studies covered 16 medicines or therapeutic classes; one third examined communications regarding antidepressants. Most used medical or pharmacy claims and a few rigorously examined patient-provider communication, decision making, or risk perceptions. Advisories recommending increased clinical or laboratory monitoring generally led to decreased drug use, but only modest, short-term increases in monitoring. Communications targeting specific subpopulations often spilled over to other groups. Repeated or sequential advisories tended to have larger but delayed effects and decreased incident more than prevalent use. Drug-specific warnings were associated with particularly large decreases in utilization, although the magnitude of substitution within therapeutic classes varied across clinical contexts. CONCLUSIONS:: Although some FDA drug risk communications had immediate and strong impacts, many had either delayed or had no impact on health care utilization or health behaviors. These data demonstrate the complexity of using risk communication to improve the quality and safety of prescription drug use, and suggest the importance of continued assessments of the effect of future advisories and label changes. Identifying factors that are associated with rapid and sustained responses to risk communications will be important for informing future risk communication efforts. Language: en

Psychometric Properties of the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Clinician and Group Adult Visit Survey

Abstract: The Consumer Assessment of Healthcare Providers and Systems (CAHPS®) surveys were developed to elicit reports from consumers about their health care experiences. The surveys cover topics such as the communication skills of providers, helpfulness of staff, and access to care, which are important to consumers and for which they are the best source for this information. The surveys and accompanying tools can be used by providers, healthcare organizations, government agencies, and researchers to assess and improve patient-centered care. Establishing the psychometric properties of CAHPS surveys is an integral step toward enabling valid comparisons on patient experience across organizations and over time.1–5 The CAHPS Clinician and Group Survey (CG-CAHPS) was developed to assess patient experiences with ambulatory care. There are three versions of CG-CAHPS: 1) a 12-Month Survey that asks patients to report on their experiences over the last 12 months, 2) an expanded 12-Month Survey that includes items to assess aspects of the Patient-Centered Medical Home (PCMH), and 3) a Visit Survey that primarily focuses on experiences during a single visit. The Visit Survey includes questions about doctor communication and office staff interactions at the patient’s most recent visit, and questions about the patient’s access to care with their doctor over the last 12 months. The survey also elicits an overall rating of the doctor from patients and asks about their willingness to recommend their doctor to family and friends. The Visit Survey was designed to collect feedback about a specific patient visit that providers can use for monitoring and improving care. In this paper we evaluate the hypothesized factor structure and reliability of the CG-CAHPS Adult Visit Survey using data submitted to the CG-CAHPS Database.

What Did the Doctor Say? Health Literacy and Recall of Medical Instructions

Abstract: Background Limited literacy has repeatedly been linked to problems comprehending health information, although the majority of studies to date have focused on reading various print health materials. We sought to investigate patients’ ability to recall spoken medical instructions in the context of a hypothetical clinical encounter, and whether limited health literacy would adversely affect performance on the task.

Language barriers and understanding of hospital discharge instructions.

Abstract: Background:Effective communication at hospital discharge is necessary for an optimal transition and to avoid adverse events. We investigated the association of a language barrier with patient understanding of discharge instructions.Methods:Spanish-speaking, Chinese-speaking, and English-speaking pat

Physician Patient-Sharing Networks and the Cost and Intensity of Care in US Hospitals

Abstract: Background:There is substantial variation in the cost and intensity of care delivered by US hospitals. We assessed how the structure of patient-sharing networks of physicians affiliated with hospitals might contribute to this variation. Methods:We constructed hospital-based professional networks based on patient-sharing ties among 61,461 physicians affiliated with 528 hospitals in 51 hospital referral regions in the US using Medicare data on clinical encounters during 2006. We estimated linear regression models to assess the relationship between measures of hospital network structure and hospital measures of spending and care intensity in the last 2 years of life. Results:The typical physician in an average-sized urban hospital was connected to 187 other doctors for every 100 Medicare patients shared with other doctors. For the average-sized urban hospital an increase of 1 standard deviation (SD) in the median number of connections per physician was associated with a 17.8% increase in total spending, in addition to 17.4% more hospital days, and 23.8% more physician visits (allP< 0.001). In addition, higher “centrality” of primary care providers within these hospital networks was associated with 14.7% fewer medical specialist visits (P< 0.001) and lower spending on imaging and tests (!9.2% and!12.9% for 1 SD increase in centrality,P< 0.001). Conclusions:Hospital-based physician network structure has a significant relationship with an institution’s care patterns for their patients. Hospitals with doctors who have higher numbers of connections have higher costs and more intensive care, and hospitals with primary carecentered networks have lower costs and care intensity.

