Transforming public health systems: using data to drive organizational capacity for quality improvement and efficiency

Introduction:

This paper examines the organization, services, and priorities of public health agencies and their capacity to be learning public health systems (LPHS). An LPHS uses data to measure population health and health risks and to evaluate its services and programs, and then integrates its own research with advances in scientific knowledge to innovate and improve its efficiency and effectiveness.

Public Health Agencies and Impact for LPHS:

Public health agencies’ (PHA) organizational characteristics vary across states, as does their funding per capita. Variations in organization, services provided, and expenditures per capita may reflect variations in community needs or may be associated with unmet needs. The status of legal statutes defining responsibilities and authorities and their relationships to other public and private agencies also vary. Little information is available on the efficiency and effectiveness of state and local PHAs, in part due to a lack of information infrastructure to capture uniform data on services provided. There are almost no data on the relationship of quality of services, staff performance, and resources to population health outcomes. By building a capacity to collect and analyze data on population health within and across communities, and by becoming a continuous learning PHA, the allocation of resources can more closely match population health needs and improve health outcomes. Accreditation of every PHA is an important first step toward becoming a learning PHA.

Conclusions:

Public Health Services and Systems Research (PHSSR) is beginning to shed light on some of these issues, particularly by investigating variation across PHAs. As this emerging discipline grows, there is a need to enhance the collection and use of data in support of building organized, effective, and efficient LPHSs with the PHA capacity to continually improve the public’s health.

Guideline-concordant antipsychotic use and mortality in schizophrenia

OBJECTIVE

To determine if care concordant with 2009 Schizophrenia Patient Outcomes Research Team (PORT) pharmacological recommendations for schizophrenia is associated with decreased mortality.

METHODS

We conducted a retrospective cohort study of adult Maryland Medicaid beneficiaries with schizophrenia and any antipsychotic use from 1994 to 2004 (N = 2132). We used Medicaid pharmacy data to measure annual and average antipsychotic continuity, to calculate chlorpromazine (CPZ) dosing equivalents, and to examine anti-Parkinson medication use. Cox proportional hazards regression models were used to examine the relationship between antipsychotic continuity, antipsychotic dosing, and anti-Parkinson medication use and mortality.

RESULTS

Annual antipsychotic continuity was associated with decreased mortality. Among patients with annual continuity greater than or equal to 90%, the hazard ratio [HR] for mortality was 0.75 (95% confidence interval [CI] 0.57-0.99) compared with patients with annual medication possession ratios (MPRs) of less than 10%. The HRs for mortality associated with continuous annual and average antipsychotic continuity were 0.75 (95% CI 0.58-0.98) and 0.84 (95% CI 0.58-1.21), respectively. Among users of first-generation antipsychotics, doses greater than or equal to 1500 CPZ dosing equivalents were associated with increased risk of mortality (HR 1.88, 95% CI 1.10-3.21), and use of anti-Parkinson medication was associated with decreased risk of mortality (HR 0.72, 95% CI 0.55-0.95). Mental health visits were also associated with decreased mortality (HR 0.96, 95% CI 0.93-0.98).

CONCLUSIONS

Adherence to PORT pharmacological guidelines is associated with reduced mortality among patients with schizophrenia. Adoption of outcomes monitoring systems and innovative service delivery programs to improve adherence to the PORT guidelines should be considered.

Adolescent Substance Abuse and Mental Health: Problem Co-Occurrence and Access to Services

The purpose of this study is to identify factors associated with adolescent alcohol or drug (AOD) abuse/dependence, mental health and co-occurring problems; as well as factors associated with access to treatment. This is a secondary analysis of data from the National Survey on Drug Use and Health (NSDUH) 2000. The 12-month prevalence rate of adolescents with only mental health problems was 10.8%, 5.1% had only AOD abuse/dependence only, and 2.7% had co-occurring problems. Approximately 15% of youth reported receiving behavioral health treatment in the past 12 months. Several factors associated with having behavioral health problems and receiving treatment are presented.

Post-myocardial-infarction quality of care among disabled Medicaid beneficiaries with and without serious mental illness

OBJECTIVE

The objective was to examine the association between serious mental illness and quality of care for myocardial infarction among disabled Maryland Medicaid beneficiaries.

METHODS

We conducted a retrospective cohort study of disabled Maryland Medicaid beneficiaries with myocardial infarction from 1994 to 2004. Cardiac procedures and guideline-based medication use were compared for persons with and without serious mental illness.

RESULTS

Of the 633 cohort members with myocardial infarction, 137 had serious mental illness. Serious mental illness was not associated with differences in receipt of cardiac procedures or guideline-based medications. Overall use of guideline-based medications was low; 30 days after the index hospitalization for myocardial infarction, 19%, 35% and 11% of cohort members with serious mental illness and 22%, 37% and 13% of cohort members without serious mental illness had any use of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, beta-blockers and statins, respectively. Study participants with and without serious mental illness had similar rates of mortality. Overall, use of beta-blockers [hazard ratio 0.93, 95% confidence interval (CI) 0.90-0.97] and statins (hazard ratio 0.93, 95% CI 0.89-0.98) was associated with reduced risk of mortality.

CONCLUSIONS

Quality improvement programs should consider how to increase adherence to medications of known benefit among disabled Medicaid beneficiaries with and without serious mental illness.

Is serious mental illness associated with earlier death among persons with HIV? Ten year follow up in Maryland Medicaid Recipients

BACKGROUND/OBJECTIVE

In the general population serious mental illness (SMI) is associated with earlier mortality. The objective of this study was to determine if SMI was associated with an increased risk of death among Maryland Medicaid beneficiaries with HIV.

METHODS

This was a retrospective cohort study of adult Maryland Medicaid recipients with HIV receiving antiretroviral therapy (ART) after January 1, 1997. SMI was defined as a specialty mental health visit and an ICD-9 diagnosis of 1) schizophrenia or related psychoses, 2) bipolar disorder or 3) major depressive disorder. Cox proportional hazards regression models were used to estimate the hazard ratios for total mortality. Analyses were adjusted for demographic characteristics, % days on ART, outpatient visits and comorbid medical conditions.

RESULTS

Overall, 623 individuals received ART after treatment inception. The total number of deaths was 278, out of which 60 deaths were in the SMI group (38.5%) and 211 in the non-SMI group (45%) (p=0.05). In multivariable analysis, SMI was not associated with mortality. Increasing age, AIDS defining illness, renal failure, cerebrovascular disease, congestive heart failure, chronic liver disease and substance abuse were independently associated with mortality, while increased percent days of HIV medication use and number of outpatient medical visits were associated with improved survival.

CONCLUSIONS

In this sample, SMI is not associated with earlier death in patients with HIV infection. ART use and primary care engagement among HIV infected individuals are associated with improved survival irrespective of an SMI diagnosis.

