PMCC PMCC

Search tips
Search criteria

Advanced
Results 1-25 (309)
 

Clipboard (0)
None

Select a Filter Below

Journals
Year of Publication
more »
1.  Improving Observational Study Estimates of Treatment Effects using Joint Modeling of Selection Effects and Outcomes: The case of AAA Repair 
Medical care  2011;49(12):1126-1132.
Background
When two treatment approaches are available, there are likely to be unmeasured confounders that influence choice of procedure, which complicates estimation of the causal effect of treatment on outcomes using observational data.
Objective
To estimate the effect of endovascular (endo) versus open surgical (open) repair, including possible modification by institutional volume, on survival following treatment for AAA, accounting for observed and unobserved confounding variables.
Research Design
Observational study of data from the Medicare program using a joint model of treatment selection and survival given treatment to estimate the effects of type of surgery and institutional volume on survival.
Subjects
We studied 61,414 eligible repairs of intact AAAs during 2001–2004.
Measures
The outcome, perioperative death, is defined as in-hospital death or death within 30 days of operation. The key predictors are use of endo, transformed endo and open volume, and endo-volume interactions.
Results
There is strong evidence of non-random selection of treatment with potential confounding variables including institutional volume and procedure date, variables not typically adjusted for in clinical trials. The best fitting model included heterogeneous transformations of endo volume for endo cases and open volume for open cases as predictors. Consistent with our hypothesis, accounting for unmeasured selection reduced the mortality benefit of endo.
Conclusion
The effect of endovascular versus open surgery varies nonlinearly with endo and open volume. Accounting for institutional experience and unmeasured selection enables better decision-making by physicians making treatment referrals, investigators evaluating treatments, and policy-makers.
doi:10.1097/MLR.0b013e3182363d64
PMCID: PMC3979312  PMID: 22011709
Abdominal aortic aneurysm; bivariate probit; endovascular and open surgery; selection; volume-outcome relationship
2.  WHEN DOES AN EPISODE OF CARE FOR CANCER BEGIN? 
Medical care  2013;51(4):324-329.
Background
Little is known about the medical care resources devoted to diagnosing and treating cancer-related symptoms prior to a definitive cancer diagnosis. Previous research using SEER-Medicare data to measure incremental costs and utilization associated with cancer started with the date of diagnosis. We hypothesized that health care use increases prior to diagnosis of a new primary cancer.
Methods
We used a longitudinal case-control design to estimate incremental medical care utilization rates. Cases were 121,293 persons enrolled between January, 2000 and December, 2008 with one or more primary cancers. We selected 522,839 controls randomly from among all health plan members who had no tumor registry evidence of cancer prior to January, 2009, and we frequency matched controls to cancer cases on a five-to-one ratio by age group, gender, and having health plan eligibility in the year of diagnosis of the index cancer case. Utilization data were extracted for all cases and controls for the period 2000-2008 from standardized distributed data warehouses. To determine when and the extent to which patterns of medical care use change preceding a cancer diagnosis, we compute hospitalization rates, hospital days, emergency department visits, same-day surgical procedures, ambulatory medical office visits, imaging procedures, laboratory tests, and ambulatory prescription dispensings per 1,000 persons per month within integrated delivery systems.
Results
One- to three-fold increases in monthly utilization rates were observed during the three to five months prior to a cancer diagnosis, compared to matched non-cancer control groups. This pattern was consistent for both aged and non-aged cancer patients. Aged cancer patients had higher utilization rates than non-aged cancer patients throughout the year prior to a cancer diagnosis.
Conclusion
The pre-diagnosis phase is a resource-intensive component of cancer care episodes and should be included in cost of cancer estimates. More research is needed to determine whether reliable prognostic markers can be identified as the start of a cancer episode prior to a pathology-based diagnosis.
doi:10.1097/MLR.0b013e3182731277
PMCID: PMC3596420  PMID: 23222500
Cancer; medical care use; utilization; phase of care; hospital discharges; inpatient days; emergency department visits; same-day surgery; ambulatory visits; dispensings; imaging procedures; laboratory tests
3.  Variation in Receipt of Radiation Therapy after Breast-Conserving Surgery: Assessing the Impact of Physicians and Geographic Regions 
Medical care  2013;51(4):330-338.
