Elizabeth M. Sloss

The Vulnerable Elders Survey: A Tool for Identifying Vulnerable Older People in the Community

OBJECTIVES: To develop a simple method for identifying community‐dwelling vulnerable older people, defined as persons age 65 and older at increased risk of death or functional decline. To assess whether self‐reported diagnoses and conditions add predictive ability to a function‐based survey.

Selecting Target Conditions for Quality of Care Improvement in Vulnerable Older Adults

OBJECTIVE: To identify a set of geriatric conditions as optimal targets for quality improvement to be used in a quality measurement system for vulnerable older adults.

Comparing VA and Non-VA Quality of Care: A Systematic Review

BackgroundThe Veterans Affairs (VA) health care system aims to provide high-quality medical care to veterans in the USA, but the quality of VA care has recently drawn the concern of Congress. The objective of this study was to systematically review published evidence examining the quality of care provided at VA health care facilities compared to quality of care in other facilities and systems.MethodsBuilding on the search strategy and results of a prior systematic review, we searched MEDLINE (from January 1, 2005, to January 1, 2015) to identify relevant articles on the quality of care at VA facilities compared to non-VA facilities. Articles from the prior systematic review published from 2005 and onward were also included and re-abstracted. Studies were classified, analyzed, and summarized by the Institute of Medicine’s quality dimensions.ResultsSixty-nine articles were identified (including 31 articles from the prior systematic review and 38 new articles) that address one or more Institute of Medicine quality dimensions: safety (34 articles), effectiveness (24 articles), efficiency (9 articles), patient-centeredness (5 articles), equity (4 articles), and timeliness (1 article). Studies of safety and effectiveness indicated generally better or equal performance, with some exceptions. Too few articles related to timeliness, equity, efficiency, and patient-centeredness were found from which to reliably draw conclusions about VA care related to these dimensions.DiscussionThe VA often (but not always) performs better than or similarly to other systems of care with regard to the safety and effectiveness of care. Additional studies of quality of care in the VA are needed on all aspects of quality, but particularly with regard to timeliness, equity, efficiency, and patient-centeredness.

The effects of benefit design and managed care on health care costs

Recently, the Department of Defense replaced its traditional fee-for-service insurance plan for military health care beneficiaries with an HMO/PPO hybrid. Using survey and claims data, we compare changes in costs over two years at sites that implemented this initiative (CRI) with changes at matched control sites. The results indicate that CRI substantially raised per beneficiary government costs for providing benefits (as compared to predicted costs in the absence of CRI). We attribute this difference to the higher overhead of managed care and the increased expenditures by HMO participants.

Direct Medical Costs Attributable to Acute Myocardial Infarction and Ischemic Stroke in Cohorts with Atherosclerotic Conditions

Background: The cost of acute ischemic events in persons with established atherosclerotic conditions is unknown. Methods: The direct medical costs attributable to secondary acute myocardial infarction (AMI) or ischemic stroke among persons with established atherosclerotic conditions were estimated from 1995–1998 data on 1,143 patients enrolled in US managed care plans. Results: The average 180-day costs attributable to secondary AMI or stroke were estimated as USD 19,056 in the AMI cohort having a private insurance (commercial; n = 344), USD 16,845 in the AMI cohort having government insurance (Medicare, age ≧65 years; n = 200), USD 10,267 for stroke commercial (n = 108), USD 16,280 for stroke Medicare (n = 113), USD 15,224 for peripheral arterial disease commercial (n = 170), and USD 15,182 for peripheral arterial disease Medicare (n = 208). Conclusion: These estimates can be used to study the cost-effectiveness of interventions proven to reduce these secondary events.

Medicare Home Visit Program Associated With Fewer Hospital And Nursing Home Admissions, Increased Office Visits

Clinical home visit programs for Medicare beneficiaries are a promising approach to supporting aging in place and avoiding high-cost institutional care. Such programs combine a comprehensive geriatric assessment by a clinician during a home visit with referrals to community providers and health plan resources to address uncovered issues. We evaluated UnitedHealth Groups HouseCalls program, which has been offered to Medicare Advantage plan members in Arkansas, Georgia, Missouri, South Carolina, and Texas since January 2008. We found that, compared to non-HouseCalls Medicare Advantage plan members and fee-for-service beneficiaries, HouseCalls participants had reductions in admissions to hospitals (1 percent and 14 percent, respectively) and lower risk of nursing home admission (0.67 percent and 1.3 percent, respectively). In addition, participants numbers of office visits--chiefly to specialists--increased 2-6 percent (depending on the comparison group). The programs effects on emergency department use were mixed. These results indicate that a thorough home-based clinical assessment of a members health and home environment combined with referral services can support aging in place, promote physician office visits, and preempt costly institutional care.

