Characterization of Adverse Events Detected in a Large Health Care Delivery System Using an Enhanced Global Trigger Tool over a Five‐Year Interval

Objective

To report 5 years of adverse events (AEs) identified using an enhanced Global Trigger Tool (GTT) in a large health care system.

Study Setting

Records from monthly random samples of adults admitted to eight acute care hospitals from 2007 to 2011 with lengths of stay ≥3 days were reviewed.

Study Design

We examined AE incidence overall and by presence on admission, severity, stemming from care provided versus omitted, preventability, and category; and the overlap with commonly used AE-detection systems.

Data Collection

Professional nurse reviewers abstracted 9,017 records using the enhanced GTT, recording triggers and AEs. Medical record/account numbers were matched to identify overlapping voluntary reports or AHRQ Patient Safety Indicators (PSIs).

Principal Findings

Estimated AE rates were as follows: 61.4 AEs/1,000 patient-days, 38.1 AEs/100 discharges, and 32.1 percent of patients with ≥1 AE. Of 1,300 present-on-admission AEs (37.9 percent of total), 78.5 percent showed NCC-MERP level F harm and 87.6 percent were “preventable/possibly preventable.” Of 2,129 hospital-acquired AEs, 63.3 percent had level E harm, 70.8 percent were “preventable/possibly preventable”; the most common category was “surgical/procedural” (40.5 percent). Voluntary reports and PSIs captured <5 percent of encounters with hospital-acquired AEs.

Conclusions

AEs are common and potentially amenable to prevention. GTT-identified AEs are seldom caught by commonly used AE-detection systems.     

A diabetes dashboard and physician efficiency and accuracy in accessing data needed for high-quality diabetes care

PURPOSE

We compared use of a new diabetes dashboard screen with use of a conventional approach of viewing multiple electronic health record (EHR) screens to find data needed for ambulatory diabetes care.

METHODS

We performed a usability study, including a quantitative time study and qualitative analysis of information-seeking behaviors. While being recorded with Morae Recorder software and “think-aloud” interview methods, 10 primary care physicians first searched their EHR for 10 diabetes data elements using a conventional approach for a simulated patient, and then using a new diabetes dashboard for another. We measured time, number of mouse clicks, and accuracy. Two coders analyzed think-aloud and interview data using grounded theory methodology.

RESULTS

The mean time needed to find all data elements was 5.5 minutes using the conventional approach vs 1.3 minutes using the diabetes dashboard (P <.001). Physicians correctly identified 94% of the data requested using the conventional method, vs 100% with the dashboard (P <.01). The mean number of mouse clicks was 60 for conventional searching vs 3 clicks with the diabetes dashboard (P <.001). A common theme was that in everyday practice, if physicians had to spend too much time searching for data, they would either continue without it or order a test again.

CONCLUSIONS

Using a patient-specific diabetes dashboard improves both the efficiency and accuracy of acquiring data needed for high-quality diabetes care. Usability analysis tools can provide important insights into the value of optimizing physician use of health information technologies.     

Effect of usual source of care on depression among Medicare beneficiaries: an application of a simultaneous-equations model

Objective

To investigate whether having a usual source of care (USOC) resulted in lower depression prevalence among the elderly.

Data Sources

The 2001–2003 Medicare Current Beneficiaries Survey and 2002 Area Resource File.

Study Design

Twenty thousand four hundred and fifty-five community-dwelling person-years were identified for respondents aged 65+, covered by both Medicare Parts A and B in Medicare fee-for-service for a full year. USOC was defined by the question “Is there a particular medical person or a clinic you usually go to when you are sick or for advice about your health?” Ambulatory care use (ACU) was defined by having at least one physician office visit and/or hospital outpatient visit using Medicare claims. Depression was identified by a two-item screen (sadness and/or anhedonia). All measures were for the past 12 months. A simultaneous-equations (trivariate probit) model was estimated, adjusted for sampling weights and study design effects.

Principal Findings

Based on the simultaneous-equations model, USOC is associated with 3.8 percent lower probability of having depression symptoms (p = .03). Also, it had a positive effect on having any ACU (p<.001). Having any ACU had no statistically significant effect on depression (p = .96).

