Elizabeth A. McGlynn

Depression and Medication Adherence in the Treatment of Chronic Diseases in the United States: A Meta-Analysis

ObjectiveTo conduct a meta-analysis of the association between depression and medication adherence among patients with chronic diseases. Poor medication adherence may result in worse outcomes and higher costs than if patients fully adhere to their medication regimens.Data SourcesWe searched the PubMed and PsycINFO databases, conducted forward searches for articles that cited major review articles, and examined the reference lists of relevant articles.Study Eligibility Criteria, Participants, and InterventionsWe included studies on adults in the United States that reported bivariate relationships between depression and medication adherence. We excluded studies on special populations (e.g., substance abusers) that were not representative of the general adult population with chronic diseases, studies on certain diseases (e.g., HIV) that required special adherence protocols, and studies on interventions for medication adherence.Study Appraisal and Synthesis MethodsData abstracted included the study population, the protocol, measures of depression and adherence, and the quantitative association between depression and medication adherence. Synthesis of the data followed established statistical procedures for meta-analysis.ResultsThe estimated odds of a depressed patient being non-adherent are 1.76 times the odds of a non-depressed patient, across 31 studies and 18,245 participants. The association was similar across disease types but was not as strong among studies that used pharmacy records compared to self-report and electronic cap measures.LimitationsThe meta-analysis results are correlations limiting causal inferences, and there is some heterogeneity among the studies in participant characteristics, diseases studied, and methods used.ConclusionsThis analysis provides evidence that depression is associated with poor adherence to medication across a range of chronic diseases, and we find a new potential effect of adherence measurement type on this relationship. Although this study cannot assess causality, it supports the importance that must be placed on depression in studies that assess adherence and attempt to improve it.

CareTrack: Assessing the appropriateness of health care delivery in Australia

Objective: To determine the percentage of health care encounters at which a sample of adult Australians received appropriate care (ie, care in line with evidence‐based or consensus‐based guidelines).

Associations Between Physician Characteristics and Quality of Care

BACKGROUNDnInformation on physicians performance on measures of clinical quality is rarely available to patients. Instead, patients are encouraged to select physicians on the basis of characteristics such as education, board certification, and malpractice history. In a large sample of Massachusetts physicians, we examined the relationship between physician characteristics and performance on a broad range of quality measures.nnnMETHODSnWe calculated overall performance scores on 124 quality measures from RANDs Quality Assessment Tools for each of 10,408 Massachusetts physicians using claims generated by 1.13 million adult patients. The patients were continuously enrolled in 1 of 4 Massachusetts commercial health plans from 2004 to 2005. Physician characteristics were obtained from the Massachusetts Board of Registration in Medicine. Associations between physician characteristics and overall performance scores were assessed using multivariate linear regression.nnnRESULTSnThe mean overall performance score was 62.5% (5th to 95th percentile range, 48.2%-74.9%). Three physician characteristics were independently associated with significantly higher overall performance: female sex (1.6 percentage points higher than male sex; P < .001), board certification (3.3 percentage points higher than noncertified; P < .001), and graduation from a domestic medical school (1.0 percentage points higher than international; P < .001). There was no significant association between performance and malpractice claims (P = .26).nnnCONCLUSIONSnFew characteristics of individual physicians were associated with higher performance on measures of quality, and observed associations were small in magnitude. Publicly available characteristics of individual physicians are poor proxies for performance on clinical quality measures.

Focus Groups Highlight That Many Patients Object To Clinicians’ Focusing On Costs

Having patients weigh costs when making medical decisions has been proposed as a way to rein in health care spending. We convened twenty-two focus groups of people with insurance to examine their willingness to discuss health care costs with clinicians and consider costs when deciding among nearly comparable clinical options. We identified the following four barriers to patients taking cost into account: a preference for what they perceive as the best care, regardless of expense; inexperience with making trade-offs between health and money; a lack of interest in costs borne by insurers and society as a whole; and noncooperative behavior characteristic of a commons dilemma, in which people act in their own self-interest although they recognize that by doing so, they are depleting limited resources. Surmounting these barriers will require new research in patient education, comprehensive efforts to shift public attitudes about health care costs, and training to prepare clinicians to discuss costs with their patients.

Physicians With The Least Experience Have Higher Cost Profiles Than Do Physicians With The Most Experience

Health plans and Medicare are using cost profiles to identify which physicians account for more health care spending than others. By identifying the costliest physicians, health plans and Medicare hope to craft policy interventions to reduce total health care spending. To identify which physician types, if any, might be costlier than others, we analyzed cost profiles created from health plan claims for physicians in Massachusetts. We found that physicians with fewer than ten years of experience had 13.2 percent higher overall costs than physicians with forty or more years of experience. We found no association between costs and other physician characteristics, such as having had malpractice claims or disciplinary actions, board certification status, and the size of the group in which the physician practices. Although winners and losers are inevitable in any cost-profiling effort, physicians with less experience are more likely to be negatively affected by policies that use cost profiles, unless they change their practice patterns. For example, these physicians could be excluded from high-value networks or receive lower payments under Medicares planned value-based payment program. We cannot fully explain the mechanism by which more-experienced physicians have lower costs, but our results suggest that the more costly practice style of newly trained physicians may be a driver of rising health care costs overall.