Injury risk and severity in a sample of Maryland residents with serious mental illness

OBJECTIVE

Adults with serious mental illness experience premature mortality and heightened risk for medical disease, but little is known about the burden of injuries in this population. The objective of this study was to describe injury incidence among persons with serious mental illness.

METHODS

We conducted a retrospective cohort study of 6234 Maryl and Medicaid recipients with serious mental illness from 1994-2001. Injuries were classified using the Barell Matrix. Relative risks were calculated to compare injury rates among the study cohort with injury rates in the United States population. Cox proportional hazards modeling with time dependent covariates was used to assess factors related to risk of injury and injury-related death.

RESULTS

Forty-three percent of the Maryland Medicaid cohort had any injury diagnosis. Of the 7298 injuries incurred, the most common categories were systemic injuries due to poisoning (10.4%), open wounds to the head/face (8.9%), and superficial injuries, fractures, and sprains of the extremities (8.6%, 8.5%, and 8.4%, respectively). Injury incidence was 80% higher and risk for fatal injury was more than four and a half times higher among the cohort with serious mental illness compared to the general population. Alcohol and drug abuse were associated with both risk of injury and risk of injury-related death with hazard ratios of 1.87 and 4.76 at the p<0.05 significance level, respectively.

CONCLUSIONS

The superficial, minor nature of the majority of injuries is consistent with acts of minor victimization and violence or falls. High risk of fatal and non-fatal injury among this group indicates need for increased injury prevention efforts targeting persons with serious mental illness and their caregivers.

A web-based program to empower patients who have schizophrenia to discuss quality of care with mental health providers

OBJECTIVE

This study evaluated a Web-based tool to help patients with schizophrenia communicate with clinicians about evidence-based treatments.

METHODS

Fifty patients used an interactive Web-based intervention featuring actors simulating a patient discussing treatment concerns (intervention group; N=24) or were shown an educational video about schizophrenia treatment before an appointment for routine follow-up care (control group; N=26). The visits were recorded and analyzed by using the Roter Interaction Analysis System.

RESULTS

Visits by patients in the intervention group were longer (24 versus 19 minutes, p<.05) and had a proportionately greater patient contribution to the dialogue (288 versus 229 statements, p<.05) and a smaller ratio of clinician to patient talk (1.1 versus 1.4, p<.05) compared with visits by the control group. Patients in the intervention group asked more questions about treatment (2 versus .9, p<.05), disclosed more lifestyle information (76 versus 53 statements, p<.005), and more often checked that they understood information (3.6 versus 2.1 checks, p<.05). Clinicians asked more questions about treatment (7.5 versus 5.1, p<.05) and the medical condition (7.8 versus 4.7, p<.05) to control group patients but made more statements of empathy (1.3 versus .4, p<.03) and cues of interest (48 versus 22, p<.05) with the intervention group. The patient-centeredness ratio was greater for visits by patients in the intervention group than by the control group (8.5 versus 3.2, p<.05). Patients' tone was more dominant and respectful (p<.05) and clinicians' tone was more sympathetic (p<.05) during visits by patients in the intervention.

CONCLUSIONS

The Web-based tool empowered persons with schizophrenia to engage more fully in a patient-centered dialogue about their treatment.

A web-based program to empower patients who have schizophrenia to discuss quality of care with mental health providers

OBJECTIVE

This study evaluated a Web-based tool to help patients with schizophrenia communicate with clinicians about evidence-based treatments.

METHODS

Fifty patients used an interactive Web-based intervention featuring actors simulating a patient discussing treatment concerns (intervention group; N=24) or were shown an educational video about schizophrenia treatment before an appointment for routine follow-up care (control group; N=26). The visits were recorded and analyzed by using the Roter Interaction Analysis System.

RESULTS

Visits by patients in the intervention group were longer (24 versus 19 minutes, p<.05) and had a proportionately greater patient contribution to the dialogue (288 versus 229 statements, p<.05) and a smaller ratio of clinician to patient talk (1.1 versus 1.4, p<.05) compared with visits by the control group. Patients in the intervention group asked more questions about treatment (2 versus .9, p<.05), disclosed more lifestyle information (76 versus 53 statements, p<.005), and more often checked that they understood information (3.6 versus 2.1 checks, p<.05). Clinicians asked more questions about treatment (7.5 versus 5.1, p<.05) and the medical condition (7.8 versus 4.7, p<.05) to control group patients but made more statements of empathy (1.3 versus .4, p<.03) and cues of interest (48 versus 22, p<.05) with the intervention group. The patient-centeredness ratio was greater for visits by patients in the intervention group than by the control group (8.5 versus 3.2, p<.05). Patients' tone was more dominant and respectful (p<.05) and clinicians' tone was more sympathetic (p<.05) during visits by patients in the intervention.

CONCLUSIONS

The Web-based tool empowered persons with schizophrenia to engage more fully in a patient-centered dialogue about their treatment.

Advanced practice nurse outcomes 1990-2008: a systematic review

Advanced practice registered nurses have assumed an increasing role as providers in the health care system, particularly for underserved populations. The aim of this systematic review was to answer the following question: Compared to other providers (physicians or teams without APRNs) are APRN patient outcomes of care similar? This systematic review of published literature between 1990 and 2008 on care provided by APRNs indicates patient outcomes of care provided by nurse practitioners and certified nurse midwives in collaboration with physicians are similar to and in some ways better than care provided by physicians alone for the populations and in the settings included. Use of clinical nurse specialists in acute care settings can reduce length of stay and cost of care for hospitalized patients. These results extend what is known about APRN outcomes from previous reviews by assessing all types of APRNs over a span of 18 years, using a systematic process with intentionally broad inclusion of outcomes, patient populations, and settings. The results indicate APRNs provide effective and high-quality patient care, have an important role in improving the quality of patient care in the United States, and could help to address concerns about whether care provided by APRNs can safely augment the physician supply to support reform efforts aimed at expanding access to care.

Adding the patient perspective to comparative effectiveness research

Comparative effectiveness research generates evidence that helps consumers, clinicians, purchasers, and policy makers make better decisions about health care. Capturing the patient's perspective is central to this research because it provides a complete picture of treatment impact. This can be done with standardized questionnaires that ask patients to report on their functioning, well-being, symptoms, and satisfaction with care. These data, however, are not collected routinely in either clinical research or practice. Strategies and incentives to link patient-reported outcomes to data from conventional sources--including clinical research, electronic health records, and administrative data--will accelerate the development of useful evidence.

Evaluation of guideline-concordant care for bipolar disorder among privately insured youth

OBJECTIVE

To describe and quantify the prevalence of treatments and services for youth with bipolar disorder and to assess whether concordance with treatment guidelines is associated with inpatient hospitalization and emergency department visits.