Background
Among older women with early stage breast cancer, patients with a short life expectancy (LE) are much less likely to benefit from adjuvant radiation therapy (RT). Little is known about the impact of physicians and regional factors on the use of RT across LE groups.
Objective
To determine the relative contribution of patient, physician and regional factors on the use of RT.
Design
Retrospective cohort.
Subjects
Women age 67–94 diagnosed with stage I breast cancer between 1998–2007 receiving breast-conserving surgery.
Measures
We evaluated patient, physician and regional factors for their association with RT across strata of LE using a three-level hierarchical logistic regression model. Risk-standardized treatment rates (RSTRs) for the receipt of radiation were calculated according to primary surgeon and region.
Results
Approximately 43.6% of the 2,253 women with a short LE received RT, compared to 90.8% of the 11,027 women with a long LE. Among women with a short LE, the probability of receiving RT varied substantially across primary surgeons; RSTRs ranged from 27.7% to 67.3% (mean 43.9%). There was less variability across geographic regions; RSTRs ranged from 42.0–45.2% (mean 43.6%). Short LE patients were more likely to receive RT in areas with high radiation oncologist density (OR 1.59; 95% CI, 1.07–2.36).
Conclusions
While there is wide variation across geographic regions in the use of RT among women with breast cancer and short LE, the regional variation was substantially diminished after accounting for the operating surgeon.
doi:10.1097/MLR.0b013e31827631b0
PMCID: PMC3596448  PMID: 23151590
breast-conserving surgery; radiation therapy; life expectancy; small-area analysis; SEER program
4.  Physicians’ beliefs about breast cancer surveillance testing are consistent with test overuse 
Medical care  2013;51(4):315-323.
Background
Overuse of surveillance testing for breast cancer survivors is an important problem but its extent and determinants are incompletely understood. The objectives of this study were to determine the extent to which physicians’ breast cancer surveillance testing beliefs are consistent with test overuse, and to identify factors associated with these beliefs.
Methods
2009–2010 cross-sectional survey of US medical oncologists and primary care physicians (PCPs). Physicians responded to a clinical vignette ascertaining beliefs about appropriate breast cancer surveillance testing. Multivariable analyses examined the extent to which test beliefs were consistent with overuse and associated with physician and practice characteristics and physician perceptions, attitudes, and practices.
Results
1098 medical oncologists and 980 PCPs completed the survey (response rate 57.5%). Eighty-four percent of PCPs (95% CI: 81.4%–86.5%) and 72% of oncologists (95% CI: 69.8%– 74.7%) reported beliefs consistent with blood test overuse, while 50% of PCPs (95% CI: 47.3%– 53.8%) and 27% of oncologists (95% CI: 23.9%–29.3%) reported beliefs consistent with imaging test overuse. Among PCPs, factors associated with these beliefs included smaller practice size, lower patient volume, and practice ownership. Among oncologists, factors included older age, international medical graduate status, lower self-efficacy (confidence in knowledge), and greater perceptions of ambiguity (conflicting expert recommendations) regarding survivorship care.
Conclusions
Beliefs consistent with breast cancer surveillance test overuse are common, greater for PCPs and blood tests than for oncologists and imaging tests, and associated with practice characteristics and perceived self-efficacy and ambiguity about testing. These results suggest modifiable targets for efforts to reduce surveillance test overuse.
doi:10.1097/MLR.0b013e31827da908
PMCID: PMC3596481  PMID: 23269111
5.  Limitations of basing screening policies on screening trials: The US Preventive Services Task Force and prostate cancer screening 
Medical care  2013;51(4):295-300.
Background
The US Preventive Services Task Force recently recommended against prostate-specific antigen (PSA) screening for prostate cancer based primarily on evidence from the European Randomized Study of Screening for Prostate Cancer (ERSPC) and the US Prostate, Lung, Colorectal, and Ovarian (PLCO) cancer screening trial.
