Impact of health insurance education program on health care professional students: An interventional study

In the complex landscape of health care, the relationship between medical practice and health insurance is increasingly crucial for effective care delivery. This paper emphasises the importance of integrating health insurance education into medical training, focusing on its impact on patient outcomes, health care accessibility, and system sustainability. It posits that health care providers with a comprehensive understanding of health insurance can offer more informed, efficient care by adeptly navigating coverage complexities. The study utilised a pretest-post-test design with a yearlong health insurance education curriculum at Wake Forest University School of Medicine. Student participants from various medical programmes self-assessed their knowledge and comfort across 13 health insurance topics before and after the intervention. The curriculum included workshops and a capstone project, emphasising real-life patient insurance challenges. Results show statistically significant improvements in 13 participants' understanding of health insurance concepts, highlighting the curriculum's effectiveness. The findings advocate for the inclusion of health insurance education in medical curricula. Such knowledge is vital in systems with diverse insurance models, like the United States, where understanding insurance intricacies is key to patient care. The study's limitations, such as a small sample size and reliance on self-reported data, suggest the need for further research with more participants and objective measures. In conclusion, incorporating health insurance education into medical training is essential for preparing health care professionals to navigate insurance complexities, make informed treatment decisions, and guide patients effectively. This approach fosters well-rounded professionals capable of managing both medical and financial aspects of patient care, leading to more equitable and efficient health care delivery. Future research should explore the long-term effects of this education on clinical practice and patient outcomes, particularly its impact on health care costs and patient satisfaction.

The Association of Frailty and Neighborhood Disadvantage with Emergency Department Visits and Hospitalizations in Older Adults

BACKGROUND

Risk stratification and population management strategies are critical for providing effective and equitable care for the growing population of older adults in the USA. Both frailty and neighborhood disadvantage are constructs that independently identify populations with higher healthcare utilization and risk of adverse outcomes.

OBJECTIVE

To examine the joint association of these factors on acute healthcare utilization using two pragmatic measures based on structured data available in the electronic health record (EHR).

DESIGN

In this retrospective observational study, we used EHR data to identify patients aged ≥ 65 years at Atrium Health Wake Forest Baptist on January 1, 2019, who were attributed to affiliated Accountable Care Organizations. Frailty was categorized through an EHR-derived electronic Frailty Index (eFI), while neighborhood disadvantage was quantified through linkage to the area deprivation index (ADI). We used a recurrent time-to-event model within a Cox proportional hazards framework to examine the joint association of eFI and ADI categories with healthcare utilization comprising emergency visits, observation stays, and inpatient hospitalizations over one year of follow-up.

KEY RESULTS

We identified a cohort of 47,566 older adults (median age = 73, 60% female, 12% Black). There was an interaction between frailty and area disadvantage (P = 0.023). Each factor was associated with utilization across categories of the other. The magnitude of frailty's association was larger than living in a disadvantaged area. The highest-risk group comprised frail adults living in areas of high disadvantage (HR 3.23, 95% CI 2.99-3.49; P < 0.001). We observed additive effects between frailty and living in areas of mid- (RERI 0.29; 95% CI 0.13-0.45; P < 0.001) and high (RERI 0.62, 95% CI 0.41-0.83; P < 0.001) neighborhood disadvantage.

CONCLUSIONS

Considering both frailty and neighborhood disadvantage may assist healthcare organizations in effectively risk-stratifying vulnerable older adults and informing population management strategies. These constructs can be readily assessed at-scale using routinely collected structured EHR data.

Patient Characteristics Associated with Telemedicine Use for Diabetes Mellitus Care: Experience of a University Health System

OBJECTIVES

The objective was to understand the characteristics of patients who used telemedicine for diabetes management to inform future implementation of telemedicine.

METHODS

We examined patient characteristics associated with telemedicine use for diabetes mellitus (DM) care between March 1, 2020 and April 1, 2021 (the coronavirus disease 2019 pandemic period) in a large university health system when telemedicine visits increased rapidly. Logistic regression models assessed patient characteristics associated with telemedicine visits and delays in DM process measures (hemoglobin A1c checks, nephropathy, and retinopathy evaluations) during the pandemic period after adjusting for potential confounders and corresponding values before the pandemic period (March 1, 2019-February 29, 2020).

RESULTS

A total of 45,159 patients were seen from 987,791 visits during the pandemic period. The number of visits averaged one visit less during the pandemic period than before the pandemic period. Approximately 5.4% of patients used telemedicine during the pandemic period from 42,750 visits. The mean (standard deviation) telemedicine visit was 1.28 (0.91). Men, Asian, Black, and other race (vs White), having Medicare or uninsured (vs private insurance), were less likely to use telemedicine. Patients with more visits before the pandemic period were more likely to use telemedicine and less likely to experience a delay in DM process measures during the pandemic period. Telemedicine users were 18% less likely to experience a delay in nephropathy visits than nonusers, but without difference for other process measures.

CONCLUSIONS

Race, sex, insurance, and prepandemic in-person visits were associated with telemedicine use for DM management in a large health system. Telemedicine use was not associated with delays in hemoglobin A1c testing, nephropathy, and retinopathy assessments. Understanding reasons for not using telemedicine is important to be able to deliver equitable DM care.

The Prevalence of Low-Value Prostate Cancer Screening in Primary Care Clinics: A Study Using the National Ambulatory Medical Care Survey

INTRODUCTION

There has been an increasing focus on improving value in health care and deimplementing the use of low-value services, such as prostate cancer (PC) screening for men aged >70 years. The objectives of this study are to (1) identify the proportion of primary care visits at which low-value PC screening is ordered, and (2) identify predisposing, enabling, and health care need characteristics associated with low-value PC screening in the United States. METHODS: This was a secondary analysis of the National Ambulatory Medicare Care Survey datasets from 2013 to 2016 and 2018. Andersen's Behavioral Model of Health Services Use guided independent variable selection. Weighted multivariable logit models were used to analyze data. RESULTS: There were 6.71 low-value prostate-specific antigens (PSAs) per 100 visits and 1.65 low-value digital rectal exams (DREs) per 100 visits. For each additional service ordered by primary care providers, the odds of ordering a low-value PSA increased by 49%, and the odds of performing a low-value DRE increased by 37%. CONCLUSIONS: The use of low-value PSAs and DREs was sizable during the observed time period. Organizations who want to reduce low-value PSAs and DREs may want to focus interventions on providers who order a high number of tests.