METHOD

Insurance claims of 423 privately insured youth (ages 6-18) having prescription drug coverage and diagnosed with bipolar disorder were examined from the 2000-2001 Thomson Medstat MarketScan database, a national (US) dataset. Treatments and services were examined for the 6 months following the index bipolar disorder diagnosis, defined as the first diagnosis after a diagnosis-free period of 6 months.

RESULTS

The majority of youth did not receive guideline-concordant care. Only 26% (n = 109) received a mood stabilizer or antipsychotic, as recommended, within 1 month of a bipolar diagnosis. Antidepressant monotherapy, which is contraindicated in therapeutic guidelines, was observed for 33% (n = 140) of youth. Less than 40% of youth received adjunctive psychotherapy. Guideline concordance was statistically significantly related to a lower likelihood of an inpatient hospitalization or an emergency department visit.

CONCLUSIONS

Although deviation from guidelines may be warranted in some cases due to individual variation and patient complexity or patient and/or family preferences, these findings suggest that evidence-based guidelines are not followed in clinical practice. Incorporation of guideline-concordant care may increase the likelihood of overall better quality of care and presage better long-term outcomes for youths diagnosed with bipolar disorder.

Pattern of mortality in a sample of Maryland residents with severe mental illness

In a cohort of Maryland Medicaid recipients with severe mental illness followed from 1993-2001, we compared mortality with rates in the Maryland general population including race and gender subgroups. Persons with severe mental illness died at a mean age of 51.8 years, with a standardized mortality ratio of 3.7 (95%CI, 3.6-3.7).

Quality of care for heart failure among disabled Medicaid recipients with and without severe mental illness

OBJECTIVE

To examine the association between severe mental illness (SMI) and quality of care in heart failure.

METHODS

We conducted a cohort study between 2001 and 2004 of disabled Maryland Medicaid participants with heart failure. Quality measures and clinical outcomes were compared for individuals with and without SMI.

RESULTS

Of 1801 individuals identified with heart failure, 341 had comorbid SMI. SMI was not associated with differences in quality measures, including left ventricular assessment [adjusted relative risk (aRR) 0.99; 95% CI 0.91-1.07], utilization of angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) (aRR 1.04; 95% CI 0.92-1.17), or beta-blocker use (aRR 1.13; 95% CI 0.99-1.29). During the study period, 52.2% of individuals in the cohort filled a prescription for an ACE inhibitor or ARB and 45.5% filled a beta-blocker prescription. Individuals with and without SMI had similar rates of clinical outcomes, including hospitalizations, readmissions, and mortality. Both medication interventions were associated with improved mortality.

CONCLUSIONS

In this sample of disabled Medicaid recipients with heart failure, persons with SMI received similar quality of care as those without SMI. Both groups had low rates of beneficial medical treatments. Quality improvement programs should consider how best to target these vulnerable populations.

Financial and quality-of-life burden of dysfunctional uterine bleeding among women agreeing to obtain surgical treatment

PURPOSE

In this study, we sought to 1) describe elements of the financial and quality-of-life burden of dysfunctional uterine bleeding (DUB) from the perspective of women who agreed to obtain surgical treatment; 2) explore associations between DUB symptom characteristics and the financial and quality-of-life burden; 3) estimate the annual dollar value of the financial burden; and 4) estimate the most that could be spent on surgery to eliminate DUB symptoms for which medical treatment has been unsuccessful that would result in a $50,000/quality-adjusted life-year incremental cost-effectiveness ratio.

METHODS

We collected baseline data on DUB symptoms and aspects of the financial and quality-of-life burden for 237 women agreeing to surgery for DUB in a randomized trial comparing hysterectomy with endometrial ablation. Measures included out-of-pocket pharmaceutical expenditures, excess expenditures on pads or tampons, the value of time missed from paid work and home management activities, and health utility. We used chi2 and t tests to assess the statistical significance of associations between DUB characteristics and the financial and quality-of-life burden. The annual financial burden was estimated.

RESULTS

Pelvic pain and cramps were associated with activity limitations and tiredness was associated with a lower health utility. Excess pharmaceutical and pad and tampon costs were $333 per patient per year (95% confidence interval [CI], $263-$403). Excess paid work and home management loss costs were $2,291 per patient per year (95% CI, $1847-$2752). Effective surgical treatment costing $40,000 would be cost-effective compared with unsuccessful medical treatment.

CONCLUSION

The financial and quality-of-life effects of DUB represent a substantial burden.

Substitutive Hospital at Home for older persons: effects on costs

OBJECTIVE

To compare the cost of substitutive Hospital at Home care versus traditional inpatient care for older patients with community-acquired pneumonia, exacerbation of chronic obstructive pulmonary disease, exacerbation of congestive heart failure, or cellulitis.

STUDY DESIGN

Prospective nonrandomized clinical trial involving 455 community-dwelling older patients in 3 Medicare managed care health systems and at a Department of Veterans Affairs medical center.

METHODS

Costs were analyzed across all patients, within each of the separate health systems, and by condition. Generalized linear models controlling for confounders and using a log link and gamma family specification were used to make inferences about the statistical significance of cost differences. t Tests were used to make inferences regarding differences in follow-up utilization.

RESULTS

The costs of the Hospital at Home intervention were significantly lower than those of usual acute hospital care (mean [SD], $5081 [$4427] vs $7480 [$8113]; P <.001). Laboratory and procedure expenditures were lower across all study sites and at each site individually. There were minimal significant differences in health service utilization between the study groups during the 8 weeks after the index hospitalization. As-treated analysis results were consistent with Hospital at Home costs being lower.

CONCLUSIONS

Total costs seem to be lower when substitutive Hospital at Home care is available for patients with congestive heart failure or chronic obstructive pulmonary disease. This result may be related to the study-based requirement for continuous nursing input. Savings may be possible, particularly for care of conditions that typically use substantial laboratory tests and procedures in traditional acute settings.

The association of self-reported neighborhood disorganization and social capital with adolescent alcohol and drug use, dependence, and access to treatment

AIMS

This research examines adolescent perceptions of neighborhood disorganization and social capital to determine if they are associated with adolescent alcohol or drug (AOD) use, AOD dependence, and access to AOD treatment.

DESIGN

This is a secondary analysis of data from the 1999 and 2000 National Survey on Drug Use and Health (NSDUH). The NSDUH is a cross-sectional survey of a random sample of the non-institutionalized United States population and is conducted in respondents' homes.

PARTICIPANTS

Youth between the ages of 12 and 17, yielding a sample size of 38,115 respondents.

MEASUREMENTS

Neighborhood disorganization was self-reported by youth in response to eight items; 10 items measured social capital. AOD use was also self-reported. AOD dependence was assessed by a series of questions regarding symptoms and impairment that is consistent with the criteria specified in the DSM-IV.

