The Health Effects of Medicare for the Near-Elderly Uninsured

Objective. To determine whether Medicare enrollment at age 65 has an effect on the health trajectory of the near-elderly uninsured.
Data Sources. Eight biennial waves (1992–2006) of the Health and Retirement Study, a nationally representative panel survey of noninstitutionalized 51–61 year olds and their spouses.
Study Design. We use a quasi-experimental approach to compare the health effects of insurance for the near-elderly uninsured with previously insured contemporaneous controls. The primary outcome measure is overall self-reported health status combined with mortality (i.e., excellent to very good, good, fair to poor, dead).
Results. The change in the trajectory of overall health status for the previously uninsured that can be attributed to Medicare is small and not statistically significant. For every 100 persons in the previously uninsured group, joining Medicare is associated with 0.6 fewer in excellent or very good health (95 percent CI: −4.8, 3.3), 0.3 more in good health (95 percent CI: −3.8, 4.1), 2.5 fewer in fair or poor health (95 percent CI: −7.4, 2.3), and 2.8 more dead (−4.0, 10.0) by age 73. The health trajectory patterns from physician objective health measures are similarly small and not statistically significant.
Conclusions. Medicare coverage at age 65 for the previously uninsured is not linked to improvements in overall health status.     

The Boomers Are Coming: A Total Cost of Care Model of the Impact of Population Aging on Health Care Costs in the United States by Major Practice Category

Objective. To project the impact of population aging on total U.S. health care per capita costs from 2000 to 2050 and for the range of clinical areas defined by Major Practice Categories (MPCs).
Data Sources. Secondary data: HealthPartners health plan administrative data; U.S. Census Bureau population projections 2000–2050; and MEPS 2001 health care annual per capita costs.
Study Design. We calculate MPC-specific age and gender per capita cost rates using cross-sectional data for 2002–2003 and project U.S. changes by MPC due to aging from 2000 to 2050.
Data Collection Methods. HealthPartners data were grouped using purchased software. We developed and validated a method to include pharmacy costs for the uncovered.
Principal Findings. While total U.S. per capita costs due to aging from 2000 to 2050 are projected to increase 18 percent (0.3 percent annually), the impact by MPC ranges from a 55 percent increase in kidney disorders to a 12 percent decrease in pregnancy and infertility care. Over 80 percent of the increase in total per capita cost will result from just seven of the 22 total MPCs.
Conclusions. Understanding the differential impact of aging on costs at clinically specific levels is important for resource planning, to effectively address future medical needs of the aging U.S. population.     

The Role of Outpatient Facilities in Explaining Variations in Risk-Adjusted Readmission Rates between Hospitals

Objective. Validate risk-adjusted readmission rates as a measure of inpatient quality of care after accounting for outpatient facilities, using premature infants as a test case.
Study Setting. Surviving infants born between January 1, 1998 and December 12, 2001 at five Northern California Kaiser Permanente neonatal intensive care units (NICU) with 1-year follow-up at 32 outpatient facilities.
Study Design. Using a retrospective cohort of premature infants ( N =898), Poisson's regression models determined the risk-adjusted variation in unplanned readmissions between 0–1 month, 0–3 months, 3–6 months, and 3–12 months after discharge attributable to patient factors, NICUs, and outpatient facilities.
Data Collection. Prospectively collected maternal and infant hospital data were linked to inpatient, outpatient, and pharmacy databases.
Principal Results. Medical and sociodemographic factors explained the largest amount of variation in risk-adjusted readmission rates. NICU facilities were significantly associated with readmission rates up to 1 year after discharge, but the outpatient facility where patients received outpatient care can explain much of this variation. Characteristics of outpatient facilities, not the NICUs, were associated with variations in readmission rates.
Conclusion. Ignoring outpatient facilities leads to an overstatement of the effect of NICUs on readmissions and ignores a significant cause of variations in readmissions.     