Objective
To examine limitations of basing screening policy on evidence from screening trials.
Methods
We review published modeling studies that examine population and trial data. The studies (1) project the roles of screening and changes in primary treatment in the US mortality decline, (2) extrapolate the ERSPC mortality reduction to the long-term US setting, (3) estimate overdiagnosis based on US incidence trends, and (4) quantify the impact of control arm screening on PLCO mortality results.
Results
Screening plausibly explains 45% and changes in primary treatment can explain 33% of the US prostate cancer mortality decline. Extrapolating the ERSPC results to the long-term US setting implies an absolute mortality reduction at least 5 times greater than that observed in the trial. Approximately 28% screen-detected cases are overdiagnosed in the US versus 58% of screen-detected cases suggested by the ERSPC results. Control arm screening can explain the null result in the PLCO trial.
Conclusions
Modeling studies indicate that population trends and trial results extended to the long-term population setting are consistent with greater benefit of PSA screening—and more favorable harm-benefit tradeoffs—than has been suggested by empirical trial evidence.
doi:10.1097/MLR.0b013e31827da979
PMCID: PMC3604989  PMID: 23269114
Mass screening; policy development; prostatic neoplasms; simulation modeling
6.  Intended Versus Inferred Management after PET For Cancer Restaging: Analysis of Medicare Claims Linked to a Coverage With Evidence Development Registry 
Medical care  2013;51(4):361-367.
Background
The National Oncologic PET Registry (NOPR) ascertained changes in the intended management of cancer patients using questionnaire data obtained before and after PET under Medicare’s coverage with evidence development (CED) policy.
Objective
To assess the concordance between intended care plans and care received as ascertained through administrative claims data.
Research Design
Analysis of linked data of NOPR participants from 2006–2008 and their corresponding Medicare claims.
Subjects
Consenting patients age >65 years having their first PET for restaging of bladder, kidney, ovarian, pancreas, prostate, small cell lung or stomach cancer.
Measures
Agreement [positive predictive values and kappas] between NOPR post-PET intended management plans for treatment (systemic-therapy, radiotherapy, surgery or combinations), biopsy, or watching as compared to claims-inferred care 30 days after PET.
Results
8,460 patients with linked data were assessed. 43.5% had metastatic disease. 45.3% had treatment planned (predominantly systemic therapy only), 11.1% biopsy and 43.5% watching. Claims confirmed intended plans (PPV) for single-mode systemic therapy in 62.0%, radiation in 66.0%, surgery in 45.6%, and biopsy in 55.7%. 25.7% of patients with a plan of watching had treatment claims. By cancer type, kappa ranged for systemic-therapy only from 0.17–0.40 and for watching from 0.21–0.41. Agreement rates varied by cancer types but were minimally associated with patient age, performance status, comorbidity or stage.
Conclusion
Among elderly cancer patients undergoing PET for restaging, there was moderate concordance between their physicians’ planned management and claims-inferred actions within a narrow time window. When higher accuracy levels are required in future CED studies, alternative designs will be needed.
doi:10.1097/MLR.0b013e318287d860
PMCID: PMC3662234  PMID: 23481033
positron emission tomography; cohort studies; Medicare; medical record linkage; health services research; neoplasm staging
7.  Response: Reading between the lines of cancer screening trials: Using modeling to understand the evidence 
Medical care  2013;51(4):304-306.
In our article about limitations of basing screening policy on screening trials, we offered several examples of ways in which modeling, using data from large screening trials and population trends, provided insights that differed somewhat from those based only on empirical trial results. In this editorial, we take a step back and consider the general question of whether randomized screening trials provide the strongest evidence for clinical guidelines concerning population screening programs. We argue that randomized trials provide a process that is designed to protect against certain biases but that this process does not guarantee that inferences based on empirical results from screening trials will be unbiased. Appropriate quantitative methods are key to obtaining unbiased inferences from screening trials. We highlight several studies in the statistical literature demonstrating that conventional survival analyses of screening trials can be misleading and list a number of key questions concerning screening harms and benefits that cannot be answered without modeling. While we acknowledge the centrality of screening trials in the policy process, we maintain that modeling constitutes a powerful tool for screening trial interpretation and screening policy development.
doi:10.1097/MLR.0b013e31828a7e1a
PMCID: PMC3670760  PMID: 23481032
8.  Timeliness of abnormal screening and diagnostic mammography follow-up at facilities serving vulnerable women 
Medical care  2013;51(4):307-314.