RESULTS

A little more than half of the youth reported never using alcohol or drugs (54.3%), 41.1% reported lifetime AOD use, and 4.6% were AOD dependent. Two percent reported receiving AOD treatment. Medium and high levels of social capital were negatively associated with AOD use and dependence. Social capital was unrelated to access to AOD treatment. Neighborhood disorganization was positively associated with AOD use, dependence, and access to treatment.

CONCLUSIONS

After controlling for individual- and family-level characteristics, neighborhood disorganization and social capital were associated with AOD use and dependence. The findings suggest that subjective measures of social context may be an important component of the complex biopsychosocial model of adolescent AOD addiction and treatment utilization.

Toward learning from patient safety reporting systems

PURPOSE

To evaluate the frequency and type of factors involved in incidents reported to a patient safety reporting system and answer specific questions to enhance the value of PSRS data to improve patient safety.

MATERIALS AND METHODS

Prospective cohort study of incidents reported from adult and pediatric intensive care units (ICUs) in the United States to the web-based, voluntary, and anonymous Intensive Care Unit Safety Reporting System. Results from July 1, 2002, to June 30, 2004. Main outcome variables were incidents that could or did lead to patient harm.

RESULTS

Analysis includes 2075 incidents from 23 ICUs. Median number of reports/ICU/month was 3; 5 hospitals submitted 58% of reports. Harm was reported in 42% of incidents with 18 deaths. Common event types: medication/therapeutics (42%) and incorrect/incomplete care delivery (20%); 48% of line/tube/drain incidents led to physical harm. Deficiencies in training/education contributed to 49% of incidents and teamwork issues 32%; 42% of incidents had 2 or more contributing factors. As the number of contributing factors per incident increased, so did risk of harm.

CONCLUSIONS

The Intensive Care Unit Safety Reporting System provides a mechanism for multiple ICUs to identify hazards. Data trends show a correlation between multiple contributing factors and higher rates of harm. Further research is needed to help determine how to use PSRS data to improve patient safety.

Informal caregivers and the risk of nursing home admission among individuals enrolled in the program of all-inclusive care for the elderly

PURPOSE

We sought to determine whether participants in the Program of All-Inclusive Care for the Elderly (PACE) with an informal caregiver have a higher or lower risk of nursing home admission than those without caregivers.

DESIGN AND METHODS

We performed a secondary data analysis of 3,189 participants aged 55 years or older who were enrolled in 11 PACE programs during the period from June 1, 1990 through June 30, 1998. Cox proportional hazard models determined whether having any caregiver, as well as specific caregiver characteristics, such as either living separately from the enrollee, being over the age of 75 years, providing personal care, not reducing or quitting work to provide care, or not being a spouse, predicted time to nursing home admission.

RESULTS

Fewer than half of the participants (49.4%) lived with a caregiver, and 12.4% had no caregiver. Individuals who lived with their caregiver were frailer than either those who lived separately or those without a caregiver. We measured frailty in terms of functional and cognitive status, incontinence, and multiple behavioral disturbances. The presence of a caregiver did not change the risk for institutionalization. None of the caregiver characteristics were associated with a higher risk of nursing home admission.

IMPLICATIONS

Unlike individuals in the general population, participants in PACE who lack an informal caregiver are not at higher risk of institutionalization. Further research is required to ascertain whether PACE's comprehensive formal services compensate for the lack of informal caregiving in limiting the risk for institutionalization.

Adverse events during medical and surgical hospitalizations for persons with schizophrenia

CONTEXT

Persons with schizophrenia have a high risk of premature mortality. It is not clear if greater risk for adverse events during hospitalization is a contributing factor.

OBJECTIVES

To estimate the prevalence of adverse events in medical and surgical hospitalizations for persons with schizophrenia compared with those for persons without schizophrenia and to examine the relation between adverse events and intensive care unit admission, in-hospital death, length of stay, and total charges for hospitalizations for persons with schizophrenia.

DESIGN

Cross-sectional study.

SETTING

We studied discharges from all Maryland acute care hospitals' medical and surgical services in 2001 and 2002. Patients There were 1746 medical and surgical hospitalizations for adults with a secondary diagnosis of schizophrenia and 732 158 for adults without schizophrenia.

MAIN OUTCOME MEASURES

For primary outcomes, we applied the Agency for Healthcare Research and Quality's Patient Safety Indicators (PSIs), which were developed to detect adverse events in administrative data. We compared PSIs for hospitalizations for patients with a secondary diagnosis of schizophrenia with those for patients without and determined the association between schizophrenia and each PSI adjusting for patient and hospital characteristics. For hospitalizations for patients with schizophrenia, for secondary outcomes we examined the association between each PSI and intensive care unit admission, in-hospital death, length of stay, and total charges.

RESULTS

Hospitalizations for patients with schizophrenia had the following higher adjusted relative odds of having PSIs compared with those for patients without schizophrenia: infections due to medical care (odds ratio [OR], 2.49 [95% confidence interval (CI), 1.28 to 4.88]); postoperative respiratory failure (OR, 2.08 [95% CI, 1.41 to 3.06]); postoperative deep venous thrombosis (OR, 1.96 [95% CI, 1.18 to 3.26]); and postoperative sepsis (OR, 2.29 [95% CI, 1.49 to 3.51]). For hospitalizations for patients with schizophrenia, having respiratory failure or sepsis resulted in at least twice the adjusted odds for intensive care unit admission and death. The median adjusted increase in length of stay was at least 10 days, and median hospital charges were elevated by at least $20 000 for infections due to medical care, respiratory failure, deep venous thrombosis, and sepsis.

CONCLUSIONS

Medical and surgical hospitalizations for persons with schizophrenia had at least twice the odds of several types of adverse events than those for persons without schizophrenia. These adverse events were associated with poor clinical and economic outcomes during the hospital admission. Efforts to reduce these adverse events should become a research priority.

Characteristics predicting nursing home admission in the program of all-inclusive care for elderly people

PURPOSE

This study determined overall risk and predictors of long-term nursing home admission within the Program of All-Inclusive Care for the Elderly (PACE).

DESIGN AND METHODS

DataPACE records for 4,646 participants aged 55 years or older who were enrolled in 12 Medicare- and Medicaid-capitated PACE programs during the period from June 1, 1990, to June 30, 1998, were obtained. Participants were enrolled for at least 30 days and had baseline evaluations within 30 days of enrollment. Cox proportional hazard models predicting an outcome of nursing home admission of 30 days or longer were estimated.

