Medicare claims data may be a fruitful data source for research or quality measurement in mammography. However, it is uncertain whether claims data can accurately distinguish screening from diagnostic mammograms, particularly when claims are not linked with cancer registry data.
To validate claims-based algorithms that can identify screening mammograms with high positive predictive value (PPV) in claims data with and without cancer registry linkage.
Development of claims-derived algorithms using classification and regression tree analyses within a random half-sample of bilateral mammogram claims with validation in the remaining half-sample.
Female fee-for-service Medicare enrollees age 66 years and older who underwent bilateral mammography from 1999 to 2005 within Breast Cancer Surveillance Consortium (BCSC) registries in four states (CA, NC, NH, and VT), enabling linkage of claims and BCSC mammography data (N=383,730 mammograms obtained by 146,346 women).
Sensitivity, specificity, and PPV of algorithmic designation of a “screening” purpose of the mammogram using a BCSC-derived reference standard.
In claims data without cancer registry linkage, a three-step claims derived algorithm identified screening mammograms with 97.1% sensitivity, 69.4% specificity, and a PPV of 94.9%. In claims that are linked to cancer registry data, a similar three-step algorithm had higher sensitivity (99.7%), similar specificity (62.7%), and higher PPV (97.4%).
Simple algorithms can identify Medicare claims for screening mammography with high predictive values in Medicare claims alone and in claims linked with cancer registry data.
Breast Cancer Screening; Mammography; Validation Studies; Medicare; Quality Assessment
Breast cancer is frequently diagnosed after an abnormal mammography result. Language barriers can complicate communication of those results.
We evaluated the association of non-English language with delay in follow-up. Methods: Retrospective cohort study of women at three mammography facilities participating in the San Francisco Mammography Registry (SFMR) with an abnormal mammogram result from 1997-2008. We measured median time from report of abnormal result to first follow-up test.
Of 13,014 women with 16,109 abnormal mammograms, 4,027 (31%) had a non-English patient language. Clinical facilities differed in proportion of non-English-speakers and in time to first follow-up test: facility A (38%; 25 days), facility B (18%; 14 days), facility C (51%; 41 days). Most (67%) mammography examinations had BIRADS 0 (incomplete) assessment, requiring radiographic follow-up. At 30 days of follow-up 67% of all English speakers with incomplete assessments had a follow-up exam compared with 50% of all non-English speakers (p<.0001). The facility with the least delay and the lowest proportion of non-English speakers, had the biggest difference by language; compared to English speakers and adjusting for education, non-English speakers had twice the odds of >30 day delay in follow-up (OR 2.3; 95 CI 1.4-3.9).
There are considerable differences among facilities in delays in diagnostic follow-up of abnormal mammography results. More attention must be paid to understanding mammography facility factors, such as wait time to schedule diagnostic mammography and radiology workload, in order to improve rates of timely follow-up, particularly for those facilities disproportionately serving vulnerable non-English speaking patients.
Among patients with type 2 diabetes, it is not known whether risk factor control is better or worse for those who also have heart disease, depression, multiple other co-morbidities and associated management challenges.
To examine the relationship between this complex constellation of multi-morbidities, adherence to treatment and risk factor control among patients with type 2 diabetes, independent of regimen intensity.
Observational cross-sectional study.
1314 patients with diabetes from the Reducing Racial Disparities in Diabetes Coached Care (R2D2C2) Study.
A composite cardiometabolic risk factor profile (CMRP) was the dependent variable. Independent variables included a composite measure of patient complexity, patient-reported adherence to treatment, history of coronary heart disease (CHD), and intensity of medication regimen.
A higher proportion of the most complex patients reported problems with adherence compared to the least complex patients (83.5% vs. 43.3%, p<.001). Compared to those without a history of CHD, fewer patients with CHD reported problems with medication adherence (59.3% vs. 69.3%, p<.01) and had better risk factor control, independent of complexity and regimen intensity. Better risk factor control was independently associated with less patient complexity (p=.003) and to history of CHD (p=.01).
The presence of a complex illness profile was associated with poorer control of risk factors. Those with CHD were more adherent to treatment and had better risk factor control. The occurrence of CHD may present an opportunity for physicians to emphasize risk factor management. Absent such a dramatic event, diabetes patients with a complex illness profile may be at highest risk for cardiovascular events and in greatest need of prevention of cardiac disease.
Clinicaltrial.gov identifier: NCT01123239
Risk factors; diabetes; patient complexity; comorbidity; cardiovascular disease
Factors contributing to racial differences in health care system distrust (HCSD) are currently unknown. Proposed potential contributing factors are prior experiences of racial discrimination and racial residential segregation.
