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Normand SLT, Zelevinsky K, Abing HK, Horvitz-Lennon M. Statistical Approaches for Quantifying the Quality of Neurosurgical Care. World Neurosurg 2022; 161:331-342.e1. [PMID: 35505552 PMCID: PMC9074098 DOI: 10.1016/j.wneu.2022.01.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 01/10/2022] [Accepted: 01/11/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Quantifying quality of health care can provide valuable information to patients, providers, and policy makers. However, the observational nature of measuring quality complicates assessments. METHODS We describe a conceptual model for defining quality and its implications about the data collected, how to make inferences about quality, and the assumptions required to provide statistically valid estimates. Twenty-one binary or polytomous quality measures collected from 101,051 adult Medicaid beneficiaries aged 18-64 years with schizophrenia from 5 U.S. states show methodology. A categorical principal components analysis establishes dimensionality of quality, and item response theory models characterize the relationship between each quality measure and a unidimensional quality construct. Latent regression models estimate racial/ethnic and geographic quality disparities. RESULTS More than 90% of beneficiaries filled at least 1 antipsychotic prescription and 19% were hospitalized for schizophrenia during a 12-month observational period in our multistate cohort with approximately 2/3 nonwhite beneficiaries. Four quality constructs emerged: inpatient, emergency room, pharmacologic/ambulatory, and ambulatory only. Using a 2-parameter logistic model, pharmacologic/ambulatory care quality varied from -2.35 to 1.26 (higher = better quality). Black and Latinx beneficiaries had lower pharmacologic/ambulatory quality compared with whites. Race/ethnicity modified the association of state and pharmacologic/ambulatory care quality in latent regression modeling. Average quality ranged from -0.28 (95% confidence interval, -2.15 to 1.04) for blacks in New Jersey to 0.46 [95% confidence interval, -0.89 to 1.40] for whites in Michigan. CONCLUSIONS By combining multiple quality measures using item response theory models, a composite measure can be estimated that has more statistical power to detect differences among subjects than the observed mean per subject.
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Affiliation(s)
- Sharon-Lise T Normand
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, USA; Department of Biostatistics, Harvard Chan School of Public Health, Boston, Massachusetts, USA.
| | - Katya Zelevinsky
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, USA
| | - Haley K Abing
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, USA
| | - Marcela Horvitz-Lennon
- RAND Corporation, Boston, Massachusetts, USA; Cambridge Health Alliance, Cambridge, Massachusetts, USA
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Cook BL, Kim G, Morgan KL, Chen CN, Nillni A, Alegría M. Measuring Geographic "Hot Spots" of Racial/Ethnic Disparities: An Application to Mental Health Care. J Health Care Poor Underserved 2018; 27:663-84. [PMID: 27180702 DOI: 10.1353/hpu.2016.0091] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
This article identifies geographic "hot spots" of racial/ethnic disparities in mental health care access. Using data from the 2001-2003 Collaborative Psychiatric Epidemiology Surveys(CPES), we identified metropolitan statistical areas(MSAs) with the largest mental health care access disparities ("hot spots") as well as areas without disparities ("cold spots"). Racial/ethnic disparities were identified after adjustment for clinical need. Richmond, Virginia and Columbus, Georgia were found to be hot spots for Black-White disparities, regardless of method used. Fresno, California and Dallas, Texas were ranked as having the highest Latino-White disparities and Riverside, California and Houston, Texas consistently ranked high in Asian-White mental health care disparities across different methods. We recommend that institutions and government agencies in these "hot spot" areas work together to address key mechanisms underlying these disparities. We discuss the potential and limitations of these methods as tools for understanding health care disparities in other contexts.
