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Medicaid managed care for mental health services: The survival of safe

Research Activities, March 2009, No. 343

Research Briefs

Blewett, L. A., Ziegenfuss, J., and Davern, M. E. (2008). "Local access to care programs (LACPs): New developments in the access to care for the uninsured." (AHRQ contract no. 290-00-0017). Milbank Quarterly 86(3), pp. 459-479.

Local access to care programs (LACPs) are community initiatives to facilitate access to needed health care services to the uninsured through a local organizing entity. To learn more about these little-studied entities, the researchers performed a literature review, Internet search, and interviews with key actors. They developed a typology and described a set of characteristics of the 47 LACPs they were able to document. They found that LACPs may be sponsored by counties, local provider-based programs, national provider networks working through networks of local providers, or local initiatives using funding from employers, employees, and the community. LACPs serve people not qualified for public programs for reasons such as income levels or lack of citizenship; public funding for them is generally unstable and dwindling. Their size varies greatly, from 80 enrollees to over 50,000 and they usually offer only primary care services. Few formal evaluations of the impact of LACPs have been completed but several are currently underway.

Brady, J., Ho, K., and Clancy, C. M. (2008). "The quality and disparities reports: Why is progress so slow?" American Journal of Medical Quality 23(5), pp. 396-398.

Health care quality improvement is an aspirational endeavor, never completely fulfilled. As a nation, however, we are improving, according to Carolyn M. Clancy, M.D., Director of the Agency for Healthcare Research and Quality (AHRQ) and colleagues. However, the rate of improvement is modest, and appears to be slowing, as shown by AHRQ's annual reports on quality and disparities. The data indicate that the pace of improvement is unacceptably slow. Between 2000 and 2005, the annual median rate of improvement based on measures of five areas of health care reported in AHRQ's annual National Healthcare Quality Reports (NHQRs) was 1.5 percent, down from 2.3 percent annually for the longer period from 1994 to 2005. Many measures with the greatest variation show that patients are treated very differently from State to State and that there has been little change in this situation since the first NHQR (2003). Similarly, patient safety measures showed an average annual improvement of only 1 percent.

Brown, T. M., and Bittner, V. (2008). "Biomarkers of atherosclerosis: Clinical applications." (AHRQ grant HS13852). Current Cardiology Reports 10, pp. 497-504.

Numerous blood-based biomarkers are associated with increased cardiovascular risk after adjusting for traditional risk factors. The authors conducted a literature review on these biomarkers and examined whether incorporating these markers may improve clinical decisionmaking. Studies have identified the following biomarkers as risk factors for cardiovascular disease: apolipoprotein B; cardiac troponin-I; brain natriuretic peptide; cystatin C; inflammatory biomarkers such as myeloperoxidase, lipoprotein-associated phospholipase A2, and C-reactive protein; and plasma fibrinogen, a coagulation marker. Recent investigations have also focused on incorporating multiple biomarkers simultaneously into traditional risk prediction models to improve prediction. To be clinically useful, biomarkers must change management. When biomarkers associated with cardiovascular risk are elevated, intensification of therapy may be directed toward reducing the biomarker itself. However, the data on biomarkers thus far has been limited to assessing cardiovascular risk, with no studies examining whether changing treatment plans on the basis of these data modifies this risk.

Cohen, J. T., and Neumann, P. J. (2008). "Using decision analysis to better evaluate pediatric clinical guidelines." (AHRQ grant HS16760). Health Affairs 27(5), pp. 1467-1475.

Decision analysis synthesizes information and focuses on estimating the consequences of alternative health measures. The authors propose the use of decision analysis as a way of augmenting the traditional frameworks of evidentiary criteria for clinical guidelines. Their analysis of criteria used by major medical organizations such as the American Academy of Family Physicians (AAFP), the American Academy of Pediatrics (AAP), the Canadian Task Force on Preventive Medicine (CTFPM), and the U.S. Preventive Services Task Force (USPSTF) suggests that these frameworks do not independently characterize evidence quality and net benefits and do not systematically evaluate research needs. For example, both the AAP and the CTFPM place strong emphasis on randomized controlled trials (RCTs) in evaluating evidence quality. A study design itself might not be a reliable indicator. There can be external validity differences in generalizing RCT results because RCT studies focus on carefully selected patients, in carefully monitored settings. For interventions intended for children, the frequent absence of direct evidence highlights a key advantage of decision analysis: its focus on quantifying outcomes of interest to the decisionmaker, regardless of the availability of direct evidence.