RESULTS

The cumulative risk of admission to nursing homes for 30 days or longer was 14.9% within 3 years. Individuals enrolled from a nursing home were at very high risk for future admission, with a relative risk of 5.20 when compared with those living alone. Among individuals enrolled in PACE from the community, age, instrumental activity of daily living dependence, and bowel incontinence were predictive of subsequent nursing home admission. Asians and Blacks had a lower risk of institutionalization than Whites. However, other characteristics were not independently predictive of institutionalization, namely poor cognitive status, number of chronic conditions, activity of daily living deficits, urinary incontinence, several behavioral disturbances, and duration of program operation. Before adjusting for other variables, there was substantial site variability in risk of nursing home admission; this decreased considerably after other characteristics were adjusted for.

IMPLICATIONS

Despite the fact that 100% of the PACE participants were nursing home certifiable, the risk of being admitted to a nursing home long term following enrollment from the community is low. The presence of some reversible risk factors may have implications for early intervention to reduce risk further, although the effect of these interventions is likely to be modest. Individuals who received long-term care in a nursing home prior to enrollment in PACE remain at high risk of readmission, despite the availability of comprehensive services.

Creating the web-based intensive care unit safety reporting system

In an effort to improve patient safety, researchers at the Johns Hopkins University designed and implemented a comprehensive Web-based Intensive Care Unit Safety Reporting System (ICUSRS). The ICUSRS collects data about adverse events and near misses from all staff in the ICU. This report reflects data on 854 reports from 18 diverse ICUs across the United States. Reporting is voluntary, and data collected is confidential, with patient, provider, and reporter information deidentified. Preliminary data include system factors reported, degree of patient harm, reporting times, and evaluations of the system. Qualitative and quantitative data are reported back to the ICU site study teams and frontline staff through monthly reports, case discussions, and a quarterly newsletter.

Relationship of physician estimate of underlying asthma severity to asthma outcomes

BACKGROUND

Implementation of national guidelines for the treatment of asthma requires physician estimates of patients' underlying asthma severity. Asthma severity is commonly assigned based on respiratory symptoms.

OBJECTIVE

To evaluate the relationship of guideline-based physician assessments to asthma control.

METHODS

Data were collected by survey as part of a cohort study of adults with asthma. Physicians estimated the underlying severity of their patients' asthma as mild, moderate, or severe. We evaluated the relationship of these estimates to (1) general health status, asthma symptoms, and patient-reported emergency department (ED) visits and hospitalizations in the previous year and (2) outcomes in the following year.

RESULTS

A total of 3,468 adults with asthma had physicians who completed assessments of their severity. Physician evaluation of severity was significantly associated with the patient's recent general health status, asthma symptom control, ED visits, and hospitalizations (P < .001 for all). Future outcomes, including hospitalizations and ED visits for asthma, increased with increasing severity rating (hospitalizations: 5% [mild] vs 11% [moderate] vs 19% [severe]; ED visits: 15% [mild] vs 22% [moderate] vs 32% [severe]; P < .001 for all).

CONCLUSION

This study provides evidence of the validity of physician assessments of patients' underlying asthma severity using the strategy recommended by national guidelines.

The Schizophrenia Patient Outcomes Research Team (PORT): updated treatment recommendations 2003

Since publication of the original Schizophrenia Patient Outcomes Research Team (PORT) treatment recommendations in 1998, considerable scientific advances have occurred in our knowledge about how to help persons with schizophrenia. Today an even stronger body of research supports the scientific basis of treatment. This evidence, taken in its entirety, points to the value of treatment approaches combining medications with psychosocial treatments, including psychological interventions, family interventions, supported employment, assertive community treatment, and skills training. The most significant advances lie in the increased options for pharmacotherapy, with the introduction of second generation antipsychotic medications, and greater confidence and specificity in the application of psychosocial interventions. Currently available treatment technologies, when appropriately applied and accessible, should provide most patients with significant relief from psychotic symptoms and improved opportunities to lead more fulfilling lives in the community. Nonetheless, major challenges remain, including the need for (1) better knowledge about the underlying etiologies of the neurocognitive impairments and deficit symptoms that account for much of the disability still associated with schizophrenia; (2) treatments that more directly address functional impairments and that promote recovery; and (3) approaches that facilitate access to scientifically based treatments for patients, the vast majority of whom currently do not have such access.

Predicting patient-reported asthma outcomes for adults in managed care

OBJECTIVE

To develop and evaluate a set of questionnaire-based screening tools to identify risk for 1-year adverse outcomes in adults with moderate to severe asthma.

STUDY DESIGN

Prospective cohort study in 16 managed care organizations in the United States.

PATIENTS AND METHODS

Patients (n = 4888) with moderate-to-severe asthma completed baseline and 1-year questionnaires (response rate, 79%). Adverse outcomes included hospitalization in the past year; emergency department (ED) visit in the past year; days of lost activity in the past month; a composite measure combining hospitalization, ED use, and lost days; and severe symptoms. Risk models were constructed for each of these 5 outcomes. Candidate predictors included baseline demographic characteristics, prior asthma healthcare use, access to care, symptoms, and treatment. Outcome variables were dichotomized, and logistic regression analysis was used to estimate the probability of 1-year outcomes.

RESULTS

The patients' mean age was 45 years; 69% were female, and 83% were white. At 1-year follow-up, 9% had been hospitalized in the past year, 35% had used the ED, and 36% had reduced activity in the past month; 54% reported at least 1 of these, and 53% reported severe symptoms. Twenty-one items were retained for the 5 final risk models. Overall, the strongest predictors were comorbid illnesses and prior ED use. Model discrimination using receiver operating characteristic area ranged from 0.67 to 0.78 for predicting hospitalization, ED use, lost days, any one of these outcomes, and symptoms.

CONCLUSIONS

The questionnaire-based risk models identified with good discrimination asthmatics at increased risk for a range of adverse outcomes. Risk models based on patient-reported data could be used to target individuals for intervention.

Patient-centered communication, ratings of care, and concordance of patient and physician race

BACKGROUND

African-American patients who visit physicians of the same race rate their medical visits as more satisfying and participatory than do those who see physicians of other races. Little research has investigated the communication process in race-concordant and race-discordant medical visits.

OBJECTIVES

To compare patient-physician communication in race-concordant and race-discordant visits and examine whether communication behaviors explain differences in patient ratings of satisfaction and participatory decision making.

DESIGN

Cohort study with follow-up using previsit and postvisit surveys and audiotape analysis.

SETTING

16 urban primary care practices.

PATIENTS

252 adults (142 African-American patients and 110 white patients) receiving care from 31 physicians (of whom 18 were African-American and 13 were white).

MEASUREMENTS

Audiotape measures of patient-centeredness, patient ratings of physicians' participatory decision-making styles, and overall satisfaction.

RESULTS

Race-concordant visits were longer (2.15 minutes [95% CI, 0.60 to 3.71]) and had higher ratings of patient positive affect (0.55 point, [95% CI, 0.04 to 1.05]) compared with race-discordant visits. Patients in race-concordant visits were more satisfied and rated their physicians as more participatory (8.42 points [95% CI, 3.23 to 13.60]). Audiotape measures of patient-centered communication behaviors did not explain differences in participatory decision making or satisfaction between race-concordant and race-discordant visits.

