Relationship between regional per capita Medicare expenditures and patient perceptions of quality of care

Geographic Variation in Operative Management of Adhesive Small Bowel Obstruction

INTRODUCTION

Variation in surgical management exists nationally. We hypothesize that geographic variation exists in adhesive small bowel obstruction (aSBO) management.

MATERIALS AND METHODS

A retrospective analysis of a national commercial insurance claims database (MarketScan) sample (2017-2019) was performed in adults with hospital admission due to aSBO. Geographic variation in rates of surgical intervention for aSBO was evaluated by state and compared to a risk-adjusted national baseline using a Bayesian spatial rates Poisson regression model. For individual-level analysis, patients were identified in 2018, with 365-d look back and follow-up periods. Logistic regression was performed for individual-level predictors of operative intervention for aSBO.

RESULTS

Two thousand one hundred forty-five patients were included. State-level analysis revealed rates of operative intervention for aSBO were significantly higher in Missouri and lower in Florida. On individual-level analysis, age (P < 0.01) and male sex (P < 0.03) but not comorbidity profile or prior aSBO, were negatively associated with undergoing operative management for aSBO. Patients presenting in 2018 with a history of admission for aSBO the year prior experienced a five-fold increase in odds of representation (odds ratio: 5.4, 95% confidence interval: 3.1-9.6) in 2019. Patients who received an operation for aSBO in 2018 reduced the odds of readmission in the next year by 77% (odds ratio: 0.23, 95% confidence interval: 0.1-0.5). The volume of operations performed within a state did not influence readmission.

CONCLUSIONS

Surgical management of aSBO varies across the continental USA. Operative intervention is associated with decreased rates of representation in the following year. These data highlight a critical need for standardized guidelines for emergency general surgery patients.

Value in psoriasis (IRIS) trial: implementing value-based healthcare in psoriasis management - a 1-year prospective clinical study to evaluate feasibility and value creation

INTRODUCTION

Currently, the healthcare sector is under tremendous financial pressure, and many acknowledge that a dramatic shift is required as the current system is not sustainable. Furthermore, the quality of care that is delivered varies strongly. Several solutions have been proposed of which the conceptual framework known as value-based healthcare (VBHC) is further explored in this study for psoriasis. Psoriasis is a chronic inflammatory skin disease, which is associated with a high disease burden and high treatment costs. The objective of this study is to investigate the feasibility of using the VBHC framework for the management of psoriasis.

METHODS AND ANALYSIS

This is a prospective clinical study in which new patients attending the psoriasis clinic (PsoPlus) of the Ghent University Hospital will be followed up during a period of 1 year. The main outcome is to determine the value created for psoriasis patients. The created value will be considered as a reflection of the evolution of the value score (ie, the weighted outputs (outcomes) divided by weighted inputs (costs)) obtained using data envelopment analysis. Secondary outcomes are related to comorbidity control, outcome evolution and treatment costs. In addition, a bundled payment scheme will be determined as well as potential improvements in the treatment process. A total of 350 patients will be included in this trial and the study initiation is foreseen on 1 March 2023.

ETHICS AND DISSEMINATION

This study has been approved by the Ethics Committee of the Ghent University Hospital. The findings of this study will be disseminated by various means: (1) publication in one or more peer-reviewed dermatology and/or management journals, (2) (inter)national congresses, (3) via the psoriasis patient community and (4) through the research team's social media channels.

TRIAL REGISTRATION NUMBER

NCT05480917.

Initiating value-based healthcare in psoriasis: Proposing a value-based outcome set for daily clinical practice

BACKGROUND

With the current trend in healthcare moving towards a more value-based approach, it is essential to understand what value encompasses.

OBJECTIVES

To develop an actionable value-based outcome set (VOS) for daily practice.

METHODS

A mixed method approach was used consisting of four phases. Formerly, a systematic review was conducted, providing an overview of all patient-relevant outcomes defined in current literature. These 23 outcomes were then presented to a group of patients, using a modified nominal group technique (NGT), to establish whether these results represented all of their relevant outcomes. Subsequently, these outcomes were ranked according to importance by patients attending our academic specialized psoriasis clinic. A review of the literature was performed to assess which instruments were available and suitable to evaluate the outcomes in this VOS. Finally, a pilot feasibility test was performed amongst patients.

RESULTS

Of the 23 outcomes, two were omitted from the ranking exercise after the NGT. In the ranking exercise, 120 patients participated. The median age was 50.0 (IQR 25.0) years and 36.7% were female. Median PASI score was 2.4 (IQR 5.2), and treatments varied from topicals to biologicals. The outcomes scored as most important were symptom control, treatment efficacy, confidence in care and control of disease. The least important outcomes were comorbidity control, productivity and cost of care. A significant difference was shown between the ranking of the outcomes (p < 0.001). In total, 12 instruments were selected, which are reported by both patient and provider, to measure the outcomes in this VOS. Median completion time for the patient part was 30 min (IQR 2.8).

CONCLUSIONS

This VOS is a first proposal to evaluate psoriasis care in a value-based manner. Measuring these outcomes can enable us to critically appraise and improve current care processes, within the reality of available resources, thereby increasing value for patients.

Impact of "Defensive Medicine" On the Costs of Diabetes and Associated Conditions

OBJECTIVES

Geographic variation in healthcare spending is typically attributed to differences in patient health status and provider practice patterns. While medicolegal considerations (i.e., "defensive medicine") anecdotally impact healthcare spending, this phenomenon is difficult to measure. The purpose of this study was to explore the association between the medicolegal environment and Medicare costs for diabetes and associated conditions of interest to vascular surgeons. Specifically, we hypothesized that an adverse medicolegal environment is associated with higher per-capita Medicare costs for diabetic patients.

METHODS

Medicare data including the most recent (2018) Medicare Geographic Variation Public Use Files and Chronic Conditions Data Files were linked to National Practitioner Database (NPDB) files from the preceding 5 years (2013-2017), in addition to US Census data and AMA workforce statistics. State-level medicolegal environment was characterized by K-means clustering across a panel of metrics related to malpractice payment magnitude and prevalence. Per-capita Medicare spending for diabetes was compared across 5 distinct medicolegal environments. Costs were standardized and risk-adjusted to account for known geographic variation in healthcare costs and patient population. Analysis of variance (ANOVA) was applied to unadjusted data, followed by multivariate regression modeling. Readmissions rates, per-capita imaging studies, per-capita tests, per-capita procedures, and lower extremity amputation rates were compared between the least litigious quintile from the K-means clustering and the two most litigious quintiles.

