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1.  Racial and Ethnic Differences in Use of Mammography Between Medicare Advantage and Traditional Medicare 
Breast cancer is a leading cause of mortality for women in all racial/ethnic groups. We compared use of mammography by race/ethnicity in Medicare health maintenance organizations (HMOs), preferred provider organizations (PPOs), and traditional Medicare.
We matched 495 836 women in HMOs and 81 480 women in PPOs who were aged 65 to 69 years during 2009 to women enrolled in traditional Medicare by race/ethnicity, Medicaid eligibility status, and geographic area. We identified mammography use from the Healthcare Effectiveness Data and Information Set for Medicare HMOs and PPOs and from claims data for traditional Medicare with the same specifications. We then compared racial/ethnic differences in rates of mammography in HMOs and PPOs to matched populations in traditional Medicare and estimated differences with z tests. All statistical tests were two-sided.
Relative to matched white women, mammography rates were statistically significantly higher for black, Hispanic, and Asian/Pacific Islander women in HMOs (6.1, 5.4, and 0.9 percentage points, respectively; all P ≤ .003) and statistically significantly lower for all three groups in traditional Medicare (3.3, 7.4, and 7.7 percentage points, respectively; all P < .001). Similar improvements in mammography rates also were observed in PPOs among all minority groups relative to traditional Medicare.
Higher rates of mammography in HMOs and PPOs were associated with a reversal of racial and ethnic differences observed in traditional Medicare. These differences may be related to lower patient cost-sharing and better systems to promote preventive services in managed care plans, as well as unmeasured characteristics or beliefs of minority women who enroll in these health plans relative to those in traditional Medicare.
PMCID: PMC3866158  PMID: 24316600
2.  Commentary: Assessing the Health Effects of Medicare Coverage for Previously Uninsured Adults: A Matter of Life and Death? 
Health Services Research  2010;45(5 Pt 1):1407-1422.
In contrast to a previous study we conducted and other evidence, a recent study found no significant effects of Medicare coverage after age 65 on overall health for previously uninsured adults and significant adverse effects on survival for some of these adults. We discuss explanations for these inconsistent findings, particularly the different ways in which deaths were handled, a key methodological challenge in longitudinal analyses of health. We demonstrate that analytic approaches suitable for examining effects of coverage on health measures may not be suitable for effects on mortality. Thus, estimates may be misleading when these different outcomes are jointly modeled. We also present new survival analyses that suggest Medicare coverage significantly attenuated the rising risk of death for previously uninsured adults.
PMCID: PMC2965513  PMID: 20337735
Medically uninsured; mortality; Medicare; insurance coverage; aging
3.  The Validity of Race and Ethnicity in Enrollment Data for Medicare Beneficiaries 
Health Services Research  2012;47(3 Pt 2):1300-1321.
To assess the validity of race/ethnicity in Medicare databases for studies of racial/ethnic disparities.
Data Sources
The 2010 Medicare Consumer Assessments of Healthcare Providers and Systems (CAHPS®) survey was linked to Medicare enrollment data and local area characteristics from the 2000 Census.
Study Design
Race/ethnicity was cross-tabulated for CAHPS and Medicare data. Within each self-reported category, demographic, geographic, health, and health care variables were compared between those that were and were not similarly identified in Medicare data.
Data Collection Methods
The Medicare CAHPS survey included 343,658 responses from elderly participants (60 percent response rate). Data were weighted for sampling and nonresponse to be representative of the national population of elderly Medicare beneficiaries.
Principal Findings
Self-reported Hispanics, Asians, Pacific Islanders, and American Indians were underidentified in Medicare enrollment data. Individuals in these groups who were identified in Medicare data tended to be more strongly identified with their group, poorer, and in worse health and to report worse health care experiences than those who were not so identified.
Self-reported members of racial and ethnic groups other than Whites and Blacks who are identified in Medicare data differ substantially from those who are not so identified. These differences should be considered in assessments of disparities in health and health care among Medicare beneficiaries.
PMCID: PMC3349013  PMID: 22515953
Medicare; race; ethnicity; disparities; CAHPS
4.  Integrating Multiple Social Statuses in Health Disparities Research: The Case of Lung Cancer 
Health Services Research  2012;47(3 Pt 2):1255-1277.
