David M. Carlisle

What Is the Concordance Between the Medical Record and Patient Self-Report as Data Sources for Ambulatory Care?

Background:The validity of quality of care assessments relies upon data quality, yet little is known about the relative completeness and validity of data sources for evaluating the quality of care. Objectives:We evaluated concordance between ambulatory medical record and patient survey data. Levels of concordance, variations by type of item, sources of disagreement between data sources, and implications for quality of care assessment efforts are discussed. Design and Subjects:This was an observational study that included 1270 patients sampled from 39 West Coast medical organizations with at least 1 of the following: diabetes, ischemic heart disease, asthma or chronic obstructive pulmonary disease, or low back pain. Measures:Items from both data sources were grouped into 4 conceptual domains: diagnosis, clinical services delivered, counseling and referral, and medication use. We present total agreement, kappa, sensitivity, and specificity at the item and domain-levels and for all items combined. Results:We found good concordance between survey and medical records overall, but there was substantial variation within and across domains. The worst concordance was in the counseling and referrals domain, the best in the medication use domain. Patients were able to report with good sensitivity on memorable items. Conclusions:Quality ratings are likely to vary in differing directions, depending on the data source used. The most appropriate data source for analyses of components of and overall quality of care must be considered in light of study objectives and resources. We recommend data collection from multiple sources to most accurately portray the patient and provider experience of medical care.

Racial and ethnic disparities in the use of cardiovascular procedures: associations with type of health insurance.

OBJECTIVES This study examined whether disparities in the use of cardiovascular procedures exist among African Americans, Latinos, and Asians relative to White patients, within health insurance categories. METHODS Hospital discharge records (n = 104,952) of Los Angeles Country, California, residents with possible coronary artery disease were analyzed. RESULTS After adjustment for confounders, lower odds of procedure use were found for African American and Latino patients for most types of insurance. Asians and Pacific Islanders had odds of procedure use similar to those of White patients. Disparities were absent among the privately insured. CONCLUSIONS Racial and ethnic disparities in procedure rates were evident in all types of insurance except private insurance.

Racial and ethnic differences in the use of invasive cardiac procedures among cardiac patients in Los Angeles County, 1986 through 1988.

OBJECTIVES The purpose of the study was to compare use of invasive cardiovascular procedures among Latino, Asian, African-American, and White patients. METHODS In a cross-sectional study of hospital discharge data, multiple logistic regression was used to model use of coronary artery angiography, bypass graft surgery, and angioplasty among adult Los Angeles County residents discharged from California hospitals between 1986 and 1988 with primary diagnoses consistent with possible ischemic heart disease. RESULTS After potential demographic, socioeconomic, and clinical confounders, including hospital procedure volume, were controlled, Latinos were less likely than Whites to undergo angiography (odds ratio [OR] = 0.90) and bypass graft surgery (OR = 0.87). African Americans were less likely to receive bypass graft surgery (OR = 0.62) and angioplasty (OR = 0.80). Asians were as likely as Whites to receive each procedure. The impact of adjustment for hospital procedure volume was greater for Latinos and Asians than for African Americans. CONCLUSIONS Administrative data suggest that disparities in use of invasive cardiovascular procedures are not limited to African Americans. Hospital procedure volume appears to be an important factor related to such disparities. The causes of racial/ethnic differences in reported procedure rates remain unclear.

Influence of Payor on Use of Invasive Cardiac Procedures and Patient Outcome After Myocardial Infarction in the United States

OBJECTIVES We sought to determine the influence of payor status on the use and appropriateness of cardiac procedures. BACKGROUND The use of invasive procedures affects the cost of cardiovascular care and may be influenced by payor status. METHODS We compared treatment and outcomes of myocardial infarction among four payor groups: fee for service (FFS), health maintenance organization (HMO), Medicaid and uninsured. Multivariate comparison was performed on the use of invasive cardiac procedures, length of hospital stay and in-hospital mortality in 17,600 patients <65 years old enrolled in the National Registry of Myocardial Infarction from June 1994 to October 1995. To determine the appropriateness of coronary angiography, we compared its use in patients at low and high risk for cardiac events. RESULTS Angiography was performed in 86% of FFS, 80% of HMO, 61% of Medicaid and 75% of uninsured patients. FFS patients were more likely to undergo angiography than HMO (odds ratio [OR] 1.27, 95% confidence interval [CI] 1.13 to 1.42), Medicaid (OR 2.43, 95% CI 2.11 to 2.81) and uninsured patients (OR 1.99, 95% CI 1.76 to 2.25). Similar patterns for the use of coronary revascularization were found. Among those at low risk, FFS patients were as likely to undergo angiography as HMO patients but more likely than Medicaid and uninsured patients. For those at high risk, FFS patients were more likely to undergo angiography than patients in other payor groups. Adjusted mean length of stay (7.3 days) was similar among all payor groups, but adjusted mortality was higher in the Medicaid group (Medicaid vs. FFS: OR 1.55, 95% CI 1.19 to 2.01). CONCLUSIONS Payor status is associated with the use and appropriateness of invasive cardiac procedures but not length of hospital stay after myocardial infarction. The higher in-hospital mortality in the Medicaid cohort merits further study.