Gerhard, T. (2008, November). "Bias: Considerations for research practice." (AHRQ grant HS16097). American Journal of Health-System Pharmacists 65, pp. 2159-2168.

The author provides an introduction to the concept of bias for pharmacy practice researchers to help facilitate the conduct of methodologically sound research. "Bias" refers to the presence of systematic error in a study. The most common classification systems distinguish between confounding, selection, and information bias. Bias can be introduced by factors that determine who is exposed to the drug or intervention of interest in the population (confounding bias), factors related to who is included in the study (selection bias), and errors of assessment and measurement (information bias). Bias can only adequately be discussed in the context of a study's population. Investigators should aim to avoid bias in the design of a study, adjust for bias in the study analysis if bias cannot be avoided, and quantify and discuss the effects of residual bias on study results.

Holden, R. J., Or, C. K. L., Alper, S. J., and others (2008). "A change management framework for macroergonomic field research." (AHRQ grant HS13610). Applied Ergonomics 39, pp. 459-474.

The authors present a new framework for macroergonomic field research, one based on proposals that (a) such research can be conceptualized as a change in itself, complete with necessary perturbations and a need for adoption and acceptance, and (b) principles derived from the literature on organization-level change management can be applied by field researchers in order to achieve a variety of research implementation goals, including adoption, acceptance, and data quality. They review the literature on change management and derive 30 principles of change management, covering topics such as political awareness, assembling the change team, generating buy-in, and management support. For each of the change management principles, practical considerations for field research management are given. The authors urge other field researchers to develop their own principle-based research practices and to further explore literature on change management for inspiration. Finally, they suggest that other researchers adopt research frameworks such as theirs in order to guide not only how to design research but also how to implement it successfully.

Huskamp, H. A., Donohue, J. M., Koss, C. and others (2008). "Generic entry, reformulations and promotion of SSRIs in the US." (AHRQ grant HS10803). Pharmacoeconomics 26(7), pp. 603-616.

The level of pharmaceutical promotional expenditures for a given drug is usually affected by the introduction of competing generic products, but other factors may also be important. The researchers examined the impacts of generic competition, the introduction of reformulated products, and new indication approval on promotional expenditures for one class of antidepressants, the selective serotonin reuptake inhibitors (SSRIs). Between 2001 and 2006, four SSRIs (Prozac, Paxil, Zoloft, and Celexa) lost patent protection and consequently faced generic competition. Their manufacturers responded by introducing new product formulations of existing brand molecules (the original brand name drug products) and obtaining FDA approval to market their SSRI for new clinical indications other than depression. The researchers found that promotional spending for a specific brand name drug product generally declined after generic versions entered the market. However, the effect of generic competition on promotional spending appeared to be closely linked to the choice of product reformulation strategy pursued by the manufacturer. For example, the manufacturer of Paxil increased detailing expenditures after the FDA approved its use for generalized anxiety disorder but did not alter direct-to-consumer advertising. By contrast, when both Paxil and Zoloft received FDA approval to be marketed for social anxiety disorder, detailing expenditures did not change.

Jerant, A., DiMatteo, R., Arnstein, J., and others (2008, November). "Self-report adherence measures in chronic illness." (AHRQ grant HS13603). Medical Care 46(11), pp. 1134-1139.