To illustrate the complex patterns that emerge when race/ethnicity, socioeconomic status (SES), and gender are considered simultaneously in health care disparities research and to outline the needed research to understand them by using disparities in lung cancer risks, treatment, and outcomes as an example.
Principal Findings
SES, gender, and race/ethnicity are social categories that are robust predictors of variations in health and health services utilization. These are usually considered separately, but intersectionality theory indicates that the impact of each depends on the others. Each reflects historically and culturally contingent variations in social, economic, and political status. Distinct patterns of risk and resilience emerge at the intersections of multiple social categories and shape the experience of health, health care access, utilization, quality, and outcomes where these categories intersect. Intersectional approaches call for greater attention to understand social processes at multiple levels of society and require the collection of relevant data and utilization of appropriate analytic approaches to understand how multiple risk factors and resources combine to affect the distribution of disease and its management.
Understanding how race/ethnicity, gender, and SES are interactive, interdependent, and social identities can provide new knowledge to enhance our efforts to effectively address health disparities.
PMCID: PMC3418828  PMID: 22568674
Health care disparities; smoking; lung cancer; race/ethnicity; socioeconomic status; gender
5.  Comparing the implementation of team approaches for improving diabetes care in community health centers 
Patient panel management and community-based care management may be viable strategies for community health centers to improve the quality of diabetes care for vulnerable patient populations. The objective of our study was to clarify implementation processes and experiences of integrating office-based medical assistant (MA) panel management and community health worker (CHW) community-based management into routine care for diabetic patients.
Mixed methods study with interviews and surveys of clinicians and staff participating in a study comparing the effectiveness of MA and CHW health coaching for improving diabetes care. Participants included 24 key informants in five role categories and 249 clinicians and staff survey respondents from 14 participating practices. We conducted thematic analyses of key informant interview transcripts to clarify implementation processes and describe barriers to integrating the new roles into practice. We surveyed clinicians and staff to assess differences in practice culture among intervention and control groups. We triangulated findings to identify concordant and disparate results across data sources.
Implementation processes and experiences varied considerably among the practices implementing CHW and MA team-based approaches, resulting in differences in the organization of health coaching and self-management support activities. Importantly, CHW and MA responsibilities converged over time to focus on health coaching of diabetic patients. MA health coaches experienced difficulty in allocating dedicated time due to other MA responsibilities that often crowded out time for diabetic patient health coaching. Time constraints also limited the personal introduction of patients to health coaches by clinicians. Participants highlighted the importance of a supportive team climate and proactive leadership as important enablers for MAs and CHWs to implement their health coaching responsibilities and also promoted professional growth.
Implementation of team-based strategies to improve diabetes care for vulnerable populations was diverse, however all practices converged in their foci on health coaching roles of CHWs and MAs. Our study suggests that a flexible approach to implementing health coaching is more important than fidelity to rigid models that do not allow for variable allocation of responsibilities across team members. Clinicians play an instrumental role in supporting health coaches to grow into their new patient care responsibilities.
PMCID: PMC4264557  PMID: 25468448
Diabetes mellitus; Implementation; Community health centers; Organizational change
6.  The European Cancer Patient’s Bill of Rights: Action Steps for Success 
The Oncologist  2014;19(3):225-227.
The European Cancer Concord (ECC) has partnered with patients, caregivers, clinicians, and advocates to construct three articles that form a Patient’s Bill of Rights. We propose four key action steps that will advance the agenda of the ECC. These include (a) robust cancer registries, (b) monitoring of quality of care, (c) broader stakeholder engagement, and (d) dissemination of best practices.
PMCID: PMC3958471  PMID: 24567282
7.  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.
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.
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.
PMCID: PMC3654676  PMID: 22406968
Lung Cancer; Colorectal Cancer; Cancer Populations
8.  Psychosocial stress and cigarette smoking persistence, cessation, and relapse over 9–10 years: A prospective study of middle-aged adults in the United States 
Cancer causes & control : CCC  2013;24(10):1849-1863.
Year-to-year decreases in smoking in the US have been observed only sporadically in recent years, which suggest a need for intensified efforts to identify those at risk for persistent smoking. To address this need, we examined the association between a variety of psychosocial stressors and smoking persistence, cessation, and relapse over 9–10 years among adults in the United States (N=4938, ages 25–74).
