Showing papers in "Medical Care in 2016"

The Economic Burden of Prescription Opioid Overdose, Abuse, and Dependence in the United States, 2013.

Abstract: Importance:It is important to understand the magnitude and distribution of the economic burden of prescription opioid overdose, abuse, and dependence to inform clinical practice, research, and other decision makers. Decision makers choosing approaches to address this epidemic need cost information t

Comparison of SEER Treatment Data With Medicare Claims

Abstract: Background: The population-based Surveillance, Epidemiology, and End Results (SEER) registries collect information on first-course treatment, including surgery, chemotherapy, radiation therapy, and hormone therapy. However, the SEER program does not release data on chemotherapy or hormone therapy due to uncertainties regarding data completeness. Activities are ongoing to investigate the opportunity to supplement SEER treatment data with other data sources.

Racial and Ethnic Disparities in Health Care Access and Utilization Under the Affordable Care Act

Abstract: Objective:To examine racial and ethnic disparities in health care access and utilization after the Affordable Care Act (ACA) health insurance mandate was fully implemented in 2014.Research Design:Using the 2011–2014 National Health Interview Survey, we examine changes in health care access and utili

A Time Trade-off-derived Value Set of the EQ-5D-5L for Canada.

Abstract: Background:The 5-level version of the EQ-5D (EQ-5D-5L) was recently developed. A number of preference-based scoring systems are being developed for several countries around the world.Objective:To develop a value set for the EQ-5D-5L based on societal preferences in Canada.Methods:We used age, sex, a

The Best Use of the Charlson Comorbidity Index With Electronic Health Care Database to Predict Mortality.

Abstract: Background:The most used score to measure comorbidity is the Charlson index. Its application to a health care administrative database including International Classification of Diseases, 10th edition (ICD-10) codes, medical procedures, and medication required studying its properties on survival. Our

Discrimination and Delayed Health Care Among Transgender Women and Men: Implications for Improving Medical Education and Health Care Delivery.

Abstract: Background:The transgender community experiences health care discrimination and approximately 1 in 4 transgender people were denied equal treatment in health care settings. Discrimination is one of the many factors significantly associated with health care utilization and delayed care.Objectives:We

The Digital Divide and Patient Portals: Internet Access Explained Differences in Patient Portal Use for Secure Messaging by Age, Race, and Income.

Abstract: BACKGROUND Online access to health records and the ability to exchange secure messages with physicians can improve patient engagement and outcomes; however, the digital divide could limit access to web-based portals among disadvantaged groups. OBJECTIVES To understand whether sociodemographic differences in patient portal use for secure messaging can be explained by differences in internet access and care preferences. RESEARCH DESIGN Cross-sectional survey to examine the association between patient sociodemographic characteristics and internet access and care preferences; then, the association between sociodemographic characteristics and secure message use with and without adjusting for internet access and care preference. SUBJECTS One thousand forty-one patients with chronic conditions in a large integrated health care delivery system (76% response rate). MEASURES Internet access, portal use for secure messaging, preference for in-person or online care, and sociodemographic and health characteristics. RESULTS Internet access and preference mediated some of the differences in secure message use by age, race, and income. For example, using own computer to access the internet explained 52% of the association between race and secure message use and 60% of the association between income and use (Sobel-Goodman mediation test, P<0.001 for both). Education and sex-related differences in portal use remained statistically significant when controlling for internet access and preference. CONCLUSIONS As the availability and use of patient portals increase, it is important to understand which patients have limited access and the barriers they may face. Improving internet access and making portals available across multiple platforms, including mobile, may reduce some disparities in secure message use.

Better Nurse Staffing and Nurse Work Environments Associated With Increased Survival of In-Hospital Cardiac Arrest Patients.

Abstract: Background:Although nurses are the most likely first responders to witness an in-hospital cardiac arrest (IHCA) and provide treatment, little research has been undertaken to determine what features of nursing are related to cardiac arrest outcomes.Objectives:To determine the association between nurs

A Detailed Exploration Into the Association of Prescribed Opioid Dosage and Overdose Deaths Among Patients With Chronic Pain

Abstract: Background:High opioid dosage has been associated with overdose, and clinical guidelines have cautioned against escalating dosages above 100 morphine-equivalent mg (MEM) based on the potential harm and the absence of evidence of benefit from high dosages. However, this 100 MEM threshold was chosen s

Measuring Care Continuity: A Comparison of Claims-based Methods.