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Innovative technologies and social inequalities in health: A scoping review of the literature. PLoS One 2018; 13:e0195447. [PMID: 29614114 PMCID: PMC5882163 DOI: 10.1371/journal.pone.0195447] [Citation(s) in RCA: 110] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 03/22/2018] [Indexed: 11/19/2022] Open
Abstract
The aim of this study was to systematically review the range, nature, and extent of current research activity exploring the influence of innovative health-related technologies on social inequalities in health, with specific focus on a deeper understanding of the variables used to measure this connection and the pathways leading to the (re)production of inequalities. A review process was conducted, based on scoping review techniques, searching literature published from January 1, 1996 to November 25, 2016 using MEDLINE, Scopus, and ISI web of science. Search, sorting, and data extraction processes were conducted by a team of researchers and experts using a dynamic, reflexive examination process. Of 4139 studies collected from the search process, a total of 33 were included in the final analysis. Results of this study include the classification of technologies based on how these technologies are accessed and used by end users. In addition to the factors and mechanisms that influence unequal access to technologies, the results of this study highlight the importance of variations in use that importantly shape social inequalities in health. Additionally, focus on health care services technologies must be accompanied by investigating emerging technologies influencing healthy lifestyle, genomics, and personalized devices in health. Findings also suggest that choosing one measure of social position over another has important implications for the interpretation of research results. Furthermore, understanding the pathways through which various innovative health technologies reduce or (re)produce social inequalities in health is context dependent. In order to better understand social inequalities in health, these contextual variations draw attention to the need for critical distinctions between technologies based on how these various technologies are accessed and used. The results of this study provide a comprehensive starting point for future research to further investigate how innovative technologies may influence the unequal distribution of health as a human right.
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Jones AL, Cochran SD, Leibowitz A, Wells KB, Kominski G, Mays VM. Racial, Ethnic, and Nativity Differences in Mental Health Visits to Primary Care and Specialty Mental Health Providers: Analysis of the Medical Expenditures Panel Survey, 2010-2015. Healthcare (Basel) 2018; 6:healthcare6020029. [PMID: 29565323 PMCID: PMC6023347 DOI: 10.3390/healthcare6020029] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Revised: 03/10/2018] [Accepted: 03/15/2018] [Indexed: 11/26/2022] Open
Abstract
Background. Black and Latino minorities have traditionally had poorer access to primary care than non-Latino Whites, but these patterns could change with the Affordable Care Act (ACA). To guide post-ACA efforts to address mental health service disparities, we used a nationally representative sample to characterize baseline race-, ethnicity-, and nativity-associated differences in mental health services in the context of primary care. Methods. Data were obtained from the Medical Expenditures Panel Survey (MEPS), a two-year panel study of healthcare use, satisfaction with care, and costs of services in the United States (US). We pooled data from six waves (14–19) of participants with serious psychological distress to examine racial, ethnic, and nativity disparities in medical and mental health visits to primary care (PC) and specialty mental health (SMH) providers around the time of ACA reforms, 2010–2015. Results. Of the 2747 respondents with serious psychological distress, 1316 were non-Latino White, 632 non-Latino Black, 532 identified as Latino with Mexican, Central American, or South American (MCS) origins, and 267 as Latino with Caribbean island origins; 525 were foreign/island born. All racial/ethnic groups were less likely than non-Latino Whites to have any PC visit. Of those who used PC, non-Latino Blacks were less likely than Whites to have a PC mental health visit, while foreign born MCS Latinos were less likely to visit an SMH provider. Conditional on any mental health visit, Latinos from the Caribbean were more likely than non-Latino Whites to visit SMH providers versus PC providers only, while non-Latino Blacks and US born MCS Latinos received fewer PC mental health visits than non-Latino Whites. Conclusion. Racial-, ethnic-, and nativity-associated disparities persist in PC provided mental health services.
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Affiliation(s)
- Audrey L Jones
- Informatics, Decision-Enhancement and Analytic Sciences Center (IDEAS 2.0), VA Salt Lake City Health Care System, Salt Lake City, UT 84148, USA.
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT 84132, USA.
| | - Susan D Cochran
- Department of Epidemiology, Jonathan and Karin Fielding School of Public Health, University of California, Los Angeles (UCLA), CA 90095, USA.
- Department of Statistics, University of California, Los Angeles, CA 90095, USA.
- UCLA Center for Bridging Research Innovation, Training and Education for Minority Health Disparities Solutions, Los Angeles, CA 90095, USA.
| | - Arleen Leibowitz
- UCLA Luskin School of Public Affairs, Los Angeles, CA 90095, USA.
| | - Kenneth B Wells
- UCLA David Geffen School of Medicine, Los Angeles, CA 90095, USA.