Using information provided at baseline and follow-up, participants were categorized as non-smokers, persistent smokers, ex-smokers, and relapsed smokers. Stressors related to relationships, finances, work-family conflict, perceived inequality, neighborhood, discrimination, and past-year family problems were assessed at baseline and follow-up.
High stress at both assessments was associated with greater odds of persistent smoking for stressors related to relationships, finances, work, perceived inequality, past-year family problems, and a summary score. Among respondents who were smokers at baseline, high stress at both time-points for relationship stress, perceived inequality, and past-year family problems was associated with nearly double the odds of failure to quit.
Interventions to address psychosocial stress may be important components within smoking cessation efforts.
PMCID: PMC3776130  PMID: 23860953
cigarette smoking; smoking cessation; smoking persistence; psychosocial stress; longitudinal; Midlife in the United States (MIDUS)
9.  Service Use at the End of Life in Medicare Advantage versus Traditional Medicare 
Medical care  2013;51(10):931-937.
Relative to traditional fee-for-service Medicare, managed care plans caring for Medicare beneficiaries may be better positioned to promote recommended services and discourage burdensome procedures with little clinical value at the end of life.
To compare end-of-life service use for enrollees in Medicare Advantage health maintenance organizations (MA-HMO) relative to similar individuals enrolled in traditional Medicare (TM).
Research Design, Subjects, Measures
For a national cohort of Medicare decedents continuously enrolled in MA-HMOs or TM in their year of death, 2003-2009, we obtained hospice enrollment information and individual-level Healthcare Effectiveness Data and Information Set (HEDIS®) utilization measures for MA-HMO decedents for up to one year prior to death. We developed comparable claims-based measures for TM decedents matched on age, sex, race, and location.
Hospice use in the year preceding death was higher among MA than TM decedents in 2003 (38% vs. 29%), but the gap narrowed over the study period (46% vs. 40% in 2009). Relative to TM, MA decedents had significantly lower rates of inpatient admissions (5-14% lower), inpatient days (18-29%), and emergency department visits (42-54%). MA decedents initially had lower rates of ambulatory surgery and procedures that converged with TM rates by 2009 and had modestly lower rates of physician visits initially that surpassed TM rates by 2007.
Relative to comparable TM decedents in the same local areas, MA-HMO decedents more frequently enrolled in hospice and used fewer inpatient and emergency department services, demonstrating that MA plans provide less end-of-life care in hospital settings.
PMCID: PMC3804008  PMID: 23969590
Medicare; managed care; hospice; end of life
10.  Profiling Hospitals by Survival of Patients with Colorectal Cancer 
Health Services Research  2011;46(3):729-746.
To profile hospitals by survival rates of colorectal cancer patients in multiple periods after initial treatment.
Data Sources
California Cancer Registry data from 50,544 patients receiving primary surgery with curative intent for stage I–III colorectal cancer in 1994–1998, supplemented with hospital discharge abstracts.
Study Design
We estimated a single Bayesian hierarchical model to quantify associations of survival to 30 days, 30 days to 1 year, and 1–5 years by hospital, adjusted for patient age, sex, race, stage, tumor site, and comorbidities. We compared two profiling methods for 30-day survival and four longer-term profiling methods by the fractions of hospitals with demonstrably superior survival profiles and of hospital pairs whose relative standings could be established confidently.
Principal Findings
Interperiod correlation coefficients of the random effects are (95 percent credible interval 0.27, 0.85), (0.20, 0.76), and (0.19, 0.82). The three-period model ranks 5.4 percent of pairwise comparisons by 30-day survival with at least 95 percent confidence, versus 3.3 percent of pairs using a single-period model, and 15–20 percent by weighted multiperiod methods.
The quality of care for colorectal cancer provided by a hospital system is somewhat consistent across the immediate postoperative and long-term follow-up periods. Combining mortality profiles across longer periods may improve the statistical reliability of outcome comparisons.
PMCID: PMC3087866  PMID: 21210794
Cancer care; colorectal cancer; provider profiling; quality measurement; Bayesian inference
11.  Quality of Ambulatory Care in Medicare Advantage HMOs and Traditional Medicare 
Health affairs (Project Hope)  2013;32(7):1228-1235.
