School of Population Health Faculty Papers

Analyzing the Health Care Cost Curve: A Case Study

Robert Liberthal — Fri, 04 Jan 2013 12:21:27 PST

Since the data analyzed in this study consisted of time series data, time series methods were applied to normalize the data for analysis. One primary concern was the possibility of seasonality in the data, since the motivation for the study was to determine whether the cost curve should be modeled daily, monthly, or annually. One source of potential seasonality would be spending that varied by month that was not due to the tendency of spending to rise over time, such as the arrival of new residents in a hospital on July 1. A second source of seasonality would be due to the tendency for utilization to be higher on weekdays than on weekends, which would make daily spending growth seem more volatile than it truly is. A number of regressors were applied in order to correct for the possibility that spending was higher in particular months, on weekdays as opposed to weekend days, or particular weekdays or a specific weekend day.

Insights from the 2007 disease management colloquium.

David B Nash et al. — Tue, 31 Jul 2012 12:42:02 PDT

Indirect costs associated with surgery for low back pain-a secondary analysis of clinical trial data.

Reginald Fayssoux et al. — Fri, 13 Apr 2012 13:00:16 PDT

This study examines the indirect costs associated with surgery for axial low back pain using data obtained from a prospective multicenter clinical trial that compared Charité artificial disc replacement with anterior lumbar interbody fusion using iliac crest bone graft. While 75% of study subjects reported full- or part-time employment prior to surgery, this percentage dropped to 45% at 6 weeks postoperatively. Return to preoperative employment levels occurred at approximately 6 months postoperatively. Two years after surgery, employment levels were 16% higher than preoperative levels. Lost productivity related to absenteeism resulted in lost wages averaging $2884 per patient during the first postoperative year. Although short-term indirect costs of surgery are substantial from a societal perspective, the higher employment rate at 2 years suggests a long-term economic benefit. The findings demonstrate the significant, though not surprising, impact of spinal disability on productivity, and the importance of including measurement of lost productivity and return to work in the economic evaluation of related interventions.

Using hospital discharge abstract data to identify incident breast cancer cases and assess quality of care

Elaine J. Yuen et al. — Fri, 13 Apr 2012 11:54:51 PDT

Improved cardiac management with a disease management program incorporating comprehensive lipid profiling.

John F McAna et al. — Mon, 02 Apr 2012 07:36:57 PDT

The objective of this study was to evaluate the improved effectiveness of a disease management treatment protocol incorporating comprehensive lipid profiling and targeted lipid care based on lipid profile findings in patients with ischemic heart disease (IHD) or congestive heart failure (CHF) enrolled in a managed care plan. This retrospective cohort study, conducted over a 2-year period, compared outcomes between patients with a standard lipid profile to those evaluated with a comprehensive lipid profile. All adult members of the WellMed Medical Management, Inc. managed care health plan diagnosed with IHD or CHF, and continuously enrolled between July 1, 2006 and June 30, 2008, were included in the study. Cases were defined as those who had at least 1 comprehensive lipid test (the VAP [vertical auto profile] ultracentrifuge test) during this period (n=1767); they were compared to those who had no lipid testing or traditional standard lipid testing only (controls, n=289). Univariate statistics were analyzed to describe the groups, and bivariate t tests or chi-squares examined differences between the 2 cohorts. Multivariate regression analyses were performed to control for potential confounders. The results show that the case group had lower total costs ($4852.62 vs. $7413.18; P=0.0255), fewer inpatient stays (13.1% vs. 18.3% of controls; P=0.0175) and emergency department visits (11.9% vs. 15.6% of controls; P=0.0832). Prescription use and frequency of lipid measurement suggested improved control resulting from a targeted approach to managing specific dyslipidemias. A treatment protocol incorporating a comprehensive lipid profile appears to improve care and reduce utilization and costs in a disease management program for cardiac patients.

Comparison of GE Centricity Electronic Medical Record database and National Ambulatory Medical Care Survey findings on the prevalence of major conditions in the United States.