Insurance and Geographic Variations in Non-invasive Prenatal Testing

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Impact of the COVID-19 Pandemic on Diabetes Care Among a North Carolina Patient Population

In this study, researchers reviewed electronic health record data to assess whether the coronavirus disease 2019 pandemic was associated with disruptions in diabetes care processes of A1C testing, retinal screening, and nephropathy evaluation among patients receiving care with Wake Forest Baptist Health in North Carolina. Compared with the pre-pandemic period, they found an increase of 13-21 percentage points in the proportion of patients delaying diabetes care for each measure during the pandemic. Alarmingly, delays in A1C testing were greatest for individuals with the most severe disease and may portend an increase in diabetes complications.

Racial and ethnic differences in uptake of cell-free fetal DNA aneuploidy screening in an urban safety net hospital

OBJECTIVE

To identify racial disparities in cell-free fetal DNA (cffDNA) first-line aneuploidy screening use among advanced maternal age women at a safety net hospital.

STUDY DESIGN

This retrospective cohort study of women 35 and older who delivered at Boston Medical Center from 2012 to 2015 compared to women who used cffDNA for first-line aneuploidy screening to those who did not. Maternal conventional demographics and social determinants of health were collected. We investigated the relationship between race and odds of cffDNA use, adjusting for covariates by stepwise logistic regression.

RESULTS

We identified 1223 women. Seventy-two percent were publicly insured. Upon adjusting for parity, prenatal care site, year of delivery, and insurance status, odds of cffNDA use remained lower for Black and Hispanic women (adjusted odds ratio [aOR] 0.47, 95% confidence interval [CI] 0.30, 0.71 and aOR 0.34 [0.21, 0.55]) compared to White women. Language proved to be an effect modifier among Hispanic women that attenuated but did not resolve the disparity in use among Hispanic compared to White women. Racial differences in cffDNA use persisted across the study period.

CONCLUSION

Disparity in cffDNA screening uptake exists by race in this diverse urban population. The gap in utilization between Hispanic and White women may be related to primary preferred language.

Provider and Practice Experience Integrating the Dose-HPV Intervention into Clinical Practice

INTRODUCTION

Few studies have rigorously evaluated the drivers of successful implementation of interventions to improve human papillomavirus (HPV) vaccination rates. The aim of this study was to evaluate the implementation of Development of Systems and Education for HPV Vaccination (DOSE HPV), a performance improvement intervention.

METHODS

Primary care providers (PCPs), nurses, and individuals with leadership roles from pediatric and family medicine practices who attended DOSE HPV intervention sessions participated in qualitative interviews immediately following intervention completion. The study team professionally transcribed interviews and performed qualitative coding using inductive methods. Final analysis employed the Promoting Action on Research implementation in Health Services (PARiHS) model.

RESULTS

Twenty-six individuals participated: 12 PCPs, 5 nurses, and 9 individuals with dual leadership and PCP roles. Participants described five factors that they felt contributed to program success: (1) evidence-based, goal-directed education; (2) personalized data feedback; (3) clinical leadership support; (4) collaborative facilitation; (5) repeated contacts/longitudinal structure of the intervention. Barriers to implementing the intervention included: (1) inability to standardize workflow across practices; (2) low pediatric volume, (3) competing priorities/lack of incentives, (4) ineffective involvement of nurses, (5) poor communication between clinical leadership and staff.

DISCUSSION

Although many HPV testing interventions have been implemented, findings have been mixed. It is clear that having an effective, evidence-based intervention by itself is not enough to get it into practice. Rather, it is crucial to consider implementation factors to ensure consistent implementation and sustainability. Key factors for the success of the DOSE HPV intervention appear to include a collaborative approach, provision of useful evidence to motivate behavior change, and repeated contacts to ensure accountability for implementing changes. Workflow issues, ineffective lines of communication, and competing priorities at both the visit and the patient and population management levels can hinder implementation.

Changes in Hospitalizations at US Safety-Net Hospitals Following Medicaid Expansion

This cross-sectional study examines whether inpatient utilization among patients with lower socioeconomic status and among those who belong to racial/ethnic minority groups changed differentially in states that expanded Medicaid following the Patient Protection and Affordable Care Act (ACA).

Diabetes Control During Massachusetts Insurance Reform

Racial/ethnic disparities in glycemic control-a key diabetes outcome measure-continue to widen, even though the overall prevalence of glycemic control in the US has improved. Health insurance coverage may be associated with improved glycemic control, but few studies examine effects during a period of policy change. We assessed changes in glycemic control by racial/ethnic groups following the Massachusetts Health Insurance Reform for patients at two urban safety-net academic health systems between January 2005 and December 2013. We analyzed outcomes for three measures of poor glycemic control: 1) lack of a hemoglobin A1C (A1C) measure during a 6-month period; 2) A1C >8%; 3) A1C >9% before, during, and after implementation of insurance reform. We did not find increased rates of A1C monitoring or control following insurance reform overall or for specific racial/ethnic groups. We found evidence of worsened, not improved, glycemic control in some racial/ethnic groups in the post-reform period. The expansion of affordable insurance coverage was not associated with improved glycemic control in vulnerable populations.

The Influence of Health Insurance Stability on Racial/Ethnic Differences in Diabetes Control and Management

Objective

This study examined whether health insurance stability was associated with improved type 2 diabetes mellitus (DM) control and reduced racial/ethnic health disparities.

Methods

We utilized electronic medical record data (2005-2013) from two large, urban academic health systems with a racially/ethnically diverse patient population to examine insurance coverage, and three DM outcomes (poor diabetes control, A1c ≥8.0%; very poor diabetes control A1c >9.0%; and poor BP control, ≥ 130/80 mm Hg) and one DM management outcome (A1c monitoring). We used generalized estimating equations adjusting for age, sex, comorbidities, site of care, education, and income. Additional analysis examined if insurance stability (stable public or private insurance over the six-month internal) moderates the impact of race/ethnicity on DM outcomes.

Results

Nearly 50% of non-Hispanic (NH) Whites had private insurance coverage, compared with 33.5% of NH Blacks, 31.5% of Asians, and 31.1% of Hispanics. Overall, and within most racial/ ethnic groups, insurance stability was associated with better glycemic control compared with those with insurance switches or always being uninsured, with uninsured NH Blacks having significantly worse BP control. More NH Black and Hispanic patients had poorly controlled (A1c≥8%) and very poorly controlled (A1c>9%) diabetes across all insurance stability types than NH Whites or Asians. The interaction between insurance instability and race/ethnic groups was statistically significant for A1c monitoring and BP control, but not for glycemic control.

Conclusion

Stable insurance coverage was associated with improved DM outcomes for all racial / ethnic groups, but did not eliminate racial ethnic disparities.

Effect of provider recommendation style on the length of adolescent vaccine discussions

OBJECTIVE

To determine whether providers' vaccine recommendation style affects length of the adolescent vaccine discussions.

