Marco D. Huesch

Public hospital quality report awareness: evidence from National and Californian Internet searches and social media mentions, 2012

Objectives Publicly available hospital quality reports seek to inform consumers of important healthcare quality and affordability attributes, and may inform consumer decision-making. To understand how much consumers search for such information online on one Internet search engine, whether they mention such information in social media and how positively they view this information. Setting and design A leading Internet search engine (Google) was the main focus of the study. Google Trends and Google Adwords keyword analyses were performed for national and Californian searches between 1 August 2012 and 31 July 2013 for keywords related to ‘top hospital’, best hospital’, and ‘hospital quality’, as well as for six specific hospital quality reports. Separately, a proprietary social media monitoring tool was used to investigate blog, forum, social media and traditional media mentions of, and sentiment towards, major public reports of hospital quality in California in 2012. Primary outcome measures (1) Counts of searches for keywords performed on Google; (2) counts of and (3) sentiment of mentions of public reports on social media. Results National Google search volume for 75 hospital quality-related terms averaged 610 700 searches per month with strong variation by keyword and by state. A commercial report (Healthgrades) was more commonly searched for nationally on Google than the federal governments Hospital Compare, which otherwise dominated quality-related search terms. Social media references in California to quality reports were generally few, and commercially produced hospital quality reports were more widely mentioned than state (Office of Statewide Healthcare Planning and Development (OSHPD)), or non-profit (CalHospitalCompare) reports. Conclusions Consumers are somewhat aware of hospital quality based on Internet search activity and social media disclosures. Public stakeholders may be able to broaden their quality dissemination initiatives by advertising on Google or Twitter and using social media interactively with consumers looking for relevant information.

MEASURING THE EFFECT OF POLICY INTERVENTIONS AT THE POPULATION LEVEL: SOME METHODOLOGICAL CONCERNS

Health policy evaluations estimate the response of population aggregate outcomes to interventions. However, clarity on the form of the expected causal relationship, the parameter identification strategy, and the mode of hypothesis testing is required to overcome a number of conceptual and methodological problems. We use the New Jersey statewide smoking ban as an example. We examine statewide admission rates for acute myocardial infarctions, strokes and lower limb fractures, and emergency room encounter rates for asthma exacerbations before and after the smoking ban. We discuss the identification options and show the sensitivity of estimates of the response function to different specifications of the stochastic and intervention components and to different modes of inference. Model misspecification is demonstrated by rolling Chow tests for structural breaks in repeated observations.

Using Social Media, Online Social Networks, and Internet Search as Platforms for Public Health Interventions: A Pilot Study

OBJECTIVE To pilot public health interventions at women potentially interested in maternity care via campaigns on social media (Twitter), social networks (Facebook), and online search engines (Google Search). DATA SOURCES/STUDY SETTING Primary data from Twitter, Facebook, and Google Search on users of these platforms in Los Angeles between March and July 2014. STUDY DESIGN Observational study measuring the responses of targeted users of Twitter, Facebook, and Google Search exposed to our sponsored messages soliciting them to start an engagement process by clicking through to a study website containing information on maternity care quality information for the Los Angeles market. PRINCIPAL FINDINGS Campaigns reached a little more than 140,000 consumers each day across the three platforms, with a little more than 400 engagements each day. Facebook and Google search had broader reach, better engagement rates, and lower costs than Twitter. Costs to reach 1,000 targeted users were approximately in the same range as less well-targeted radio and TV advertisements, while initial engagements-a user clicking through an advertisement-cost less than

Is blood thicker than water? Peer effects in stent utilization among Floridian cardiologists

1 each. CONCLUSIONS Our results suggest that commercially available online advertising platforms in wide use by other industries could play a role in targeted public health interventions.

Measurement and risk adjustment of prelabor cesarean rates in a large sample of California hospitals

Variations in physician practice are pervasive and costly, and may be harmful. The objective of much policy in the West is to increase the interconnectedness of physicians, furthering the transfer of information and thus reducing variation. This study tests whether physicians are influenced by the practice of peers, or if propensity, mere context or sorting of like-minded physicians better explain similarities and differences in practice. We study US cardiologists who place coronary stents into patients with blocked arteries around the heart. Organized in locally competing physician groups and also as solo practitioners, they see patients in offices, but insert the stents at a shared production facility - the cath lab. We examine their use of the popular drug-eluting coronary stents between their launch and rapid adoption in early 2003, and through the period of late 2006 in which private and public reports of serious late side-effects eventually led to reductions in use. Our analyses use administrative claims data on nearly 1000 cardiologists and their patients in Florida, USA, merged with Florida physician licensure data. Collectively these physicians used these stents nearly a quarter of a million times in the 4 year period reviewed. Pooled and panel linear regressions for device utilization by a physicians are estimated using measures of peer utilization, physician characteristics and controls for unobservable physician characteristics, common shocks and selection effects. We find strong evidence for intra-group but against inter-group practice spillovers. Even when sharing the same lab, competing cardiologists did not appear to correlate practices. Our results are consistent with a view that policies aimed at increasing the interconnectedness of physicians must first consider the organizational barriers and competitive forces that can stymie knowledge transfer even among physicians working closely together.

Factors associated with increased cesarean risk among African American women: evidence from California, 2010.