Albert G. Crawford et al. — Fri, 23 Mar 2012 12:50:45 PDT

The study objective was to facilitate investigations by assessing the external validity and generalizability of the Centricity Electronic Medical Record (EMR) database and analytical results to the US population using the National Ambulatory Medical Care Survey (NAMCS) data and results as an appropriate validation resource. Demographic and diagnostic data from the NAMCS were compared to similar data from the Centricity EMR database, and the impact of the different methods of data collection was analyzed. Compared to NAMCS survey data on visits, Centricity EMR data shows higher proportions of visits by younger patients and by females. Other comparisons suggest more acute visits in Centricity and more chronic visits in NAMCS. The key finding from the Centricity EMR is more visits for the 13 chronic conditions highlighted in the NAMCS survey, with virtually all comparisons showing higher proportions in Centricity. Although data and results from Centricity and NAMCS are not perfectly comparable, once techniques are employed to deal with limitations, Centricity data appear more sensitive in capturing diagnoses, especially chronic diagnoses. Likely explanations include differences in data collection using the EMR versus the survey, particularly more comprehensive medical documentation requirements for the Centricity EMR and its inclusion of laboratory results and medication data collected over time, compared to the survey, which focused on the primary reason for that visit. It is likely that Centricity data reflect medical problems more accurately and provide a more accurate estimate of the distribution of diagnoses in ambulatory visits in the United States. Further research should address potential methodological approaches to maximize the validity and utility of EMR databases.

Prevalence of obesity, type II diabetes mellitus, hyperlipidemia, and hypertension in the United States: findings from the GE Centricity Electronic Medical Record database.

Albert G Crawford et al. — Fri, 23 Mar 2012 12:36:19 PDT

This study analyzed GE Centricity Electronic Medical Record (EMR) data to examine the effects of body mass index (BMI) and obesity, key risk factor components of metabolic syndrome, on the prevalence of 3 chronic diseases: type II diabetes mellitus, hyperlipidemia, and hypertension. These chronic diseases occur with high prevalence and impose high disease burdens. The rationale for using Centricity EMR data is 2-fold. First, EMRs may be a good source of BMI/obesity data, which are often underreported in surveys and administrative databases. Second, EMRs provide an ideal means to track variables over time and, thus, allow longitudinal analyses of relationships between risk factors and disease prevalence and progression. Analysis of Centricity EMR data showed associations of age, sex, race/ethnicity, and BMI with diagnosed prevalence of the 3 conditions. Results include uniform direct correlations between age and BMI and prevalence of each disease; uniformly greater disease prevalence for males than females; varying differences by race/ethnicity (ie, African Americans have the highest prevalence of diagnosed type II diabetes and hypertension, while whites have the highest prevalence of diagnosed hypertension); and adverse effects of comorbidities. The direct associations between BMI and disease prevalence are consistent for males and females and across all racial/ethnic groups. The results reported herein contribute to the growing literature about the adverse effects of obesity on chronic disease prevalence and about the potential value of EMR data to elucidate trends in disease prevalence and facilitate longitudinal analyses.

Insights from "Creating the Healthcare Workforce for the 21(st) Century" Conference.

Amanda R Solis — Thu, 22 Mar 2012 12:58:01 PDT

Improved cardiac management with a disease management program incorporating comprehensive lipid profiling.