Background
Whether timeliness of follow-up after abnormal mammography differs at facilities serving vulnerable populations such as women with limited education or income, in rural areas, and racial/ethnic minorities is unknown.
Methods
We examined receipt of diagnostic evaluation following abnormal mammography using 1998-2006 Breast Cancer Surveillance Consortium-linked Medicare claims. We compared whether time to recommended breast imaging or biopsy depended on whether women attended facilities serving vulnerable populations. We characterized a facility by the proportion of mammograms performed on women with limited education or income, in rural areas, or racial/ethnic minorities.
Results
We analyzed 30,874 abnormal screening examinations recommended for follow-up imaging across 142 facilities and 10,049 abnormal diagnostic examinations recommended for biopsy across 114 facilities. Women at facilities serving populations with less education or more racial/ethnic minorities had lower rates of follow-up imaging (4-5% difference, p<0.05), and women at facilities serving more rural and low income populations had lower rates of biopsy (4-5% difference, p<0.05). Women undergoing biopsy at facilities serving vulnerable populations had longer times until biopsy than those at facilities serving non-vulnerable populations (21.6 days vs. 15.6 days; 95% CI for mean difference 4.1-7.7). The proportion of women receiving recommended imaging within 11 months and biopsy within 3 months varied across facilities (interquartile range 85.5%-96.5% for imaging and 79.4%-87.3% for biopsy).
Conclusions
Among Medicare recipients, follow-up rates were slightly lower at facilities serving vulnerable populations, and among those women who returned for diagnostic evaluation, time to follow-up was slightly longer at facilities that served vulnerable population. Interventions should target variability in follow-up rates across facilities, and evaluate effectiveness particularly at facilities serving vulnerable populations.
doi:10.1097/MLR.0b013e318280f04c
PMCID: PMC3966312  PMID: 23358386
mammography; timeliness; disparities; facility
9.  Effect of Copayments on Use of Outpatient Mental Health Services Among Elderly Managed Care Enrollees 
Medical care  2011;49(3):281-286.
Background
Recent parity legislation will require many insurers and the federal Medicare program to reduce mental health copayments, so that they are equivalent to copayments for other covered services. The effect of changes in mental health cost sharing has not been well studied, particularly among elderly populations.
Objective
To examine the consequences of increasing and decreasing copayments on the use of outpatient mental health services among the elderly.
Research Design
Difference-in-differences (DID) design comparing the use of outpatient mental health care in Medicare plans that changed mental health copayments compared with concurrent trends in matched control plans with unchanged copayments.
Study Population
A total of 1,147,916 enrollees aged 65 years and older in 14 Medicare plans that increased copayments by ≥25%, 3 plans that decreased copayments by ≥25%, and 17 matched control plans with unchanged copayments.
Results
In 14 plans that increased mental health copayments from a mean of $14.43 to $21.07, the proportion of enrollees who used mental health services remained at 2.2% in the year before and year after the increase (adjusted DID, 0.1 percentage points; 95% confidence interval, 0.0–0.1). Among 3 plans that decreased copayments from a mean of $25.00 to $8.33, utilization rates were 1.2% before and after the decrease (adjusted DID, 0.1 percentage points; 95% confidence interval, −0.2 to 0.3). Stratified analyses by age, gender, race, and presence of a disability yielded similar results.