Abstract: Background:Assessing care continuity is important in evaluating the impact of health care reform and changes to health care delivery. Multiple measures of care continuity have been developed for use with claims data.Objective:This study examined whether alternative continuity measures provide distin

A Systematic Review of the Impact of Potentially Inappropriate Medication on Health Care Utilization and Costs Among Older Adults.

Abstract: Background Potentially inappropriate medications (PIMs) are defined as those medicines having a greater potential risk than benefit for older adults. In this systematic literature review, we evaluate the current evidence on health care service use and health care costs associated with PIMs among older adults. Methods A literature search was conducted in August 2015 without publication date restrictions using the databases PubMed and Scopus. Selected articles included in the review of articles were: (1) observational cohort or case-control, or intervention studies; (2) investigating PIM use among older adults aged 65 years or older with outcomes on health care utilization (eg, hospitalization) or health care costs; and (3) use of some published criteria for assessing PIMs. Results Of 825 abstracts screened, in total 51 articles proceeded to full-text review. Of those full-text articles, 39 articles were included in this review. Most of the articles found that PIMs had a statistically significant effect on health care service use, especially on hospitalization, among older adults. The findings of impact on length of stay or readmissions were inconclusive. Five studies found statistically significant higher medical or total health care costs for PIM users compared those who did not use any PIMs. Conclusions PIMs can, in addition to health and quality of life problems, also lead to greater health care service use and, thus, higher health care costs. However, the heterogeneity of the study settings makes the interpretation of the results difficult. Further studies, especially on economic issues with country-specific criteria, are needed.

A Comprehensive Assessment of Family Physician Gender and Quality of Care: A Cross-Sectional Analysis in Ontario, Canada.

Abstract: Background:Studies evaluating primary care quality across physician gender are limited to primary and secondary prevention.Objectives:Investigate the relationship between family physician gender and quality of primary care using indicators that cover 5 key dimensions of primary care.Research Design:

Role of Geography and Nurse Practitioner Scope-of-Practice in Efforts to Expand Primary Care System Capacity: Health Reform and the Primary Care Workforce.

Abstract: Background Little is known about the geographic distribution of the overall primary care workforce that includes both physician and nonphysician clinicians--particularly in areas with restrictive nurse practitioner scope-of-practice laws and where there are relatively large numbers of uninsured. Objective We investigated whether geographic accessibility to primary care clinicians (PCCs) differed across urban and rural areas and across states with more or less restrictive scope-of-practice laws. Research design An observational study. Subjects 2013 Area Health Resource File (AHRF) and US Census Bureau county travel data. Measures The measures included percentage of the population in low-accessibility, medium-accessibility, and high-accessibility areas; number of geographically accessible primary care physicians (PCMDs), nurse practitioners (PCNPs), and physician assistants (PCPAs) per 100,000 population; and number of uninsured per PCC. Results We found divergent patterns in the geographic accessibility of PCCs. PCMDs constituted the largest share of the workforce across all settings, but were relatively more concentrated within urban areas. Accessibility to nonphysicians was highest in rural areas: there were more accessible PCNPs per 100,000 population in rural areas of restricted scope-of-practice states (21.4) than in urban areas of full practice states (13.9). Despite having more accessible nonphysician clinicians, rural areas had the largest number of uninsured per PCC in 2012. While less restrictive scope-of-practice states had up to 40% more PCNPs in some areas, we found little evidence of differences in the share of the overall population in low-accessibility areas across scope-of-practice categorizations. Conclusions Removing restrictive scope-of-practice laws may expand the overall capacity of the primary care workforce, but only modestly in the short run. Additional efforts are needed that recognize the locational tendencies of physicians and nonphysicains.

Social Determinants of Health, Cost-related Nonadherence, and Cost-reducing Behaviors Among Adults With Diabetes: Findings From the National Health Interview Survey.

Abstract: Background:Cost-related nonadherence (CRN) is prevalent among individuals with diabetes and can have significant negative health consequences We examined health-related and non–health-related pressures and the use of cost-reducing strategies among the US adult population with and without diabetes t

Post-discharge Follow-up Characteristics Associated With 30-Day Readmission After Heart Failure Hospitalization.

