Carter C. Rakovski

Evaluating diagnosis-based case-mix measures: how well do they apply to the VA population?

Background.Diagnosis-based case-mix measures are increasingly used for provider profiling, resource allocation, and capitation rate setting. Measures developed in one setting may not adequately capture the disease burden in other settings. Objectives.To examine the feasibility of adapting two such measures, Adjusted Clinical Groups (ACGs) and Diagnostic Cost Groups (DCGs), to the Department of Veterans Affairs (VA) population. Research Design. A 60% random sample of veterans who used health care services during FY 1997 was obtained from VA inpatient and outpatient administrative databases. A split-sample technique was used to obtain a 40% sample (n = 1,046,803) for development and a 20% sample (n = 524,461) for validation. Methods.Concurrent ACG and DCG risk adjustment models, using 1997 diagnoses and demographics to predict FY 1997 utilization (ambulatory provider encounters, and service days–the sum of a patient’s inpatient and outpatient visit days), were fitted and cross-validated. Results.Patients were classified into groupings that indicated a population with multiple psychiatric and medical diseases. Model R-squares explained between 6% and 32% of the variation in service utilization. Although reparameterized models did better in predicting utilization than models with external weights, none of the models was adequate in characterizing the entire population. For predicting service days, DCGs were superior to ACGs in most categories, whereas ACGs did better at discriminating among veterans who had the lowest utilization. Conclusions.Although “off-the-shelf” case-mix measures perform moderately well when applied to another setting, modifications may be required to accurately characterize a population’s disease burden with respect to the resource needs of all patients.

Applying a Risk-Adjustment Framework to Primary Care: Can We Improve on Existing Measures?

Outcome-based performance measurement and prospective payment are common features of the current managed care environment. Increasingly, primary care clinicians and health care organizations are being asked to assume financial risk for enrolled patients based on negotiated capitation rates. Therefore, the need for methods to account for differences in risk among patients enrolled in primary care organizations has become critical. Although current risk-adjustment measures represent significant advances in the measurement of morbidity in primary care populations, they may not adequately capture all the dimensions of patient risk relevant to primary care. We propose a risk-adjustment framework for primary care that incorporates clinical features related to patients’ health status and nonclinical factors related to patients’ health behaviors, psychosocial factors, and social environment. Without this broad perspective, clinicians with more unhealthy and more challenging populations are at risk of being inadequately compensated and inequitably compared with peers. The risk-adjustment framework should also be of use to health care organizations that have been mandated to deliver high-quality primary care but are lacking the necessary tools.

Do different case-mix measures affect assessments of provider efficiency? Lessons from the Department of Veterans Affairs.

&NA; Although case‐mix adjustment is critical for provider profiling, little is known regarding whether different case‐mix measures affect assessments of provider efficiency. We examine whether two case‐mix measures, Adjusted Clinical Groups (ACGs) and Diagnostic Cost Groups (DCGs), result in different assessments of efficiency across service networks within the Department of Veterans Affairs (VA). Three profiling indicators examine variation in resource use. Although results from the ACGs and DCGs generally agree on which networks have greater or lesser efficiency than average, assessments of individual network efficiency vary depending upon the case‐mix measure used. This suggests that caution should be used so that providers are not misclassified based on reported efficiency.

Risk adjustment for measuring health outcomes: an application in VA long-term care.

An empirically derived risk adjustment model is useful in distinguishing among facilities in their quality of care. We used Veterans Affairs (VA) administrative databases to develop and validate a risk adjustment model to predict decline in functional status, an important outcome measure in long-term care, among patients residing in VA long-term care facilities. This model was used to compare facilities on adjusted and unadjusted rates of decline. Predictors of decline included age, time between assessments, baseline functional status, terminal illness, pressure ulcers, pulmonary disease, cancer, arthritis, congestive heart failure, substance-related disorders, and various neurologic disorders. The model performed well in the development and validation databases (c statistics, 0.70 and 0.68, respectively). Risk-adjusted rates and rankings of facilities differed from unadjusted ratings. We conclude that judgments of facility performance depend on whether risk-adjusted or unadjusted decline rates are used. Valid risk adjustment models are therefore necessary when comparing facilities on outcomes.

Do fall predictors in middle aged and older adults predict fall status in persons 50+ with fibromyalgia? An exploratory study.

We explored potential predictors of fall status in 70 community-dwelling persons > or =50 years of age with fibromyalgia (FM). Over 40% of the sample reported one or more falls in the year prior to the study. A logistic regression model using 10 variables known to predict falls in middle aged and older persons predicted 45% of the variance in fall status. Three variables offered significant independent contributions to the overall model predicting fall status: perception of postural instability, balance performance, and executive function processing speed. The results support prior work in both nonclinical and clinical populations of middle aged and older adults indicating that falls are associated with multiple risk factors. Prospective designs with larger samples are needed to (a) validate and extend these findings, and (b) identify risk factors related to fall status that are unique to persons with FM.

Who rides the glass escalator? Gender, race and nationality in the national nursing assistant study

Evidence for Christine Williams’s ‘glass escalator’ effect documents how professional men entering female-dominated occupations may advance more quickly toward authority positions and higher salaries. However, studies of men’s benefits from occupational segregation have neglected low-wage and diverse groups of workers. Using the representative US National Nursing Assistant Study (NNAS), the article examines organizational measures of inequality and discrimination – wages, benefits and working conditions – to understand whether a glass escalator exists among nursing assistants and how it is affected by gender, race, citizenship and facility characteristics. Though gender inequalities were present, citizenship, race, facility type and size emerged as the most important factors in determining advantages for workers, suggesting a revision of the glass escalator metaphor may be in order. NNAS results imply that identity characteristics like nationality and contextual factors like workplace matter and underscore the importance of using an intersectional approach to examine inequality.