METHODS

We analyzed vaccine discussions using audio-recordings of clinical encounters where adolescents were eligible for HPV vaccines ± meningococcal vaccines. We measured length of vaccine discussions, the provider's use of an "indicated" (vaccination due at visit) or "elective" (vaccination is optional) recommendation style, and vaccine receipt. Parent and child demographics, parental vaccination intentions, and parental satisfaction with vaccine discussion were collected from pre- and post-visit surveys. We used linear and logit regressions with random effects to estimate recommendation style's association with discussion length and with vaccine receipt, respectively.

RESULTS

We analyzed 106 vaccine discussions (82 HPV; 24 meningococcal) across 82 clinical encounters and 43 providers. Vaccine discussions were longer when providers presented vaccination as elective versus indicated (140 vs. 74 s; p-value < 0.001). Controlling for vaccine type, parental vaccination intent, and patient characteristics, an elective style was associated with 41 seconds longer vaccine discussion (p-value < 0.05). Providers used the indicated style more frequently with the meningococcal vaccine than with the HPV vaccine (96% vs. 72%; p-value < 0.05). Parents' odds of vaccinating were 9.3 times higher following an indicated versus an elective presentation (p-value < 0.05). Vaccine discussion length and presentation style were not associated with parental satisfaction.

CONCLUSIONS

Our results suggest that using an indicated recommendation improves vaccine discussions' efficiency and effectiveness, but this style is used more often with meningococcal than HPV vaccines. Increasing providers' use of indicated styles for HPV vaccines has the potential to increase vaccination rates and save time during medical visits.

Improving HPV Vaccination Rates: A Stepped-Wedge Randomized Trial

OBJECTIVES

To evaluate the effectiveness of a stepped-wedge randomized trial of Development of Systems and Education for Human Papillomavirus Vaccination (DOSE HPV), a multilevel intervention.

METHODS

DOSE HPV is a 7-session program that includes interprofessional provider education, communication training, data feedback, and tailored systems change. Five primary care pediatric and/or family medicine practices completed interventions between 2016 and 2018; all chose to initiate vaccination at ages 9 to 10. We compared vaccination rates in the preintervention, intervention, and postintervention periods among 9- to 17-year-olds using random-effects generalized linear regression models appropriate for stepped-wedge design, accounting for calendar time and clustering of patients by providers and clinic. Outcomes included (1) the likelihood that eligible patients would receive vaccination during clinic visits; (2) the likelihood that adolescents would complete the series by age 13; and (3) the cumulative effect on population-level vaccine initiation and completion rates. Postintervention periods ranged from 6 to 18 months.

RESULTS

In the intervention and postintervention periods, the adjusted likelihood of vaccination at an eligible visit increased by >10 percentage points for ages 9 to 10 and 11 to 12, and completion of the vaccine series by age 13 increased by 4 percentage points (P < .001 for all comparisons). Population-level vaccine initiation coverage increased from 75% (preintervention) to 84% (intervention) to 90% (postintervention), and completion increased from 60% (preintervention) to 63% (intervention) to 69% (postintervention).

CONCLUSIONS

Multilevel interventions that include provider education, data feedback, tailored systems changes, and early initiation of the human papillomavirus vaccine series may improve vaccine series initiation and completion beyond the conclusion of the intervention period.

Relative contributions of parental intention and provider recommendation style to HPV and meningococcal vaccine receipt

We described the relative contributions of parental intention and provider recommendation style to HPV and meningococcal vaccine receipt. Parent-child dyads that were eligible for both meningococcal and HPV vaccines participated in pre-visit surveys and consented to audio recording of their clinical interactions with healthcare providers related to vaccination. Surveys were analyzed for parent and child demographics and parental intention to vaccinate children with HPV and/or meningococcal vaccines. Audio recordings were analyzed for provider recommendation style, defined as indicated (provider stated vaccine was due at that visit) or not, and for child receipt of vaccines. Linear and logistic regression models were used to determine the relative contributions of parental intention and provider recommendation style to vaccine receipt. 56 parents/child dyads participated. 79% of children received HPV vaccines, and 93% received meningococcal vaccines. After controlling for demographic variables, parental intention did not differ by vaccine type. However, providers were less likely to use an indicated recommendation for HPV than for meningococcal vaccine. After controlling for demographic factors, parental intention, and provider recommendation style, vaccine type (HPV or meningococcal) was no longer associated with vaccine receipt Differences that were previously attributed to vaccine-specific factors may be explained by parents' and providers' roles in vaccine receipt. These findings suggest that interventions and policy recommendations regarding adolescent vaccination should focus on increasing parental demand for vaccines and ensuring that providers present all vaccines as the medical standard of care.

One-year costs of medical admissions with and without a 30-day readmission and enhanced risk adjustment

BACKGROUND

To overcome the limitations of administrative data in adequately adjusting for differences in patients' risk of readmissions, recent studies have added supplemental data from patient surveys and other sources (e.g., electronic health records). However, judging the adequacy of enhanced risk adjustment for use in assessment of 30-day readmission as a hospital quality indicator is not straightforward. In this paper, we evaluate the adequacy of risk adjustment by comparing the one-year costs of those readmitted within 30 days to those not after excluding the costs of the readmission.

METHODS

In this two-step study, we first used comprehensive administrative and survey data on a nationally representative Medicare cohort of hospitalized patients to compare patients with a medical admission who experienced a 30-day readmission to patients without a readmission in terms of their overall Medicare payments during 12 months following the index discharge. We then examined the extent to which a series of enhanced risk adjustment models incorporating code-based comorbidities, self-reported health status and prior healthcare utilization, reduced the payment differences between the admitted and not readmitted groups.

RESULTS

Our analytic cohort consisted 4684 index medical hospitalization of which 842 met the 30-day readmission criteria. Those readmitted were more likely to be older, White, sicker and with higher healthcare utilization in the previous year. The unadjusted subsequent one-year Medicare spending among those readmitted ($56,856) was 60% higher than that among the non-readmitted ($35,465). Even with enhanced risk adjustment, and across a variety of sensitivity analyses, one-year Medicare spending remained substantially higher (46.6%, p < 0.01) among readmitted patients.

CONCLUSIONS

Enhanced risk adjustment models combining health status indicators from administrative and survey data with previous healthcare utilization are unable to substantially reduce the cost differences between those medical admission patients readmitted within 30 days and those not. The unmeasured patient severity that these cost differences most likely reflect raises the question of the fairness of programs that place large penalties on hospitals with higher than expected readmission rates.