Developing a data infrastructure for a learning health system: the PORTAL network

The Kaiser Permanente & Strategic Partners Patient Outcomes Research To Advance Learning (PORTAL) network engages four healthcare delivery systems (Kaiser Permanente, Group Health Cooperative, HealthPartners, and Denver Health) and their affiliated research centers to create a new national network infrastructure that builds on existing relationships among these institutions. PORTAL is enhancing its current capabilities by expanding the scope of the common data model, paying particular attention to incorporating patient-reported data more systematically, implementing new multi-site data governance procedures, and integrating the PCORnet PopMedNet platform across our research centers. PORTAL is partnering with clinical research and patient experts to create cohorts of patients with a common diagnosis (colorectal cancer), a rare diagnosis (adolescents and adults with severe congenital heart disease), and adults who are overweight or obese, including those with pre-diabetes or diabetes, to conduct large-scale observational comparative effectiveness research and pragmatic clinical trials across diverse clinical care settings.

Exploring public attitudes towards approaches to discussing costs in the clinical encounter.

ABSTRACTBACKGROUNDPatients’ willingness to discuss costs of treatment alternatives with their physicians is uncertain.OBJECTIVETo explore public attitudes toward doctor–patient discussions of insurer and out-of-pocket costs and to examine whether several possible communication strategies might enhance patient receptivity to discussing costs with their physicians.DESIGNFocus group discussions and pre-discussion and post-discussion questionnaires.PARTICIPANTSTwo hundred and eleven insured individuals with mean age of 48xa0years, 51xa0% female, 34xa0% African American, 27xa0% Latino, and 50xa0% with incomes below 300xa0% of the federal poverty threshold, participated in 22 focus groups in Santa Monica, CA and in the Washington, DC metro area.MAIN MEASUREMENTSAttitudes toward discussing out-of-pocket and insurer costs with physicians, and towards physicians’ role in controlling costs; receptivity toward recommended communication strategies regarding costs.KEY RESULTSParticipants expressed more willingness to talk to doctors about personal costs than insurer costs. Older participants and sicker participants were more willing to talk to the doctor about all costs than younger and healthier participants (ORu2009=u20091.8, pu2009=u20090.004; ORu2009=u20091.6, pu2009=u20090.027 respectively). Participants who face cost-related barriers to accessing health care were in greater agreement than others that doctors should play a role in reducing out-of-pocket costs (ORu2009=u20092.4, pu2009=u20090.011). Participants did not endorse recommended communication strategies for discussing costs in the clinical encounter. In contrast, participants stated that trust in one’s physician would enhance their willingness to discuss costs. Perceived impediments to discussing costs included rushed, impersonal visits, and clinicians who are insufficiently informed about costs.CONCLUSIONSThis study suggests that trusting relationships may be more conducive than any particular discussion strategy to facilitating doctor–patient discussions of health care costs. Better public understanding of how medical decisions affect insurer costs and how such costs ultimately affect patients personally will be necessary if discussions about insurer costs are to occur in the clinical encounter.

Quality measures to assess care transitions for hospitalized children

BACKGROUND: Transitions between sites of care are inherent to all hospitalizations, yet we lack pediatric-specific transitions-of-care quality measures. We describe the development and validation of new transitions-of-care quality measures obtained from medical record data. METHODS: After an evidence review, a multistakeholder panel prioritized quality measures by using the RAND/University of California, Los Angeles modified Delphi method. Three measures were endorsed, operationalized, and field-tested at 3 children’s hospitals and 2 community hospitals: quality of hospital-to-home transition record content, timeliness of discharge communication between inpatient and outpatient providers, and ICU-to-floor transition note quality. Summary scores were calculated on a scale from 0 to 100; higher scores indicated better quality. We examined between-hospital variation in scores, associations of hospital-to-home transition quality scores with readmission and emergency department return visit rates, and associations of ICU-to-floor transition quality scores with ICU readmission and length of stay. RESULTS: A total of 927 charts from 5 hospitals were reviewed. Mean quality scores were 65.5 (SD 18.1) for the hospital-to-home transition record measure, 33.3 (SD 47.1) for the discharge communication measure, and 64.9 (SD 47.1) for the ICU-to-floor transition measure. The mean adjusted hospital-to-home transition summary score was 61.2 (SD 17.1), with significant variation in scores between hospitals (P < .001). Hospital-to-home transition quality scores were not associated with readmissions or emergency department return visits. ICU-to-floor transition note quality scores were not associated with ICU readmissions or hospital length of stay. CONCLUSIONS: These quality measures were feasible to implement in diverse settings and varied across hospitals. The development of these measures is an important step toward standardized evaluation of the quality of pediatric transitional care.

Cost Implications to Health Care Payers of Improving Glucose Management among Adults with Type 2 Diabetes

Objective. To assess the cost implications to payers of improving glucose management among adults with type 2 diabetes. Data Source/Study Setting. Medical-record data from the Community Quality Index (CQI) study (1996-2002), pharmaceutical claims from four Massachusetts health plans (2004-2006), Medicare Fee Schedule (2009), published literature. Study Design. Probability tree depicting glucose management over 1 year. Data Collection/Extraction Methods. We determined how frequently CQI study subjects received recommended care processes and attained Health Care Effectiveness Data and Information Set (HEDIS) treatment goals, estimated utilization of visits and medications associated with recommended care, assigned costs based on utilization, and then modeled how hospitalization rates, costs, and goal attainment would change if all recommended care was provided. Principal Findings. Relative to current care, improved glucose management would cost U.S.

Using Medicaid and CHIP Claims Data to Support Pediatric Quality Measurement: Lessons From 3 Centers of Excellence in Measure Development

327 (U.S.