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State Adoption of Nursing Home Pay-For-Performance

Werner, R. M., Konetzka, R. T., Liang, K. — Wed, 18 Nov 2009 15:58:54 PST

Whereas numerous policies have been adopted to improve quality of care in nursing homes over the past several decades—with varying degrees of success—health care payment has been a largely untapped but potentially powerful policy tool to improve quality of care. Recently, however, payers have invested significant resources in the development and implementation of pay-for-performance (P4P) programs for nursing homes. The authors present results from a survey of state Medicaid agencies documenting the use and structure of P4P in nursing homes. Although the number of states that are implementing nursing home P4P is growing, the structure of these incentives varies across states, and little evidence exists to guide the planning or implementation of these initiatives.

Prenatal Care Utilization in Excess of Recommended Levels: Trends From 1985 to 2004

Lauderdale, D. S., VanderWeele, T. J., Siddique, J., Lantos, J. D. — Fri, 13 Nov 2009 08:55:09 PST

Indexes of prenatal care adequacy distinguish care that includes more than the recommended number of visits because extra visits may signal a high-risk pregnancy. Using Natality files from 1985 to 2004, the authors found such "superadequate" care increased from 19.5% of pregnancies in 1985 to 30.0% in 2004. Although there were dramatic changes in the demographics of childbearing over the same 20 years, those changes do not explain the increase in extra prenatal visits: Superadequate care increased within every stratum defined by maternal birthplace, race, age, education, gravidity, marital status, and multiple birth. Had the demographics of childbearing not changed since 1985, the superadequate rate would be just as high in 2004. Although randomized controlled trials have found that reduced visit schedules for low-risk women do not lead to worse maternal or perinatal outcomes, the cost-effectiveness of more intense visit schedules is not known.

Explaining Racial and Ethnic Differences in Antidepressant Use Among Adolescents

Kirby, J. B., Hudson, J., Miller, G. E. — Fri, 13 Nov 2009 08:55:09 PST

We investigate the extent to which antidepressant use among adolescents varies across racial and ethnic subgroups. Using a representative sample of U.S. adolescents, we find that non-Hispanic White adolescents are over twice as likely as Hispanic adolescents, and over five times as likely as non-Hispanic Black adolescents to use antidepressants. Results from a decomposition analysis indicate that racial/ethnic differences in characteristics, including household income, parental education, health insurance, and having a usual source of care explain between one half and two thirds of the gap in antidepressant use between Hispanics and non-Hispanic Whites. In contrast, none of the gap between Whites and Blacks in antidepressant use is explained by differences in observed characteristics. Further analysis suggests that there are large racial/ethnic differences in the extent to which behavioral and mental health problems prompt antidepressant use and that this may, in part, account for the large differences across race/ethnicity observed in our study.

Testing the Association Between Patient Safety Indicators and Hospital Structural Characteristics in VA and Nonfederal Hospitals

Rivard, P. E., Elixhauser, A., Christiansen, C. L., Zhao, S., Rosen, A. K. — Fri, 30 Oct 2009 09:44:04 PDT

This study tested the association between hospital structural characteristics—teaching status, bedsize, and nurse staffing—and potentially preventable adverse events. The authors calculated 14 Agency for Healthcare Research and Quality Patient Safety Indicators (PSIs) and a PSI composite, using discharge databases from VA and nonfederal hospitals. This study compared the likelihood of PSI events in hospitals, controlling for structural and other characteristics, including patients’ case-mix. Additional controls were employed to account for differences in VA versus nonfederal patients and data. The study found some associations, most notably a positive (unfavorable) association between status as a major teaching hospital and six PSIs. However, for most PSIs, the authors found no association between the structural characteristics tested and likelihood of PSI events. The study’s findings extend previous research showing a lack of consistent relationship between structural characteristics and patient safety. However, the results also suggest continued need for examination of the relationship between teaching status and potentially preventable adverse events.

Engaging Patients as Vigilant Partners in Safety: A Systematic Review

Schwappach, D. L. B. — Mon, 26 Oct 2009 09:23:03 PDT

Several initiatives promote patient involvement in error prevention, but little is known about its feasibility and effectiveness. A systematic review was conducted on the evidence of patients’ attitudes toward engagement in error prevention and the effectiveness of efforts to increase patient participation. Database searches yielded 3,840 candidate articles, of which 21 studies fulfilled the inclusion criteria. Patients share a positive attitude about engaging in their safety at a general level, but their intentions and actual behaviors vary considerably. Studies applied theories of planned behavior and indicate that self-efficacy, preventability of incidents, and effectiveness of actions seem to be central to patients’ intention to engage in error prevention. Rigorous evaluations of major educational campaigns are lacking. Interventions embedded within clinical settings have been effective to some extent. Evidence suggests that involvement in safety may be successful if interventions promote complex behavioral change and are sensitively implemented in health care settings.

