Improving the use of hospice services in nursing homes: a randomized controlled trial

Context  Hospice care may improve the quality of end-of-life care for nursing home residents, but hospice is underutilized by this population, at least in part because physicians are not aware of their patients’ preferences. Objective  To determine whether it is possible to increase hospice utilization and improve the quality of end-of-life care by identifying residents whose goals and preferences are consistent with hospice care. Design, Setting, and Participants  Randomized controlled trial (December 2003-December 2004) of nursing home residents and their surrogate decision makers (N=205) in 3 US nursing homes. Intervention  A structured interview identified residents whose goals for care, treatment preferences, and palliative care needs made them appropriate for hospice care. These residents’ physicians were notified and asked to authorize a hospice informational visit. Main Outcome Measures  The primary outcome measures were (1) hospice enrollment within 30 days of the intervention and (2) families’ ratings of the quality of care for residents who died during the 6-month follow-up period. Results  Of the 205 residents in the study sample, 107 were randomly assigned to receive the intervention, and 98 received usual care. Intervention residents were more likely than usual care residents to enroll in hospice within 30 days (21/107 [20%] vs 1/98 [1%]; P<.001 [Fisher exact test]) and to enroll in hospice during the follow-up period (27/207 [25%] vs 6/98 [6%]; P<.001). Intervention residents had fewer acute care admissions (mean: 0.28 vs 0.49; P = .04 [Wilcoxon rank sum test]) and spent fewer days in an acute care setting (mean: 1.2 vs 3.0; P = .03 [Wilcoxon rank sum test]). Families of intervention residents rated the resident’s care more highly than did families of usual care residents (mean on a scale of 1-5: 4.1 vs 2.5; P = .04 [Wilcoxon rank sum test]). Conclusion  A simple communication intervention can increase rates of hospice referrals and families’ ratings of end-of-life care and may also decrease utilization of acute care resources.      

Evaluation of restorative care vs usual care for older adults receiving an acute episode of home care

Context  Illness and hospitalization often trigger functional decline among older persons. Home care services implemented for functional decline provide an opportunity to intervene to improve outcomes. Objective  To compare functional status and the likelihood of remaining at home for persons receiving restorative care vs usual home care. Design and Setting  Intervention using prospective individual matching conducted between November 1, 1998, and April 30, 2000. Six offices of a home care agency in Connecticut were used. One branch office served as the restorative care unit and the other 5 served as usual care offices. Participants  Patients receiving home care through the restorative care office who were 65 years or older; in receipt of Medicare-covered home care lasting at least 7 days; with absence of severe cognitive impairment; and not terminal, bedridden, or requiring total care were matched with patients from 1 of the usual care offices. The matching factors included age, sex, race, baseline self-care function, cognitive status, whether hospitalization preceded the home care episode, and date of the home care episode. Of the 712 eligible restorative care patients, 691 (97%) were matched with a usual care patient. Intervention  Restorative care, provided by the home care agency nursing, therapy, and home health aide staff, was based on principles from geriatric medicine, nursing, rehabilitation, and goal attainment. Main Outcome Measures  Remaining at home, functional status at completion of the home care episode, and duration and intensity of home care episode. Results  Compared with usual care, and after adjusting for baseline characteristics and other factors, restorative care was associated with a greater likelihood of remaining at home (82% vs 71%; odds ratio [OR], 1.99; 95% confidence interval [CI], 1.47-2.69) and a reduced likelihood of visiting an emergency department (10% vs 20%; OR, 0.44; 95% CI, 0.32-0.61). Home care episodes were shorter (mean [SD], 24.8 [26.8] days vs 34.3 [44.2] days; S = -17 821; P<.001). Restorative care patients had better mean (SD) scores than usual care patients in self-care (11.0 [2.1] vs 10.7 [2.5]; P = .07 after adjustment), home management (9.5 [2.9] vs 9.2 [3.0]; P = .05 after adjustment), and mobility (3.3 [0.8] vs 3.2 [0.9]; P = .02 after adjustment). Conclusions  This trial suggests that reorganizing the structure and goals of home care can enhance health outcomes of older patients without increasing health care utilization.      