John F McAna et al. — Thu, 22 Mar 2012 12:22:42 PDT

Abstract The objective of this study was to evaluate the improved effectiveness of a disease management treatment protocol incorporating comprehensive lipid profiling and targeted lipid care based on lipid profile findings in patients with ischemic heart disease (IHD) or congestive heart failure (CHF) enrolled in a managed care plan. This retrospective cohort study, conducted over a 2-year period, compared outcomes between patients with a standard lipid profile to those evaluated with a comprehensive lipid profile. All adult members of the WellMed Medical Management, Inc. managed care health plan diagnosed with IHD or CHF, and continuously enrolled between July 1, 2006 and June 30, 2008, were included in the study. Cases were defined as those who had at least 1 comprehensive lipid test (the VAP [vertical auto profile] ultracentrifuge test) during this period (n=1767); they were compared to those who had no lipid testing or traditional standard lipid testing only (controls, n=289). Univariate statistics were analyzed to describe the groups, and bivariate t tests or chi-squares examined differences between the 2 cohorts. Multivariate regression analyses were performed to control for potential confounders. The results show that the case group had lower total costs ($4852.62 vs. $7413.18; P=0.0255), fewer inpatient stays (13.1% vs. 18.3% of controls; P=0.0175) and emergency department visits (11.9% vs. 15.6% of controls; P=0.0832). Prescription use and frequency of lipid measurement suggested improved control resulting from a targeted approach to managing specific dyslipidemias. A treatment protocol incorporating a comprehensive lipid profile appears to improve care and reduce utilization and costs in a disease management program for cardiac patients. (Population Health Management 2012;15:46-51).

Current and future directions in frailty research.

Anita Mohandas et al. — Fri, 16 Mar 2012 11:07:31 PDT

The concept of frailty has been evolving dramatically for the past 30 years. Through its evolution, a variety of single and multidimensional models have been used to describe frailty. This article reviews the current literature related to the defining dimensions of frailty and identifies the gaps in the literature requiring additional research. A detailed literature review was performed to identify key dimensions and models currently being used to define frailty, classify interventions that have been developed to reverse frailty, and identify potential areas for future research within this field. Despite the large body of research defining the dimensions of frailty, no consensus exists on a comprehensive, operational definition. A standardized definition will be critical to design effective interventions at earlier stages along the continuum of frailty and interpret findings from evaluation studies. Identified gaps in the literature include studies supporting the utility of expanding the definition of frailty to incorporate social determinants, studies evaluating the role of obesity in the development of frailty, and the need for longitudinal studies for defining the pathways to developing frailty. This review highlights the need for an accurate definition of frailty and for longitudinal research to explore the development of frailty and evaluate the effectiveness of the frailty reversal interventions that may avert or delay adverse outcomes within this susceptible population. These future research needs are discussed within the context of the growing pressures to bring down health care costs, and the role of comparative effectiveness research and cost-effectiveness research in identifying interventions with the potential to help slow the growth of health care spending among the elderly.

Chronic care at the crossroads: Exploring solutions for chronic care management. Report on the US Summit.

Janice L Clarke — Thu, 15 Mar 2012 09:43:28 PDT

Report on the US Summit

Patient empowerment and multimodal hand hygiene promotion: a win-win strategy.

Maryanne McGuckin et al. — Tue, 13 Mar 2012 12:42:52 PDT

Patient empowerment is a new concept in health care that has now been extended to the domain of patient safety. Within the framework of the development of the new World Health Organization (WHO) Guidelines on Hand Hygiene in Health Care, the authors conducted a review of the literature from 1997 to 2008 to identify the evidence supporting programs aimed at encouraging patients to take an active role in their care. Patient empowerment is an integral part of the WHO hand hygiene multimodal strategy. Hand hygiene promotion strategies that have demonstrated evidence of successfully empowering patients include one or all of the following components: educational tools, motivation and reminder tools, and role modeling. What is important is that programs and models to empower patients must be developed with an inbuilt evaluation component that includes both qualitative and quantitative measures to determine not only what works but under what conditions and within which organizational context.

Hand hygiene compliance rates in the United States--a one-year multicenter collaboration using product/volume usage measurement and feedback.

Maryanne McGuckin et al. — Tue, 13 Mar 2012 12:18:47 PDT

Hand hygiene (HH) is the single most important factor in the prevention of health care-acquired infections. The 3 most frequently reported methods of measuring HH compliance are: (1) direct observation, (2) self-reporting by health care workers (HCWs), and (3) indirect calculation based on HH product usage. This article presents the results of a 12-month multicenter collaboration assessing HH compliance rates at US health care facilities by measuring product usage and providing feedback about HH compliance. Our results show that HH compliance at baseline was 26% for intensive care units (ICUs) and 36% for non-ICUs. After 12 months of measuring product usage and providing feedback, compliance increased to 37% for ICUs and 51% for non-ICUs. (ICU, P = .0119; non-ICU, P < .001). HH compliance in the United States can increase when monitoring is combined with feedback. However, HH still occurs at or below 50% compli- ance for both ICUs and non-ICUs.