Medication adherence has been associated in some studies with improved chronic illness outcomes. Although a number of measurement approaches for medication adherence are commonly used, there is no gold standard measure. The researchers explored the reliability and validity of three different kinds of self-report medication adherence measures focusing on general adherence tendencies, medication-taking habits, and specific quantities of pills taken over an identified period of time, expressed as a proportion [number of pills taken/number of pills prescribed (PT/PP)]. The participants were mostly women over 40 years of age with one or more chronic diseases. The correlations observed among PT/PP and general adherence measures were modest. The researchers also found that PT/PP recall over 3-4 days may yield adherence estimates that are practically as reliable and valid as those collected over longer recall intervals. Also, better PT/PP adherence measured at 2 weeks was associated with improved adjusted Health Assessment Questionnaire scores at 6 months.

Jiang, H. J., Friedman, B., and Andrews, R. (2008, July). "Changes in hospital readmissions for diabetes-related conditions: Differences by payer." Managed Care Interface, pp. 24-30.

This study examines changes in long-term (180-day) hospital readmissions for diabetes-related conditions between 1999 and 2003. Information on hospital stays was obtained from the Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases (SID). For both years, Medicaid patients had the highest observed readmission rates, which were more than 10 percent higher than those for Medicare patients and over 50 percent higher than those for private patients. Between 1999 and 2003, there was a small and significant (4.5 percent) decrease in the observed readmission rate among the privately insured. In comparison, no significant changes were found in readmission rates for the Medicare and Medicaid populations, except among the Medicare HMO population, where the risk of readmission was significantly lower (5.8 percent).These findings suggest that diabetes care and outcomes are improving in the United States, particularly among those enrolled in private health plans.

Reprints (AHRQ Publication No. 09-R013) are available from the AHRQ Publications Clearinghouse.

Lautenbach, E., Bilker, W.B., Tolomeo, P., and Maslow, J. N. (2008, September). "Impact of diversity of colonizing strains on strategies for sampling escherichia coli from fecal specimens." (AHRQ grant HS10399). Journal of Clinical Microbiology, pp. 3094-3096.

This study analyzes the genetic diversity of Escherichia coli colonization in fecal samples from long-term care facility (LTCF) residents. The researchers' goal was to determine the likelihood of identifying both common and uncommon strains of E. coli using different strategies for colony sampling from fecal specimens. They found that approximately 40 percent of the 49 LTCF residents were colonized with multiple strains of E. coli. Of 83 total strains from all subjects, 17 accounted for fewer than 20 percent of colonies in the samples tested. Of 49 total subjects, 12 had at least 1 strain present in fewer than 20 percent of colonies. The results demonstrated that the ability to accurately characterize E. coli strain diversity in human subjects is directly related to the number of colonies sampled and the underlying prevalence of the strain.

Linder, J. A. (2008, September). "Antibiotics for treatment of acute respiratory tract infections: Decreasing benefit, increasing risk, and the irrelevance of antimicrobial resistance." (AHRQ grant HS14563). Clinical Infectious Diseases 47, pp. 744-746.

In an editorial commentary, the author argues against the overprescribing of antibiotics with special emphasis on the use of antibiotics for treatment of predominantly viral acute respiratory tract infections. Overall, such infections (excluding pneumonia) account for 50 percent of antibiotic prescribing to adults and 75 percent of antibiotic prescribing to children. He discusses a new study that found that antibiotics were responsible for nearly 20 percent of emergency department visits for drug-related adverse events. According to a recent systematic review, multidimensional interventions involving physicians and patients appeared more effective in reducing inappropriate prescribing of antibiotics than either clinician educational interventions or interventions that used audit and feedback. He concludes by arguing that treating a viral illness with antibiotics does not make sense microbiologically. Also, the benefit of antibiotics for treatment of most acute respiratory tract infections appears to be decreasing and the real risks of antibiotic prescribing are becoming clearer. These risks include a 5 to 25 percent chance of causing diarrhea and a 1 in 1000 likelihood of an emergency department visit due to a bad reaction.

Liu, L., Ma, J. Z., and O'Quigley, J. (2008). "Joint analysis of multi-level repeated measures data and survival: an application to the end stage renal disease (ESRD) data." (AHRQ grant HS16543). Statistics in Medicine 27, pp. 5679-5691.

