Henry J. Carretta

Delivery system characteristics and their association with quality and costs of care: implications for accountable care organizations.

Background: Implementation of accountable care organizations (ACOs) is currently underway, but there is limited empirical evidence on the merits of the ACO model. Purpose: The aim was to study the associations between delivery system characteristics and ACO competencies, including centralization strategies to manage organizations, hospital integration with physicians and outpatient facilities, health information technology, infrastructure to monitor community health and report quality, and risk-adjusted 30-day all-cause mortality and case-mixed-adjusted inpatient costs for the Medicare population. Methodology: Panel data (2006–2009) were assembled from Florida and multiple sources: inpatient hospital discharge, vital statistics, the American Hospital Association, the Healthcare Information and Management Systems Society, and other databases. We applied a panel study design, controlling for hospital and market characteristics. Principal Findings: Hospitals that were in centralized health systems or became more centralized over the study period had significantly larger reductions in mortality compared with hospitals that remained freestanding. Surprisingly, tightly integrated hospital–physician arrangements were associated with increased mortality; as such, hospitals may wish to proceed cautiously when developing specific types of alignment with local physician organizations. We observed no statistically significant differences in the growth rate of costs across hospitals in any of the health systems studied relative to freestanding hospitals. Although we observed quality improvement in some organizational types, these outcome improvements were not coupled with the additional desired objective of lower cost growth. This implies that additional changes not present during our study period, potentially changes in provider payment approaches, are essential for achieving the ACO objectives of higher quality of care at lower costs. Practice Implications: Provider organizations implementing ACOs should consider centralizing service delivery as a viable strategy to improve quality of care, although the strategy did not result in lower cost growth.

Service Utilization of Veterans Dually Eligible for VA and Medicare Fee-For-Service: 1999-2004

OBJECTIVE To examine care system choices for Veterans dually-eligible for VA and Medicare FFS following changes in VA eligibility policy, which expanded availability of VA health care services. DATA SOURCES VA and Medicare FFS enrollment and outpatient utilization databases in 1999 and 2004. STUDY DESIGN Multinomial logistic regression was used to examine odds of VA-only and Medicare-only utilization, relative to dual utilization, in 1999 and 2004. Observational cohort comprising a 5% random sample of dually-eligible Veterans: 73,721 in 1999 and 125,042 in 2004. PRINCIPAL FINDINGS From 1999 to 2004, persons with the highest HCC risk scores had decreasing odds of exclusive VA reliance (OR=0.26 in 1999 and 0.17 in 2004, p<0.05), but had increasing odds of exclusive Medicare reliance (OR=0.43 in 1999 and 0.56 in 2004, p<0.05).Persons in high VA priority groups had decreasing odds of exclusive VA reliance, as well as decreasing odds of exclusive Medicare reliance, indicating increasing odds of dual use. Newly eligible Veterans with the highest HCC risk scores had higher odds of dual system use, while newly eligible Black Veterans had lower odds of dual system use. CONCLUSIONS Veterans newly eligible for VA healthcare services, particularly those with the highest risk scores, had higher odds of dual system use compared to earlier eligibles. Providers should ensure coordination of care for Veterans who may be receiving care from multiple sources. Provisions of the Patient Protection and Affordable Care Act may help to ensure care coordination for persons receiving care from multiple systems.

Examination of hospital characteristics and patient quality outcomes using four inpatient quality indicators and 30-day all-cause mortality.

The study objective was to examine hospital mortality outcomes and structure using 2008 patient-level discharges from general community hospitals. Discharges from Florida administrative files were merged to the state mortality registry. A cross-sectional analysis of inpatient mortality was conducted using Inpatient Quality Indicators (IQIs) for acute myocardial infarction (AMI), congestive heart failure (CHF), stroke, pneumonia, and all-payer 30-day postdischarge mortality. Structural characteristics included bed size, volume, ownership, teaching status, and system affiliation. Outcomes were risk adjusted using 3M APR-DRG. Volume was inversely correlated with AMI, CHF, stroke, and 30-day mortality. Similarities and differences in the direction and magnitude of the relationship of structural characteristics to 30-day postdischarge and IQI mortality measures were observed. Hospital volume was inversely correlated with inpatient mortality outcomes. Other hospital characteristics were associated with some mortality outcomes. Further study is needed to understand the relationship between 30-day postdischarge mortality and hospital quality.