Conclusions
Few older adults in managed care plans used outpatient mental health services. Among this population, increasing or decreasing mental health copayments had negligible effects on the likelihood of using outpatient mental health care.
doi:10.1097/MLR.0b013e31820399f6
PMCID: PMC3970196  PMID: 21301371
Cost sharing; mental health services/utilization; health insurance benefits; Medicare; managed care
10.  Identifying Patients with Severe Sepsis Using Administrative Claims: Patient-Level Validation of the Angus Implementation of the International Consensus Conference Definition of Severe Sepsis 
Medical care  2012;10.1097/MLR.0b013e318268ac86.
Background
Severe sepsis is a common and costly problem. Although consistently defined clinically by consensus conference since 1991, there have been several different implementations of the severe sepsis definition using ICD-9-CM codes for research. We conducted a single center, patient-level validation of one common implementation of the severe sepsis definition, the so-called “Angus” implementation.
Methods
Administrative claims for all hospitalizations for patients initially admitted to general medical services from an academic medical center in 2009–2010 were reviewed. On the basis of ICD-9-CM codes, hospitalizations were sampled for review by three internal medicine-trained hospitalists. Chart reviews were conducted with a structured instrument, and the gold standard was the hospitalists’ summary clinical judgment on whether the patient had severe sepsis.
Results
3,146 (13.5%) hospitalizations met ICD-9-CM criteria for severe sepsis by the Angus implementation (“Angus-positive”) and 20,142 (86.5%) were Angus-negative. Chart reviews were performed for 92 randomly-selected Angus-positive and 19 randomly-selected Angus-negative hospitalizations. Reviewers had a kappa of 0.70. The Angus implementation’s positive predictive value (PPV) was 70.7% (95%CI: 51.2%, 90.5%). The negative predictive value was 91.5% (95%CI: 79.0%, 100%). The sensitivity was 50.4% (95%CI: 14.8%, 85.7%). Specificity was 96.3% (95%CI: 92.4%, 100%). Two alternative ICD-9-CM implementations had high PPVs but sensitivities of less than 20%.
Conclusions
The Angus implementation of the international consensus conference definition of severe sepsis offers a reasonable but imperfect approach to identifying patients with severe sepsis when compared with a gold standard of structured review of the medical chart by trained hospitalists.
doi:10.1097/MLR.0b013e318268ac86
PMCID: PMC3568444  PMID: 23001437
11.  Racial and Ethnic Disparities in Detection and Treatment of Depression and Anxiety Among Psychiatric and Primary Health Care Visits, 1995–2005 
Medical care  2008;46(7):668-677.
Context
Recent evidence questions whether formerly documented disparities in care for common mental disorders among African Americans and Hispanics still remain. Also, whether disparities exist mainly in psychiatric settings or primary health care settings is unknown.
Objective
To comprehensively examine time trends in outpatient diagnosis and treatment of depression and anxiety among ethnic groups in primary care and psychiatric settings.
Design and Setting
Analyses of office-based outpatient visits from the National Ambulatory Medical Care Study from 1995–2005 (n = 96,075).
Participants
Visits to office-based primary care physicians and psychiatrists in the United States.
Main Outcome Measures
Diagnosed with depression or anxiety, received counseling or a referral for counseling, received an antidepressant prescription, and any counseling or antidepressant care.
Results
In these analyses of 10-year trends in treatment of common mental disorders, disparities in counseling/referrals for counseling, antidepressant medications, and any care vastly improved or were eliminated over time in psychiatric visits. Continued disparities in diagnoses, counseling/referrals for counseling, antidepressant medication, and any care are found in primary care visits.
Conclusions
Disparities in care for depression and anxiety among African Americans and Hispanics remain in primary care. Quality improvement efforts are needed to address cultural and linguistic barriers to care.
doi:10.1097/MLR.0b013e3181789496
PMCID: PMC3956700  PMID: 18580385
depression; anxiety; mental health; treatment; diagnosis; ethnic disparities
12.  Agreement Between Electronic Medical Record-based and Self-Administered Pain Numeric Rating Scale: Clinical and Research Implications 
Medical care  2013;51(3):245-250.
Background
Pain screening may improve the quality of care by identifying patients in need of further assessment and management. Many healthcare systems use the numeric rating scale (NRS) for pain screening, and record the score in the patients’ electronic medical record (EMR).