For patients with end stage renal disease, increases in hematocrit level have been associated with significant clinical benefits and improved survival rates. However, the longitudinal pattern of hematocrit level and its impact on patient survival have not been fully explored. The researchers sought to model both longitudinal hematocrit level and patient survival by the use of a joint model of repeated measures. They propose a multilevel joint random effects model and then present the corresponding estimation method by Gaussian quadrature. To assess the performance of the proposed estimation method, simulation studies were conducted. Using the U.S. Renal Data System (USRDS), they then applied their method to the joint model of longitudinal measures of hematocrit level and death for patients clustered within 126 dialysis centers. In this application, the researchers show a significant association between longitudinal hematocrit measurements and survival at the subject level, but not at the cluster level for the USRDS data.

Liu, L., and Yu, Z. (2008). "A likelihood reformulation method in non-normal random effects models." (AHRQ grant HS16543). Statistics in Medicine 27, pp. 3105-3124.

The researchers propose a novel estimation method that reformulates the conditional likelihood on nonnormal random effects. By dividing and multiplying the conditional likelihood by a normal density function, they reformulate the resulting likelihood for integration over normal random effects in the Gaussian quadrature scenario. Standard computing programs, such as SAS Proc NLMIXED, can then be employed for parameter estimates. This method of "likelihood reformulation" yields similar results to the probability integral transformation method, while reducing computational time tremendously. This method only needs to specify the density function explicitly. Thus, it can handle random effects whose inverse cumulative distribution function is of no closed form or not available in the specific software. Therefore, it can accommodate a much wider range of applications. The researchers give three examples to illustrate the implementation of their method and present simulation studies to assess its performance. Finally, they apply the method to two real data sets.

Mutter, R., Rosko, M. D., and Wong, H. S. (2008, December). "Measuring hospital inefficiency: The effects of controlling for quality and patient burden of illness." HSR: Health Services Research 43(6), pp. 1992-2013.

Existing hospital efficiency measures that do not explicitly account for quality of care may overstate actual levels of hospital inefficiency. The researchers sought to assess the impact of employing a variety of controls for hospital quality and patient burden of illness on the mean estimated inefficiency and relative ranking of hospitals as generated by stochastic frontier analysis (SFA).They also compare strategies for controlling multiple dimensions of patient burden of illness. Thirty comorbidities contributing to a patient's burden of illness were identified by the application of the Comorbidity Software to hospital data from the Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases and an SFA model developed by Jondrow, et al., was used to estimate hospital cost-inefficiency. A principal finding was that measures produced by the Comorbidity Software, when applied to hospital data from the HCUP databases, appear to account for variations in patient burden of illness that had previously been masquerading as inefficiency.

Reprints (AHRQ Publication No. 09-R011) are available from the AHRQ Publications Clearinghouse.

Plantinga, L. C., Fink, N. E., Melamed, M. L., and others (2008). "Serum phosphate levels and risk of infection in incident dialysis patients." (AHRQ grant HS08365). Clinical Journal of the American Society of Nephrology 3, pp. 1398-1406.

Hyperphosphatemia occurs frequently in dialysis patients and may be associated with immune dysfunction. Although the evidence is conflicting, the risk for infectious morbidity and mortality has been shown to be increased in patients with increased phosphate levels. This national prospective cohort study of 1,010 dialysis patients in 80 treatment centers found that high levels of phosphate (greater than 5.5 mg/dl) early in the course of dialysis were associated with increased risk for subsequent infection. The association was not explained by evidence of secondary hyperparathyroidism or uremia as a result of poor dialysis, suggesting that phosphate may be an independent risk factor for infection. When sepsis was examined, high phosphate was associated with increased risk but only with adjustment. Regardless of adjustment, high phosphate was associated with increased incidence of osteomyelitis; however, the association of high phosphate with respiratory infections was not statistically significant. The researchers conclude that their results are consistent with the call for better hyperphosphatemia management in dialysis patients.