Doctor and pharmacy shopping for controlled substances.

Abstract: Background:Prescription drug abuse is a major health concern nationwide, with West Virginia having one of the highest prescription drug death rates in the United States. Studies are lacking that compare living subjects with persons who died from drug overdose for evidence of doctor and pharmacy shop

Can Hospital Cultural Competency Reduce Disparities in Patient Experiences with Care

Abstract: Background Cultural competency has been espoused as an organizational strategy to reduce health disparities in care.

Initial validation of a self-report measure of the extent of and reasons for medication nonadherence.

Abstract: Medication nonadherence is a significant clinical problem in chronic disease management.(1, 2) Medication nonadherence is associated with increased healthcare spending, hospitalization rates, morbidity, and premature mortality.(3) Obtaining accurate estimates of medication nonadherence is essential to determine where intervention resources should be directed. There is no ‘gold standard’ for assessing nonadherence.(4, 5) Pill refills, pill counts, and computerized bottle caps can approximate how much medication patients are consuming, but only patients can report reasons for not taking their medications. The self-report method is also appealing because it can be administered in any setting, is low-cost, and can provide immediate feedback at the point of care. Considerable effort has been made to assess self-reported medication nonadherence, yielding several self-report instruments.(6–9) Although an expert committee recently identified medication nonadherence as one of the constructs that should be assessed routinely in electronic health records, it did not recommend an existing measure and suggested further work was needed.(10) Others have also concluded that existing measures lack reliability and validity.(11) Recently, we examined existing self-report measures of medication nonadherence to determine how measurement could be improved.(12) A key limitation of existing measures is that they confound two related but distinct nonadherence constructs: the extent to which doses are missed and the reasons for missing doses. Each construct is assessed by a different type of psychometric model, which has important measurement implications (Table 1). Existing self-report measures were not developed with this distinction in mind, compromising reliability and validity.(12) We developed a self-report measure that assesses the extent of and reasons for medication nonadherence separately using appropriate psychometric models. We developed the measure within the context of hypertension (HTN) because its prevalence is high and nonadherence to antihypertensive medications is common.(13, 14) We provide initial validation results. Table 1 Using Effect vs. Causal Indicators for Measuring Extent of Nonadherence and Reasons for Nonadherence, Respectively

Will the NP workforce grow in the future? New forecasts and implications for healthcare delivery.

Abstract: Background:The nurse practitioner (NP) workforce has been a focus of considerable policy interest recently, particularly as the Patient Protection and Affordable Care Act may place additional demands on the healthcare professional workforce. The NP workforce has been growing rapidly in recent years,

Factors contributing to all-cause 30-day readmissions: a structured case series across 18 hospitals.

Abstract: Objective:To understand factors leading to all-cause 30-day readmissions in a community hospital population.Research Design:Structured case series of 537 readmissions using chart reviews, interviews with treating physicians, patients and family caregivers, and overall case assessment by a nurse-phys

Strategies for de-identification and anonymization of electronic health record data for use in multicenter research studies.

Abstract: Background:De-identification and anonymization are strategies that are used to remove patient identifiers in electronic health record data. The use of these strategies in multicenter research studies is paramount in importance, given the need to share electronic health record data across multiple en

Increased documented brief alcohol interventions with a performance measure and electronic decision support.

Abstract: Background Alcohol screening and brief interventions (BIs) are ranked the third highest US prevention priority, but effective methods of implementing BI into routine care have not been described. Objectives This study evaluated the prevalence of documented BI among Veterans Affairs (VA) outpatients with alcohol misuse before, during, and after implementation of a national performance measure (PM) linked to incentives and dissemination of an electronic clinical reminder (CR) for BI. Methods VA outpatients were included in this study if they were randomly sampled for national medical record reviews and screened positive for alcohol misuse (Alcohol Use Disorders Identification Test-Consumption score ≥5) between July 2006 and September 2008 (N=6788). Consistent with the PM, BI was defined as documented advice to reduce or abstain from drinking plus feedback linking drinking to health. The prevalence of BI was evaluated among outpatients who screened positive for alcohol misuse during 4 successive phases of BI implementation: baseline year (n=3504), after announcement (n=753) and implementation (n=697) of the PM, and after CR dissemination (n=1834), unadjusted and adjusted for patient characteristics. Results Among patients with alcohol misuse, the adjusted prevalence of BI increased significantly over successive phases of BI implementation, from 5.5% (95% CI 4.1%-7.5%), 7.6% (5.6%-10.3%), 19.1% (15.4%-23.7%), to 29.0% (25.0%-33.4%) during the baseline year, after PM announcement, PM implementation, and CR dissemination, respectively (test for trend P Conclusions A national PM supported by dissemination of an electronic CR for BI was associated with meaningful increases in the prevalence of documented brief alcohol interventions.