Objective
Determine level of agreement between EMR and patient survey NRS, and whether discrepancies vary by demographic and clinical characteristics.
Methods
We linked survey data from a sample of Veterans receiving care in eight Veterans Affairs (VA) medical facilities, to EMR data including an NRS collected on the day of the survey in order to compare responses to the NRS question from these two sources. We assessed correlation, agreement on clinical cut-points (e.g. severe), and, using the survey as the gold standard, whether patient characteristics were associated with a discrepancy on moderate-severe pain.
Results
A total of 1,643 participants had a survey and EMR NRS score on the same day. The correlation was 0.56 (95% CI 0.52/0.59), but the mean EMR score was significantly lower than the survey score (1.72 vs. 2.79; p<0.0001). Agreement was moderate (kappa=0.35). Characteristics associated with a increased odds of a discrepancy included: diabetes (adjusted odds ratio (AOR)=1.48), post traumatic stress disorder (AOR=1.59), major depressive disorder (AOR=1.81), other race vs. white (AOR=2.29), and facility in which care was received.
Conclusions
The underestimation of pain using EMR data, especially clinically actionable levels of pain, has important clinical and research implications. Improving the quality of pain care may require better screening.
doi:10.1097/MLR.0b013e318277f1ad
PMCID: PMC3572341  PMID: 23222528
Veterans; pain measurement; electronic medical records
13.  Improving the Reliability of Physician “Report Cards” 
Medical care  2013;51(3):266-274.
Background
Performance measures are widely used to profile primary care physicians (PCPs) but their reliability is often limited by small sample sizes. We evaluated there liability of individual PCP profiles and whether they can be improved by combining measures into composites or by profiling practice groups.
Methods
We performed a cross-sectional analysis of electronic health record data for patients with diabetes (DM), congestive heart failure (CHF), ischemic vascular disease (IVD), or eligible for preventive care services seen by a PCP within a large, integrated healthcare system between April 2009 and May 2010. We evaluated performance on 14 measures of DM care, 9 of CHF, 7 of IVD, and 4 of preventive care.
Results
There were 51,771 patients seen by 163 physicians in 17 clinics. Few PCPs (0 to 60%) could be profiled with 80% reliability using single process or intermediate-outcome measures. Combining measures into single-disease composites improved reliability for DM and preventive care with 74.5% and 76.7% of PCPs having sufficient panel sizes, but composites remained unreliable for CHF and IVD. 85.3% of PCPs could be reliably profiled using a single overall composite. Aggregating PCPs into practice groups (3 to 21 PCPs per group) did not improve reliability in most cases due to little between-group practice variation.
Conclusion
Single measures rarely differentiate between individual PCPs or groups of PCPs reliably. Combining measures into single- or multi-disease composites can improve reliability for some common conditions, but not all. Assessing PCP practice groups with in a single healthcare system, rather than individual PCPs, did not substantially improve reliability.
doi:10.1097/MLR.0b013e31827da99c
PMCID: PMC3669898  PMID: 23295578
quality measurement; reliability; physician profiling
14.  The Importance of Nursing Homes in the Spread of Methicillin-Resistant Staphylococcus aureus (MRSA) Among Hospitals 
Medical care  2013;51(3):205-215.
Background
Hospital infection control strategies and programs may not consider control of methicillin-resistant Staphylococcus aureus (MRSA) in nursing homes in a county.
Methods
Using our Regional Healthcare Ecosystem Analyst (RHEA), we augmented our existing agent-based model of all hospitals in Orange County (OC), California, by adding all nursing homes and then simulated MRSA outbreaks in various healthcare facilities.
