Jessica N. Mittler

Taking the Long View: How Well Do Patient Activation Scores Predict Outcomes Four Years Later?

Patient activation is an important predictor of health outcomes and health care usage, yet we do not know how enduring the benefits of greater patient activation are. This study uses a large panel survey of people with chronic conditions (n = 4,865) to examine whether a baseline patient activation measure predicts outcomes 4 years later, and whether changes in patient activation measure scores are associated with changes in outcomes. The findings indicate that the benefits of health activation are enduring, yielding benefits in the form of better self-management, improved functioning, and lower use of costly health care services over time. Furthermore, the findings indicate that when activation levels change, many outcomes change in the same direction. Patient activation seems to be an important and modifiable factor for influencing chronic disease outcomes; health care delivery systems can use this information to personalize and improve care.

Limits Of Readmission Rates In Measuring Hospital Quality Suggest The Need For Added Metrics

Recent national policies use risk-standardized readmission rates to measure hospital performance on the theory that readmissions reflect dimensions of the quality of patient care that are influenced by hospitals. In this article our objective was to assess readmission rates as a hospital quality measure. First we compared quartile rankings of hospitals based on readmission rates in 2009 and 2011 to see whether hospitals maintained their relative performance or whether shifts occurred that suggested either changes in quality or random variation. Next we examined the relationship between readmission rates and several commonly used hospital quality indicators, including risk-standardized mortality rates, volume, teaching status, and process-measure performance. We found that quartile rankings fluctuated and that readmission rates for lower-performing hospitals in 2009 tended to improve by 2011, while readmission rates for higher-performing hospitals tended to worsen. Regression to the mean (a form of statistical noise) accounted for a portion of the changes in hospital performance. We also found that readmission rates were higher in teaching hospitals and were weakly correlated with the other indicators of hospital quality. Policy makers should consider augmenting the use of readmission rates with other measures of hospital performance during care transitions and should build on current efforts that take a communitywide approach to the readmissions issue.

Turning readmission reduction policies into results: some lessons from a multistate initiative to reduce readmissions.

Efforts are under way nationally to reduce avoidable hospital readmissions by changing payments to hospitals, but it is unclear how well or how quickly these policy changes will produce widespread reductions in hospital readmissions. To examine some of the challenges to implementing such approaches, the authors analyzed the early experiences of 3 statewide programs to reduce preventable readmissions that began in 2009. Based on interviews with program participants in 2011, the authors identified 3 key obstacles to progress: the difficulty of developing collaborative relationships across care settings, gaps in evidence for effective interventions, and deficits in quality improvement capabilities among some organizations. These findings underscore the uncertainty of success of current readmissions policies and suggest that immediate improvement in readmission rates through a change in reimbursement may be unlikely unless these other obstacles are addressed expeditiously. In particular, cultivation of productive collaboration across care settings will be critical because these kinds of relationships are not well established or naturally occurring in most communities.

Market Variations in Intensity of Medicare Service Use and Beneficiary Experiences with Care

OBJECTIVE Examine associations between patient experiences with care and service use across markets. DATA SOURCES/STUDY SETTING Medicare fee-for-service (FFS) and managed care (Medicare Advantage [MA]) beneficiaries in 306 markets from the 2003 Consumer Assessments of Healthcare Providers and Systems (CAHPS) surveys. Resource use intensity is measured by the 2003 end-of-life expenditure index. STUDY DESIGN We estimated correlations and linear regressions of eight measures of case-mix-adjusted beneficiary experiences with intensity of service use across markets. DATA COLLECTION/EXTRACTION We merged CAHPS data with service use data, excluding beneficiaries under 65 years of age or receiving Medicaid. PRINCIPAL FINDINGS Overall, higher intensity use was associated (p<.05) with worse (seven measures) or no better care experiences (two measures). In higher-intensity markets, Medicare FFS and MA beneficiaries reported more problems getting care quickly and less helpful office staff. However, Medicare FFS beneficiaries in higher-intensity markets reported higher overall ratings of their personal physician and main specialist. Medicare MA beneficiaries in higher-intensity markets also reported worse quality of communication with physicians, ability to get needed care, and overall ratings of care. CONCLUSIONS Medicare beneficiaries in markets characterized by high service use did not report better experiences with care. This trend was strongest for those in managed care.

The Importance of Clinical Severity in the Measurement of Hospital Readmission Rates for Medicare Beneficiaries, 1997-2007

In the coming years, assessing the impact of efforts to reduce hospital readmissions will be important to policy makers and hospitals. To inform such assessments, we sought to define preexisting trends in readmission rates for patients by level of clinical severity using a difference-in-differences analysis of Medicare inpatient claims data from 1997, 2002, and 2007 for patients with acute myocardial infarction and congestive heart failure. We also examined trends in length of stay, in-hospital mortality, and postdischarge mortality by severity level to provide additional context for interpreting readmission rate trends. From 1997 to 2007, the difference in readmission rates between the highest and lowest severity quartiles increased. Length of stay and in-hospital mortality decreased for all patients; however, postdischarge mortality increased for the highest-severity patients and decreased for the lowest-severity patients. Assessments of recent policy reforms and quality improvement programs should account for underlying differential trends in readmission rates based on patient severity.

