Ming Tai-Seale

The effect of report cards on consumer choice in the health insurance market

We test the effect of report cards on consumer choice in the HMO market. Federal employees were provided with report cards on a limited basis in 1995 and then on a widespread basis in 1996. Exploiting this natural experiment, we find that subjective measures of quality and coverage influence plan choices, after controlling for plan premiums, expected out of pocket expenses and service coverages. The effect is stronger within a small sample of new hires compared to a larger sample of existing federal employees. We also find evidence that report cards increase the price elasticity of demand for health insurance.

Context Matters: The Experience of 14 Research Teams in Systematically Reporting Contextual Factors Important for Practice Change

PURPOSE We aimed to advance the internal and external validity of research by sharing our empirical experience and recommendations for systematically reporting contextual factors. METHODS Fourteen teams conducting research on primary care practice transformation retrospectively considered contextual factors important to interpreting their findings (internal validity) and transporting or reinventing their findings in other settings/situations (external validity). Each team provided a table or list of important contextual factors and interpretive text included as appendices to the articles in this supplement. Team members identified the most important contextual factors for their studies. We grouped the findings thematically and developed recommendations for reporting context. RESULTS The most important contextual factors sorted into 5 domains: (1) the practice setting, (2) the larger organization, (3) the external environment, (4) implementation pathway, and (5) the motivation for implementation. To understand context, investigators recommend (1) engaging diverse perspectives and data sources, (2) considering multiple levels, (3) evaluating history and evolution over time, (4) looking at formal and informal systems and culture, and (5) assessing the (often nonlinear) interactions between contextual factors and both the process and outcome of studies. We include a template with tabular and interpretive elements to help study teams engage research participants in reporting relevant context. CONCLUSIONS These findings demonstrate the feasibility and potential utility of identifying and reporting contextual factors. Involving diverse stakeholders in assessing context at multiple stages of the research process, examining their association with outcomes, and consistently reporting critical contextual factors are important challenges for a field interested in improving the internal and external validity and impact of health care research.

Two-Minute Mental Health Care for Elderly Patients: Inside Primary Care Visits

OBJECTIVES: To assess how care is delivered for mental disorders using videotapes of office visits involving elderly patients.

Understanding Primary Care Physicians' Propensity to Assess Elderly Patients for Depression Using Interaction and Survey Data.

Objective:The objective of this study was to examine primary care physicians’ propensity to assess their elderly patients for depression using data from videotapes and patient and physician surveys. Study Design:An observational study was informed by surveys of 389 patients and 33 physicians, and 389 videotapes of their clinical interactions. Secondary quantitative analyses used video data scored by the Assessment of Doctor–Elderly Patient Transactions system regarding depression assessment. A random-effects logit model was used to analyze the effects of patient health, competing demands, and racial and gender concordance on physicians’ propensity to assess elderly patients for depression. Results:Physicians assessed depression in only 14% of the visits. The use of formal depression assessment tools occurred only 3 times. White patients were almost 7 times more likely than nonwhite patients to be assessed for depression (odds ratio [OR], 6.9; P < 0.01). Depression assessment was less likely if the patient functioned better emotionally (OR, 0.95; P < 0.01). The propensity of depression assessment was higher in visits that covered multiple topics (OR, 1.3; P < 0.01) contrary to the notion of competing demands crowding out mental health services. Unexpectedly, depression assessment was less likely to occur in gender and racially concordant patient–physician dyads. Conclusions:Primary care physicians assessed their elderly patients for depression infrequently. Reducing the number of topics covered in visits and matching patients and physicians based on race and gender may be counterproductive to depression detection. Informed by videotapes and surveys, our findings offer new insights on the actual care process and present conclusions that are different from studies based on administrative or survey data alone.

A conceptual model of the role of complexity in the care of patients with multiple chronic conditions.

Background:Effective healthcare for people with multiple chronic conditions (MCC) is a US priority, but the inherent complexity makes both research and delivery of care particularly challenging. As part of AHRQ Multiple Chronic Conditions Research Network (MCCRN) efforts, the Network developed a conceptual model to guide research in this area. Objective:To synthesize methodological and topical issues relevant to MCC patient care into a framework that can improve the delivery of care and advance future research about caring for patients with MCC. Methods:The Network synthesized essential constructs for MCC research identified from roundtable discussion, input from expert advisors, and previously published models. Results:The AHRQ MCCRN conceptual model defines complexity as the gap between patient needs and healthcare services, taking into account both the multiple considerations that affect the needs of MCC patients, as well as the contextual factors that influence service delivery. The model reframes processes and outcomes to include not only clinical care quality and experience, but also patient health, well being, and quality of life. The single-condition paradigm for treating needs one-by-one falls apart and highlights the need for care systems to address dynamic patient needs. Conclusions:Defining complexity in terms of the misalignment between patient needs and services offers new insights in how to research and develop solutions to patient care needs.