Abstract: Background:Readmission within 30 days after hospitalization for heart failure (HF) is a major public health problem.Objective:To examine whether timing and type of post-discharge follow-up impacts risk of 30-day readmission in adults hospitalized for HF.Design:Nested matched case-control study (Janu

Validity of the Agency for Health Care Research and Quality Patient Safety Indicators and the Centers for Medicare and Medicaid Hospital-acquired Conditions: A Systematic Review and Meta-Analysis

Abstract: Background:The Agency for Health Care Research and Quality Patient Safety Indicators (PSIs) and Centers for Medicare and Medicaid Services Hospital-acquired Conditions (HACs) are increasingly being used for pay-for-performance and public reporting despite concerns over their validity. Given the pote

Comparison of Comorbidity Scores in Predicting Surgical Outcomes.

Abstract: Introduction The optimal methodology for assessing comorbidity to predict various surgical outcomes such as mortality, readmissions, complications, and failure to rescue (FTR) using claims data has not been established. Objective Compare diagnosis-based and prescription-based comorbidity scores for predicting surgical outcomes. Methods We used 100% Texas Medicare data (2006-2011) and included patients undergoing coronary artery bypass grafting, pulmonary lobectomy, endovascular repair of abdominal aortic aneurysm, open repair of abdominal aortic aneurysm, colectomy, and hip replacement (N=39,616). The ability of diagnosis-based [Charlson comorbidity score, Elixhauser comorbidity score, Combined Comorbidity Score, Centers for Medicare and Medicaid Services-Hierarchical Condition Categories (CMS-HCC)] versus prescription-based Chronic disease score in predicting 30-day mortality, 1-year mortality, 30-day readmission, complications, and FTR were compared using c-statistics (c) and integrated discrimination improvement (IDI). Results The overall 30-day mortality was 5.8%, 1-year mortality was 17.7%, 30-day readmission was 14.1%, complication rate was 39.7%, and FTR was 14.5%. CMS-HCC performed the best in predicting surgical outcomes (30-d mortality, c=0.797, IDI=4.59%; 1-y mortality, c=0.798, IDI=9.60%; 30-d readmission, c=0.630, IDI=1.27%; complications, c=0.766, IDI=9.37%; FTR, c=0.811, IDI=5.24%) followed by Elixhauser comorbidity index/disease categories (30-d mortality, c=0.750, IDI=2.37%; 1-y mortality, c=0.755, IDI=5.82%; 30-d readmission, c=0.629, IDI=1.43%; complications, c=0.730, IDI=3.99%; FTR, c=0.749, IDI=2.17%). Addition of prescription-based scores to diagnosis-based scores did not improve performance. Conclusions The CMS-HCC had superior performance in predicting surgical outcomes. Prescription-based scores, alone or in addition to diagnosis-based scores, were not better than any diagnosis-based scoring system.

ICU Telemedicine and Critical Care Mortality: A National Effectiveness Study.

Abstract: BACKGROUND Intensive care unit (ICU) telemedicine is an increasingly common strategy for improving the outcome of critical care, but its overall impact is uncertain. OBJECTIVES To determine the effectiveness of ICU telemedicine in a national sample of hospitals and quantify variation in effectiveness across hospitals. RESEARCH DESIGN We performed a multicenter retrospective case-control study using 2001-2010 Medicare claims data linked to a national survey identifying US hospitals adopting ICU telemedicine. We matched each adopting hospital (cases) to up to 3 nonadopting hospitals (controls) based on size, case-mix, and geographic proximity during the year of adoption. Using ICU admissions from 2 years before and after the adoption date, we compared outcomes between case and control hospitals using a difference-in-differences approach. RESULTS A total of 132 adopting case hospitals were matched to 389 similar nonadopting control hospitals. The preadoption and postadoption unadjusted 90-day mortality was similar in both case hospitals (24.0% vs. 24.3%, P=0.07) and control hospitals (23.5% vs. 23.7%, P<0.01). In the difference-in-differences analysis, ICU telemedicine adoption was associated with a small relative reduction in 90-day mortality (ratio of odds ratios=0.96; 95% CI, 0.95-0.98; P<0.001). However, there was wide variation in the ICU telemedicine effect across individual hospitals (median ratio of odds ratios=1.01; interquartile range, 0.85-1.12; range, 0.45-2.54). Only 16 case hospitals (12.2%) experienced statistically significant mortality reductions postadoption. Hospitals with a significant mortality reduction were more likely to have large annual admission volumes (P<0.001) and be located in urban areas (P=0.04) compared with other hospitals. CONCLUSIONS Although ICU telemedicine adoption resulted in a small relative overall mortality reduction, there was heterogeneity in effect across adopting hospitals, with large-volume urban hospitals experiencing the greatest mortality reductions.

