James X. Zhang

Diabetes in the African-American Medicare Population: Morbidity, quality of care, and resource utilization

OBJECTIVE To determine whether African-American Medicare recipients with diabetes are at increased risk for morbidity, poor quality of care, and high resource utilization. RESEARCH DESIGN AND METHODS We analyzed 1,376 patients with diabetes who were ≥65 years of age and in the 1993 Medicare Current Beneficiary Survey. Morbidity measures were the Katz Index of Activities of Daily Living, Instrumental Activities of Daily Living, overall health perception, Charlson Comorbidity Index score, and diabetic complications. Quality of care standards were glycosylated hemoglobin measurements, ophthalmological visits, lipid testing, mammography, influenza vaccination, readmission within 30 days of hospital discharge, and outpatient visits within 4 weeks of hospital discharge. We stratified Medicare reimbursement by type of service and adjusted for sex, education, and age in multivariable analyses. RESULTS Compared with white patients, African-American patients had worse health perception and lower quality of care. They were more likely to visit the emergency department and had fewer physician visits per year. African-Americans had higher reimbursement for home health services, but total reimbursement was similar after case-mix adjustment. CONCLUSIONS Improved access to preventive care for older African-Americans with diabetes may improve health perception and use of the emergency department. The potential effect on total reimbursement is unclear. Future policy interventions to improve quality of care among Medicare patients with diabetes should especially target African-Americans.

The performance of different lookback periods and sources of information for Charlson comorbidity adjustment in Medicare claims.

BACKGROUND The Charlson Score is a particularly popular form of comorbidity adjustment in claims data analysis. However, the effects of certain implementation decisions have not been empirically examined. OBJECTIVE To determine the effects of alternative data sources and lookback periods on the performance of Charlson scores in the prediction of mortality following hospitalization. SUBJECTS A representative sample of 1,387 elderly patients hospitalized in 1993, drawn from the Medicare Current Beneficiary Survey (MCBS). Three years of linked Medicare claims and survey instruments were available for all patients, as was 2-year mortality follow-up. STATISTICAL METHODS Nested Cox regression and comparisons of areas under the Receiver Operating Characteristic (ROC) curve were used to evaluate ability to predict mortality. RESULTS Compared with a 1-year lookback involving solely inpatient claims, statistically and empirically significant improvements in the prediction of mortality are obtained by incorporating alternative sources of data (particularly 2 years of inpatient data and 1 year of outpatient and auxiliary claims), but only if indices derived from distinct sources of data are entered into the regression distinctly. The area under the ROC curve for 1-year mortality predication increases from 0.702 to 0.741 (P = 0.002). Furthermore, these improvements in explanatory power obtained whether one also controls for Charlson scores based on self-reported health history and/or secondary diagnoses from the claim for the index hospitalization itself. Finally, claims-based comorbidity adjustment performs comparably to survey-derived adjustment, with areas under the ROC curve of 0.702 and 0.704, respectively. CONCLUSIONS The widespread practice of comorbidity adjustment in pre-existing administrative data sources can be improved by taking more complete advantage of existing administrative data sources.

Specialty Differences in the Care of Older Patients With Diabetes

OBJECTIVES To determine differences in health status, quality of care, and resource utilization among older diabetic Medicare patients cared for by endocrinologists, internists, family practitioners, and general practitioners. METHODS The authors analyzed 1,637 patients with diabetes age 65 years or older in the 1994 Medicare Current Beneficiary Survey, a database that links patient surveys to 12 months of Medicare claims data. MEASURES Measures of morbidity were Basic and Instrumental Activities of Daily Living, health perception, Charlson Comorbidity Index score, and diabetic complications. Quality of care markers were measurement of ophthalmologic visit, lipid testing, glycosylated hemoglobin measurement, mammography, influenza vaccination, early hospital readmission, outpatient follow-up, and patient satisfaction. Resource utilization included reimbursement, relative value units, physician and emergency department visits, and hospitalizations. Age, gender, race, and education were adjusted for in multivariable analyses. RESULTS Compared with patients of family practitioners, patients of endocrinologists and internists had more comorbidity and diabetic complications but similar health perception and deficiencies in activities of daily living. The patients of endocrinologists also had higher utilization of ophthalmologic screening, lipid testing, and glycosylated hemoglobin measurement than the patients of generalist physicians, but similar rates of influenza vaccination. Patients of endocrinologists and internists had higher total reimbursement than those of family practitioners and general practitioners. Patient satisfaction was generally similar. CONCLUSIONS Older diabetic patients of endocrinologists had higher utilization of diabetes-specific process of care measures and had similar functional status despite more diabetic complications. However, they received a more costly style of care than patients of family practitioners and general practitioners. Future work needs to explore the optimal coordination of care of diabetic patients among different health providers.

Utilization and dosing of angiotensin-converting enzyme inhibitors for heart failure. Effect of physician specialty and patient characteristics.

To determine if physician specialty is associated with underutilization and underdosing of angiotensin-converting enzyme inhibitors among patients with heart failure, we reviewed the charts of 214 outpatients with decreased systolic function at an urban academic medical center. Regardless of whether patients were cared for by cardiologists, generalist physicians, or a combination of the two specialties, approximately 75% of the patients were taking an angiotensin-converting enzyme inhibitor. However, only approximately 60% of these patients were taking dosages proved to be efficacious in trials. Emphasis on adequate dosing is needed among all specialty groups.

Characteristics of patients receiving pharmaceutical samples and association between sample receipt and out-of-pocket prescription costs.

Background:Pharmaceutical samples are widely used for promotion and marketing, yet little is known about who receives samples or how their use is associated with patients prescription costs. Objective:To examine the characteristics of those receiving samples and the relationship between sample receipt and out-of-pocket prescription costs. Design, Subjects, and Measures:We divided the 2002–2003 Medical Expenditure Panel Survey, a nationally representative, panel-design longitudinal study, into baseline and analysis periods. We conducted logistic and generalized linear regression analysis of 5709 individuals in the analysis period who did not receive samples during the baseline period. The primary outcome measures were sample receipt and prescription expenditures. Results:Fourteen percent of individuals received at least 1 sample during the analysis period. On multivariate analyses sample receipt was greater among those who were younger and those not on Medicaid. In generalized linear regressions controlling for demographic characteristics and health care utilization, the predicted 180-day out-of-pocket prescription expenditures were

Insurance Status and Quality of Diabetes Care in Community Health Centers

178 [standard error (SE),

Comorbidity and the concentration of healthcare expenditures in older patients with heart failure.

3.9] for those never receiving samples. Among those receiving samples, the corresponding out-of-pocket expenditures were

The Lack of Effect of Market Structure on Hospice Use

166 (SE,

The Cost Consequences of Improving Diabetes Care: The Community Health Center Experience

8.9) for periods before sample receipt (P = 0.16 for comparison with those not receiving samples),

Disease-Specific Patterns of Hospice and Related Healthcare Use in an Incidence Cohort of Seriously Ill Elderly Patients

244 (SE,