BACKGROUND: While dramatic progress has been made lowering in-hospital mortality for coronary artery bypass graft surgery (CABG), few comprehensive studies have been done that include Caucasian, African-American, Hispanic and Asian-American/Pacific-Islander CABG inpatients and simultaneously evaluate the influence of gender. This study, analyzing five years of national data for 1.2 million CABG admissions, examines trends in in-hospital CABG mortality rates for gender and four racial/ethnic categories for CABG patients. METHODS: Using data from the Health Care Utilization Project (HCUP) for 1998-2002, 1.2 million CABG admissions were analyzed using descriptive and logistic regression analyses to evaluate the extent of the disparities in in-hospital CABG mortality rates. HCUP is a sample of nearly 1,000 hospitals from 35 states designed by the Agency for Healthcare Research and Quality (AHRQ) to approximate a 20% stratified sample of the nation's community hospitals: approximately 94% of all hospital discharges in the United States. RESULTS: Although significant progress has been made in recent years in lowering in-hospital CABG mortality, after controlling for relevant patient and socioeconomic factors, female CABG patients, regardless of their racial/ethnic group, still experience significantly higher in-hospital mortality rates than their male counterparts. Additionally, among these racial and ethnic groups, black CABG patients, whether male or female, continue to experience significantly worse in-hospital mortality rates than other races/ethnicities. CONCLUSIONS: The declines in CABG in-hospital mortality rates have not been equal across race/ethnicity and gender.
Objective
Poor quality of health care contributes to impaired health and excess mortality in individuals with severe mental disorders. This study tests a population-based medical care management intervention to improve primary medical care in community mental health settings.
Method
A total of 407 subjects with severe mental illnesses at an urban community mental health center were randomized to either care management or usual care. For individuals in the intervention group, care managers provided communication and advocacy with medical providers, health education for patients, and support in overcoming system-level fragmentation and barriers to primary medical care.
Results
At 12-month follow-up, the intervention group received an average of 58.7% of recommended preventive services, compared to 21.8% in the usual care group (p<0.001). They received a significantly higher proportion of evidence-based services for cardiometabolic conditions (34.9% vs. 27.7%, p=0.03), and were more likely to have a primary care provider (71.2% vs. 51.9%, p=0.003). On the SF-36, the intervention group showed significant improvement on the Mental Component Summary score (8.0% improvement in intervention versus 1.1% decline in the control group, p=0.008) with a nonsigificant improvement on the Physical Component Summary score. Among subjects with available laboratory data, Framingham Cardiovascular Risk Scores were significantly lower (better) for intervention (6.9%) than control (9.8%) subjects (p=0.02).
Conclusions
Medical care management was associated with significant improvements in quality and outcomes of primary care. The findings suggest that care management is a promising approach for improving medical care for patients treated in community mental health settings.
Clinicaltrials.gov identifier NCT00183313
BACKGROUND
Differences in health literacy levels by race and education are widely hypothesized to contribute to health disparities, but there is little direct evidence.
OBJECTIVE
To examine the extent to which low health literacy exacerbates differences between racial and socioeconomic groups in terms of health status and receipt of vaccinations.
DESIGN
Retrospective cohort study.
PARTICIPANTS (OR PATIENTS OR SUBJECTS)
Three thousand two hundred and sixty noninstitutionalized elderly persons enrolling in a Medicare managed care plan in 1997 in Cleveland, OH; Houston, TX; South Florida; and Tampa, FL.
MEASUREMENTS
Dependent variables were physical health SF-12 score, mental health SF-12 score, self-reported health status, receipt of influenza vaccine, and receipt of pneumococcal vaccine. Independent variables included health literacy, educational attainment, race, income, age, sex, chronic health conditions, and smoking status.
RESULTS
After adjusting for demographic and health-related variables, individuals without a high school education had worse physical and mental health and worse self-reported health status than those with a high school degree. Accounting for health literacy reduced these differences by 22% to 41%. Black individuals had worse self-reported health status and lower influenza and pneumococcal vaccination rates. Accounting for health literacy reduced the observed difference in self-reported health by 25% but did not affect differences in vaccination rates.
CONCLUSIONS
We found that health literacy explained a small to moderate fraction of the differences in health status and, to a lesser degree, receipt of vaccinations that would normally be attributed to educational attainment and/or race if literacy was not considered.
Petroleum is used widely in health care—primarily as a transport fuel and feedstock for pharmaceuticals, plastics, and medical supplies—and few substitutes for it are available. This dependence theoretically makes health care vulnerable to petroleum supply shifts, but this vulnerability has not been empirically assessed. We quantify key aspects of petroleum use in health care and explore historical associations between petroleum supply shocks and health care prices. These analyses confirm that petroleum products are intrinsic to modern health care and that petroleum supply shifts can affect health care prices. In anticipation of future supply contractions lasting longer than previous shifts and potentially disrupting health care delivery, we propose an adaptive management approach and outline its application to the example of emergency medical services.
The national program to report hospital-level outcomes for transplantation has been in place since 1991, yet it has not been addressed in the existing literature on hospital report cards. We study the impact of reported outcomes on demand at kidney transplant centers. Using a negative binomial regression with hospital fixed effects, we estimate the number of patients choosing each center as a function of reported outcomes. Parameters are identified by the within-hospital variation in outcomes over five successive report cards. We find some evidence that report cards influence younger and college-educated patients, but overall report cards do not affect demand.
OBJECTIVES: The authors present preliminary results on health-related outcomes of a randomized trial of telehealth interventions designed to reduce the incidence of secondary conditions among people with mobility impairment resulting from spinal cord injury (SCI).
