Eric M. Cheng

Primary Language and Receipt of Recommended Health Care Among Hispanics in the United States

BackgroundDisparities in health care services between Hispanics and whites in the United States are well documented.ObjectiveThe objective of the study was to determine whether language spoken at home identifies Hispanics at risk for not receiving recommended health care services.DesignThe design of the study was cross-sectional, nationally representative survey of households.PatientsThe patients were non-Hispanic white and Hispanic adults participating in the 2003 Medical Expenditure Panel Survey.MeasurementsWe compared receipt of ten recommended health care services by ethnicity and primary language adjusting for demographic and socioeconomic characteristics, health status, and access to care.ResultsThe sample included 12,706 whites and 5,500 Hispanics. In bivariate comparisons, 57.0% of whites received all eligible health care services compared to 53.6% for Hispanics who spoke English at home, 44.9% for Hispanics who did not speak English at home but who were comfortable speaking English, and 35.0% for Hispanics who did not speak English at home and were uncomfortable speaking English (p < .001). In multivariate logistic models, compared to non-Hispanic whites, Hispanics who did not speak English at home were less likely to receive all eligible health care services, whether they were comfortable speaking English (risk ratio [RR] 0.88, 95% confidence interval [CI] 0.74–0.97) or not (RR 0.84, 95% CI 0.68–0.95).ConclusionsSpeaking a language other than English at home identified Hispanics at risk for not receiving recommended health care services, whether they were comfortable in speaking English or not. Identifying the mechanism for disparities by language usage may lead to interventions to reduce ethnic disparities.

Patterns of Emergency Medical Services Use and Its Association With Timely Stroke Treatment Findings From Get With the Guidelines-Stroke

Background— Prior studies found that only about half of stroke patients arrived at hospitals via emergency medical services (EMSs), yet since then, there have been efforts to increase public awareness that time is brain. Using contemporary Get With the Guidelines-Stroke data, we assessed nationwide EMS use by stroke patients. Methods and Results— We analyzed data from 204 591 patients with ischemic and hemorrhagic stroke admitted to 1563 Get With the Guidelines-Stroke participating hospitals with data on National Institute of Health Stroke Score and insurance status. Hospital arrival by EMSs was observed in 63.7% of patients. Older patients, those with Medicaid and Medicare insurance, and those with severe stroke were more likely to activate EMSs. In contrast, minority race and ethnicity and living in rural communities were associated with decreased odds of EMS use. EMS transport was independently associated with earlier arrival (onset-to-door time, ⩽3 hours; adjusted odds ratio, 2.00; 95% confidence interval, 1.93–2.08), prompter evaluation (more patients with door-to-imaging time, ⩽25 minutes; odds ratio, 1.89; 95% confidence interval, 1.78–2.00), more rapid treatment (more patients with door-to-needle time, ⩽60 minutes; odds ratio, 1.44; 95% confidence interval, 1.28–1.63), and more eligible patients to be treated with tissue-type plasminogen activator if onset is ⩽2 hours (67% versus 44%; odds ratio, 1.47; 95% confidence interval, 1.33–1.64). Conclusions— Although EMS use is independently associated with more rapid evaluation and treatment of stroke, more than one third of stroke patients fail to use EMSs. Interventions aimed at increasing EMS activation should target populations at risk, particularly younger patients and those of minority race and ethnicity.

Association of specialist involvement and quality of care for Parkinson's disease†

Because Parkinsons disease (PD) has multiple neurological symptoms and often complex treatments, the quality of PD care may be higher when a specialist is involved. We examined the medical records, from 1998 to 2004, of 401 Los Angeles veterans with Parkinsons disease to determine whether care met key indicators of PD care quality. All care following a visit to a movement‐disorder specialist or general neurologist was classified as specialty care. We compared adherence to each indicator by level of specialist involvement through logistic regression models. Over the study period, 10 indicators of PD care quality were triggered 2,227 times. Overall, movement disorder specialist involvement (78%) was associated with higher adherence to indicators than did general neurologist involvement (70%, P = 0.006) and nonneurologist involvement (52%, P < 0.001). The differences between movement disorder specialist and nonneurologist involvement were especially large for four indicators: treatment of wearing‐off, assessments of falls, depression, and hallucinations. There is significant room for improving aspects of PD care quality among patients who do not have the involvement of a specialist. Quality of care interventions should involve specialists in management of motor symptoms and incorporate methods for routine assessment of nonmotor PD symptoms.

