Measuring the physician perspective on quality of care in health plans.

Physicians provide one source of information about the quality of care in health plans, but concerns exist that physicians cannot distinguish quality from financial considerations or other underlying attitudes. We examined whether physicians can (a) distinguish different domains of health plan quality and (b) distinguish health plan quality from their underlying attitudes. We analyzed data on 419 generalist physicians from four health plans. Three scales assessed physicians' perceptions of facilitators and barriers to high-quality care in the plans and the clinical capabilities of plan physicians. Structural equation modeling indicated that physicians could distinguish domains of health plan quality. Physicians could also distinguish plan quality from their attitudes toward the plan, but plan quality was more highly correlated with general managed care attitudes than expected. These data suggest that physicians can provide information about health plan quality, but it will be important to validate these measures against patient outcomes.

Disenrollment from Medicare HMOs.

BACKGROUND: Since the program's inception, there has been great interest in determining whether beneficiaries who enter and subsequently leave Medicare health maintenance organizations (HMOs) are more or less costly than those remaining in fee-for-service (FFS) Medicare. OBJECTIVES: To examine whether relatively high-cost beneficiaries disenroll from Medicare HMOs (disenrollment bias) and whether disenrollment bias varies by Medicare HMO market characteristics. In addition, we compare rates of surgical procedures and hospitalizations for ambulatory care-sensitive conditions for disenrollees and continuing FFS beneficiaries. DESIGN: Cross-sectional analysis of 1994 Medicare data. PARTICIPANTS AND METHODS: Medicare beneficiaries were first sampled from the 124 counties with at least 1000 Medicare HMO enrollees. From this pool, HMO disenrollees and a sample of continuing FFS beneficiaries were drawn. The FFS beneficiaries were assigned dates of "pseudodisenrollment." Expenditures and inpatient service use were compared for 6 months after disenrollment or pseudodisenrollment. RESULTS: The HMO disenrollees were no more likely than the continuing FFS beneficiaries to have positive total expenditures (Part A plus Part B) or Part B expenditures in the first 6 months after disenrollment. However, disenrollees were more likely to have Part A expenditures. Among beneficiaries with spending, disenrollees had higher total and Part B expenditures than continuing FFS beneficiaries. Moreover, the disparity in total and Part B spending between disenrollees and continuing FFS beneficiaries increased with HMO market penetration. Although Part A spending was higher for disenrollees with spending, it was not sensitive to changes in market share. The HMO disenrollees received more surgical procedures and were hospitalized for more of the ambulatory care-sensitive conditions than the FFS beneficiaries. CONCLUSIONS: On several measures, Medicare HMOs experienced favorable disenrollment relative to continuing FFS beneficiaries as recently as 1994, which increased as HMO market share increased.

Asthma outcomes at an inner-city school-based health center.

Childhood asthma has reached near-epidemic levels in the US cities. Innovative strategies to identify children with asthma and prevent asthma morbidity are needed. This study measured asthma outcomes after initiation of an inner-city elementary school health center with a schoolwide focus on asthma detection and treatment. The site was an inner-city elementary school in Minneapolis, Minn. The study design incorporated a pre and post comparison with a longitudinal cohort of children (n = 67) and a cross-sectional cohort of children before (n = 156) and after (n = 114) the intervention. Hospitalization rates for asthma decreased 75% to 80% over the study period. Outpatient visits for care in the absence of asthma symptoms doubled (p < .01), and the percentage of students seeing a specialist for asthma increased (p < .01). Use of peak flow meters, use of asthma care plans, and use of inhalers also improved (p < .01). While no change occurred in school absenteeism, parents reported that their children had less awakening with asthma and that asthma was less disruptive to family plans. This schoolwide intervention that included identification of children with asthma, education, family support, and clinical care using an elementary school health center was effective in improving asthma outcomes for children.

Interpreting results in mental health research.

It is often difficult to interpret the clinical or policy significance of findings from mental health research when results are presented only in terms of statistical significance. Results expressed in terms of p values or as a metric corresponding to a mental health status scale are seldom intuitively meaningful. To help interpret the significance of research results, we demonstrate a social validity approach that relates scores on mental health status scales to four subsequent major life events. A logistic regression model is used to estimate the relation between mental health status scores and the probability of subsequent major life events, using data obtained on Medicaid beneficiaries with schizophrenia from an evaluation of the Utah Prepaid Mental Health Plan. Using this relatively simple approach will demonstrate to policy makers, clinicians, and researchers the social impact of an outcome, thereby aiding in the interpretation of the significance of results.

Implementing CQI projects in hospitals.

