Changes in US health care access in the 90s: race and income differences from the CARDIA Study. Coronary Artery Risk Development in Young Adults

OBJECTIVE

Health care financing is changing rapidly in the United States. We investigated whether and how health care access is changing concurrently with changes in financing, with special attention to a minority population.

METHODS

We examined a longitudinal biracial (half African-American, half White) urban cohort of 3,565 individuals, aged 25-37 years old, in 1992-93 and again in 1995-96. We measured access by self-reported (1) health insurance status, (2) regular source of medical care, and (3) lack of care due to financial problems.

RESULTS

In 1992-93, 30.3% of the cohort experienced at least one access barrier, with a decline to 26.8% in 1995-96 (P<.005). However, access improved more for Whites than for African Americans; and access improved for higher, but not for lower, income groups (7% improvement for high income, vs 2% deterioration for lower income, P<.01). In addition, there was an 11% to 19% absolute increase in individuals making co-payments for health care utilization across all race/sex groups, with African Americans having markedly higher proportions of cost-sharing. African-American, low income, and unemployed individuals reported more acute care, but fewer outpatient visits. Income and employment explained racial differences.

CONCLUSION

While access has improved or stabilized for higher income groups, there is a widening gap according to income, accompanied by an acute care pattern for low income groups that may be both inadequate and cost inefficient.

Improving quality improvement using achievable benchmarks for physician feedback: a randomized controlled trial

CONTEXT

Performance feedback and benchmarking, common tools for health care improvement, are rarely studied in randomized trials. Achievable Benchmarks of Care (ABCs) are standards of excellence attained by top performers in a peer group and are easily and reproducibly calculated from existing performance data.

OBJECTIVE

To evaluate the effectiveness of using achievable benchmarks to enhance typical physician performance feedback and improve care.

DESIGN

Group-randomized controlled trial conducted in December 1996, with follow-up through 1998.

SETTING AND PARTICIPANTS

Seventy community physicians and 2978 fee-for-service Medicare patients with diabetes mellitus who were part of the Ambulatory Care Quality Improvement Project in Alabama.

INTERVENTION

Physicians were randomly assigned to receive a multimodal improvement intervention, including chart review and physician-specific feedback (comparison group; n = 35) or an identical intervention plus achievable benchmark feedback (experimental group; n = 35).

MAIN OUTCOME MEASURE

Preintervention (1994-1995) to postintervention (1997-1998) changes in the proportion of patients receiving influenza vaccination; foot examination; and each of 3 blood tests measuring glucose control, cholesterol level, and triglyceride level, compared between the 2 groups.

RESULTS

The proportion of patients who received influenza vaccine improved from 40% to 58% in the experimental group (P<.001) vs from 40% to 46% in the comparison group (P =.02). Odds ratios (ORs) for patients of achievable benchmark physicians vs comparison physicians who received appropriate care after the intervention, adjusted for preintervention care and nesting of patients within physicians, were 1.57 (95% confidence interval [CI], 1.26-1.96) for influenza vaccination, 1.33 (95% CI, 1.05-1.69) for foot examination, and 1.33 (95% CI, 1.04-1.69) for long-term glucose control measurement. For serum cholesterol and triglycerides, the achievable benchmark effect was statistically significant only after additional adjustment for physician characteristics (OR, 1.40 [95% CI, 1.08-1.82] and OR, 1.40 [95% CI, 1.09-1.79], respectively).

CONCLUSION

Use of achievable benchmarks significantly enhances the effectiveness of physician performance feedback in the setting of a multimodal quality improvement intervention.

Optimal reporting of health care process measures: inferential statistics as help or hindrance?

In this paper we discuss the appropriate application of inferential statistics to practice profiles and other measures of care. To accomplish our objectives, we first describe the relative merits of measuring three well-recognized domains of medical quality: structure, process, and outcome. Next, we discuss inferential statistics as used in quality improvement. We then describe several common circumstances that arise in the measurement of medical care, giving attention to the application of inferential statistics to each situation. We end with a brief discussion of statistical techniques commonly used in the measurement of quality and challenges that arise with their use.

Relationship of hospital teaching status with quality of care and mortality for Medicare patients with acute MI

CONTEXT

Issues of cost and quality are gaining importance in the delivery of medical care, and whether quality of care is better in teaching vs nonteaching hospitals is an essential question in this current national debate.

OBJECTIVE

To examine the association of hospital teaching status with quality of care and mortality for fee-for-service Medicare patients with acute myocardial infarction (AMI).