Mobility impairments and use of preventive services in women with multiple sclerosis : observational study

Use of preventive health services is affected by factors such as patient demographics, clinical characteristics, type of provider, and type of healthcare system.1 Although people with multiple sclerosis may have impaired mobility, their lifespans are similar to age matched population controls. They therefore need standard preventive services to prevent early mortality. We evaluated the relation between mobility and use of preventive services in women with multiple sclerosis. In 1996, we sent questionnaires to 1164 adults with multiple sclerosis who had received outpatient care in 1993 or 1994 from one of three systems of health care (two forms of managed care and fee for service insurance) in two regions of the United States.2 The overall response rate was 80% (930/1164). We report here survey analyses from the 713 women respondents. We collected self reported rates of cervical smear testing, mammography, and breast examination (if over age 50), blood pressure checks, cholesterol screening, and physician …

Development of quality of care indicators for Parkinson's disease

Parkinsons disease (PD) is a major cause of disability. To date, there have been no large‐scale efforts to measure the quality of PD care because of a lack of quality indicators for conducting an explicit review of PD care processes. We present a set of quality indicators for PD care. Based on a structured review of the medical literature, 79 potential indicators were drafted. Through a two‐round modified Delphi process, an expert panel of seven movement disorders specialists rated each indicator on criteria of validity, feasibility, impact on outcomes, room for improvement, and overall utility. Seventy‐one quality indicators met validity and feasibility thresholds. Applying thresholds for impact on outcomes, room for improvement, and overall utility, a subset of 29 indicators was identified, spanning dopaminergic therapy, assessment of functional status, assessment and treatment of depression, coordination of care, and medication use. Multivariable analysis showed that overall utility ratings were driven by validity and impact on outcomes (P < 0.01). An expert panel can reach consensus on a set of highly rated quality indicators for PD care, which can be used to assess quality of PD care and guide the design of quality improvement projects.

Piloting the NPF data-driven quality improvement initiative.

OBJECTIVE To pilot a data-driven quality care program in National Parkinson Foundation (NPF) Centers of Excellence. BACKGROUND Evidence from comparative effectiveness research (CER) can be used to guide decisions regarding health care and to improve quality and efficiency of care. We propose to develop the infrastructure required to conduct CER across an extensive network of NPF Centers of Excellence. METHODS We present the staged planning for a pilot study which will demonstrate the development and implementation of the infrastructure that will be needed for a large standardized patient-centered, clinical practice database for PD. This database will support CER and drive quality improvement studies. RESULTS We describe the infrastructure for the ongoing pilot feasibility testing in a subset of six NPF Centers of Excellence, and we discuss the impact that the data (available in 2010) could have in guiding PD management. CONCLUSION This preliminary experience will facilitate the longitudinal tracking of therapies and of outcomes in PD clinical practice. Further, we are hopeful that the information will provide insight into PD that will extend beyond the clinical trials population (the population included in most available PD databases). This prospective standardized real-world multi-center clinical practice database will aim to identify positive health outcomes associated with treatment approaches, and to identify variations in clinical outcomes that may suggest improvements in best clinical practice patterns.

Optimizing Algorithms to Identify Parkinson's Disease Cases Within an Administrative Database

Patients assigned the diagnostic ICD‐9‐CM code for Parkinsons disease (PD) in an administrative database may not truly carry that diagnosis because of the various error sources. Improved ability to identify PD cases within databases may facilitate specific research goals. Experienced chart reviewers abstracted the working diagnosis of all 577 patients assigned diagnostic code 332.0 (PD) during 1 year at a VA Healthcare System. We then tested the ability of various algorithms making use of PD and non‐PD diagnostic codes, specialty of clinics visited, and medication prescription data to predict the abstracted working diagnosis. Chart review determined 436 (75.6%) patients to be PD or Possibly PD, and 141 (24.4%) to be Not PD. Our tiered consensus algorithm preferentially used data from specialists over nonspecialists improved PPV to 83.2% (P = 0.003 vs. baseline). When presence of a PD prescription was an additional criterion, PPV increased further to 88.2% (P = 0.04 vs. without medication criterion), but sensitivity decreased from 87.4 to 77.1% (P = 0.0001). We demonstrate that algorithms provide better identification of PD cases than using a single occurrence of the diagnostic code for PD, and modifications of such algorithms can be tuned to maximize parameters that best meet the goals of a particular database query.