RESULTS

Median (IQR) unadjusted Medicare per-capita expenditure on diabetic patients was $15,963 ($14,885 to $17,673), ranging from $13,762 (Iowa) to $21,865 (D.C.). 1.6-fold variation persisted after payment standardization. Cluster analysis based on malpractice-related variables yields 5 distinct medicolegal environments, based on litigation frequency and malpractice payment amounts. Per-capita spending on diabetes varied, ranging from $15,799 in states with low payments and infrequent litigation to $18,838 in states with the most adverse medicolegal environment (P<.05). After cost standardization and risk adjustment with multiple linear regression, malpractice claim prevalence (per 100 physicians) remained an independent predictor of states with the highest DM spending (p=0.022)[Table1]. Moreover, diabetic patients in states with adverse medicolegal environments had more procedures, imaging studies, and readmissions (p<.05 for all) but did not have significant differences in amputation rates compared to less litigious states.

CONCLUSION

An adverse medicolegal environment is independently associated with higher healthcare costs but does not result in improved outcome (i.e. amputation rate) for diabetic Medicare beneficiaries. Across states, a 1% increase in lawsuits/100 physicians was associated with a >10% increase in risk-adjusted standardized per-capita costs. These findings demonstrate the potential contribution of "defensive medicine" to variation in healthcare utilization and spending in a population of interest to vascular surgeons.

Impact of primary care funding on patient satisfaction: a retrospective longitudinal study of English general practice, 2013-2016

BACKGROUND

Providing high-quality clinical care and good patient experience are priorities for most healthcare systems.

AIM

To understand the relationship between general practice funding and patient-reported experience.

DESIGN AND SETTING

Retrospective longitudinal study of English general practice-level data for the financial years 2013-2014 to 2016-2017.

METHOD

Data for all general practices in England from the General and Personal Medical Services database were linked to patient experience data from the GP Patient Survey (GPPS). Panel data multivariate regression was used to estimate the impact of general practice funding (current or lagged 1 year) per patient on GPPS-reported patient experience of access, continuity of care, professionalism, and overall satisfaction. Confounding was controlled for by practice, demographic, and GPPS responder characteristics, and for year effects.

RESULTS

Inflation-adjusted mean total annual funding per patient was £133.66 (standard deviation [SD] = £39.46). In all models, higher funding was associated with better patient experience. In the model with lagged funding and practice fixed effects (model 6), a 1 SD increase in funding was associated with increases in scores in the domains of access (1.18%; 95% confidence interval [CI] = 0.89 to 1.47), continuity (0.86%; 95% CI = 0.19 to 1.52), professionalism of GP (0.47%; 95% CI = 0.22 to 0.71), professionalism of nurse (0.51%; 95% CI = 0.24 to 0.77), professionalism of receptionist (0.51%; 95% CI = 0.24 to 0.78), and in overall satisfaction (0.88%; 95% CI = 0.52 to 1.24).

CONCLUSION

Better-funded general practices were more likely to have higher reported patient experience ratings across a wide range of domains.

Geographic Variation In Medicare Per Capita Spending Narrowed From 2007 To 2017

We examined the trends in geographic variation in Medicare per capita spending and growth from 2007 to 2017 and found that the variation narrowed during this period. The difference in Medicare price- and risk-adjusted per capita spending between hospital referral regions (HRRs) in the top decile and those in the bottom decile decreased from $3,388 in 2007 to $2,916 in 2017-a reduction of $472, or 14 percent. The spending convergence occurred almost entirely between 2009 and 2014, during the early years of the Affordable Care Act (ACA). The highest-spending HRRs in 2007 had the lowest annual growth rates from 2007 to 2017, and the lowest-spending HRRs in 2007 had the highest annual growth rates. We also found that a greater supply of postacute care providers, especially hospice providers, significantly predicted lower spending growth across HRRs after the implementation of the ACA.

Systemic overuse of health care in a commercially insured US population, 2010-2015

BACKGROUND

Overuse is a leading contributor to the high cost of health care in the United States. Overuse harms patients and is a definitive waste of resources. The Johns Hopkins Overuse Index (JHOI) is a normalized measure of systemic health care services overuse, generated from claims data, that has been used to describe overuse in Medicare beneficiaries and to understand drivers of overuse. We aimed to adapt the JHOI for application to a commercially insured US population, to examine geographic variation in systemic overuse in this population, and to analyze trends over time to inform whether systemic overuse is an enduring problem.

METHODS

We analyzed commercial insurance claims from 18 to 64 year old beneficiaries. We calculated a semiannual JHOI for each of the 375 Metropolitan Statistical Areas and 47 rural regions of the US. We generated maps to examine geographic variation and then analyzed each region's change in their JHOI quintile from January 2011 to June 2015.

RESULTS

The JHOI varied markedly across the US. Across the country, rural regions tended to have less systemic overuse than their MSA counterparts (p < 0.01). Regional systemic overuse is positively correlated from one time period to the next (p < 0.001). Between 2011 and 2015, 53.7% (N = 226) of regions remained in the same quintile of the JHOI. Eighty of these regions had a persistently high or persistently low JHOI throughout study duration.

CONCLUSIONS

The systemic overuse of health care resources is an enduring, regional problem. Areas identified as having a persistently high rate of systemic overuse merit further investigation to understand drivers and potential points of intervention.

Regional Supply of Medical Resources and Systemic Overuse of Health Care Among Medicare Beneficiaries

BACKGROUND

Overuse of health care resources has been identified as the leading contributor to waste in the US health care system.

OBJECTIVE

To explore health care system factors associated with regional variation in systemic overuse of health care resources as measured by the Johns Hopkins Overuse Index (JHOI) which aggregates systemic overuse of 20 health care services.

DESIGN

Using Medicare fee-for-service claims data from beneficiaries age 65 or over in 2008, we calculated the JHOI for the 306 hospital referral regions in the United States. We used ordinary least squares regression and multilevel models to estimate the association of JHOI scores and characteristics of regional health care delivery systems listed in the Area Health Resource File and Dartmouth Atlas.

KEY RESULTS

Regions with a higher density of primary care physicians had lower JHOI scores, indicating less systemic overuse (P < 0.001). Regional characteristics associated with higher JHOI scores, indicating more systemic overuse, included number per 1000 residents of acute care hospital beds (P = 0.002) and of hospital-based anesthesiologists, pathologists, and radiologists (P = 0.02).

CONCLUSIONS

Regional variations in health care resources including the clinician workforce are associated with the intensity of systemic overuse of health care. The role of primary care doctors in reducing health care overuse deserves further attention.

Impact of comorbid mental health needs on racial/ethnic disparities in general medical care utilization among older adults

OBJECTIVE

The objective is to apply the Institute of Medicine definition of healthcare disparities in order to compare (1) racial/ethnic disparities in general medical care use among older adults with and without comorbid mental health need and (2) racial/ethnic disparities in general medical care use within the group with comorbid mental health need.