Conclusions

USOC was associated with lower depression prevalence and higher realized access (ACU) among community-dwelling Medicare beneficiaries.     

The role of matched controls in building an evidence base for hospital-avoidance schemes: a retrospective evaluation

Objective

To test whether two hospital-avoidance interventions altered rates of hospital use: “intermediate care” and “integrated care teams.”

Data Sources/Study Setting

Linked administrative data for England covering the period 2004 to 2009.

Study Design

This study was commissioned after the interventions had been in place for several years. We developed a method based on retrospective analysis of person-level data comparing health care use of participants with that of prognostically matched controls.

Data Collection/Extraction Methods

Individuals were linked to administrative datasets through a trusted intermediary and a unique patient identifier.

Principal Findings

Participants who received the intermediate care intervention showed higher rates of unscheduled hospital admission than matched controls, whereas recipients of the integrated care team intervention showed no difference. Both intervention groups showed higher rates of mortality than did their matched controls.

Conclusions

These are potentially powerful techniques for assessing impacts on hospital activity. Neither intervention reduced admission rates. Although our analysis of hospital utilization controlled for a wide range of observable characteristics, the difference in mortality rates suggests that some residual confounding is likely. Evaluation is constrained when performed retrospectively, and careful interpretation is needed.     

Walking the Line: Navigating Market and Gift Economies of Care in a Consumer‐Directed Home‐Based Care Program for Older Adults

Context

Paid caregivers of low-income older adults navigate their role at what Hochschild calls the “market frontier”: the fuzzy line between the “world of the market,” in which services are exchanged for monetary compensation, and the “world of the gift,” in which caregiving is uncompensated and motivated by emotional attachment. We examine how political and economic forces, including the reduction of long-term services and supports, shape the practice of “walking the line” among caregivers of older adults.

Methods

We used data from a longitudinal qualitative study with related and nonrelated caregivers (n = 33) paid through California’s In-Home Supportive Services (IHSS) program and consumers of IHSS care (n = 49). We analyzed the semistructured interviews (n = 330), completed between 2010 and 2014, using a constructivist grounded theory approach.

Findings

Related and nonrelated caregivers are often expected to “gift” hours of care above and beyond what is compensated by formal services. Cuts in formal services and lapses in pay push caregivers to further “walk the line” between market and gift economies of care. Both related and nonrelated caregivers who choose to stay on and provide more care without pay often face adverse economic and health consequences. Some, including related caregivers, opt out of caregiving altogether. While some consumers expect that caregivers would be willing to “walk the line” in order to meet their needs, most expressed sympathy for them and tried to alter their schedules or go without care in order to limit the caregivers’ burden.

Conclusions

Given economic and health constraints, caregivers cannot always compensate for cuts in formal supports by providing uncompensated time and resources. Similarly, low-income older adults are not competitive in the caregiving marketplace and, given the inadequacy of compensated hours, often depend on unpaid care. Policies that restrict formal long-term services and supports thus leave the needs of both caregivers and consumers unmet.     

Mental Health and High‐Cost Health Care Utilization: New Evidence from Axis II Disorders

Objective

To analyze the associations between Axis II (A2) disorders and two measures of health care utilization with relatively high cost: emergency department (ED) episodes and hospital admissions.

Data Source/Study Setting

Wave I (2001/2002) and Wave II (2004/2005) of the National Longitudinal Survey on Alcohol and Related Conditions (NESARC).

Study Design

A national probability sample of adults. Gender-stratified regression analysis adjusted for a range of covariates associated with health care utilization.

Data Collection

The target population of the NESARC is the civilian noninstitutionalized population aged 18 years and older residing in the United States. The cumulative survey response rate is 70.2 percent with a response rate of 81 percent (N = 43,093) in Wave I and 86.7 percent (N = 34,653) in Wave II.

Principal Findings

Both men and women with A2 disorders are at elevated risk for ED episodes and hospital admissions. Associations are robust after adjusting for a rich set of confounding factors, including Axis I (clinical) psychiatric disorders. We find evidence of a dose–response relationship, while antisocial and borderline disorders exhibit the strongest associations with both measures of health care utilization.

