Denise L. Anthony

Are Regional Variations in End-of-Life Care Intensity Explained by Patient Preferences?: A Study of the US Medicare Population

Objective:We sought to test whether variations across regions in end-of-life (EOL) treatment intensity are associated with regional differences in patient preferences for EOL care. Research Design:Dual-language (English/Spanish) survey conducted March to October 2005, either by mail or computer-assisted telephone questionnaire, among a probability sample of 3480 Medicare part A and/or B eligible beneficiaries in the 20% denominator file, age 65 or older on July 1, 2003. Data collected included demographics, health status, and general preferences for medical care in the event the respondent had a serious illness and less than 1 year to live. EOL concerns and preferences were regressed on hospital referral region EOL spending, a validated measure of treatment intensity. Results:A total of 2515 Medicare beneficiaries completed the survey (65% response rate). In analyses adjusted for age, sex, race/ethnicity, education, financial strain, and health status, there were no differences by spending in concern about getting too little treatment (39.6% in lowest spending quintile, Q1; 41.2% in highest, Q5; P value for trend, 0.637) or too much treatment (44.2% Q1, 45.1% Q5; P = 0.797) at the end of life, preference for spending their last days in a hospital (8.4% Q1, 8.5% Q5; P = 0.965), for potentially life-prolonging drugs that made them feel worse all the time (14.4% Q1, 16.5% Q5; P = 0.326), for palliative drugs, even if they might be life-shortening (77.7% Q1, 73.4% Q5; P = 0.138), for mechanical ventilation if it would extend their life by 1 month (21% Q1, 21.4% Q5; P = 0.870) or by 1 week (12.1% Q1, 11.7%; P = 0.875). Conclusions:Medicare beneficiaries generally prefer treatment focused on palliation rather than life-extension. Differences in preferences are unlikely to explain regional variations in EOL spending.

Trusted paths for browsers

Computer security protocols usually terminate in a computer; however, the human-based services which they support usually terminate in a human. The gap between the human and the computer creates potential for security problems. We examine this gap, as it is manifested in secure Web servers. Felten et al. demonstrated the potential, in 1996, for malicious servers to impersonate honest servers. In this paper, we show how malicious servers can still do this---and can also forge the existence of an SSL session and the contents of the alleged server certificate. We then consider how to systematically defend against Web spoofing, by creating a trusted path from the browser to the human user. We present potential designs, propose a new one, prototype it in open-source Mozilla, and demonstrate its effectiveness via user studies.

Privacy in Location-Aware Computing Environments

This study explores how privacy preferences vary with place and social context. These findings are useful for designing privacy policies and user interfaces for pervasive computing.

Continuity of Care and the Risk of Preventable Hospitalization in Older Adults

IMPORTANCE Preventable hospitalizations are common among older adults for reasons that are not well understood. OBJECTIVE To determine whether Medicare patients with ambulatory visit patterns indicating higher continuity of care have a lower risk of preventable hospitalization. DESIGN Retrospective cohort study. SETTING Ambulatory visits and hospital admissions. PARTICIPANTS Continuously enrolled fee-for-service Medicare beneficiaries older than 65 years with at least 4 ambulatory visits in 2008. EXPOSURES The concentration of patient visits with physicians measured for up to 24 months using the continuity of care score and usual provider continuity score on a scale from 0 to 1. MAIN OUTCOMES AND MEASURES Index occurrence of any 1 of 13 preventable hospital admissions, censoring patients at the end of their 24-month follow-up period if no preventable hospital admissions occurred, or if they died. RESULTS Of the 3,276,635 eligible patients, 12.6% had a preventable hospitalization during their 2-year observation period, most commonly for congestive heart failure (25%), bacterial pneumonia (22.7%), urinary infection (14.9%), or chronic obstructive pulmonary disease (12.5%). After adjustment for patient baseline characteristics and market-level factors, a 0.1 increase in continuity of care according to either continuity metric was associated with about a 2% lower rate of preventable hospitalization (continuity of care score hazard ratio [HR], 0.98 [95% CI, 0.98-0.99; usual provider continuity score HR, 0.98 [95% CI, 0.98-0.98). Continuity of care was not related to mortality rates. CONCLUSIONS AND RELEVANCE Among fee-for-service Medicare beneficiaries older than 65 years, higher continuity of ambulatory care is associated with a lower rate of preventable hospitalization.