METHODS

Data were obtained from the Medical Expenditure Panel Survey (years 2004-2012). The sample included 21,263 participants aged 65+ years (14,973 non-Latino Caucasians, 3530 African-Americans, and 2760 Latinos). Physical illness was determined by having one of the 11 priority chronic health illnesses. Comorbid mental health need was defined as having one of the chronic illnesses plus a Kessler-6 Scale >12, or two-item Patient Health Questionnaire >2. General medical care use refers to receipt of non-mental health specialty care. Two-part generalized linear models were used to estimate and compare general medical care use and expenditures among older adults with and without a comorbid mental health need.

RESULTS

Racial/ethnic disparities in general medical care expenditures were greater among those with comorbid mental health need compared with those without. Among those with comorbid mental health need, non-Latino Caucasians had significantly greater expenditures on prescription drug use than African-Americans and Latinos.

CONCLUSIONS

Expenditure disparities reflect differences in the amount of resources provided to African-Americans and Latinos compared with non-Latino Caucasians. This is not equivalent to disparities in quality of care. Interventions and policies are needed to ensure that racial/ethnic minority older adults receive equitable services that enable them to manage effectively their comorbid mental and physical health needs. Copyright © 2016 John Wiley & Sons, Ltd.

Payer Type and Low-Value Care: Comparing Choosing Wisely Services across Commercial and Medicare Populations

OBJECTIVE

To compare low-value health service use among commercially insured and Medicare populations and explore the influence of payer type on the provision of low-value care.

DATA SOURCES

2009-2011 national Medicare and commercial insurance administrative data.

DESIGN

We created claims-based algorithms to measure seven Choosing Wisely-identified low-value services and examined the correlation between commercial and Medicare overuse overall and at the regional level. Regression models explored associations between overuse and regional characteristics.

METHODS

We created measures of early imaging for back pain, vitamin D screening, cervical cancer screening over age 65, prescription opioid use for migraines, cardiac testing in asymptomatic patients, short-interval repeat bone densitometry (DXA), preoperative cardiac testing for low-risk surgery, and a composite of these.

PRINCIPAL FINDINGS

Prevalence of four services was similar across the insurance-defined groups. Regional correlation between Medicare and commercial overuse was high (correlation coefficient = 0.540-0.905) for all measures. In both groups, similar region-level factors were associated with low-value care provision, especially total Medicare spending and ratio of specialists to primary care physicians.

CONCLUSIONS

Low-value care appears driven by factors unrelated to payer type or anticipated reimbursement. These findings suggest the influence of local practice patterns on care without meaningful discrimination by payer type.

Effects of hospital palliative care on health, length of stay, and in-hospital mortality across intensive and non-intensive-care units: A systematic review and metaanalysis

OBJECTIVE

Hospital palliative care has been shown to improve quality of life and optimize hospital utilization for seriously ill patients who need intensive care. The present review examined whether hospital palliative care in intensive care (ICU) and non-ICU settings will influence hospital length of stay and in-hospital mortality.

METHOD

A systematic search of CINAHL/EBSCO, the Cochrane Library, Google Scholar, MEDLINE/Ovid, PubMed, and the Web of Science through 12 October 2016 identified 16 studies that examined the effects of hospital palliative care and reported on hospital length of stay and in-hospital death. Random-effects pooled odds ratios and mean differences with corresponding 95% confidence intervals were estimated. Heterogeneity was measured by the I 2 test. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system was utilized to assess the overall quality of the evidence.

RESULTS

Of the reviewed 932 articles found in our search, we reviewed the full text of 76 eligible articles and excluded 60 of those, which resulted in a final total of 16 studies for analysis. Five studies were duplicated with regard to outcomes. A total of 18,330 and 9,452 patients were analyzed for hospital length of stay and in-hospital mortality from 11 and 10 studies, respectively. Hospital palliative care increased mean hospital length of stay by 0.19 days (pooled mean difference = 0.19; 95% confidence interval [CI 95%] = -2.22-2.61 days; p = 0.87; I 2 = 95.88%) and reduced in-hospital mortality by 34% (pooled odds ratio = 0.66; CI 95% = 0.52-0.84; p < 0.01; I 2 = 48.82%). The overall quality of evidence for both hospital length of stay and in-hospital mortality was rated as very low and low, respectively.

SIGNIFICANCE OF RESULTS

Hospital palliative care was associated with a 34% reduction of in-hospital mortality but had no correlation with hospital length of stay.

Risk of hospitalisation after primary treatment for prostate cancer

OBJECTIVE

To compare the risk of hospitalisation and associated costs in patients after treatment for prostate cancer.

PATIENTS AND METHODS

We identified 29 571 patients aged 66-75 years without significant comorbidity from the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database who were diagnosed with localised prostate cancer between 2004 and 2009. We compared the rates of all-cause and treatment-related hospitalisation that occurred within 365 days of the initiation of definitive therapy. We used multivariable logistic regression analysis to identify determinants associated with hospitalisation.

RESULTS

Men who underwent radical prostatectomy (RP) rather than radiotherapy (RT) had lower odds of being hospitalised for any cause after therapy [odds ratio (OR) 0.80, 95% confidence interval (CI): 0.74-0.87]. Patients who underwent RP rather than RT had higher odds of being hospitalised for treatment-related complications (OR 1.15, 95% CI: 1.03-1.29). However, men who underwent external beam RT (EBRT)/intensity modulated RT (IMRT) (OR 0.84, 95% CI: 0.72-0.99) had a 16% lower odds of hospitalisation from treatment-related complications than patients undergoing RP. Using propensity score-weighted analyses there was no significant difference in the odds of hospitalisation from treatment-related complications for men who underwent RP vs RT (OR 1.06, 95% CI: 0.92-1.21). Patients hospitalised for treatment-related complications after RT were costlier than patients who underwent RP (Mean $18 381 vs $13 203, P < 0.001).

CONCLUSIONS

With the exception of men who underwent EBRT/IMRT, there was no statistically significant difference in the odds of hospitalisation from treatment-related complications. Costs from hospitalisation after treatment were significantly higher for men undergoing RT than RP. Our findings are relevant in the context of penalties linked to hospital readmissions and bundled payment models.

Impact of Inpatient Palliative Care on Treatment Intensity for Patients with Serious Illness

BACKGROUND

Palliative care is associated with decreased treatment intensity and improved quality for individual patients at the end of life, but little is known about how hospital-wide outcomes are affected by the diffusion of palliative care principles.

OBJECTIVE

We examined the relationship between presence of palliative care programs and hospitals' average treatment intensity, as indicated by mean intensive care unit (ICU) length of stay (LOS) and days under Medicare hospice coverage, in the last six months of life among Medicare beneficiaries aged 67 and over with serious chronic illness.

METHODS

We linked hospital-level data from the American Hospital Association Annual Survey, National Palliative Care Registry, and Dartmouth Atlas of Health Care to examine hospital-level treatment intensity for chronically ill Medicare beneficiaries who died in 2010. We used propensity score-adjusted linear regression to estimate the relationship between palliative care programs and hospitals' mean ICU LOS and hospice length of enrollment.

