Large administrative databases such as Medicaid billing databases could be used to study care and outcomes of lupus nephritis if these patients could be correctly identified from claims data. We aimed to develop and validate an algorithm for the correct identification of cases of lupus nephritis using ICD-9 billing codes. We used the Research Patient Data Resource (RPDR) query tool at our institution to identify patients with potential lupus nephritis. We compared four ICD-9 code based strategies, identifying patients seen between 2000 - 2007 with Medicaid medical insurance with greater than two claims for a diagnosis of SLE (ICD-9 code 710.0) and a combination of greater than two nephrologist visits and/or renal ICD-9 codes. We assessed performance using the positive predictive value (PPV). 234 subjects were identified and medical records reviewed. Our third strategy, based on a combination of lupus and renal ICD-9 codes and nephrologist encounter claims, had the highest PPV (88%) for the identification of patients with lupus nephritis. This strategy may offer a sound method of identifying patients with lupus nephritis for health services research in addition to serving as a model for using claims data as a way to better understand rare diseases such as lupus.
Lupus nephritis; medical claims data
This study describes patterns of choosing a provider and of consumer satisfaction among prepaid Medicaid beneficiaries in Monroe County, New York, and compares their level of satisfaction to that of fee-for-service Medicaid beneficiaries. Two interview surveys were conducted with AFDC and HR (general assistance) Medicaid eligibles, the first under the fee-for-service system servicing the Medicaid population, and the second 18 months after the introduction of a mandatory, prepaid managed care system for Medicaid beneficiaries. The results show significant ethnic differences in patient choice of provider and provider site. Given the choice, Medicaid beneficiaries switch from clinics as their usual source of care to private physician practice. Under prepayment, white Medicaid beneficiaries tripled their affiliations with private doctors, while "others" doubled theirs. The results also demonstrate higher levels of patient satisfaction with "humaneness of doctors" and with "quality of care" among those beneficiaries under prepaid care, than previously documented for those under fee-for-service. The evaluations of humaneness and quality of medical system may reflect the respondents' perceptions that the process of receiving care under prepaid, managed care is somehow different, no longer second class, and better that it was under the fee-for-service Medicaid.
To test the effect of a consumer-directed model (Cash and Counseling) of Medicaid personal care services (PCS) or home-and community-based waiver services (HCBS) on the cost of Medicaid services.
Data Sources/Study Setting
Medicaid claims data were collected for all enrollees in the Cash and Counseling demonstration. Demonstration enrollees included those eligible for PCS (in Arkansas), those assessed to receive such services (in New Jersey), and recipients of Medicaid HCBS (in Florida). Enrollment occurred from December 1998 through April 2001. The follow-up period covered up to 24 months after enrollment.
Demonstration volunteers were randomly assigned to have the option to participate in Cash and Counseling (the treatment group), or to receive Medicaid services as usual from an agency (the control group). Ordinary least squares regressions were used to estimate the effect of the program on costs for Medicaid PCS/waiver services and other Medicaid services, while controlling for consumers' preenrollment characteristics and preenrollment Medicaid spending. Models were estimated separately for nonelderly and elderly adults in each state and for children in Florida.
Data Extraction Methods
Each state supplied claims data for demonstration enrollees.
Largely because the program increased consumers' ability to get the authorized amount of paid care, expenditures for personal care/waiver services were higher for the treatment group than for the control group in each state and age group, except among the elderly in Florida. Higher costs for personal care/waiver services were partially offset by savings in other Medicaid services, particularly those related to long-term care. During year 1, total Medicaid costs were generally higher for the treatment group than for the control group, with treatment–control cost differences ranging from 1 percent (and statistically insignificant) for the elderly in Florida to 17 percent for the elderly in Arkansas. In year 2, these cost differences were generally greater than in year 1. Only in Arkansas did the treatment–control difference in total cost shrink over time—to less than 5 percent (and statistically insignificant) in year 2.
Medicaid costs were generally higher under Cash and Counseling because those in the traditional system did not get the services they were entitled to. Compared with the treatment group, (1) control group members were less likely to receive any services at all (despite being authorized for them), and (2) service recipients received a lower proportion of the amount of care that was authorized. In addition, a flaw in Florida's reassessment procedures led to treatment group members receiving more generous benefit amounts than control group members. To keep total Medicaid costs per recipient at the level incurred under the traditional system, consumer-directed programs need to be carefully designed and closely monitored.
