Health Services Research

Mục tiêu. Mục tiêu của nghiên cứu này là đánh giá tính hợp lệ của dữ liệu xuất viện bệnh viện hành chính trong phiên bản Phân Loại Bệnh Quốc Tế Thứ 10 (ICD‐10) và để xác định xem có sự cải thiện nào trong tính hợp lệ của mã hóa các tình trạng lâm sàng so với dữ liệu ICD‐9 Sửa Đổi Lâm Sàng (ICD‐9‐CM) hay không.

Phương pháp. Chúng tôi đã xem xét 4.008 hồ sơ bệnh án được lựa chọn ngẫu nhiên của những bệnh nhân nhập viện từ ngày 1 tháng 1 đến ngày 30 tháng 6 năm 2003 tại bốn bệnh viện giảng dạy ở Alberta, Canada để xác định sự hiện diện hoặc không có 32 tình trạng lâm sàng và để đánh giá độ đồng thuận giữa dữ liệu ICD‐10 và dữ liệu hồ sơ. Chúng tôi sau đó mã hóa lại các hồ sơ tương tự bằng ICD‐9‐CM và xác định độ đồng thuận giữa dữ liệu ICD‐9‐CM và dữ liệu hồ sơ trong việc ghi nhận những tình trạng tương tự. Độ chính xác của dữ liệu ICD‐10 so với dữ liệu hồ sơ được so sánh với độ chính xác của dữ liệu ICD‐9‐CM so với dữ liệu hồ sơ.

Kết quả. Giá trị độ nhạy dao động từ 9.3 đến 83.1 phần trăm cho ICD‐9‐CM và từ 12.7 đến 80.8 phần trăm cho dữ liệu ICD‐10. Giá trị tiên đoán dương dao động từ 23.1 đến 100 phần trăm cho ICD‐9‐CM và từ 32.0 đến 100 phần trăm cho dữ liệu ICD‐10. Giá trị độ đặc hiệu và giá trị tiên đoán âm luôn ở mức cao đối với cả hai cơ sở dữ liệu ICD‐9‐CM và ICD‐10. Trong số 32 tình trạng được đánh giá, dữ liệu ICD‐10 có độ nhạy cao hơn đáng kể cho một tình trạng và thấp hơn cho bảy tình trạng so với dữ liệu ICD‐9‐CM. Hai cơ sở dữ liệu có giá trị độ nhạy tương tự nhau đối với 24 tình trạng còn lại.

Kết luận. Tính hợp lệ của dữ liệu hành chính ICD‐9‐CM và ICD‐10 trong việc ghi nhận tình trạng lâm sàng là tương tự nhau, mặc dù tính hợp lệ khác nhau giữa các phiên bản mã hóa đối với một số tình trạng. Việc triển khai mã hóa ICD‐10 chưa cải thiện đáng kể chất lượng dữ liệu hành chính so với ICD‐9‐CM. Những đánh giá trong tương lai như nghiên cứu này là cần thiết vì tính hợp lệ của dữ liệu ICD‐10 có thể được cải thiện khi các mã hóa viên có thêm kinh nghiệm với hệ thống mã hóa mới.

Purpose. We report the validation of an instrument to measure mistrust of health care organizations and examine the relationship between mistrust and health care service underutilization.

Methods. We conducted a telephone survey of a random sample of households in Baltimore City, MD. We surveyed 401 persons and followed up with 327 persons (81.5 percent) 3 weeks after the baseline interview. We conducted tests of the validity and reliability of the Medical Mistrust Index (MMI) and then conducted multivariate modeling to examine the relationship between mistrust and five measures of underutilization of health services.

Results. Using principle components analysis, we reduced the 17‐item MMI to 7 items with a single dimension. Test–retest reliability was moderately strong, ranging from Pearson correlation of 0.346–0.697. In multivariate modeling, the MMI was predictive of four of five measures of underutilization of health services: failure to take medical advice (b=1.56, p<.01), failure to keep a follow‐up appointment (b=1.11, p=.01), postponing receiving needed care (b=0.939, p=.01), and failure to fill a prescription (b=1.48, p=.002). MMI was not significantly associated with failure to get needed medical care (b=0.815, p=.06).

Conclusions. The MMI is a robust predictor of underutilization of health services. Greater attention should be devoted to building greater trust among patients.

Objective.To assess the contribution of primary care systems to a variety of health outcomes in 18 wealthy Organization for Economic Cooperation and Development (OECD) countries over three decades.

Data Sources/Study Setting.Data were primarily derived from OECDHealth Data 2001and from published literature. The unit of analysis is each of 18 wealthy OECD countries from 1970 to 1998 (totaln=504).

Study Design.Pooled, cross‐sectional, time‐series analysis of secondary data using fixed effects regression.

Data Collection/Extraction Methods.Secondary analysis of public‐use datasets. Primary care system characteristics were assessed using a common set of indicators derived from secondary datasets, published literature, technical documents, and consultation with in‐country experts.

Principal Findings.The strength of a country's primary care system was negatively associated with (a) all‐cause mortality, (b) all‐cause premature mortality, and (c) cause‐specific premature mortality from asthma and bronchitis, emphysema and pneumonia, cardiovascular disease, and heart disease (p<0.05 in fixed effects, multivariate regression analyses). This relationship was significant, albeit reduced in magnitude, even while controlling for macro‐level (GDP per capita, total physicians per one thousand population, percent of elderly) and micro‐level (average number of ambulatory care visits, per capita income, alcohol and tobacco consumption) determinants of population health.

Conclusions.(1) Strong primary care system and practice characteristics such as geographic regulation, longitudinality, coordination, and community orientation were associated with improved population health. (2) Despite health reform efforts, few OECD countries have improved essential features of their primary care systems as assessed by the scale used here. (3) The proposed scale can also be used to monitor health reform efforts intended to improve primary care.

