Robert L. Ohsfeldt

The Aftermath of Hip Fracture: Discharge Placement, Functional Status Change, and Mortality

The authors prospectively explored the consequences of hip fracture with regard to discharge placement, functional status, and mortality using the Survey on Assets and Health Dynamics Among the Oldest Old (AHEAD). Data from baseline (1993) AHEAD interviews and biennial follow-up interviews were linked to Medicare claims data from 1993-2005. There were 495 postbaseline hip fractures among 5,511 respondents aged >or=69 years. Mean age at hip fracture was 85 years; 73% of fracture patients were white women, 45% had pertrochanteric fractures, and 55% underwent surgical pinning. Most patients (58%) were discharged to a nursing facility, with 14% being discharged to their homes. In-hospital, 6-month, and 1-year mortality were 2.7%, 19%, and 26%, respectively. Declines in functional-status-scale scores ranged from 29% on the fine motor skills scale to 56% on the mobility index. Mean scale score declines were 1.9 for activities of daily living, 1.7 for instrumental activities of daily living, and 2.2 for depressive symptoms; scores on mobility, large muscle, gross motor, and cognitive status scales worsened by 2.3, 1.6, 2.2, and 2.5 points, respectively. Hip fracture characteristics, socioeconomic status, and year of fracture were significantly associated with discharge placement. Sex, age, dementia, and frailty were significantly associated with mortality. This is one of the few studies to prospectively capture these declines in functional status after hip fracture.

Factors motivating and affecting health information exchange usage.

OBJECTIVE Health information exchange (HIE) is the process of electronically sharing patient-level information between providers. However, where implemented, reports indicate HIE system usage is low. The aim of this study was to determine the factors associated with different types of HIE usage. DESIGN Cross-sectional analysis of clinical data from emergency room encounters included in an operational HIE effort linked to system user logs using crossed random-intercept logistic regression. MEASUREMENTS Independent variables included factors indicative of information needs. System usage was measured as none, basic usage, or a novel pattern of usage. RESULTS The system was accessed for 2.3% of all encounters (6142 out of 271,305). Novel usage patterns were more likely for more complex patients. The odds of HIE usage were lower in the face of time constraints. In contrast to expectations, system usage was lower when the patient was unfamiliar to the facility. LIMITATIONS Because of differences between HIE efforts and the fact that not all types of HIE usage (ie, public health) could be included in the analysis, results are limited in terms of generalizablity. CONCLUSIONS This study of actual HIE system usage identifies patients and circumstances in which HIE is more likely to be used and factors that are likely to discourage usage. The paper explores the implications of the findings for system redesign, information integration across exchange partners, and for meaningful usage criteria emerging from provisions of the Health Information Technology for Economic & Clinical Health Act.

Hospital episodes and physician visits: the concordance between self-reports and medicare claims.

Background:Health services use typically is examined using either self-reports or administrative data, but the concordance between the 2 is not well established. Objective:We evaluated the concordance of hospital and physician utilization data from self-reports and claims data, and identified factors associated with disagreement. Methods:We performed a secondary analysis on linked observational and administrative data. A national sample of 4310 respondents who were 70 years old or older at their baseline interviews was used. Self-reported and Medicare claims-based hospital episodes and physician visits for 12 months before baseline were examined. Kappa statistics were used to evaluate concordance, and multivariable multinomial logistic regression was used to identify factors associated with overreporting (self-reports > claims), underreporting (self-reports < claims), and concordant-reporting (self-reports ∼ claims). Results:The concordance of hospital episodes was high (κ = 0.767 for the 2 × 2 comparison of none vs. some and κ = 0.671 for the 6 × 6 comparison of none, 1, …, 4, or 5 or more), but concordance for physician visits was low (κ = 0.255 for the 2 × 2 comparison of none versus some and κ = 0.351 for the 14 × 14 comparison of none, 1, ..., 12, and 13 or more). Multivariable multinomial logistic regression indicated that over-, under-, and concordant-reporting of hospital episodes was significantly associated with gender, alcohol consumption, arthritis, cancer, heart disease, psychologic problems, lower body functional limitations, self-rated health, and depressive symptoms. Over-, under-, and concordant-reporting of physician visits were significantly associated with age, gender, race, living alone, veteran status, private health insurance, arthritis, cancer, diabetes, hypertension, heart disease, lower body functional limitations, and poor memory. Conclusions:Concordance between self-reported and claims-based hospital episodes was high, but concordance for physician visits was low. Factors significantly associated with bidirectional (over- and underreporting) and unidirectional (over- or underreporting) error patterns were detected. Therefore, caution is advised when drawing conclusions based on just one physician visit data source.

Differences in income between male and female physicians.

Previous studies suggest that female physicians earn less on average from the practice of medicine than their male counterparts even after differences in personal characteristics are taken into account. In our study of sex differences in physician earnings, we estimate hourly earnings equations for 1982 using a specification that controls for differences in personal characteristics between male and female physicians more completely than the specification used in previous studies. We also employ more precise estimators for the unexplained earnings differential. Our results suggest that previous studies have overstated the unexplained differential in hourly earnings. We find that female physicians in 1982 earned 12-13 percent less than male physicians due to discrimination or unexplained factors.