Random digit dialing survey of 762 African-American and 1267 White adults living in 40 US Metropolitan Statistical Areas (MSAs). Measures included the Revised Health Care System Distrust scale, the Experiences of Discrimination scale, metrics of access to care, sociodemographic characteristics, and the level of racial residential segregation in the city (using the isolation index).
In unadjusted analyses, African Americans had higher levels of HCSD, particularly values distrust, and greater experiences of discrimination. Experience of discrimination was also strongly associated with HCSD. Adjusting for sociodemographic characteristics, health care access and residential segregation had little effect on the association between African-American race and overall HCSD or values distrust. In contrast, adjusting for experiences of racial discrimination reversed the association so that distrust was lower among African Americans than Whites (OR 0.53, 95% CI 0.33–0.85 for the overall measure). The Sobel test for mediation was strongly significant (p<0.001).
Higher HCSD among African Americans is explained by a greater burden of experiences of racial discrimination than Whites. Reasons for higher distrust among Whites after adjusting for experiences of racial discrimination are not known. Efforts to eliminate racial discrimination and restore trust given prior discrimination are needed.
Racial differences in patient trust have been observed, but it is unclear which physician communication behaviors are related to trust, and whether the relationship of communication and trust differs among black and white patients.
We sought to determine whether there were associations between physician communication behaviors, visit process measures and patient trust, particularly within racial groups.
Study participants included 39 primary care physicians and 227 black and white hypertensive patients from community-based practices in Baltimore, Maryland. Physician informational and affective communication behaviors and visit process measures were coded from visit audiotapes using the Roter Interaction Analysis System. Patient trust was measured using items from the Trust in Physician Scale, and dichotomized (high/low). Logistic regression analysis using generalized estimating equations was used to assess the association of each physician communication behavior and visit process measure with patient trust, among the entire sample and then stratified by patient race.
Positive physician affect and longer visits were significantly associated with high patient trust in unadjusted analyses. After adjustment for covariates, positive physician affect remained a significant predictor of high patient trust in the overall sample (OR 1.26; 95%CI 1.08, 1.48; p=0.004) and after stratification by race, among black patients (OR 1.35; 95%CI 1.09, 1.67; p=0.006).
Physician communication behaviors may have a varying effect on patient trust, depending on patient race. Communication skills training programs targeting emotion-handling and rapport-building behaviors are promising strategies to reduce disparities in healthcare and to enhance trust among ethnic minority patients.
patient-physician communication; trust; African Americans
The research goals of the Cancer Care Outcomes Research and Surveillance (CanCORS) Consortium are to determine how characteristics and beliefs of patients, providers, and health-care organizations influence the treatments and outcomes of individuals with newly diagnosed lung and colorectal cancers. Because CanCORS results will inform national policy, it is important to know how they generalize to the United States population with these cancers.
This study assessed the representativeness of the CanCORS cohort of 10,547 patients with lung cancer (LC) or colorectal cancer (CRC) enrolled between 2003 and 2005. We compared characteristics (gender, race, age and disease stage) to the Surveillance, Epidemiology and End Results (SEER) population of 234,464 patients with new onset of these cancers during the CanCORS recruitment period.
The CanCORS sample is well matched to the SEER Program for both cancers. In CanCORS, 41% LC / 47% CRC were female versus 47% LC / 49% CRC in SEER. African American, Hispanic and Asian cases differed by no more than 5 percentage points between CanCORS and SEER. The SEER population is slightly older, with the percentage of patients over 75 years 33.1% LC / 37.3% CRC in SEER versus 26.9% LC / 29.4% in CanCORS, and also has a slightly higher proportion of early stage patients. We also found that the CanCORS cohort was representative within specific SEER regions that map closely to CanCORS sites.
This study demonstrates that the CanCORS Consortium was successful in enrolling a demographically representative sample within the CanCORS regions.
Lung Cancer; Colorectal Cancer; Cancer Populations
Despite the rollout of Medicare Part D, cost-related non-adherence (CRN) among older adults remains a problem.
To examine the rate and correlates of self-reported CRN among a population of older persons with diabetes.
1,264 Part D patients with diabetes, who entered the coverage gap in 2006.
Initial administrative medication lists were verified in computer-assisted telephone interviews, in which participants brought their medication bottles to the phone. Medications were classified into cardiometabolic (diabetes, hypertension, cholesterol-lowering), symptom relief, and “other.” Participants were asked if they had any cost-related non-adherence during 2006, and if so to which medication/s. We used the person-medication dyad as the unit of analysis, and tested a multivariate random effects logistic regression model to analyze the correlates of CRN.