- UCLA Center for Health Services and Society, Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA 90095, USA.
- Department of Health Policy and Management, Jonathan and Karin Fielding School of Public Health, University of California, Los Angeles, CA 90095, USA.
| | - Gerald Kominski
- Department of Health Policy and Management, Jonathan and Karin Fielding School of Public Health, University of California, Los Angeles, CA 90095, USA.
- UCLA Center for Health Policy Research, Los Angeles, CA 90024, USA.
| | - Vickie M Mays
- UCLA Center for Bridging Research Innovation, Training and Education for Minority Health Disparities Solutions, Los Angeles, CA 90095, USA.
- Department of Health Policy and Management, Jonathan and Karin Fielding School of Public Health, University of California, Los Angeles, CA 90095, USA.
- Department of Psychology, University of California, Los Angeles, CA 90095, USA.
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Jackson JW, Fulchino L, Rogers J, Mogun H, Polinski J, Henderson DC, Schneeweiss S, Fischer MA. "Impact of drug-reimbursement policies on prescribing: A case-study of a newly marketed long-acting injectable antipsychotic among relapsed schizophrenia patients". Pharmacoepidemiol Drug Saf 2017; 27:95-104. [PMID: 29168261 DOI: 10.1002/pds.4354] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Revised: 10/17/2017] [Accepted: 10/18/2017] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To quantify and explain variation in use of long-acting injectable antipsychotics (LAIs) in the United States, and understand the relationship between patient characteristics, drug reimbursement policies, and LAI prescribing after relapse. METHODS A cohort of recently relapsed patients with schizophrenia ages 18 to 64, were identified immediately after discharge from a related inpatient hospitalization, partial hospitalization, or emergency room visit, drawn from 2004 to 2006 Medicaid claims, and followed for 90 days until LAI initiation. Data on state-level Medicaid prior authorization (PA) policies for LAIs were collected. Sequential longitudinal Poisson regression models were developed to understand the relationship between patient and PA policy variables and LAI prescribing, including prior adherence to oral antipsychotics, demographics, clinical variables, and presence of PA policy for LAI. RESULTS Among 36 282 patients, 3.1% received risperidone LAI, and 3.8% received a first-generation (FGA) LAI with wide variation across states. Prior adherence ranged from 29% to 89% but was marginally associated with initiation and did not explain variation for LAI prescribing. FGA initiation was associated with geography and race/ethnicity but not PA policy. For risperidone LAI initiation, demographics and clinical factors explained, respectively, 5.0% and 3.0% of the variation; PA policy had a large negative association with initiation (RR = 0.41; 95%CI 0.20-0.87) and explained 8.4% of the variation. CONCLUSIONS PA policies may represent a major treatment barrier for risperidone LAI among relapsed patients. Non-adherence plays a little role in predicting which patients receive LAIs. Policy makers and health insurers will need to consider these findings when guiding the use of LAIs. KEY POINTS Among a nationwide cohort of relapsed schizophrenia patients enrolled in US Medicaid, 3.1% received Risperdal Consta, a long-acting injectable antipsychotic (LAI), and 3.8% initiated a first-generation first-generation LAI within 90 days after discharge. During 2004 to 2006, there was marked variation in 90 day post-relapse initiation of Risperdal-Consta-a newly marketed medication during this period-and also marked variation in 90 day post-relapse initiation of any first-generation LAI, which appeared to be associated with race/ethnicity and geography. Prior authorization policies were associated with substantially lower initiation of Risperdal Consta in this cohort of relapsed patients even after accounting for clinical indication (non-adherence), relapse history, demographics, adjunctive medication, and mental health service use.