Results
The addition of nursing homes substantially changed MRSA transmission dynamics throughout the County. The presence of nursing homes substantially potentiated the effects of hospital outbreaks on other hospitals, leading to an average 46.2% (range: 3.3–156.1%) relative increase above and beyond the impact when only hospitals are included for an outbreak in OC’s largest hospital. An outbreak in the largest hospital affected all other hospitals (average 2.1% relative prevalence increase) and the majority (~90%) of nursing homes (average 3.2% relative increase) after six months. An outbreak in the largest nursing home had effects on multiple OC hospitals, increasing MRSA prevalence in directly connected hospitals by an average 0.3% and in hospitals not directly connected via patient transfers by an average 0.1% after six months. A nursing home outbreak also had some effect on MRSA prevalence in other nursing homes.
Conclusions
Nursing homes, even those not connected by direct patient transfers, may be a vital component of a hospital’s infection control strategy. To achieve effective control, a hospital may want to better understand how regional nursing homes and hospitals are connected via both direct and indirect (with intervening stays at home) patient sharing.
doi:10.1097/MLR.0b013e3182836dc2
PMCID: PMC3687037  PMID: 23358388
MRSA; Outbreak; Long-term Care; Nursing Homes; Hospitals
15.  Chronic disease management for recently homeless Veterans: a clinical practice improvement program to apply home telehealth technology to a vulnerable population 
Medical care  2013;51(3 0 1):S44-S51.
Background
Though vulnerable populations may benefit from in-home health information technologies (HIT) that promote disease self-management, there is a “digital divide” in which these groups are often unlikely to use such programs. We describe the early phases of applying and testing an existing Veterans Administration (VA) HIT care management program, Care Coordination Home Telehealth (CCHT), to recently homeless Veterans in the U.S. Department of Housing and Urban Development-VA Supportive Housing (HUD-VASH) program. Peers were used to support patient participation.
Methods
CCHT uses in-home messaging devices to provide health education and daily questions about clinical indicators from chronic illness care guidelines, with patient responses reviewed by VA nurses. Patients could also receive adjunctive peer support. We used medical record review, Veteran interviews, and staff surveys to “diagnose” barriers to CCHT use, assess program acceptability, explore the role of peer support, and inform future quality improvement.
Subjects
Fourteen eligible Veterans in HUD-VASH agreed to CCHT participation. Ten of these Veterans opted to have adjunctive peer support and the other four enrolled in CCHT usual care.
Results
Though barriers to enrollment/engagement must be addressed, this subset of Veterans in HUD-VASH was satisfied with CCHT. Most Veterans did not require support from peers to engage in CCHT but valued peer social assistance amidst the isolation felt in their scattered-site homes.
Conclusions
HIT tools hold promise for in-home care management for recently housed Veterans. Patient-level barriers to enrollment must be addressed in the next steps of quality improvement, testing and evaluating peer-driven CCHT recruitment.
doi:10.1097/MLR.0b013e31827808f6
PMCID: PMC3786687  PMID: 23407011
Homeless; disease management; peer support
16.  Distinguishing Screening from Diagnostic Mammograms using Medicare Claims Data 
Medical care  2012;10.1097/MLR.0b013e318269e0f5.
Background
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.
Objectives
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.
Research Design
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.
Subjects
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).
Measures
Sensitivity, specificity, and PPV of algorithmic designation of a “screening” purpose of the mammogram using a BCSC-derived reference standard.
Results
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%).
Conclusions
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.
doi:10.1097/MLR.0b013e318269e0f5
PMCID: PMC3534834  PMID: 22922433
Breast Cancer Screening; Mammography; Validation Studies; Medicare; Quality Assessment
17.  Language Barriers, Location of Care and Delays in Follow-up of Abnormal Mammograms 
Medical care  2012;50(2):171-178.
Background
Breast cancer is frequently diagnosed after an abnormal mammography result. Language barriers can complicate communication of those results.
Objectives
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.
Results
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).
Conclusions
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.
doi:10.1097/MLR.0b013e31822dcf2d
PMCID: PMC3918470  PMID: 21993060
18.  Patient complexity and risk factor control among multi-morbid patients with Type 2 diabetes: Results from the R2D2C2 study 
Medical care  2013;51(2):180-185.
Background
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.
Objective
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.
Research Design
Observational cross-sectional study.