Approximately 16% of participants reported any CRN. CRN was more frequent for cholesterol-lowering medications [Relative risk 1.54, 95%CI 1.01-2.32] compared to medications taken for symptom relief. CRN was reported less frequently with increasing age above 75 years, compared to patients between 65 and 69. In addition, compared to those with incomes >$40,000, CRN risk for those with incomes <$25,000 was markedly higher [RR 3.05, 95%CI 1.99-4.65].
In summary, we found high rates of CRN among Medicare beneficiaries with diabetes, particularly those with lower incomes. We observed more frequent CRN for cholesterol-lowering medications as compared to medications for symptom relief. Efforts to ensure medication affordability for this population will be important in boosting adherence to key medications.
Patients with acute myocardial infarction (AMI) who are admitted to hospitals without coronary revascularization are frequently transferred to hospitals with this capability. We sought to determine if the timeliness of hospital transfer and quality of destination hospitals differed between black and white patients.
We evaluated all white and black Medicare beneficiaries admitted with AMI at non-revascularization hospitals in 2006 who were transferred to a revascularization hospital. We compared hospital length of stay prior to transfer and the transfer destination's 30-day risk-standardized mortality rate (RSMR) for AMI between black and white patients. We used hierarchical regression to adjust for patient characteristics and examine within- and across-hospital effects of race on 30-day mortality and length of stay prior to transfer.
A total of 25,947 (42%) white and 2,345 (37%) black patients with AMI were transferred from 857 urban and 774 rural non-revascularization hospitals to 928 revascularization hospitals. Median (IQR) length of stay prior to transfer was 1 day (1-3) for white patients and 2 days (1-4) for black patients (p<0.001). In adjusted models, black patients tended to be transferred more slowly than white patients, a finding due to both across-hospital and within-hospital effects. For example, within an given urban hospital black patients were transferred an additional 0.24 days (95% CI 0.03-0.44) later than white patients. Additionally, the lengths of stay prior to transfer for all patients at urban hospitals increased by 0.37 days (95% CI 0.28-0.47) for every 20% increase in the proportion of AMI patients who were black. These results were attenuated in rural hospitals. The RSMR of the revascularization hospital to which patients were ultimately sent did not differ between black and white patients
Black patients are transferred more slowly to revascularization hospitals after AMI than white patients, resulting from both less timely transfers within hospitals as well as admission to hospitals with greater delays in transfer; however, 30-day mortality of the revascularization hospital to which both groups were sent to appeared similar. Race-based delays in transfer may contribute to known racial disparities in outcomes of AMI.
Healthcare Disparities; Patient Transfer; Critical Care; Cardiovascular Diseases; Quality Indicators
Improving patient safety was a strong motivation behind duty hour regulations implemented by ACGME on July 1, 2003. We investigated whether rates of Patient Safety Indicators (PSIs) changed following these reforms.
Observational study of patients admitted to VA (N=826,047) and Medicare (N=13,367,273) acute-care hospitals from 7/1/2000–6/30/2005. We examined changes in patient safety events in more vs. less teaching-intensive hospitals before (2000–2003) and after (2003–2005) duty hour reform, using conditional logistic regression, adjusting for patient age, gender, comorbidities, secular trends, baseline severity, and hospital site.
Ten PSIs were aggregated into 3 composite measures based on factor analyses: “Continuity of Care,” “Technical Care,” and “Other” composites.
“Continuity of Care” composite rates showed no significant changes post-reform in hospitals of different teaching intensity in either VA or Medicare. In the VA, there were no significant changes post-reform for the “Technical Care” composite. In Medicare, the odds of a Technical Care PSI event in more vs. less teaching-intensive hospitals in post-reform year 1 were 1.12 (95% CI; 1.01–1.25); there were no significant relative changes in post-reform year 2. “Other” composite rates increased in VA in post-reform year 2 in more vs. less teaching-intensive hospitals (OR, 1.63; 95% CI, 1.10–2.41), but not in Medicare in either post-reform year.
Duty hour reform had no systematic impact on PSI rates. In the few cases where there were statistically significant increases in the relative odds of developing a PSI, the magnitude of the absolute increases were too small to be clinically meaningful.
Patient safety; hospital quality; resident duty hour reform; administrative data
Differentiating between appropriate and inappropriate resource use represents a critical challenge in health services research. The New York University Emergency Department (NYU ED) visit severity algorithm attempts to classify visits to the ED based on diagnosis, but it has not been formally validated.