DESIGN, SETTING, AND PATIENTS

Analysis of Cooperative Cardiovascular Project data for 114,411 Medicare patients from 4361 hospitals (22,354 patients from 439 major teaching hospitals, 22,493 patients from 455 minor teaching hospitals, and 69,564 patients from 3467 nonteaching hospitals) who had AMI between February 1994 and July 1995.

MAIN OUTCOME MEASURES

Administration of reperfusion therapy on admission, aspirin during hospitalization, and beta-blockers and angiotensin-converting enzyme inhibitors at discharge for patients meeting strict inclusion criteria; mortality at 30, 60, and 90 days and 2 years after admission.

RESULTS

Among major teaching, minor teaching, and nonteaching hospitals, respectively, administration rates for aspirin were 91.2%, 86.4%, and 81.4% (P<.001); for angiotensin-converting enzyme inhibitors, 63. 7%, 60.0%, and 58.0% (P<.001); for beta-blockers, 48.8%, 40.3%, and 36.4% (P<.001); and for reperfusion therapy, 55.5%, 58.9%, and 55.2% (P =.29). Differences in unadjusted 30-day, 60-day, 90-day, and 2-year mortality among hospitals were significant at P<.001 for all time periods, with a gradient of increasing mortality from major teaching to minor teaching to nonteaching hospitals. Mortality differences were attenuated by adjustment for patient characteristics and were almost eliminated by additional adjustment for receipt of therapy.

CONCLUSIONS

In this study of elderly patients with AMI, admission to a teaching hospital was associated with better quality of care based on 3 of 4 quality indicators and lower mortality. JAMA. 2000;284:1256-1262

Relation of race and sex to the use of reperfusion therapy in Medicare beneficiaries with acute myocardial infarction

BACKGROUND

There are few reports describing the combined influence of the race and sex of a patient on the use of reperfusion therapy for acute myocardial infarction.

METHODS

To determine the relation of race and sex to the receipt of reperfusion therapy for myocardial infarction in the United States, we reviewed the medical records of 234,769 Medicare patients with myocardial infarction. From these records we identified 26,575 white or black patients who met strict eligibility criteria for reperfusion therapy. We then performed bivariate and multivariate analyses of prevalence ratios to determine predictors of the use of reperfusion therapy in four subgroups of patients categorized according to race and sex: white men, white women, black men, and black women.

RESULTS

Among eligible patients, white men received reperfusion therapy with the highest frequency (59 percent), followed by white women (56 percent), black men (50 percent), and black women (44 percent). After adjustment for differences in demographic and clinical characteristics, white women were as likely as white men to receive reperfusion therapy (prevalence ratio, 1.00; 95 percent confidence interval, 0.98 to 1.03). Likewise, black women were as likely as black men to receive reperfusion therapy (prevalence ratio, 1.00; 95 percent confidence interval, 0.89 to 1.13). However, black women were significantly less likely to receive reperfusion therapy than white men (prevalence ratio, 0.90; 95 percent confidence interval, 0.82 to 0.98), as were black men (prevalence ratio, 0.85; 95 percent confidence interval, 0.78 to 0.93).

CONCLUSIONS

After adjustment for differences in clinical and demographic characteristics and clinical presentation, differences according to sex in the use of reperfusion therapy are minimal. However, blacks, regardless of sex, are significantly less likely than whites to receive this potentially lifesaving therapy.

The art and science of searching MEDLINE to answer clinical questions. Finding the right number of articles

The current medical environment makes information retrieval a matter of practical importance for clinicians. Many avenues present themselves to the clinician, but here we focus on MEDLINE by summarizing the current state of the art and providing an innovative approach for skill enhancement. Because new search engines appear rapidly, we focus on generic principles that can be easily adapted to various systems, even those not yet available. We propose an idealized classification system for the results of a MEDLINE search. Type A searches produce a few articles of high quality that are directly focused on the immediate question. Type B searches yield a large number of articles, some more relevant than others. Type C searches produce few or no articles, and those that are located are not germane. Providing that relevant, high-quality articles do exist, type B and C searches may often be improved with attention to search technique. Problems stem from poor recall and poor precision. The most daunting task lies in achieving the balance between too few and too many articles. By providing a theoretical framework and several practical examples, we prepare the searcher to overcome the following barriers: a) failure to begin with a well-built question; b) failure to use the Medical Subject Headings; c) failure to leverage the relationship between recall and precision; and d) failure to apply proper limits to the search. Thought and practice will increase the utility and enjoyment of searching MEDLINE.

