Medical Care Research and Review current issue

Review: Use of Electronic Medical Records for Health Outcomes Research: A Literature Review

Dean, B. B., Lam, J., Natoli, J. L., Butler, Q., Aguilar, D., Nordyke, R. J. — Fri, 30 Oct 2009 15:37:39 PDT

This review assessed the use of electronic medical record (EMR) systems in outcomes research. We systematically searched PubMed to identify articles published from January 2000 to January 2007 involving EMR use for outpatient-based outcomes research in the United States. EMR-based outcomes research studies (n = 126) have increased sixfold since 2000. Although chronic conditions were most common, EMRs were also used to study less common diseases, highlighting the EMRs’ flexibility to examine large cohorts as well as identify patients with rare diseases. Traditional multi-variate modeling techniques were the most commonly used technique to address confounding and potential selection bias. Data validation was a component in a quarter of studies, and many evaluated the EMR’s ability to achieve similar results previously achieved using other data sources. Investigators using EMR data should aim for consistent terminology, focus on adequately describing their methods, and consider appropriate statistical methods to control for confounding and treatment-selection bias.

The Cost-Effectiveness of Direct-to-Consumer Advertising for Prescription Drugs

Atherly, A., Rubin, P. H. — Fri, 30 Oct 2009 15:37:39 PDT

In this paper we use published information to analyze the economic value of Direct to Consumer Advertising (DTCA). The reviewed research finds that DTCA leads to increased demand for the advertised drug and that the effect of the drug tends to be class-wide rather than product specific. There is weak evidence that DTCA may increase compliance and improve clinical outcomes. However, there is little research on the effect of DTCA on inappropriate prescribing or on the characteristics of patients who respond to treatment. On net, if the advertised drugs are cost effective on average and the patients using the drugs in response to the advertisement are similar to other users, DTCA is likely cost effective. Overall, the literature to date is consistent with the idea that DTCA is beneficial, but further research is needed before definitive conclusions can be drawn.

Physician Clinical Information Technology and Health Care Disparities

Ketcham, J. D., Lutfey, K. E., Gerstenberger, E., Link, C. L., McKinlay, J. B. — Fri, 30 Oct 2009 15:37:39 PDT

The authors develop a conceptual framework regarding how information technology (IT) can alter within-physician disparities, and they empirically test some of its implications in the context of coronary heart disease. Using a random experiment on 256 primary care physicians, the authors analyze the relationships between three IT functions (feedback and two types of clinical decision support) and five process-of-care measures. Endogeneity is addressed by eliminating unobserved patient characteristics with vignettes and by proxying for omitted physician characteristics. The results indicate that IT has no effects on physicians’ diagnostic certainty and treatment of vignette patients overall. The authors find that treatment and certainty differ by patient age, gender, and race. Consistent with the framework, IT’s effects on these disparities are complex. Feedback eliminated the gender disparities, but the relationships differed for other IT functions and process measures. Current policies to reduce disparities and increase IT adoption may be in discord.

Determinants of Hospitalist Efficiency: A Qualitative and Quantitative Study

Dynan, L., Stein, R., David, G., Kenny, L. C., Eckman, M., Short, A. D. — Fri, 30 Oct 2009 15:37:39 PDT

Using qualitative and quantitative methods, the authors develop and test hypotheses about the impact of hospitalists on efficiency and quality of care relative to teaching teams. Departure of actual from self-perceived benefits for hospitalists, both individually and collectively, is studied. It was found that hospitalists are, on average, more efficient diagnosticians and/or enhance throughput, as evidenced by having relatively lower charges, through reductions in testing and length-of-stay, than teaching teams. Much of that benefit is concentrated among patients admitted by intensivists. The authors find little evidence of quality focus or of greater use of community resources among hospitalists. Indeed, hospitalists were found to have no effect on the choice of postdischarge outlets. The authors document variation in care delivery among hospitalists. In particular, it was found that among hospitalists there is more variation in achieving shorter length of stay but less variation in use of diagnostic testing.

Group Health Cooperative's Transformation Toward Patient-Centered Access

Fri, 30 Oct 2009 15:37:39 PDT

The Institute of Medicine suggests redesigning health care to ensure safe, effective, timely, efficient, equitable, and patient-centered care. The concept of patient-centered access supports these goals. Group Health, a mixed-model health care system, attempted to improve patients’ access to care through the following changes: (a) offering a patient Web site with patient access to patient—physician secure e-mail, electronic medical records, and health promotion information; (b) offering advanced access to primary physicians; (c) redesigning primary care services to enhance care efficiency; (d) offering direct access to physician specialists; and (e) aligning primary physician compensation through incentives for patient satisfaction, productivity, and secure messaging with patients. In the 2 years following the redesign, patients reported higher satisfaction with certain aspects of access to care, providers reported improvements in the quality of service given to patients, and enrollment in Group Health stayed aligned with statewide trends in health care coverage.

CEO Compensation and Hospital Financial Performance

Reiter, K. L., Sandoval, G. A., Brown, A. D., Pink, G. H. — Fri, 30 Oct 2009 15:37:39 PDT

Growing interest in pay-for-performance and the level of chief executive officers’ (CEOs’) pay raises questions about the link between performance and compensation in the health sector. This study compares the compensation of nonprofit hospital CEOs in Ontario, Canada to the three longest reported and most used measures of hospital financial performance. Our sample consisted of 132 CEOs from 92 hospitals between 1999 and 2006. Unbalanced panel data were analyzed using fixed effects regression. Results suggest that CEO compensation was largely unrelated to hospital financial performance. Inflation-adjusted salaries appeared to increase over time independent of hospital performance, and hospital size was positively correlated with CEO compensation. The apparent upward trend in salary despite some declines in financial performance challenges the fundamental assumption underlying this article, that is, financial performance is likely linked to CEO compensation in Ontario. Further research is needed to understand long-term performance related to compensation incentives.