Conclusions

This study provides the first published estimates of the associations between A2 disorders and high-cost health care utilization in a large, nationally representative survey. The findings underscore the potential implications of these disorders on health care expenditures.     

A comparison of health care use for physician-referred and self-referred episodes of outpatient physical therapy

Objective

To compare patient profiles and health care use for physician-referred and self-referred episodes of outpatient physical therapy (PT).

Data Source

Five years (2003–2007) of private health insurance claims data, from a Midwest insurer, on beneficiaries aged 18–64.

Study Design

Retrospective analyses of health care use of physician-referred (N = 45,210) and self-referred (N = 17,497) ambulatory PT episodes of care was conducted, adjusting for age, gender, diagnosis, case mix, and year.

Data Collection/Extraction

Physical therapy episodes began with the physical therapist initial evaluation and ended on the last date of service before 60 days of no further visits. Episodes were classified as physician-referred if the patient had a physician claim from a reasonable referral source in the 30 days before the start of PT.

Principal Findings

The self-referred group was slightly younger, but the two groups were very similar in regard to diagnosis and case mix. Self-referred episodes had fewer PT visits (86 percent of physician-referred) and lower allowable amounts ($0.87 for every $1.00), after covariate adjustment, but did not differ in related health care utilization after PT.

Conclusions

Health care use during PT episodes was lower for those who self-referred, after adjusting for key variables, but did not differ after the PT episode.     

The effect of the MassHealth hospital pay-for-performance program on quality

Objective

To test the effect of Massachusetts Medicaid''s (MassHealth) hospital-based pay-for-performance (P4P) program, implemented in 2008, on quality of care for pneumonia and surgical infection prevention (SIP).

Data

Hospital Compare process of care quality data from 2004 to 2009 for acute care hospitals in Massachusetts (N = 62) and other states (N = 3,676) and American Hospital Association data on hospital characteristics from 2005.

Study Design

Panel data models with hospital fixed effects and hospital-specific trends are estimated to test the effect of P4P on composite quality for pneumonia and SIP. This base model is extended to control for the completeness of measure reporting. Further sensitivity checks include estimation with propensity-score matched control hospitals, excluding hospitals in other P4P programs, varying the time period during which the program was assumed to have an effect, and testing the program effect across hospital characteristics.

Principal Findings

Estimates from our preferred specification, including hospital fixed effects, trends, and the control for measure completeness, indicate small and nonsignificant program effects for pneumonia (−0.67 percentage points, p>.10) and SIP (−0.12 percentage points, p>.10). Sensitivity checks indicate a similar pattern of findings across specifications.

Conclusions

Despite offering substantial financial incentives, the MassHealth P4P program did not improve quality in the first years of implementation.     

Interpretations of Integration in Early Accountable Care Organizations

Context

It is widely hoped that accountable care organizations (ACOs) will improve health care quality and reduce costs by fostering integration among diverse provider groups. But how do implementers actually envision integration, and what will integration mean in terms of managing the many social identities that ACOs bring together?

Methods

Using the lens of the social identity approach, this qualitative study examined how four nascent ACOs engaged with the concept of integration. During multiday site visits, we conducted interviews (114 managers and physicians), observations, and document reviews.

Findings

In no case was the ACO interpreted as a new, overarching entity uniting disparate groups; rather, each site offered a unique interpretation that flowed from its existing strategies for social-identity management: An independent practice association preserved members’ cherished value of autonomy by emphasizing coordination, not “integration”; a medical group promoted integration within its employed core, but not with affiliates; a hospital, engaging community physicians who mistrusted integrated systems, reimagined integration as an equal partnership; an integrated delivery system advanced its careful journey towards intergroup consensus by presenting the ACO as a cultural, not structural, change.

Conclusions

The ACO appears to be a model flexible enough to work in synchrony with whatever social strategies are most context appropriate, with the potential to promote alignment and functional integration without demanding common identification with a superordinate group. “Soft integration” may be a promising alternative to the vertically integrated model that, though widely assumed to be ideal, has remained unattainable for most organizations.     