Rosen, J., Mulsant, B. H., Marino, P., and others (2008). "Web-based training and interrater reliability testing for scoring the Hamilton Depression Rating Scale." (AHRQ grant HS11976). Psychiatry Research 161, pp. 126-130.

In clinical trials, the reliability of the data collected ultimately determines the validity of the studies' conclusions. When multiple raters are used in a clinical psychiatry trial, differences between raters in terms of interviewing technique and scoring criteria introduce variability that can distort outcome measures. Rater reliability is an issue often ignored in clinical trials. The researchers performed an initial evaluation in which 17 raters (na�ve, experienced, expert) completed a tutorial and then rated 6 videotaped interviews in which patients responded to interviewer questions regarding the items on the Hamilton Depression Rating Scale (HDRS). The interview subjects were seven patients taking part in a National Institute of Mental Health study, who each had three HDRS interviews at different stages of treatment. In the second stage field trial, 13 raters also completed a tutorial and rated 6 videotaped HDRS interviews. The interrater reliabilities were excellent for both groups. The study used a Web-based system with three components: a scoring-tutorial program, a reliability testing program, and an administrative program.

Rosolowsky, E.T., Niewczas, M.A., Ficociello, L.H., and others (2008). "Between hyperfiltration and impairment: Demystifying early renal functional changes in diabetic nephropathy." (AHRQ grant T32 HS00063). Diabetes Research and Clinical Practice 25, pp. S46-S53.

The reliability and accuracy of serum cystatin-C-based estimates of glomerular filtration rates (GFR) have made feasible large-scale prospective studies directed at monitoring patterns of renal function change prior to the development of proteinuria. Contrary to earlier studies, these recent studies have found that the process of renal function loss may begin prior to the onset of proteinuria. The 2nd Joslin Kidney Study on the Natural History of Microalbuminuria in Type 1 Diabetes sought to identify clinical and biochemical factors that are associated with early renal decline. It found that both serum uric acid and components of the tumor-necrosis-factor-alpha (TNF alpha) may be involved in early renal decline. However, the exact nature of the roles that serum uric acid and TNF alpha pathway play in the setting of early reductions in renal function has yet to be elucidated.

Scanlon, D. P., Swaminathan, S., Lee, W., and Chernew, M. (2008, December). "Does competition improve health care quality?" (AHRQ grant HS10771). HSR: Health Services Research, 43(6), pp. 1931-1951.

Advocates of the competitive approach assert that competition will both reduce costs and improve quality; however, empirical evidence relating health maintenance organization (HMO) competition to HMO quality is sparse. The researchers examined the effects of competition on HMOs' quality measures. They used measures from the Healthcare Effectiveness Data and Information Set (HEDIS) and the Consumer Assessment of Healthcare Providers and Systems Survey (CAHPS) to measure quality. To measure competition, they used the Herfindahl-Hirschman Index, InterStudy data on the number of HMOs, and other sources. The results suggest that there is not a consistent relationship between HMO competition and quality. Some results are even conflicting, with estimates from CAHPS measures suggesting that more competition results in a worse plan rating, but also a better physician rating. Estimates from the HEDIS measure on the beta-blocker medication rate suggest that performance decreases with greater competition.

Sege, R. D., and Flaherty, E. G. (2008, December). "Forty years later: Inconsistencies in reporting of child abuse." (AHRQ grant HS16359). Archives of Disease in Children 93, pp. 823-824.

Many case of child abuse go unrecognized and unreported, occasionally with tragic consequences. The authors review recent health services literature that reveals the current barriers to reporting, which fall into two major areas: the failure to identify maltreatment and deciding not to report suspected abuse to State authorities. Lack of knowledge about child abuse and common presenting complaints may be a substantial cause of underreporting. Pediatricians in children's hospitals seem to recognize child abuse at substantially greater rates than emergency physicians in general hospitals, according to one study. One study of 15,000 children with physical injuries found that only 1 in 4 with injuries judged "likely," "possibly," or "very likely" to have been caused by abuse were reported to child protective services (CPS). Clinicians may have been influenced not to report by negative media reports, by published studies that suggest that children who have been reported continue to experience abuse, or a belief that they could intervene with family more effectively than CPS. The authors conclude by recommending steps that would lead to improved outcomes for children.