OBJECTIVE Prelabor cesareans in women without a prior cesarean is an important quality measure, yet one that is seldom tracked. We estimated patient-level risks and calculated how sensitive hospital rankings on this proposed quality metric were to risk adjustment. STUDY DESIGN This retrospective cohort study linked Californian patient data from the Agency for Healthcare Research and Quality with hospital-level operational and financial data. Using the outcome of primary prelabor cesarean, we estimated patient-level logistic regressions in progressively more detailed models. We assessed incremental fit and discrimination, and aggregated the predicted patient-level event probabilities to construct hospital-level rankings. RESULTS Of 408,355 deliveries by women without prior cesareans at 254 hospitals, 11.0% were prelabor cesareans. Including age, ethnicity, race, insurance, weekend and unscheduled admission, and 12 well-known patient risk factors yielded a model c-statistic of 0.83. Further maternal comorbidities, and hospital and obstetric unit characteristics only marginally improved fit. Risk adjusting hospital rankings led to a median absolute change in rank of 44 places compared to rankings based on observed rates. Of the 48 (49) hospitals identified as in the best (worst) quintile on observed rates, only 23 (18) were so identified by the risk-adjusted model. CONCLUSION Models predict primary prelabor cesareans with good discrimination. Systematic hospital-level variation in patient risk factors requires risk adjustment to avoid considerably different classification of hospitals by outcome performance. An opportunity exists to define this metric and report such risk-adjusted outcomes to stakeholders.

Why technology matters as much as science in improving healthcare

OBJECTIVES We studied if both observed and unobserved maternal health in African American women in hospitals or communities were associated with cesarean delivery of infants. METHODS We examined the relationship between African American race and cesarean delivery among 493 433 women discharged from 255 Californian hospitals in 2010 using administrative data; we adjusted for patient comorbidities and maternal, fetal, and placental risk factors, as well as clustering of patients within hospitals. RESULTS Cesarean rates were significantly higher overall for African American women than other women (unadjusted rate 36.8% vs 32.7%), as were both elective and emergency primary cesarean rates. Elevated risks persisted after risk adjustment (odds ratio generally > 1.27), but the prevalence of particular risk factors varied. Although African American women were clustered in some hospitals, the proportion of African Americans among all women delivering in a hospital was not related to its overall cesarean rate. CONCLUSIONS To address the higher likelihood of elective cesarean delivery, attention needs to be given to currently unmeasured patient-level health factors, to the quality of provider-physician interactions, as well as to patient preferences.

External Adjustment Sensitivity Analysis for Unmeasured Confounding: An Application to Coronary Stent Outcomes, Pennsylvania 2004–2008

BackgroundMore than half a million new items of biomedical research are generated every year and added to Medline. How successful are we at applying this steady accumulation of scientific knowledge and so improving the practice of medicine in the USA?DiscussionThe conventional wisdom is that the US healthcare system is plagued by serious cost, access, safety and quality weaknesses. A comprehensive solution must involve the better translation of an abundance of clinical research into improved clinical practice.Yet the application of knowledge (i.e. technology) remains far less well funded and less visible than the generation, synthesis and accumulation of knowledge (i.e. science), and the two are only weakly integrated. Worse, technology is often seen merely as an adjunct to practice, e.g. electronic health records.Several key changes are in order. A helpful first step lies in better understanding the distinction between science and technology, and their complementary strengths and limitations. The absolute level of funding for technology development must be increased as well as being more integrated with traditional science-based clinical research. In such a mission-oriented federal funding strategy, the ties between basic science research and applied research would be better emphasized and strengthened.SummaryIt bears repeating that only by applying the wealth of existing and future scientific knowledge can healthcare delivery and patient care ever show significant improvement.

Cesarean delivery on maternal request.

BACKGROUND Assessing the real-world comparative effectiveness of common interventions is challenged by unmeasured confounding. OBJECTIVE To determine whether the mortality benefit shown for drug-eluting stents (DES) over bare metal stents (BMS) in observational studies persists after controls for/tests for confounding. DATA SOURCES/STUDY SETTING Retrospective observational study involving 38,019 patients, 65 years or older admitted for an index percutaneous coronary intervention receiving DES or BMS in Pennsylvania in 2004-2005 followed up for death through 3 years. STUDY DESIGN Analysis was at the patient level. Mortality was analyzed with Cox proportional hazards models allowing for stratification by disease severity or DES use propensity, accounting for clustering of patients. Instrumental variables analysis used lagged physician stent usage to proxy for the focal stent type decision. A method originating in work by Cornfield and others in 1954 and popularized by Greenland in 1996 was used to assess robustness to confounding. PRINCIPAL FINDINGS DES was associated with a significantly lower adjusted risk of death at 3 years in Cox and in instrumented analyses. An implausibly strong hypothetical unobserved confounder would be required to fully explain these results. CONCLUSIONS Confounding by indication can bias observational studies. No strong evidence of such selection biases was found in the reduced risk of death among elderly patients receiving DES instead of BMS in a Pennsylvanian state-wide population.

Slippery Slopes and Landing on Your Feet

to increased surface expression with the putative result of an increased proinflammatory response. However, it was recently shown for the TLR1 I602S genotype that homozygosity for the minor allele protects against gastric disease and that this protection is mediated by an increased Th1 response.2 In other studies, in agreement with our hypothesis, the cytokine profile of specific H pylori–induced dendritic cells polarizes the balance between mucosal Th1 and Th17 cells on one side and regulatory T-helper cells on the other side toward a response biased by regulatory T-helper cells.3 This explains the previously paradoxical finding that TLR2-deficient mice are able to clear H pylori more effectively than wild-type mice, similar to the findings from our study.4 Although we remain convinced that our proposed mechanism is the relevant one for H pylori infection, and this appears to be confirmed by Yang et al,2 we find the hypothesis of Wurfel and Hawn intriguing and agree that only in-depth experimental studies will resolve the issue. We believe that their arguments and interpretation are valid for a disease like sepsis, but would suggest that H pylori infection (a smoldering inflammatory reaction in which the pathogen has found its specific niche) is controlled by a tight balance between innate and adaptive immune responses.