Length of stay in home care before and after the 1997 Balanced Budget Act

Context  Prior to 1997, home health agencies (HHAs) were reimbursed on a fee-for-service basis and had incentives to provide more services. The 1997 Balanced Budget Act (BBA) reduced payments for home care services to help control Medicare spending. Objective  To examine the length of stay in home care before and after the 1997 BBA. Design and Setting  Cross-sectional study of home care patients in the 1996 and 1998 National Home and Hospice Care Surveys, which surveyed 1053 HHAs in 1996 and 1088 HHAs in 1998. Patients  Nationally representative random sample of home care patients with Medicare coverage in 1996 (4127 patients) and 1998 (4051 patients). Main Outcome Measure  Length of stay in home care (based on the number of days a patient was enrolled in home care services). Results  From 1996 to 1998, unadjusted median length of stay decreased by 16 days for all home care patients (60-44 days, P = .002). The decrease affected for-profit HHAs more than not-for-profit HHAs (111-55 days [51% decrease, P = .002] vs 46-36 days [22% decrease, P = .042]). In a Cox proportional hazards model of time to discharge from home care, post-BBA year (1998) was associated with a shorter length of stay in home care (adjusted hazard ratio [aHR] for home care discharge, 1.39 [95% confidence interval {CI}, 1.19-1.61]), and for-profit status was associated with a longer length of stay in home care (aHR, 0.82 [95% CI, 0.71-0.94]) after adjusting for patient demographics, diagnoses, and functional status. Conclusion  After the 1997 BBA, length of stay in home care decreased among Medicare patients, particularly among those receiving care from for-profit HHAs.      

Effectiveness of collaborative care for older adults with Alzheimer disease in primary care: a randomized controlled trial

Context  Most older adults with dementia will be cared for by primary care physicians, but the primary care practice environment presents important challenges to providing quality care. Objective  To test the effectiveness of a collaborative care model to improve the quality of care for patients with Alzheimer disease. Design, Setting, and Patients  Controlled clinical trial of 153 older adults with Alzheimer disease and their caregivers who were randomized by physician to receive collaborative care management (n = 84) or augmented usual care (n = 69) at primary care practices within 2 US university-affiliated health care systems from January 2002 through August 2004. Eligible patients (identified via screening or medical record) met diagnostic criteria for Alzheimer disease and had a self-identified caregiver. Intervention  Intervention patients received 1 year of care management by an interdisciplinary team led by an advanced practice nurse working with the patient's family caregiver and integrated within primary care. The team used standard protocols to initiate treatment and identify, monitor, and treat behavioral and psychological symptoms of dementia, stressing nonpharmacological management. Main Outcome Measures  Neuropsychiatric Inventory (NPI) administered at baseline and at 6, 12, and 18 months. Secondary outcomes included the Cornell Scale for Depression in Dementia (CSDD), cognition, activities of daily living, resource use, and caregiver's depression severity. Results  Initiated by caregivers' reports, 89% of intervention patients triggered at least 1 protocol for behavioral and psychological symptoms of dementia with a mean of 4 per patient from a total of 8 possible protocols. Intervention patients were more likely to receive cholinesterase inhibitors (79.8% vs 55.1%; P = .002) and antidepressants (45.2% vs 27.5%; P = .03). Intervention patients had significantly fewer behavioral and psychological symptoms of dementia as measured by the total NPI score at 12 months (mean difference, –5.6; P = .01) and at 18 months (mean difference, –5.4; P = .01). Intervention caregivers also reported significant improvements in distress as measured by the caregiver NPI at 12 months; at 18 months, caregivers showed improvement in depression as measured by the Patient Health Questionnaire-9. No group differences were found on the CSDD, cognition, activities of daily living, or on rates of hospitalization, nursing home placement, or death. Conclusions  Collaborative care for the treatment of Alzheimer disease resulted in significant improvement in the quality of care and in behavioral and psychological symptoms of dementia among primary care patients and their caregivers. These improvements were achieved without significantly increasing the use of antipsychotics or sedative-hypnotics. Trial Registration  clinicaltrials.gov Identifier: NCT00246896      

Barriers to health care research for children and youth with psychosocial problems

Context  The 1999 surgeon general's report on mental health concluded that insufficient attention to mental health disorders is being paid in children's primary medical care services. This lack of attention has occurred despite considerable attention to this issue in the planning documents of many federal agencies. Objective  To assess the extent to which federal agencies' portfolios of funded research grants were consistent with the directives for primary care–based mental health services for children and adolescents featured in their planning documents. Data Source  A cross-sectional review of the 66 749 abstracts listed in the April 2001 Computer Retrieval of Information on Scientific Projects (CRISP) database of currently funded research grants supported by the US Department of Health and Human Services. Abstracts were rated by whether they targeted primary care, examined behavioral or emotional issues, and examined or modified a facet of primary care. Data Synthesis  Of the 45 022 research abstracts in the CRISP database, 2720 (6%) contained the words children, adolescents, or youth. Sixty-three abstracts contained work on children, adolescents, or youth in primary care (0.14% of the portfolio). Of these 63 abstracts, only 21 (0.05% of the portfolio) addressed behavioral or emotional issues. Of the 21 projects, only 11 examined aspects of the primary care process. When the distribution of child and adult studies on the treatment of depression within primary care settings was examined, it was found that adults received 15 times the research attention compared with children. Conclusion  Even though the importance of primary care as a system for identifying and treating behavioral and emotional problems in children has been recognized for more than 20 years, little attention is being paid to this topic in the research portfolios of the National Institutes of Health and other federal agencies that support research.      