Toward personalizing treatment for depression: predicting diagnosis and severity

Objective Depression is a prevalent disorder difficult to diagnose and treat. In particular, depressed patients exhibit largely unpredictable responses to treatment. Toward the goal of personalizing treatment for depression, we develop and evaluate computational models that use electronic health record (EHR) data for predicting the diagnosis and severity of depression, and response to treatment. Materials and methods We develop regression-based models for predicting depression, its severity, and response to treatment from EHR data, using structured diagnosis and medication codes as well as free-text clinical reports. We used two datasets: 35 000 patients (5000 depressed) from the Palo Alto Medical Foundation and 5651 patients treated for depression from the Group Health Research Institute. Results Our models are able to predict a future diagnosis of depression up to 12 months in advance (area under the receiver operating characteristic curve (AUC) 0.70–0.80). We can differentiate patients with severe baseline depression from those with minimal or mild baseline depression (AUC 0.72). Baseline depression severity was the strongest predictor of treatment response for medication and psychotherapy. Conclusions It is possible to use EHR data to predict a diagnosis of depression up to 12 months in advance and to differentiate between extreme baseline levels of depression. The models use commonly available data on diagnosis, medication, and clinical progress notes, making them easily portable. The ability to automatically determine severity can facilitate assembly of large patient cohorts with similar severity from multiple sites, which may enable elucidation of the moderators of treatment response in the future.

Prioritization of evidence-based preventive health services during periodic health examinations

BACKGROUND Delivery of preventive services sometimes falls short of guideline recommendations. PURPOSE To evaluate the multilevel factors associated with evidence-based preventive service delivery during periodic health examinations (PHEs). METHODS Primary care physicians were recruited from an integrated delivery system in southeast Michigan. Audio recordings of PHE office visits conducted from 2007 to 2009 were used to ascertain physician recommendation for or delivery of 19 guideline-recommended preventive services. Alternating logistic regression was used to evaluate factors associated with service delivery. Data analyses were completed in 2011. RESULTS Among 484 PHE visits to 64 general internal medicine and family physicians by insured patients aged 50-80 years, there were 2662 services for which patients were due; 54% were recommended or delivered. Regression analyses indicated that the likelihood of service delivery decreased with patient age and with each concern the patient raised, and it increased with increasing BMI and with each additional minute after the scheduled appointment time the physician first presented. The likelihood was greater with patient-physician gender concordance and less if the physician used the electronic medical record in the exam room or had seen the patient in the past 12 months. CONCLUSIONS A combination of patient, patient-physician relationship, and visit contextual factors are associated with preventive service delivery. Additional studies are warranted to understand the complex interplay of factors that support and compromise preventive service delivery.

Determinants of Antidepressant Treatment Compliance: Implications for Policy:

Depression is among the most prevalent, devastating, and undertreated disorders in our society. Treatment with antidepressant medications is effective in controlling symptoms, but treatment beyond the point of symptom resolution is necessary to restore functional status and prevent recurrent episodes. An important step in improving compliance is to identify the determinants of antidepressant treatment compliance. A broader motivation for our study is to examine compliance by patients with a chronic but treatable disease. With claims data between 1990 and 1993, this study uses logistic regression analysis to examine the determinants of compliance among 2,012 antidepressant recipients. The results show that initiating treatment with a tricyclic antidepressant reduces the probability of antidepressant treatment compliance. Initiating treatment with a selective serotonin reuptake inhibitor and undergoing family, group, or individual psychotherapy treatments increase the probability of compliance. Case management does not meaningfully affect compliance. Implications for policy and clinical practice are discussed.

Analyses of nursing home residents with multiple sclerosis and depression using the Minimum Data Set

Depression is the most common psychiatric condition among people with multiple sclerosis (MS). A total of 14 009 people with MS at admission to a nursing facility were analyzed using the Minimum Data Set and 36% also had depression. This study developed profiles of nursing home residents with MS who also had depression and compared them with other residents with MS. MS residents with depression were significantly more likely to be female and younger than other MS residents, with significant racial differences as well. MS residents with depression were significantly more likely than other MS residents to have a history of mental health conditions, exhibit mood indicators, and have unsettled relationships. Both groups of MS residents had high levels of physical disability, although MS residents with depression tended to be slightly less disabled. MS residents with depression were more likely than other MS residents to experience daily pain and more likely to have the diseases common to all residents with MS. This research found that most MS residents with depression did not receive mental health services, demonstrating that nursing facilities must improve the mental healthcare provided to residents with MS with depression.

Management of chronic pain among older patients: Inside primary care in the US

Under‐treatment of pain is a worldwide problem. We examine how often pain was addressed and the factors that influence how much time was spent on treating pain.