Comparative responsiveness of the PROMIS pain interference short forms, brief pain inventory, PEG, and SF-36 bodily pain subscale

Abstract: Purpose To compare the sensitivity to change and the responsiveness to intervention of the PROMIS Pain Interference short forms, Brief Pain Inventory (BPI), 3-item PEG scale, and SF-36 Bodily Pain subscale in a sample of patients with persistent musculoskeletal pain of moderate severity. Methods Standardized response means, standardized effect sizes, and receiver operating curve analyses were used to assess change between baseline and 3-month assessments in 250 participants who participated in a randomized clinical effectiveness trial of collaborative telecare management for moderate to severe and persistent musculoskeletal pain. Results The BPI, PEG, and SF-36 Bodily Pain measures were more sensitive to patient-reported global change than the PROMIS Pain Interference short forms, especially for the clinically improved group, for which the change detected by the PROMIS short forms was not statistically significant. The BPI was more responsive to the clinical intervention than the SF-36 Bodily Pain and PROMIS Pain Interference measures. Post hoc analyses exploring these findings did not suggest that differences in content or rating scale structure (number of response options or anchoring language) adequately explained the observed differences in the detection of change. Conclusions In this clinical trial, the BPI and PEG measures were better able to detect change than the SF-36 Bodily Pain and PROMIS Pain Interference measures.

Increased Risk of Burnout for Physicians and Nurses Involved in a Patient Safety Incident.

Abstract: Background:Human errors occur everywhere, including in health care Not only the patient, but also the involved health professional is affected (ie, the “second victim”)Objectives:To investigate the prevalence of health care professionals being personally involved in a patient safety incident (PSI)

A Narrative Review of Patient and Family Engagement: The "Foundation" of the Medical "Home".

Abstract: Background:Patient and family engagement (PFE) is vital to the spirit of the medical home. This article reflects the efforts of an expert consensus panel, the Patient and Family Engagement Workgroup, as part of the Society of General Internal Medicine’s 2013 Research Conference.Objective:To review e

Accelerating research impact in a learning health care system VA's quality enhancement research initiative in the choice act era

Abstract: Background:Since 1998, the Veterans Health Administration (VHA) Quality Enhancement Research Initiative (QUERI) has supported more rapid implementation of research into clinical practice.Objectives:With the passage of the Veterans Access, Choice and Accountability Act of 2014 (Choice Act), QUERI fur

Distinguishing Selection Bias and Confounding Bias in Comparative Effectiveness Research.

Abstract: Comparative effectiveness research (CER) aims to provide patients and physicians with evidence-based guidance on treatment decisions. As researchers conduct CER they face myriad challenges. Although inadequate control of confounding is the most-often cited source of potential bias, selection bias that arises when patients are differentially excluded from analyses is a distinct phenomenon with distinct consequences: confounding bias compromises internal validity, whereas selection bias compromises external validity. Despite this distinction, however, the label "treatment-selection bias" is being used in the CER literature to denote the phenomenon of confounding bias. Motivated by an ongoing study of treatment choice for depression on weight change over time, this paper formally distinguishes selection and confounding bias in CER. By formally distinguishing selection and confounding bias, this paper clarifies important scientific, design, and analysis issues relevant to ensuring validity. First is that the 2 types of biases may arise simultaneously in any given study; even if confounding bias is completely controlled, a study may nevertheless suffer from selection bias so that the results are not generalizable to the patient population of interest. Second is that the statistical methods used to mitigate the 2 biases are themselves distinct; methods developed to control one type of bias should not be expected to address the other. Finally, the control of selection and confounding bias will often require distinct covariate information. Consequently, as researchers plan future studies of comparative effectiveness, care must be taken to ensure that all data elements relevant to both confounding and selection bias are collected.

The Role of Bias by Emergency Department Providers in Care for American Indian Children.