Consumer-direction; personal care; costs
To analyze the implementation of Medicaid preferred drug lists (PDLs) in a number of states and determine its impact on quality of care and cost relative to other segments of healthcare.
We reviewed research and case studies found by searching library databases, primarily MEDLINE and EBSCOHost, and searching pertinent journals. Keywords initially included “drug lists,” “prior authorization,” “prior approval,” and “Medicaid.” We added terms such as “influence use of other healthcare services,” “quality of care,” and “overall economic impact.” We mainly used primary sources.
Based on our literature review, we determined that there are a number of issues regarding Medicaid PDLs that need to be addressed. Some issues include: (a) the potential for PDLs to influence the utilization of other healthcare services, (b) criteria used by Medicaid for determining acceptance of drugs onto a PDL, (c)the effect of PDL implementation on compliance to new regimens, (d) the potential effects of restricting medication availability on quality of care, (e) administrative costs associated with PDLs, and (f) satisfaction rates among patients and medical providers. This review highlighted expected short-term cost savings with limited degree of compromised quality of PDL implementation, but raised the concern about the potential long-term decline in quality of care and overall economic impact.
The number of concerns raised indicates that further studies are warranted regarding both short-term cost benefits as well as potential long-term effects of Medicaid PDL implementation. Objective analysis of these effects is necessary to ensure cost-effectiveness and quality of care.
preferred drug lists; medicaid; healthcare costs; managed care
Little is known about the sociodemographic correlates of kidney transplantation and survival among U.S. children with lupus nephritis-associated ESRD. We aimed to identify predictors of listing for kidney transplantation (wait-listing), kidney transplantation, and mortality among children with lupus nephritis-associated ESRD.
Children aged 5–18 years with new onset lupus nephritis-associated ESRD were identified in the U.S. Renal Data System (1995–2006). We investigated demographic and clinical characteristics, causes of death and predictors of wait-listing, kidney transplantation, and mortality during the first 5 years of ESRD. Cox proportional hazards models were used.
583 children had incident lupus nephritis-associated ESRD. Mean age at ESRD onset was 16.2 years (SD 2.4); 51% were African American and 24% Hispanic. Within 5 years 292 (49%) were wait-listed, 193 (33%) received a kidney transplant and 131 (22%) died. Main causes of death were cardiopulmonary (31%) and infectious (16%). Children in the Northeast and West (vs. South) were more than twice as likely to be wait-listed (P<0.001, P<0.001) and over 50% more likely to be transplanted (P<0.04). There were fewer kidney transplants among older vs. younger (OR 0.59, P=0.009), African American vs. white (OR 0.48, P<0.001), Hispanic vs. non-Hispanic (OR 0.63, P=0.03) children, and those with Medicaid vs. private insurance (OR 0.7, P=0.03). Mortality was almost double among African American vs. white children (OR 1.83, P<0.001).
Among U.S. children with lupus nephritis-associated ESRD age, race, ethnicity, insurance and geographic region were associated with significant variation in 5-year wait-listing for kidney transplant, kidney transplantation and mortality.
Systemic Lupus Erythematosus; Pediatric Rheumatology; Nephritis; Survival; End Stage Renal Disease; Children; Disparities; Outcomes
Persons with low socioeconomic status have an increased risk of endstage renal disease (ESRD) due to systemic lupus erythematosus (SLE), possibly because of limited access to care. We examined if the incidence of ESRD due to SLE was higher in geographic areas with poorer access to care.
In this population-based ecological study, we tested associations between the incidence of ESRD due to SLE and the proportion of hospitalizations with no insurance, Medicaid or managed care insurance, residence in a primary care-provider shortage area or rural area, and rate of hospitalizations for ambulatory care-sensitive conditions, by ZIP code in California in 1999–2004.
The incidence of ESRD due to SLE was higher in ZIP codes with higher proportions of hospitalizations with no insurance (r = 0.22, p < 0.0001) or Medicaid (r = 0.21, p < 0.0001), and in ZIP codes with higher rates of hospitalizations for ambulatory care-sensitive conditions (r = 0.23, p < 0.0001). In multivariate analyses, incidences were higher in ZIP codes with higher proportions of hospitalizations with Medicaid (p < 0.0001) and higher rates of hospitalizations for ambulatory care-sensitive conditions (p = 0.06), independent of the socioeconomic status of the ZIP code residents.
The incidence of ESRD due to SLE is higher in areas with higher proportions of residents who have public insurance and higher rates of avoidable hospitalizations, suggesting that limited access to care may contribute to this complication of SLE.