Randomized, Controlled Trial of an Intervention to Enable Stroke Survivors Throughout the Los Angeles County Safety Net to “Stay With the Guidelines”

Background— Stroke is the leading cause of adult disability. Inpatient programs optimize secondary stroke prevention care at the time of hospital discharge, but such care may not be continued after hospital discharge. Methods— To improve the delivery of secondary stroke preventive services after hospital discharge, we have designed a chronic care model–based program called SUSTAIN (Systemic Use of STroke Averting INterventions). This care intervention includes group clinics, self-management support, report cards, decision support through care guides and protocols, and coordination of ongoing care. The first specific aim is to test, in a randomized, controlled trial, whether SUSTAIN improves blood pressure control among an analytic sample of 268 patients with a recent stroke or transient ischemic attack discharged from 4 Los Angeles County public hospitals. Secondary outcomes consist of control of other stroke risk factors, lifestyle habits, medication adherence, patient perceptions of care quality, functional status, and quality of life. A second specific aim is to conduct a cost analysis of SUSTAIN from the perspective of the Los Angeles County Department of Health Services by using direct costs of the intervention, cost equivalents of associated utilization of county system resources, and cost equivalents of the observed and predicted averted vascular events. Conclusions— If SUSTAIN is effective, we will have the expertise and findings to advocate for its continued support at Los Angeles County hospitals and to disseminate the SUSTAIN program to other settings serving indigent, minority populations. Clinical Trial Registration— URL: http://www.clinicaltrials.gov. Unique identifier: NCT00861081.

Quality indicators for multiple sclerosis

Determining whether persons with multiple sclerosis (MS) receive appropriate, comprehensive healthcare requires tools for measuring quality. The objective of this study was to develop quality indicators for the care of persons with MS. We used a modified version of the RAND/UCLA Appropriateness Method in a two-stage process to identify relevant MS care domains and to assess the validity of indicators within high-ranking care domains. Based on a literature review, interviews with persons with MS, and discussions with MS providers, 25 MS symptom domains and 14 general health domains of MS care were identified. A multidisciplinary panel of 15 stakeholders of MS care, including 4 persons with MS, rated these 39 domains in a two-round modified Delphi process. The research team performed an expanded literature review for 26 highly ranked domains to draft 86 MS care indicators. Through another two-round modified Delphi process, a second panel of 18 stakeholders rated these indicators using a nine-point response scale. Indicators with a median rating in the highest tertile were considered valid. Among the most highly rated MS care domains were appropriateness and timeliness of the diagnostic work-up, bladder dysfunction, cognition dysfunction, depression, disease-modifying agent usage, fatigue, integration of care, and spasticity. Of the 86 preliminary indicators, 76 were rated highly enough to meet predetermined thresholds for validity. Following a widely accepted methodology, we developed a comprehensive set of quality indicators for MS care that can be used to assess quality of care and guide the design of interventions to improve care among persons with MS.

Factors related to agreement between self-reported and conventional Expanded Disability Status Scale (EDSS) scores.

Background: Although the Expanded Disability Status Scale (EDSS) remains a widely used scale for evaluating impairments in people with multiple sclerosis (MS), EDSS assessments are infeasible in certain situations. A self-administered version of the EDSS would be potentially usefulif it yielded similar results as the conventional physician-based version. Methods: We developed a self-administered patient questionnaire to obtain ratings of neurologic impairments, and developed algorithms to estimate EDSS scores. We mailed the questionnaires to all new consecutive patients scheduled to be seen at an MS clinic. Questionnaires were completed prior to the visit, and traditional EDSS ratings were made by one of two neurologists at the visit. One hundred and forty-six pairs of patient questionnaires and physician EDSS assessments were obtained. Results: Kappa values for agreement between the physicians EDSS scores and the questionnaire-derived scores were 0.13 (for exact agreement), 0.39 (+0.5 EDSS steps), and 0.56 (+1.0 EDSS steps). A scatterplot showed that agreement was best at EDSS scores 53.0 and 45.0. Better agreement was obtained when patients had a higher level of education, and when the physician was more certain of the diagnosis of MS. Conclusions: While the self-assessed EDSS scores do not agree highly enough to take the place of conventional EDSS scores, they may be sufficient for MS trial screening or for assessing outcomes across broad categories of disability.