Research Activities, January 2011, No. 365
Cohen, S.B., Ezzati-Rice, T., and Zodet, M. (2009, December). "The impact of survey design modifications on health insurance coverage estimates in a National Longitudinal Health Care Survey." Health Services Outcomes Research Methods 9(4), Epub. Aug. 6, 2010.
The Medical Expenditures Panel Survey (MEPS) is one of the core U.S. health surveys that serves as a primary source for national health insurance coverage estimates. In 2007, the survey's design was modified in two ways: (1) a new sample design attributable to the sample redesign of the National Health Interview Survey, and (2) an upgrade to the CAPI platform for the survey instrument, moving from a DOS to a Windows-based environment. This paper examines several dimensions of the potential impact of these modifications. One part examines the alignment in MEPS coverage estimates across panels. This was supplemented by a model-based analysis of the impact of recent MEPS design modifications on coverage estimates. The final series of analyses attempted to isolate the effects of MEPS sample design modifications and adjustments for survey attrition on health insurance coverage estimates from those attributable to the CAPI design modifications introduced in 2007.
Dikmen, S., Machamer, J., Fann, J. R., and Temskin, N. R. (2010). "Rates of symptom reporting following traumatic brain injury." (AHRQ grants HS04146, HS05304). Journal of the International Neuropsychological Society 16, pp. 410-411.
Although often discounted because they cannot be independently verified, self-reported posttraumatic symptoms (PTS) are commonly the problems that people with traumatic brain injury (TBI) present to health care providers. There is no doubt that PTS are common immediately after the injury. The question is how long they persist, the number of persons who will continue to have them, and what predicts who will continue to have symptoms. The researchers examined 732 patients with a broad range of injury severity at 1 month and 1 year after TBI, in comparison with 120 general trauma subjects whose injury spared the head. Symptoms are commonly reported in both groups at 1 month. At 1 year postinjury, 53 percent of people with TBI and 24 percent of people with other trauma reported 3 or more symptoms. Problems with irritability, memory, and temper were the most likely to be reported at 1 year. Symptom reporting in the TBI group was significantly related to age, sex, pre-injury alcohol abuse, pre-injury psychiatric history, and severity of TBI.
Donovan, J. L., Kanaan, A. O., Thomson, M. S., and others (2010, May). "Effects of clinical decision support on psychotropic medications prescribing in the long-term care setting." (AHRQ grants HS10481, HS15430). Journal of the American Geriatric Society 58(5), pp. 1005-1007.
The researchers sought to discover if the implementation of a computerized clinical decision support system, which provided specific recommendations on dosing and choice of psychotropic drugs, would increase the prescription of recommended doses and reduce the prescription of nonrecommended drugs in the long-term care (LTC) setting. The study followed 813 different LTC residents in the intervention and control groups over a 12-month period. It found that the overall rate of inappropriate orders was 1.58 per 100 resident-months on the intervention units and 1.61 per 100 resident-months in the control units. The lack of improvement in prescribing quality was perhaps due to a low overall rate of inappropriate prescribing in the study facility, which is a large, academically affiliated LTC facility.
Engelberg, R.A., Downey, L., Wenrich, M.D., and others (2010, June). "Measuring the quality of end-of-life care." (AHRQ grant HS11425). Journal of Pain and Symptom Management 39(6), pp. 951-971.
The researchers sought to examine the measurement characteristics of the new Quality of End-of-Life Care (QEOLC) questionnaire in which respondents rate physician skills at providing quality end-of-life care. A total of 801 patients with life-limiting conditions, 310 of their families, and 885 nurses filled out a mailed copy of the questionnaire. The study describes the psychometric characteristics, including the domain structure and construct validity of the QEOLC questionnaire. The original 54-item QEOLC questionnaire was reduced to a set of 29 items for patients, 30 items for families, and 31 items for nurses, based on previously defined criteria. Using structural equation modeling techniques corrected for clustering under physicians, the researchers identified a patient-specific factor based on 11 items, a family-specific factor based on 22 items, a nurse-specific factor based on 11 items, and a common single-factor solution based on 10 items.
Fishman, P. A., Bonomi, A. E., Anderson, M. L., and others (2010). "Changes in health care costs over time following the cessation of intimate partner violence." (AHRQ grant HS10909). Journal of General Internal Medicine 25(9), pp. 920-925.