To assess the validity of the NYU algorithm. Research Design: A longitudinal study in a single integrated delivery system (IDS) from January 1999 to December 2001.
2,257,445 commercial and 261,091 Medicare members of an IDS.
ED visits were classified as emergent, non-emergent, or intermediate severity, using the NYU ED algorithm. We examined the relationship between visit-severity and the probability of future hospitalizations and death using a logistic model with a general estimating equation (GEE) approach.
Among commercially insured subjects, ED visits categorized as emergent were significantly more likely to result in a hospitalization within one-day (OR=3.37, 95% CI: 3.31–3.44) or death within 30-days (OR=2.81, 95% CI: 2.62–3.00) than visits categorized as non-emergent. We found similar results in Medicare patients and in sensitivity analyses using different probability thresholds. ED overuse for non-emergent conditions was not related to socio-economic status or insurance type.
The evidence presented supports the validity of the NYU ED visit severity algorithm for differentiating ED visits based on need for hospitalization and/or mortality risk; therefore, it can contribute to evidence-based policies aimed at reducing the use of the ED for non-emergencies.
Access/Utilization of Services; Health Care Financing/Insurance; Emergency Care; NYU Algorithm; Billings
For patients recovering from severe acute illness, admission to a long-term acute care hospital (LTAC) is an increasingly common alternative to continued management in an intensive care unit.
To examine the effectiveness of LTAC transfer in patients with chronic critical illness.
Retrospective cohort study in United States hospitals from 2002 to 2006.
Medicare beneficiaries with chronic critical illness, defined as mechanical ventilation and at least 14 days of intensive care.
Survival, costs and hospital readmissions. We used multivariate analyses and instrumental variables to account for differences in patient characteristics, the timing of LTAC transfer and selection bias.
A total of 234,799 patients met our definition of chronic critical illness. Of these, 48,416 (20.6%) were transferred to an LTAC. In the instrumental variable analysis, patients transferred to an LTAC experienced similar survival compared to patients who remained in an intensive care unit (adjusted hazard ratio = 0.99, 95% CI: 0.96 to 1.01, p=0.27). Total hospital-related costs in the 180 days following admission were lower among patients transferred to LTACs (adjusted cost difference = -$13,422, 95% CI: -26,662 to -223, p=0.046). This difference was attributable to a reduction in skilled nursing facility admissions (adjusted admission rate difference = -0.591 (95% CI: -0.728 to -0.454, p <0.001). Total Medicare payments were higher (adjusted cost difference = $15,592, 95% CI: 6,343 to 24,842, p=0.001).
Patients with chronic critical illness transferred to LTACs experience similar survival compared with patients who remain in intensive care units, incur fewer health care costs driven by a reduction in post-acute care utilization, but invoke higher overall Medicare payments.
mechanical ventilation; costs; Medicare; patient readmission; intensive care
To determine the effect of postoperative length of stay on 30-day readmission after coronary artery bypass surgery.
Data Sources/Study Setting
We analyzed a final database consisting of Medicare claims of a cohort (N=157,070) of all fee-for-service beneficiaries undergoing bypass surgery during 2007-2008, the American Hospital Association annual survey file, and the rural urban commuting area file.
We regressed the probability of 30-day readmission on postoperative length of stay using (1) a (naïve) logit model that controlled for observed patient and hospital covariates only; and (2) a residual inclusion instrumental variable (IV) logit model that further controlled for unobserved confounding. The IV was defined using a measure of the hospital’s risk-adjusted length of stay for patients admitted for gastrointestinal hemorrhage.
The naïve logit model predicted that a one-day reduction in median post-operative length of stay (i.e. from a median of 6 days to 5 days) lowered the 30-day readmission rate by 2 percentage points. The IV model predicted that a one-day reduction in median post-operative length of stay increased 30-day readmission rate by 3 percentage points.
The findings indicate that a reduction in postoperative length of stay is associated with an increased risk for 30-day readmission among Medicare patients undergoing bypass surgery, after both observed and unobserved confounding effects are corrected.
bypass surgery; length of stay; 30-day readmission; instrumental variables; Medicare; quality of care
The mass media can exert considerable influence over the relative saliency of different public policy concerns. Because emotional resonance can have a strong impact on how the general public and policymakers perceive specific issues, the purpose of this study is to characterize the tone of nursing home coverage in the national media.
