Grant R. Martsolf

Early experiences with consumer engagement initiatives to improve chronic care.

Engaging consumers to be more active participants in their health and health care is an appealing strategy for reforming the U.S. health care system, but little is known about how to mount and sustain communitywide consumer engagement initiatives. The Robert Wood Johnson Foundation launched a program in 2006 in fourteen communities to align forces around improving quality and efficiency by promoting public reporting and expanding the involvement of consumers in all facets of their care. These multistakeholder organizations provide an early glimpse into the opportunities and challenges that lie ahead as policymakers attempt to integrate consumers more completely in their reform strategies.

Examining the value of inpatient nurse staffing: an assessment of quality and patient care costs.

Background:Inpatient quality deficits have important implications for the health and well-being of patients. They also have important financial implications for payers and hospitals by leading to longer lengths of stay and higher intensity of treatment. Many of these costly quality deficits are particularly sensitive to nursing care. Objective:To assess the effect of nurse staffing on quality of care and inpatient care costs. Design:Longitudinal analysis using hospital nurse staffing data and the Healthcare Cost and Utilization Project State Inpatient Databases from 2008 through 2011. Subjects:Hospital discharges from California, Nevada, and Maryland (n=18,474,860). Methods:A longitudinal, hospital-fixed effect model was estimated to assess the effect of nurse staffing levels and skill mix on patient care costs, length of stay, and adverse events, adjusting for patient clinical and demographic characteristics. Results:Increases in nurse staffing levels were associated with reductions in nursing-sensitive adverse events and length of stay, but did not lead to increases in patient care costs. Changing skill mix by increasing the number of registered nurses, as a proportion of licensed nursing staff, led to reductions in costs. Conclusions:The study findings provide support for the value of inpatient nurse staffing as it contributes to improvements in inpatient care; increases in staff number and skill mix can lead to improved quality and reduced length of stay at no additional cost.

Consumer Trust in Sources of Physician Quality Information

Trust in the source of information about physician quality is likely to be an important factor in how consumers use that information in encounters with their doctor or in decisions about choice of provider. In this article, the authors use survey data from a nationally representative sample of 8,140 individuals with chronic illness to examine variation in consumer trust in different sources of physician quality information and how market segmentation factors explain such variation. The authors find that consumers place greater trust in physicians and hospitals relative to institutional sources and personal sources. The level of trust, however, varies considerably across consumers as a function of demographic, socioeconomic, behavioral/lifestyle factors but is not related to measures of context. These results suggest that the sources of public reports comparing physician quality may be a barrier to the use of quality data by consumers in the ways envisioned by supporters of greater quality transparency.

Editors and Researchers Beware: Calculating Response Rates in Random Digit Dial Health Surveys

OBJECTIVE To demonstrate that different approaches to handling cases of unknown eligibility in random digit dial health surveys can contribute to significant differences in response rates. DATA SOURCE Primary survey data of individuals with chronic disease. STUDY DESIGN We computed response rates using various approaches, each of which make different assumptions about the disposition of cases of unknown eligibility. DATA COLLECTION Data were collected via telephone interviews as part of the Aligning Forces for Quality (AF4Q) consumer survey, a representative survey of adults with chronic illnesses in 17 communities and nationally. PRINCIPAL FINDINGS We found that various approaches to estimating eligibility rates can lead to substantially different response rates. CONCLUSIONS Health services researchers must consider strategies to standardize response rate reporting, enter into a dialog related to why response rate reporting is important, and begin to utilize alternate methods for demonstrating that survey data are valid and reliable.