Abstract: Background American Indian children have high rates of emergency department (ED) use and face potential discrimination in health care settings. Objective Our goal was to assess both implicit and explicit racial bias and examine their relationship with clinical care. Research design We performed a cross-sectional survey of care providers at 5 hospitals in the Upper Midwest. Questions included American Indian stereotypes (explicit attitudes), clinical vignettes, and the Implicit Association Test. Two Implicit Association Tests were created to assess implicit bias toward the child or the parent/caregiver. Differences were assessed using linear and logistic regression models with a random effect for study site. Results A total of 154 care providers completed the survey. Agreement with negative American Indian stereotypes was 22%-32%. Overall, 84% of providers had an implicit preference for non-Hispanic white adults or children. Older providers (50 y and above) had lower implicit bias than those middle aged (30-49 y) (P=0.01). American Indian children were seen as increasingly challenging (P=0.04) and parents/caregivers less compliant (P=0.002) as the proportion of American Indian children seen in the ED increased. Responses to the vignettes were not related to implicit or explicit bias. Conclusions The majority of ED care providers had an implicit preference for non-Hispanic white children or adults compared with those who were American Indian. Provider agreement with negative American Indian stereotypes differed by practice and respondents' characteristics. These findings require additional study to determine how these implicit and explicit biases influence health care or outcomes disparities.

Serious Mental Illness and Risk for Hospitalizations and Rehospitalizations for Ambulatory Care-sensitive Conditions in Denmark: A Nationwide Population-based Cohort Study.

Abstract: Background:Hospitalizations for ambulatory care-sensitive conditions (ACSCs) and early rehospitalizations increase health care costsObjectives:To determine if individuals with serious mental illnesses (SMIs) (eg, schizophrenia or bipolar disorder) are at increased risk for hospitalizations for ACSC

Outcomes are Worse in US Patients Undergoing Surgery on Weekends Compared With Weekdays.

Abstract: Background:Increasing surgical access to previously underserved populations in the United States may require a major expansion of the use of operating rooms on weekends to take advantage of unused capacity. Although the so-called weekend effect for surgery has been described in other countries, it i

Outcomes and Resource Use of Sepsis-associated Stays by Presence on Admission, Severity, and Hospital Type.

Abstract: Objective: To establish a baseline for the incidence of sepsis by severity and presence on admission in acute care hospital settings before implementation of a broad sepsis screening and response initiative.

Sensitivity of Medicare Claims to Identify Cancer Recurrence in Elderly Colorectal and Breast Cancer Patients.

Abstract: BACKGROUND Researchers are increasingly interested in using observational data to evaluate cancer outcomes following treatment, including cancer recurrence and disease-free survival. Because population-based cancer registries do not collect recurrence data, recurrence is often imputed from health claims, primarily by identifying later cancer treatments after initial treatment. The validity of this approach has not been established. RESEARCH DESIGN We used the linked Surveillance, Epidemiology, and End Results-Medicare data to assess the sensitivity of Medicare claims for cancer recurrence in patients very likely to have had a recurrence. We selected newly diagnosed stage II/III colorectal (n=6910) and female breast cancer (n=3826) patients during 1994-2003 who received initial cancer surgery, had a treatment break, and then died from cancer in 1994-2008. We reviewed all claims from the treatment break until death for indicators of recurrence. We focused on additional cancer treatment (surgery, chemotherapy, radiation therapy) as the primary indicator, and used multivariate logistic regression analysis to evaluate patient factors associated with additional treatment. We also assessed metastasis diagnoses and end-of-life care as recurrence indicators. RESULTS Additional treatment was the first indicator of recurrence for 38.8% of colorectal patients and 35.2% of breast cancer patients. Patients aged 70 and older were less likely to have additional treatment (P < 0.05), in adjusted analyses. Over 20% of patients either had no recurrence indicator before death or had end-of-life care as their first indicator. CONCLUSIONS Identifying recurrence through additional cancer treatment in Medicare claims will miss a large percentage of patients with recurrences; particularly those who are older.

Validation of Case Finding Algorithms for Hepatocellular Cancer From Administrative Data and Electronic Health Records Using Natural Language Processing.

Abstract: Background Accurate identification of hepatocellular cancer (HCC) cases from automated data is needed for efficient and valid quality improvement initiatives and research. We validated HCC ICD-9 codes, and evaluated whether natural language processing (NLP) by the Automated Retrieval Console (ARC) for document classification improves HCC identification.

Trends in the Treatment of Metastatic Colon and Rectal Cancer in Elderly Patients.

Abstract: Background:Little is known about the use and costs of antineoplastic regimens for elderly patients with metastatic colorectal cancer (mCRC). We report population-based trends over a 10-year period in the treatment, survival, and costs in mCRC patients, stratified by ages 65–74 and 75+.Methods:We use