A growing literature has documented increased health care costs for women who have experienced intimate partner violence (IPV) compared with other women. These greater costs are sustained for some time after IPV ends, but research has yet to show whether health care costs for these women return to baseline at some point. The researchers followed total health care costs over an 11-year period for women enrolled in the Group Health Cooperative and compared costs for women who experienced IPV with those who never experienced IPV. IPV resulted in $585 greater annual health care costs during the period of abuse and these costs remained significantly higher for 3 years following the end of the abuse. By the fourth year, differences were not statistically significant, and by the fifth year, costs for IPV and non-IPV groups were similar.
Hetsroni, I., Rosenberg, H., Grimm, P., and Marx, R. G. (2010, May). "Mycobacterium fortuitum infection following patellar tendon repair: A case report." (AHRQ grant HS16075). Journal of Bone & Joint Surgery 92(5), pp. 1254-1256.
Mycobacterium fortuitum is a ubiquitous, rapidly growing mycobacterial species that has been encountered following trauma, prosthetic arthroplasty, and fracture surgery with internal fixation. The authors report a case of an otherwise healthy man who underwent patellar tendon repair that was complicated by a Mycobacterium fortuitum infection. Infections involving this pathogen often present a therapeutic challenge. In this case, 2 months passed from the primary operation until the infection was treated appropriately with aggressive surgery and specific chemotherapy. Had specimens not been submitted for mycobacterial analysis, there might have been an adverse outcome. This case was exceptional in that the infection was found following a soft-tissue procedure in an otherwise healthy patient. The authors believe that the cost and morbidity of an overlooked diagnosis justify aerobic and anaerobic cultures being universally accompanied by mycobacterial cultures at the time of debridement of musculoskeletal infections.
Isaac, T., Zaslavsky, A. M., Cleary, P. D., and Landon, B. E. (2010, August). "The relationship between patients' perception of care and measures of hospital quality and safety." (AHRQ grant 13190). HSR: Health Services Research 45(4), pp. 1024-1040.
The researchers sought to determine the extent to which patient experiences with hospital care are related to other measures of hospital quality and safety. Using data from 929 hospitals, they examined the relationship between Hospital Consumer Assessment of Healthcare Providers and Systems scores and technical measures of quality and safety. The study found consistent relationships between patient experiences and technical quality as defined by measures used in the Hospital Quality Alliance program and complication rates, as measured by the Agency for Healthcare Research and Quality's Patient Safety Indicators. Two overall measures of hospital performance, the overall rating of the hospital and willingness to recommend the hospital, were strongly related to better technical performance in processes of care related to pneumonia, congestive heart failure, myocardial infarction, and for surgical care.
Kesselheim, A. S., and Outterson, K. (2010). "Fighting antibiotic resistance: Marrying new financial incentives to meeting public health goals." (AHRQ grant HS18465). Health Affairs 29(9), pp. 1689-1696.
Rising rates of antibiotic resistance have become a clear public health crisis. Many proposals have been offered to address this issue. The authors argue for an integrated focus on both producing new drugs and making careful and more limited use of existing ones. They propose to tie reimbursement for antibiotics more directly to objective evidence of appropriate prescription rates and positive public health outcomes. This would involve applying the principles of value-based reimbursement to paying for continued antibiotic effectiveness. They also propose a conservation-based market exclusivity strategy, whereby the Food and Drug Administration would set specific effectiveness targets for each antibiotic. If the observed data met the specific target and equitable access to the drug was observed, the company would continue to enjoy marketing exclusivity. This kind of program would encourage manufacturers to create programs to restrict clinically inappropriate use of their products, such as funding hospital-based infection control efforts.
Lale, A., Moloney, R., and Alexander, G.C. (2010, July). "Academic medical centers and underserved communities: Modern complexities of an enduring relationship." (AHRQ grant HS15699). Journal of the National Medical Association 102(7), pp. 605-613.
Academic medical centers have a tripartite mission of education, research, and clinical care. About 75 percent of these centers are located in underserved communities with large minority populations that are often underinsured or uninsured. To explore stakeholders' views regarding the ethical, legal, and financial obligations of private academic medical centers to their surrounding neighborhoods, the researchers conducted 19 interviews with a variety of key stakeholders (medical students, faculty physicians, administrators, and community-based physicians) at a single academic medical center. Every respondent believed that academic medical centers have some obligation to their surrounding communities. However, they differed regarding the extent of the obligation as well as how to best unite the service goals of the medical profession with the fiscal realities of the institution. Half of the respondents directly connected the challenges facing these centers to inefficiencies and inequities in the broader health care system.
Mazumdar, M., Banerjee, S., and Van Epps, H.L. (2010). "Improved reporting of statistical design and analysis: Guidelines, education, and editorial policies." In: Bang, H., et al. (editors). Statistical Methods in Molecular Biology. New York: Humana Press. pp. 563-598.