ACCESS TO CARE; ENDSTAGE RENAL DISEASE; SOCIOECONOMIC STATUS; SYSTEMIC LUPUS ERYTHEMATOSUS
Lupus nephritis is one of the most serious manifestations and one of the strongest predictors of a poor outcome in systemic lupus erythematosus (SLE). Recent evidence implicated a potential role of interlukin-17 (IL-17) in the pathogenesis of lupus nephritis. However, the correlation between IL-17 expression level and the severity of lupus nephritis still remains incompletely understood. In this study, we found that serum IL-17 expression level was associated with the severity of lupus nephritis, which was evaluated by histopathology of kidney sections and urine protein. Of note, we showed that enforced expression of IL-17 using adenovirus construct that expresses IL-17 could enhance the severity of lupus nephritis, while blockade of IL-17 using neutralizing antibody resulted in decreased severity of lupus nephritis. Consistently, we observed an impaired induction of lupus nephritis in IL-17-deficient mice. Further, we revealed that IL-17 expression level was associated with immune complex deposition and complement activation in kidney. Of interest, we found that IL-17 was crucial for increasing anti-double-stranded DNA (dsDNA) antibody production in SLE. Our results suggested that IL-17 expression level positively correlated with the severity of lupus nephritis, at least in part, because of its contribution to anti-dsDNA antibody production. These findings provided a novel mechanism for how IL-17 expression level correlated with disease pathogenesis and suggested that management of IL-17 expression level was a potential and promising approach for treatment of lupus nephritis.
Section 401 of the Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA) requires the Department of Health and Human Services (HHS) to identify and publish healthcare quality measures for children enrolled in the Children's Health Insurance Program (CHIP) or Medicaid. CHIPRA also requires core measures to identify disparities by race and ethnicity, among other factors. State Medicaid and CHIP programs are currently facing significant budgetary pressures that are likely to increase with eligibility expansions and programmatic changes resulting from the Patient Protection and Affordable Care Act (PPACA). To limit the burden on states and increase the likelihood of states' voluntarily reporting on core pediatric quality measures, HHS may consider utilizing existing data sources. This article examines the feasibility of utilizing Medicaid Statistical Information System (MSIS) data to identify and analyze the core children's healthcare quality measures required by CHIPRA.
Five key themes related to the feasibility of using MSIS as a data source for quality measures are identified: states have significant experience with data collection, performance measurement, and quality oversight for children in Medicaid and CHIP; CHIPRA provisions related to reporting of quality measures will be implemented at a time when states are facing major fiscal constraints; MSIS provides potential opportunities as it offers a rich source of data, but the difficulties in obtaining clean data should not be underestimated; MSIS has limitations; and states, the federal government, providers, and enrollees benefit from standardization in data and quality measurement.
MSIS; children's quality measures; Medicaid; CHIP
To develop sufficient managed care capacity to accomplish the goal of transitioning Medicaid recipients into managed care, state policymakers have relied on commercial health maintenance organizations to open their panels of providers to the Medicaid population. However, while commercial health maintenance organization involvement in Medicaid managed care was high initially, since 1996 New York State has had 14 commercial plans leave the New York State Medicaid Managed Care Program. It has been speculated that the exodus of these commercial plans would have a negative impact on Medicaid enrolleeś access and quality of care. This paper attempts to evaluate the impact of this departure from the perspective of quality and access measures and plan audit performance. Univariate and multivariate analyses were performed to evaluation the effect of commercial managed care plans leaving the Medicaid program. The overall performance of plans that remained in the program was compared to that of the plans that chose to leave for the two time periods 1996–1997 and 1998–2000. Access to care, quality of care, and annual audit performance data were analyzed. The departure of commercial health plans from the New York State Medicaid Managed Care Program has not had a statistically significant negative effect on the quality of care provided to Medicaid recipients as evaluated by standardized performance measures. In addition, there were no instances when there was a negative impact of the exit of the commercial plans on access to care. Managed care plans that chose to remain in Medicaid passed the Quality Assurance Reporting Requirements audit at a significantly (P<.01) higher rate than plans that chose to leave.