Where You Live Matters: Quality and Racial/Ethnic Disparities in Schizophrenia Care in Four State Medicaid Programs

Objective

To determine whether (a) quality in schizophrenia care varies by race/ethnicity and over time and (b) these patterns differ across counties within states.

Data Sources

Medicaid claims data from California, Florida, New York, and North Carolina during 2002–2008.

Study Design

We studied black, Latino, and white Medicaid beneficiaries with schizophrenia. Hierarchical regression models, by state, quantified person and county effects of race/ethnicity and year on a composite quality measure, adjusting for person-level characteristics.

Principal Findings

Overall, our cohort included 164,014 person-years (41–61 percent non-whites), corresponding to 98,400 beneficiaries. Relative to whites, quality was lower for blacks in every state and also lower for Latinos except in North Carolina. Temporal improvements were observed in California and North Carolina only. Within each state, counties differed in quality and disparities. Between-county variation in the black disparity was larger than between-county variation in the Latino disparity in California, and smaller in North Carolina; Latino disparities did not vary by county in Florida. In every state, counties differed in annual changes in quality; by 2008, no county had narrowed the initial disparities.

Conclusions

For Medicaid beneficiaries living in the same state, quality and disparities in schizophrenia care are influenced by county of residence for reasons beyond patients’ characteristics.     

Self-rated health as a comprehensive indicator of lifestyle-related health status

Objectives

To evaluate the usefulness of self-rated health (SRH) as a comprehensive indicator of lifestyle-related health status by examining the relationships between SRH and: (1) history of cancer and cardiovascular disease; (2) treatment of hypertension, diabetes, and dyslipidemia; (3) abnormalities in clinical parameters including blood pressure, fasting glucose, and lipids; and (4) lifestyle habits.

Methods

3744 health-check examinees at Tokai University Hachioji Hospital seen between April 2009 and March 2010 were enrolled. SRH was graded as “good,” “relatively good,” “relatively poor,” or “poor.” For statistical comparison, the differences among “healthy” (=good), “relatively healthy” (=relatively good), and “unhealthy” (=relatively poor plus poor) groups were examined. Mantel–Haenszel odds ratios were calculated to remove the confounding effect of age, using the healthy group as the reference. The Mantel-extension method was used as a trend test.

Results

1049 subjects rated their health as good, 2194 as relatively good, 428 as relatively poor, and 73 as poor. The prevalence of all diseases showed significant odds ratios and trends as SRH deteriorated. Obesity, blood pressure, glucose metabolism, and lipids deteriorated significantly as SRH became poorer, and a trend was observed in all parameters. Weight change, exercise, smoking, and rest showed significant odds ratios and trends as SRH deteriorated.

Conclusion

SRH appears useful as a comprehensive indicator of lifestyle-related health status.

Electronic supplementary material

The online version of this article (doi:10.1007/s12199-012-0274-x) contains supplementary material, which is available to authorized users.     

The Impact of Tiered Physician Networks on Patient Choices

Objective

To assess whether patient choice of physician or health plan was affected by physician tier-rankings.

Data Sources

Administrative claims and enrollment data on 171,581 nonelderly beneficiaries enrolled in Massachusetts Group Insurance Commission health plans that include a tiered physician network and who had an office visit with a tiered physician.

Study Design

We estimate the impact of tier-rankings on physician market share within a plan of new patients and on the percent of a physician''s patients who switch to other physicians with fixed effects regression models. The effect of tiering on consumer plan choice is estimated using logistic regression and a pre–post study design.

Principal Findings

Physicians in the bottom (least-preferred) tier, particularly certain specialist physicians, had lower market share of new patient visits than physicians with higher tier-rankings. Patients whose physician was in the bottom tier were more likely to switch health plans. There was no effect of tier-ranking on patients switching away from physicians whom they have seen previously.

Conclusions

The effect of tiering appears to be among patients who choose new physicians and at the lower end of the distribution of tiered physicians, rather than moving patients to the “best” performers. These findings suggest strong loyalty of patients to physicians more likely to be considered their personal doctor.     

Practice audits to reduce caesareans in a tertiary referral hospital in south-western China

Objective

To assess the effectiveness of a three-stage intervention to reduce caesarean deliveries in a Chinese tertiary hospital.