The proportion of original manuscripts published in biomedical journals that contain some form of statistical analysis is estimated at 60-90 percent. The complexity of published statistical analyses has increased steadily in recent decades and statistical flaws have been revealed in many published reports. To help avoid errors and improve statistical reporting, four approaches are suggested: (1) development of guidelines for statistical reporting that could be adopted by all journals, (2) improvement in statistics curricula in biomedical research programs with an emphasis on hands-on teaching by biostatisticians, (3) expansion and enhancement of biomedical science curricula in statistics programs, and (4) increased participation of biostatisticians in the peer-review process along with the adoption of more rigorous journal editorial policies regarding statistics. The authors discuss each of these approaches in detail.
Pylypchuk, Y. (2010). "Adverse selection and the effect of health insurance on utilization of prescribed medicine among patients with chronic conditions." In: Dor, A. (editor). Pharmaceutical Markets and Insurance Worldwide. [Advances in Health Economics and Health Services Research, Vol. 22]. UK: Emerald Group Publishing, Ltd. pp. 233-272. Reprints (AHRQ Publication No. 11-R011) are available from the AHRQ Publications Clearinghouse.
The researcher used 2000-2003 data from the Medical Expenditure Survey to determine the association between health insurance coverage and expenditures for drugs that treat chronic diseases. He compared four types of health insurance: no insurance, health maintenance organization (HMO) insurance with drug coverage, and non-HMO health insurance with and without drug coverage. He found that drug coverage was very important in understanding drug expenses among patients with chronic conditions (specifically, hypertension, diabetes, and asthma). Patients with a silent chronic condition such as hypertension are more likely to buy their prescribed medication if they have drug coverage, while patients with noticeable chronic conditions (diabetes or asthma) are more likely to get their medications whether or not they have drug coverage.
Richard, C. J., and Engebretson, J. (2010). "Negotiating living with an arteriovenous fistula for hemodialysis." (AHRQ grant HS10826). Continuing Nursing Education 37(4), pp. 363-374.
Establishing and maintaining a vascular access is one of the biggest problems in hemodialysis. The researchers examined how clients with end-stage renal disease on hemodialysis negotiate living with an arteriovenous fistula. A fistula is the preferred access for hemodialysis, and clients must continually monitor and protect their fistula. The researchers interviewed 14 clients for 1.5 to 4 hours. The overarching theme emerging from the clients' experiences was vulnerability. An underlying theme was body awareness. Vulnerability is based partly on being dependent on the health care system, which, in turn, can lead to mistrust of that system extending to the technology and the providers. Other themes are the need to cope with maintenance and the stigma of the vascular access. Providers need to be aware of the feelings clients have about their vascular access, including stigma, and encourage them to express these feelings in a nonjudgmental environment.
Rivera-Rodriguez, A. J., and Karsh, B-T. (2010). "Interruptions and distractions in healthcare: Review and reappraisal." (AHRQ grant HS13610). Quality and Safety in Health Care 19, pp. 304-312.
Interruptions in health care settings can be disruptive and be a contributing factor to medical errors. The authors systematically reviewed the peer-reviewed literature on this subject to determine the state of the science and to identify gaps. A total of 33 papers were included in their review. There were several important findings. First, interruptions occur frequently, regardless of the setting. Second, there is a gap in the existing research in that only seven studies examined outcomes related to interruptions. Third, the studies that have been done looked at interruptions only from the perspective of the one being interrupted and not the interrupter. Finally, few studies examined the cognitive implications of interruptions by measuring subsequent performance, such as errors or problem identification. These implications are at the heart of why the study of interruptions is important. The authors conclude by discussing some of these implications and making recommendations for future research.
Routh, J. C., Gong, E. M., Cannon, G. M. (2010). "Variation among internet based calculators in predicting spontaneous resolution of vesicoureteral reflux." (AHRQ grant T32 HS00063). Journal of Urology 183, pp. 1568-1573.
Vesicoureteral reflux (VUR) is an abnormal movement of urine from the bladder into the ureters or kidneys. It is a condition more likely to affect younger children. Pediatric urologists have developed prediction models applicable to VUR, specifically to predict the probability of its spontaneous resolution. Several of these models are published as Internet-based calculators, usable by both providers and parents. The researchers sought to discover if the currently available calculators for VUR resolution produced systematically different results. They found systematic differences among the three Internet-based calculators. For one patient, the estimated probability ranged from 24 to 89 percent, while another had a probability of 7 to 48 percent. Also, the three calculators produced widely divergent discriminatory abilities when a variety of threshold cutoff values were used. For certain patients, such differences have the potential to significantly influence clinical decisionmaking.