Beta-blocker initiation and adherence after hospitalization for acute myocardial infarction.

Vittorio Maio, PharmD, MS, MSPH et al. — Thu, 18 Aug 2011 08:18:33 PDT

Aims: We sought to: (1) estimate the proportion of patients who initiated beta-blocker therapy after acute myocardial infarction (AMI) in Regione Emilia-Romagna (RER); (2) examine predictors of post-AMI beta-blocker initiation; and (3) assess adherence to such therapy.

Methods and Results: Using healthcare claims data covering all of RER, we identified a cohort of 24,367 patients with a hospitalization for AMI between 2004 and 2007, who were discharged from the hospital alive and without contraindications to beta-blocker therapy. We estimated the proportion of eligible patients with at least one prescription for a beta-blocker following discharge and performed a multivariable logistic regression analysis to identify independent predictors of post-AMI beta-blocker initiation. We computed the proportion of days covered (PCD) as a measure of medication adherence at 6 and 12 months post-discharge. Following discharge, 16,383 (67%) cohort members initiated beta-blocker therapy. Independent predictors of beta-blocker initiation included age and receipt of invasive procedures during hospitalization, such as coronary artery bypass graft surgery (odds ratio [OR], 2.37; 95% confidence interval [CI], 2.00-2.81), percutaneous transluminal coronary angioplasty (OR, 1.42; 95% CI, 1.31-1.54), and cardiac catheterization (OR, 1.21; 95% CI, 1.11-1.32). Among initiators, adherence to beta-blocker treatment at 6 and 12 months was low and decreased in each study year.

Conclusion: Overall, use of and adherence to post-AMI beta-blocker therapy was suboptimal in RER between 2004 and 2007. Older patients and those with indicators of frailty were less likely to initiate therapy. The proportion of patients adherent at 6 and 12 months decreased over time.

Appropriate medication prescribing in elderly patients: how knowledgeable are primary care physicians? A survey study in Parma, Italy.

Vittorio Maio, PharmD, MS, MPH et al. — Thu, 18 Aug 2011 08:06:35 PDT

What is known and Objective: Increasing attention is being paid to inappropriate medication prescribing for the elderly. A growing body of studies have detected a prevalence of inappropriate prescribing ranging from 12% to 40% worldwide, including Regione Emilia-Romagna, Italy. To improve quality of prescribing, a multi-phase pilot project in the Local Health Unit (LHU) of Parma, Regione Emilia-Romagna, was established. This phase aimed to assess primary care physicians' knowledge of appropriate prescribing in elderly patients. Methods: In total, 155 primary care physicians (51% of the total), convened by the LHU of Parma for an educational session, were asked to complete anonymously a 19-item paper survey. Knowledge of inappropriate medication use in the elderly was assessed using seven clinical vignettes based on the 2002 Beers Criteria. Topics tested included hypertension, osteoarthritis, arrhythmias, insomnia and depression. Data regarding physician's perceived barriers to appropriate prescribing for elderly patients were also collected. To evaluate the relationship between physician knowledge scores and physician characteristics, physicians were classified as having a 'low score' (three or below) or a 'high score' (six or more) with respect to their knowledge of prescribing for the elderly.

Results and Discussion: All physicians completed the survey. Most physicians (88%) felt confident in their ability to prescribe appropriate medications for the elderly. Thirty-nine physicians (25%) received a 'high score' compared to 26 (17%) who received a 'low score'. 'Lower score' respondents had been in practice for a longer time (P < 0·05) than 'higher score' respondents. Perceived barriers to appropriate prescribing included potential drug interactions (79% of respondents) and the large number of medications a patient is already taking (75%).

What is new and Conclusion: The study results show an unsatisfactory knowledge of appropriate prescribing among primary care physicians in the LHU of Parma, especially among older physicians. Educational strategies tailored to primary care physicians should be establish to enhance knowledge in this area and improve quality of prescribing.