Racial/Ethnic Disparities in Readmissions in US Hospitals: The Role of Insurance Coverage

We examine differences in rates of 30-day readmissions across patients by race/ethnicity and the extent to which these differences were moderated by insurance coverage. We use hospital discharge data of patients in the 18 years and above age group for 5 US states, California, Florida, Missouri, New York, and Tennessee for 2009, the latest year prior to the start of Centers for Medicare & Medicaid Services’ Hospital Compare program of public reporting of hospital performance on 30-day readmissions. We use logistic regression models by state to estimate the association between insurance status, race, and the likelihood of a readmission within 30 days of an index hospital admission for any cause. Overall in 5 states, non-Hispanic blacks had a slightly higher risk of 30-day readmissions relative to non-Hispanic whites, although this pattern varied by state and insurance coverage. We found higher readmission risk for non-Hispanic blacks, compared with non-Hispanic whites, among those covered by Medicare and private insurance, but lower risk among uninsured and similar risk among Medicaid. Hispanics had lower risk of readmissions relative to non-Hispanic whites, and this pattern was common across subgroups with private, Medicaid, and no insurance coverage. Uninsurance was associated with lower risk of readmissions among minorities but higher risk of readmissions among non-Hispanic whites relative to private insurance. The study found that risk of readmissions by racial ethnic groups varies by insurance status, with lower readmission rates among minorities who were uninsured compared with those with private insurance or Medicare, suggesting that lower readmission rates may not always be construed as a good outcome, because it could result from a lack of insurance coverage and poor access to care, particularly among the minorities.

False-positive mammography and its association with health service use

OBJECTIVES

A false-positive mammogram can result in anxiety, distress, and increased perceptions of breast cancer risk, potentially changing how women utilize healthcare. This study examined whether having an abnormal mammogram, considered a proxy for elevated risk perception, was associated with greater future health service use (outpatient visits and referrals).

STUDY DESIGN

A retrospective cohort study using electronic health record data, spanning 2008 to 2012, from Boston Medical Center, a safety-net hospital.

METHODS

We grouped 3920 women aged 40 to 75 years receiving primary care and who had a mammogram between 2010 and 2011 into 3 categories: false-positive mammogram at index date; previous false positive, but normal index mammogram; and no history of false-positive mammograms. We contrasted the longitudinal changes in outpatient visits and provider referrals, before versus after the index mammogram, between women with false-positive mammogram and those without using Poisson regression models with a difference-in-differences specification. Clinical, visit, and demographic data were obtained from the institutional clinical data warehouse.

RESULTS

Adjusting for baseline differences in sociodemographic characteristics across risk groups and for secular changes between pre- and postindex periods, a current false-positive mammogram was associated with an 18% increase in overall outpatient visits (incidence rate ratio [IRR], 1.18; 95% CI, 1.07-1.51), but no corresponding increase in provider referrals (IRR, 1.15; 95% CI, 0.99‑1.34), relative to never having a false positive. A previous false-positive mammogram had no associated change in outpatient utilization (IRR, 0.99; 95% CI, 0.91-1.07).

CONCLUSIONS

Providers should discuss the implications of mammography findings at the time of screening to help mitigate potential detrimental effects and promote appropriate engagement in health services.

Health Literacy and Education as Mediators of Racial Disparities in Patient Activation Within an Elderly Patient Cohort

The Patient Activation Measure (PAM) assesses facets of patient engagement to identify proactive health behaviors and is an important predictor of health outcomes. Health literacy and education are also important for patient participation and successful navigation of the health care system. Because health literacy, education, and patient activation are associated with racial disparities, we sought to investigate whether health literacy and education would mediate racial differences in patient activation. Participants were 265 older adults who participated in a computer-based exercise interventional study. Health literacy was assessed using the Test of Functional Health Literacy in Adults (TOFHLA). Of 210 eligible participants, 72% self-identified as Black and 28% as White. In adjusted analyses, education and health literacy each significantly reduced racial differences in patient activation. These findings are especially important when considering emerging data on the significance of patient activation and new strategies to increase patient engagement.

Patient Activation Mediates Health Literacy Associated with Hospital Utilization among Whites

Background:

Reducing the 30-day hospital readmission rate is a national priority, and patient activation has emerged as a modifiable target to reduce hospital readmissions.

Objective:

Prior studies demonstrate that low patient activation and low health literacy are each associated with higher rates of hospital utilization. The aim of this study was to use path analysis methods to assess if patient activation mediates the relationship between health literacy and hospital utilization in the 30 days after discharge.

Methods:

We performed a secondary analysis of data from a randomized controlled trial of patients receiving care at an urban safety net hospital. Path analyses were used to assess patient activation as a mediator of the relationship of education and health literacy with 30-day hospital utilization. The final model was stratified by race and ethnicity.

Key Results:

In the overall study sample, a patient activation measure (PAM) score that was one standard deviation (SD) higher was associated with 18% reduced odds of hospital utilization (odds ratio [OR] 0.82; 95% confidence interval [CI] [0.73, 0.91]; p < .001). PAM mediated the relationship between education level and health literacy and hospital utilization. When stratified by race, the mediating effect of PAM was evident among Whites, but not among non-Whites. Specifically, a one SD higher PAM score was significantly associated with a 33% reduced odds of utilization among Whites (OR 0.67, 95% CI [0.57, 0.79], p < .001). With the inclusion of PAM in the model, there was no direct relationship between either health literacy or education and 30-day hospital utilization.

Conclusions:

Patient activation is only associated with hospital utilization among Whites. Further research is needed to assess if this selective protection is seen in other cohorts. Potential interventions to reduce hospital readmissions may need to consider other modifiable factors in racially and ethnically diverse populations. [Health Literacy Research and Practice. 2017;1(3):e128–e135.]

Plain Language Summary:

In this study, among White patients, the relationship between health literacy and hospital utilization within 30 days after discharge was due to patient activation. However, for non-White patients, the relationship between health literacy and hospital utilization within 30 days after discharge was not due to patient activation.

Hospital Payer and Racial/Ethnic Mix at Private Academic Medical Centers in Boston and New York City

Academic medical centers (AMCs) are widely perceived as providing the highest-quality medical care. To investigate disparities in access to such care, we studied the racial/ethnic and payer mixes at private AMCs of New York City (NYC) and Boston, two cities where these prestigious institutions play a dominant role in the health care system. We used individual-level inpatient discharge data for acute care hospitals to examine the degree of hospital racial/ethnic and insurance segregation in both cities using the Index of Dissimilarity, together with recent changes in patterns of care in NYC. In multivariable logistic regression analyses, black patients in NYC were two to three times less likely than whites, and uninsured patients approximately five times less likely than privately insured patients, to be discharged from AMCs. In Boston, minorities were overrepresented at AMCs relative to other hospitals. NYC hospitals were more segregated overall according to race/ethnicity and insurance than Boston hospitals, and insurance segregation became more pronounced in NYC after the Affordable Care Act. Although health reform improved access to insurance, access to AMCs remains limited for disadvantaged populations, which may undermine the quality of care available to these groups.

