Medical Care Research and Review recent issues

Review: Conceptualization and Measurement of Organizational Readiness for Change: A Review of the Literature in Health Services Research and Other Fields

Weiner, B. J., Amick, H., Lee, S.-Y. D. — 2008-07-17

Health care practitioners and change experts contend that organizational readiness for change is a critical precursor to successful change implementation. This article assesses how organizational readiness for change has been defined and measured in health services research and other fields. Analysis of 106 peer-reviewed articles reveals conceptual ambiguities and disagreements in current thinking and writing about organizational readiness for change. Inspection of 43 instruments for measuring organizational readiness for change reveals limited evidence of reliability or validity for most publicly available measures. Several conceptual and methodological issues that need to be addressed to generate knowledge useful for practice are identified and discussed.

Does Enrollment in a CDHP Stimulate Cost-Effective Utilization?

Hibbard, J. H., Greene, J., Tusler, M. — 2008-07-17

Consumer-driven health plans (CDHPs) are built on the assumption that with increased cost sharing consumers will select cost-effective evidence-based care. In this study, the authors explore whether patterns of utilization change after enrollment in a CDHP and whether the pattern reflects a shift toward evidence-based care. The study population is comprised of 18,025 employees and their adult dependents. The analysis uses a schema for categorizing claims data into high-priority (evidence-based care) and low-priority (limited or no evidence-based care) utilization. The findings indicate that enrollment in CDHPs resulted in a reduction of office visits in the 1st year of enrollment. These reductions in care appear to be indiscriminant, with patients cutting back in both high-and low-priority visits. The reductions in high- and low-priority visits were greater for employees with lower education and income.

Continuity of Health Insurance Coverage and Perceived Health at Age 40

Probst, J. C., Wang, J.-Y., Moore, C. G., Powell, M. P., Martin, A. B. — 2008-07-17

While a lack of health insurance or interrupted coverage has been shown to lead to poorer health status among preretirement populations, this phenomenon has not been examined among a large population of younger, working-age adults. We analyzed a nationally representative data set of persons born between 1957 and 1961, the National Longitudinal Survey of Youth—1979, to examine the links between insurance continuity and self-assessed physical and mental health at age 40. Among respondents turning 40 in 1998 or 2000, 59.8% had been continuously insured during the decade before they reached age 40. In unadjusted analysis, persons who were continuously covered had the highest scores for both physical and mental health. After controlling for respondent characteristics, insurance coverage was not significantly associated with perceived physical or mental health.

Safety-Net Hospitals

Zwanziger, J., Khan, N. — 2008-07-17

Vulnerable populations, who have difficulty accessing the health care system, primarily receive their medical care from hospitals. Policy makers have struggled to ensure the survival of "safety-net hospitals," hospitals that provide a disproportionate share of care to these patient populations. The objective of this article is to develop measures to guide analysis and policy for urban safety-net hospitals. The authors developed three safety-net measures: the socioeconomic status of hospital service area, Medicaid intensity, and uncompensated care burden and its market share. Cluster analysis was used to identify break points that distinguish a safety-net hospital from a non-safety-net hospital. The measures developed were stable and independent, but a data-driven binary assignment of hospitals to a "safety-net" category was not supported. These analyses call into question the empirical basis for distinguishing a specific group of hospitals as safety-net hospitals.

Do Hospitals With Electronic Medical Records (EMRs) Provide Higher Quality Care?: An Examination of Three Clinical Conditions

Kazley, A. S., Ozcan, Y. A. — 2008-07-17

This study investigates how hospital electronic medical record (EMR) use influences quality performance. Data include nonfederal acute care hospitals in the United States. Sources of the data include the American Hospital Association, Hospital Quality Alliance, the Healthcare Information and Management Systems Society, and the Centers for Medicare and Medicaid Services case-mix index sets. The authors use a retrospective cross-sectional format with linear regression to assess the relationship between hospital EMR use and quality performance. Quality performance is measured using 10 process indicators related to 3 clinical conditions: acute myocardial infarction, congestive heart failure, and pneumonia. The authors also use a propensity score adjustment to control for possible selection bias. After this adjustment, the authors identify a positive significant relationship between EMR use and 4 of the 10 quality indicators. They conclude that there is limited evidence of the relationship between hospital EMR use and quality.