Developing a Quality Measure for Clinical Inertia in Diabetes Care

Objective. To develop a valid quality measure that captures clinical inertia, the failure to initiate or intensify therapy in response to medical need, in diabetes care and to link this process measure with outcomes of glycemic control.
Data Sources. Existing databases from 13 Department of Veterans Affairs hospitals between 1997 and 1999.
Study Design. Laboratory results, medications, and diagnoses were collected on 23,291 patients with diabetes. We modeled the decision to increase antiglycemic medications at individual visits. We then aggregated all visits for individual patients and calculated a treatment intensity score by comparing the observed number of increases to that expected based on our model. The association between treatment intensity and two measures of glycemic control, change in HbA1c during the observation period, and whether the outcome glycosylated hemoglobin (HbA1c) was greater than 8 percent, was then examined.
Principal Findings. Increases in antiglycemic medications occured at only 9.8percent of visits despite 39percent of patients having an initial HbA1c level greater than 8 percent. A clinically credible model predicting increase in therapy was developed with the principal predictor being a recent HbA1c greater than 8 percent. There were considerable differences in the intensity of therapy received by patients. Those patients receiving more intensive therapy had greater improvements in control ( p <.001).
Conclusions. Clinical inertia can be measured in diabetes care and this process measure is linked to patient outcomes of glycemic control. This measure may be useful in efforts to improve clinicians management of patients with diabetes.     

Traveling Abroad for Medical Care: U.S. Medical Tourists' Expectations and Perceptions of Service Quality

The SERVQUAL scale has been widely used to measure service quality in the health care industry. This research is the first study that used SERVQUAL to assess U.S. medical tourists' expectations and perceptions of the service quality of health care facilities located outside the United States. Based on a sample of U.S. consumers, who had traveled abroad for medical care, the results indicated that there were significant differences between U.S. medical tourists' perceived level of service provided and their expectations of the service that should be provided for four of the five dimensions of service quality. Reliability had the largest service quality gap followed by assurance, tangibles, and empathy. Responsiveness was the only dimension without a significantly different gap score. The study establishes a foundation for future research on service quality in the rapidly growing medical tourism industry.     

The Relationship of Medicaid Payment Rates, Bed Constraint Policies, and Risk-Adjusted Pressure Ulcers

Objective. To examine the effect of Medicaid reimbursement rates on nursing home quality in the presence of certificate-of-need (CON) and construction moratorium laws.
Data Sources/Study Setting. A single cross-section of Medicaid certified nursing homes in 1999 ( N =13,736).
Study Design. A multivariate regression model was used to examine the effect of Medicaid payment rates and other explanatory variables on risk-adjusted pressure ulcer incidence. The model is alternatively considered for all U.S. nursing home markets, those most restrictive markets, and those high-Medicaid homes to isolate potentially resource-poor environments.
Data Extraction Methods. A merged data file was constructed with resident-level information from the Minimum Data Set, facility-level information from the On-Line, Survey, Certification, and Reporting (OSCAR) system and market- and state-level information from various published sources.
Principal Findings. In the analysis of all U.S. markets, there was a positive relationship between the Medicaid payment rate and nursing home quality. The results from this analysis imply that a 10 percent increase in Medicaid payment was associated with a 1.5 percent decrease in the incidence of risk-adjusted pressure ulcers. However, there was a limited association between Medicaid payment rates and quality in the most restrictive markets. Finally, there was a strong relationship between Medicaid payment and quality in high-Medicaid homes providing strong evidence that the level of Medicaid payment is especially important within resource poor facilities.
Conclusions. These findings provide support for the idea that increased Medicaid reimbursement may be an effective means toward improving nursing home quality, although CON and moratorium laws may mitigate this relationship.     

The Cost-Effectiveness of Improving Diabetes Care in U.S. Federally Qualified Community Health Centers