Differences in Perceived Need for Medical, Therapeutic, and Family Support Services Among Children With ASD

OBJECTIVE: Identifying racial and ethnic differences in perceived need for treatment among families of children with autism spectrum disorder (ASD) will improve understanding of disparities in care seeking. We described racial and ethnic differences in perceived need for services that children with ASD and their families frequently use. METHODS: We conducted bivariate analyses of racial and ethnic categories and perceived need for 6 common services used by children with ASD as found in the 2005 to 2006 (n = 2123) and the 2009 to 2010 (n = 3055) National Survey of Children With Special Health Care Needs data sets. Multivariate logistic regressions within concatenated data sets were conducted to examine associations between racial and ethnic category and perceived service needs while controlling for predisposing, enabling, and child factors. RESULTS: Compared with caregivers of white non-Hispanic children with ASD, caregivers of Hispanic children reported less need for prescription medications in adjusted multivariate analyses. Caregivers of black non-Hispanic children with ASD reported less need for prescription medications and for child and family mental health services than caregivers of white non-Hispanic children. Both English-speaking Hispanic caregivers and black non-Hispanic caregivers reported greater need for occupational, speech, and physical therapy than white non-Hispanic caregivers. No racial or ethnic differences were found in perceived need for specialty medical care or respite care. CONCLUSIONS: Caregivers of children with ASD from different racial and ethnic backgrounds may differentially perceive need for different types of care. Their perceptions may in turn affect how they prioritize and seek care, independent of their child’s specific needs.

GEOCODING PUBLIC HEALTH DATA

Krieger et al. correctly alert readers to potential sources of error when linking health data to census-derived socioeconomic data.1 The authors’ criticisms of zip code–based data speak to neither the advantages of postal zip codes (ZCs) nor the limitations of other geographies. We would like to correct some minor factual errors in Krieger et al. and to point out that researchers must pay careful attention to spatiotemporal discontinuities in all geography-based analyses. Spatiotemporal discontinuities in calculating rates for specific geographies occur because populations change over time and space. ZCs reflect population change more quickly than census tracts (CTs), and commercial products are available with current estimates of ZC populations. CTs appear more stable only because they are updated less frequently. Using 1999 estimates of cancer incidence in a numerator with 1990 estimates of population in the denominator creates problems regardless of the geographic unit. Changes in CT boundaries occur as well. Between 1980 and 1990, 23% of CTs had deliberate changes to boundaries (K. Miller, Geographic Areas Branch, US Census Bureau, oral communication, July 12, 2002). Using the CT Relationship Files,2 we calculate that at least 21% of CTs in 2000 had changes resulting in at least 2.5% of the population’s being spatially located in a new tract. Both ZCs and CTs require careful attention to potential spatiotemporal discontinuities. The authors also state that large areas of ZCs can straddle state lines. In our own research we have found only 6 cases out of more than 30 000 1999 ZCs in which state boundaries were crossed.3,4 Data from the 2000 census are being released in zip code tabulation areas. Zip code tabulation areas will be stable until the next decennial census, and they provide highly accurate sociodemographic data. Although we applaud the authors’ contributions to the growing interest in geocoding public health data and recognize the limitations of a research brief, we believe a more balanced presentation of problems with all geographic units is called for.

The Quantitative Story Behind the Quality Improvement Storyboards: A Synthesis of Quality Improvement Projects Conducted by the Multi-State Learning Collaborative

CONTEXT The Multi-State Learning Collaborative: Lead States in Public Health Quality Improvement (MLC) brought state and local health departments in 16 states together with public health system and national partners to prepare for national voluntary accreditation and to implement quality improvement (QI) practices. OBJECTIVE The MLC has collected the single largest repository of qualitative public health QI data to date. A preliminary study was conducted to explore the potential merits of further mining data sets of this size and scope and examining them quantitatively. DESIGN We addressed the following research question: What characteristics of QI projects/mini-collaboratives make them more or less likely to attain their stated objectives? Qualitative MLC data were modified and coded as quantifiable measures using categorical or Likert scale measures analyzable through quantitative methods. Descriptive and inferential statistics were calculated. RESULTS Of the 156 mini-collaboratives with complete data, chronic disease was the most commonly selected target area. Among the 4 dependent variables, results varied somewhat by outcome. There was support in 1 or more analytical models for a positive relationship between aim statements that included target objectives, time frames, measurable goals, and well-defined processes. The degree to which the intervention was logically aligned with the aim and the comprehensiveness of the QI project were also positively associated with 1 or more outcomes. The large number of statistical tests conducted may have led to type I errors for some comparisons. CONCLUSIONS Quantitative analysis and modeling of public health QI activities are feasible and desirable. It may provide critical information leading to incremental improvement in QI performance within public health practice. This work can inform the nascent national accreditation program and the developing QI in Public Health Practice Exchange.