To compare quality of care nationally between Medicare Advantage health maintenance organizations (HMOs) and traditional Medicare and determine how various types of Medicare HMOs differed in quality from traditional Medicare, we assessed performance measures of the quality of ambulatory care from the among beneficiaries matched by demographic characteristics within local areas during 2003-2009. HMO enrollees were consistently more likely than traditional Medicare beneficiaries to receive appropriate breast cancer screening, diabetes care, and cholesterol testing for cardiovascular disease. Personal physicians were rated less highly in HMOs than traditional Medicare in 2003, but more highly in 2009. Not-for-profit, larger, and older HMOs performed consistently more favorably on clinical measures and ratings of care than for-profit, smaller, and newer HMOs. The effects on ambulatory quality of care of more integrated delivery systems in Medicare HMOs may outweigh the potential incentives to restrict care under capitated payments.
PMCID: PMC3925369  PMID: 23836738
Medicare; quality of care; managed care; elderly
12.  Testing for Statistical Discrimination by Race/Ethnicity in Panel Data for Depression Treatment in Primary Care 
Health Services Research  2008;43(2):531-551.
To test for discrimination by race/ethnicity arising from clinical uncertainty in treatment for depression, also known as “statistical discrimination.”
Data Sources
We used survey data from 1,321 African-American, Hispanic, and white adults identified with depression in primary care. Surveys were administered every six months for two years in the Quality Improvement for Depression (QID) studies.
Study Design
To examine whether and how change in depression severity affects change in treatment intensity by race/ethnicity, we used multivariate cross-sectional and change models that difference out unobserved time-invariant patient characteristics potentially correlated with race/ethnicity.
Data Collection/Extraction Methods
Treatment intensity was operationalized as expenditures on drugs, primary care, and specialty services, weighted by national prices from the Medical Expenditure Panel Survey. Patient race/ethnicity was collected at baseline by self-report.
Principal Findings
Change in depression severity is less associated with change in treatment intensity in minority patients than in whites, consistent with the hypothesis of statistical discrimination. The differential effect by racial/ethnic group was accounted for by use of mental health specialists.
Enhanced physician–patient communication and use of standardized depression instruments may reduce statistical discrimination arising from clinical uncertainty and be useful in reducing racial/ethnic inequities in depression treatment.
PMCID: PMC2442383  PMID: 18370966
Statistical discrimination; racial/ethnic disparities; depression
13.  Taking the Measure of Health Care Disparities 
Health Services Research  2012;47(3 Pt 2):1225-1231.
PMCID: PMC3418834  PMID: 22568673
14.  Primary Care Careers Among Recent Graduates of Research-Intensive Private and Public Medical Schools 
Despite a growing need for primary care physicians in the United States, the proportion of medical school graduates pursuing primary care careers has declined over the past decade.
To assess the association of medical school research funding with graduates matching in family medicine residencies and practicing primary care.
Observational study of United States medical schools.
One hundred twenty-one allopathic medical schools.
The primary outcomes included the proportion of each school’s graduates from 1999 to 2001 who were primary care physicians in 2008, and the proportion of each school’s graduates who entered family medicine residencies during 2007 through 2009. The 25 medical schools with the highest levels of research funding from the National Institutes of Health in 2010 were designated as “research-intensive.”
Among research-intensive medical schools, the 16 private medical schools produced significantly fewer practicing primary care physicians (median 24.1 % vs. 33.4 %, p < 0.001) and fewer recent graduates matching in family medicine residencies (median 2.4 % vs. 6.2 %, p < 0.001) than the other 30 private schools. In contrast, the nine research-intensive public medical schools produced comparable proportions of graduates pursuing primary care careers (median 36.1 % vs. 36.3 %, p = 0.87) and matching in family medicine residencies (median 7.4 % vs. 10.0 %, p = 0.37) relative to the other 66 public medical schools.
To meet the health care needs of the US population, research-intensive private medical schools should play a more active role in promoting primary care careers for their students and graduates.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-012-2286-z) contains supplementary material, which is available to authorized users.
PMCID: PMC3663944  PMID: 23225257
primary care; medical education; research funding
15.  Clinical Inertia in Depression Treatment 
Medical care  2009;47(9):959-967.
To explore reasons for clinical inertia in the management of persistent depression symptoms.
Research Design
We characterized patterns of treatment adjustment in primary care and their relation to the patient’s clinical condition by modeling transition to a given treatment “state” conditional upon the current state of treatment. We assessed associations of patient, clinician, and practice barriers with adjustment decisions.