Selden, T. M. (2008). "The effect of tax subsidies on high health care expenditure burdens in the United States." International Journal of Health Care Finance and Economics 8, pp. 209-223.

Previous studies of families with high health care expenditure burdens have ignored the role of tax subsidies in helping to reduce both the prevalence and magnitude of high burdens. In 2002, tax subsidies accounted for 16 percent of total health care expenditures by the civilian noninstitutionalized population. Tax subsidies of this magnitude might be expected to have at least a modest effect on the prevalence and size of high burdens. The researcher presents evidence on pre- and post-subsidy high burden frequency using data from the Household Component of the Medical Expenditure Panel Survey. He found that regardless of the burden threshold chosen or the definition of private health care spending, tax subsidies had little effect on the share of the poor who were living in families with high burdens. In general, tax subsidies do not have a differentially large or targeted effect on the prevalence of high burdens, although the effect is larger among families above the poverty line.

Reprints (AHRQ Publication No. 09-R010) are available from the AHRQ Publications Clearinghouse.

Shih, C., and Berliner, E. (2008, December). "Diffusion of new technology and payment policies: Coronary stents." Health Affairs 27(6), pp. 1566-1576.

The implementation of a higher payment rate for bare metal stenting has been thought to be responsible for the acceleration in the use of stenting. The authors sought to determine if this was true or were other factors involved. They first examined the evidence on the balance of benefits and harms provided by the stents when they were initially introduced. They then considered whether the data suggest that Medicare patients were denied stents prior to the payment increase. The early studies on stenting during percutaneous transluminal coronary angioplasty found improved coronary diameter among patients with new lesions in the main coronary arteries. Analysis of later studies did not shed light on whether the diffusion of stents might have followed a different course if payment policies had been different. Both bare metal stents and the later drug-eluting stents diffused rapidly to off-label indications, suggesting the need for continuing evaluation of new technology.

Reprints (AHRQ Publication No. 09-R012) are available from the AHRQ Publications Clearinghouse.

Sprague, B. L., Trentham-Dietz, A., Klein, B. E. K., and others (2008). "Physical activity, white blood cell count, and lung cancer risk in a prospective cohort study." (AHRQ grant HS06941). Cancer Epidemiology Biomarkers Prevention 17(10), pp. 2714-2722.

Lung cancer is the leading cause of cancer death among men and women in the United States. The researchers investigated the relation between self-reported physical activity and lung cancer in a group of 4,831 subjects, 43 to 86 years of age who were followed for an average of 13 years. They also measured two inflammatory markers, white blood cell (WBC) count, and serum albumin to evaluate whether inflammation mediates the relation between physical activity and lung cancer. The study found that higher levels of physical activity at baseline were inversely associated with lung cancer incidence. After adjustment, the risk of lung cancer was reduced by over 40 percent among participants reporting 12 or more city blocks walked per day. It also found evidence for a positive association between lung cancer risk and WBC count, but not serum albumin. Finally, there was no evidence that the associations of physical activity and WBC count with lung cancer risk were mediated through the same biological pathway.

Valdmanis, V.G., Rosko, M.D., and Mutter, R.L. (2008, December). "Hospital quality, efficiency, and input slack differentials." HSR: Health Services Research 43(5), Pt. II, pp. 1830-1848.

This study uses an advance in data envelopment analysis (DEA), termed congestion analysis, to ascertain whether some hospitals might be experiencing poor quality that could be corrected by changing the number and mix of inputs. The researchers found that public hospitals were more inefficient on all four measures of inefficiency (overall, technical, scale, and quality congestion). Not-for-profit (NFP) hospitals were the next most inefficient, although there was little difference between public and NFP hospitals. Council of Teaching Hospitals member hospitals were significantly less efficient on the overall and scale measures, but did outperform the other two types of hospitals in both pure technical inefficiency and quality congestion. Organizationally, high-quality hospitals tended to have too many labor inputs, leading to inefficiency. Overall, the hospitals in the sample could increase the total amount of outputs produced by an average of 26 percent by eliminating inefficiency.