Characteristics of all, occasional, and frequent emergency department visits due to ambulatory care-sensitive conditions in Florida.

We studied characteristics of all, occasional, and frequent emergency department (ED) visits due to ambulatory care–sensitive conditions (ACSCs). We used a cross-sectional, split-sample design with multivariate logistic regressions using encounter-level, all-payer ED data from all Florida hospitals for the year of 2005. We evaluated associations of key patient characteristics, characteristics of ED utilization, and availability of primary care physicians in the area, with ED visits for ACSCs. We concluded that factors associated with ED use for ACSCs were similar for occasional and frequent ED users. Therefore, universal strategies for reduction of ED overutilization by increasing access to, timeliness, and quality of primary care for all patients likely to experience ACSCs should be used.

Malpractice paid losses and financial performance of nursing homes

BACKGROUND Floridas nursing home industry has experienced significant financial pressure over the past decade. One of the primary reasons is the dramatic increase in litigation activity for nursing home providers claiming negligent care and abuse. Although anecdotal reports indicate a higher cost because of malpractice in nursing facilities, few studies have examined the extent of malpractice paid losses and their effect on the financial performance of nursing homes. PURPOSE The purpose of this study was to examine the impact of malpractice paid losses on the financial performance of nursing homes. METHODOLOGY/APPROACH Medicare Cost Report data and Online Survey, Certification, and Reporting data for Florida skilled nursing facilities over the 6-year period from 2001 to 2006 were used to calculate the malpractice paid losses and the financial performance indicators as well as the nursing home organizational and market factors. Descriptive analysis and multivariate regression analysis were used to examine the effect of paid loss on financial performance. FINDINGS The paid loss for malpractice claims was strongly associated with financial performance. Nursing facilities with malpractice paid losses had consistently lower total margins over the study period. The threat of nursing home litigation may create an incentive for nursing homes to improve quality of care; however, large paid claims can also force nursing homes into a financial situation where the organization no longer has the resources to improve quality. PRACTICE IMPLICATIONS Nursing home managers must assess their malpractice litigation risk and identify tactics to mitigate these risks to better provide a safe and secure environment for the older persons. In addition, this research offers support for local, state, and federal policymakers to revisit the issue of malpractice litigation and the nursing home industry through its insight on the relationship of nursing home margins and litigation.

Therapy access among children with autism spectrum disorder, cerebral palsy, and attention-deficit–hyperactivity disorder: a population-based study

This study examined cross‐sectional population‐based rates in reported need and unmet need for occupational, physical, and speech therapy services in children with autism spectrum disorder (ASD) compared with children with attention‐deficit–hyperactivity disorder (ADHD) and cerebral palsy (CP).

Analyzing State Autism Private Insurance Mandates for Allied Health Services: A Pilot Study:

Due to the prevalence, severity, and costs associated with autism spectrum disorders (ASDs), it has become a public health issue. In response, state governments have adopted ASD-specific private insurance mandates requiring coverage of ASD screening, diagnosis, and treatment. Despite rapid uptake of these laws, differences exist in the type and levels of coverage, especially for allied health services including occupational therapy. We piloted a structured legal research methodology to code ASD insurance mandates that impact allied health service provisions. State private insurance mandates were obtained from WestlawNext. A coding methodology was piloted on 14 states and included variables for age and service limits, treatments covered, and medical necessity. Coding methods were feasible and highly reliable among raters. Ten of 12 states had a coverage mandate, many with specific provisions for allied health providers. A full analysis of all 50 states is warranted to identify provisions affecting allied health providers serving individuals with ASD.