Keyword searches of LexisNexis were used to identify 1,562 articles published in four national newspapers from 1999–2008. The content of each article was analyzed and tone, themes, prominence, focal entity, and geographic focus assessed. Multinomial logit was used to examine the correlates of tone.
Most articles were negative (49.2%) or neutral (40.3%); few were positive (10.5%). Both positive and negative articles were considerably more likely than neutral articles (>10 times) to be an opinion piece. Negative articles were three-quarters more likely to be on the front page and two-thirds more likely to focus on industry actors. Positive articles were ten times more likely to be about community actors and two and three-quarters more likely to be about local issues. Positive articles were considerably more likely to be about quality; negative articles about negligence/fraud and natural disasters.
Findings suggest that negative reporting predominates and its impact on public perceptions and government decision making may be reinforced by its prominence and focus on industry interests/behavior. The adverse impact of media coverage on the industry’s reputation has likely influenced consumer care choices, particularly in light of growing competition from the home- and community-based and assisted living sectors.
nursing homes; long-term care; newspapers; media; tone
Medicare and private plans are encouraging individuals to seek care at hospitals which are designated as centers of excellence. Few evaluations of such programs have been conducted. The Blue Cross Blue Shield Association, whose member plans insure one in three Americans, has established an initiative to designate hospitals as centers of excellence for knee and hip replacement.
Comparison of outcomes and costs associated with knee and hip replacement at designated hospitals and other hospitals.
Retrospective claims analysis of approximately 54 million enrollees.
Individuals with Blue Cross Blue Shield insurance who underwent a primary knee or hip replacement in 2007-2009.
Primary outcomes were any complication within 30 days of discharge and costs within 90 days following the procedure.
80,931 patients had a knee replacement and 39,532 patients had a hip replacement of which 52.2% and 56.5%, respectively, were performed at a designated hospital. Designated hospitals had a larger number of beds and were more likely to be an academic center. Patients with a knee replacement at designated hospitals did not have a statistically significantly lower overall complication rate with an odds ratio of 0.90 (p=0.08). Patients with a hip replacement treated at designated hospitals had a statistically significantly lower risk of complications with an odds ratio of 0.80 (p=0.002). There was no significant difference in 90-day costs for either procedure.
Hospitals designated as joint replacement centers of excellence had lower rates of complications for hip replacement, but there was no statistically significant difference for knee replacement. It is important to validate the criteria used to designate centers of excellence.
Orthopedic surgery; centers of excellence; outcomes; cost analysis; knee arthroplasty; knee replacement; hip arthroplasty; hip replacement
Provisions of the Affordable Care Act that increase hospitals’ financial accountability for preventable readmissions have heightened interest in identifying system-level interventions to reduce readmissions.
To determine the relationship between hospital nursing; i.e. nurse work environment, nurse staffing levels, and nurse education, and 30-day readmissions among Medicare patients with heart failure, acute myocardial infarction, and pneumonia.
Method and Design
Analysis of linked data from California, New Jersey, and Pennsylvania that included information on the organization of hospital nursing (i.e., work environment, patient-to-nurse ratios, and proportion of nurses holding a BSN degree) from a survey of nurses, as well as patient discharge data, and American Hospital Association Annual Survey data. Robust logistic regression was used to estimate the relationship between nursing factors and 30-day readmission.
Nearly one-quarter of heart failure index admissions (23.3% [n=39,954]); 19.1% (n=12,131) of myocardial infarction admissions; and 17.8% (n=25,169) of pneumonia admissions were readmitted within 30-days. Each additional patient per nurse in the average nurse’s workload was associated with a 7% higher odds of readmission for heart failure (OR=1.07, [1.05–1.09]), 6% for pneumonia patients (OR=1.06, [1.03–1.09]), and 9% for myocardial infarction patients (OR=1.09, [1.05–1.13]). Care in a hospital with a good versus poor work environment was associated with odds of readmission that were 7% lower for heart failure (OR = 0.93, [0.89–0.97]); 6% lower for myocardial infarction (OR = 0.94, [0.88–0.98]); and 10% lower for pneumonia (OR = 0.90, [0.85–0.96]) patients.
Improving nurses’ work environments and staffing may be effective interventions for preventing readmissions.
nursing; readmissions; quality of health care; work environment; organizational culture
The patient-centered medical home model has gained support, but the impact of this model on the quality and equity of care merits further evaluation.
To determine if patient-centered medical homes are associated with improved quality and equity in pediatric primary care.