Reprints (AHRQ Publication No. 09-R005) are available from the AHRQ Publications Clearinghouse.

Wall, R.J., Ely, E.W., Talbot, T.R., and others (2008). "Evidence-based algorithms for diagnosing and treating ventilator-associated pneumonia." (AHRQ grant HS15934). Journal of Hospital Medicine 3(5), pp. 409-422).

Ventilator-associated pneumonia (VAP) is a serious and common complication for patients in the intensive care unit (ICU). The goal of this descriptive study was to develop practical algorithms that assist ICU clinicians in the diagnosis and management of VAP during daily practice. The authors first review the current evidence for diagnosing VAP, then describe their approach to developing the algorithms, and finally illustrate the utility of the diagnostic algorithms using clinical teaching cases. Separate algorithms were developed for infant, pediatric, immunocompromised, and adult ICU patients. These algorithms may provide evidence-based practical guidance to clinicians seeking a standardized approach to diagnosing and managing this challenging problem. The data used in the study came from a national collaborative focused on reducing VAP and catheter-related bloodstream infections.

Weinstock, P., and Halamek, L.P. (2008). "Teamwork during resuscitation." (AHRQ grant HS 12022). Pediatric Clinics of North America 55, pp. 1011-1024.

Despite calls for effective teamwork in health care by prominent organizations, there is no accepted model of team performance. The authors examine the available evidence supporting teamwork both in pediatric health care in general and in pediatric and neonatal resuscitation. Data are just beginning to emerge on how to measure and improve teamwork among health care providers. One study showed a trend toward risk reduction for inhospital cardiorespiratory arrest after implementing a rapid response team in a pediatric tertiary care hospital. Structured simulation-based crew resource management (CRM) strategy programs (first developed in commercial aviation) have begun to fill the critical gap in teamwork training. Virtual reality-based learning opportunities also allow learners to control the learning process. In the area of neonatal resuscitation, the NeoSim program uses realistic simulation-based experiences and video debriefings to create a safe environment for hands-on practice of neonatal resuscitation. A growing number of pediatric centers have come to appreciate the value of this type of training. The researchers concluded that as this type and other types of training focused on developing teamwork spread, the quality of practice of resuscitation will improve and patients will benefit.

Westfall, J.M., Kiefe, C.I., Weissman, N.W., and others (2008). "Does interhospital transfer improve outcome of acute myocardial infarction? A propensity score analysis from the Cardiovascular Cooperative Project." (AHRQ grant HS09446). BMC Cardiovascular Disorders 8(22), pp. 1-9.

The impact of interhospital transfer of patients with acute myocardial infarction (AMI) on the processes and outcomes of care has gone largely unstudied. Since transfer rates have increased dramatically in the past decade, it is even more important to understand the risks and benefits associated with transfer. Using clinical and administrative data on 184,295 Medicare patients with AMI, the researchers found that the transferred patients (28 percent of the total) were significantly younger, less critically ill, and had lower co-morbidity than the non-transferred patients. After propensity-matching, transferred patients had generally higher quality of care and lower mortality than non-transferred patients. When they had accounted for the numerous and large differences between transferred and non-transferred patients, the researchers found that mortality for patients cared for in a rural hospital was similar to that for patients cared for in an urban hospital. Previous studies that deleted transferred patients from their analyses had found that rural and smaller hospitals had worse outcomes.

Willging, C.E., Waitzkin, H., and Nicdao, E. (2008, September). "Medicaid managed care for mental health services: The survival of safety net institutions in rural settings." (AHRQ grant HS09703). Qualitative Health Research 18(9), pp. 1231-1246.