Medicaid Nursing Home Payment and the Role of Provider Taxes

Grabowski, D. C., Zhanlian Feng, , Mor, V. — 2008-07-17

In the context of recent state budget shortfalls and the repeal of the Boren Amendment, state Medicaid expenditures for nursing home care were considered a potential target for payment cuts. The authors examine this issue using data from a survey of state nursing home payment policies. Results indicate that aggregate inflation-adjusted Medicaid payment rates steadily increased through 2004, and this growth is partly attributable to the adoption of nursing home provider taxes in many states. A recent proposal to cap provider taxes, if enacted, may lead to a decrease in Medicaid payment rates for nursing home care.

Review: How Do Hospital Organizational Structure and Processes Affect Quality of Care?: A Critical Review of Research Methods

Hearld, L. R., Alexander, J. A., Fraser, I., Jiang, H. J. — 2008-05-12

Interest in organizational contributions to the delivery of care has risen significantly in recent years. A challenge facing researchers, practitioners, and policy makers is identifying ways to improve care by improving the organizations that provide this care, given the complexity of health care organizations and the role organizations play in influencing systems of care. This article reviews the literature on the relationship between the structural characteristics and organizational processes of hospitals and quality of care. The review uses Donabedian's structure—process—outcome and level of analysis frameworks to organize the literature. The results of this review indicate that a preponderance of studies are conducted at the hospital level of analysis and are predominantly focused on the organizational structure—quality outcome relationship. The article concludes with recommendations of how health services researchers can expand their research to enhance one's understanding of the relationship between organizational characteristics and quality of care.

The Impact of Contract Primary Care on Health Care Expenditures and Quality of Care

Liu, C.-F., Chapko, M. K., Perkins, M. W., Fortney, J., Maciejewski, M. L. — 2008-05-12

The Department of Veterans Affairs (VA) established community-based outpatient clinics to improve veterans' access to primary care. This article compares VA use and expenditures among primary care users at 76 VA-staffed community clinics (n = 17,060) and 32 non-VA contract community clinics receiving capitation (n = 6,842) using VA administrative databases. It estimates utilization using negative binomial models and expenditures using generalized linear one-part or two-part models. Contract community clinic patients are less likely to use all types of outpatient services than VA-staffed community clinic patients but had similar quality of care. For patients seeking care, contract community clinic patients had similar specialty care expenditures but lower primary care, outpatient, and overall expenditures. Results suggest that capitated contract clinics did not shift costs to specialty care and appeared to be an economically efficient mechanism for improving veterans' access to primary care while meeting VA quality of care standards.

How Sensitive Are Multilevel Regression Findings to Defined Area of Context?: A Case Study of Mammography Use in California

Mobley, L. R., Kuo, T.-M., Andrews, L. — 2008-05-12

The authors develop a hybrid model of health care use that blends features of the traditional Aday—Andersen behavioral model with the socioecological modeling perspective. They use the model to conceptualize the various levels of influence expected from socioecological variables in individuals' mammography use decisions, build contextual variables from fine-grained data into four different types of geographic areas, and then use two- and three-level modeling of personal and area-level contextual factors to explain observed behavior. The central focus is on whether differentiating the conceptualized levels of influence seems to materially affect regression findings. The test could conceivably be confounded by the modifiable areal unit problem, but little evidence for this is found. Findings for California women suggest that distinctions do matter in how the levels of influence are defined for local neighborhood contextual factors. Studies using only county-level contextual factors will miss some meaningful associations related to interpersonal/proximate-level factors.

Medicaid 1915(c) Waiver Use and Expenditures for Persons Living With HIV/AIDS

Miller, N. A., Elder, K. T., Kitchener, M., Yu Kang, , Harrington, C. — 2008-05-12

States' use of Medicaid 1915(c) waiver services for persons living with HIV/AIDS (PLWHA) has been limited. The authors examine state-level factors related to the decision to offer waiver services, as well as waiver use and expenditures in states offering waivers for PLWHA. They use fixed effects cross-sectional time series models to explore these state factors. States with Democratic governors were more likely to offer waiver services and were found to have higher rates of use and greater expenditures and to devote a larger share of long-term care dollars to waiver services for PLWHA. State supply of both institutional and residential care beds was negatively related to use and expenditures. Medicaid community-based care has been found to be related to improved outcomes and reduced costs of care. Ways to foster 1915(c) waiver expansion are important so as to increase access to care for PLWHA.

Are There Differential Effects of Managed Care on Publicly Insured Children With Chronic Health Conditions?