Gender and Cooperation: Explaining Loan Repayment in Micro-Credit Groups*

Does gender affect cooperation? In this paper we analyze the effects of gender and group gender composition on prosocial behavior. We make two competing predictions: one based on literature suggesting that women are more cooperative than men, the other building on research regarding the effect of expectations on behavior. Using data drawn from micro-credit borrowing groups, we find that gender composition, not gender per se, is correlated with the likelihood that individuals will default on loan payments. The findings suggest that behavior which might appear to be a consequence of inherent gender differences more likely results from expectations associated with group gender composition. Are women more cooperative than men? Observation suggests that they may be. At a minimum, people expect to see differences, but the evidence is decidedly mixed. Some studies find that women cooperate more than men; others find that they cooperate less. Still other research suggests that it is not gender itself that affects behavior; rather, the composition of groups accounts for differences in cooperation levels. In the present study we provide new data regarding this issue, with a focus on cooperation in micro-credit borrowing groups. We distinguish between gender and the gender composition of these groups to evaluate their effects on one kind of cooperative behavior, the repayment of loans.

Medication administration quality and health information technology: a national study of US hospitals

OBJECTIVE To determine whether the use of computerized physician order entry (CPOE) and electronic medication administration records (eMAR) is associated with better quality of medication administration at medium-to-large acute-care hospitals. DATA/STUDY SETTING: A retrospective cross-sectional analysis of data from three sources: CPOE/eMAR usage from HIMSS Analytics (2010), medication quality scores from CMS Hospital Compare (2010), and hospital characteristics from CMS Acute Inpatient Prospective Payment System (2009). The analysis focused on 11 quality indicators (January-December 2009) at 2603 medium-to-large (≥ 100 beds), non-federal acute-care hospitals measuring proportion of eligible patients given (or prescribed) recommended medications for conditions, including acute myocardial infarction, heart failure, and pneumonia, and surgical care improvement. Using technology adoption by 2008 as reference, hospitals were coded: (1) eMAR-only adopters (n=986); (2) CPOE-only adopters (n=115); and (3) adopters of both technologies (n=804); with non-adopters of both technologies as reference group (n=698). Hospitals were also coded for duration of use in 2-year increments since technology adoption. Hospital characteristics, historical measure-specific patient volume, and propensity scores for technology adoption were used to control for confounding factors. The analysis was performed using a generalized linear model (logit link and binomial family). PRINCIPAL FINDINGS Relative to non-adopters of both eMAR and CPOE, the odds of adherence to all measures (except one) were higher by 14-29% for eMAR-only hospitals and by 13-38% for hospitals with both technologies, translating to a marginal increase of 0.4-2.0 percentage points. Further, each additional 2 years of technology use was associated with 6-15% higher odds of compliance on all medication measures for eMAR-only hospitals and users of both technologies. CONCLUSIONS Implementation and duration of use of health information technologies are associated with improved adherence to medication guidelines at US hospitals. The benefits are evident for adoption of eMAR systems alone and in combination with CPOE.

Rational Rhetoric in Politics: The Debate Over Ratifying the U.S. Constitution

During the debate over ratifying the U.S. Constitution, both the Federalists and the Anti-Federalists offered inconsistent arguments. They violated principles of transitivity (e.g., statements such as “A furthers B” and “B furthers C” coexist with the statement “A hinders C”). Using cognitive mapping to extract the network of causal assertions offered during the debate, and transaction resource theory to identify game-theoretic structures in these maps, including coordination, bargaining, and social dilemma games, we find that violations of transitivity have only two sources. They arise in bargaining games, where concessions not only entail costs but also reduce the prospect for a costly conflict, and social dilemmas, where cooperation not only entails individual costs but also increases the amount of public good produced. Thus conflicting valuations of concessions and cooperation generate an ambivalence that is reflected in transitivity violations. Hence these violations serve as markers within the maps that indicate the presence of either bargaining games or social dilemmas. These games also reflect situations in which debaters have incentives to engage in strategic manipulation of information.