Disparities in potentially avoidable emergency department (ED) care: ED visits for ambulatory care sensitive conditions

Abstract: Introduction:Hospital care for ambulatory care sensitive conditions (ACSC) is potentially avoidable and often viewed as an indicator of suboptimal primary care. However, potentially preventable encounters with the health care system also occur in emergency department (ED) settings. We examined ED vi

Development of and field test results for the CAHPS PCMH Survey.

Abstract: Objective: To develop and evaluate survey questions that assess processes of care relevant to Patient-Centered Medical Homes (PCMHs). Research Design: We convened expert panels, reviewed evidence on effective care practices and existing surveys, elicited broad public input, and conducted cognitive interviews and a field test to develop items relevant to PCMHs that could be added to the Consumer Assessment of Healthcare Providers and Systems (CAHPS s ) Clinician & Group (CG-CAHPS) 1.0 Survey. Surveys were tested using a 2-contact mail protocol in 10 adults and 33 pediatric practices (both private and community health centers) in Massachusetts. A total of 4875 completed surveys were received (overall response rate of 25%). Analyses: We calculated the rate of valid responses for each item. We conducted exploratory factor analyses and estimated itemto-total correlations, individual and site-level reliability, and correlations among proposed multi-item composites. Results: Ten items in 4 new domains (Comprehensiveness, Information, Self-Management Support, and Shared Decision-Making) and 4 items in 2 existing domains (Access and Coordination of Care) were selected to be supplemental items to be used in conjunction with the adult CG-CAHPS 1.0 Survey. For the child version, 4 items in each of 2 new domains (Information and Self-Management Support) and 5 items in existing domains (Access, ComprehensivenessPrevention, Coordination of Care) were selected. Conclusions: This study provides support for the reliability and validity of new items to supplement the CG-CAHPS 1.0 Survey to

A Longitudinal Examination of a Pay-for-Performance Program for Diabetes Care: Evidence From a Natural Experiment

Abstract: Background:Numerous studies have examined the impacts of pay-for-performance programs, yet little is known about their long-term effects on health care expenses.Objectives:This study aimed to examine the long-term effects of a pay-for-performance program for diabetes care on health care utilization

Using electronic health care records for drug safety signal detection: a comparative evaluation of statistical methods.

Abstract: Background:Drug safety monitoring relies primarily on spontaneous reporting, but electronic health care record databases offer a possible alternative for the detection of adverse drug reactions (ADRs).Objectives:To evaluate the relative performance of different statistical methods for detecting drug

Association of Chronic Diseases and Impairments with Disability in Older Adults: A Decade of Change?

Abstract: BACKGROUND Little is known about how the relationship between chronic disease, impairment, and disability has changed over time among older adults. OBJECTIVE To examine how the associations of chronic disease and impairment with specific disability have changed over time. RESEARCH DESIGN Repeated cross-sectional analysis, followed by examining the collated sample using time interaction variables, of 3 recent waves of the Health and Retirement Study. SUBJECTS The subjects included 10,390, 10,621 and 10,557 community-dwelling adults aged 65 years and above in 1998, 2004, and 2008. MEASUREMENTS : Survey-based history of chronic diseases including hypertension, heart disease, heart failure, stroke, diabetes, cancer, chronic lung disease, and arthritis; impairments, including cognition, vision, and hearing; and disability, including mobility, complex activities of daily living (ADL), and self-care ADL. RESULTS Over time, the relationship of chronic diseases and impairments with disability was largely unchanged; however, the association between hypertension and complex ADL disability weakened from 1998 to 2004 and 2008 [odds ratio (OR) = 1.24; 99% confidence interval (CI), 1.06-1.46; OR = 1.07; 99% CI, 0.90-1.27; OR = 1.00; 99% CI, 0.83-1.19, respectively], as it did for hypertension and self-care disability (OR = 1.32; 99% CI, 1.13-1.54; OR=0.97; 99% CI, 0.82-1.14; OR = 0.99; 99% CI, 0.83-1.17). The association between diabetes and self-care disability strengthened from 1998 to 2004 and 2008 (OR = 1.21; 99% CI, 1.01-1.46; OR = 1.37; 99% CI, 1.15-1.64; OR = 1.52; 99% CI, 1.29-1.79), as it also did for lung disease and self-care disability (OR = 1.64; 99% CI, 1.33-2.03; OR = 1.63; 99% CI, 1.32-2.01; OR = 2.11; 99% CI, 1.73-2.57). CONCLUSIONS Although relationships between diseases, impairments, and disability were largely unchanged, disability became less associated with hypertension and more with diabetes and lung disease.