Survey data on patients in active care for major depression was collected at six-month intervals over a two-year period for the Quality Improvement for Depression (QID) studies.
Patient and clinician characteristics were collected at baseline. Depression severity and treatment were measured at each interval.
Approximately one-third of the observation periods ending with less than a full response resulted in an adjustment recommendation. Clinicians often respond correctly to the combination of severe depression symptoms and less than maximal treatment by changing the treatment. Appropriate adjustment is less common, however, in management of less severely depressed patients who do not improve after starting treatment, particularly if their care already meets minimal treatment intensity guidelines.
Our findings suggest that quality improvement efforts should focus on promoting appropriate adjustments for patients with persistent depression symptoms, particularly those with less severe depression.
PMCID: PMC4003881  PMID: 19704353
Depression; Clinical inertia; Evidence-based medicine; Physician practice patterns
16.  Physicians’ beliefs about breast cancer surveillance testing are consistent with test overuse 
Medical care  2013;51(4):315-323.
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.
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.
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.
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.
PMCID: PMC3596481  PMID: 23269111
17.  Chemotherapy use and patient treatment preferences in advanced colorectal cancer: a prospective cohort study 
Cancer  2012;119(4):854-862.
Our objective was to determine how patient preferences guide the course of palliative chemotherapy for advanced colorectal cancer.
Eligible patients with metastatic colorectal cancer (mCRC) were enrolled nationwide in a prospective, population-based cohort study. Data were obtained via medical record abstraction and patient surveys. Logistic regression was used to evaluate: patient characteristics associated with seeing medical oncology and receiving chemotherapy; and patient characteristics, beliefs and preferences associated with receiving >1 line of chemotherapy and receiving combination chemotherapy.
Among 702 patients with mCRC, 91% saw a medical oncologist, and among those, 82% received chemotherapy. Patients 65-75 and ≥75 years were less likely to see an oncologist, as were patients who were too sick to complete their own survey. In adjusted analyses patients ≥75 years and with moderate or severe comorbidity were less likely to receive chemotherapy, as were patients who were too sick to complete their own survey. Patients received chemotherapy even if they believed chemotherapy would not extend their life (90%), chemotherapy would not likely help with cancer-related problems (89%), or preferred treatment focusing on comfort even if it meant not living as long (90%). Older patients were less likely to receive combination first-line therapy. Patient preferences and beliefs were not associated with receipt of >1 line of chemotherapy or combination chemotherapy.
The majority of patients received chemotherapy even if they expressed negative or marginal preferences or beliefs regarding chemotherapy. Patient preferences and beliefs were not associated with intensity or number of chemotherapy regimens.
PMCID: PMC3548062  PMID: 22972673
Colorectal cancer; decision making; patient preference; cohort studies; quality of healthcare
18.  Cost-Effectiveness of Patient Mailings to Promote Colorectal Cancer Screening 
Medical care  2010;48(6):553-557.
Programs to promote colorectal cancer screening are common, yet information regarding the cost effectiveness of such efforts is limited.
To assess the cost effectiveness of patient mailings to increase rates of colorectal cancer screening.
Research Design
Incremental cost-effectiveness analysis of a randomized, controlled trial. The intervention involved 21,860 patients aged 50 to 80 years across 11 health centers overdue for colorectal cancer screening. Patients were randomized to receive a mailing that included a tailored letter, educational brochure, and fecal-occult-blood test kit at baseline and 6 months follow up.
We calculated the incremental cost-effectiveness of these mailings to promote colorectal cancer screening via fecal-occult-blood testing, flexible sigmoidoscopy, or colonoscopy using internal cost estimates of labor and supplies.
Colorectal cancer screening rates were higher for patients in the intervention compared to control patients (44% versus 38%, p<0.001). The total cost of the intervention was approximately $5.48 per patient, resulting in a cost-effectiveness ratio of $94 per additional patient screened. This estimate ranged from $69 to $156, based on assumptions of the cost of the intervention components, magnitude of intervention effect, age range and size of the targeted patient population.
Tailored patient mailings are a cost-effective approach to improve rates of colorectal cancer screening.
PMCID: PMC3225409  PMID: 20473196
Colorectal cancer screening; cost effectiveness; quality improvement; patient mailings
19.  Unintended consequences of eliminating Medicare payments for consultations1 
JAMA internal medicine  2012;173(1):15-21.