CONCLUSIONS

Race-concordant visits are longer and characterized by more patient positive affect. Previous studies link similar communication findings to continuity of care. The association between race concordance and higher patient ratings of care is independent of patient-centered communication, suggesting that other factors, such as patient and physician attitudes, may mediate the relationship. Until more evidence is available regarding the mechanisms of this relationship and the effectiveness of intercultural communication skills programs, increasing ethnic diversity among physicians may be the most direct strategy to improve health care experiences for members of ethnic minority groups.

Prevalence and correlates of obesity in a community sample of individuals with severe and persistent mental illness

Individuals with severe and persistent mental illness (SPMI) have a preponderance of weight problems, possibly even greater than the obesity epidemic in the general population. Although atypical antipsychotics cause weight gain, their contribution to obesity has not been characterized in a community setting where individuals may take multiple psychotropics associated with weight gain. Using survey information including measured height and weight from a random sample of Maryland Medicaid recipients with SPMI, we compared obesity prevalence to the National Health and Nutrition Examination Survey (NHANES III) sample and a Maryland sample (Behavioral Risk Factor Surveillance System) of the general population adjusted to SPMI demographic characteristics. We investigated correlates of obesity in the SPMI sample. The results indicate that both men and especially women with SPMI had a higher prevalence of obesity than the general population; this portends substantial health implications. A fourfold association between atypical antipsychotics and prevalent obesity was found in men but not in women; further work should clarify mechanisms of obesity in the SPMI.

Evidence-based psychosocial treatment practices in schizophrenia: lessons from the patient outcomes research team (PORT) project

The care of persons with schizophrenia, the prototypical severe mental illness, has been a barometer of mental health care policy for decades. The prevalence, severity, and costs of schizophrenia combine to make this illness a major health problem throughout the world. In 1992, the Agency for Health Care Policy and Research and the National Institute of Mental Health funded the Schizophrenia Patient Outcomes Research Team (PORT) at the University of Maryland School of Medicine and the Johns Hopkins University School of Public Health. The PORT undertook several activities, including a comprehensive review of the empirical literature on the treatment of persons with schizophrenia; development of evidence-based treatment recommendations; description of current treatment practices; and comparison of these current practices to the evidence-based treatment recommendations, using administrative claims data and a survey of persons under treatment for schizophrenia; and dissemination of the treatment recommendations to evaluate impacts on practices. The PORT found that despite considerable evidence for effective treatments for persons with schizophrenia, most patients do not receive an appropriately comprehensive treatment "package." In particular, efficacious psychosocial treatments are highly underutilized.

Outpatient prescriptions for atypical antipsychotics for African Americans, Hispanics, and whites in the United States

BACKGROUND

New antipsychotic medications introduced during the past decade-clozapine (1990), risperidone (1994), olanzapine (1996), and quetiapine fumarate (1997)-offer a decrease in serious adverse effects compared with traditional antipsychotic medications, but at up to 10 times the cost. We examined whether ethnic minorities achieve access to these new advanced treatments.

METHODS

Using national data on physician office and hospital outpatient department visits from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey from 1992 through 2000, we selected all patient visits at which an antipsychotic medication (atypical or traditional) was prescribed or continued and the patient was aged between 18 and 69 years. We performed a series of cross-sectional logistic regression analyses to determine the association of ethnic group and receipt of an atypical antipsychotic prescription over time, adjusted for potential confounders such as age, diagnosis, and health insurance type.

RESULTS

Antipsychotic medication was prescribed or continued in 5032 visits; 33% of overall visits involved an atypical antipsychotic prescription. During 1992 to 1994, the adjusted relative odds of receipt of an atypical antipsychotic prescription for African Americans was 0.50 (95% confidence interval [CI], 0.26-0.96) and for Hispanics was 0.43 (95% CI, 0.16-1.18) compared with whites. During 1995 to 1997, the odds of receipt of a prescription for atypical antipsychotics increased for African Americans (odds ratio [OR], 0.69; 95% CI, 0.54-0.85) and for Hispanics (OR, 0.84; 95% CI, 0.65-1.07) compared with whites; and during 1998 to 2000, the relative odds continued to increase for African Americans (OR, 0.88; 95% CI, 0.78-0.97) and for Hispanics (OR, 1.05; 95% CI, 0.92-1.16) compared with whites. For visits specified for psychotic disorders, receipt of atypical antipsychotics was still lower for African Americans by 1998 to 2000 (adjusted OR, 0.74; 95% CI, 0.61-0.89) compared with whites, while for Hispanics the relative odds was equivalent (adjusted OR, 1.05; 95% CI, 0.87-1.19).

CONCLUSION

Early gaps between ethnic groups in receipt of atypical antipsychotic prescriptions decreased throughout the 1990s but persisted for African Americans with psychotic disorders.

Lower physician estimate of underlying asthma severity leads to undertreatment

BACKGROUND

Asthma undertreatment has been linked to poor outcomes. National guidelines recommend that physicians classify asthma severity based on pretreatment symptoms and titrate care as the disease changes in the individual patient. This study evaluated the extent to which the physician estimate of underlying severity affects a patient's asthma care.

METHODS

Data used were collected from a cohort of adults with asthma enrolled in managed care. Eligible patients were adults enrolled in managed care with medical encounters coded for asthma. Physicians were eligible if they were main asthma providers. The patient survey covered demographics, symptoms, asthma treatment, and self-management knowledge. Physicians were asked to assess the underlying severity of their patients' asthma.

RESULTS

There were 4005 patients with asthma with physician estimates of underlying severity. Of the patients, 70.1% were female (mean age, 44.8 years) and 83.5% were white. Most patients' current asthma symptoms were moderate (39.4%) and severe (50.1%). Most physician estimates of underlying severity were mild (44.6%) and moderate (44.5%). Among those patients reporting moderate symptoms, daily inhaled corticosteroid use was reported in 35.2% when physician estimates were mild, 53.0% when moderate, and 68.1% when severe (P =.001). Rates of peak flowmeter ownership, allergy testing, and self-management knowledge tracked similarly with physician estimates of underlying severity.

CONCLUSIONS

Physician estimates of underlying asthma severity appear to determine asthma care. For patients with inadequate symptom control, lower physician estimates of underlying severity were associated with care that is less consistent with national guidelines. To improve the quality of asthma care, physicians need to update treatment based on their patients' current symptoms and adapt care accordingly.

Gaps in asthma care of the oldest adults

OBJECTIVES

To assess the adequacy of asthma care reported by a group of older adults who were subsequently hospitalized for their asthma.

DESIGN

Prospective cohort study.

SETTING

Fifteen managed care organizations in the United States.