Abstract WMP91: Disparities in Inpatient Mortality from Acute Stroke: Near-national Estimates for Hispanics

Background: Hispanics are the largest minority in the US, yet there is little national data describing stroke outcomes among Hispanic patients.

Objective: To measure inpatient mortality following admission for ischemic stroke (IS), hemorrhagic stroke (HS), and subarachnoid hemorrhage (SAH) among non-Hispanic blacks, non-Hispanic whites, and Hispanics.

Methods: We combined discharge data (2010-11) from universe of admissions at all non-federal hospitals from 15 states that account for 85% of the Hispanic population and had near-complete reporting of race/ethnicity (AZ, CA, CO, FL, IL, MA, MD, NJ, NM, NV, NY, OR, PA, TX, VA). We identified all hospitalizations for IS, HS, and SAH, and estimated logistic and hospital-level hierarchical logistic regression models to obtain rates of inpatient mortality by race/ethnicity adjusted for patient characteristics (age, sex, race/ethnicity, comorbidities) and hospital characteristics (annual hospital stroke volume).

Results: We found 567,498 discharges for acute stroke; Hispanics accounted for 11.7%, blacks for 15.6% and whites for 68.7%. Among all discharges, IS accounted for 83%, HS 12% and SAH 5%. Compared to whites, Hispanics and blacks were younger and had lower observed mortality rate for all stroke subtypes (IS: whites 5.2%, blacks 3.3%, Hispanics 4.3%, p<0.001; HS: whites 25.7%, blacks 20.8%, Hispanics 21.3%, p<0.001; and SAH: whites 20.2%, blacks 17.5%, Hispanics 19.3%, p<0.001). In the fully adjusted model, compared to whites, Hispanic inpatient mortality was lower for HS but nor for IS or SAH (Table); in contrast, blacks had lower inpatient mortality for IS and HS (Table). Individual states’ overall adjusted stroke mortality for all subgroups combined was not significantly different for Hispanics, with the exception of CA (OR 0.90, 95% CI 0.85-0.96).

Conclusion: In a near-national sample, Hispanic patients had lower adjusted inpatient mortality rates than whites for HS, and similar rates for IS and SAH.

Do Acute Myocardial Infarction and Heart Failure Readmissions Flagged as Potentially Preventable by the 3M Potentially Preventable Readmissions Software Have More Process-of-Care Problems?

BACKGROUND

The 3M Potentially Preventable Readmissions (3M-PPR) software matches clinically related index admission and readmission diagnoses that may signify in-hospital or postdischarge quality problems. To assess whether the PPR algorithm identifies preventable readmissions, we compared processes of care between PPR software-flagged and nonflagged cases.

METHODS AND RESULTS

Using 2006 to 2010 national VA administrative data, we identified acute myocardial infarction and heart failure discharges associated with 30-day all-cause readmissions, then flagged cases (PPR-Yes/PPR-No) using the 3M-PPR software. To assess care quality, we abstracted medical records of 100 readmissions per condition using tools containing explicit processes organized into admission work-up, in-hospital evaluation/treatment, discharge readiness, postdischarge period. We derived quality scores, scaled to a maximum of 25 per section (maximum total score=100) and compared cases on total and section-specific mean scores. For acute myocardial infarction, 77 of 100 cases were flagged as PPR-Yes. Section quality scores were highest for in-hospital evaluation/treatment (20.5±2.8) and lowest for postdischarge care (6.8±9.1). Total and section-related mean scores did not differ by PPR status; respective PPR-Yes versus PPR-No total scores were 61.6±11.1 and 60.4±9.4; P=0.98. For heart failure, 86 of 100 cases were flagged as PPR-Yes. Section scores were highest for discharge readiness (18.8±2.4) and lowest for postdischarge care (7.3±8.1). Like acute myocardial infarction, total and section-related mean scores did not differ by PPR status; PPR-Yes versus PPR-No total scores were 61.2±10.8 and 63.4±7.0, respectively; P=0.47.

CONCLUSIONS

Among VA acute myocardial infarction and heart failure readmissions, the 3M-PPR software does not distinguish differences in case-level quality of care. Whether 3M-PPR software better identifies preventable readmissions by using other methods to capture poorly documented processes or performing different comparisons requires further study.

The effect of Medicaid expansions on demand for care from the Veterans Health Administration

BACKGROUND

Adequate access to care at Veterans Health Administration (VA) medical centers has become a high-profile policy issue. The Affordable Care Act (ACA) could improve access to care for veterans, particularly if its Medicaid expansion is implemented in all states. The relationship between Medicaid expansion on the one hand and VA enrollment and utilization on the other has not previously been explored for all states.

METHODS

Using VA and other public data from 2002 to 2008, we calculated a measure of Medicaid eligibility sensitive to state-year varying policy change but not changes in demographics or economic conditions. Next, controlling for potential confounding factors, we estimated fixed effects Poisson models of VA enrollment and inpatient and outpatient utilization. We then used these estimates to simulate the effect of the ACA׳s Medicaid expansion on demand for VA care.

RESULTS

If the ACA׳s Medicaid expansion had been implemented in all states, enrollment for VA health coverage, acute inpatient care (days), and outpatient visits would have been 9%, 6%, and 12% lower, respectively. In states that did not expand Medicaid in 2014, VA enrollment, inpatient days, and outpatient visits were, respectively, 10, 6, and 13 percentage points higher than they would have been otherwise.

CONCLUSION

VA medical centers in states that did not expand Medicaid in 2014 are likely to have experienced a higher demand, and commensurately longer wait times. As policymakers continue to address VA capacity issues, they should be mindful of the potential role of Medicaid, and that it will change over time as more states adopt the expansion.

Do pneumonia readmissions flagged as potentially preventable by the 3M PPR software have more process of care problems? A cross-sectional observational study

BACKGROUND

In the USA, administrative data-based readmission rates such as the Centers for Medicare and Medicaid Services' all-cause readmission measures are used for public reporting and hospital payment penalties. To improve this measure and identify better quality improvement targets, 3M developed the Potentially Preventable Readmissions (PPRs) measure. It matches clinically related index admission and readmission diagnoses that may indicate readmissions resulting from admission- or post-discharge-related quality problems.

OBJECTIVE

To examine whether PPR software-flagged pneumonia readmissions are associated with poorer quality of care.