Using the 2007/2008 National Survey of Children’s Health, a nationally representative survey of parents/guardians of children (age 0–17), we evaluated the association of patient-centered medical homes with ten quality of care measures using multivariable regression models, adjusting for demographic and socioeconomic covariates. For quality indicators that were significantly associated with medical homes, we determined if this association differed by race/ethnicity.
Compared to children without medical homes, those withmedical homes had significantly better adjusted rates for six of ten quality measures (all p≤0.02) such as obtaining a developmental history (adjusted rates % (SE): 41.7 (1.3) vs. 52.0 (1.1), p<0.001). Having a medical home was associated with better adjusted rates of receiving a developmental history exam for both white and black children, but the disparity between these groups was not significantly narrowed (difference in risk differences (SE): 0.9 (4.3) for Whites vs. Blacks; p=0.83).
Our results underscore the benefits of the medical home model for children while highlighting areas for improvement, such as narrowing disparities. Our findings also emphasize the key role of patient experience measures in the evaluation of medical homes.
According to recent US census data, 52 million people reported speaking a language other than English at home, and almost 45% of this population reported limited English proficiency (LEP). Colorectal cancer (CRC) ranks among the top 3 most common cancers for several Asian ethnic groups, yet screening remains underutilized by Asian Americans.
This article describes the development of culturally and linguistically appropriate intervention materials for individuals with LEP. We discuss lessons learned from this research and implications for the translation of research into practice.
The Health Behavior Framework served as the conceptual model for this study, and qualitative findings guided the development of our intervention materials (a video and pamphlet). To recommend Western preventive behaviors, the research team bridged the gap between Western and Chinese values and beliefs by devoting particular attention to: (1) the target population's sociocul-tural values and health beliefs; and (2) unique linguistic features of the Chinese language.
Key lessons learned from this study include the importance of: (1) a conceptual framework to guide intervention development; (2) incorporating sociocultural values and health beliefs into the intervention; (3) addressing and capitalizing on complex linguistics issues; (4) using qualitative methodology in cross-cultural research; and (5) contributions from a multicultural and multilingual research team. Other lessons relate to the translation of research findings into practice. We surmise that lessons learned from this study may be pertinent to the promotion of CRC screening among other patient groups with LEP and applicable to additional cancer screening tests.
limited English proficiency; colorectal cancer screening; culturally and linguistically appropriate materials
Although there is considerable interest in underutilization of lipid testing, little is known about the prevalence and factors associated with overtesting of serum lipids.
We assessed the number of different days in which outpatient lipid testing was performed in a 5% national sample of patients with parts A and B Medicare in 2006. Covariates included patient characteristics (age, race, prior diagnosis of lipid disorder, and other indications for lipid testing), number of usual care physicians (UCP), type of UCP, total outpatient physician encounters, and health referral region (HRR) characteristics (average per-patient Medicare expenditures and percent of patients seeing multiple UCPs).
Among the 1,151,891 patients, 11.9% underwent 3 or more outpatient measurements of serum lipids. In multivariable analyses, the total number of UCPs providing care for the patient was associated with multiple lipid testing, independent of patient characteristics, indications for lipid testing, and total outpatient encounters. There was a strong association among HRRs between the rate of multiple lipid testing and average Medicare expenditures (r = 0.56). This was reduced after including the percentage of patients with more than 2 medical subspecialist UCPs in the HRR in a partial correlation (r = 0.31).
Multiple lipid testing is associated with the presence of multiple providers, independent of indications for testing, comorbidity, and total physician visits. Much of the association of multiple lipid testing with medical expenditures at the level of HRR appears to be explained by differences in exposure to multiple providers.
lipids; multiple testing; overutilization; Medicare
Few studies of acute depression care have examined the provision of psychotherapy or combined treatment in addition to medication management. This study examined acute phase depression treatment in the VA healthcare system, including measures of medication treatment (MT), psychotherapy (PT), and combined treatment (CT = MT plus PT). Both low level care (receipt of any MT, PT, or CT, but all below guideline levels) as well as guideline concordant care (GC MT, PT, and CT) were examined.
The sample included 41,412 patients with new depression diagnoses. Analyses examined the relationship between demographics and psychiatric comorbidities (eg, substance use disorders, post-traumatic stress disorder, depression with both substance use disorders and post-traumatic stress disorder) and receipt of each type of care (low level and guideline concordant MT, PT, and CT).
The majority (75%) received at least some treatment, with 35% of the sample receiving guideline concordant care (particularly GC MT). Those with psychiatric comorbidities generally were more likely to receive GC care, older veterans were less likely to receive each type of care, and African Americans were less likely to receive GC MT but more likely to receive GC PT and GC CT than whites.