PARTICIPANTS

Adults with asthma, enrolled in managed care.

MEASUREMENTS

Patient survey of demographics, asthma symptoms, health status, comorbid conditions, asthma treatment, asthma knowledge, and asthma self-management at baseline and 1 year later.

RESULTS

Of 254 older adults, 38 (15.0%) reported being hospitalized for asthma at 1-year follow-up. Of these, 22.9% owned a peak flow meter (PFM). Of those with allergies, only about half (56.0%) had been told how to avoid allergens and had been referred for formal allergy testing. Adrenergic drug use was high in some patients. Nearly all (94.6%) used beta-agonist metered-dose inhalers (MDIs); 60.0% reported theophylline; 17.1% reported beta-agonist MDI overuse (>8 puffs per day); 10.5% reported beta-agonist MDI over-use and theophylline; and 13.2% reported both beta-agonist MDI over-use and oral beta-agonist use. Only 18.4% of respondents rated their overall asthma attack knowledge as excellent. Compared with nonhospitalized older adults, the hospitalized group reported care that was more consistent with guidelines, but also higher rates of potentially toxic combinations of adrenergic drugs. Compared with younger hospitalized adults, older hospitalized adults had clear deficiencies, including lower use of PFMs (55.3% vs 22.9%) and worse asthma self-management knowledge.

CONCLUSIONS

There are many opportunities to improve both the pharmacologic and non-pharmacologic care of older adults with asthma. Overuse of and potentially toxic combinations of inhaled and oral sympathomimetics should probably be avoided. Older asthmatics may also benefit from increased specialty referral, PFM use, allergy testing, and asthma teaching.

Treatment outcomes in schizophrenia: implications for practice, policy, and research

Outcomes research on treatments for schizophrenia has identified a number of efficacious interventions. The degree to which such scientific knowledge influences the care delivered in everyday practice depends on a large number of patient, practitioner, service system, and other social factors. The current atmosphere for change in the health care delivery system poses both risks and opportunities to improve care for persons with this disorder. Scientific knowledge about treatment outcomes must inform this rapid evolution of practice, policy, and research to ensure that effective treatments are preserved and available for all who need them and that new treatments continue to be developed, evaluated, and disseminated.

Treatment patterns among adult patients with asthma: factors associated with overuse of inhaled beta-agonists and underuse of inhaled corticosteroids

BACKGROUND

Overuse of inhaled beta-agonists and underuse of inhaled corticosteroids by patients with asthma may have adverse consequences. This study was performed to identify factors associated with misuse of these types of asthma medication.

METHODS

We examined baseline data from a longitudinal survey of adult patients with asthma. The setting was a consortium of 15 national managed care organizations serving 11 large employers. Baseline surveys were completed by 6612 health plan enrollees at least 18 years old who had had at least 2 visits with a diagnostic code for asthma in the preceding 2 years. The main outcome measures were the overuse of inhaled beta-agonists and the underuse of inhaled corticosteroids. Independent variables were patient and process of care factors.

RESULTS

Among patients with moderate or severe asthma, 16% of users of inhaled beta-agonists reported overuse (>8 puffs per day on days of use), and 64% of users of inhaled corticosteroids reported underuse (use on < or =4 days/wk or < or =4 puffs per day). Overuse of inhaled beta-agonists was most strongly associated with concomitant treatment with inhaled corticosteroids or anticholinergic agents, increased asthma symptom severity, problems in obtaining asthma medication, and male sex. Underuse of inhaled corticosteroids was associated with nonwhite race, younger age (18 to 34 years), lower use of inhaled beta-agonist, lower symptom severity, and not possessing a peak flow meter. Rates of misuse of medication also varied by speciality of the patient's provider (generalist, allergist, or pulmonologist).

CONCLUSIONS

Overuse of inhaled beta-agonists may be caused by symptom severity, while underusers of corticosteroids may interrupt use as symptoms abate. This study demonstrated an important opportunity to improve medication use among patients with asthma.

Mental health service utilization by African Americans and Whites: the Baltimore Epidemiologic Catchment Area Follow-Up

OBJECTIVE

To compare mental health service utilization and its associated factors between African Americans and whites in the 1980s and 1990s.

DESIGN

Household-based longitudinal study with baseline interviews in 1981 and follow-up interviews from 1993 to 1996.

SETTING

The Baltimore Epidemiologic Catchment Area (ECA) Follow-Up.

SUBJECTS

Subjects included 1,662 adults (590 African Americans and 1,072 whites).

MAIN OUTCOME VARIABLE

Use of mental health services, defined as talking to any health professional about emotional or nervous problems or alcohol or drug-related problems within the 6 months preceding each interview.

RESULTS

In 1981, crude rates of mental health service use in general medical (GM) settings and specialty mental health settings were similar for African Americans and whites (11.7%). However, after adjustment for predisposing, need, and enabling factors, individuals receiving mental health services were less likely to be African American. Mental health service use increased by 6.5% over follow-up, and African Americans were no longer less likely to report receiving any mental health services in the 1990s. African Americans were more likely than whites to report discussing mental health problems in GM settings without having seen a mental health specialist. They were less likely than whites to report use of specialty mental health services, but this finding was not statistically significant, possibly because of low rates of specialty mental health use by both race groups. Psychiatric distress was the strongest predictor of mental health service use. Attitudes positively associated with use of mental health services were more prevalent among African Americans than whites.

CONCLUSIONS

Mental health service use increased in the past decade, with the greatest increase among African Americans in GM settings. Although it is possible that the racial disparity in use of specialty mental health services remains, the GM setting may offer a safety net for some mental health concerns of African Americans.

A comparison of ambulatory Medicaid claims to medical records: a reliability assessment

This study compares the documentation of ambulatory care visits and diagnoses in Medicaid paid claims and in medical records. Data were obtained from Maryland Medicaid's 1988 paid claims files for 2407 individuals who were continuously enrolled for the fiscal year, had at least one billed visit for one of six indicator conditions, and had received the majority of their care from one provider. The patients sampled were also stratified on the basis of the case-mix adjusted cost of their usual source of care. The medical records for these individuals as maintained by their usual source of care were abstracted by trained nurse reviewers to compare claims and record information. Linked claim and medical record data for sampled patients were used to calculate: (i) the percent of billed visits documented in the record, (ii) the percent of medical record visits where both the date and the diagnosis agreed with the claims data, and (iii) the ratio of medical record visits to visits from billed claims. Included in the analysis were independent variables specifying place of residence, type and costliness of usual care source, level of patient utilization, and indicator condition on which patient was sampled. Ninety percent of the visits chronicled in the paid claims were documented in the medical record with 82% agreeing on both date and diagnosis. Compared to the medical records kept by private physicians and community health centers, a significantly lower percent of hospital medical records agreed with the claims data. Total volume of visits was 2.6% higher in the medical records than in the claims. Claims data substantially understated visits in the medical record by 25% for low cost providers and by 41% for patients with low use rates (based on claims information). Conversely, medical records substantially understated billed visits by 19% for rural patients and by 10% for persons with high visit rates. Although Medicaid claims are relatively accurate and useful for examining average ambulatory use patterns, they are subject to significant biases when comparing subgroups of providers classified by case-mix adjusted cost and patients classified by utilization rates. Medicaid programs are using claims data for profiling and performance assessment need to understand the limitations of administrative data.