RESULTS

Among 974 hospitals meeting inclusion criteria, we compared 295 hospitals with palliative care programs to 679 hospitals without. Hospitals with palliative care programs were higher volume, more likely to be teaching hospitals, and have oncology services and less likely to be located in rural areas. In propensity score weighted analyses, the mean ICU LOS in hospitals with palliative care was shorter by 0.23 days (standard error [SE] = 0.26), but this was not statistically significant (p = 0.76). In addition, the mean length of hospice enrollment among beneficiaries served by hospitals with palliative care was longer by 0.22 days (SE = 0.61), but also was not statistically significant (p = 0.76).

CONCLUSIONS

Hospital-based palliative care programs alone may not be sufficient to impact ICU LOS or hospice length of enrollment for all chronically ill older adults admitted to hospitals. Future work should measure hospital-wide palliative care outcomes and effects of core palliative knowledge and skills provided by nonpalliative care specialists.

Patients' preferences explain a small but significant share of regional variation in medicare spending

This study assessed the extent to which differences in patients' preferences across geographic areas explained differences in traditional fee-for-service Medicare spending across Dartmouth Atlas of Health Care Hospital Referral Regions (HRRs). Preference measures were based on results of a survey that asked patients questions about their physicians, their own health status, and the care they would want in their last six months of life. We found that patients' preferences explained 5 percent of the variation across HRRs in total Medicare spending. In comparison, supply factors, such as the number of physicians, specialists, and hospital beds, explained 23 percent, and patients' health and income explained 12 percent. We also explored the relative importance of preferences in determining three components of total spending: spending at the end of life, inpatient spending, and spending on physician services. Relative to supply factors, health, and income, patients' preferences explained the largest share of variation in end-of-life spending and the smallest share of variation in spending on physician services. We conclude that variation in preferences contributes to differences across areas in Medicare spending. Medicare policy must consider both supply factors and patients' preferences in deciding how much to accommodate area variation in spending and the extent to which that variation should be subsidized by taxpayers.

Another Pill, Another Test, and Another Procedure: One Resident's Reflection on Healthcare Cost Containment

In the United States, healthcare expenditures have continued to rise at alarming rates despite numerous strategies to contain costs. One area of focus that is underappreciated is doctor-patient communication about expectations of treatment. Studies have shown that clinicians' misperceptions of assumptions about patients' expectations are an essential component to our nation's healthcare overuse problem. Strategies to address these misperceptions and assumptions as a method of reducing costs and providing higher-quality care to our patients are warranted.

Hospice Enrollment, Local Hospice Utilization Patterns, and Rehospitalization in Medicare Patients

BACKGROUND

Rehospitalizations are prevalent and associated with decreased quality of life. Although hospice has been advocated to reduce rehospitalizations, it is not known how area-level hospice utilization patterns affect rehospitalization risk.

OBJECTIVES

The study objective was to examine the association between hospice enrollment, local hospice utilization patterns, and 30-day rehospitalization in Medicare patients.

METHODS

With a retrospective cohort design, 1,997,506 hospitalizations were assessed between 2005 and 2009 from a 5% national sample of Medicare beneficiaries. Local hospice utilization was defined using tertiles representing the percentage of all deaths occurring in hospice within each Hospital Service Area (HSA). Cox proportional hazard models were used to assess the relationship between 30-day rehospitalization, hospice enrollment, and local hospice utilization, adjusting for patient sociodemographics, medical history, and hospital characteristics.

RESULTS

Rates of patients dying in hospice were 27% in the lowest hospice utilization tertile, 41% in the middle tertile, and 53% in the highest tertile. Patients enrolled in hospice had lower rates of 30-day rehospitalization than those not enrolled (2.2% versus 18.8%; adjusted hazard ratio [HR], 0.12; 95% confidence interval [CI], 0.118-0.131). Patients residing in areas of low hospice utilization were at greater rehospitalization risk than those residing in areas of high utilization (19.1% versus 17.5%; HR, 1.05; 95% CI, 1.04-1.06), which persisted beyond that accounted for by individual hospice enrollment.

CONCLUSIONS

Area-level hospice utilization is inversely proportional to rehospitalization rates. This relationship is not fully explained by direct hospice enrollment, and may reflect a spillover effect of the benefits of hospice extending to nonenrollees.

Should health care providers be accountable for patients' care experiences?

Measures of patients' care experiences are increasingly used as quality measures in accountability initiatives. As the prominence and financial impact of patient experience measures have increased, so too have concerns about the relevance and fairness of including them as indicators of health care quality. Using evidence from the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) surveys, the most widely used patient experience measures in the United States, we address seven common critiques of patient experience measures: (1) consumers do not have the expertise needed to evaluate care quality; (2) patient "satisfaction" is subjective and thus not valid or actionable; (3) increasing emphasis on improving patient experiences encourages health care providers and plans to fulfill patient desires, leading to care that is inappropriate, ineffective, and/or inefficient; (4) there is a trade-off between providing good patient experiences and providing high-quality clinical care; (5) patient scores cannot be fairly compared across health care providers or plans due to factors beyond providers' control; (6) response rates to patient experience surveys are low, or responses reflect only patients with extreme experiences; and (7) there are faster, cheaper, and more customized ways to survey patients than the standardized approaches mandated by federal accountability initiatives.

Elderly breast and colorectal cancer patients' clinical course: patient and contextual influences

BACKGROUND

The social and medical environments that surround people are each independently associated with their cancer course. The extent to which these characteristics may together mediate patients' cancer care and outcomes is not known.

METHODS

Using multilevel methods and data, we studied elderly breast and colorectal cancer patients (level I) within urban social (level II: ZIP code tabulation area) and health care (level III: hospital service area) contexts. We sought to determine (1) which, if any, observable social and medical contextual attributes were associated with patient cancer outcomes after controlling for observable patient attributes, and (2) the magnitude of residual variation in patient cancer outcomes at each level.

RESULTS

Numerous patient attributes and social area attributes, including poverty, were associated with unfavorable patient cancer outcomes across the full clinical cancer continuum for both cancers. Health care area attributes were not associated with patient cancer outcomes. After controlling for observable covariates at all 3 levels, there was substantial residual variation in patient cancer outcomes at all levels.

CONCLUSIONS

After controlling for patient attributes known to confer risk of poor cancer outcomes, we find that neighborhood socioeconomic disadvantage exerts an independent and deleterious effect on residents' cancer outcomes, but the area supply of the specific types of health care studied do not. Multilevel interventions targeted at cancer patients and their social areas may be useful. We also show substantial residual variation in patient outcomes across social and health care areas, a finding potentially relevant to traditional small area variation research methods.