Patient race/ethnicity and shared medical record use among diabetes patients

Abstract: BACKGROUND Previous studies have documented racial/ethnic differences in patients' use of websites providing shared electronic medical records between patients and health care professionals. Less is known about whether these are driven by patient-level preferences and/or barriers versus broader provider or system factors. METHODS Cross-sectional study of diabetes patients in an integrated delivery system in 2008-2009. Primary measures were race/ethnicity and shared medical record (SMR) use. Covariates included sociodemographics (age, sex, income, education), health status (comorbidity, diabetes severity), and provider characteristics (encouragement of SMR, secure messaging use, clinic). RESULTS The majority (62%) of Whites used the SMR, compared with 34% of Blacks, 37% of Asians, and 55% of other race/ethnicity (P<0.001). Most respondents (76%) stated that their provider had encouraged them to use the SMR, with no differences by race/ethnicity. Patients saw primary care providers who used a similar amount of secure messaging in their practices-except Asians, who were less likely to see high-messaging providers. In fully adjusted models, Blacks [odds ratio (OR), 0.18; 95% confidence interval (CI), 0.11-0.30] and Asians (OR, 0.40; 95% CI, 0.20-0.77) were significantly less likely than Whites to use the SMR. When restricted to individuals reporting at least occasional Internet use, this finding remained for Black respondents (OR, 0.25; 95% CI, 0.10-0.63). CONCLUSIONS Among diabetes patients, differences in SMR use by race/ethnicity were not fully explained by differences in age, sex, sociodemographics, health status, or provider factors-particularly for Black patients. There were few racial/ethnic differences in provider encouragement or provider secure messaging use that would have suggested disparities at the provider level.

Validating the patient safety indicators in the Veterans Health Administration: do they accurately identify true safety events?

Abstract: Background:The Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators (PSIs) use administrative data to detect potentially preventable in-hospital adverse events. However, few studies have determined how accurately the PSIs identify true safety events.Objectives:We examined the

Mental Comorbidity and Quality of Diabetes Care Under Medicaid: A 50-State Analysis

Abstract: Background Patients with comorbid medical and mental conditions are at risk for poor quality of care. With the anticipated expansion of Medicaid under health reform, it is particularly important to develop national estimates of the magnitude and correlates of quality deficits related to mental comorbidity among Medicaid enrollees.

Estimating Proximity to Care: Are straight line and zipcode centroid distances acceptable proxy measures?

Abstract: Background Spatial accessibility of health care may be measured by proximity of patient residence to health services, typically in driving distance or driving time. Precise driving distances and times are rarely available. While straight line distances between zipcode centroids and between precise address locations are used as proxy measures for distance to care, the accuracy of these measures has received little study.

The effect of improving processes of care on patient outcomes: evidence from the United Kingdom's quality and outcomes framework.

Abstract: Background:Despite the extensive use of process of care measures in pay-for-performance programs, little is known about the effect of improving process performance on patient outcomes.Methods:Retrospective longitudinal analysis of data extracted from 7228 family practices in the United Kingdom’s Qua

Risk-adjusted payment and performance assessment for primary care.

Abstract: Background:Many wish to change incentives for primary care practices through bundled population-based payments and substantial performance feedback and bonus payments. Recognizing patient differences in costs and outcomes is crucial, but customized risk adjustment for such purposes is underdeveloped

The hospital standardized mortality ratio fallacy: a narrative review.

Abstract: Background:Outcome measures, like hospital standardized mortality ratios (HSMRs), are increasingly used to assess quality of care. The validity of HSMRs and their accuracy to reflect quality of care is heavily contested.Objective:We explored apparent and potential shortcomings and adverse effects of