Access to care; Commercial managed care; Health care delivery; Managed care; Medicaid managed care; Quality assessment
OBJECTIVE: To assess the impact of switching from a fee-for-service (FFS) delivery system to managed care on access to, use of, and satisfaction with health care for children. DATA SOURCES/STUDY SETTING: A 1998 survey of Medicaid recipients in rural Minnesota. STUDY DESIGN: Using a quasi-experimental framework, we compare the experiences of children on Medicaid living in counties that had switched to managed care with those of children living in counties operating under FFS Medicaid. We address the impact of Medicaid managed care (MMC) on access to, use of, and satisfaction with care. DATA COLLECTION METHODS: A stratified random sample of children on Medicaid was drawn based on Medicaid enrollment files. Telephone interviews were conducted with the child's parent or guardian between March and June 1998. An overall response rate of 70 percent was achieved, yielding a sample of 1,106 children (814 in MMC and 792 in Medicaid FFS). PRINCIPAL FINDINGS: We find very few significant differences in access to, use of, or satisfaction with health care services for children under MMC relative to FFS. MMC did not change the patterns of health care service use or the location at which care is delivered, two major goals of MMC initiatives. CONCLUSIONS: Our results suggest that the Medicaid program's shift from FFS to managed care had little impact on the pattern of children's health care use, the location at which they obtained care, or the satisfaction with the care they received.
To estimate the effects of Medicaid managed care (MMC) programs on Medicaid enrollees’ access to and use of health care services at the national level.
Data Sources/Study Setting
1991–1995 National Health Interview Surveys (NHIS) and a 1998 Urban Institute survey on state Medicaid managed care programs.
Using multivariate regression models, we estimated the effect of living in a county with an MMC program on several access and use measures for nonelderly women who receive Medicaid through AFDC and child Medicaid recipients. We focus on mandatory programs and estimate separate effects for primary care case management (PCCM) programs, health maintenance organization (HMO) programs, and mixed PCCM/HMO programs, relative to fee-for-service (FFS) Medicaid. We control for individual and county characteristics, and state and year effects.
Data Collection/Extraction Method
This study uses pooled individual-level data from up to five years of the NHIS (1991–1995), linked to information on Medicaid managed care characteristics at the county level from the 1998 MMC survey.
We find virtually no effects of mandatory PCCM programs. For women, mandatory HMO programs reduce some types of non–emergency room (ER) use, and increase reported unmet need for medical care. The PCCM/HMO programs increase access, but had no effects on use. For children, mandatory HMO programs reduce ER visits, and increase the use of specialists. The PCCM/HMO programs reduce ER visits, while increasing other types of use and access.
Mandatory PCCM/HMO programs improved access and utilization relative to traditional FFS Medicaid, primarily for children. Mandatory HMO programs caused some access problems for women.
Medicaid; managed care; HMO; primary care case management; health care access
This study examines the effects of Medicaid payment generosity on access and care for adult and child Medicaid beneficiaries.
Three years of the National Surveys of America's Families (1997, 1999, 2002) are linked to the Urban Institute Medicaid capitation rate surveys, the Area Resource File, and the American Hospital Association survey files.
In order to identify the effect of payment generosity apart from unmeasured differences across areas, we compare the experiences of Medicaid beneficiaries with groups that should not be affected by Medicaid payment policies. To assure that these groups are comparable to Medicaid beneficiaries, we reweight the data using propensity score methods. We use a difference-in-differences model to assess the effects of Medicaid payment generosity on four categories of access and use measures (continuity of care, preventive care, visits, and perceptions of provider communication and quality of care).
Higher payments increase the probability of having a usual source of care and the probability of having at least one visit to a doctor and other health professional for Medicaid adults, and produce more positive assessments of the health care received by adults and children. However, payment generosity has no effect on the other measures that we examined, such as the probability of receiving preventive care or the probability of having unmet needs.
Higher payment rates can improve some aspects of access and use for Medicaid beneficiaries, but the effects are not dramatic.