Rural residence and cancer outcomes in the United States: issues and challenges

"Neighborhoods and health" research has shown that area social factors are associated with the health outcomes that patients with cancer experience across the cancer control continuum. To date, most of this research has been focused on the attributes of urban areas that are associated with residents' poor cancer outcomes with less focused on attributes of rural areas that may be associated with the same. Perhaps because there is not yet a consensus in the United States regarding how to define "rural," there is not yet an accepted analytic convention for studying issues of how patients' cancer outcomes may vary according to "rural" as a contextual attribute. The research that exists reports disparate findings and generally treats rural residence as a patient attribute rather than a contextual factor, making it difficult to understand what factors (e.g., unmeasured individual poverty, area social deprivation, area health care scarcity) may be mediating the poor outcomes associated with rural (or non-rural) residence. Here, we review literature regarding the potential importance of rural residence on cancer patients' outcomes in the United States with an eye towards identifying research conventions (i.e., spatial and analytic) that may be useful for future research in this important area.

Is there room for containing healthcare costs? An analysis of regional spending differentials in Italy

This work aims at identifying the determinants of health spending differentials among Italian regions and at highlighting potential margins for savings. The analysis exploits a data set for the 21 Italian regions and autonomous provinces starting in the early 1990s and ending in 2006. After controlling for standard healthcare demand indicators, remaining spending differentials are found to be significant, and they appear to be associated with differences in the degree of appropriateness of treatments, health sector supply structure and social capital indicators. In general, higher regional expenditure does not appear to be associated with better reported or perceived quality in health services. In the regions that display poorer performances, inefficiencies appear not to be uniformly distributed among expenditure items. Overall, results suggest that savings could be achieved without reducing the amount of services provided to citizens. This seems particularly important given the expected rise in spending associated with the forecasted demographic developments.

State unemployment in recessions during 1991-2009 was linked to faster growth in Medicare spending

During the US recession of 2007-09, overall health care spending growth fell, but Medicare spending growth increased. Using state-level data from the period 1991-2009, we show that these divergent trends were also observed within states. Furthermore, increases in state unemployment rates were associated with higher Medicare spending per capita and increased hospital use by Medicare beneficiaries. For example, a one-percentage-point point rise in the unemployment rate was associated with a $40 (0.7 percent) increase in Medicare spending per capita. Our results suggest that economic downturns contribute to Medicare spending and use. One of many possible explanations may be that health care providers have greater capacity, inclination, and financial incentive to treat Medicare patients during recessions as a result of slackening demand from the non-Medicare population.

Association between physician supply, local practice norms, and outpatient visit rates

BACKGROUND

There is considerable regional variation in Medicare outpatient visit rates; such variations may be the consequence of patient health, race/ethnicity differences, patient preferences, or physician supply and beliefs about the efficacy of frequently scheduled visits.

OBJECTIVE

The objective of the study was to test associations between varying regional Medicare outpatient visit rates and beneficiaries' health, race/ethnicity, preferences, and physician practice norms and supply.

METHODS

We used Medicare claims from 2006 and 2007 and data from national surveys of 3 different groups in 2005-Medicare beneficiaries, cardiologists, and primary care physicians. Regression analysis tested explanations for outpatient visit rates: patient health (self-reported and hierarchical condition category score), self-reported race/ethnicity, preferences for care, and local physician practice norms and supply in beneficiaries' Hospital Referral Regions (HRRs) of residence.

RESULTS

Beneficiaries in the highest quintile of the hierarchical condition category scores experienced 4.99 more visits than those in the lowest. Beneficiaries who were black experienced 2.14 fewer visits than others with similar health and preferences. Higher care-seeking preferences were marginally significantly associated with more visits, whereas education and poverty were insignificant. HRRs with high physician supply and high-frequency practice norms were associated with 2.04 additional visits per year, whereas HRRs with high supply but low-frequency norms were associated with 1.45 additional visits. Adjusting for all individual beneficiary covariates explained <20% of the original associations between visit rates and physician supply and practice norms.

CONCLUSIONS

Medicare beneficiaries' health status, race, and preferences help explain individual office visit frequency; in particular, African-American patients appear to experience lower access to care. Yet, these factors explain a small fraction of the observed regional differences associated with physician supply and beliefs about the appropriate frequency of office visits.

Geographic variation in cardiovascular procedure use among Medicare fee-for-service vs Medicare Advantage beneficiaries

IMPORTANCE

Little is known about how different financial incentives between Medicare Advantage and Medicare fee-for-service (FFS) reimbursement structures influence use of cardiovascular procedures.

OBJECTIVE

To compare regional cardiovascular procedure rates between Medicare Advantage and Medicare FFS beneficiaries.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional study of Medicare beneficiaries older than 65 years between 2003-2007 comparing rates of coronary angiography, percutaneous coronary intervention (PCI), and coronary artery bypass graft (CABG) surgery across 32 hospital referral regions in 12 states.

MAIN OUTCOMES AND MEASURES

Rates of coronary angiography, PCI, and CABG surgery.

RESULTS

We evaluated a total of 878,339 Medicare Advantage patients and 5,013,650 Medicare FFS patients. Compared with Medicare FFS patients, Medicare Advantage patients had lower age-, sex-, race-, and income-adjusted procedure rates per 1000 person-years for angiography (16.5 [95% CI, 14.8-18.2] vs 25.9 [95% CI, 24.0-27.9]; P < .001) and PCI (6.8 [95% CI, 6.0-7.6] vs 9.8 [95% CI, 9.0-10.6]; P < .001) but similar rates for CABG surgery (3.1 [95% CI, 2.8-3.5] vs 3.4 [95% CI, 3.1-3.7]; P = .33). There were no significant differences between Medicare Advantage and Medicare FFS patients in the rates per 1000 person-years of urgent angiography (3.9 [95% CI, 3.6-4.2] vs 4.3 [95% CI, 4.0-4.6]; P = .24) or PCI (2.4 [95% CI, 2.2-2.7] vs 2.7 [95% CI, 2.5-2.9]; P = .16). Procedure rates varied widely across hospital referral regions among Medicare Advantage and Medicare FFS patients. For angiography, the rates per 1000 person-years ranged from 9.8 to 40.6 for Medicare Advantage beneficiaries and from 15.7 to 44.3 for Medicare FFS beneficiaries. For PCI, the rates ranged from 3.5 to 16.8 for Medicare Advantage and from 4.7 to 16.1 for Medicare FFS. The rates for CABG surgery ranged from 1.5 to 6.1 for Medicare Advantage and from 2.5 to 6.0 for Medicare FFS. Across regions, we found no statistically significant correlation between Medicare Advantage and Medicare FFS beneficiary utilization for angiography (Spearman r = 0.19, P = .29) and modest correlations for PCI (Spearman r = 0.33, P = .06) and CABG surgery (Spearman r = 0.35, P = .05). Among Medicare Advantage beneficiaries, adjustment for additional cardiac risk factors had little influence on procedure rates.