End-of-life practices in European intensive care units: the Ethicus Study

Context  While the adoption of practice guidelines is standardizing many aspects of patient care, ethical dilemmas are occurring because of forgoing life-sustaining therapies in intensive care and are dealt with in diverse ways between different countries and cultures. Objectives  To determine the frequency and types of actual end-of-life practices in European intensive care units (ICUs) and to analyze the similarities and differences. Design and Setting  A prospective, observational study of European ICUs. Participants  Consecutive patients who died or had any limitation of therapy. Intervention  Prospectively defined end-of-life practices in 37 ICUs in 17 European countries were studied from January 1, 1999, to June 30, 2000. Main Outcome Measures  Comparison and analysis of the frequencies and patterns of end-of-life care by geographic regions and different patients and professionals. Results  Of 31 417 patients admitted to ICUs, 4248 patients (13.5%) died or had a limitation of life-sustaining therapy. Of these, 3086 patients (72.6%) had limitations of treatments (10% of admissions). Substantial intercountry variability was found in the limitations and the manner of dying: unsuccessful cardiopulmonary resuscitation in 20% (range, 5%-48%), brain death in 8% (range, 0%-15%), withholding therapy in 38% (range, 16%-70%), withdrawing therapy in 33% (range, 5%-69%), and active shortening of the dying process in 2% (range, 0%-19%). Shortening of the dying process was reported in 7 countries. Doses of opioids and benzodiazepines reported for shortening of the dying process were in the same range as those used for symptom relief in previous studies. Limitation of therapy vs continuation of life-sustaining therapy was associated with patient age, acute and chronic diagnoses, number of days in ICU, region, and religion (P<.001). Conclusion  The limiting of life-sustaining treatment in European ICUs is common and variable. Limitations were associated with patient age, diagnoses, ICU stay, and geographic and religious factors. Although shortening of the dying process is rare, clarity between withdrawing therapies and shortening of the dying process and between therapies intended to relieve pain and suffering and those intended to shorten the dying process may be lacking.      

Missing clinical information during primary care visits

Context  The coordinating function of primary care is information-intensive and may be impeded by missing clinical information. However, missing clinical information has not been explicitly investigated in the primary care setting. Objective  To describe primary care clinicians’ reports of missing clinical information. Design, Setting, and Participants  Cross-sectional survey conducted in 32 primary care clinics within State Networks of Colorado Ambulatory Practices and Partners (SNOCAP), a consortium of practice-based research networks participating in the Applied Strategies for Improving Patient Safety medical error reporting study. Two hundred fifty-three clinicians were surveyed about 1614 patient visits between May and December 2003. For every visit during 1 half-day session, each clinician completed a questionnaire about patient and visit characteristics and stated whether important clinical information had been missing. Clinician characteristics were also recorded. Main Outcome Measures  Reports of missing clinical information frequency, type, and presumed location; perceived likelihood of adverse effects, delays in care, and additional services; and time spent looking for missing information. Multivariate analysis was conducted to assess the relationship of missing information to patient, visit, or clinician characteristics, adjusting for potential confounders and effects of clustering. Results  Clinicians reported missing clinical information in 13.6% of visits; missing information included laboratory results (6.1% of all visits), letters/dictation (5.4%), radiology results (3.8%), history and physical examination (3.7%), and medications (3.2%). Missing clinical information was frequently reported to be located outside their clinical system but within the United States (52.3%), to be at least somewhat likely to adversely affect patients (44%), and to potentially result in delayed care or additional services (59.5%). Significant time was reportedly spent unsuccessfully searching for missing clinical information (5-10 minutes, 25.6%; >10 minutes, 10.4%). After adjustment, reported missing clinical information was more likely when patients were recent immigrants (odds ratio [OR], 1.78; 95% confidence interval [CI], 1.06-2.99), new patients (OR, 2.39; 95% CI, 1.70-3.35), or had multiple medical problems compared with no problems (1 problem: OR, 1.09; 95% CI, 0.69-1.73; 2-5 problems: OR, 1.87; 95% CI, 1.21-2.89; >5 problems: OR, 2.78; 95% CI, 1.61-4.80). Missing clinical information was less likely in rural practices (OR, 0.52; 95% CI, 0.29-0.92) and when individual clinicians reported having full electronic records (OR, 0.40; 95% CI, 0.17-0.94). Conclusions  Primary care clinicians report that missing clinical information is common, multifaceted, likely to consume time and other resources, and may adversely affect patients. Additional research on missing information is needed to focus on validating clinicians’ perceptions and on conducting prospective studies of its causes and sequelae.      