Prior to 2010, Medicare payments for consultations (commonly billed by specialists) were substantially higher than for office visits of similar complexity (commonly billed by primary care physicians). In January 2010, Medicare eliminated consultation payments from the Part B Physician Fee Schedule and increased fees for office visits. This change was intended to be budget neutral and to decrease payments to specialists while increasing payments to primary care physicians. We assessed the impact of this policy on spending, volume, and complexity for outpatient office encounters in 2010.
We examined 2007–2010 outpatient claims for 2,247,810 Medicare beneficiaries with Medicare Supplemental (Medigap) coverage through large employers in the Thomson Reuters MarketScan Database. We used segmented regression analysis to study changes in spending, volume, and complexity of office encounters adjusted for age, sex, health status, secular trends, seasonality, and hospital referral region.
“New” office visits largely replaced consultations in 2010. An average of $10.20 (6.5 percent) more was spent per beneficiary per quarter on physician encounters after the policy. The total volume of physician encounters did not change significantly. The increase in spending was largely explained by higher office visit fees from the policy and a shift toward higher complexity visits to both specialists and primary care physicians.
The elimination of consultations led to a net increase in spending on visits to both primary care physicians and specialists. Higher prices, partially due to the subjectivity of codes in the physician fee schedule, explained the spending increase, rather than higher volumes.
PMCID: PMC3547540  PMID: 23336095
20.  Diversity in Cardiovascular Outcomes Among Chinese and South Asian Patients 
Circulation  2010;122(16):1550-1552.
PMCID: PMC3169177  PMID: 20921435
21.  Quality and Equity of Primary Care with Patient-Centered Medical Homes: Results from a National Survey 
Medical care  2013;51(1):68-77.
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.
Research Design
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.
PMCID: PMC3766903  PMID: 23047125
22.  Patients' Experiences With Care for Lung Cancer and Colorectal Cancer: Findings From the Cancer Care Outcomes Research and Surveillance Consortium 
Journal of Clinical Oncology  2010;28(27):4154-4161.
To assess patients' experiences with cancer care, ratings of their quality of care, and correlates of these assessments.
Patients and Methods
For 4,093 patients with lung cancer and 3,685 patients with colorectal cancer in multiple US regions and health care delivery systems, we conducted telephone surveys of patients or their surrogates in English, Spanish, or Chinese at 4 to 7 months after diagnosis. The surveys assessed ratings of the overall quality of cancer care and experiences with three domains of interpersonal care (physician communication, nursing care, and coordination and responsiveness of care).
English-speaking Asian/Pacific Islander patients and Chinese-speaking patients and those in worse health reported significantly worse adjusted experiences with all three domains of interpersonal care, whereas white, black, and Hispanic patients reported generally similar experiences with interpersonal care. The overall quality of cancer care was rated as excellent by 44.4% of patients with lung cancer and 53.0% of patients with colorectal cancer, and these ratings were most strongly correlated with positive experiences with coordination and responsiveness of care (Spearman rank coefficients of 0.49 and 0.42 for lung and colorectal cancer, respectively). After multivariate adjustment, excellent ratings were less common for each cancer among black patients, English-speaking Asian/Pacific Islander patients, Chinese-speaking patients, and patients reporting worse health status (all P ≤ .05).
Patients' reports and ratings of care differed significantly by race, language, and health status. Efforts to improve patients' experiences with cancer care should focus on problems affecting Asian and Pacific Islander patients and those in worse health.
PMCID: PMC2953972  PMID: 20713876
23.  Psychosocial Stress and Change in Weight Among US Adults 
American Journal of Epidemiology  2009;170(2):181-192.
The association of psychosocial stress with weight gain may have important implications for clinical practice and workplace and public health interventions. To determine whether multiple domains of psychosocial stress were associated with weight gain from 1995 to 2004, the authors analyzed a nationally representative longitudinal cohort of 1,355 men and women in the United States. Change in body mass index was assessed for multiple domains of psychosocial stress related to work, personal relationships, life constraints, and finances, controlling for other factors associated with weight gain. All analyses were stratified by sex and weighted to account for the complex survey design. Among men with high baseline body mass index, weight gain was associated with increasing levels of psychosocial stress related to job-related demands (P < 0.001 for interaction with baseline body mass index), lack of skill discretion (P = 0.014), lack of decision authority (P = 0.026), and difficulty paying bills (P = 0.004). Among women with high baseline body mass index, weight gain was associated with job-related demands (P < 0.001 for interaction with baseline body mass index), perceived constraints in life (P < 0.001), strain in relations with family (P = 0.016), and difficulty paying bills (P = 0.010). Interventions to address psychosocial stress may limit weight gain among overweight and obese men and women.