Payment levels; Medicaid; access and use; propensity score methods
STUDY QUESTIONS: What is the extent of variation in patterns of ambulatory care practice across one state's Medicaid program once case mix is controlled for? How much of this variation in resource consumption is explained by factors linked to the provider, patient, and geographic subarea? DATA SOURCES/STUDY SETTING: Practices of all providers delivering care to persons who were continuously enrolled in the Maryland Medicaid program during FY 1988 were studied. A computerized summary of all services received during this year for 134,725 persons was developed using claims data. We also obtained data from the state's beneficiary and provider files and the American Medical Association's masterfile. Each patient was assigned a "usual source of care" (primary provider) based on the actual patterns of service. The Ambulatory Care Group (ACG) measure was used to help control for case mix. STUDY DESIGN: This was a cross-sectional study based on the universe of continuously enrolled Medicaid enrollees in one state. PRINCIPAL FINDINGS: After controlling for case mix, the variation in patient resource use by type of primary provider was 19 percent for ambulatory visits, 46 percent for ancillary testing, 61 percent for prescriptions, and 81 percent for hospitalizations. Across Maryland counties, comparing the low- to high-use jurisdiction, there was 41 percent variation in case mix-adjusted visit rates, 72 percent variation in pharmacy use, and 325 percent variation in hospital days. At the individual practice level, physician characteristics explain up to 17 percent of ambulatory resource use and geographic area explains only a few percent, while patient characteristics explain up to 60 percent of variation. CONCLUSIONS: Since a large proportion of variation was explained by patient case mix, it is evident that risk adjustment is essential for these types of analyses. However, even after adjustment, resource use varies considerably across types of ambulatory care provider and region, with consequent implications for efficiency of health services delivery.
To investigate disenrollment from public insurance at the 6-year transitional birthday when eligibility for many children moves from Medicaid to State Children's Health Insurance Program (S-CHIP).
Data from Georgia's S-CHIP (PeachCare) and Medicaid programs from 2000 to 2002.
The likelihood of dropping public coverage after the reference birthday is modeled for children turning age 6 compared with a control cohort of children turning age 9 controlling for demographic and geographic differences between enrollees.
Over 17 percent of 6-year-olds versus only 7 percent of the control cohort dropped coverage. After controlling for other factors (e.g., race/ethnicity, prior enrollment, and geographic region) having lower historical expenditures is predictive of dropping coverage among all children, although the unadjusted effect is stronger among children enrolled in PeachCare before their sixth birthday. Only 1 percent of Medicaid children who remained covered transitioned to PeachCare.
Turnover at transitional birthdays identifies a common pathway for children into the ranks of the uninsured. Facilitating continuous enrollment would retain in the programs children with lower than average expenditures. This may be one of the more cost effective ways of reducing the number of uninsured children in Georgia.
S-CHIP; Medicaid; expenditures; transitions; enrollment
To describe the use of post-acute home care (PAHC) and total Medicaid expenditures among hospitalized nonelderly adult Medicaid eligibles and to test whether health services utilization rates or total Medicaid expenditures were lower among Medicaid eligibles who used PAHC compared to those who did not.
5,299 Medicaid patients aged 18–64 discharged in 1992–1996 from 29 hospitals in the Cleveland Health Quality Choice (CHQC) project.
Linked Ohio Medicaid claims and CHQC medical record abstract data.
One stay per patient was randomly selected.
Observational study. To control for treatment selection bias, we developed a model predicting the probability (propensity) a patient would be referred to PAHC, as a proxy for the patient's need for PAHC. We matched 430 patients who used Medicaid-covered PAHC (“USE”) to patients who did not (“NO USE”) by their propensity scores. Study outcomes were inpatient re-admission rates and days of stay (DOS), nursing home admission rates and DOS, and mean total Medicaid expenditures 90 and 180 days after discharge.
Of 3,788 medical patients, 12.1 percent were referred to PAHC; 64 percent of those referred used PAHC. Of 1,511 surgical patients, 10.9 percent were referred; 99 percent of those referred used PAHC. In 430 pairs of patients matched by propensity score, mean total Medicaid expenditures within 90 days after discharge were $7,649 in the USE group and $5,761 in the NO USE group. Total Medicaid expenditures were significantly higher in the USE group compared to the NO USE group for medical patients after 180 days (p<.05) and surgical patients after 90 and 180 days (p<.001). There were no significant differences for any other outcome. Sensitivity analysis indicates the results may be influenced by unmeasured variables, most likely functional status and/or care-giver support.
Thirty-six percent of the medical patients referred to PAHC did not receive Medicaid-covered services. This suggests potential underuse among medical patients. The high post-discharge expenditures suggest opportunities for reducing costs through coordinating utilization or diverting it to lower-cost settings. Controlling for patients' need for services, PAHC utilization was not associated with lower utilization rates or lower total Medicaid expenditures. Medicaid programs are advised to proceed cautiously before expanding PAHC utilization and to monitor its use carefully. Further study, incorporating non-economic outcomes and additional factors influencing PAHC use, is warranted.
Medicaid, home care; post-acute care; outcomes; cost of care; propensity score
Many states expanded their Medicaid managed care programs during the 1990s, causing concern about impacts on health care for affected populations. We investigate the relationship between Medicaid managed care enrollment and health care for children.