Financial barriers to health care and outcomes after acute myocardial infarction

Context  The prevalence and consequences of financial barriers to health care services and medications are not well documented for patients with an acute myocardial infarction (AMI). Objective  To measure the baseline prevalence of self-reported financial barriers to health care services or medication (as defined by avoidance due to cost) among individuals following AMI and their association with subsequent health care outcomes. Design, Setting, and Participants  The Prospective Registry Evaluating Myocardial Infarction: Event and Recovery (PREMIER), an observational, multicenter US study of patients with AMI over 12 months in 2498 individuals enrolled from January 2003 through June 2004. Main Outcome Measures  Health status symptoms (Seattle Angina Questionnaire [SAQ]), overall health status function (Short Form-12), and rehospitalization. Results  The prevalence of self-reported financial barriers to health care services or medication was 18.1% and 12.9%, respectively. Among individuals who reported financial barriers to health care services or medication, 68.9% and 68.5%, respectively, were insured. At 1-year follow-up, individuals with financial barriers to health care services were more likely to have lower SAQ quality-of-life score (77.9 vs 86.2; adjusted mean difference= –4.0; 95% confidence interval [CI], –6.3 to –1.8), and increased rates of all-cause rehospitalization (49.3% vs 38.1%; adjusted hazard ratio [HR], 1.3; 95% CI, 1.1-1.5) and cardiac rehospitalization (25.7% vs 17.7%; adjusted HR, 1.3; 95% CI, 1.0-1.6). At 1-year follow-up, individuals with financial barriers to medication were more likely to have angina (34.9% vs 17.9%; adjusted odds ratio, 1.55; 95% CI, 1.1-2.2), lower SAQ quality-of-life score (74.0 vs 86.1; adjusted mean difference = –7.6; 95% CI, –10.2 to –4.9), and increased rates of all-cause rehospitalization (57.0% vs 37.8%; risk-adjusted HR, 1.5; 95% CI, 1.2-1.8) and cardiac rehospitalization (33.7% vs 17.3%; adjusted HR, 1.7; 95% CI, 1.3-2.2). Conclusion  Financial barriers to health care services and medications are associated with worse recovery after AMI, manifested as more angina, poorer quality of life, and higher risk of rehospitalization.      

Delivery of preventive services to older adults by primary care physicians

Context  Rates of preventive services remain below national goals. Objective  To identify characteristics of physicians and their practices that are associated with the quality of preventive care their patients receive. Design  Cross-sectional analysis of data on US physician respondents to the 2000-2001 Community Tracking Study Physician Survey linked to claims data on Medicare beneficiaries they treated in 2001. Physician variables included training and qualifications and sex. Practice setting variables included practice type, size, sources of revenue, and access to information technology. Analyses were adjusted for patient demographics and comorbidity, as well as community characteristics. Setting and Participants  Primary care delivered by 3660 physicians providing usual care to 24 581 Medicare beneficiaries aged 65 years and older. Main Outcome Measures  Proportion of eligible beneficiaries receiving each of 6 preventive services: diabetic monitoring with hemoglobin A_1c measurement or eye examinations, screening for colon or breast cancer, and vaccination for influenza or pneumococcus in 2001. Results  Overall, the proportion of beneficiaries receiving services was below national goals. Physician and, more consistently, practice-level characteristics were both associated with differences in the delivery of services. The strongest associations were with practice type and the percentage of practice revenue derived from Medicaid. For instance, beneficiaries receiving usual care in practices with less than 6% of revenue from Medicaid were more likely than those with more than 15% of revenue derived from Medicaid to receive diabetic eye examinations (48.9% vs 43%; P = .02), hemoglobin A_1c monitoring (61.2% vs 48.4%; P<.001), mammograms (52.1% vs 38.9%; P<.001), colon cancer screening (10.0% vs 8.5%; P = .60), and influenza (50.2% vs 39.2%; P<.001) and pneumococcal (8.2% vs 6.4%; P<.001) vaccinations. Other variables associated with delivery of preventive services after adjustment for patient and geographic factors included obtaining usual health care from a physician who worked in group practices of 3 or more, who was a graduate of a US or Canadian medical school, or who reported availability of information technology to generate preventive care reminders or access treatment guidelines. Conclusions  Delivery of routine preventive services is suboptimal for Medicare beneficiaries. However, patients treated within particular practice settings and by particular subgroups of physicians are at particular risk of low-quality care. Profiling these practices may help develop tailored interventions that can be directed to sites where the opportunities for quality improvement are greatest.      

Effectiveness of home blood pressure monitoring, Web communication, and pharmacist care on hypertension control: a randomized controlled trial

Beverly B. Green, MD, MPH; Andrea J. Cook, PhD; James D. Ralston, MD, MPH; Paul A. Fishman, PhD; Sheryl L. Catz, PhD; James Carlson, PharmD; David Carrell, PhD; Lynda Tyll, RN, MS; Eric B. Larson, MD, MPH; Robert S. Thompson, MD

JAMA. 2008;299(24):2857-2867.

Context  Treating hypertension decreases mortality and disability from cardiovascular disease, but most hypertension remains inadequately controlled.