Chronic bronchitis: prevalence, smoking habits, impact, and antismoking advice.

Although the prevalence of chronic bronchitis has been measured in several populations, its impact on quality of life has not been assessed. We report the prevalence and impact of chronic bronchitis (defined as having phlegm on most days for at least 3 months during the previous year) among 4,708 adults ages 20 to 69 representative of the nonaged U.S. population. Men reported chronic bronchitis more frequently than women (12 vs 8%); smokers, regardless of age and sex, reported chronic bronchitis more frequently than former or never smokers. Among both men and women 35 years of age or older, current smokers--as opposed to ex- or never smokers--with chronic bronchitis had the poorest forced expiratory volume in 1 sec (FEV1). The most commonly reported impact of chronic bronchitis was worry, followed by pain and restricted activity days, regardless of age, sex, or smoking habits. Of those current and ex-smokers who had seen a physician about their chronic bronchitis, 65% of men and 44% of women had decreased or stopped smoking. Among those current and ex-smokers with chronic bronchitis who did not consult a physician, the proportion of those who had decreased or stopped smoking was 29% for men and 37% for women. Finally, only 43% of male current smokers and 55% of female current smokers who had chronic bronchitis reported that a physician had advised them to decrease or stop smoking.

Comparing Quality of Care in Veterans Affairs and Non-Veterans Affairs Settings

BackgroundCongress, veterans’ groups, and the press have expressed concerns that access to care and quality of care in Department of Veterans Affairs (VA) settings are inferior to access and quality in non-VA settings.ObjectiveTo assess quality of outpatient and inpatient care in VA at the national level and facility level and to compare performance between VA and non-VA settings using recent performance measure data.Main MeasuresWe assessed Patient Safety Indicators (PSIs), 30-day risk-standardized mortality and readmission measures, and ORYX measures for inpatient safety and effectiveness; Healthcare Effectiveness Data and Information Set (HEDIS®) measures for outpatient effectiveness; and Consumer Assessment of Healthcare Providers and Systems Hospital Survey (HCAHPS) and Survey of Healthcare Experiences of Patients (SHEP) survey measures for inpatient patient-centeredness. For inpatient care, we used propensity score matching to identify a subset of non-VA hospitals that were comparable to VA hospitals.Key ResultsVA hospitals performed on average the same as or significantly better than non-VA hospitals on all six measures of inpatient safety, all three inpatient mortality measures, and 12 inpatient effectiveness measures, but significantly worse than non-VA hospitals on three readmission measures and two effectiveness measures. The performance of VA facilities was significantly better than commercial HMOs and Medicaid HMOs for all 16 outpatient effectiveness measures and for Medicare HMOs, it was significantly better for 14 measures and did not differ for two measures. High variation across VA facilities in the performance of some quality measures was observed, although variation was even greater among non-VA facilities.ConclusionsThe VA system performed similarly or better than the non-VA system on most of the nationally recognized measures of inpatient and outpatient care quality, but high variation across VA facilities indicates a need for targeted quality improvement.

Supporting Readiness: Ensuring Excellent PTSD and Depression Care for Service Members

Abstract : Service members with PTSD or depression receive an abundance of medical care. The median number of outpatient visits for any reason is 41 per year for PTSD patients, and 30 visits per year for depression patients. Service members with PTSD or depression are seen by many different providers; the median number ofunique providers during the study year was 14 for patients with PTSD, and 12 for those with depression. These service members frequently had other sychological health concerns, such as sleep and anxiety disorders. Five out of six service members received at least one psychotropic medication, and 45 percent of patients with PTSD and 31 percent of patients with depression received four or more medications. Excellent care is appropriate, timely, and coordinated. Given this combinationof care utilization, number of different providers, and co-occurring diagnoses, ensuring coordination of care for these service members is extremely important.