Impact of Race/Ethnicity and Socioeconomic Status on Risk-Adjusted Hospital Readmission Rates Following Hip and Knee Arthroplasty

BACKGROUND Readmission rates following total hip arthroplasty (THA) and total knee arthroplasty (TKA) are increasingly used to measure hospital performance. Readmission rates that are not adjusted for race/ethnicity and socioeconomic status, patient risk factors beyond a hospitals control, may not accurately reflect a hospitals performance. In this study, we examined the extent to which risk-adjusting for race/ethnicity and socioeconomic status affected hospital performance in terms of readmission rates following THA and TKA. METHODS We calculated 2 sets of risk-adjusted readmission rates by (1) using the Centers for Medicare & Medicaid Services standard risk-adjustment algorithm that incorporates patient age, sex, comorbidities, and hospital effects and (2) adding race/ethnicity and socioeconomic status to the model. Using data from the Healthcare Cost and Utilization Project, 2011 State Inpatient Databases, we compared the relative performances of 1,194 hospitals across the 2 methods. RESULTS Addition of race/ethnicity and socioeconomic status to the risk-adjustment algorithm resulted in (1) little or no change in the risk-adjusted readmission rates at nearly all hospitals; (2) no change in the designation of the readmission rate as better, worse, or not different from the population mean at >99% of the hospitals; and (3) no change in the excess readmission ratio at >97% of the hospitals. CONCLUSIONS Inclusion of race/ethnicity and socioeconomic status in the risk-adjustment algorithm led to a relative-performance change in readmission rates following THA and TKA at <3% of the hospitals. We believe that policymakers and payers should consider this result when deciding whether to include race/ethnicity and socioeconomic status in risk-adjusted THA and TKA readmission rates used for hospital accountability, payment, and public reporting. LEVEL OF EVIDENCE Prognostic Level III. See instructions for Authors for a complete description of levels of evidence.

Association Between the Opening of Retail Clinics and Low-Acuity Emergency Department Visits.

Study objective We assess whether the opening of retail clinics near emergency departments (ED) is associated with decreased ED utilization for low‐acuity conditions. Methods We used data from the Healthcare Cost and Utilization Project State Emergency Department Databases for 2,053 EDs in 23 states from 2007 to 2012. We used Poisson regression models to examine the association between retail clinic penetration and the rate of ED visits for 11 low‐acuity conditions. Retail clinic “penetration” was measured as the percentage of the ED catchment area that overlapped with the 10‐minute drive radius of a retail clinic. Rate ratios were calculated for a 10‐percentage‐point increase in retail clinic penetration per quarter. During the course of a year, this represents the effect of an increase in retail clinic penetration rate from 0% to 40%, which was approximately the average penetration rate observed in 2012. Results Among all patients, retail clinic penetration was not associated with a reduced rate of low‐acuity ED visits (rate ratio=0.999; 95% confidence interval=0.997 to 1.000). Among patients with private insurance, there was a slight decrease in low‐acuity ED visits (rate ratio=0.997; 95% confidence interval=0.994 to 0.999). For the average ED in a given quarter, this would equal a 0.3% reduction (95% confidence interval 0.1% to 0.6%) in low‐acuity ED visits among the privately insured if retail clinic penetration rate increased by 10 percentage points per quarter. Conclusion With increased patient demand resulting from the expansion of health insurance coverage, retail clinics may emerge as an important care location, but to date, they have not been associated with a meaningful reduction in low‐acuity ED visits.

Cost of Transformation among Primary Care Practices Participating in a Medical Home Pilot

Medical home initiatives encourage primary care practices to invest in new structural capabilities such as patient registries and information technology, but little is known about the costs of these investments. To estimate costs of transformation incurred by primary care practices participating in a medical home pilot. We interviewed practice leaders in order to identify changes practices had undertaken due to medical home transformation. Based on the principles of activity-based costing, we estimated the costs of additional personnel and other investments associated with these changes. The Pennsylvania Chronic Care Initiative (PACCI), a statewide multi-payer medical home pilot. Twelve practices that participated in the PACCI. One-time and ongoing yearly costs attributed to medical home transformation. Practices incurred median one-time transformation-associated costs of

Measuring Workplace Climate in Community Clinics and Health Centers.

30,991 per practice (range,

Multistakeholder Perspectives on Composite Measures of Ambulatory Care Quality: A Qualitative Descriptive Study

7694 to

Primary Care Nurse Practitioner Practice Characteristics: Barriers and Opportunities for Interprofessional Teamwork

117,810), equivalent to