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Affiliation(s)
- John W Jackson
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.,Schizophrenia Research Program, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA.,Harvard T.H. Chan School of Public Health, Department of Epidemiology, Boston, MA, USA
| | - Lisa Fulchino
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - James Rogers
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Helen Mogun
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Jennifer Polinski
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.,CVS Caremark Corporation, Woonsocket, RI, USA
| | - David C Henderson
- Schizophrenia Research Program, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Sebastian Schneeweiss
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.,Harvard T.H. Chan School of Public Health, Department of Epidemiology, Boston, MA, USA
| | - Michael A Fischer
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
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Cook BL, Trinh NH, Li Z, Hou SSY, Progovac AM. Trends in Racial-Ethnic Disparities in Access to Mental Health Care, 2004-2012. Psychiatr Serv 2017; 68:9-16. [PMID: 27476805 PMCID: PMC5895177 DOI: 10.1176/appi.ps.201500453] [Citation(s) in RCA: 268] [Impact Index Per Article: 38.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE This study compared trends in racial-ethnic disparities in mental health care access among whites, blacks, Hispanics, and Asians by using the Institute of Medicine definition of disparities as all differences except those due to clinical appropriateness, clinical need, and patient preferences. METHODS Racial-ethnic disparities in mental health care access were examined by using data from a nationally representative sample of 214,597 adults from the 2004-2012 Medical Expenditure Panel Surveys. The main outcome measures included three mental health care access measures (use of any mental health care, any outpatient care, and any psychotropic medication in the past year). RESULTS Significant disparities were found in 2004-2005 and in 2011-2012 for all three racial-ethnic minority groups compared with whites in all three measures of access. Between 2004 and 2012, black-white disparities in any mental health care and any psychotropic medication use increased, respectively, from 8.2% to 10.8% and from 7.6% to 10.0%. Similarly, Hispanic-white disparities in any mental health care and any psychotropic medication use increased, respectively, from 8.4% to 10.9% and 7.3% to 10.3%. CONCLUSIONS No reductions in racial-ethnic disparities in access to mental health care were identified between 2004 and 2012. For blacks and Hispanics, disparities were exacerbated over this period. Clinical interventions that improve identification of symptoms of mental illness, expansion of health insurance, and other policy interventions that remove financial barriers to access may help to reduce these disparities.
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Affiliation(s)
- Benjamin Lê Cook
- Dr. Cook is with the Department of Psychiatry, Harvard Medical School, Boston (e-mail: ). He is also with the Center for Multicultural Mental Health Research, Cambridge Health Alliance, Cambridge, Massachusetts, where Ms. Hou and Dr. Progovac are affiliated. Dr. Progovac is also with the Department of Health Care Policy, Harvard Medical School, Boston. Dr. Trinh is with the Department of Psychiatry, Massachusetts General Hospital, Boston. Ms. Li is with the Department of Global Health and Population, Harvard School of Public Health, Boston
| | - Nhi-Ha Trinh
- Dr. Cook is with the Department of Psychiatry, Harvard Medical School, Boston (e-mail: ). He is also with the Center for Multicultural Mental Health Research, Cambridge Health Alliance, Cambridge, Massachusetts, where Ms. Hou and Dr. Progovac are affiliated. Dr. Progovac is also with the Department of Health Care Policy, Harvard Medical School, Boston. Dr. Trinh is with the Department of Psychiatry, Massachusetts General Hospital, Boston. Ms. Li is with the Department of Global Health and Population, Harvard School of Public Health, Boston
| | - Zhihui Li
- Dr. Cook is with the Department of Psychiatry, Harvard Medical School, Boston (e-mail: ). He is also with the Center for Multicultural Mental Health Research, Cambridge Health Alliance, Cambridge, Massachusetts, where Ms. Hou and Dr. Progovac are affiliated. Dr. Progovac is also with the Department of Health Care Policy, Harvard Medical School, Boston. Dr. Trinh is with the Department of Psychiatry, Massachusetts General Hospital, Boston. Ms. Li is with the Department of Global Health and Population, Harvard School of Public Health, Boston
| | - Sherry Shu-Yeu Hou