Objective  To determine if a new model of care that uses patient Web services, home blood pressure (BP) monitoring, and pharmacist-assisted care improves BP control.

Design, Setting, and Participants  A 3-group randomized controlled trial, the Electronic Communications and Home Blood Pressure Monitoring study was based on the Chronic Care Model. The trial was conducted at an integrated group practice in Washington state, enrolling 778 participants aged 25 to 75 years with uncontrolled essential hypertension and Internet access. Care was delivered over a secure patient Web site from June 2005 to December 2007.

Interventions  Participants were randomly assigned to usual care, home BP monitoring and secure patient Web site training only, or home BP monitoring and secure patient Web site training plus pharmacist care management delivered through Web communications.

Main Outcome Measures  Percentage of patients with controlled BP (<140/90 mm Hg) and changes in systolic and diastolic BP at 12 months.

Results  Of 778 patients, 730 (94%) completed the 1-year follow-up visit. Patients assigned to the home BP monitoring and Web training only group had a nonsignificant increase in the percentage of patients with controlled BP (<140/90 mm Hg) compared with usual care (36% [95% confidence interval {CI}, 30%-42%] vs 31% [95% CI, 25%-37%]; P = .21). Adding Web-based pharmacist care to home BP monitoring and Web training significantly increased the percentage of patients with controlled BP (56%; 95% CI, 49%-62%) compared with usual care (P < .001) and home BP monitoring and Web training only (P < .001). Systolic BP was decreased stepwise from usual care to home BP monitoring and Web training only to home BP monitoring and Web training plus pharmacist care. Diastolic BP was decreased only in the pharmacist care group compared with both the usual care and home BP monitoring and Web training only groups. Compared with usual care, the patients who had baseline systolic BP of 160 mm Hg or higher and received home BP monitoring and Web training plus pharmacist care had a greater net reduction in systolic BP (–13.2 mm Hg [95% CI, –19.2 to –7.1]; P < .001) and diastolic BP (–4.6 mm Hg [95% CI, –8.0 to –1.2]; P < .001), and improved BP control (relative risk, 3.32 [95% CI, 1.86 to 5.94]; P<.001).

Conclusion  Pharmacist care management delivered through secure patient Web communications improved BP control in patients with hypertension.

Trial Registration  clinicaltrials.gov Identifier: NCT00158639

     

Systematic implementation of an advance directive program in nursing homes: a randomized controlled trial

Context  Although advance directives are commonly used in the community, little is known about the effects of their systematic implementation. Objectives  To examine the effect of systematically implementing an advance directive in nursing homes on patient and family satisfaction with involvement in decision making and on health care costs. Design  Randomized controlled trial conducted June 1, 1994, to August 31, 1998. Setting and Participants  A total of 1292 residents in 6 Ontario nursing homes with more than 100 residents each. Intervention  The Let Me Decide advance directive program included educating staff in local hospitals and nursing homes, residents, and families about advance directives and offering competent residents or next-of-kin of mentally incompetent residents an advance directive that provided a range of health care choices for life-threatening illness, cardiac arrest, and nutrition. The 6 nursing homes were pair-matched on key characteristics, and 1 home per pair was randomized to take part in the program. Control nursing homes continued with prior policies concerning advance directives. Main Outcome Measures  Residents' and families' satisfaction with health care and health care services utilization over 18 months, compared between intervention and control nursing homes. Results  Of 527 participating residents in intervention nursing homes, 49% of competent residents and 78% of families of incompetent residents completed advance directives. Satisfaction was not significantly different in intervention and control nursing homes. The mean difference (scale, 1-7) between intervention and control homes was -0.16 (95% confidence interval [CI], -0.41 to 0.10) for competent residents and 0.07 (95% CI, -0.08 to 0.23) for families of incompetent residents. Intervention nursing homes reported fewer hospitalizations per resident (mean, 0.27 vs 0.48; P = .001) and less resource use (average total cost per patient, Can $3490 vs Can $5239; P = .01) than control nursing homes. Proportion of deaths in intervention (24%) and control (28%) nursing homes were similar (P = .20). Conclusion  Our data suggest that systematic implementation of a program to increase use of advance directives reduces health care services utilization without affecting satisfaction or mortality.      