Data Sources and Measures
Repeated cross-sections of Medicaid-covered children under 18 years of age from the 1996/1997 and 1998/1999 Community Tracking Study Household Surveys (n=2,602) matched to state-year CMS Medicaid managed care enrollment data. For each individual, we constructed measures of health care utilization (provider and emergency department visits, hospitalizations, surgeries); health care access (usual source of care, unmet medical needs, put-off needed care); and satisfaction (satisfaction overall, with doctor choice, and with last visit).
Regression analysis of the relationship between within-state changes in Medicaid managed care enrollment rates and changes in mean utilization, access, and satisfaction measures for children covered by Medicaid, controlling for a range of potentially confounding factors.
Increases in Medicaid health maintenance organization (HMO) enrollment are associated with less emergency room use, more outpatient visits, fewer hospitalizations, higher rates of reporting having put off care, and lower satisfaction with the most recent visit. Medicaid primary care case management (PCCM) plans are associated with increases in outpatient visits, but also with higher rates of reporting unmet medical needs, putting off care, and having no usual source of care.
Both Medicaid HMO and PCCM plans can have important impacts on health care utilization, access, and satisfaction. Some impacts may be positive (e.g., less ED use and more outpatient provider use), although concern about increasing challenges in access to care and satisfaction is also warranted.
Medicaid; managed care; primary care case management; utilization; access
Latinos are the largest minority group in the United States and experience persistent disparities in access to and quality of health care.
(1) To determine the relationship between nativity/immigration status and self-reported quality of care and preventive care. (2) To assess the impact of a usual source of health care on receipt of preventive care among Latinos.
Using cross-sectional data from the 2007 Pew Hispanic Center/Robert Wood Johnson Foundation Hispanic Healthcare Survey, a nationally representative telephone survey of 4,013 Latino adults, we compared US-born Latinos with foreign-born Latino citizens, foreign-born Latino permanent residents and undocumented Latinos. We estimated odds ratios using separate multivariate ordered logistic models for five outcomes: blood pressure checked in the past 2 years, cholesterol checked in the past 5 years, perceived quality of medical care in the past year, perceived receipt of no health/health-care information from a doctor in the past year, and language concordance.
Undocumented Latinos had the lowest percentages of insurance coverage (37% vs 77% US-born, P < 0.001), usual source of care (58% vs 79% US-born, P < 0.001), blood pressure checked (67% vs 87% US-born, P < 0.001), cholesterol checked (56% vs 83% US-born, P < 0.001), and reported excellent/good care in the past year (76% vs 80% US-born, P < 0.05). Undocumented Latinos also reported the highest percentage receiving no health/health-care information from their doctor (40% vs 20% US-born, P < 0.001) in the past year. Adjusted results showed that undocumented status was associated with lower likelihood of blood pressure checked in the previous 2 years (OR = 0.60; 95% CI, 0.43–0.84), cholesterol checked in the past 5 years (OR = 0.62; 95% CI, 0.39–0.99), and perceived receipt of excellent/good care in the past year (OR = 0.56; 95% CI, 0.39–0.77). Having a usual source of care increased the likelihood of a blood pressure check in the past 2 years and a cholesterol check in the past 5 years.
In this national sample, undocumented Latinos were less likely to report receiving blood pressure and cholesterol level checks, less likely to report having received excellent/good quality of care, and more likely to receive no health/health-care information from doctors, even after adjusting for potential confounders. Our study shows that differences in nativity/immigration status should be taken into consideration when we discuss perceived quality of care among Latinos.
Latinos; quality of care; immigrants; preventive care
To evaluate previous research findings of the relationship between nurse staffing and quality of care by examining the effects of change in registered nurse staffing on change in quality of care.
Data Sources/Study Setting
Secondary data from the American Hospital Association (AHA)(nurse staffing, hospital characteristics), InterStudy and Area Resource Files (ARF) (market characteristics), Centers for Medicare and Medicaid Services (CMS) (financial performance), and Healthcare Cost and Utilization Project (HCUP) (quality measures—in-hospital mortality ratio and the complication ratios for decubitus ulcers, pneumonia, and urinary tract infection, which were risk-adjusted using the Medstat® disease staging algorithm).
Data from a longitudinal cohort of 422 hospitals were analyzed from 1990–1995 to examine the relationships between nurse staffing and quality of care.