- Dr. Cook is with the Department of Psychiatry, Harvard Medical School, Boston (e-mail: ). He is also with the Center for Multicultural Mental Health Research, Cambridge Health Alliance, Cambridge, Massachusetts, where Ms. Hou and Dr. Progovac are affiliated. Dr. Progovac is also with the Department of Health Care Policy, Harvard Medical School, Boston. Dr. Trinh is with the Department of Psychiatry, Massachusetts General Hospital, Boston. Ms. Li is with the Department of Global Health and Population, Harvard School of Public Health, Boston
| | - Ana M Progovac
- Dr. Cook is with the Department of Psychiatry, Harvard Medical School, Boston (e-mail: ). He is also with the Center for Multicultural Mental Health Research, Cambridge Health Alliance, Cambridge, Massachusetts, where Ms. Hou and Dr. Progovac are affiliated. Dr. Progovac is also with the Department of Health Care Policy, Harvard Medical School, Boston. Dr. Trinh is with the Department of Psychiatry, Massachusetts General Hospital, Boston. Ms. Li is with the Department of Global Health and Population, Harvard School of Public Health, Boston
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Horvitz-Lennon M, Volya R, Garfield R, Donohue JM, Lave JR, Normand SLT. Where You Live Matters: Quality and Racial/Ethnic Disparities in Schizophrenia Care in Four State Medicaid Programs. Health Serv Res 2015; 50:1710-29. [PMID: 25759240 DOI: 10.1111/1475-6773.12296] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To determine whether (a) quality in schizophrenia care varies by race/ethnicity and over time and (b) these patterns differ across counties within states. DATA SOURCES Medicaid claims data from California, Florida, New York, and North Carolina during 2002-2008. STUDY DESIGN We studied black, Latino, and white Medicaid beneficiaries with schizophrenia. Hierarchical regression models, by state, quantified person and county effects of race/ethnicity and year on a composite quality measure, adjusting for person-level characteristics. PRINCIPAL FINDINGS Overall, our cohort included 164,014 person-years (41-61 percent non-whites), corresponding to 98,400 beneficiaries. Relative to whites, quality was lower for blacks in every state and also lower for Latinos except in North Carolina. Temporal improvements were observed in California and North Carolina only. Within each state, counties differed in quality and disparities. Between-county variation in the black disparity was larger than between-county variation in the Latino disparity in California, and smaller in North Carolina; Latino disparities did not vary by county in Florida. In every state, counties differed in annual changes in quality; by 2008, no county had narrowed the initial disparities. CONCLUSIONS For Medicaid beneficiaries living in the same state, quality and disparities in schizophrenia care are influenced by county of residence for reasons beyond patients' characteristics.
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Affiliation(s)
| | - Rita Volya
- Department of Health Care Policy, Harvard Medical School, Boston, MA
| | | | - Julie M Donohue
- Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Judith R Lave
- Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Sharon-Lise T Normand
- Department of Health Care Policy, Harvard Medical School, Boston, MA.,Department of Biostatistics, Harvard School of Public Health, Boston, MA
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Horvitz-Lennon M, Volya R, Donohue JM, Lave JR, Stein BD, Normand SLT. Disparities in quality of care among publicly insured adults with schizophrenia in four large U.S. states, 2002-2008. Health Serv Res 2014; 49:1121-44. [PMID: 24628414 DOI: 10.1111/1475-6773.12162] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE To examine racial/ethnic disparities in quality of schizophrenia care and assess the size of observed disparities across states and over time. DATA SOURCES Medicaid claims data from CA, FL, NY, and NC. STUDY DESIGN Observational repeated cross-sectional panel cohort study of white, black, and Latino fee-for-service adult beneficiaries with schizophrenia. Main outcome was the relationship of race/ethnicity and year with a composite measure of quality of schizophrenia care derived from 14 evidence-based quality indicators. PRINCIPAL FINDINGS Quality was assessed for 325,373 twelve-month person-episodes between 2002 and 2008, corresponding to 123,496 Medicaid beneficiaries. In 2002, quality was lowest for blacks in all states. With the exception of FL, quality was lower for Latinos than whites. In CA, blacks had about 43 percent of the individual indicators met compared to 58 percent for whites. Quality improved annually for all groups in CA, NY, and NC. While in CA the improvement was slightly larger for Latinos, in FL quality improved for blacks but declined for Latinos and whites. CONCLUSIONS Quality of schizophrenia care is poor and racial/ethnic disparities exist among Medicaid beneficiaries from four states. The size of the disparities varied across the states, and most of the initial disparities were unchanged by 2008.
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