Effect of mandatory parental notification on adolescent girls' use of sexual health care services

Context  Mandatory parental notification for adolescents to obtain prescribed contraceptives is a controversial issue. Recently, legislation that would prohibit prescribed contraceptives for adolescents without parental involvement was introduced in 10 states and the US Congress. Objective  To determine the effect of mandatory parental notification for prescribed contraceptives on use of sexual health care services by adolescent girls. Design, Setting, and Participants  Girls younger than 18 years and seeking services at all 33 Planned Parenthood family planning clinics in Wisconsin (n = 1118) were surveyed during the spring of 1999. A response rate of 85% was achieved, yielding a sample of 950 girls. Main Outcome Measures  Percentages of girls who reported that they would stop using all sexual health care services, delay testing or treatment for human immunodeficiency virus (HIV) or other sexually transmitted diseases (STDs), or discontinue using specific (but not all) services because of parental notification. Results  Fifty-nine percent (n = 556) indicated they would stop using all sexual health care services, delay testing or treatment for HIV or other STDs, or discontinue use of specific (but not all) sexual health care services if their parents were informed that they were seeking prescribed contraceptives. Eleven percent indicated they would discontinue or delay STD tests or treatment, even though the survey made it clear that mandatory parental notification would occur only for prescribed contraceptives. Analyses comparing girls of different ages and races and from urban vs rural clinics showed that, although the 17-year-olds and African American girls were significantly less likely to stop using sexual health care services with mandatory parental notification, roughly half of the 17-year-olds (56%) and African American girls (49%) indicated that they would stop using all sexual health care services, delay testing or treatment for HIV or other STDs, or discontinue use of specific (but not all) services with mandatory parental notification. Conclusion  Mandatory parental notification for prescribed contraceptives would impede girls' use of sexual health care services, potentially increasing teen pregnancies and the spread of STDs.      

Use of health care services by lower-income and higher-income uninsured adults

Context  More than 45 million individuals in the United States lack health insurance, potentially limiting their access to and use of appropriate health care services. Although the uninsured comprise a range of income levels, little attention has been directed at higher-income uninsured adults and their patterns of care. Objective  To examine whether having higher income attenuates the association between being uninsured and using fewer recommended health care services. Design, Setting, and Participants  Cross-sectional analysis of data from the 2002 Behavioral Risk Factor Surveillance System, drawn from a nationally representative sample of households. Participants were community-dwelling adults (n = 194 943; 50% women) aged 18 to 64 years in 2002. Main Outcome Measures  Self-reported use of screening for cervical, breast, and colorectal cancer; serum cholesterol screening and measurement, aspirin use, and tobacco cessation and weight loss counseling for cardiovascular risk reduction; and serum cholesterol and glycosylated hemoglobin measurement, eye and foot examination, and influenza and pneumococcal vaccination for diabetes management. Results  Among eligible adults, use of cancer prevention services ranged from 51% for colorectal cancer screening to 88% for cervical cancer screening, while use of cardiovascular risk reduction services ranged from 38% for weight loss counseling to 81% for aspirin use, and use of services for diabetes management ranged from 33% for pneumococcal vaccination to 88% for serum glycosylated hemoglobin measurement. In bivariate analyses, health insurance and annual household income were both strongly associated with use of nearly all examined health care services (P values <.01). Using multivariable analysis, increased annual household income did not significantly increase the likelihood of uninsured compared with insured adults receiving recommended health care services for cancer prevention, cardiovascular risk reduction, or diabetes management (P values >.05). Conclusions  Even among higher-income adults, lack of health care insurance was associated with significantly decreased use of recommended health care services; increased income did not attenuate the difference in use between uninsured and insured adults. Efforts to improve the use of recommended health care services among the uninsured should focus on patient education and expanding insurance eligibility for both lower-income and higher-income adults.      

The relationship between managed care insurance and use of lower-mortality hospitals for CABG surgery

Context  Explicit information about the quality of coronary artery bypass graft (CABG) surgery has been available for nearly a decade in New York State; however, the extent to which managed care insurance plans direct enrollees to the lowest-mortality CABG surgery hospitals remains unknown. Objective  To compare the proportion of patients with managed care insurance and fee-for-service (FFS) insurance who undergo CABG surgery at lower-mortality hospitals. Design  A retrospective cohort study of CABG surgery discharges from 1993 to 1996, using New York Department of Health databases and multivariate analysis to estimate the use of lower-mortality hospitals by patients with different types of health insurance. Setting  Cardiac surgical centers in New York, of which 14 were classified as lower-mortality hospitals (mean rate, 2.1%) and 17 were classified as higher-mortality hospitals (mean rate, 3.2%). Patients  A total of 58,902 adults older than 17 years who were hospitalized for CABG surgery. Patients were excluded if their CABG surgery was combined with any valve procedure or left ventricular aneurysm resection or if they were younger than 65 years and enrolled in Medicare FFS or Medicare managed care. Main Outcome Measure  Probability of a patient receiving CABG surgery at a lower-mortality hospital. Results  Compared with patients with private FFS insurance (n=18,905), patients with private managed care insurance (n=7169) and Medicare managed care insurance (n=880) were less likely to receive CABG surgery at a lower-mortality hospital (relative risk [RR] of surgery at a lower-mortality hospital compared with patients with private FFS insurance, 0.77; 95% confidence interval [CI], 0.74-0.81; P<.001; and RR, 0.61; 95% CI, 0.54-0.70; P<.001, respectively, after controlling for multiple potential confounding factors). Patients with Medicare FFS insurance used lower-mortality hospitals at rates more similar to those with private FFS insurance (n=31,948; RR, 0.95; 95% CI, 0.91-0.98; P=.004). Conclusions  Patients in New York State with private managed care and Medicare managed care insurance were significantly less likely to use lower-mortality hospitals for CABG surgery compared with patients with private FFS insurance.      