CONCLUSIONS AND RELEVANCE

Although Medicare beneficiaries enrolled in capitated Medicare Advantage programs had lower angiography and PCI procedure rates than those enrolled in Medicare FFS, the degree of geographic variation in procedure rates was substantial among Medicare Advantage beneficiaries and was similar in magnitude to that observed among Medicare FFS beneficiaries.

Characterizing the public's preferential attitudes toward end-of-life care options: a role for the threshold technique?

OBJECTIVES

To assess the Threshold Technique's (TT) feasibility in community-wide surveys of U.S. Medicare beneficiaries' preferences for end-of-life (EOL) care options.

STUDY SETTING

Study participants were community-dwelling Medicare beneficiaries in four different regions in the United States.

STUDY DESIGN

During personal interviews, participants considered four EOL scenarios, each presenting a choice between a less intense and more intense care option.

DATA COLLECTION

Participants selected their initially favored option. Depending on that choice, in the subsequent TT the length of life offered by the more intense option was systematically increased or decreased until the participant "switched" to his or her initially rejected option.

PRINCIPAL FINDINGS

Participants were able to select an initially favored option (in 3 of the 4 scenarios; this was the less intense option). The majority of participants were able to engage with the subsequent TT. In all scenarios, regardless of the increase/decrease in the length of life offered by the more intense option, the majority of participants were unwilling to "switch" to their initially rejected option.

CONCLUSIONS

In surveys of populations' preferential attitudes toward EOL care options, the TT was a feasible elicitation method, engaging most participants and measuring the strength of their attitudes. Further methodological work is merited, involving (1) populations with various participant characteristics, and (2) different attributes in the TT task itself.

Do patients with advanced cognitive impairment admitted to hospitals with higher rates of feeding tube insertion have improved survival?

CONTEXT

Research is conflicting on whether receiving medical care at a hospital with more aggressive treatment patterns improves survival.

OBJECTIVES

The aim of this study was to examine whether nursing home residents admitted to hospitals with more aggressive patterns of feeding tube insertion had improved survival.

METHODS

Using the 1999-2007 Minimum Data Set matched to Medicare claims, we identified hospitalized nursing home residents with advanced cognitive impairment who did not have a feeding tube inserted prior to their hospital admissions. The sample included 56,824 nursing home residents and 1773 acute care hospitals nationwide. Hospitals were categorized into nine groups based on feeding tube insertion rates and whether the rates were increasing, staying the same, or decreasing between the periods of 2000-2003 and 2004-2007. Multivariate logit models were used to examine the association between the hospital patterns of feeding tube insertion and survival among hospitalized nursing home residents with advanced cognitive impairment.

RESULTS

Nearly one in five hospitals (N=366) had persistently high rates of feeding tube insertion. Being admitted to these hospitals with persistently high rates of feeding tube insertion was not associated with improved survival when compared with being admitted to hospitals with persistently low rates of feeding tube insertion. The adjusted odds ratios were 0.93 (95% confidence interval [CI]: 0.87, 1.01) and 1.02 (95% CI: 0.95, 1.09) for one-month and six-month posthospitalization survival, respectively.

CONCLUSION

Hospitals with more aggressive patterns of feeding tube insertion did not have improved survival for hospitalized nursing home residents with advanced cognitive impairment.

The association between health care quality and cost: a systematic review

BACKGROUND

Although there is broad policy consensus that both cost containment and quality improvement are critical, the association between costs and quality is poorly understood.

PURPOSE

To systematically review evidence of the association between health care quality and cost.

DATA SOURCES

Electronic literature search of PubMed, EconLit, and EMBASE databases for U.S.-based studies published between 1990 and 2012.

STUDY SELECTION

Title, abstract, and full-text review to identify relevant studies.

DATA EXTRACTION

Two reviewers independently abstracted data with differences reconciled by consensus. Studies were categorized by level of analysis, type of quality measure, type of cost measure, and method of addressing confounders.

DATA SYNTHESIS

Of 61 included studies, 21 (34%) reported a positive or mixed-positive association (higher cost associated with higher quality); 18 (30%) reported a negative or mixed-negative association; and 22 (36%) reported no difference, an imprecise or indeterminate association, or a mixed association. The associations were of low to moderate clinical significance in many studies. Of 9 studies using instrumental variables analysis to address confounding by unobserved patient health status, 7 (78%) reported a positive association, but other characteristics of these studies may have affected their findings.

LIMITATIONS

Studies used widely heterogeneous methods and measures. The review is limited by the quality of underlying studies.

CONCLUSION

Evidence of the direction of association between health care cost and quality is inconsistent. Most studies have found that the association between cost and quality is small to moderate, regardless of whether the direction is positive or negative. Future studies should focus on what types of spending are most effective in improving quality and what types of spending represent waste.

PRIMARY FUNDING SOURCE

Robert Wood Johnson Foundation.

Variation in use of dual-chamber implantable cardioverter-defibrillators: results from the national cardiovascular data registry

BACKGROUND

Among patients without an indication for a pacemaker, current evidence is inconclusive whether a dual-chamber implantable cardioverter-defibrillator (ICD) is superior to a single-chamber ICD. The current use of dual-chamber ICDs is not well characterized.

METHODS

We conducted a cross-sectional study exploring hospital-level variation in the use of dual-chamber ICDs across the United States. Patients receiving a primary prevention ICD from 2006 through 2009 without a documented indication for a pacemaker were included. Multivariate hierarchical logistic regression was used to explore patient, health care provider, and physician factors related to the use of a dual-chamber device.

RESULTS

Dual-chamber devices were implanted in 58% of the 87,115 patients without a pacing indication among 1293 hospitals, with hospital rates ranging from 0% in 33 centers to 100% in 109 centers. In multivariate analysis, geographic region was a strong independent predictor of dual-chamber device use, ranging from 36.4% in New England (reference region) to 66.4% in the Pacific region (odds ratio [OR], 5.25; 95% CI, 3.35-8.21). Hospital clustering was assessed using a median OR which was 3.96, meaning that 2 identical patients at different hospitals would have nearly a 4-fold difference in their chance of receiving a dual-chamber ICD.

CONCLUSIONS

Use of dual-chamber ICDs for the primary prevention of sudden cardiac death among patients without an indication for permanent pacing varies markedly at the hospital level in the United States. This is a clear example of how practice can vary independent of patient factors.

The importance of measuring strength-of-preference scores for health care options in preference-sensitive care

OBJECTIVE

The objective was to determine whether a paired-comparison/Leaning Scale (LS) method: 1) could feasibly be used to elicit strength-of-preference scores for elective health care options in large community-based survey settings and 2) could reveal preferential subgroups that would have been overlooked if only a categorical-response format had been used.