HMO vs fee-for-service care of older persons with acute myocardial infarction.

OBJECTIVES Health maintenance organizations (HMOs) continue to grow in number and in their enrollment of Medicare recipients. They are also increasingly viewed as organizational structures that might contribute to control of health care costs. Yet little is known about the quality of care that elderly HMO enrollees receive. METHODS We compared patients from three HMOs to a fee-for-service (FFS) sample that was national in scope. Sickness at admission, the quality of process of care, and mortality were assessed for patients aged 65 years and older who had been hospitalized with a diagnosis of acute myocardial infarction. RESULTS After adjustment for sickness at admission, there were no significant mortality differences between the HMO and FFS groups at either 30 (23.2% vs 23.5%) or 180 days (34.4% vs 34.5%) after admission. Compliance with process criteria was higher for the HMO group as a whole (P < .05). The HMOs had greater compliance with three of five scales measuring different aspects of care for patients with acute myocardial infarction. CONCLUSIONS We conclude that older patients from our participating HMOs who were hospitalized for acute myocardial infarction received hospital care that was generally better in terms of process than that received by patients in a national FFS sample.

Administrative versus clinical data for coronary artery bypass graft surgery report cards: the view from California.

Objective:The objective of this study was to compare the performance of a risk model for isolated coronary artery bypass graft (CABG) surgery based on administrative data with that of a clinical risk model in predicting mortality and identifying hospital performance outliers. Methods:Clinical data records from the California CABG Mortality Reporting Program for 38,230 isolated CABG patients undergoing surgery in 2000–2001 were linked to records in the California patient discharge data (PDD) abstract. Risk factors based on administrative data that mirrored clinical risk factors were developed using the condition present at admission indicator in the PDD to separate preoperative acute conditions from complications of surgery. Using logistic regression, risk model performance across data sources was compared along with hospital risk-adjusted mortality ranks and quality ratings. Results:The administrative data showed lower prevalence of risk factors when compared with the clinical data. The clinical risk model had somewhat better discrimination (C = 0.824) than the administrative model (C = 0.799). The clinical model yielded 17 outliers and the administrative model 16 with agreement on 12 hospitals’ status. Performance of the administrative risk model was minimally affected by removal of information from prior admissions and removal of risk factors not confirmed in the clinical record. Conclusions:Unique properties of the California administrative data, including the ability to distinguish acute preoperative risk factors from complications of surgery, permitted construction of an administrative risk model that predicts mortality on par with most published clinical models. Despite this, the administrative model identified slightly different hospital outliers, which may indicate somewhat biased assessments of hospital patient risk.

Cash and Compassion: Profit Status and the Delivery of Hospice Services

OBJECTIVES To evaluate the relationship of hospice profit status to patient selection and service delivery. DESIGN We analyzed responses to the 1997 California Office of Statewide Health Planning and Development (OSHPD) annual home care and hospice survey. Outcomes included the percentages of patients with noncancer diagnoses, referred from long-term care, and with government payers; average length of stay (LOS); the intensity and skill mix of nursing services; and potential availability of chemotherapy and radiotherapy. Reduced models controlled for facility type, profit status, urbanicity, and patient-days. Complete models additionally controlled for patient gender, age, race/ethnicity, diagnosis, referral source, and primary reimbursement source. PARTICIPANTS All 176 licensed California hospices in 1997. RESULTS We report comparisons of for-profit and not-for-profit hospices as the absolute difference in percentage points between outcomes (e.g., a difference of 40% vs. 50% is reported as a 10 percentage point difference). In reduced models, for-profit hospices reported 17 percentage points more discharges with noncancer diagnoses, 15 percentage points more long-term care referrals, and 8 percentage points more patients with government payers. Average LOS did not differ by profit status. In reduced models, for-profit hospices delivered 0.20 more daily nursing visits on average; this difference was attributable to patient characteristics. The ratio of skilled to total nursing visits was 11 percentage points lower for for-profit hospices compared to not-for-profit hospices in reduced models (7 in complete models). Profit status was unrelated to the potential availability of chemotherapy and radiotherapy. CONCLUSION For-profit hospices compared to not-for profit hospices serve a higher percentage of persons with noncancer diagnoses, residents of long-term care, and persons with government insurance. Differences in patterns of nursing services among hospices were related to patient characteristics. The potential availability of complex palliative services did not differ by profit status.