International Evidence on Medical Spending

Robert D. Lieberthal — Tue, 31 May 2011 13:14:33 PDT

Abstract
U.S. medical spending is high by measures including the level of spending, level of spending per capita, and level of spending as a share of GDP. U.S. medical spending growth is average by measures including the annual growth rate, annual growth rate per capita, and annual growth in spending as a percent of GDP. The volatility of U.S. medical spending growth is low by measures including the standard deviation, skew, and excess kurtosis.

Foreign healthcare systems, with a much larger government involvement, have not been able to control medical spending growth better than the U.S. with its mixed system. Foreign cost curves start at a lower level, but increase as quickly or even faster. In many countries, the variance around the trend is high, or a single trend over time does not exist. The implication is that it is difficult to find a foreign solution to the U.S.’s problems with high medical spending, and that the U.S. may be a world leader in terms of minimizing medical spending
volatility.

If the U.S. healthcare cost curve comes to resemble that of other countries, the risk of long-tailed lines of insurance linked to the cost of medical care will increase. The healthcare cost curve is a macroeconomic process, so there may be no ways for insurers to bend their cost curve. Insurers may be able to use market solutions, such as prediction markets, inflation-indexed bonds, and futures contracts, to improve prediction and hedging of long-term medical spending growth. My recommendations for insurers are cognizance and
caution when writing long-tailed lines of insurance linked to medical spending.

Prevalence and Risk of Polypharmacy among the Elderly in an Outpatient Setting: A Retrospective Cohort Study in the Emilia-Romagna Region, Italy

S. Lane Slabaugh et al. — Wed, 05 Jan 2011 07:25:07 PST

Background: Polypharmacy, the simultaneous taking of many medications, has been well documented and is a topic of much concern for those looking to improve the quality of care for the elderly. Elderly patients often develop complicated and multi-factorial health states that require extensive pharmacotherapy, leaving this population at risk for exposure to drug-drug interactions and other adverse events. Previous literature supports an association between an increase in the rate of adverse events as the number of drugs taken by a patient increases.

Objective: We sought to evaluate the prevalence of polypharmacy, and to determine patient characteristics that are predictive of exposure to polypharmacy, in the elderly population of the Emilia-Romagna region in Italy.

Methods: We conducted a retrospective cohort study of the 2007 Emilia-Romagna outpatient pharmacy database linked with patient information available from a demographic file of approximately 1 million Emilia-Romagna residents aged ≥65 years. The cohort was comprised of 887 165 elderly subjects who had at least one prescription filled during the study year. Using the World Health Organization’s defined daily dose (DDD) to determine the duration of treatment for a given drug, we defined a polypharmacy episode as overlapping treatment with five or more medications occurring for at least one day. The prevalence of polypharmacy was measured together with subject characteristics found to be predictive of polypharmacy exposure.

Results: A total of 349 689 elderly people in the population (39.4%) were exposed to at least one episode of polypharmacy during the study period. The prevalence of polypharmacy substantially increased with age and with a higher number of chronic conditions. Over 35% of those exposed to polypharmacy were exposed for 101 or more days of the year. The top three classes of medications involved in polypharmacy were antithrombotics, peptic ulcer disease and gastro-oesophageal reflux disease agents and ACE inhibitors. The odds of exposure to polypharmacy were higher for older subjects, males and subjects living in urban areas.

Conclusions: This study provides evidence that the prevalence of polypharmacy in the elderly in Emilia-Romagna is substantial. Educational programmes should be developed to inform clinicians about the magnitude of the polypharmacy phenomenon and the patient characteristics associated with polypharmacy. Raising physicians’ awareness of polypharmacy may help to ensure safe, effective and appropriate use of medication in the elderly.

Quality improvement in small office settings: an examination of successful practices.

Daniel Wolfson et al. — Wed, 22 Sep 2010 12:02:27 PDT

BACKGROUND: Physicians in small to moderate primary care practices in the United States (U.S.) (<25>physicians) face unique challenges in implementing quality improvement (QI) initiatives, including limited resources, small staffs, and inadequate information technology systems 23,36. This qualitative study sought to identify and understand the characteristics and organizational cultures of physicians working in smaller practices who are actively engaged in measurement and quality improvement initiatives.