Davidoff, A., Hill, I., Courtot, B., Adams, E. — 2008-05-12

The authors use variation across states and over time in managed care (MC) programs for publicly insured children to examine whether effects differ for children with chronic health conditions (CWCHC) and those without. The authors pool data from the 1997 to 2002 National Health Interview Survey and link county, year, and health status information on type of MC programs implemented. Findings show that the effects of MC are concentrated on CWCHC and that CWCHC experience reductions in use of specialist, mental health, and prescription drugs. Capitated programs with mental health or specialty carve-outs are associated with a greater number and larger decreases in service use compared to integrated capitated programs. While it is not possible to determine whether MC programs resulted in more appropriate use of services, corresponding reductions in perceived access were not observed, suggesting that net effects of MC on service use represent improvements in care coordination.

Stochastic Frontier Analysis of Hospital Inefficiency: A Review of Empirical Issues and an Assessment of Robustness

Rosko, M. D., Mutter, R. L. — 2008-03-10

Twenty stochastic frontier analysis (SFA) studies of hospital inefficiency in the United States were analyzed. Results from best-practice methods were compared against previously used methods in hospital studies to ascertain the robustness of SFA in estimating cost inefficiency. To compare past studies and analyze new data, SFA methods were varied by (a) the assumptions of the structure of costs and distribution of the error term, (b) inclusion of quality and product descriptor measures, and (c) use of simultaneous and two-stage estimation techniques. SFA results were relatively insensitive to several model variations.

The Relationship Between Medical Practice Characteristics and Quality of Care for Cardiovascular Disease

2008-03-10

The settings in which health care services are delivered have the potential to influence the quality of health care services in numerous ways, but little is known about the relationship between characteristics of medical practices and quality of care. In this study, the authors studied patients with coronary heart disease (CHD). The authors surveyed 225 medical practices in 2000 and 2001 and obtained information on quality measures from the medical records for more than 1,600 of their patients with CHD. Results suggest that quality of care, at least for common conditions with agreed-on measures, is not strongly influenced by financial characteristics of medical practices, although there does seem to be some relationship with practice structure such as size and quality.

The Response of Small Businesses to Variation in the Price of Health Insurance: Results From a Randomized Controlled Trial

Kronick, R., Olsen, L. C., Gilmer, T. P. — 2008-03-10

There is substantial interest in attempts to reduce the number of uninsured persons by providing subsidies to small businesses. To measure the responsiveness of small businesses to offers of subsidized coverage, the authors conducted a randomized controlled trial in which selected groups of San Diego businesses were offered the opportunity to purchase coverage at prices ranging from $20 to $100 per month for an employee-only policy. At $20 per month, an estimated 40% of eligible businesses purchased insurance; at $100 per month, 13% purchased insurance. Small businesses not currently offering insurance to employees are not very responsive to large reductions in the price of coverage. Programs to subsidize insurance for small businesses and their employees are unlikely to substantially reduce the number of uninsured persons.

Hospital Responses to the Leapfrog Group in Local Markets

Scanlon, D. P., Christianson, J. B., Ford, E. W. — 2008-03-10

The Leapfrog (LF) initiative, directed at improving patient safety in hospitals, may be the most ambitious, coordinated attempt to date on the part of large employers to shape the delivery of health care in America. This article assesses the role of market conditions and other factors in influencing hospital responses to LF activities at the community level. Community characteristics were found to be important in explaining hospital participation in a LF safety standards survey at the study sites. However, characteristics of the individual hospitals, and of the LF goals themselves, were more important in explaining the relatively limited progress by hospitals across all sites in achieving those goals over a 5-year period.

Nurse Aide Agency Staffing and Quality of Care in Nursing Homes

Castle, N. G., Engberg, J., Aiju Men, — 2008-03-10

Data from a large sample of nursing homes are used to examine the association between use of nurse aide agency staff and quality. Agency use data come from a survey conducted in 2005 (N = 2,840), and the quality indicators come from the Nursing Home Compare Web site. The authors found a nonlinear relationship between nurse aide agency levels and quality; however, in general, higher nurse aide agency levels were associated with low quality. The results have policy and practice implications, the most significant of which is that use of nurse aide agency staff of less than 14 full-time equivalents per 100 beds has little influence on quality, whereas nurse aide agency staff of more than 25 full-time equivalents per 100 beds has a substantial influence on quality.