Achievable benchmarks of care: the ABCs of benchmarking

Benchmarking is generally considered to be an important tool for quality improvement. Traditional approaches to benchmarking have relied on subjective identification of 'leaders in the field'. We derive an objective, reproducible and attainable Achievable Benchmark of Care (ABC) by measuring and analysing performance on process-of-care indicators. Three characteristics of the ABC that we deem essential are: (1) benchmarks represent a measurable level of excellence; (2) benchmarks are demonstrably attainable; (3) benchmarks are derived from data in an objective, reproducible and predetermined fashion. From these characteristics it follows that (4) providers with high performance are selected to define a level of excellence in a predetermined fashion, but (5) providers with high performance on small numbers of cases do not influence unduly benchmark levels. We use the 'pared mean' to operationalize the ABC. Roughly, the pared mean summarizes the performance of top-ranked providers whereby at least 10% of the patient pool across all providers is included. Bayesian estimators for adjustment of performance of providers with small sample sizes are used to rank providers. Randomized controlled trials to assess the independent effect of the ABC in quality improvement projects are under way. We have developed a methodology objectively and reproducibly to derive a level of excellent, attainable performance, based on measured performance by a group of providers. The ABC can be applied to groups of providers in communities, to institutions and departments within them, or to individual practitioners.

Measurement of mammography rates for quality improvement

To determine the best source of high-quality data related to mammography rates, a study was undertaken to compare chart audit and claims data from the Health Care Financing Administration's Ambulatory Quality Improvement Project. Because claims data captured a higher percentage of mammograms than chart audit data in this study, quality improvement projects should consider utilizing claims data only to ascertain mammography rates.

Can data-driven benchmarks be used to set the goals of healthy people 2010?

OBJECTIVES

Expert panels determined the public health goals of Healthy People 2000 subjectively. The present study examined whether data-driven benchmarks provide a better alternative.

METHODS

We developed the "pared-mean" method to define from data the best achievable health care practices. We calculated the pared-mean benchmark for screening mammography from the 1994 National Health Interview Survey, using the metropolitan statistical area as the "provider" unit. Beginning with the best-performing provider and adding providers in descending sequence, we established the minimum provider subset that included at least 10% of all women surveyed on this question. The pared-mean benchmark is then the proportion of women in this subset who received mammography.

RESULTS

The pared-mean benchmark for screening mammography was 71%, compared with the Healthy People 2000 goal of 60%.

CONCLUSIONS

For Healthy People 2010, benchmarks derived from data reflecting the best available care provide viable alternatives to consensus-derived targets. We are currently pursuing additional refinements to the data-driven pared-mean benchmark approach.

Identifying achievable benchmarks of care: concepts and methodology

Webster's Dictionary defines a benchmark as 'something that serves as a standard by which others can be measured'. Benchmarking pervades the health care quality improvement literature, and benchmarks are usually based on subjective assessment rather than on measurements derived from data. As such, benchmarks may fail to yield an achievable level of excellence that can be replicated under specific conditions. In this paper, we provide an overview of benchmarking in health care. We then describe the evolution of our data-driven method for identifying an Achievable Benchmark of Care (ABC) on the basis of process-of-care indicators. Here, our experience leads us to postulate the following premises for sound benchmarks: (i) benchmarks should represent a level of excellence; (ii) benchmarks should be demonstrably attainable; (iii) providers with high performance should be selected from among all providers in a predefined way using reliable data; (iv) all providers with high performance levels should contribute to the benchmark level; and (v) providers with high performance levels but small numbers of cases should not unduly influence the level of the benchmark. An example of an ABC applied to the cooperative cardiovascular project leads the reader through the computation of an ABC. Finally, we consider several refinements of the original ABC concept that are in progress, e.g. how to approach the special problems posed by very small denominators. The ABC methodology has been well accepted in multiple quality improvement projects. This approach lends objectivity and reliability to benchmarks that have been a widely used, but until now, arbitrarily defined tool.

A comparison of two types of extinction following fixed-ratio training

Five groups of pigeons were food reinforced on various schedules. Half of each group were extinguished in the normal manner; the others were presented with a stimulus change, previously paired with reinforcement, each time they completed their respective fixed ratios. Response rate in training was an increasing negatively accelerated function of the FR. Increasing the FR produced transitory rate changes, the amount of which yielded a quantitative index of ratio strain. Cumulative records of extinction performance revealed that the stimulus change exerted discriminative control by maintaining the cohesiveness of FR response units. Nevertheless, neither the absolute number of extinction responses nor extinction response units differed appreciably for the two extinction procedures.