Inpatient Rehabilitation Facilities: Variation in Organizational Practice in Response to Prospective Payment

Durkin, E. M., Deutsch, A., Heinemann, A. W. — Mon, 26 Oct 2009 09:23:02 PDT

When Medicare implemented a prospective payment system (PPS) for inpatient rehabilitation facilities (IRFs) in 2002, a lack of organizational research on IRFs hampered the ability to predict how providers would modify their behavior in response to the PPS. This study consists of 36 key informant interviews that examined the experiences of nine IRFs in the lead-up to and aftermath of the IRF-PPS. Drawing on earlier work by Oliver, the authors develop a taxonomy of the new organizational practices that IRFs adopted in response to the changing payment system. A model of key organizational and environmental characteristics that predict the adoption of these practices based on an IRF’s willingness and/or capacity to comply with institutional pressure is then proposed. The proposed model can also be applied to other regulatory changes affecting IRFs.

Trends During 1993-2004 in the Availability and Use of Revascularization After Acute Myocardial Infarction in Markets Affected by Certificate of Need Regulations

Vaughan Sarrazin, M. S., Bayman, L., Cram, P. — Mon, 12 Oct 2009 14:14:21 PDT

This study examines trends in the diffusion of coronary artery bypass graft (CABG) and percutaneous coronary intervention (PCI) during 1993-2004 for patients with acute myocardial infarction in markets with and without Certificate of Need (CON) regulations for open-heart surgery or cardiac catheterization and in markets that repealed CON for either of these procedures. In contrast to prior studies, this study accounts for regional hospital markets that cross state boundaries—often with different CON activities in each state. The overall use of CABG increased modestly throughout the 1990s and subsequently decreased, corresponding to a dramatic increase in PCI. There was a greater rise in the number of CABG programs in markets with significant reduction in CON regulations during 1993-2004 compared with other markets, but CON reduction was not related to growth of PCI programs. Reimbursement, ease of use, clinician endorsement, and technological advances in PCI may outweigh effects of CON.

Consequences of Participating in Multidisciplinary Medical Team Meetings for Surgical, Nonsurgical, and Supporting Specialties

Molleman, E., Broekhuis, M., Stoffels, R., Jaspers, F. — Thu, 08 Oct 2009 09:40:25 PDT

This study examines the consequences for medical specialists of participating in multidisciplinary medical team meetings in terms of perceived clinical autonomy, domain distinctiveness, and professional accountability. These consequences may influence their willingness to cooperate and the quality of teamwork. The authors hypothesized that multidisciplinary medical team meetings would be more of a threat to the professional identity of surgical specialists than to the professional identity of nonsurgical and supporting specialists. A survey among 1,827 Dutch medical specialists supported the authors’ hypotheses. However, a few specific specialties had response patterns that deviated from our expectations. The results are related to specialty choice, to the training of medical specialties, and to having a role in leading team meetings.

Mental Health and Family Out-of-Pocket Expenditure Burdens

Zuvekas, S. H., Selden, T. M. — Tue, 22 Sep 2009 14:58:12 PDT

A growing literature finds that a significant fraction of American families experience high or "catastrophic" burdens of medical spending. Families facing mental health problems may be especially vulnerable to high burdens. This study uses data from the Medical Expenditure Panel Survey to determine the annual and within-year concentration of medical spending and the extent to which mental health treatment contributes to high out-of-pocket burdens among families with and without mental health problems. On average, families incurred 44% of non–mental health and 37% of out-of-pocket mental health treatment expenditures in a single month. Families with one or more members experiencing mental health problems were more likely to have periods of high out-of-pocket spending burdens. However, this study found that mental health treatment itself contributes little to high out-of-pocket spending burdens. Most of the burden was due to other medical conditions and lower average incomes among families with mental health problems.

Provider Attitudes Associated With Adherence to Evidence-Based Clinical Guidelines in a Managed Care Setting

Waddimba, A. C., Meterko, M., Beckman, H. B., Young, G. J., Burgess, J. F. — Wed, 19 Aug 2009 08:59:55 PDT

In a cross-sectional observational study of Rochester (New York) primary care physicians (PCPs) enrolled in a pay-for-performance (P4P) collaboration, the authors investigated attitudinal factors associated with provider adherence to evidence-based clinical guidelines targeted by explicit incentives. The multivariable adherence model linked guideline adherence rates to provider attitudes among 186 survey respondents, adjusting for individual, practice, and community characteristics. Adherence was defined as the percentage of expected services that were delivered. Attitudes associated with adherence, independent of specialty and prior behavior, were financial salience (adjusted odds ratio [OR] = 3.6; 95% confidence interval [CI] = 1.7-8.4), peer cooperation (OR = 2.0; 95% CI = 1.0-4.0), control (OR = 0.5; 95% CI = 0.3-1.0), and autonomy regarding the health plan (OR = 0.3; 95% CI = 0.1-0.6). The most adherent providers perceived P4P as financially salient and felt supported by peers. Some PCPs might have perceived P4P and external interventions as challenging their autonomy and "crowding out" their intrinsic motivation, leading them to reduce efforts aimed at guideline adherence.