Objective. To analyze the blend of retrospective (fee‐for‐service, productivity‐based salary) and prospective (capitation, nonproductivity‐based salary) methods for compensating individual physicians within medical groups and independent practice associations (IPAs) and the influence of managed care on the compensation blend used by these physician organizations.

Data Sources. Of the 1,587 medical groups and IPAs with 20 or more physicians in the United States, 1,104 responded to a one‐hour telephone survey, with 627 providing detailed information on physician payment methods.

Study Design. We calculated the distribution of compensation methods for primary care and specialty physicians, separately, in both medical groups and IPAs. Multivariate regression methods were used to analyze the influence of market and organizational factors on the payment method developed by physician organizations for individual physicians.

Principal Findings. Within physician organizations, approximately one‐quarter of physicians are paid on a purely retrospective (fee‐for‐service) basis, approximately one‐quarter are paid on a purely prospective (capitation, nonproductivity‐based salary) basis, and approximately one‐half on blends of retrospective and prospective methods. Medical groups and IPAs in heavily penetrated managed care markets are significantly less likely to pay their individual physicians based on fee‐for‐service than are organizations in less heavily penetrated markets.

Conclusions. Physician organizations rely on a wide range of prospective, retrospective, and blended payment methods and seek to align the incentives faced by individual physicians with the market incentives faced by the physician organization.

Objectives. The purpose of this study was to examine the extent to which measures of health plan clinical performance and measures of patient perceptions of care are associated with health plan organizational characteristics, including the percentage of care provided based on a group or staff model delivery system, for‐profit (tax) status, and affiliation with a national managed care firm.

Data Sources. Data describing health plans on region, age of health plan, for‐profit status, affiliation with a national managed care firm, percentage of Medicare business, total enrollment, ratio of primary care physicians to specialists, HMO penetration, and form of health care delivery system (e.g., IPA, network, mixed, staff, group) were obtained from InterStudy. Clinical performance measures for women's health screening rates, child and adolescent immunization rates, heart disease screening rates, diabetes screening rates, and smoking cessation were developed from HEDIS^® data. Measures of patient perceptions of care are obtained from CAHPS^® survey data submitted as Healthplan Employer Data and Information Set, Consumer Assessment of Health Plans 2.0 H.

Study Design. Multivariate regression cross‐sectional analysis of 272 health plans was used to evaluate the relationship of health plan characteristics with measures of clinical performance and patient perceptions of care.

Principal Findings. The form of delivery system, measured by percent of care delivered by staff and group model systems, is significantly related (p≤.05) with four of the five clinical performance indices but none of the three satisfaction performance indices. Other variables significantly associated with performance were being geographically located in the Northeast, having nonprofit status, and for patient satisfaction, not being part of a larger insurance company.

Conclusions. These comparative results provide evidence suggesting that the type of delivery system used by health plans is related to many clinical performance measures but is not related to patient perceptions of care. These findings underscore the importance of the form of the delivery system and the need for further inquiry that examines the relationship between organizational form and performance.

Objective. We examined the implications of reliability adjustment on hospital mortality with surgery.

Data Source. We used national Medicare data (2003–2006) for three surgical procedures: coronary artery bypass grafting (CABG), abdominal aortic aneurysm (AAA) repair, and pancreatic resection.

Study Design. We conducted an observational study to evaluate the impact of reliability adjustment on hospital mortality rankings. Using hierarchical modeling, we adjusted hospital mortality for reliability using empirical Bayes techniques. We assessed the implication of this adjustment on the apparent variation across hospitals and the ability of historical hospital mortality rates (2003–2004) to forecast future mortality (2005–2006).

Principal Findings. The net effect of reliability adjustment was to greatly diminish apparent variation for all three operations. Reliability adjustment was also particularly important for identifying hospitals with the lowest future mortality. Without reliability adjustment, hospitals in the “best” quintile (2003–2004) with pancreatic resection had a mortality of 7.6 percent in 2005–2006; with reliability adjustment, the “best” hospital quintile had a mortality of 2.7 percent in 2005–2006. For AAA repair, reliability adjustment also improved the ability to identify hospitals with lower future mortality. For CABG, the benefits of reliability adjustment were limited to the lowest volume hospitals.

Conclusion. Reliability adjustment results in more stable estimates of mortality that better forecast future performance. This statistical technique is crucial for helping patients select the best hospitals for specific procedures, particularly uncommon ones, and should be used for public reporting of hospital mortality.

Objective. To estimate patients' elasticity of demand, willingness to pay, and consumer surplus for five high‐cost specialty medications treating metastatic disease or hematologic malignancies.

Data Source/Study Setting. Claims data from 71 private health plans from 1997 to 2005.

Study Design. This is a revealed preference analysis of the demand for specialty drugs among cancer patients. We exploit differences in plan generosity to examine how utilization of specialty oncology drugs varies with patient out‐of‐pocket costs.

Data Collection/Extraction Methods. We extracted key variables from administrative health insurance claims records.

Principal Findings. A 25 percent reduction in out‐of‐pocket costs leads to a 5 percent increase in the probability that a patient initiates specialty cancer drug therapy. Among patients who initiate, a 25 percent reduction in out‐of‐pocket costs reduces the number of treatments (claims) by 1–3 percent, depending on the drug. On average, the value of these drugs to patients who use them is about four times the total cost paid by the patient and his or her insurer, although this ratio may be lower for oral specialty therapies.

Conclusions. The decision to initiate therapy with specialty oncology drugs is responsive to price, but not highly so. Among patients who initiate therapy, the amount of treatment is equally responsive. The drugs we examine are highly valued by patients in excess of their total costs, although oral agents warrant further scrutiny as copayments increase.