Patterns of usual care for schizophrenia: initial results from the Schizophrenia Patient Outcomes Research Team (PORT) Client Survey

To examine the conformance of current patterns of usual care for persons with schizophrenia to the Schizophrenia Patient Outcomes Research Team (PORT) Treatment Recommendations, the PORT surveyed a stratified random sample of 719 persons diagnosed with schizophrenia in two States. The types of treatment settings surveyed included acute inpatient programs and continuing outpatient programs in urban and rural locales. Using data from medical record reviews and patient interviews, the PORT assessed the conformance of current care with 12 of the Treatment Recommendations. The rates at which patients' treatment conformed to the recommendations were modest at best, generally below 50 percent. Conformance rates were higher for pharmacological than for psychosocial treatments and in rural areas than in urban ones. Rates of Treatment Recommendation conformance for minority patients were lower than those for Caucasians, and patterns of care varied between the two States. The findings indicate that current usual treatment practices likely fall substantially short of what would be recommended based on the best evidence on treatment efficacy. This disparity underscores the need for greater efforts to ensure that treatment research results are translated into practice.

Translating research into practice: the Schizophrenia Patient Outcomes Research Team (PORT) treatment recommendations

Beginning in 1992, the Agency for Health Care Policy and Research and the National Institute of Mental Health funded the Schizophrenia Patient Outcomes Research Team (PORT) to develop and disseminate recommendations for the treatment of schizophrenia based on existing scientific evidence. These Treatment Recommendations, presented here in final form for the first time, are based on exhaustive reviews of the treatment outcomes literature (previously published in Schizophrenia Bulletin, Vol. 21, No. 4, 1995) and focus on those treatments for which there is substantial evidence of efficacy. The recommendations address antipsychotic agents, adjunctive pharmacotherapies, electroconvulsive therapy, psychological interventions, family interventions, vocational rehabilitation, and assertive community treatment/intensive case management. Support for each recommendation is referenced to the previous PORT literature reviews, and the recommendations are rated according to the level of supporting evidence. The PORT Treatment Recommendations provide a basis for moving toward "evidence-based" practice for schizophrenia and identify both the strengths and limitations in our current knowledge base.

Principles for assessment of patient outcomes in mental health care

With the dramatic changes that are occurring in mental health and substance abuse treatment systems, it is imperative that the field keep its focus on the patient and the patient's outcomes of care. Outcomes management systems that measure the processes of care, the patient's characteristics, and the patient's outcomes of care can be helpful in maintaining this focus. To facilitate the development of these systems, the Outcomes Roundtable, a group of mental health consumer, professional, service, and policy-making organizations, has articulated a set of 12 broadly applicable principles of outcomes assessment. The principles call for outcomes assessments that are appropriate to the question being answered, that use tools with demonstrated validity and reliability and sensitivity to clinically important changes over time, and that always include the consumer perspective. In addition, the principles recommend outcomes assessments that create minimal burden for respondents and are adaptable to different health care systems, that include general health status as well as mental health status, and that include consumers' evaluation of treatment and outcomes. Outcomes assessment tools should quantify the type and extent of treatment, should include generic and disorder-specific information, and should measure areas of personal functioning affected by the disorder. Outcomes should be reassessed at clinically meaningful points in time. Outcomes assessment should use appropriate scientific design and representative samples and should examine outcomes of consumers who prematurely leave treatment as well as those who continue in treatment.

Building research capacity into a national physician database

The range of physician financial arrangements with managed care and insurers, as well as practice arrangements, is becoming increasingly complex. Little is known systematically about these changes, yet there is growing evidence that financial arrangements, utilization management, and other practice characteristics make a substantial difference in treatment patterns, patient mix, and costs of care. Current data systems and surveys frequently do not capture the new information needed to track these changes. New elements of information should be included in national surveys and in a national physician database. A list of recommended data items for a national data base is provided as a starting point for identifying a minimal data set to be included in national statistical systems.

Systemwide provider performance in a Medicaid program. Profiling the care of patients with chronic illnesses

OBJECTIVES

This study illustrates how claims data can be applied to examine cost and clinical performance of providers in the Medicaid program.

METHODS

The authors conducted a cross-sectional analysis of Medicaid beneficiaries in Maryland with diabetes mellitus, hypertension, and asthma treated on an ambulatory basis by hospital-based outpatient departments, physician office-based providers, and community health centers. The study year was July 1987 to June 1988. The authors defined the cost performance (high, medium, or low) of providers in the management of each of the three chronic illnesses, both before and after casemix adjustment, using a classification system based on ambulatory diagnoses (ambulatory care groups). The authors constructed claims-based clinical performance indicators for each of the three conditions. These included the number of patients admitted to acute-care hospitals for any and specific (diabetes mellitus, hypertension, and asthma) causes, the number of patients without a follow-up visit within 30 days of being discharged from the hospital, and the number of patients with consecutive emergency room visits during the study period.

RESULTS

The ambulatory care group casemix classification system explained 23%, 33%, and 36% of the variation in total payments for patients with hypertension, diabetes, and asthma, respectively. Without adjustment for casemix, 35% to 50% of providers would be misclassified regarding their cost performance. Forty-one (19.4%) of 211 providers who treated all three illnesses were in the same cost group for all three illnesses and 95 (43%) of 223 providers who treated two of the three illnesses were in the same cost group for both illnesses. Among office-based physicians, for all three chronic illnesses, high-cost providers had more admissions (P < 0.01) for ambulatory care-sensitive conditions than low-cost providers. Among hospital outpatient departments, only high-cost providers of asthma had more admissions (P < 0.05) for asthma than low-cost providers. There was no statistically significant (P > 0.05) difference in the clinical performance indicators between high-cost and low-cost hospital outpatient department providers of primary care for hypertensive and diabetic Medicaid beneficiaries. For the other clinical performance indicators, the results were not consistent across the three illnesses or across the different types of providers.

CONCLUSIONS

Without adjustments for casemix, a large number of providers are misclassified regarding to cost performance. In addition, most providers are not equally efficient in managing different chronic illnesses. Provider cost performance is not associated consistently with clinical performance, although severity differences not captured by the casemix adjustment may account for these observations. These measurement methods and relationships between provider performance measures may be useful to state Medicaid programs that seek to contain costs, enhance coordination of care, and improve health.