METHODS

Using a retrospective observational study design and Veterans Health Administration (VA) data, we identified pneumonia discharges associated with 30-day readmissions, and then flagged cases as PPR-yes or PPR-no using the PPR software. To assess quality of care, we abstracted electronic medical records of 100 random readmissions using a tool containing explicit care processes organised into admission work-up, in-hospital evaluation/treatment, discharge readiness and post-discharge period. We derived quality scores, scaled to a maximum of 25 per section (maximum total score=100) and compared cases by total and section-specific mean scores using t tests and effect size (ES) to characterise the clinical significance of findings.

RESULTS

Our abstraction sample was selected from 11,278 pneumonia readmissions (readmission rate=16.5%) during 1 October 2005-30 September 2010; 77% were flagged as PPR-yes. Contrary to expectations, total and section mean quality scores were slightly higher, although non-significantly, among PPR-yes (N=77) versus PPR-no (N=23) cases (respective total scores, 71.2±8.7 vs 65.8±11.5, p=0.14); differences demonstrated ES >0.30 overall and for admission work-up and post-discharge period sections.

CONCLUSIONS

Among VA pneumonia readmissions, PPR categorisation did not produce the expected quality of care findings. Either PPR-yes cases are not more preventable, or preventability assessment requires other data collection methods to capture poorly documented processes (eg, direct observation).

Why are U.S. girls getting meningococcal but not human papilloma virus vaccines? Comparison of factors associated with human papilloma virus and meningococcal vaccination among adolescent girls 2008 to 2012

BACKGROUND

Human papilloma virus (HPV) vaccination rates in the United States remain low, compared with other recommended adolescent vaccines. We compared factors associated with intention to receive and receipt of HPV and meningococcal vaccines and completion of the HPV vaccine series among U.S. adolescent girls.

METHODS

Secondary analysis of data from the National Immunization Survey-Teen for 2008 through 2012 was performed. Multivariable logistic modeling was used to determine factors associated with intent to receive and receipt of HPV and meningococcal vaccination, completion of the HPV vaccine series among girls who started the series, and receipt of HPV vaccination among girls who received meningococcal vaccination.

FINDINGS

Provider recommendation increased the odds of receipt and intention to receive both HPV and meningococcal vaccines. Provider recommendation was also associated with a three-fold increase in HPV vaccination among girls who received meningococcal vaccination (p<.001), indicating a relationship between provider recommendation and missed vaccine opportunities. However, White girls were 10% more likely to report provider recommendation than Black or Hispanic girls (p<.01), yet did not have higher vaccination rates, implying a role for parental refusal. No factors predicted consistently the completion of the HPV vaccine series among those who started.

CONCLUSION

Improving provider recommendation for co-administration of HPV and meningococcal vaccines would reduce missed opportunities for initiating the HPV vaccine series. However, different interventions may be necessary to improve series completion.

What is the value of adding Medicare data in estimating VA hospital readmission rates?

OBJECTIVE

To determine the effects of including diagnostic and utilization data from a secondary payer on readmission rates and hospital profiles.

DATA SOURCES/STUDY SETTING

Veterans Health Administration (VA) and Medicare inpatient and outpatient administrative data for veterans discharged from 153 VA hospitals during FY 2008-2010 with a principal diagnosis of acute myocardial infarction, heart failure, or pneumonia.

STUDY DESIGN

We estimated hospital-level risk-standardized readmission rates derived using VA data only. We then used data from both VA and Medicare to reestimate readmission rates and compared hospital profiles using two methods: Hospital Compare and the CMS implementation of the Hospital Readmissions Reduction Program (HRRP).

DATA COLLECTION/EXTRACTION METHODS

Retrospective data analysis using VA hospital discharge and outpatient data matched with Medicare fee-for-service claims by scrambled Social Security numbers.

PRINCIPAL FINDINGS

Less than 2 percent of hospitals in any cohort were classified discordantly by the Hospital Compare method when using VA-only compared with VA/Medicare data. In contrast, using the HRRP method, 13 percent of hospitals had differences in whether they were flagged as having excessive readmission rates in at least one cohort.

CONCLUSIONS

Inclusion of secondary payer data may cause changes in hospital profiles, depending on the methodology used. An assessment of readmission rates should include, to the extent possible, all available information about patients' utilization of care.

Effectiveness of a provider-focused intervention to improve HPV vaccination rates in boys and girls

BACKGROUND

HPV vaccination is universally recommended for boys and girls, yet vaccination rates remain low nationwide.

METHODS

We conducted a provider-focused intervention that included repeated contacts, education, individualized feedback, and strong quality improvement incentives to raise HPV vaccination rates at two federally qualified community health centers. To estimate the effectiveness of the intervention, rates of initiation of vaccination, and completion of the next needed HPV vaccination (dose 1, 2 or 3) among boys and girls ages 11-21 were compared at baseline and two follow-up periods in two intervention health centers (n4093 patients) and six control health centers (n9025 patients). We conducted multivariable logistic regression accounting for clustering by practice.

RESULTS

Girls and boys in intervention practices significantly increased HPV vaccine initiation during the active intervention period relative to control practices (girls OR 1.6, boys OR 11; p<0.001 for both). Boys at intervention practices were also more likely to continue to initiate vaccination during the post-intervention/maintenance period (OR 8.5; p<0.01). Girls and boys at intervention practices were more also likely to complete their next needed HPV vaccination (dose 1, 2 or 3) than those at control practices (girls OR 1.4, boys OR 23; p<0.05 for both). These improvements were sustained for both boys and girls in the post-intervention/maintenance period (girls OR 1.6, boys OR 25; p<0.05 for both).

CONCLUSIONS

Provider-focused interventions including repeated contacts, education, individualized feedback, and strong quality improvement incentives have the potential to produce sustained improvements in HPV vaccination rates.

Comparison of the Agency for Healthcare Research and Quality Patient Safety Indicator Rates Among Veteran Dual Users

This study compares rates of 11 Agency for Healthcare Research and Quality Patient Safety Indicators (PSIs) among 266 203 veteran dual users (ie, those with hospitalizations in both the Veterans Health Administration [VA] and the private sector through Medicare fee-for-service coverage) during 2002 to 2007. PSI risk-adjusted rates were calculated using the PSI software (version 3.1a). Rates of pressure ulcer, central venous catheter-related bloodstream infections, and postoperative sepsis, areas in which the VA has focused quality improvement efforts, were found to be significantly lower in the VA than in the private sector. VA had significantly higher rates for 7 of the remaining 8 PSIs, although the rates of only 2 PSIs (postoperative hemorrhage/hematoma and accidental puncture or laceration) remained higher in the VA after sensitivity analyses were conducted. A better understanding of system-level differences in coding practices and patient severity, poorly documented in administrative data, is needed before conclusions about differences in quality can be drawn.