Fostering change within organizational participants of multisectoral health care alliances.

Background: A touted advantage of multisectoral health care alliances is their ability to coordinate diverse constituencies and pursue community health goals in ways that allow them to make greater progress than each constituency could independently. However, participating organizations may have goals that do not entirely overlap or necessarily align with the alliance’s goals, which can weaken or undermine an alliance’s efforts. Fostering changes within participating organizations in ways that are consistent with the alliance’s goals (i.e., alliance-oriented change) may be one mechanism by which alliances can coordinate diverse activities and improve care in their local communities. Purpose: We examined whether alliance-oriented change within participating organizations is associated with alliance decision-making and conflict management style, level of participation, perceptions of alliance participation benefits and costs, and awareness of alliance activities within participating organizations. Methodology: The study used two rounds of survey data collected from organizational participants of 14 alliances participating in the Robert Wood Johnson Foundation’s Aligning Forces for Quality program. Findings: Alliance participants generally reported low levels of alliance-oriented change within their organizations as a result of the alliance and its activities. However, participants reporting higher levels of internal change in response to alliance activities had more positive perceptions of alliance decision-making style, higher levels of participation in alliance activities, more positive perceptions of alliance participation benefits relative to costs, and greater awareness of alliance activities across multiple levels of their respective organizations. Practice Implications: Despite relatively low levels of alliance-oriented change within participating organizations, alliances may still have the means to align the goal orientations of a diverse membership and foster change that may extend the reach of the alliance in the community.

What Influences the Awareness of Physician Quality Information? Implications for Medicare

OBJECTIVE Examine the factors that are associated with awareness of physician quality information (PQI) among older people with one or more chronic illnesses and the implications for Medicare. DATA SOURCES/STUDY SETTING Random digit-dial survey of adults with one or more chronic illnesses. RESEARCH DESIGN Structural equation modeling to examine factors related to awareness of PQI. RESULTS Awareness of PQI is low (13 percent), but comparable to findings in general population surveys. Age, race, education, and self-reported health status are associated with PQI awareness. Trust in the Internet as a source of health care information and not trusting ones physician as a source of information both are associated with a greater likelihood of being aware of PQI. Patients with high levels of activation have greater trust in physicians as information sources, but this is not associated with awareness, nor is degree of satisfaction with their care experience. CONCLUSIONS Awareness of PQI among older persons with chronic illnesses is relatively low across all socio-economic and demographic subgroups. Changes in population characteristics over time are unlikely to improve awareness in this population, nor are changes in patient activation or satisfaction with care. Medicare would need a broad-based effort if it wishes to raise PQI awareness among Medicare beneficiaries in the near term. Before undertaking resource-intensive efforts to increase awareness, Medicare may want to consider what level of awareness actually is needed to accomplish the overall objective for PQI transparency, which is raising the quality of care received by beneficiaries. It may be that relatively low levels of awareness are sufficient.

Patient-physician role relationships and patient activation: the moderating effects of race and ethnicity.

The goals of this article were to empirically describe how racial and ethnic minorities compare with Whites in terms of their role relationships with physicians and examine how differences in those relationships are associated (positively or negatively) with patient activation for minority groups, relative to Whites. Based on analysis of survey data collected from a random sample of 8,140 individuals with chronic illness, we found that both Blacks and Hispanics generally perceive their role relationships with physicians to be less equitable than do Whites and that the benefits to minorities from more equitable role relationships with physicians are not uniform across dimensions of patient–physician relationships or racial and ethnic subgroups. Based on these findings, we submit that race and ethnicity should be considered in the development and assessment of tailored interventions to improve activation.

Why and How Six Aligning Forces for Quality Communities Have Focused on Reducing Disparities

Public reports on provider performance can help guide consumers’ health care decisions, yet consumer awareness and use of public reports is low and may be even lower among racial/ethnic minorities. In this qualitative research article, we describe activities implemented by multi-stakeholder alliances in six U.S. communities to increase minorities’ awareness of public reports. We also describe alliances’ motivation for deliberately targeting greater awareness among minorities. We found that alliances’ decision was influenced by the proportion of minorities and perceptions of race-based disparities in care in the community. To raise awareness, alliances collaborated with minority-serving organizations to (a) advertise their web-based public report using ethnic media outlets, (b) present their public reporting website during health education outreach events held in minority communities, and (c) translate their public report into multiple languages. We conclude that community partnerships are a promising mechanism for targeting efforts to increase awareness of public reports in minority communities.