METHODS: Patients with spinal cord injuries were recruited during their initial stay at a rehabilitation facility in Atlanta. They received a video-based intervention for nine weeks, a telephone-based intervention for nine weeks, or standard follow-up care. Participants are followed for at least one year, to monitor days of hospitalization, depressive symptoms, and health-related quality of life.
RESULTS: Health-related quality of life was measured using the Quality of Well-Being (QWB) scale. QWB scores (n = 111) did not differ significantly between the three intervention groups at the end of the intervention period. At year one post discharge, however, scores for those completing one year of enrollment (n = 47) were significantly higher for the intervention groups compared to standard care. Mean annual hospital days were 3.00 for the video group, 5.22 for the telephone group, and 7.95 for the standard care group.
CONCLUSIONS: Preliminary evidence suggests that in-home telephone or video-based interventions do improve health-related outcomes for newly injured SCI patients. Telehealth interventions may be cost-saving if program costs are more than offset by a reduction in rehospitalization costs, but differential advantages of video-based interventions versus telephone alone warrant further examination.
Background: There are limited data on factors associated with 30-day readmissions and the frequency of avoidable readmissions among patients with stroke and other cerebrovascular disease. Methods: University HealthSystem Consortium (UHC) database records were used to identify patients discharged with a diagnosis of stroke or other cerebrovascular disease at a university hospital from January 1, 2007 to December 31, 2009 and readmitted within 30 days to the index hospital. Logistic regression models were used to identify patient and clinical characteristics associated with 30-day readmission. Two neurologists performed chart reviews on readmissions to identify avoidable cases. Results: Of 2706 patients discharged during the study period, 174 patients had 178 readmissions (6.4%) within 30 days. The only factor associated with 30-day readmission was the index length of stay >10 days (vs <5 days; odds ratio [OR] 2.3, 95% CI [1.4, 3.7]). Of 174 patients readmitted within 30 days (median time to readmission 10 days), 92 (53%) were considered avoidable readmissions including 38 (41%) readmitted for elective procedures within 30 days of discharge, 27 (29%) readmitted after inadequate outpatient care coordination, 15 (16%) readmitted after incomplete initial evaluations, 8 (9%) readmitted due to delayed palliative care consultation, and 4 (4%) readmitted after being discharged with inadequate discharge instructions. Only 5% of the readmitted patients had outpatient follow-up recommended within 1 week. Conclusions: More than half of the 30-day readmissions were considered avoidable. Coordinated timing of elective procedures and earlier outpatient follow-up may prevent the majority of avoidable readmissions among patients with stroke and other cerebrovascular disease.
Most studies of competition in health care focus on prices and costs, but concerns about quality play a central role in policy debates. If demand is inelastic to quality, then competition may reduce patient welfare. This study uses a dataset of patient registrations for kidney transplantation in conjunction with a mixed logit model to gauge consumers’ responsiveness to quality when choosing hospitals. Results indicate that at the hospital level, a one-standard deviation increase in the graft-failure rate is associated with a 6% decline in patient registrations. Privately-insured patients are more responsive to quality than Medicare patients, suggesting that insurers consider quality when contracting with providers.
Objective
This study assesses the two-year outcomes, costs, and financial sustainability of a medical care management intervention for community mental health settings.
Method
A total of 407 psychiatric outpatients with serious mental illnesses were randomized to usual care or to a medical care manager, who provided care coordination and education. Two-year follow-up chart reviews and interviews assessed quality and outcomes of care, and costs from both the health system and managerial perspective.
Results
Subjects in the intervention group had sustained improvements in quality of primary care preventive services (p<0.001), quality of cardiometabolic care (p<0.001), and mental health-related quality of life (p<0.001). From a health system perspective, by year 2, the program showed a $932 reduction in total costs (95% CI (−1973, 102) with a 92.3% probability that the program was associated with lower costs than usual care. From the community mental health center perspective, the program would break even (i.e., revenues would cover setup costs) if 58% or more of clients had Medicaid or another form of insurance. Given that only 40.5% of clients in the study had Medicaid, the program was not sustainable after grant funding ended.
Conclusions
The positive long-term outcomes and favorable cost profile provided evidence of the potential value of this model. However, the discrepancy between health system and managerial cost perspectives limited the program’s financial sustainability. With anticipated insurance expansions under health reform, there is likely to be a stronger business case for safety net organizations considering implementing these and other evidence-based interventions.
by
David H Howard;
Carolyn Kenline;
Hillard M Lazarus;
Charles F LeMaistre;
Richard T Maziarz;
Philip L McCarthy;
Susan K Parsons;
David Szwajcer;
James Douglas Rizzo;
Navneet S Majhail
Objective
In 1999, three randomized controlled trials concluded that high-dose chemotherapy followed by autologous hematopoietic stem cell transplantation (HDC/HCT) is no better than conventional chemotherapy for women with breast cancer. This study documents the impact of the trials on use of HDC/HCT and describes how hospitals reacted to the trials.
Data Source
We used patient-level data on 15,847 HDC/HCTs reported to the Center for International Blood and Marrow Transplant Research between 1994 and 2005.
Study Design
We report trends in total HDC/HCT procedure volume, compare the time to hospitals' exit from the HDC/HCT market between research and nonresearch hospitals, and document trends in hospital-specific volumes in the 2 years before exit.
Principal Findings
HDC/HCT volume declined from 3,108 in 1998 to 1,363 the year after trial results were released. In 2002, only 76 procedures were performed. Teaching hospitals and the hospitals that participated in the trials were no slower to discontinue the procedure compared with nonteaching, nonparticipating hospitals. At the hospital level, volume declined steadily in the months before abandonment.
Conclusion
The results suggest that comparative effectiveness research studies that report negative results can reduce spending, but specialists may be reluctant to relinquish cutting-edge technologies.