Samuel C. Haffer

Health‐related quality of life of cancer and noncancer patients in Medicare managed care

Data from the Health Care Financing Administrations (HCFA) Medicare Health Outcomes Survey (MHOS) of patients enrolled in managed care services through Medicare were analyzed. The MHOS provided baseline estimates of quality of life of cancer survivors in comparison to a frequency age‐matched cohort of noncancer patients.

The health status of elderly veteran enrollees in the Veterans Health Administration

Objectives: To examine the health status of elderly veteran enrollees, stratified by age group, and compare with nonveteran populations.

Risk-adjusted mortality as an indicator of outcomes: comparison of the Medicare Advantage Program with the Veterans' Health Administration.

Background:The Medicare Advantage Program (MAP) and the Veterans’ Health Administration (VHA) currently provide many services that benefit the elderly, and a comparative study of their risk-adjusted mortality rates has the potential to provide important information regarding these 2 systems of care. Objective:The objective of this retrospective study was to compare mortality rates between the MAP and the VHA after controlling for case-mix differences. Subjects:This study consisted of 584,294 MAP patients and 420,514 VHA patients. Measures:We used the Death Master File to ascertain the vital status of each study subject over approximately 4 years. We used Cox regression models to estimate hazard ratios (HRs) with 95% confidence intervals (CIs) for the MAP compared with VHA patients. Results:The average age for male MAP patients was 73.8 years (±5.6) and for male VHA patients was 74.05 years (±6.3). Unadjusted mortality rates of males for VHA and MAP were 25.7% and 22.8%, respectively, over approximately 4 years (P < 0.0001), respectively. The case-mix of VHA patients, however, was sicker than those from MAP. After adjusting for case-mix, the HR for mortality in the MAP was significantly higher than that in the VHA (HR, 1.404; 95% CI = 1.383–1.426). We obtained similar results when we compared the mortality rates of females for VHA and MAP. Conclusions:After adjusting for their higher prevalence of chronic disease and worse self-reported health, mortality rates were lower for patients cared for in the VHA compared with those in the MAP. Further studies should examine what differences in care structures and processes contribute to lower mortality in the VHA.

Patients' self-report of diseases in the Medicare Health Outcomes Survey based on comparisons with linked survey and medical data from the Veterans Health Administration.

We evaluated the patient self-report questions about disease from the Medicare Health Outcomes Survey (HOS), using linked Veterans Health Administration (VA) data for patients who are eligible for both Medicare and Veterans Affairs (VA) care to estimate their utility as measures of illness burden. Patients were classified for 12 diseases on the basis of HOS question responses and these were compared with classifications based on similar questions from a VA survey or diagnostic codes from VA medical records. Agreement between classifications based on the 2 surveys was good with over 75% of patients affirming the disease in the HOS also affirming it in the VA survey for most diseases. HOS disease status also agreed well with VA-based disease status using diagnostic codes for most diseases, with reasonably good specificity (70%–94%) and sensitivity (65%–85%). The relatively poor measures of agreement for some of the conditions could be related to differences in question wording and other factors. These findings varied only slightly by education, age, and race. Furthermore, independent decrements in health status, derived from the SF-36 associated with each disease based on the survey questions, were similar in the 2 surveys. These results suggest that patients can provide reasonably good reports of their morbidity in survey questions and that patient self-report questions about disease can be used reliably in case-mix adjustments and in stratifications of patients by diseases.

Change in health-related quality of life of newly diagnosed cancer patients, cancer survivors, and controls*

Data from the 1998 Health Outcomes Survey (HOS) of patients who were enrolled in Medicare managed care and follow‐up data from the 2000 HOS resurvey were analyzed to examine changes in health‐related quality of life (HRQOL) of newly diagnosed cancer patients, cancer survivors, and patients without cancer.

Smoking and functional status among Medicare managed care enrollees.

BACKGROUND Smoking is a major determinant of health status and outcomes. Current smoking has been associated with lower scores on the Short Form-36 Health Survey (SF-36). Whether this occurs among the elderly and disabled Medicare populations is not known. This study assessed the relationships between smoking status and both physical and mental functioning in the Medicare managed-care population. METHODS During the spring of 1998, data were collected from 134309 elderly and 8640 disabled Medicare beneficiaries for Cohort 1, Round 1 of the Medicare Health Outcomes Survey. We subsequently used these data to calculate mean standardized SF-36 scores, self-reported health status, and prevalence of smoking-related illness, by smoking status, after adjusting for demographic factors. RESULTS Among the disabled, everyday and someday smokers had lower standardized physical component (PCS) and mental component (MCS) scores than never smokers (-2.4 to -4.5 points; p <0.01 for all). Among the elderly, the lowest PCS and MCS scores were seen among recent quitters (-5.1 and -3.7 points, respectively, below those for never smokers; p <0.01 for both), but current smokers also had significantly lower scores on both scales. For the elderly and disabled populations, MCS scores of long-term quitters were the same as nonsmokers. Similar patterns were seen across all eight SF-36 scales. Ever smokers had higher odds of reporting both less-than-good health and a history of smoking-related chronic disease. CONCLUSIONS In the elderly and disabled Medicare populations, smokers report worse physical and mental functional status than never smokers. Long-term quitters have better functional status than those who still smoke. More effort should be directed at helping elderly smokers to quit earlier. Smoking cessation has implications for improving both survival and functional status.