Objective. To estimate the incremental cost-effectiveness of improving diabetes care with the Health Disparities Collaborative (HDC), a national collaborative quality improvement (QI) program conducted in community health centers (HCs).
Data Sources/Study Setting. Data regarding the impact of the Diabetes HDC program came from a serial cross-sectional follow-up study (1998, 2000, 2002) of the program in 17 Midwestern HCs. Data inputs for the simulation model of diabetes came from the latest clinical trials and epidemiological studies.
Study Design. We conducted a societal cost-effectiveness analysis, incorporating data from QI program evaluation into a Monte Carlo simulation model of diabetes.
Data Collection/Extraction Methods. Data on diabetes care processes and risk factor levels were extracted from medical charts of randomly selected patients.
Principal Findings. From 1998 to 2002, multiple processes of care (e.g., glycosylated hemoglobin testing [HbA_1C] [71→92 percent] and ACE inhibitor prescribing [33→55 percent]) and risk factor levels (e.g., 1998 mean HbA_1C 8.53 percent, mean difference 0.45 percent [95 percent confidence intervals −0.72, −0.17]) improved significantly. With these improvements, the HDC was estimated to reduce the lifetime incidence of blindness (17→15 percent), end-stage renal disease (18→15 percent), and coronary artery disease (28→24 percent). The average improvement in quality-adjusted life year (QALY) was 0.35 and the incremental cost-effectiveness ratio was $33,386/QALY.
Conclusions. During the first 4 years of the HDC, multiple improvements in diabetes care were observed. If these improvements are maintained or enhanced over the lifetime of patients, the HDC program will be cost-effective for society based on traditionally accepted thresholds.     

Are nonspecific practice guidelines potentially harmful? A randomized comparison of the effect of nonspecific versus specific guidelines on physician decision making.

OBJECTIVE: To test the ability of two different clinical practice guideline formats to influence physician ordering of electrodiagnostic tests in low back pain. DATA SOURCES/STUDY DESIGN: Randomized controlled trial of the effect of practice guidelines on self-reported physician test ordering behavior in response to a series of 12 clinical vignettes. Data came from a national random sample of 900 U.S. neurologists, physical medicine physicians, and general internists. INTERVENTION: Two different versions of a practice guideline for the use of electrodiagnostic tests (EDT) were developed by the U.S. Agency for Health Care Policy and Research Low Back Problems Panel. The two guidelines were similar in content but varied in the specificity of their recommendations. DATA COLLECTION: The proportion of clinical vignettes for which EDTs were ordered for appropriate and inappropriate clinical indications in each of three physician groups were randomly assigned to receive vignettes alone, vignettes plus the nonspecific version of the guideline, or vignettes plus the specific version of the guideline. PRINCIPAL FINDINGS: The response rate to the survey was 71 percent. The proportion of appropriate vignettes for which EDTs were ordered averaged 77 percent for the no guideline group, 71 percent for the nonspecific guideline group, and 79 percent for the specific guideline group (p = .002). The corresponding values for the number of EDTs ordered for inappropriate vignettes were 32 percent, 32 percent, and 26 percent, respectively (p = .08). Pairwise comparisons showed that physicians receiving the nonspecific guidelines ordered fewer EDTs for appropriate clinical vignettes than did physicians receiving no guidelines (p = .02). Furthermore, compared to physicians receiving nonspecific guidelines, physicians receiving specific guidelines ordered significantly more EDTs for appropriate vignettes (p = .0007) and significantly fewer EDTs for inappropriate vignettes (p = .04). CONCLUSIONS: The clarity and clinical applicability of a guideline may be important attributes that contribute to the effects of practice guidelines.     

Impact of Public Reporting on Unreported Quality of Care

Objective. The impact of quality improvement incentives on nontargeted care is unknown and some have expressed concern that such incentives may be harmful to nontargeted areas of care. Our objective is to examine the effect of publicly reporting quality information on unreported quality of care.
Data Sources/Study Setting. The nursing home Minimum Data Set from 1999 to 2005 on all postacute care admissions.
Study Design. We studied 13,683 skilled nursing facilities and examined how unreported aspects of clinical care changed in response to changes in reported care after public reporting was initiated by the Centers for Medicare and Medicaid Services on their website, Nursing Home Compare, in 2002.
Principal Findings. We find that overall both unreported and reported care improved following the launch of public reporting. Improvements in unreported care were particularly large among facilities with high scores or that significantly improved on reported measures, whereas low-scoring facilities experienced no change or worsening of their unreported quality of care.
Conclusions. Public reporting in the setting of postacute care had mixed effects on areas without public reporting, improving in high-ranking facilities, but worsening in low-ranking facilities. While the benefits of public reporting may extend beyond areas that are being directly measured, these initiatives may also widen the gap between high- and low-quality facilities.