Predictors of Nursing Home Hospitalization: A Review of the Literature

Grabowski, D. C., Stewart, K. A., Broderick, S. M., Coots, L. A. — 2008-01-09

Hospitalization of nursing home residents is costly and potentially exposes residents to iatrogenic disease and psychological harm. This article critically reviews the association between the decision to hospitalize and factors related to the residents' welfare and preferences, the providers' attitudes, and the financial implications of hospitalization. Regarding the resident's welfare, factors associated with hospitalization included sociodemographics, health characteristics, nurse staffing, the presence of ancillary services, and the use of hospices. Patient preferences (e.g., advance directives) and provider attitudes (e.g., overburdening of staff) were also associated with increased hospitalization. Finally, financial variables related to hospitalization included nursing home ownership status and state Medicaid policies, such as nursing home payment rates and bed-hold requirements. Most studies relied on potentially confounded research designs, which leave open the issue of selection bias. Nevertheless, the existing literature asserts that nursing home hospitalizations are frequent, often preventable, and related to facility practices and state Medicaid policies.

Reducing Hospitalizations From Long-Term Care Settings

Konetzka, R. T., Spector, W., Limcangco, M. R. — 2008-01-09

Hospital spending represents approximately one third of total national health spending, and the majority of hospital spending is by public payers. Elderly individuals with long-term care needs are at particular risk for hospitalization. While some hospitalizations are unavoidable, many are not, and there may be benefits to reducing hospitalizations in terms of health and cost. This article reviews the evidence from 55 peer-reviewed articles on interventions that potentially reduce hospitalizations from formal long-term care settings. The interventions showing the strongest potential are those that increase skilled staffing, especially through physician assistants and nurse practitioners; improve the hospital-to-home transition; substitute home health care for selected hospital admissions; and align reimbursement policies such that providers do not have a financial incentive to hospitalize. Much of the evidence is weak and could benefit from improved research design and methodology.

Using Patient Safety Indicators to Estimate the Impact of Potential Adverse Events on Outcomes

2008-01-09

The authors estimated the impact of potentially preventable patient safety events, identi- fied by Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators (PSIs), on patient outcomes: mortality, length of stay (LOS), and cost. The PSIs were applied to all acute inpatient hospitalizations at Veterans Health Administration (VA) facil- ities in fiscal 2001. Two methods—regression analysis and multivariable case matching— were used independently to control for patient and facility characteristics while predicting the effect of the PSI on each outcome. The authors found statistically significant (p < .0001) excess mortality, LOS, and cost in all groups with PSIs. The magnitude of the excess varied considerably across the PSIs. These VA findings are similar to those from a previously published study of nonfederal hospitals, despite differences between VA and non-VA systems. This study contributes to the literature measuring outcomes of medical errors and provides evidence that AHRQ PSIs may be useful indicators for comparison across delivery systems.

The Effect of Care Team Composition on the Quality of HIV Care

Rodriguez, H. P., Marsden, P. V., Landon, B. E., Wilson, I. B., Cleary, P. D. — 2008-01-09

Compared to single-clinician care, care provided by multiple clinicians might result in higher-quality care, especially if some of them have condition-specific expertise and complementary knowledge, skills, and roles. Individual physician continuity, which has been shown to be associated with care quality, necessarily decreases when care is provided by multiple clinicians. This study uses data from the HIV Cost and Services Utilization Study to assess the effect of care team composition on the quality of HIV care. In adjusted analyses, care teams composed of three or more clinicians were associated with more consistent prescribing of pneumocystis carinii pneumonia prophylaxis when medically indicated ( p < .01). Patients with multiple physicians generally reported worse care coordination, however, and had more inappropriate use of emergency services. These findings indicate both advantages and disadvantages to having multiple clinicians. More effort should be devoted to facilitating coordination when multiple clinicians provide care.

Why Using Current Medications to Select a Medicare Part D Plan May Lead to Higher Out-of-Pocket Payments

Domino, M. E., Stearns, S. C., Norton, E. C., Yeh, W.-S. — 2008-01-09

While medications are one of the most stable categories of health care expenses, the actual composition of drug products used may be highly variable over time. Medicare beneficiaries selecting among Part D prescription drug plans (PDPs) are often advised to base plan selection on current medication lists. However, this approach may lead to higher out-of-pocket payments relative to payments under other plans if drug switches are common. This article uses a sample of Medicare beneficiaries from the 2003 Medical Expenditure Panel Survey to estimate how changes in actual drug use during a 1-year period affect estimated annual costs, given the initial choice of the lowest-cost PDP. While 57% of the sample had no difference in expenditure for plans selected based on initial versus end-of-the-year drug lists, 43% experienced average increases of $556 in annualized expenses due to drug switches. Implementable suggestions for improving the selection of Part D plans are provided.