PMCID: PMC2727271  PMID: 19465744
body mass index; longitudinal studies; obesity; overweight; stress, psychological; weight gain
24.  Physician Roles in the Cancer-Related Follow-Up Care of Cancer Survivors 
Family medicine  2013;45(7):463-474.
Information about primary care physicians’ (PCPs) and oncologists’ involvement in cancer-related follow-up care, and care coordination practices, is lacking but essential to improving cancer survivors’ care. This study assesses PCPs’ and oncologists’ self-reported roles in providing cancer-related follow-up care for survivors who are within five years of completing cancer treatment.
In 2009, the National Cancer Institute and American Cancer Society conducted a nationally-representative survey of PCPs (n=1014) and medical oncologists (n=1125) (response rate=57.6%; cooperation rate=65.1%). Mailed questionnaires obtained information on physicians’ roles in providing cancer-related follow-up care to early-stage breast and colon cancer survivors; personal and practice characteristics; beliefs about and preferences for follow-up care; and care coordination practices.
Over 50% of PCPs reported providing cancer-related follow-up care for survivors, mainly by co-managing with an oncologist. In contrast, over 70% of oncologists reported fulfilling these roles by providing the care themselves. In adjusted analyses, PCP co-management was associated with: specialty, training in late or long-term effects of cancer, higher cancer patient volume, favorable attitudes about PCP care involvement, preference for a shared model of survivorship care, and receipt of treatment summaries from oncologists. Among oncologists, only preference for a shared care model was associated with co-management with PCPs.
PCPs and oncologists differ in their involvement in cancer-related follow-up care of survivors, with co-management more often reported by PCPs than by oncologists. Given anticipated national shortages of PCPs and oncologists, study results suggest that improved communication and coordination between these providers is needed to ensure optimal delivery of follow-up care to cancer survivors.
PMCID: PMC3755767  PMID: 23846965
neoplasms; survivorship; physicians; primary health care; physicians’ practice patterns
25.  Patient and Physician Reminders to Promote Colorectal Cancer Screening: A Randomized Controlled Trial 
Archives of internal medicine  2009;169(4):364-371.
Screening reduces colorectal cancer mortality, but effective screening tests remain underused. Systematic reminders to patients and physicians could increase screening rates.
We conducted a randomized controlled trial of patient and physician reminders in 11 ambulatory health centers. Participants included 21,860 patients ages 50 to 80 overdue for colorectal cancer screening and 110 primary care physicians. Patients were randomly assigned to receive mailings containing an educational pamphlet, fecal-occult-blood test kit, and instructions for direct scheduling of flexible sigmoidoscopy or colonoscopy. Physicians were randomly assigned to receive electronic reminders during office visits with patients overdue for screening. The primary outcome was receipt of fecal-occult-blood testing, flexible sigmoidoscopy, or colonoscopy over 15 months, and the secondary outcome was detection of colorectal adenomas.
Screening rates were higher for patients who received mailings compared to those who did not (44.0% vs. 38.1%, p<0.001). The effect increased with age: +3.7% for ages 50-59; +7.3% for ages 60-69; and +10.1% for ages 70-80 (p=0.01 for trend). Screening rates were similar among patients of physicians receiving electronic reminders and the control group (41.9% vs. 40.2%, p=0.47). However, electronic reminders tended to increase screening rates among patients with 3 or more primary care visits (59.5% vs. 52.7%, p=0.07). Detection of adenomas tended to increase with patient mailings (5.7% vs. 5.2%, p=0.10) and physician reminders (6.0% versus 4.9%, p=0.09).
Mailed reminders to patients are an effective tool to promote colorectal cancer screening, and electronic reminders to physicians may increase screening among adults who more frequently use primary care.
( ID number NCT00355004)
PMCID: PMC2683730  PMID: 19237720
Colorectal Cancer Screening; Reminder Systems; Quality Improvement; Randomized Controlled Trial

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