Identifying Future High-Healthcare Users: Exploring the Value of Diagnostic and Prior Utilization Information

ObjectiveDiagnosis-based risk-adjustment measures are increasingly being promoted as disease management tools. We compared the ability of several types of predictive models to identify future high-risk older people likely to benefit from disease management.Study designVeterans Health Administration (VHA) data were used to identify veterans ≥65 years of age who used healthcare services during fiscal years (FY) 1997 and 1998 and who remained alive through FY 1997. This yielded a development sample of 412 679 individuals and a validation sample of 207 294.MethodsProspective risk-adjustment models were fitted and tested using Adjusted Clinical Groups (ACGs), Diagnostic Cost Groups (DCGs), a prior-utilization model (prior), and combined models (prior + ACGs and prior + DCGs). Prespecified high use in FY 1998 was defined as ≥92 days of care (top 2.2%) for an individual (i.e. the number of days during the year in which an individual received inpatient or outpatient healthcare services). We developed a second outcome, defined as ≥164 days of care (top 1.0%), to explore whether changing the criterion for high risk would affect the number of misclassifications.ResultsThe diagnosis-based models performed better than the prior model in identifying a subgroup of future high-cost individuals with high disease burden and chronic diseases appropriate for disease management. The combined models performed best at correctly classifying those without high use in the prospective year. The utility for efficiently identifying high-risk cases appeared limited because of the high number of individuals misclassified as future high-risk cases by all the models. Changing the criterion for high risk generally decreased the number of patients misclassified. There was little agreement between the models regarding who was identified as high risk.ConclusionHealth plans should be aware that different risk-adjustment measures may select dissimilar groups of individuals for disease management. Although diagnosis-based measures show potential as predictive modeling tools, combining a diagnosis-based measure with prior-utilization model may yield the best results.

Does the “Glass Escalator” Compensate for the Devaluation of Care Work Occupations? The Careers of Men in Low- and Middle-Skill Health Care Jobs

Feminized care work occupations have traditionally paid lower wages compared to non–care work occupations when controlling for human capital. However, when men enter feminized occupations, they often experience a “glass escalator,” leading to higher wages and career mobility as compared to their female counterparts. In this study, we examine whether men experience a “wage penalty” for performing care work in today’s economy, or whether the glass escalator helps to mitigate the devaluation of care work occupations. Using data from the Survey of Income and Program Participation for the years 1996-2011, we examine the career patterns of low- and middle-skill men in health care occupations. We found that men in occupations that provide the most hands-on direct care did experience lower earnings compared to men in other occupations after controlling for demographic characteristics. However, men in more technical allied health occupations did not have significantly lower earnings, suggesting that these occupations may be part of the glass escalator for men in the health care sector. Minority men were significantly more likely than white men to be in direct care occupations, but not in frontline allied health occupations. Male direct care workers were less likely to transition to unemployment compared to men in other occupations.

Association of employment and working conditions with physical and mental health symptoms for people with fibromyalgia

Purpose: This study examines physical and mental health symptoms among people with fibromyalgia (FM) by employment status and working conditions. Method: Secondary data analysis of the 2007 National Fibromyalgia Association Questionnaire study resulted in employment and symptom information for 1702 people of working age with FM. In this cross-sectional internet study, six factors of symptom clusters (physical, mental health, sleeping, concentration, musculoskeletal, support) were seen in the data. Linear regression models used employment, age, income, gender, and education to predict symptom clusters. Among those employed, working conditions were also associated with symptom severity. Results: In the predominately female sample, 51% were working. Of these, 70% worked over 30 hours/week and half had flexible hours. Employment, higher income, and education were strongly associated with fewer symptoms. Working conditions, including level of physical and mental exertion required on the job as well as coworkers’ understanding of FM, were related to symptoms, particularly physical and mental health symptoms. Many participants reported modifying their work environment (66%) or changing occupations (33%) due to FM. Conclusions: Work modifications could allow more people with FM to remain employed and alleviate symptoms. Persons with FM should be counseled to consider what elements of their work may lead to symptom exacerbation. Implications for Rehabilitation People with fibromyalgia (FM) are at increased risk for unemployment. People with FM who remain working experience benefits, including fewer physical and mental health symptoms, higher income, and more social support. To remain working, people with FM may require an altered work situation, such as flexible or reduced hours. Persons with FM should be counselled upon diagnosis to consider which elements of their work may lead to symptom exacerbation or problems with work productivity.

A Comparison of Women With Fibromyalgia Syndrome to Criterion Fitness Standards: A Pilot Study

PURPOSE To compare fitness of women with fibromyalgia syndrome (FMS) aged 50+ with performance standards associated with functional independence in late life. METHODS Data came from a longitudinal study tracking physical and cognitive function of 93 women with FMS and included the most recent symptoms, activity levels, and fitness assessments. RESULTS Most women performed below criterion-referenced fitness standards for all measures. Nearly 90% percent of those < 70 years scored below the standard for lower body strength. Only ~20% of respondents < 70 years old met the criteria for aerobic endurance. A third of those aged over 70 met the standard in agility and dynamic balance. Physical activity was positively associated with fitness performance, while pain and depression symptoms were negatively associated. DISCUSSION High proportions of women with FMS do not meet fitness standards recommended for maintaining physical independence in late life, indicating a risk for disability. Regular fitness assessments and targeted exercise interventions are warranted.