Mary Ellen Murray

A randomized trial of a tailored barriers intervention for Cancer Information Service (CIS) callers in pain

ABSTRACT Cancer pain management can be improved by overcoming patients’ attitudinal barriers to reporting pain and using analgesics. A simple cost‐effective barriers intervention designed to reach a large number of persons with cancer has not yet been tested. Such an intervention should be tested against barriers’ assessment‐alone, as well as no‐treatment control. The purpose of this study was to test the efficacy and the cost effectiveness of a tailored barriers intervention (TBI), an educational intervention tailored to participants’ attitudinal barriers toward reporting pain and using analgesics. This was a randomized three‐group (TBI, assessment‐alone, or control) trial with measures at baseline and 28 days later conducted at the NorthCentral and Heartland offices of the Cancer Information Service (CIS), an NCI program that provides information to persons seeking answers to cancer‐related questions. Participants (1256 adult CIS callers diagnosed with cancer with moderate to severe pain in the past week) joined the study and were randomized. Of these participants, 970 (77.23%) provided follow‐up data. The TBI consisted of educational messages tailored to each participant’s attitudinal barriers, delivered orally over the telephone, followed by a printed mailed copy. The outcome measures were attitudinal barriers to pain management, as well as pain outcomes (duration, severity, and interference with life activities). At follow‐up the TBI group had significantly lower attitudinal barriers scores compared to assessment‐alone and control, but the groups did not differ on the pain outcome variables. TBI and assessment‐alone had similar cost effectiveness. The TBI needs to be strengthened to achieve reductions in pain severity.

A Test of Mental Health Parity: Comparisons of Outcomes of Hospital Concurrent Utilization Review

The Mental Health Parity Act of 1996 had as its goal the equity of coverage of mental health care and physical health care. The purpose of this study was to examine the outcomes of hospital concurrent utilization review as a measure of the progress toward the equity goal. The study examined 4 years of denials of certification for reimbursement by payers of inpatient care (1998–2001). Psychiatry was first compared to clinical services with a like number of annual admissions and then compared to clinical services with a like number of concurrent reviews. For each year, psychiatry had the highest numbers of cases denied and patient days denied. The most frequent reason for a psychiatric denial was that the inpatient benefit level had been exceeded. There was only one instance, in 4 years, when this reason (benefit limit exceeded) was given for a patient with a physical illness. This study provides evidence of the current inequity of reimbursement for treatment of mental illness.

Substitution of hospital staff in concurrent utilization review.

Substitution of hospital staff performing concurrent utilization review (CUR) was evaluated using a production process framework. There were no differences in the number of reimbursement denials or denied days among 4 job classifications of hospital staff performing CUR, indicating that educational preparation of staff did not affect outcomes. The implications are that hospitals could substitute assistive staff in place of registered nurses to complete the CUR function, potentially increasing the availability of professional nurses.

A Model for Economic Evaluation of Health Technology

A production process model of resource utilization is proposed as a way to guide economic evaluation of health care technology. The model is illustrated in a project that is a three-year study being directed by Dr. Patricia Flatley Brennan through application to an existing randomized clinical trial, the “HeartCare” project. The purpose of the original study, HeartCare, is to study the impact of an Internet-based technology on nursing practice and patient outcomes. This model provides a structure to analyze costs of the research technology from three time perspectives: (1) development of the technology, (2) implementation, and (3) maintenance of the technology. Patient perception of the value of the technology was also studied. The economic analysis uses two strategies, cost analysis and willingness to pay (WTP) to evaluate the HeartCare research project.