Prenatal care effectiveness and utilization in Brazil

The impact of prenatal care use on birth outcomes has been understudied in South American countries. This study assessed the effects of various measures of prenatal care use on birth weight (BW) and gestational age outcomes using samples of infants born without and with common birth defects from Brazil, and evaluated the demand for prenatal care. Prenatal visits improved BW in the group without birth defects through increasing both fetal growth rate and gestational age, but prenatal care visits had an insignificant effect on BW in the group with birth defects when adjusting for gestational age. Prenatal care delay had no effects on BW in both infant groups but increased preterm birth risk in the group without birth defects. Inadequate care versus intermediate care also increased LBW risk in the group without birth effects. Quantile regression analyses revealed that prenatal care visits had larger effects at low compared with high BW quantiles. Several other prenatal factors and covariates such as multivitamin use and number of previous live births had significant effects on the studied outcomes. The number of prenatal care visits was significantly affected by several maternal health and fertility indicators. Significant geographic differences in utilization were observed as well. The study suggests that more frequent use of prenatal care can increase BW significantly in Brazil, especially among pregnancies that are uncomplicated with birth defects but that are at high risk for low birth weight. Further research is needed to understand the effects of prenatal care use for pregnancies that are complicated with birth defects.

The Economics of Specialty Hospitals

Specialty hospitals, particularly those specializing in surgery and owned by physicians, have generated a relatively high degree of policy attention over the past several years. The main focus of policy debates has been in two areas: the extent to which specialty hospitals might compete unfairly with incumbent general hospitals and the extent to which physician ownership might be associated with higher usage. Largely absent from the debates, however, has been a discussion of the basic economic model of specialty hospitals. This article reviews existing literature, reports, and findings from site visits to explore the economic rationale for specialty hospitals. The discussion focuses on six factors associated with specialization: consumer demand, procedural operating margins, clinical efficiencies, procedural economies of scale, economies (and diseconomies) of scope, and competencies and learning. A better understanding of the economics of specialization will help policy makers evaluate the full spectrum of advantages and disadvantages of specialty hospitals.

Letter: Effects of tobacco excise taxes on the use of smokeless tobacco products in the USA

Data from the September 1985 Current Population Survey are used to estimate the effects of tobacco excise taxes and state laws restricting smoking in public places on the likelihood of current use of cigarettes or smokeless tobacco (ST) products (moist snuff or chewing tobacco) among males in the USA. The results indicate that higher ST excise tax rates are associated with a reduced probability of ST use, whereas higher cigarette excise tax rates are associated with an increased probability of ST use, holding other factors constant. State laws restricting smoking have no apparent effect on ST use.

The determinants of the choice between public and private production of a publicly funded service

The public choice literature contains little formal analysis of the bureaucratic choice of production modes — public or private — of publicly funded services. An important question to be addressed is why some governmental bodies choose to provide a publicly funded service with publicly owned and operated production units whereas other governmental bodies contract with private firms to provide the same publicly funded service. This paper is the first formal attempt to remedy this gap in the literature. We develop a theoretical explanation of the government decision makers choice between public and private production modes based on utility maximizing behavior. We then examine empirically this choice employing logit analysis. The empirical results, which include several tests for robustness, confirm our theoretical explanation. The results are significant and suggest that non-monetary constraints are an important factor affecting this choice of production modes and that monetary constraints are less influential.

Squeezing the Balloon: Propensity Scores and Unmeasured Covariate Balance

OBJECTIVE To assess the covariate balancing properties of propensity score-based algorithms in which covariates affecting treatment choice are both measured and unmeasured. DATA SOURCES/STUDY SETTING A simulation model of treatment choice and outcome. STUDY DESIGN Simulation. DATA COLLECTION/EXTRACTION METHODS Eight simulation scenarios varied with the values placed on measured and unmeasured covariates and the strength of the relationships between the measured and unmeasured covariates. The balance of both measured and unmeasured covariates was compared across patients either grouped or reweighted by propensity scores methods. PRINCIPAL FINDINGS Propensity score algorithms require unmeasured covariate variation that is unrelated to measured covariates, and they exacerbate the imbalance in this variation between treated and untreated patients relative to the full unweighted sample. CONCLUSIONS The balance of measured covariates between treated and untreated patients has opposite implications for unmeasured covariates in randomized and observational studies. Measured covariate balance between treated and untreated patients in randomized studies reinforces the notion that all covariates are balanced. In contrast, forced balance of measured covariates using propensity score methods in observational studies exacerbates the imbalance in the independent portion of the variation in the unmeasured covariates, which can be likened to squeezing a balloon. If the unmeasured covariates affecting treatment choice are confounders, propensity score methods can exacerbate the bias in treatment effect estimates.

Failure to recognize and act on abnormal test results: the case of screening bone densitometry.

BACKGROUND Failure to follow up on abnormal test results is common. A model was developed to capture the reasons why providers did not take action on abnormal test results. METHODS A systematic review of the medical literature was conducted to identify why providers did not follow up on test results. The reasons were then synthesized to develop an operational model. The model was tested by reviewing electronic medical records of consecutive patients diagnosed with osteoporosis through a dual-energy x-ray absorptiometry (DXA) scan to determine whether: (1) the scan results had been reeviewed; (2) therapy was recommended; (3) the scan results were not reviewed and why this occurred. RESULTS Of the 48 newly diagnosed osteoporosis patients, 16 did not receive a recommendation to begin treatment. There was no evidence that the scan results wrere reviewed in 11 of the 16 cases (23% of all abnormal scans); the scan results of an additional 5 patients were reviewed but no treatment was recommended. DISCUSSION AND CONCLUSIONS A clinically significant ercentage of DXA scan results went unrecognized. As a long-term solution, direct patient notification could theoretically reduce the burden on providers, activate and empower patients, and create a back-up system for ensuring that patients are notified of their test results.