Methods

A retrospective study was conducted to assess whether educating staff, educating patients and auditing surgeon practices (introduced in 2005) had reduced caesarean delivery rates. Multiple logistic regression was used to check for a potential association between caesarean rates and rates of admission to the neonatal intensive care unit (NICU).

Findings

The caesarean delivery rate ranged from 53.5% to 56.1% in 2001–2004 and from 43.9% to 36.1% in 2005–2011. When 2001–2004 and 2005–2011 were treated as “before” and “after” periods to evaluate the intervention’s impact on the mean caesarean section rate, a significant reduction was noted: from 54.8% to 40.3% (odds ratio, OR: 0.56; 95% confidence interval, CI: 0.52–0.59; χ² test: P < 0.001). The overall drop in the caesarean section rate was significant (χ² test: P < 0.001) and inversely correlated with the years (Spearman’s ρ: −0.096; P < 0.001). Although complicated pregnancies increased after 2004, the primary caesarean section rate decreased annually by 20% on average in 2005–2011, after practice audits were implemented. Multiple logistic regression showed a positive association between the caesarean delivery rate and the rate of admission to the NICU (adjusted OR: 1.26; 95% CI: 1.14–1.40).

Conclusion

Patient and staff education and practice audits reduced the Caesarean section rate in a tertiary referral hospital without an increase in admissions to the NICU.     

Widely used pesticides with previously unknown endocrine activity revealed as in vitro antiandrogens

Background

Evidence suggests that there is widespread decline in male reproductive health and that antiandrogenic pollutants may play a significant role. There is also a clear disparity between pesticide exposure and data on endocrine disruption, with most of the published literature focused on pesticides that are no longer registered for use in developed countries.

Objective

We used estimated human exposure data to select pesticides to test for antiandrogenic activity, focusing on highest use pesticides.

Methods

We used European databases to select 134 candidate pesticides based on highest exposure, followed by a filtering step according to known or predicted receptor-mediated antiandrogenic potency, based on a previously published quantitative structure–activity relationship (QSAR) model. In total, 37 pesticides were tested for in vitro androgen receptor (AR) antagonism. Of these, 14 were previously reported to be AR antagonists (“active”), 4 were predicted AR antagonists using the QSAR, 6 were predicted to not be AR antagonists (“inactive”), and 13 had unknown activity, which were “out of domain” and therefore could not be classified with the QSAR (“unknown”).

Results

All 14 pesticides with previous evidence of AR antagonism were confirmed as antiandrogenic in our assay, and 9 previously untested pesticides were identified as antiandrogenic (dimethomorph, fenhexamid, quinoxyfen, cyprodinil, λ-cyhalothrin, pyrimethanil, fludioxonil, azinphos-methyl, pirimiphos-methyl). In addition, we classified 7 compounds as androgenic.

Conclusions

Due to estimated antiandrogenic potency, current use, estimated exposure, and lack of previous data, we strongly recommend that dimethomorph, fludioxonil, fenhexamid, imazalil, ortho-phenylphenol, and pirimiphos-methyl be tested for antiandrogenic effects in vivo. The lack of human biomonitoring data for environmentally relevant pesticides presents a barrier to current risk assessment of pesticides on humans.     

Treatment adjustment and medication adherence for complex patients with diabetes, heart disease, and depression: a randomized controlled trial

PURPOSE

Medication nonadherence, inconsistent patient self-monitoring, and inadequate treatment adjustment exacerbate poor disease control. In a collaborative, team-based, care management program for complex patients (TEAMcare), we assessed patient and physician behaviors (medication adherence, self-monitoring, and treatment adjustment) in achieving better outcomes for diabetes, coronary heart disease, and depression.

METHODS

A randomized controlled trial was conducted (2007–2009) in 14 primary care clinics among 214 patients with poorly controlled diabetes (glycated hemoglobin [HbA_1c] ≥8.5%) or coronary heart disease (blood pressure >140/90 mm Hg or low-density lipoprotein cholesterol >130 mg/dL) with coexisting depression (Patient Health Questionnaire-9 score ≥10). In the TEAMcare program, a nurse care manager collaborated closely with primary care physicians, patients, and consultants to deliver a treat-to-target approach across multiple conditions. Measures included medication initiation, adjustment, adherence, and disease self-monitoring.