Sawyer, M., Weeks, K., Goeschel, C. A., and others (2010). "Using evidence, rigorous measurement, and collaboration to eliminate central catheter-associated bloodstream infections." (AHRQ grant HS14246). Critical Care Medicine 38(8 Suppl.), pp. S292-S298.
A safety project developed at Johns Hopkins School of Medicine and implemented in more than 100 intensive care units in Michigan led to a 66 percent reduction in central line (catheter)-associated bloodstream infections (CLABSIs) and a median CLABSI rate of zero. The authors describe the evolution of the Michigan project into a national program called On the CUSP. The Agency for Healthcare Research and Quality (AHRQ) initially supported the Michigan program and has extended funding to an additional 10 States, with private philanthropies supporting the program in another 18 States. After Secretary of Health and Human Services Kathleen Sebelius called for a reduction of 75 percent in CLABSIs within 3 years, AHRQ expanded support to all 50 States, the District of Columbia, and Puerto Rico. The On the CUSP program has three main components: a model for translating research into practice to prevent CLABSI; a Comprehensive Unit-based Safety Program to improve culture and teamwork; and a rigorous system to measure, report, and improve CLABSIs and other variables.
Viswanathan, M., Kraschnewski, J. L., Nishikawa, B., and others (2010, September). "Outcomes and costs of community health worker interventions. A systematic review." (AHRQ Contract No. 290-07-0056). Medical Care 48(9), pp. 792-808.
Community health workers (CHWs) are increasingly expected to provide cost-effective improvements in health outcomes for the underserved. The researchers conducted a systematic review of the literature on outcomes and costs of CHW interventions. They identified 53 studies on outcomes and 6 on cost or cost-effectiveness. The outcomes included knowledge, behavior, satisfaction, health outcomes, and health care utilization. The study found limited evidence that CHW interventions can improve participant knowledge compared with alternative approaches such as no intervention, media, mail, or usual care plus pamphlets. There was mixed evidence for CHW effectiveness on participant behavior change and health outcomes. There was low- or moderate-strength evidence suggesting that CHWs can increase appropriate health care utilization for some interventions. The evidence on cost effectiveness was insufficient to evaluate CHW interventions relative to other public health interventions.
Zuvekas, S. (2010). "The financing of mental health and substance abuse services: Insurance, managed care, and reimbursement." In: Levin, B.L, Hennessy, K.D., and Petrila, J. (editors). Mental Health Services: A Public Health Perspective. Third edition. New York: Oxford University Press. pp. 13-41. Reprints (AHRQ Publication No. 11-R007) are available from the AHRQ Publications Clearinghouse.
Changes in the Medicaid and Medicare public insurance programs and private health plans increasingly drive how mental health and substance abuse (MH/SA) services are organized, delivered, and financed. The principal goals of this chapter are to (1) understand how these insurance models operate in theory and in practice, and (2) understand the implications of the increasing strains on employer-based private health insurance and public insurance systems for the future of MH/SA services. The shift to insurance-financed systems has led to a relative shift in resources away from individuals with severe and persistent mental illness (SMI) toward those with other mental disorders such as anxiety, depression, and attention deficit hyperactivity disorder. It is the integration with insurance-based systems that has led to fragmentation in financing for treatment of people with SMI. Overcoming this fragmentation in SMI treatment is a central goal of current mental health reform efforts.
Zuvekas, S. H., and Cohen, J. W. (2010). "Paying physicians by capitation: Is the past now prologue?" Health Affairs 29(9), pp. 1661-1666. Reprints (AHRQ Publication No. 11-R003) are available from the AHRQ Publications Clearinghouse.
Continued increases in health care costs and concerns about quality of care have brought renewed interest in physician payment reform. Along with it has come a renewed interest in capitation because of its strong cost containment incentives. The researchers explored the prospect for reform by using data from the Medical Expenditures Panel Survey to analyze trends in physician capitation over the period 1996-2007. The focus is on how individual physicians or physician practices are paid. The researchers found that the percentage of physician visits covered under capitation fell from almost 16 percent in 1996 to 7 percent by 2007. Among the Western States, capitation remained highest in California (29 percent) and Oregon (18 percent). The reasons for decline appear to be not only consumer and physician backlash, but also the administrative complexity of calculating and negotiating capitation rates. Also, capitation may not have delivered on its promise of cost containment.