Association of Health Plans' Healthcare Effectiveness Data and Information Set (HEDIS) Performance With Outcomes of Enrollees With Diabetes

Background:Few quality of care evaluations examine the relationship between clinical processes and patient outcomes. Objective:To determine the association between health plan performance on Healthcare Effectiveness Data and Information Set (HEDIS) clinical processes and intermediate outcome measures and Health Outcomes Survey (HOS) self-reported physical and mental health scores among Medicare plan enrollees with diabetes. Research Design:Secondary data analysis of 2002 HEDIS and 2001–2003 HOS data. Subjects:This study focused on Medicare plan enrollees with self-reported diabetes (N = 8184). Measures:Plan-level HEDIS diabetes care measures for 2002 and longitudinal, patient-level 2001–2003 HOS physical and mental health outcomes scores. Hierarchical linear models estimated the relationship between plan HEDIS performance on diabetes process of care and intermediate outcome measures and 2-year changes in enrollee HOS physical and mental health scores. Results:Each 10% point improvement in plan performance on HEDIS intermediate outcomes (ie, the proportion of well-controlled diabetes) was related to significant positive increase in the probability of being healthy as measured by both enrollee physical health scores (7 percentage point increase, P < 0.05) and mental health scores (11 percentage point increase, P < 0.01). Similar increases in plan process of care measures were associated with increases in the probability of being healthy as measured by enrollee mental health scores (11 percentage point increase, P < 0.001). Conclusions:This study represents one of the first attempts to link plan HEDIS performance to changes in enrollee health. The results suggest that improved quality of care, as measured by process and intermediate outcomes measures for diabetes, can result in better health among patients with diabetes. Further research should address whether this relationship exists in other quality measures, clinical conditions, and populations.

Do Community and Caregiver Factors Influence Hospice Use at the End of Life Among Older Adults With Alzheimer Disease

Hospice is an underused service among people with Alzheimer disease. This study used the Hospice Use Model to examine community, care recipient, and caregiver characteristics associated with hospice use before death among 145 community-dwelling care recipients with Alzheimer disease and their caregivers. Secondary analysis using logistic regression modeling indicated that older age, male gender, black race, and better functional health of care recipients with Alzheimer disease were associated with a decreased likelihood of using hospice (model &khgr;25 = 23.5, P = .0003). Moreover, care recipients recruited from an Alzheimer clinic were more likely to use hospice than those recruited from adult day-care centers. Caregiver factors were not independent predictors of hospice use. However, there was a significant interaction between hours of care provided each week and recruitment site. Among care recipients from the Alzheimer clinic, the probability of hospice use increased as caregiving intensity increased. This relationship was reversed in care recipients from day-care centers. Results suggest that adult day-care centers need to partner with hospice programs in the community. In conclusion, care recipient and community service factors influence hospice use in individuals with Alzheimer disease.

Assessing Beneficiary Health Outcomes and Disease Management Initiatives in Medicare

AbstractIntroduction: Provisions in the Balanced Budget Act of 1997 directed the US Centers for Medicare and Medicaid Services (CMS, formerly the Health Care Financing Administration) to begin focusing attention on the standardized measurement of health outcomes of Medicare beneficiaries as well as testing the effectiveness of various disease management interventions at improving these outcomes.The CMS, in collaboration with the US National Committee for Quality Assurance, developed the Medicare Health Outcomes Survey (HOS) as the first health outcomes measure from the patient’s perspective in Medicare managed care. This new source of data, using the Medical Outcomes Study Short Form 36-Item Health survey (SF-36®) as its core measure, provides valuable standardized health outcomes information about Medicare managed care enrollees in general and the chronically ill in particular. Study design: From May through July 1998, a longitudinal, self-administered survey which utilized the SF-36® (a health status measure which assesses both physical and mental functioning) was administered to 1000 randomly sampled Medicare beneficiaries who were continuously enrolled for a 6-month period in a Medicare managed care health plan. This cohort was re-surveyed from April though June of 2000. We analyzed data from the cohort I baseline and re-measurement analytic sample of 51 700 individuals. Results: Using the change in SF-36® physical component summary scores and mental component summary scores over a 2-year period, we demonstrated that the presence of chronic disease has a negative impact on both the physical and mental health functioning of Medicare managed care enrollees over time. With few exceptions, the negative effect of chronic disease on physical and mental health is found to be independent of gender, race, and socioeconomic status as measured by level of educational attainment. Differences in mean health status scores across levels of chronic conditions suggest that preventing the onset of disease is best for maintaining optimal health. Conclusions: Disease management interventions which are properly designed and implemented have been shown to measurably improve patient outcomes by providing high quality, cost-effective care. Recognizing the need for standardized outcome measures and scientifically validated disease management interventions, the CMS has taken a leadership role by developing and implementing the Medicare HOS and disease management demonstration projects.

Differences in risk-adjusted mortality between medicaid-eligible patients enrolled in medicare advantage plans and those enrolled in the veterans health administration.

BackgroundWe compared risk-adjusted mortality rates between Medicaid-eligible patients in the Medicare Advantage plans (“MA dual enrollees”) and Medicaid-eligible patients in the Veterans Health Administration (“VHA dual enrollees”). MethodsWe used the Death Master File to ascertain the vital status of 1912 MA and 2361 VHA dual enrollees. We used Cox regression models to estimate hazard ratios (HRs) with 95% confidence intervals (CIs). ResultsThe 3-year mortality rates of VHA and MA dual enrollees were 15.8% and 19.0%, respectively. The adjusted HR of mortality in the MA dual enrollees was significantly higher than in the VHA dual enrollees (HR, 1.260 [95% CI, 1.044–1.520]). This was also the case for elderly patients and those from racial/ethnic minority groups. ConclusionsThe VHA had better health outcomes than did MA plans. The VHAs performance is reassuring, given its emphasis on equal access to healthcare in an environment that is less dependent on patient financial considerations.