Although it is difficult to benchmark, the VA overall seems similar or better than the private sector in providing guideline concordant acute phase treatment for its depressed patients. The majority of veterans received some acute phase depression treatment, but only a minority seem to receive guideline concordant care (particularly PT and CT).
depression; quality of care; treatment guidelines; psychotherapy; pharmacotherapy; combined treatment
To evaluate the effectiveness of standardized, patient-centered label (PCL) instructions to improve comprehension of prescription drug use compared to typical instructions.
500 adult patients recruited from two academic and two community primary care clinics in Chicago, IL and Shreveport, LA were assigned to receive: 1) standard prescription instructions written as times per day (once, twice three times per day) [usual care], 2) PCL instructions that specify explicit timing with standard intervals (morning, noon, evening, bedtime) [PCL], or 3) PCL instructions with a graphic aid to visually depict dose and timing of the medication [PCL + Graphic]. The outcome was correct interpretation of label instructions.
Instructions with the PCL format were more likely to be correctly interpreted compared to standard instructions (Adjusted Relative Risk (RR) 1.33, 95% Confidence Interval (CI) 1.25 – 1.41). Inclusion of the graphic aid (PCL + Graphic) decreased rates of correct interpretation compared to PCL instructions alone (RR 0.93, 95% CI 0.89 - 0.97). Lower literate patients were better able to interpret PCL instructions (low literacy: RR 1.39, 95% CI 1.14 – 1.68; p=0.001).
The PCL approach could improve patients' understanding and use of their medication regimen.
Prescription; medication; comprehension; patient; labels; safety; health literacy
Full-field digital mammography (FFDM) has largely replaced screen-film mammography (SFM) for breast cancer screening, but how this affects downstream breast-related use and costs is unknown.
To compare breast-related healthcare use and costs among Medicare beneficiaries undergoing SFM versus FFDM from 1999 to 2005.
Retrospective cohort study.
Medicare-enrolled women ages 66 and older with mammograms in Breast Cancer Surveillance Consortium registries.
Subsequent follow-up with additional imaging or breast biopsy within 12 months was ascertained through Medicare claims. Associated mean costs were estimated by screening modality and year, adjusting for confounding factors and clustering within mammography facilities using Generalized Estimating Equations.
Among 138,199 women, 332,324 SFM and 22,407 FFDM mammograms were analyzed. Approximately 6.5% of SFM and 9.0% of FFDM had positive findings. In 2001 subsequent imaging was higher among FFDM versus SFM (127.5 vs. 97.4 follow-up mammography claims per 1000 index mammograms) whereas subsequent biopsy was lower among FFDM versus SFM (19.2 vs. 24.9 per 1000 index mammograms) with differences decreasing over time. From 2001 to 2004, mammography subsequent to FFDM had higher mean costs than SFM ($82.60 vs. $64.31 in 2001). The only cost differences between SFM and FFDM for ultrasound or biopsy were in 2001.
Subsequent breast-related healthcare use differed early in FFDM introduction, but diminished over time with differences attributable to higher recall rates for additional imaging and lower rates of biopsy in those undergoing FFDM vs. SFM. Remaining cost differences are due to higher reimbursement rates for FFDM vs. SFM.
Mammography screening; Full Field Digital; Cost; Medicare; work-up; false positive; health services
Self-report measures of medication nonadherence confound the extent of and reasons for medication nonadherence. Each construct is assessed with a different type of psychometric model, which dictates how to establish reliability and validity.
To evaluate the psychometric properties of a self-report measure of medication nonadherence that assesses separately the extent of nonadherence and reasons for nonadherence.
Cross sectional survey involving the new measure and comparison measures to establish convergent, discriminant, and concurrent validity. The new measure was re-administered 2 to 21 days later.
202 veterans with treated hypertension were recruited from the Durham Veterans Affairs Medical Center.
A new self-report measure assessed the extent of nonadherence and reasons for nonadherence. Comparison measures included self-reported medication self-efficacy, beliefs about medications, impression management, conscientiousness, habit strength, and an existing nonadherence measure.
Three items assessing the extent of nonadherence produced reliable scores for this sample, alpha=0.84 (95% CI: 0.80, 0.87). Correlations with comparison measures provided evidence of convergent and discriminant validity. Correlations with systolic (r=0.27, p<.0001) and diastolic (r=0.27, p<.0001) blood pressure provided evidence of concurrent validity. Reasons for nonadherence was assessed with 21 independent items. Intraclass correlations (ICC) were 0.58 for the extent score and ranged from 0.07 to 0.64 for the reasons.