Subjects
1314 patients with diabetes from the Reducing Racial Disparities in Diabetes Coached Care (R2D2C2) Study.
Measures
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.
Results
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).
Conclusions
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.
Trial Registration
Clinicaltrial.gov identifier: NCT01123239
doi:10.1097/MLR.0b013e318273119b
PMCID: PMC3552007  PMID: 23047130
Risk factors; diabetes; patient complexity; comorbidity; cardiovascular disease
19.  Prior Experiences of Racial Discrimination and Racial Differences in Health Care System Distrust 
Medical care  2013;51(2):144-150.
Purpose
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.
Methods
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).
Results
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).
Conclusions
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.
doi:10.1097/MLR.0b013e31827310a1
PMCID: PMC3552105  PMID: 23222499
20.  Physician Communication Behaviors and Trust among Black and White Patients with Hypertension 
Medical care  2013;51(2):151-157.
Background
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.
Objective
We sought to determine whether there were associations between physician communication behaviors, visit process measures and patient trust, particularly within racial groups.
Methods
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.
Results
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).
Conclusion
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.
doi:10.1097/MLR.0b013e31827632a2
PMCID: PMC3552122  PMID: 23132201
patient-physician communication; trust; African Americans
21.  Representativeness of Participants in the Cancer Care Outcomes Research and Surveillance (CanCORS) Consortium Relative to the Surveillance, Epidemiology and End Results (SEER) Program 
Medical care  2013;51(2):e9-15.
Background
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.
Research Design
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.
Results
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.
Conclusions
This study demonstrates that the CanCORS Consortium was successful in enrolling a demographically representative sample within the CanCORS regions.
doi:10.1097/MLR.0b013e318222a711
PMCID: PMC3654676  PMID: 22406968
Lung Cancer; Colorectal Cancer; Cancer Populations
22.  Cost-related Nonadherence by Medication Type among Medicare Part D Beneficiaries with Diabetes 
Medical care  2013;51(2):193-198.
Background
Despite the rollout of Medicare Part D, cost-related non-adherence (CRN) among older adults remains a problem.
Objectives
To examine the rate and correlates of self-reported CRN among a population of older persons with diabetes.
Research Design
Cross-sectional.
Subjects
1,264 Part D patients with diabetes, who entered the coverage gap in 2006.
Measures
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.
Results
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].
Conclusions
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.
doi:10.1097/MLR.0b013e318270dc52
PMCID: PMC3780603  PMID: 23032359
23.  Race and timeliness of transfer for revascularization in patients with acute myocardial infarction 
Medical care  2011;49(7):662-667.
Objectives
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.
Methods
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.
Results
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
Conclusions
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.
doi:10.1097/MLR.0b013e31821d98b2
PMCID: PMC3905793  PMID: 21677592
Healthcare Disparities; Patient Transfer; Critical Care; Cardiovascular Diseases; Quality Indicators
24.  Effects of Resident Duty Hour Reform on Surgical and Procedural Patient Safety Indicators Among Hospitalized VA and Medicare Patients 
Medical care  2009;47(7):723-731.
Objective
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.
Research Design
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.
Measures
Ten PSIs were aggregated into 3 composite measures based on factor analyses: “Continuity of Care,” “Technical Care,” and “Other” composites.
Results
“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.
Conclusions
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.
doi:10.1097/MLR.0b013e31819a588f
PMCID: PMC3893754  PMID: 19536029
Patient safety; hospital quality; resident duty hour reform; administrative data
25.  Validation of an Algorithm for Categorizing the Severity of Hospital Emergency Department Visits 
Medical care  2010;48(1):10.1097/MLR.0b013e3181bd49ad.
Background
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.
Objective
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.
Subjects
2,257,445 commercial and 261,091 Medicare members of an IDS.
Measures
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.
Results
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.
Conclusions
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.
doi:10.1097/MLR.0b013e3181bd49ad
PMCID: PMC3881233  PMID: 19952803
Access/Utilization of Services; Health Care Financing/Insurance; Emergency Care; NYU Algorithm; Billings

Results 1-25 (309)