Data Collection/Extraction Methods
A generalized method of moments estimator for dynamic panel data was used to analyze the data.
Increasing registered nurse staffing had a diminishing marginal effect on reducing mortality ratio, but had no consistent effect on any of the complications. Selected hospital characteristics, market characteristics, and financial performance had other independent effects on quality measures.
The findings provide limited support for the prevailing notion that improving registered nurse (RN) staffing unconditionally improves quality of care.
Quality of care; HCUP; nurse staffing
To examine service cost and access for persons with severe mental illness under Medicaid mental health capitation payment in Colorado. Capitation contracts were made with two organizational models: community mental health centers (CMHCs) that manage and deliver services (direct capitation [DC]) and joint ventures between CMHCs and a for-profit managed care firm (managed behavioral health organization, [MBHO]) and compared to fee for service (F.F.S.).
Data Sources/Study Setting
Both primary and secondary data were collected for the year prior to the new financing policy and the following two years (1995–1998).
A stratified random sample of 522 severely mentally ill subjects was selected from comparable geographic areas within the capitated and FFS regions of Colorado. Major variables include service cost, utilization, and access (probability of service use) derived from secondary claims data, subject reported access collected at six-month intervals, and baseline outcomes (symptoms, functioning, and quality of life).
In comparison to the FFS area, cost per person was reduced in the capitated areas in each of the two years following implementation. By the end of year two, cost per person was reduced by two-thirds in the MBHO areas and by one-fifth in the DC areas. Reductions in access were found for both capitated areas, although reductions in utilization for those receiving service were found only in the MBHO model.
Medicaid mental health capitation in Colorado resulted in cost reducing service changes for persons with severe mental illness. Assessment of outcome change is necessary to identify cost effectiveness.
Managed care; capitation; mental health
The study examines the association between managed care enrollment and preventable hospitalization patterns of adult Medicaid enrollees hospitalized in four states.
Data Sources/Study Setting
Hospital discharge data from the Healthcare Cost and Utilization Project (HCUP) database of the Agency for Healthcare Research and Quality (AHRQ) for New York (NY), Pennsylvania (PA), Wisconsin (WI), and Tennessee (TN) residents in the age group 20–64 hospitalized in those states, linked to the Area Resource File (ARF) and American Hospital Association (AHA) survey files for 1997.
The study uses separate logistic models for each state comparing preventable admissions with marker admissions (urgent, insensitive to primary care). The model controls for socioeconomic and demographic variables, and severity of illness.
Consistently in different states, private health maintenance organization (HMO) enrollment was associated with fewer preventable admissions than marker admissions, compared to private fee-for-service (FFS). However, Medicaid managed care enrollment was not associated with a reduction in preventable admissions, compared to Medicaid FFS.
Our analysis suggests that the preventable hospitalization pattern for private HMO enrollees differs significantly from that for commercial FFS enrollees. However, little difference is found between Medicaid HMO enrollees and Medicaid FFS patients. The findings did not vary by the level of Medicaid managed care penetration in the study states.
Preventable hospitalization; ambulatory care sensitive admissions; Medicaid; managed care; HMO enrollment; access
Little is known about why minorities have a lower propensity to use private doctors' offices for their usual source of care than non-Hispanic whites. This study used the 2001 Commonwealth Fund's Health Care Quality Survey of adults to determine if this disparity is due to racial and ethnic differences in attitudes about health and healthcare, and perceptions of racial and ethnic discrimination in healthcare. We found that race and ethnic disparities at the site of the usual source of care persisted even after controlling for individuals' attitudes about health and healthcare, and their perceptions about racial and ethnic discrimination in healthcare. We found that the impact of attitudes and perceptions did vary by subgroups. These factors were important for Asians' site of usual source of care but had little impact on African Americans' site of usual of care. However, despite their differential impact by race and ethnicity, attitudes and perceptions were not the source of observed disparities in site of care. Therefore, in addition to focusing on provider-patient relationships, perhaps future research and policymakers should focus on system-level factors to explain and increase minority use of care in private physicians' offices.
To determine the effectiveness of screening and treatment for depression among ambulatory indigent patients visiting resident physicians.
Two-group randomized trial (N = 33 intervention, N = 28 usual care) with baseline, 6-month, and 12-month outcome measurements.
Internal Medicine Residency Clinic.
Clinic patients over 18 years of age who screened positive for depression on the PRIME-MD during a visit to their resident physician. Patients were not receiving treatment nor seeking care for any emotional problems. All patients were either enrolled in Medicaid or had income below the poverty line.