Older Patients Perceptions of “Unnecessary” Tests and Referrals: A National Survey of Medicare Beneficiaries

ContextUnnecessary exposure to medical interventions can harm patients. Many hope that generalist physicians can limit such unnecessary exposure.ObjectiveTo assess older Americans’ perceptions of the need for tests and referrals that their personal physician deemed unnecessary.DesignTelephone survey with mail follow-up in English and Spanish, conducted from May to September 2005 (overall response rate 62%).Study ParticipantsNationally representative sample of 2,847 community-dwelling Medicare beneficiaries. Main analyses focus on the 2,319 who had a personal doctor (“one you would see for a check-up or advice if you were sick”) whom they described as a generalist (“doctor who treats many different kinds of problems”).Main Outcome MeasureProportion of respondents wanting a test or referral that their generalist suggested was not necessary using 2 clinical vignettes (cough persisting 1 week after other flu symptoms; mild but definite chest pain lasting 1 week).ResultsEighty-two percent of Medicare beneficiaries had a generalist physician; almost all (97%) saw their generalist at least once in the past year. Among those with a generalist, 79% believed that it is “better for a patient to have one general doctor who manages most of their medical problems” than to have each problem cared for by a specialist. Nevertheless, when faced with new symptoms, many would want tests and referrals that their doctor did not think necessary. For a cough persisting 1 week after flu symptoms, 34% would want to see a lung specialist even if their generalist told them they “probably did not need to see a specialist but could if they wanted to.” For 1 week of mild but definite chest pain when walking up stairs, 55% would want to see a heart specialist even if their generalist did not think it necessary. In these same scenarios, even higher proportions would want diagnostic testing; 57% would want a chest x-ray for the cough, and 74% would want “special tests” for the chest pain.ConclusionsWhen faced with new symptoms, many older patients report that they would want a diagnostic test or specialty referral that their generalist thought was unnecessary. Generalists striving to provide patient-centered care while at the same time limiting exposure to unnecessary medical interventions will need to address their patients’ perceptions regarding the need for these services.

Institutionalizing HIPAA Compliance Organizations and Competing Logics in U.S. Health Care

Health care in the United States is highly regulated, yet compliance with regulations is variable. For example, compliance with two rules for securing electronic health information in the 1996 Health Insurance Portability and Accountability Act took longer than expected and was highly uneven across U.S. hospitals. We analyzed 3,321 medium and large hospitals using data from the 2003 Health Information and Management Systems Society Analytics Database. We find that organizational strategies and institutional environments influence hospital compliance, and further that institutional logics moderate the effect of some strategies, indicating the interplay of regulation, institutions, and organizations that contribute to the extensive variation that characterizes the U.S. health care system. Understanding whether and how health care organizations like hospitals respond to new regulation has important implications both for creating desired health care reform and for medical sociologists interested in the changing organizational structure of health care.

Negotiating stigma in health care: disclosure and the role of electronic health records

The implementation of electronic health records facilitates information sharing which can create challenges for stigma management and disclosure during the clinical encounter. Building on theories of stigma management, we analysed 30 in-depth interviews of sexual minority men in the USA to explore how they perceived the role of electronic health records in the clinical encounter in general and for disclosure in particular. Participants expressed concerns about privacy but also saw potential benefits to electronic health records. Similarly, while some thought electronic health records improved communication with providers, others experienced the electronic health record as a barrier to open and trusting communication. New information technologies are changing health-care encounters, but present a double-edged sword that underscores the challenge of negotiating health care for stigmatised individuals. It remains to be seen if information technology will enhance care for all or further alienate already apprehensive health seekers from disclosing personal health information.