RESULTS

Pharmacotherapy initiation and adjustment rates were sixfold higher for antidepressants (relative rate [RR] = 6.20; P <.001), threefold higher for insulin (RR = 2.97; P <.001), and nearly twofold higher for antihypertensive medications (RR = 1.86, P <.001) among TEAMcare relative to usual care patients. Medication adherence did not differ between the 2 groups in any of the 5 therapeutic classes examined at 12 months. TEAMcare patients monitored blood pressure (RR = 3.20; P <.001) and glucose more frequently (RR = 1.28; P = .006).

CONCLUSIONS

Frequent and timely treatment adjustment by primary care physicians, along with increased patient self-monitoring, improved control of diabetes, depression, and heart disease, with no change in medication adherence rates. High baseline adherence rates may have exerted a ceiling effect on potential improvements in medication adherence.     

Long-term exposure to traffic-related air pollution and the risk of coronary heart disease hospitalization and mortality

Background

Epidemiologic studies have demonstrated that exposure to road traffic is associated with adverse cardiovascular outcomes.

Objectives

We aimed to identify specific traffic-related air pollutants that are associated with the risk of coronary heart disease (CHD) morbidity and mortality to support evidence-based environmental policy making.

Methods

This population-based cohort study included a 5-year exposure period and a 4-year follow-up period. All residents 45–85 years of age who resided in Metropolitan Vancouver during the exposure period and without known CHD at baseline were included in this study (n = 452,735). Individual exposures to traffic-related air pollutants including black carbon, fine particles [aerodynamic diameter ≤ 2.5 μm (PM_2.5)], nitrogen dioxide (NO₂), and nitric oxide were estimated at residences of the subjects using land-use regression models and integrating changes in residences during the exposure period. CHD hospitalizations and deaths during the follow-up period were identified from provincial hospitalization and death registration records.

Results

An interquartile range elevation in the average concentration of black carbon (0.94 × 10⁻⁵/m filter absorbance, equivalent to approximately 0.8 μg/m³ elemental carbon) was associated with a 3% increase in CHD hospitalization (95% confidence interval, 1–5%) and a 6% increase in CHD mortality (3–9%) after adjusting for age, sex, preexisting comorbidity, neighborhood socioeconomic status, and copollutants (PM_2.5 and NO₂). There were clear linear exposure–response relationships between black carbon and coronary events.

Conclusions

Long-term exposure to traffic-related fine particulate air pollution, indicated by black carbon, may partly explain the observed associations between exposure to road traffic and adverse cardiovascular outcomes.     

Leveraging Electronic Health Records to Develop Measurements for Processes of Care

Objectives

To assess the reliability of data in electronic health records (EHRs) for measuring processes of care among primary care physicians (PCPs) and examine the relationship between these measures and clinical outcomes.

Data Sources/Study Setting

EHR data from 15,370 patients with diabetes, 49,561 with hypertension, in a group practice serving four Northern California counties.

Study Design/Methods

Exploratory factor analysis (EFA) and multilevel analyses of the relationships between processes of care variables and factor scales with control of hemoglobin A1c, blood pressure (BP), and low density lipoprotein (LDL) among patients with diabetes and BP among patients with hypertension.

Principal Findings

Volume of e-messages, number of days to the third-next-available appointment, and team communication emerged as reliable factors of PCP processes of care in EFA (Cronbach''s alpha = 0.73, 0.62, and 0.91). Volume of e-messages was associated with higher odds of LDL control (≤100) (OR = 1.13, p < .05) among patients with diabetes. Frequent in-person visits were associated with better BP (OR = 1.02, p < .01) and LDL control (OR = 1.01, p < .01) among patients with diabetes, and better BP control (OR = 1.04, p < .01) among patients with hypertension.

Conclusions

The EHR offers process of care measures which can augment patient-reported measures of patient-centeredness. Two of them are significantly associated with clinical outcomes. Future research should examine their association with additional outcomes.     

Market Variations in Intensity of Medicare Service Use and Beneficiary Experiences with Care

Objective

Examine associations between patient experiences with care and service use across markets.