STUDY DESIGN

Medicare beneficiaries in four different regions of the United States were interviewed in person. Participants considered eight clinical scenarios, each with two to three different health care options. For each scenario, participants categorically selected their favored option, then indicated how strongly they favored that option relative to the alternative on a paired-comparison bidirectional LS.

RESULTS

Two hundred two participants were interviewed. For seven of the eight scenarios, a clear majority (>50%) indicated that, overall, they categorically favored one option over the alternative(s). However, the bidirectional strength-of-preference LS scores revealed that, in four scenarios, for half of those participants, their preference for the favored option was actually "weak" or "neutral."

CONCLUSION

Investigators aiming to assess population-wide preferential attitudes toward different elective health care scenarios should consider gathering ordinal-level strength-of-preference scores and could feasibly use the paired-comparison/bidirectional LS to do so.

Seniors' perceptions of health care not closely associated with physician supply

We conducted a national random survey of Medicare beneficiaries to better understand the association between the supply of physicians and patients' perceptions of their health care. We found that patients living in areas with more physicians per capita had perceptions of their health care that were similar to those of patients in regions with fewer physicians. In addition, there were no significant differences between the groups of patients in terms of numbers of visits to their personal physician in the previous year; amount of time spent with a physician; or access to tests or specialists. Our results suggest that simply training more physicians is unlikely to lead to improved access to care. Instead, focusing health policy on improving the quality and organization of care may be more beneficial.

Assessing Medicare beneficiaries' strength-of-preference scores for health care options: how engaging does the elicitation technique need to be?

OBJECTIVE

The objective was to determine if participants' strength-of-preference scores for elective health care interventions at the end-of-life (EOL) elicited using a non-engaging technique are affected by their prior use of an engaging elicitation technique.

DESIGN

Medicare beneficiaries were randomly selected from a larger survey sample. During a standardized interview, participants considered four scenarios involving a choice between a relatively less- or more-intense EOL intervention. For each scenario, participants indicated their favoured intervention, then used a 7-point Leaning Scale (LS1) to indicate how strongly they preferred their favoured intervention relative to the alternative. Next, participants engaged in a Threshold Technique (TT), which, depending on the participant's initially favoured intervention, systematically altered a particular attribute of the scenario until the participant switched preferences. Finally, they repeated the LS (LS2) to indicate how strongly they preferred their initially-favoured intervention.

RESULTS

Two hundred and two participants were interviewed (189-198 were included in this study). The concordance of individual participants' LS1 and LS2 scores was assessed using Kendall tau-b correlation coefficients; scores of 0.74, 0.84, 0.85 and 0.89 for scenarios 1-4, respectively, were observed.

CONCLUSION

Kendall tau-b statistics indicate a high concordance between LS scores, implying that the interposing engaging TT exercise had no significant effects on the LS2 strength-of-preference scores. Future investigators attempting to characterize the distributions of strength-of-preference scores for EOL care from a large, diverse community could use non-engaging elicitation methods. The potential limitations of this study require that further investigation be conducted into this methodological issue.

Regional variations in physicians' attitudes and recommendations surrounding implantable cardioverter-defibrillators

INTRODUCTION

This study was designed to determine if physicians' attitudes and recommendations surrounding implantable cardioverter-defibrillators (ICDs) are regionally associated with ICD use.

METHODS AND RESULTS

A national sample of 9969 members of the American College of Cardiology was surveyed electronically. Responses were merged with rates of ICD implantation from the National Cardiovascular Data Registry. Multivariable regression was used to assess trends between regional use and responses. We received 1210 responses (12%) and used 1124 after exclusions. Across regions, physicians were equally likely to recommend ICDs to males or females with ischemic (∼99% for both; P = NS) or nonischemic cardiomyopathy (85 vs. 88% P = 0.85). Significant increasing trends in the probability recommending ICD therapy were found when the patient was "frail" (21% to 32%; P = .03) or had a life expectancy <1 year (5% to 10%; P = .05). These differences were not associated with attitudes toward ICDs.

CONCLUSIONS

Independent of variations in physicians' attitudes towards ICDs, physicians in regions of low ICD use are not less likely to recommend ICDs in situations clearly supported by guidelines while those in regions of high ICD use are more likely to recommend ICDs to patients who might have limited benefit.

Regional variation in the use of implantable cardioverter-defibrillators for primary prevention: results from the National Cardiovascular Data Registry

BACKGROUND

Although the use of implantable cardioverter-defibrillators (ICDs) for the primary prevention of sudden cardiac death varies by sex, race, and hospital, geographic variation in ICD use remains unexplored. Our objective was to quantify regional variations in the utilization of primary prevention ICDs in the United States, and to evaluate if an association exists between utilization and physician supply or the proportion of patients meeting the trial inclusion criteria.

METHODS AND RESULTS

This is a cross-sectional analysis among the Medicare, fee-for-service population from the National Cardiovascular Data Registry. Using hospital referral regions, we calculated the age-, sex-, and race-adjusted rates of ICD placement for each region and assessed the correlation between these rates and (1) physician supply and (2) the proportion of patients meeting trial inclusion criteria. Substantial variation was found across quintiles of rate ratios of ICD implantation, ranging from 0.39 to 1.77 (compared with a national mean rate of 1.0). This ratio was not correlated with the supply of cardiologists (R(2)=0.01), electrophysiologists (R(2)=0.01), or with the proportion of patients meeting trial inclusion criteria (R(2)<0.01). Over all, 13% of all patients receiving ICDs did not meet trial criteria.

CONCLUSIONS

Marked geographic variation in the use of primary prevention ICDs exists across the United States that is not correlated with physician supply. Although >1 in 10 patients received ICDs outside of trial criteria, this potential overuse did not explain the variation. Future studies should consider underuse or misuse of primary prevention ICDs as causes of geographic variation.

Regional variations in palliative care: do cardiologists follow guidelines?

OBJECTIVES

Regional variation in health care use in the last 6 months of life is well documented. Our objective was to examine whether an association exists between cardiologists' tendencies to discuss palliative care for patients with advanced heart failure and the regional use of health care in the last 6 months of life.

METHODS

We performed a national mail survey of a random sample of 994 eligible Cardiologists from the American Medical Association Masterfile. Hypothetical patient scenarios were used to explore physician management of patient scenarios.

RESULTS

We received 614 responses (response rate: 62%). In a 75-year-old with symptomatic chronic heart failure and asymptomatic nonsustained ventricular tachycardia, cardiologists in regions with high use in the last 6 months of life were less likely to have discussions about palliative care (23% versus 32% for comparisons between the highest and lowest quintiles, p = 0.04). Similarly, in an 85 year-old with symptomatic chronic heart failure and an acute exacerbation, cardiologists in high use regions were less likely to have discussions about palliative care (35% versus 47%, p = 0.0008).

CONCLUSIONS

Despite professional guidelines suggesting that cardiologists discuss palliative care with patients with late stage heart failure, less than half of cardiologists would discuss palliative care in two elderly patients with late-stage heart failure and this guideline discordance was worse in the regions with more health care use in the last 6 months of life.