The effect of hospital experience on mortality among patients hospitalized with acquired immunodeficiency syndrome in California

BACKGROUND Several studies in the 1980s suggested that mortality rates for patients hospitalized with the acquired immunodeficiency syndrome (AIDS) were lower in hospitals that cared for greater numbers of AIDS patients. We sought to determine whether this observation persisted in the mid-1990s in California. SUBJECTS AND METHODS We performed an analysis of hospital discharge data for 7,901 adults discharged with human immunodeficiency virus (HIV) or AIDS-related diagnoses from all acute care hospitals (n = 333) in California during 1994. The main outcome measure was in-hospital mortality, adjusted for severity of illness, comorbidity, prior hospitalizations, and other patient and hospital characteristics. RESULTS Among 7,901 persons hospitalized with AIDS, the unadjusted inpatient mortality was 9.0%. The adjusted mortality rate varied significantly (P <0.0001) from 12.4% among institutions with the lowest quartile of AIDS experience to 10.3%, 6.3%, and 7.6% by quartile of greater AIDS experience. Increasing severity of illness, comorbidity, and previous hospitalizations were also significant predictors of increased mortality. Sex, race, and insurance status were not associated with hospital mortality. CONCLUSIONS Hospital mortality for AIDS patients was greater among less experienced hospitals. The difference in mortality rate was equivalent to more than four additional deaths per 100 patients with AIDS admitted to the least experienced hospitals. This finding was not explained by severity of illness, comorbidity, or other case-mix variables.

Underuse and Overuse of Diagnostic Testing for Coronary Artery Disease in Patients Presenting with New-Onset Chest Pain

PURPOSE To determine the extent of overuse and underuse of diagnostic testing for coronary artery disease and whether the socioeconomic status, health insurance, gender, and race/ethnicity of a patient influences the use of diagnostic tests. SUBJECTS AND METHODS We identified patients who presented with new-onset chest pain not due to myocardial infarction at one of five Los Angeles-area hospital emergency departments between October 1994 and April 1996. Explicit criteria for diagnostic testing were developed using the RAND/University of California, Los Angeles, expert panel method. They were applied to data collected by medical record review and patient questionnaire. RESULTS Of the 356 patients, 181 met necessity criteria for diagnostic cardiac testing. Of these, 40 (22%) failed to receive necessary tests. Only 7 (3%) of the 215 patients who received some form of cardiac testing had tests that were judged to be inappropriate. Underuse was significantly more common in patients with only a high school education (30% vs 15% for those with some college, P = 0.02) and those without health insurance (34% vs 15% of insured patients, P = 0.01). In a multivariate logistic regression model, only the lack of a post-high school education was a significant predictor of underuse (odds ratio 2.2, 95% confidence interval 1.0 to 4.4). CONCLUSION Among patients with new-onset chest pain, underuse of diagnostic testing for coronary artery disease was much more common than overuse. Underuse was primarily associated with lower levels of patient education.

Impact of Public Reporting on Access to Coronary Artery Bypass Surgery: The California Outcomes Reporting Program

BACKGROUND California launched the coronary artery bypass graft surgery (CABG) Outcomes Reporting Program in 2003 for all nonfederal hospitals performing this procedure. The program provides annual public reports of risk-adjusted operative mortality rates by hospital and surgeon. However, the impact of this program on operative mortality and access to surgery for high-risk patients has not been clarified. METHODS The cohort consisted of all isolated CABG cases from the California CABG Outcomes Reporting Program database for 2003 and 2006. We applied the same multivariable logistic risk adjustment model to each year to compute predicted and risk-adjusted operative mortality for isolated CABG by hospital and surgeons. Changes in surgical volume and observed, predicted, and risk-adjusted operative mortality were compared by quintiles of patients based on the predicted risk and among hospitals and surgeons between 2003 and 2006. RESULTS Total volume of isolated CABG decreased by 26.5% from 2003 (N=21,276) to 2006 (N=15,647). The reduction in CABG volume between 2003 and 2006 was universal among hospitals and surgeons regardless of their performance status in 2003. The change in patient case mix for a majority of hospitals and surgeons was insignificant, and overall patient risk was stable (statewide predicted operative mortality rate for 2003, 3.06%; 95% confidence interval, 2.98 to 3.13; and for 2006, 3.05%; 95% confidence interval, 2.97 to 3.14). Yet, the statewide observed mortality declined from 2.90% in 2003 to 2.22% in 2006 (p=0.0001). Overall, the empiric odds ratio of operative death for 2006 patients was 24% lower than for 2003 patients. In 2006, patients with the highest predicted operative mortality risk (4th and 5th quintiles) had 35% and 26% lower odds of operative mortality, respectively, when compared with patients from 2003. CONCLUSIONS Although total CABG volume decreased from 2003 to 2006 by almost 27%, patient case mix for most hospitals and surgeons was unchanged. Despite similar patient characteristics, the operative mortality for patients in the highest risk group was 26% lower in 2006 than in 2003. We found no evidence of decreased access to CABG for high-risk patients in California during the period of public reporting of isolated CABG outcomes.