Data Sources/Study Setting

Medicare fee-for-service (FFS) and managed care (Medicare Advantage [MA]) beneficiaries in 306 markets from the 2003 Consumer Assessments of Healthcare Providers and Systems (CAHPS) surveys. Resource use intensity is measured by the 2003 end-of-life expenditure index.

Study Design

We estimated correlations and linear regressions of eight measures of case-mix-adjusted beneficiary experiences with intensity of service use across markets.

Data Collection/Extraction

We merged CAHPS data with service use data, excluding beneficiaries under 65 years of age or receiving Medicaid.

Principal Findings

Overall, higher intensity use was associated (p<.05) with worse (seven measures) or no better care experiences (two measures). In higher-intensity markets, Medicare FFS and MA beneficiaries reported more problems getting care quickly and less helpful office staff. However, Medicare FFS beneficiaries in higher-intensity markets reported higher overall ratings of their personal physician and main specialist. Medicare MA beneficiaries in higher-intensity markets also reported worse quality of communication with physicians, ability to get needed care, and overall ratings of care.

Conclusions

Medicare beneficiaries in markets characterized by high service use did not report better experiences with care. This trend was strongest for those in managed care.     

Cultural adaptation of birthing services in rural Ayacucho, Peru

Problem

Maternal mortality is particularly high among poor, indigenous women in rural Peru, and the use of facility care is low, partly due to cultural insensitivities of the health care system.

Approach

A culturally appropriate delivery care model was developed in poor and isolated rural communities, and implemented between 1999 and 2001 in cooperation with the Quechua indigenous communities and health professionals. Data on birth location and attendance in one health centre have been collected up to 2007.

Local setting

The international nongovernmental organization, Health Unlimited, and its Peruvian partner organization, Salud Sín Límites Perú, conducted the project in Santillana district in Ayacucho.

Relevant changes

The model involves features such as a rope and bench for vertical delivery position, inclusion of family and traditional birth attendants in the delivery process and use of the Quechua language. The proportion of births delivered in the health facility increased from 6% in 1999 to 83% in 2007 with high satisfaction levels.

Lessons learned

Implementing a model of skilled delivery attendance that integrates modern medical and traditional Andean elements is feasible and sustainable. Indigenous women with little formal education do use delivery services if their needs are met. This contradicts common victim-blaming attitudes that ascribe high levels of home births to “cultural preferences” or “ignorance”.     

Does enhanced information exchange between social insurance physicians and occupational physicians improve patient work resumption? A controlled intervention study

Background

Patient work resumption after sickness absence varies even among patients with similar pathologies and characteristics. Explanations remain uncertain. One newly investigated field is “information asymmetry”, a situation in which critical information is not appropriately exchanged between stakeholders in disability management. It is hypothesised that information asymmetry between social insurance physicians and occupational physicians prolongs sickness absence.

Objectives

To assess the influence of enhanced information exchange between these physicians on patient outcome.

Methods

Non‐randomised controlled intervention study. The setting was the work inability assessment consultation of social insurance physicians in Belgium. Inclusion criteria were: employee, age 18–50, and subacute (more than one month) sickness absence. The intervention was a structured information exchange (through the use of a communication form) between the patient''s social insurance physician and occupational physician. The intervention started when the patient''s sickness absence reached the subacute stage, and ended when the sickness absence benefit was ceased or the duration exceeded one year. The primary outcome measure was the sickness absence benefit status of the patient assessed one year after benefit onset.

Results

Of the 1883 patients asked to enrol in the study, 1564 (84%) participated; 505 (32%) of 1564 patients were assigned to the intervention group and 1059 (68%) to the control group; 1553 (99%) of 1564 patients completed the study. In the intervention group, 86% received no sickness absence benefit at the end of the study, versus 84% in the control group (95% CI 0.91–1.15). No significant differences in other outcome parameters were obtained.

Conclusions

Information exchange between physicians may not be enough to influence work resumption among patients on sickness absence. Further research on stakeholders'' information asymmetry and its effect on the outcome of patients are necessary. The complexity of information asymmetry in disability management cannot be underestimated.