Abstract 126: Massachusetts Health Reform Did Not Reduce 30-day Readmissions for Acute Myocardial Infarction among Massachusetts Residents Overall or among Racial/Ethnic Minorities

Introduction: After Massachusetts (MA) health reform, the percent of uninsured residents fell, particularly among minorities. Studies have not examined the effect of this policy change on 30-day readmission rates, and disparities in such rates, following acute myocardial infarction (AMI).

Hypothesis : 30-day readmission rates will decline in patients age 18-64 (affected by health reform) vs. patients age ≥ 65 (most unaffected)

Methods: We used 2004-2009 MA discharge data. We compared all-cause 30-day readmission rates after a hospitalization for AMI overall, and among racial subgroups, for patients age 18-64 vs. age ≥ 65 in the period prior to and following reform. We used chi-square tests to compare unadjusted 30-day readmissions for AMI between groups. Treating patients age 18-64 as the intervention cohort, and those age ≥ 65 as the control cohort, we used logistic regression to conduct difference-in-difference analysis that estimates odds of readmission in the post-reform period vs. the pre-reform period in MA adjusted for secular changes. The model was also adjusted for age, gender, and medical comorbidity. To assess differences in white vs. minority disparities over time between the pre and post reform periods among patients age 18-64 vs. age ≥ 65, we used logistic regression to conduct difference-in-difference-in-differences analysis.

Results: Among patients age 18-64, pre-reform and post reform readmission rates were 11.5% and 10.5%. Among patients age ≥ 65, they were 24.0% and 22.2%. The post-reform decrease among patients age 18-64 was not different than the decrease among patients age ≥ 65 (difference-in-difference adjusted OR (AOR) =1.0; 95% CI=0.9-1.2). Among patients age 18-64, blacks had higher readmission rates than whites pre and post-reform. Post-reform changes in readmission rates among non-elderly and elderly adults were not significantly different among whites, blacks, and Hispanics. There was no significant change in the presence of disparities between whites and blacks or between whites and Hispanics among non-elderly and elderly adults pre- and post-reform.

Conclusions: A major coverage expansion in MA was not associated with a reduction in 30-day readmissions for AMI overall or a reduction in racial and ethnic disparities.

Validation of self-reported epilepsy for purposes of community surveillance

We evaluated the validity of questions designed to identify lifetime and active epilepsy, medication use, and seizure occurrence on population-based surveys. Subjects were interviewed by telephone, and responses were compared with information in their medical records. Prevalence, sensitivity, specificity, and positive predictive value (PPV) were calculated. The prevalence of ever having been diagnosed with epilepsy was 3.1% by self-report and 2.7% by medical record review. Sensitivity was 84.2%, specificity was 99.2%, and PPV was 73.5% for self-reported lifetime epilepsy, and values were similar for active epilepsy. By comparison, sensitivity was higher and specificity was lower for epilepsy medication use and seizure occurrence. The PPV for seizure occurrence was substantially higher for a recall period of 12 months than for 3 months. These results compare favorably with results for other chronic conditions, such as diabetes and arthritis, and indicate that questionnaires can be used to identify epilepsy at a population level.

Abstract A104: The impact of insurance instability and care after abnormal cancer screening

The intent of health insurance reform is to improve care through the expansion of access to care for minority, vulnerable, and underinsured populations. In 2006 the Massachusetts Health Reform Legislation sought to improve access to care by increasing insurance coverage. We sought to assess the impact of insurance instability on vulnerable women with an abnormal screening event, looking at whether they achieved a diagnostic resolution, comparing pre and post insurance reform cohorts. We studied women at 6 community health centers, as they care for a disproportionate group of women with unstable insurance coverage.

We analyzed billing data for all women following an abnormal breast or cervical cancer screening exam at 6 community health centers in two cohorts: 2004–2005 (pre reform) and 2007–2008 (post reform). We observed insurance claims for eighteen months before and after the abnormal screening exam, and recorded insurance coverage and frequency of health insurance switches. We categorized switches into five levels of favorability from the most favorable representing women who were always privately insured to the least favorable representing women who were always uninsured. The outcome of interest is the time it takes to reach diagnostic resolution, dichotomized to those who resolved within 365 days of abnormal screening and those who did not. We conducted Mantel-Haenszel Chi square analyses to observe if insurance instability changed the proportion of women with diagnostic resolution between the pre and post reform periods.

We examined 1944 women, 433 women in the pre reform period and 1511 women in the post reform period. Subjects had an average age of 43 (± 16) years and were 35% white, 32% black, 28% Hispanic, and 5% other, primarily Vietnamese. Women in the sample received care at their community health center for an average of 25 months and during that time had an average of 17 visits. At the time of the abnormal cancer screening in the pre reform period, 21% of women were uninsured, 46% had public insurance, and 32% had private insurance. We placed women into 5 categories of insurance instability: 21% were always privately insured, 18% were always publically insured, 21% had at least one switch but were never uninsured, 22% had at least one switch to an uninsured state, and 18% were consistently without insurance. The proportion always uninsured dropping from 25% to 16%, and the proportion always privately insured increasing from 17% to 23% in the pre-compared to post-insurance reform period, 2 27.7, p &lt; .0001. We did not find that insurance stability was associated with women reaching diagnostic resolution within one year, comparing pre and post periods, Mantel-Haenszel 2 (df 4) 6.07, p = 0 .19.

Limitations of the study include the inability to assess the length of non coverage between switches or to identify switches which occurred between health care visits. Insurance reform significantly improved coverage, with fewer women consistently uninsured. Our results did not show an association between changes in insurance stability and delays in time to diagnostic resolution.

Citation Information: Cancer Epidemiol Biomarkers Prev 2011;20(10 Suppl):A104.

The quality of care for adults with epilepsy: an initial glimpse using the QUIET measure

Background

We examined the quality of adult epilepsy care using the Quality Indicators in Epilepsy Treatment (QUIET) measure, and variations in quality based on the source of epilepsy care.

Methods

We identified 311 individuals with epilepsy diagnosis between 2004 and 2007 in a tertiary medical center in New England. We abstracted medical charts to identify the extent to which participants received quality indicator (QI) concordant care for individual QI's and the proportion of recommended care processes completed for different aspects of epilepsy care over a two year period. Finally, we compared the proportion of recommended care processes completed for those receiving care only in primary care, neurology clinics, or care shared between primary care and neurology providers.