Resident physicians were educated to follow AHCPR (AHRQ; Agency for Healthcare Research and Quality) guidelines for diagnosis and treatment of depression in a primary care setting. For the intervention group patients, a screening nurse advised residents regarding the positive screen, handed them a standardized protocol outline, and attempted to arrange behavioral care. The patients in the usual care group were provided the results of the screen by the screening nurse before their visit with the resident, and advised to seek care for their symptoms.
Results for the primary outcome of depression symptoms measured with the Beck Depression Inventory (BDI) demonstrated that intervention was successful in reducing symptoms relative to usual care (difference = −4.9 BDI points, P = .05, 95% confidence interval [CI], −9.8 to −0.005 effect size = −0.41). During the 12-month follow-up, 70% of intervention patients were treated for depression (of these, 91% with antidepressants), while 15% of usual care patients were treated with antidepressants for depression. Another 18% of the usual care group had depression noted, but no treatment was identified. BDI differences between intervention and control groups were similar at the 6- and 12-month measures. Quality of life and costs were also measured, but differences between the groups were not significant in this regard.
Screening and treatment for depression by resident physicians was successful in reducing symptoms relative to usual care in an indigent population. Almost twice as many intervention patients as usual care controls demonstrated a substantial reduction (10 BDI points) in symptoms related to depression.
depression treatment; low-income patients; randomized trial
Pregnancy is not invariably contra-indicated in patients with pre-existing renal disease. Clinical data now exist that permit the clinician to distinguish such patients who are likely to experience difficulty during pregnancy from those in whom pregnancy can be undertaken with high expectation of success. Patients suffering from systemic lupus erythematosus, active or inactive, with or without lupus nephritis, should avoid pregnancy. Patients with other forms of chronic renal disease in whom the serum creatinine concentration prior to pregnancy is less than 1.5 mg/dL are not exposed to increased maternal or fetal risk. On the other hand, patients with serum creatinine values exceeding 1.6 mg/dL experience a high incidence of maternal and fetal complications and should avoid pregnancy. The life expectancy of recipients of a renal transplant is uncertain, and these patients should receive counselling as to the advisability of undertaking pregnancy. The maternal risk in such patients is not inordinately high, but the fetal risk is considerable.
OBJECTIVE: To provide a descriptive analysis of asthma prevalence and costs in a Medicaid population and gauge the degree of adherence with expert guidelines for asthma medication management from the National Asthma Education and Prevention Program. DATA SOURCES: Kentucky Medicaid administrative data for 1996. STUDY DESIGN: A cross-sectional retrospective analysis was used to determine adherence with asthma medication guidelines and utilization of asthma-related health care services and costs. Multivariate logistic regression was used to determine the relationship between nonadherence with the guidelines and utilization of health care services. PRINCIPAL FINDINGS: Of the 530,000 Medicaid recipients, 24,365 (4.6 percent) were identified as having asthma. Average annual asthma-related costs ($616) accounted for less than 20 percent of total health care costs ($3,645). Nonadherence to the guidelines was prevalent. Less than 40 percent of the patients received a prescription for a rescue medication, and fewer than 10 percent of the patients who received daily inhaled short-acting beta-2 agonists were regular users of inhaled steroids. Nonadherence to the guidelines was associated with an increased risk of an asthma-related hospitalization (odds ratio = 1.5, p < .05). CONCLUSIONS: Guideline nonadherence was widespread and associated with an increase in exacerbations of asthma that resulted in hospitalizations. Asthma prevalence and utilization of health care services in a Medicaid population were similar to previous estimates reported nationally and in health maintenance organizations.
Increased Type I IFNs or IFN-I have been associated with human systemic lupus erythematosus. Interestingly augmenting or negating IFN-I activity in murine lupus not only modulates systemic autoimmunity, but also impacts lupus nephritis, suggesting that IFN-I may be acting at the level of the end-organ. We find resident renal cells to be a dominant source of IFN-I in an experimental model of autoantibody-induced nephritis. In this model, augmenting IFN-I amplified antibody-triggered nephritis, whereas ablating IFN-I activity ameliorated disease. One mechanism through which increased IFN-I drives immune-mediated nephritis might be operative through increased recruitment of inflammatory monocytes and neutrophils, though this hypothesis needs further validation. Collectively, these studies indicate that an important contribution of IFN-I toward the disease pathology seen in systemic autoimmunity may be exercised at the level of the end-organ.