Chiang-Hua Chang

End-Of-Life Care For Medicare Beneficiaries With Cancer Is Highly Intensive Overall And Varies Widely

Studies have shown that cancer care near the end of life is more aggressive than many patients prefer. Using a cohort of deceased Medicare beneficiaries with poor-prognosis cancer, meaning that they were likely to die within a year, we examined the association between hospital characteristics and eleven end-of-life care measures, such as hospice use and hospitalization. Our study revealed a relatively high intensity of care in the last weeks of life. At the same time, there was more than a twofold variation within hospital groups with common features, such as cancer center designation and for-profit status. We found that these hospital characteristics explained little of the observed variation in intensity of end-of-life cancer care and that none reliably predicted a specific pattern of care. These findings raise questions about what factors may be contributing to this variation. They also suggest that best practices in end-of-life cancer care can be found in many settings and that efforts to improve the quality of end-of-life care should include every hospital category.

Has Asthma Medication Use in Children Become More Frequent, More Appropriate, or Both?

Objective. Despite national initiatives to improve asthma medical treatment, the appropriateness of physician prescribing for children with asthma remains unknown. This study measures trends and recent patterns in the pediatric use of medications approved for reversible obstructive airway disease (asthma medications). Design. Population-based longitudinal and cross-sectional analyses. Setting. A nonprofit staff model health maintenance organization located in the Puget Sound area of Washington state. Participants. Children 0 to 17 years of age enrolled continuously during any one of the years from 1984 to 1993 (N = 83 232 in 1993). Primary Outcome Measures. Percent of enrollees filling prescriptions for asthma medications and fill rates by medication class and estimated duration of inhaled antiinflammatory medication use. Results. Between 1984 and 1993, the frequency of asthma medication use increased: the percent of children filling any asthma medication prescription increased from 4.0% to 8.1%, whereas the percent filling an inhaled antiinflammatory inhaler rose from 0.4% to 2.4%. In contrast, the intensity of inhaled antiinflammatory use decreased among users; 37% of users filled more than two inhalers during the year in 1984, and 29% in 1993. In high β-agonist users (filling more than two β-agonist inhalers each quarter per year), the estimated duration of inhaled antiinflammatory use increased slightly from a mean of 4.1 months per year in 1984–1986 to 5.0 months in 1991–1993; estimated duration of use in adolescents 10 to 17 years of age was approximately half that of children 5 to 9 years of age. Conclusions. The proportion of children using asthma medications increased substantially during the study period, but the use of inhaled antiinflammatory medication per patient remained low even for those using large amounts of inhaled β-agonists. These findings suggest that most asthma medications were used by children with mild lower airway symptoms and that inhaled antiinflammatory medication use in children with more severe disease fell short of national guidelines.

Primary Care Physician Workforce and Medicare Beneficiaries’ Health Outcomes

CONTEXT Despite a widespread interest in increasing the numbers of primary care physicians to improve care and to moderate costs, the relationship of the primary care physician workforce to patient-level outcomes remains poorly understood. OBJECTIVE To measure the association between the adult primary care physician workforce and individual patient outcomes. DESIGN, SETTING, AND PARTICIPANTS A cross-sectional analysis of the outcomes of a 2007 20% sample of fee-for-service Medicare beneficiaries aged 65 years or older (N = 5,132,936), which used 2 measures of adult primary care physicians (general internists and family physicians) across Primary Care Service Areas (N = 6542): (1) American Medical Association (AMA) Masterfile nonfederal, office-based physicians per total population and (2) office-based primary care clinical full-time equivalents (FTEs) per Medicare beneficiary derived from Medicare claims. MAIN OUTCOME MEASURES Annual individual-level outcomes (mortality, ambulatory care sensitive condition [ACSC] hospitalizations, and Medicare program spending), adjusted for individual patient characteristics and geographic area variables. RESULTS Marked variation was observed in the primary care physician workforce across areas, but low correlation was observed between the 2 primary care workforce measures (Spearman r = 0.056; P < .001). Compared with areas with the lowest quintile of primary care physician measure using AMA Masterfile counts, beneficiaries in the highest quintile had fewer ACSC hospitalizations (74.90 vs 79.61 per 1000 beneficiaries; relative rate [RR], 0.94; 95% confidence interval [CI], 0.93-0.95), lower mortality (5.38 vs 5.47 per 100 beneficiaries; RR, 0.98; 95% CI, 0.97-0.997), and no significant difference in total Medicare spending (

Geographic Maldistribution of Primary Care for Children

8722 vs

Association of Age, Gender, and Race with Intensity of End-of-Life Care for Medicare Beneficiaries with Cancer

8765 per beneficiary; RR, 1.00; 95% CI, 0.99-1.00). Beneficiaries residing in areas with the highest quintile of primary care clinician FTEs compared with those in the lowest quintile had lower mortality (5.19 vs 5.49 per 100 beneficiaries; RR, 0.95; 95% CI, 0.93-0.96), fewer ACSC hospitalizations (72.53 vs 79.48 per 1000 beneficiaries; RR, 0.91; 95% CI, 0.90-0.92), and higher overall Medicare spending (

Regional Variation in Rates of Low Birth Weight

8857 vs

Health System Characteristics and Rates of Readmission After Acute Myocardial Infarction in the United States

8769 per beneficiary; RR, 1.01; 95% CI, 1.004-1.02). CONCLUSION A higher level of primary care physician workforce, particularly with an FTE measure that may more accurately reflect ambulatory primary care, was generally associated with favorable patient outcomes.