METHODS: We undertook a qualitative study, based on semi-structured, open-ended interviews conducted with practices (N = 39) that used performance data to drive quality improvement activities.

RESULTS: Physicians indicated that benefits to performing measurement and QI included greater practice efficiency, patient and staff retention, and higher staff and clinician satisfaction with practice. Internal facilitators included the designation of a practice champion, cooperation of other physicians and staff, and the involvement of practice leaders. Time constraints, cost of activities, problems with information management and or technology, lack of motivated staff, and a lack of financial incentives were commonly reported as barriers.

CONCLUSION: These findings shed light on how physicians engage in quality improvement activities, and may help raise awareness of and aid in the implementation of future initiatives in small practices more generally.

Prevalence, knowledge and care patterns for gastro-oesophageal reflux disease in United States minority populations.

Elaine Yuen et al. — Mon, 13 Sep 2010 07:17:06 PDT

BACKGROUND: While there is evidence of ethnic variation in the prevalence of gastro-oesophageal reflux disease (GERD) symptoms, few population-based studies examine GERD symptom prevalence amongst the growing Hispanic minority in the US as well as Asians in the West. AIM: To examine the prevalence, awareness and care patterns for GERD across different ethnic groups.

METHODS: A population-based, cross-sectional survey was fielded in English, Chinese and Spanish that assessed self-reported GERD prevalence, awareness and care patterns in four ethnic groups (Caucasian, African American, Asian, Hispanic).

RESULTS: A total of 1172 subjects were included for analysis: 34.6% experienced GERD symptoms at least monthly, 26.2% at least weekly and 8.2% at least daily. Statistically significant differences in raw prevalence rates between racial groups were found: 50% of Hispanics experienced heartburn at least monthly, compared with 37% of Caucasians, 31% of African Americans and 20% of Asians (P > 0.0001). Significant differences in knowledge and care-seeking patterns by ethnicity were also observed.

CONCLUSIONS: This study confirms the high prevalence of GERD symptoms in the US and introduces Hispanics as the ethnicity with the highest prevalence rate. Asians in the US have higher rates of symptoms than in the Far East. These data demonstrate a need for culturally appropriate education about GERD symptoms and treatment.

Impact of ALLHAT publication on antihypertensive prescribing patterns in Regione Emilia-Romagna, Italy

Vittorio Maio, PharmD, MS, MSPH et al. — Tue, 23 Feb 2010 08:08:46 PST

Background and objective: Studies from the US and Canada observed changes in antihypertensive prescribing patterns in accordance with Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) study findings immediately after the study's publication, but little is known about the impact of ALLHAT in Italy. The objective of this study was to examine antihypertensive prescribing patterns in Regione Emilia-Romagna (RER), Italy, following the publication of the ALLHAT main results.

Methods: We conducted a time series analysis using automated pharmacy data of approximately 4 million RER residents between 1 January 2000 and 31 December 2003. We computed monthly relative percentages of prescriptions for all antihypertensive medications and separately for all new antihypertensives defined as no recorded antihypertensive use in the previous year. A stepwise auto-regressive forecasting model based on data prior to the ALLHAT publication was used to estimate predicted relative percentages for the 12 months following the ALLHAT publication. Observed and predicted values were compared.

Results and discussion: Use of thiazide-type diuretics showed a general increasing trend over the study period, but the difference between the observed and predicted values reached statistical significance only for new prescriptions in October 2003 (3·71% vs. 2·32%; P = 0·0170). The relative percentage of new angiotensin-converting enzyme inhibitor and angiotensin receptor blocker (ACE/ARB) prescriptions was higher than predicted for the months May to August 2003 (P < 0·05), but no significant differences were observed for total ACE/ARB prescriptions. Modest changes in patterns of prescribing of calcium channel blockers and α-blockers were observed.

Conclusion: We found little evidence that the ALLHAT study had an impact on antihypertensive prescribing patterns in RER in the year following their publication.