Few accounts document how safety net institutions (SNIs) have responded to the introduction of Medicaid managed care (MMC) for the provision of mental health services. The researchers conducted an ethnographic study in two rural, culturally distinct regions of New Mexico to assess the effects of MMC and the implications for future reform. In conducting 160 interviews at 6 SNIs, they found that the responses of SNIs to MMC varied from nonparticipation in MMC to forming an alliance with other SNIs to enhance collective bargaining power with managed care organizations. Other survival strategies included trying to reduce exposure to low-income clients and tapping into non-MMC clients to cover the costs of caring for the uninsured. The researchers found that numerous barriers impaired access under MMC: service fragmentation, transportation, lack of cultural and linguistic competency, Medicaid enrollment, stigma and confidentiality, and immigration status. In general, MMC did not improve quality of care for Hispanics or American Indians.

Yelin, E. (2008, August). "Out-of-pocket payments in arthritis: Spur to prudent purchasing or red herring?" (AHRQ grant HS13893). Arthritis & Rheumatism 58 (8), pp. 2225-2227.

Cost-sharing, i.e., requiring patients to pay more out-of-pocket for health care, has become a central feature of health policy in the United States. In particular, the Medicare Prescription Drug Improvement and Modernization Act has a complex set of cost-sharing rules for the drug benefit. The author challenges the view that cost-sharing fosters prudent buying by creating an incentive for the patient to equilibrate costs and benefits more thoroughly. Conceptions of "good value" may differ, with some patients choosing to relieve pain rather than cure disease and others being more averse to losses than to gains of equal expected value and prevalence. In addition, an earlier study found that higher levels of cost sharing led to indiscriminate reductions in both appropriate and inappropriate care. A new study found that cost-sharing for persons with arthritis is increasing. Without evidence to show that cost-sharing does not have a harmful effect on the health of persons with arthritis, discussion about prudent buying is a red herring, notes this author.

Yost, K.J., Hahn, E. A., Zaslavsky, A.M., and others (2008). "Predictors of health-related quality of life in patients with colorectal cancer." (AHRQ grant HS09869). Health and Quality of Life Outcomes 6(66), pp. 1-10.

Since most patients with colorectal cancer survive at least 5 years after diagnosis, health-related quality of life (HRQL) is an important outcome for them. The researchers sought to identify variables that predict HRQL in a prospective, population-base study of 830 patients with colorectal cancer. HRQL was measured in the initial and followup surveys by the Functional Assessment of Cancer Therapy-Colorectal (FACT-C). This survey includes subscales measuring physical, functional, social/family, and emotional well-being as well as a colorectal cancer subscale. The average time between initial and followup surveys was 10.2 months. Emotional well-being scores were the most stable over time. The most consistent finding was that patients with poor general health and problems with certain domains of perceived quality of cancer care may be at risk for poor HRQL. Being male, unmarried, or Hispanic were also characteristics associated with being at risk for specific poor HRQL outcomes.

Zettel-Watson, L., Ditto, P.H., Danks, J.H., and Smucker, W.D. (2008). "Actual and perceived gender differences in the accuracy of surrogate decisions about life-sustaining medical treatment among older spouses." (AHRQ grant HS08180). Death Studies 32, pp. 273-290.

Because accurate substituted judgment is instrumental in the maintenance of patient autonomy at the end of life, researchers have begun to investigate patient and surrogate factors that may be associated with surrogate accuracy. One factor that has received surprisingly little attention is surrogate gender. Using a series of nine hypothetical illness scenarios, the researchers examined the influence of surrogate gender on the accuracy of substituted judgments about the use of life-sustaining treatment. The sample consisted of 249 older adults and their self-selected surrogate decisionmakers. In eight of the nine scenarios, wives tended to be more accurate than their husbands, although this difference was statistically significant for only the Alzheimer's disease scenario. In all instances where gender differences were found, husbands committed significantly more overtreatment errors than did wives acting as surrogates. Also, husbands had more confidence than their wives in their spouses' accuracy.

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Page last reviewed March 2009
Internet Citation: Medicaid managed care for mental health services: The survival of safe: Research Activities, March 2009, No. 343. March 2009. Agency for Healthcare Research and Quality, Rockville, MD.