The dual conceptualization of medication nonadherence allowed a stronger evaluation of the reliability and validity than was previously possible with measures that confounded these two constructs. Measurement of self-reported nonadherence consistent with psychometric principles will enable reliable, valid evaluation of interventions to reduce nonadherence.
adherence; reliability; scale development; self-report
Prostate-specific antigen (PSA) testing for prostate cancer (PCa) is controversial, with concerning rates of both over- and under-screening. The reasons for the observed rates of screening are unknown, and few studies have examined the relationship of psychological health to PSA screening rates. Understanding this relationship can help guide interventions to improve informed-decision making (IDM) for screening.
A nationally-representative sample of men 57–85 years old without PCa (N=1,169) from the National Social life, Health and Aging Project (NSHAP) was analyzed. The independent relationship of validated psychological health scales measuring stress, anxiety, and depression to PSA testing rates was assessed using multvariable logistic regression analyses.
PSA screening rates were significantly lower for men with higher perceived stress (OR=0.76, p=0.006), but not for higher depressive symptoms (OR=0.89, p=0.22) when accounting for stress. Anxiety influences PSA screening through an interaction with number of doctor visits (p=0.02). Among the men who visited the doctor 1 time, those with higher anxiety were less likely to be screened (OR=0.65, p=0.04). Conversely, among those who visited the doctor 10+ times with higher anxiety were more likely to be screened (OR=1.71, p=0.04).
Perceived stress significantly lowers PSA screening likelihood, and it appears to partly mediate the negative relationship of depression with screening likelihood. Anxiety affects PSA screening rates differently for men with different numbers of doctor visits. Interventions to influence PSA screening rates should recognize the role of the patients’ psychological state to improve their likelihood of making informed decisions and improve screening appropriateness.
prostate cancer; screening; stress; anxiety; depression
Self-care management is recognized as a key component of care for multi-morbid older adults, but the characteristics of those most likely to participate in Chronic Disease Self-Management (CDSM) programs and how to maximize participation in such programs are unknown.
To identify individual factors associated with attending CDSM programs in a sample of multi-morbid older adults.
Participants in the intervention arm of a matched-pair cluster-randomized controlled trial of the Guided Care model were invited to attend a six-session CDSM course. Logistic regression was used to identify factors independently associated with attendance.
All subjects (N=241) were 65 years or older, were at high risk for health care utilization, and were not homebound.
Baseline information on demographics, health status, health activities, and quality of care was available for CDSM participants and non-participants. Participation was defined as attendance at five or more CDSM sessions.
22.8% of multi-morbid older adults who were invited to CDSM courses participated in five or more sessions. Having better physical health (OR[95% CI] = 2.3[1.1–4.8]) and rating one’s physician poorly on support for patient activation (OR[95% CI] = 2.8[1.3–6.0]) were independently associated with attendance.
Multi-morbid older adults who are in better physical health and who are dissatisfied with their physicians’ support for patient activation are more likely to participate in CDSM courses.
health promotion; self-management; geriatrics; Guided Care; chronic disease; selection bias
Digital mammography is the dominant modality for breast cancer screening in the US. No previous studies have investigated how introducing digital mammography affects downstream breast-related care.
Compare breast-related health care use following a screening mammogram before and after introduction of digital mammography.
Research design and subjects
Longitudinal study of screening mammograms from 14 radiology facilities contributing data to the Breast Cancer Surveillance Consortium performed in the one year before and four years after each facility introduced digital mammography, along with linked Medicare claims. We included 30,211 mammograms for women age 66 years and older without breast cancer.
Rates of false-positive recall and short-interval follow-up based on radiologists’ assessments and recommendations; rates of follow-up mammography, ultrasound, and breast biopsy use based on Medicare claims.
False-positive recall rates increased following the introduction of digital mammography. Follow-up mammography use was significantly higher across all four years after a facility began using digital compared to the year before (year one odds ratio [OR] = 1.7, 95% confidence interval [CI]: 1.4, 2.1). Among women with false-positive mammography results, use of ultrasound decreased significantly in the second through fourth years after digital mammography began (year two OR = 0.4, 95% confidence interval [CI]: 0.3, 0.6).
Introduction of a new technology led to changes in health care use that persisted for at least four years. Comparative effectiveness research on new technologies should consider not only diagnostic performance but also downstream utilization attributable to this apparent learning curve.
cancer screening; comparative effectiveness; digital mammography; health technology; learning curve; mammography