Market variations in intensity of Medicare service use and beneficiary experiences with care

OBJECTIVE

Examine associations between patient experiences with care and service use across markets.

DATA SOURCES/STUDY SETTING

Medicare fee-for-service (FFS) and managed care (Medicare Advantage [MA]) beneficiaries in 306 markets from the 2003 Consumer Assessments of Healthcare Providers and Systems (CAHPS) surveys. Resource use intensity is measured by the 2003 end-of-life expenditure index.

STUDY DESIGN

We estimated correlations and linear regressions of eight measures of case-mix-adjusted beneficiary experiences with intensity of service use across markets.

DATA COLLECTION/EXTRACTION

We merged CAHPS data with service use data, excluding beneficiaries under 65 years of age or receiving Medicaid.

PRINCIPAL FINDINGS

Overall, higher intensity use was associated (p<.05) with worse (seven measures) or no better care experiences (two measures). In higher-intensity markets, Medicare FFS and MA beneficiaries reported more problems getting care quickly and less helpful office staff. However, Medicare FFS beneficiaries in higher-intensity markets reported higher overall ratings of their personal physician and main specialist. Medicare MA beneficiaries in higher-intensity markets also reported worse quality of communication with physicians, ability to get needed care, and overall ratings of care.

CONCLUSIONS

Medicare beneficiaries in markets characterized by high service use did not report better experiences with care. This trend was strongest for those in managed care.

Variation in cardiologists' propensity to test and treat: is it associated with regional variation in utilization?

BACKGROUND

Regional variation in healthcare utilization, including cardiac testing and procedures, is well documented. Some factors underlying such variation are understood, including resource supply. However, less is known about how physician behaviors and attitudes may influence variation in utilization across regions.

METHODS AND RESULTS

We performed a survey of a national sample of cardiologists using patients vignettes to ascertain physicians' self-reported propensity to test and treat patients with cardiovascular problems, computing a Cardiac Intensity Score for each physician based on his/her responses intended to measure the physician's propensity to recommend high-tech and/or invasive tests and treatments. In addition, we asked under what circumstances they would order a cardiac catheterization "for other than purely clinical reasons." For some survey items, there was substantial variation in physician responses. We found that the Cardiac Intensity Score was associated with 2 measures of population based healthcare utilization measured within geographic regions, with a stronger association with general healthcare spending than with delivery of cardiac services. Although nearly all physicians denied ordering a potentially unnecessary cardiac catheterization for financial reasons, some physicians acknowledged ordering the test for other reasons, including meeting patient and referring physician expectations, meeting peer expectations, and malpractice concerns. More than 27% of respondents reported ordering a cardiac catheterization if a colleague would in the same situation frequently or sometimes, and nearly 24% reported doing so out of fear of malpractice. These 2 factors were significantly associated with the propensity to test and treat, but only fear of malpractice was associated with regional utilization.

CONCLUSIONS

Variability in cardiologists' propensity to test and treat partly underlies regional variation in utilization of general health and cardiology services. The factor most closely associated with this propensity was fear of malpractice suits. This factor may be an appropriate target of intervention.

How much do patients' preferences contribute to resource use?

Regional variation in health care use may stem, in part, from the fact that patients in high-utilization regions demand and receive more-intensive care. We examine the association between patients' care-seeking preferences and use of services, using a national survey of Medicare patients. Patients' preferences, in addition to health and sociodemographic characteristics, are associated with differences in individuals' use of office visits. However, we find that patients' preferences for seeking primary and specialty medical care do not play a significant role in explaining regional variation in health care use.

Racial and ethnic differences in preferences for end-of-life treatment

BACKGROUND

Studies using local samples suggest that racial minorities anticipate a greater preference for life-sustaining treatment when faced with a terminal illness. These studies are limited by size, representation, and insufficient exploration of sociocultural covariables.

OBJECTIVE

To explore racial and ethnic differences in concerns and preferences for medical treatment at the end of life in a national sample, adjusting for sociocultural covariables.

DESIGN

Dual-language (English/Spanish), mixed-mode (telephone/mail) survey.

PARTICIPANTS

A total of 2,847 of 4,610 eligible community-dwelling Medicare beneficiaries age 65 or older on July 1, 2003 (62% response).

MEASUREMENTS

Demographics, education, financial strain, health status, social networks, perceptions of health-care access, quality, and the effectiveness of mechanical ventilation (MV), and concerns and preferences for medical care in the event the respondent had a serious illness and less than 1 year to live.

RESULTS

Respondents included 85% non-Hispanic whites, 4.6% Hispanics, 6.3% blacks, and 4.2% "other" race/ethnicity. More blacks (18%) and Hispanics (15%) than whites (8%) want to die in the hospital; more blacks (28%) and Hispanics (21.2%) than whites (15%) want life-prolonging drugs that make them feel worse all the time; fewer blacks (49%) and Hispanics (57%) than whites (74%) want potentially life-shortening palliative drugs, and more blacks (24%, 36%) and Hispanics (22%, 29%) than whites (13%, 21%) want MV for life extension of 1 week or 1 month, respectively. In multivariable analyses, sociodemographic variables, preference for specialists, and an overly optimistic belief in the effectiveness of MV explained some of the greater preferences for life-sustaining drugs and mechanical ventilation among non-whites. Black race remained an independent predictor of concern about receiving too much treatment [adjusted OR = 2.0 (1.5-2.7)], preference for dying in a hospital [AOR = 2.3 (1.6-3.2)], receiving life-prolonging drugs [1.9 (1.4-2.6)], MV for 1 week [2.3 (1.6-3.3)] or 1 month's [2.1 (1.6-2.9)] life extension, and a preference not to take potentially life-shortening palliative drugs [0.4 (0.3-0.5)]. Hispanic ethnicity remained an independent predictor of preference for dying in the hospital [2.2 (1.3-4.0)] and against potentially life-shortening palliative drugs [0.5 (0.3-0.7)].

CONCLUSIONS

Greater preference for intensive treatment near the end of life among minority elders is not explained fully by confounding sociocultural variables. Still, most Medicare beneficiaries in all race/ethnic groups prefer not to die in the hospital, to receive life-prolonging drugs that make them feel worse all the time, or to receive MV.

Fostering accountable health care: moving forward in medicare

To succeed, health care reform must slow spending growth while improving quality. We propose a new approach to help achieve more integrated and efficient care by fostering local organizational accountability for quality and costs through performance measurement and "shared savings" payment reform. The approach is practical and feasible: it is voluntary for providers, builds on current referral patterns, requires no change in benefits or lock-in for beneficiaries, and offers the possibility of sustained provider incomes even as total costs are constrained. We simulate the potential expenditure impact and show that significant Medicare savings are possible.