Changes in Nursing Home Staffing Levels, 1997 to 2007

Tue, 11 Aug 2009 14:07:08 PDT

A positive relationship has been demonstrated between the quality of care delivered in nursing homes and the quality of nursing staff providing the care. The general perception, however, is that there is a decline in registered nurses’ staff hours in nursing homes. The primary objective of this study is to investigate whether the levels of registered nurses (RNs), licensed practical nurses (LPNs), and nursing assistants (NAs) as well as skill mix has changed in nursing homes between the years 1997 and 2007. A descriptive research design was employed on data derived from Online Survey Certification and Reporting System database. After accounting for facility size and ownership, it was found that more nursing homes have increased—rather than decreased—LPN and NA hours per resident day between 1997 and 2007. On the other hand, more nursing homes have decreased—rather than increased—RN hours per resident day and skill mix during the same time period.

Racial/Ethnic Differences in Patients' Perceptions of Inpatient Care Using the HCAHPS Survey

Mon, 03 Aug 2009 13:08:03 PDT

Using HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems, also known as the CAHPS Hospital Survey) data from 2,684 hospitals, the authors compare the experiences of Hispanic, African American, Asian/Pacific Islander, American Indian/Alaska Native, and multiracial inpatients with those of non-Hispanic White inpatients to understand the roles of between- and within-hospital differences in patients’ perspectives of hospital care. The study finds that, on average, non-Hispanic White inpatients receive care at hospitals that provide better experiences for all patients than the hospitals more often used by minority patients. Within hospitals, patient experiences are more similar by race/ethnicity, though some disparities do exist, especially for Asians. This research suggests that targeting hospitals that serve predominantly minority patients, improving the access of minority patients to better hospitals, and targeting the experiences of Asians within hospitals may be promising means of reducing disparities in patient experience.

Characteristics of Hospitals Demonstrating Superior Performance in Patient Experience and Clinical Process Measures of Care

Tue, 28 Jul 2009 17:59:59 PDT

Prior research suggests hospital quality of care is multidimensional. In this study, the authors jointly examine patient experience of care and clinical care measures from 2,583 hospitals based on inpatients discharged in 2006 and 2007. The authors use multinomial logistic regression to identify key characteristics of hospitals that perform in the top quartile on both, either, and neither dimension of quality. Top performers on both quality measures tend to be small (<100 beds), large (>200 beds) and rural, located in the New England or West North Central Census divisions, and nonprofit. Top performers in patient experience only are most often small and rural, located in the East South Central division, and government owned. Top performers in clinical care only are most often medium to large and urban, located in the West North Central division, and non–government owned. These findings provide an overview of how these dimensions of quality vary across hospitals.

Development, Implementation, and Public Reporting of the HCAHPS Survey

Giordano, L. A., Elliott, M. N., Goldstein, E., Lehrman, W. G., Spencer, P. A. — Tue, 28 Jul 2009 17:59:58 PDT

The authors describe the history and development of the CAHPS Hospital Survey (also known as HCAHPS) and its associated protocols. The randomized mode experiment, vendor training, and "dry runs" that set the stage for initial public reporting are described. The rapid linkage of HCAHPS data to annual payment updates ("pay for reporting") is noted, which in turn led to the participation of approximately 3,900 general acute care hospitals (about 90% of all such United States hospitals). The authors highlight the opportunities afforded by this publicly reported data on hospital inpatients’ experiences and perceptions of care. These data, reported on www.hospitalcompare.hhs. gov, facilitate the national comparison of patients’ perspectives of hospital care and can be used alone or in conjunction with other clinical and outcome measures. Potential benefits include increased transparency, improved consumer decision making, and increased incentives for the delivery of high-quality health care.

Do Hospitals Rank Differently on HCAHPS for Different Patient Subgroups?

Wed, 15 Jul 2009 09:55:21 PDT

Prior research documents differences in patient-reported experiences by patient characteristics. Using nine measures of patient experience from 1,203,229 patients discharged in 2006-2007 from 2,684 acute and critical access hospitals, the authors find that adjusted hospital scores measure distinctions in quality for the average patient with high reliability. The authors also find that hospital "ranks" (the relative scores of hospitals for patients of a given type) vary substantially by patient health status and race/ ethnicity/language, and moderately by patient education and age (p < .05 for almost all measures). Quality improvement efforts should examine hospital performance with both sicker and healthier patients, because many hospitals that do well with one group (relative to other hospitals) may not do well with another. The experiences of American Indians/Alaska Natives should also receive particular attention. As HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) data accumulate, reports that drill down to hospital performance for patient subtypes (especially by health status) may be valuable.

Toward Realizing the Potential of Diversity in Composition of Interprofessional Health Care Teams: An Examination of the Cognitive and Psychosocial Dynamics of Interprofessional Collaboration

Mitchell, R., Parker, V., Giles, M., White, N. — Wed, 15 Jul 2009 09:55:21 PDT

Interprofessional approaches to health and social care have been linked to improved planning and policy development, more clinically effective services, and enhanced problem solving; however, there is evidence that professionals tend to operate in uniprofessional silos and that attempts to share knowledge across professional borders are often unsuccessful.