Comparison of performance of traditional Medicare vs Medicare managed care

Context  Since 2000, the Centers for Medicare & Medicaid Services (CMS) has been collecting information on beneficiaries' experiences with health care for Medicare managed care (MMC) and traditional fee-for-service (FFS) Medicare. Objectives  To compare beneficiary experiences with managed care and FFS arrangements throughout the country and to assess the stability of those differences over time. Design, Setting, and Participants  CMS administered managed care and FFS versions of the Consumer Assessment of Health Plans Study (CAHPS) survey to samples of beneficiaries (aged =" BORDER="0">65 years) from Medicare + Choice MMC organizations and from geographic strata within the traditional FFS Medicare program. We analyzed responses collected in 2000 and 2001 from 497 869 respondents: 299 058 beneficiaries enrolled in MMC plans (response rate, 82%) and 198 811 enrolled in FFS Medicare (response rate, 68%). Differences between MMC and FFS within states were assessed after adjustment for case mix and nonresponse. For estimates at the regional and national level, state estimates were combined after weighting by the MMC enrollment in the state. Main Outcome Measures  Four overall ratings (of the plan, personal physician, care received overall, and care received from specialists), 5 measures summarizing beneficiaries' experiences with care (getting care needed; getting care quickly; communication with clinicians; courtesy and respect of physician's office staff; and paperwork, information, and customer service), and reports of receipt of 3 preventive services (flu shots, pneumococcal vaccinations, and being advised to quit smoking) were assessed. Results  Respondents in MMC and FFS plans were similar to each other and to the Medicare population as a whole. Nationally, FFS Medicare beneficiaries rated experiences with care measured by the CAHPS survey higher than did MMC beneficiaries; for instance, in ratings of care received overall (scale of 1-10) (8.91 FFS vs 8.86 MMC, P<.001, in 2000; and 8.88 FFS vs 8.78 MMC, P<.001, in 2001). Differences between FFS and MMC varied across states, however. Managed care enrollees reported significantly fewer problems with paperwork, information, and customer service (2.62 FFS vs 2.55 MMC, P<.001, in 2000; and 2.59 FFS vs 2.51 MMC, P<.001, in 2001). Enrollees in MMC were also more likely to report having received immunizations for influenza and pneumococcus (from any source) (in 2000, 77% of MMC vs 63% of FFS respondents; P<.001), and smokers were more likely to report having received counseling to quit smoking. Conclusions  Our data suggest that managed care was better at delivering preventive services, whereas traditional Medicare was better in other aspects of care related to access and beneficiary experiences. These relative strengths should be considered when policy decisions are made that affect the availability of choice or influence beneficiaries to choose one model of care over another.      

Managed care and physicians' provision of charity care

Context  Health system changes may be affecting the ability of physicians to provide care with little or no compensation from patients who are uninsured and underinsured and may result in decreased access to physicians for uninsured persons. Objective  To examine the association between managed care and physicians' provision of charity care. Design  The 1996-1997 Community Tracking Study physician survey. Setting and Participants  A nationally representative sample of 10,881 physicians from 60 randomly selected communities. Main Outcome Measure  The number of hours in the month prior to the interview that the physician provided care for free or at reduced fees because of the financial need of the patient. Results  Overall, 77.3% of respondents provided an average of 10.3 hours of charity care per week. Physicians who derive at least 85% of their practice revenue from managed care plans were considerably less likely to provide charity care and spend fewer hours providing charity care than physicians with little involvement in managed care plans (P=.01). In addition, physicians who practice in areas with high managed care penetration provided fewer hours of charity care than physicians in other areas, regardless of their own level of involvement with managed care (P<.01). Differences in charity care provision were also shown for other important factors, including ownership of the practice and practice arrangements (more charity care occurred in solo and 2-physician practices; P<.01). Conclusion  Physicians involved with managed care plans and those who practice in areas with high managed care penetration tend to provide less charity care.      