Accessibility of Family Planning Services: Impact of Structural and Organizational Factors

OBJECTIVES: This study examines growth in the primary care physician workforce for children and examines the geographic distribution of the workforce. METHODS: National data were used to calculate the local per-capita supply of clinically active general pediatricians and family physicians, measured at the level of primary care service areas. RESULTS: Between 1996 and 2006, the general pediatrician and family physician workforces expanded by 51% and 35%, respectively, whereas the child population increased by only 9%. The 2006 per-capita supply varied by >600% across local primary care markets. Nearly 15 million children (20% of the US child population) lived in local markets with <710 children per child physician (average of 141 child physicians per 100 000 children), whereas another 15 million lived in areas with >4400 children per child physician (average of 22 child physicians per 100 000 children). In addition, almost 1 million children lived in areas with no local child physician. Nearly all 50 states had evidence of similar extremes of physician maldistribution. CONCLUSIONS: Undirected growth of the aggregate child physician workforce has resulted in profound maldistribution of physician resources. Accountability for public funding of physician training should include efforts to develop, to use, and to evaluate policies aimed at reducing disparities in geographic access to primary care physicians for children.

Geographic Access to Family Planning Facilities and the Risk of Unintended and Teenage Pregnancy

PURPOSE To measure intensity of end-of-life (EOL) care for Medicare cancer patients and variations in care by age, gender, and race. PATIENTS AND METHODS This retrospective cohort analysis of Medicare claims (20% sample) examined 235,821 Medicare Parts A and B fee-for-service patients dying with poor-prognosis cancers between 2003 and 2007. Logistic regression models quantified associations between care intensity and age, gender, and race. Measures included hospitalizations, emergency department (ED) visits, intensive care unit (ICU) admissions, in-hospital deaths, late-life chemotherapy administration, overall and late hospice enrollment within six months of death. RESULTS Within 30 days of death, 61.3% of patients were hospitalized, 10.2% were hospitalized more than once, 10.2% visited an ED more than once, 23.7% had ICU admissions, and 28.8% died in-hospital. Within two weeks of death, 6% received chemotherapy. In their final six months, 55.2% accessed hospice, 15.1% within three days of death. Older age (≥75 versus <75) was associated with lower odds ratios (ORs) of 0.49 to 0.89 for aggressive care, and an OR of 0.92 (95% CI 0.89-0.95) for late hospice enrollment. Female gender was associated with lower ORs (0.82 to 0.86) for aggressive care, and an OR of 0.84 (95% CI 0.81-0.86) for late hospice enrollment. Black (versus nonblack) race was associated with higher ORs (1.08 to 1.38) for aggressive acute care, lower ORs for late chemotherapy, OR 0.76 (95% CI 0.71-0.81), and late hospice enrollment, OR 0.81 (95% CI 0.76-0.86). CONCLUSIONS Seniors dying with poor-prognosis cancer experience high-intensity care with rates varying by age, gender, and race.

Small Geographic Area Variations in Prescription Drug Use

Objective. Low birth weight (LBW; <2500 g) is the result of complex and poorly understood interactions between the biological determinants of the mother and the fetus, the parent’s socioeconomic status, and medical care. After controlling for these established risk factors, the extent of regional variation in LBW rates remains unknown. This study measures regional variation in LBW rates and identifies regions of neonatal health services with significantly high or low adjusted rates. Methods. Linking the United States 1998 singleton birth cohort (N = 3.8 million) with county and health care characteristics, we conducted a small area analysis of LBW across 246 regions of neonatal health services. We measured observed rates and then used a multivariable, hierarchical model to estimate adjusted LBW rates by regions. We then stratified these rates by race for the 208 regions with adequate sample size. Results. Observed LBW rates varied across regions from 3.8 to 10.6 per 100 live births (interquartile range: 5.0–6.8 [25th–75th percentile]; median: 5.9). After controlling for known maternal and area risk factors, 67 (27.0%) regions had rates significantly below and 98 (39.8%) regions had rates significantly higher than the national rate of 6.0 per 100 live births. Although black mothers were more likely to give birth to an LBW newborn, regional adjusted rates still varied >3-fold within both black and nonblack subgroups. Conclusions. After controlling for known maternal and area risk factors, LBW rates markedly varied across US regions of neonatal health services for both black and nonblack mothers. Additional analyses of these regions may provide opportunities for regional accountability in pregnancy outcomes, LBW research, and targeted improvement interventions, especially in high-risk populations.