Results

The mean proportion of concordant care by indicator was 55.6 (standard deviation = 31.5). Of the 1985 possible care processes, 877 (44.2%) were performed; care specific to women had the lowest concordance (37% vs. 42% [first seizure evaluation], 44% [initial epilepsy treatment], 45% [chronic care]). Individuals receiving shared care had more aspects of QI concordant care performed than did those receiving neurology care for initial treatment (53% vs. 43%; X² = 9.0; p = 0.01) and chronic epilepsy care (55% vs. 42%; X² = 30.2; p < 0.001).

Conclusions

Similar to most other chronic diseases, less than half of recommended care processes were performed. Further investigation is needed to understand whether a shared-care model enhances quality of care, and if so, how it leads to improvements in quality.

Nursing home residence confounds gender differences in Medicare utilization an example of Simpson's paradox

BACKGROUND

Gender differences in health care utilization in older Americans may be confounded by nursing home residence. Medicare data contain several files that can be used to create a measure of nursing home residence, but prior work has not addressed which best account for potential confounding. Simpson's paradox occurs when aggregated data support a different conclusion from what the disaggregated data show. We describe such a paradox that appeared when we sharpened our definition of "nursing home residence" while examining gender differences in Medicare utilization at the end of life.

METHODS

To understand gender-specific health care utilization at the end of life, we conducted a retrospective analysis of a national random sample of Medicare beneficiaries aged 66 or older who died in 2001 with Parts A and B data for 18 months before death. We sought to associate each of total hospital days and costs during the final 6 months of life with numbers of primary care physician visits in the 12 preceding months. In addition to demographics, comorbidities, and geography, "nursing home residence" was a potential confounder, which we imputed in two ways: 1) from skilled nursing facility bills in the Part A Medicare Provider Analysis and Review (MedPAR) file; and 2) from Berenson-Eggers-Type-of-Service codes indicating widely spaced doctor visits in nursing homes obtained from Medicare's carrier file.

CONCLUSION

Gender differences in Medicare utilization are strongly confounded by nursing home resident status, which can be imputed well from Medicare's carrier file, but not MedPAR.

Comparing safety climate between two populations of hospitals in the United States

OBJECTIVE

To compare safety climate between diverse U.S. hospitals and Veterans Health Administration (VA) hospitals, and to explore the factors influencing climate in each setting.

DATA SOURCES

Primary data from surveys of hospital personnel; secondary data from the American Hospital Association's 2004 Annual Survey of Hospitals.

STUDY DESIGN

Cross-sectional study of 69 U.S. and 30 VA hospitals.

DATA COLLECTION

For each sample, hierarchical linear models used safety-climate scores as the dependent variable and respondent and facility characteristics as independent variables. Regression-based Oaxaca-Blinder decomposition examined differences in effects of model characteristics on safety climate between the U.S. and VA samples.

PRINCIPAL FINDINGS

The range in safety climate among U.S. and VA hospitals overlapped substantially. Characteristics of individuals influenced safety climate consistently across settings. Working in southern and urban facilities corresponded with worse safety climate among VA employees and better safety climate in the U.S. sample. Decomposition results predicted 1.4 percentage points better safety climate in U.S. than in VA hospitals: -0.77 attributable to sample-characteristic differences and 2.2 due to differential effects of sample characteristics.

CONCLUSIONS

Results suggest that safety climate is linked more to efforts of individual hospitals than to participation in a nationally integrated system or measured characteristics of workers and facilities.

Racial and ethnic differences in end-of-life costs: why do minorities cost more than whites?

BACKGROUND

Racial and ethnic minorities generally receive fewer medical interventions than whites, but racial and ethnic patterns in Medicare expenditures and interventions may be quite different at life's end.

METHODS

Based on a random, stratified sample of Medicare decedents (N = 158 780) in 2001, we used regression to relate differences in age, sex, cause of death, total morbidity burden, geography, life-sustaining interventions (eg, ventilators), and hospice to racial and ethnic differences in Medicare expenditures in the last 6 months of life.

RESULTS

In the final 6 months of life, costs for whites average $20,166; blacks, $26,704 (32% more); and Hispanics, $31,702 (57% more). Similar differences exist within sexes, age groups, all causes of death, all sites of death, and within similar geographic areas. Differences in age, sex, cause of death, total morbidity burden, geography, socioeconomic status, and hospice use account for 53% and 63% of the higher costs for blacks and Hispanics, respectively. While whites use hospice most frequently (whites, 26%; blacks, 20%; and Hispanics, 23%), racial and ethnic differences in end-of-life expenditures are affected only minimally. However, fully 85% of the observed higher costs for nonwhites are accounted for after additionally modeling their greater end-of-life use of the intensive care unit and various intensive procedures (such as, gastrostomies, used by 10.5% of blacks, 9.1% of Hispanics, and 4.1% of whites).

CONCLUSIONS

At life's end, black and Hispanic decedents have substantially higher costs than whites. More than half of these cost differences are related to geographic, sociodemographic, and morbidity differences. Strikingly greater use of life-sustaining interventions accounts for most of the rest.

Can primary care visits reduce hospital utilization among Medicare beneficiaries at the end of life?

BACKGROUND

Medical care at the end of life is often expensive and ineffective.

OBJECTIVE

To explore associations between primary care and hospital utilization at the end of life.

DESIGN

Retrospective analysis of Medicare data. We measured hospital utilization during the final 6 months of life and the number of primary care physician visits in the 12 preceding months. Multivariate cluster analysis adjusted for the effects of demographics, comorbidities, and geography in end-of-life healthcare utilization.

SUBJECTS

National random sample of 78,356 Medicare beneficiaries aged 66+ who died in 2001. Non-whites were over-sampled. All subjects with complete Medicare data for 18 months prior to death were retained, except for those in the End Stage Renal Disease program.

MEASUREMENTS

Hospital days, costs, in-hospital death, and presence of two types of preventable hospital admissions (Ambulatory Care Sensitive Conditions) during the final 6 months of life.

RESULTS

Sample characteristics: 38% had 0 primary care visits; 22%, 1-2; 19%, 3-5; 10%, 6-8; and 11%, 9+ visits. More primary care visits in the preceding year were associated with fewer hospital days at end of life (15.3 days for those with no primary care visits vs. 13.4 for those with > or = 9 visits, P < 0.001), lower costs ($24,400 vs. $23,400, P < 0.05), less in-hospital death (44% vs. 40%, P < 0.01), and fewer preventable hospitalizations for those with congestive heart failure (adjusted odds ratio, aOR = 0.82, P < 0.001) and chronic obstructive pulmonary disease (aOR = 0.81, P = 0.02).

CONCLUSIONS

Primary care visits in the preceding year are associated with less, and less costly, end-of-life hospital utilization. Increased primary care access for Medicare beneficiaries may decrease costs and improve quality at the end of life.