Racial disparities in the quality of care for enrollees in medicare managed care

Context  Substantial racial disparities in the use of some health services exist; however, much less is known about racial disparities in the quality of care. Objective  To assess racial disparities in the quality of care for enrollees in Medicare managed care health plans. Design and Setting  Observational study, using the 1998 Health Plan Employer Data and Information Set (HEDIS), which summarized performance in calendar year 1997 for 4 measures of quality of care (breast cancer screening, eye examinations for patients with diabetes, -blocker use after myocardial infarction, and follow-up after hospitalization for mental illness). Participants  A total of 305 574 (7.7%) beneficiaries who were enrolled in Medicare managed care health plans had data for at least 1 of the 4 HEDIS measures and were aged 65 years or older. Main Outcome Measures  Rates of breast cancer screening, eye examinations for patients with diabetes, -blocker use after myocardial infarction, and follow-up after hospitalization for mental illness. Results  Blacks were less likely than whites to receive breast cancer screening (62.9% vs 70.9%; P<.001), eye examinations for patients with diabetes (43.6% vs 50.4%; P = .02), -blocker medication after myocardial infarction (64.1% vs 73.8%; P<.005), and follow-up after hospitalization for mental illness (33.2 vs 54.0%; P<.001). After adjustment for potential confounding factors, racial disparities were still statistically significant for eye examinations for patients with diabetes, -blocker use after myocardial infarction, and follow-up after hospitalization for mental illness. Conclusion  Among Medicare beneficiaries enrolled in managed care health plans, blacks received poorer quality of care than whites.      

Gender disparities in the receipt of home care for elderly people with disability in the United States

Context  Projected demographic shifts in the US population over the next 50 years will cause families, health care practitioners, and policymakers to confront a marked increase in the number of people with disabilities living in the community. Concerns about the adequacy of community support are particularly salient to women, who make up a disproportionate number of disabled elderly people and who may be particularly vulnerable because they are more likely to live alone with limited financial resources. Objective  To address gender differences in receipt of informal and formal home care. Design, Setting, and Participants  Nationally representative survey conducted in 1993 among 7443 noninstitutionalized people (4538 women and 2905 men) aged 70 years or older. Main Outcome Measure  Number of hours per week of informal (generally unpaid) and formal (generally paid) home care received by survey participants who reported any activity of daily living (ADL) or instrumental activity of daily living (IADL) impairment (n = 3109) compared by gender and living arrangement and controlling for other factors. Results  Compared with disabled men, disabled women were much more likely to be living alone (45.4% vs 16.8%, P<.001) and much less likely to be living with a spouse (27.8% vs 73.6%, P<.001). Overall, women received fewer hours of informal care per week than men (15.7 hours; 95% confidence interval [CI], 14.5-16.9 vs 21.2 hours; 95% CI, 19.7-22.8). Married disabled women received many fewer hours per week of informal home care than married disabled men (14.8 hours; 95% CI, 13.7-15.8 vs 26.2 hours; 95% CI, 24.6-27.9). Children (>80% women) were the dominant caregivers for disabled women while wives were the dominant caregivers of disabled men. Gender differences in formal home care were small (2.8 hours for women; 95% CI, 2.5-3.1 vs 2.1 hours for men; 95% CI, 1.7-2.4). Conclusion  Large gender disparities appear to exist in the receipt of informal home care for disabled elderly people in the United States, even within married households. Programs providing home care support for disabled elderly people need to consider these large gender disparities and the burden they impose on families when developing intervention strategies in the community.      

Collaborative care management of late-life depression in the primary care setting: a randomized controlled trial

Context  Few depressed older adults receive effective treatment in primary care settings. Objective  To determine the effectiveness of the Improving Mood–Promoting Access to Collaborative Treatment (IMPACT) collaborative care management program for late-life depression. Design  Randomized controlled trial with recruitment from July 1999 to August 2001. Setting  Eighteen primary care clinics from 8 health care organizations in 5 states. Participants  A total of 1801 patients aged 60 years or older with major depression (17%), dysthymic disorder (30%), or both (53%). Intervention  Patients were randomly assigned to the IMPACT intervention (n = 906) or to usual care (n = 895). Intervention patients had access for up to 12 months to a depression care manager who was supervised by a psychiatrist and a primary care expert and who offered education, care management, and support of antidepressant management by the patient's primary care physician or a brief psychotherapy for depresssion, Problem Solving Treatment in Primary Care. Main Outcome Measures  Assessments at baseline and at 3, 6, and 12 months for depression, depression treatments, satisfaction with care, functional impairment, and quality of life. Results  At 12 months, 45% of intervention patients had a 50% or greater reduction in depressive symptoms from baseline compared with 19% of usual care participants (odds ratio [OR], 3.45; 95% confidence interval [CI], 2.71-4.38; P<.001). Intervention patients also experienced greater rates of depression treatment (OR, 2.98; 95% CI, 2.34-3.79; P<.001), more satisfaction with depression care (OR, 3.38; 95% CI, 2.66-4.30; P<.001), lower depression severity (range, 0-4; between-group difference, -0.4; 95% CI, -0.46 to -0.33; P<.001), less functional impairment (range, 0-10; between-group difference, -0.91; 95% CI, -1.19 to -0.64; P<.001), and greater quality of life (range, 0-10; between-group difference, 0.56; 95% CI, 0.32-0.79; P<.001) than participants assigned to the usual care group. Conclusion  The IMPACT collaborative care model appears to be feasible and significantly more effective than usual care for depression in a wide range of primary care practices.