BACKGROUND: Quality improvement approaches such as continuous quality improvement (CQI) and total quality management are widely used, but little is known about how much it costs to use the principles and techniques required to implement CQI processes. In the Robert Wood Johnson Foundation's Improving the Quality of Hospital Care (IQHC) program, four consortia of hospitals were funded in the early 1990s. Interviews with quality managers at 38 of the consortia hospitals were conducted in 1995 to determine the costs of conducting CQI projects to allow an estimation of the marginal cost of using CQI processes (particularly cross-disciplinary teams) to improve quality of care. CQI PROJECTS: Quality managers described 69% of project outcomes as critical to clinical services. Team members identified the issues their teams addressed and selected the project 64% of the time, the methods of analysis 87% of the time, and the approaches to resolving the problem or issue 97% of the time. Most of the respondents agreed that the team members had the authority to resolve the problem without appealing to higher levels of management. Costs for hospitals' most recently completed projects varied widely, from $148 for the entire project to $18,590. The length or duration of the projects also varied widely, from 1 month to 66 months. DISCUSSION: In the hospitals included in this sample, all of which were highly self-selected (evidenced by their participation in a voluntary consortium of hospitals focused on quality of care), knowledge of CQI processes appeared to be fairly thorough. Teams appeared to have a reasonable amount of autonomy. New CQI projects should be subjected to scrutiny in terms of their likely contribution to quality of care, as distinct from other positive outcomes.

The prevalence and effects of hunger in an emergency department patient population.

OBJECTIVES: Little is known about the prevalence and health effects of hunger among ED patients. The objectives of this study were to determine the prevalence of hunger among patients in a large urban ED and to examine whether it has adverse health effects. METHODS: A survey about hunger, choices between buying food and buying medicine, and adverse health outcomes related to food adequacy over the preceding 12 months was administered to a convenience sample of adult non-critically ill ED patients from afternoon and evening shifts. The study was conducted in the ED of Hennepin County Medical Center in Minneapolis, Minnesota. RESULTS: Of the 302 eligible patients who were asked to participate, 297 (98%) agreed. Eighteen percent reported not having enough to eat at least once in the preceding 12 months: 14% reported that they had "gotten sick" as a result of not being able to afford their medicine, resulting in an ED visit or hospital admission 50% of the time. Predictors of making choices about buying food vs medicine include having a chronic health condition, lack of private health insurance, having a reduction in food stamps, having an annual income less than $10,000, and lack of alcohol use. By patient report, a reduction in food stamps was a predictor of ED visits and hospitalizations as a result of making choices about buying food over medicine. CONCLUSION: The ED patients in this urban setting have high rates of hunger and many must make choices between buying food and medicine, which patients report results in otherwise preventable ED visits and hospitalization. Loss or reduction of food stamps is associated with increased hunger and increased perceived adverse health outcomes as a result of not being able to afford medicine.

Outcomes for Medicaid beneficiaries with schizophrenia under a prepaid mental health carve-out.

This study examines the impact of a mental health carve-out program in Utah on mental health status of Medicaid beneficiaries with schizophrenia. Three community mental health centers contracted to provide mental health care for all Medicaid beneficiaries in their service areas under managed care arrangements, while beneficiaries in the remainder of the state remained under traditional Medicaid. A pre-post evaluation was utilized, with a contemporaneous control group of Utah Medicaid beneficiaries with schizophrenia under traditional Medicaid. From 1991 to 1994, the average beneficiary's mental health status improved, but the improvement was less under the carve-out program than under traditional fee-for-service Medicaid. The difference was the greatest for beneficiaries with the worst mental health status at baseline, with effects growing over time. Medicaid beneficiaries with schizophrenia experienced less improvement in mental health status under a carve-out arrangement for mental health care compared to what would have happened under traditional Medicaid.

Screening for asthma in an inner-city elementary school in Minneapolis, Minnesota.

To the extent that the asthma morbidity so prevalent in children today is due to underdiagnosis or lack of appropriate treatment, schools are increasingly faced with the issue of defining their role in the care of children with asthma. This paper describes efforts to conduct schoolwide screening for asthma in an inner-city elementary school over the past two years. Screening methodology adopted for the project resulted in a simple and noninvasive approach for identifying children with current asthma in a school setting. While not as medically comprehensive as would be required to conclusively diagnose asthma, the simple screening approach proved efficient in identifying a population of elementary school children with a significant level of asthma morbidity. The paper discusses the effectiveness and feasibility of the screening efforts and proposes how such a screening program might be incorporated into the routine health activities undertaken at any elementary school.

Patterns of outpatient use of mental health services for Medicaid beneficiaries under a prepaid mental health carve-out.

This study examines the impact of a mental health carve-out, the Utah Prepaid Mental Health Plan (UPMHP), on use of outpatient mental health services by Medicaid beneficiaries with schizophrenia. Data were collected through interviews with the same group of Medicaid schizophrenic beneficiaries. A pre/post comparison with a contemporaneous control group examined the impact of the program on type of outpatient services used by beneficiaries. The results indicate a greater reliance on medically-oriented outpatient mental health services in treatment of beneficiaries under the UPMHP. Medicaid beneficiaries with schizophrenia in the UPMHP group received relatively fewer day treatment visits, but relatively more medication visits and individual therapy visits over the first 3 1/2 years of the program.

Women's preferences for specialists who provide cancer screening and general medical care.

In order to determine what types of specialists women prefer for medical care, we examined responses from a cross-sectional survey of adult female patients in a health plan of the independent practice association model in the Minneapolis-St. Paul metropolitan area (n = 1,204). The response rate for the survey was 90%. The women expressing a preference (60% of responders) overwhelmingly preferred to see obstetrician-gynecologists for their breast examinations and Pap smears and strongly preferred family physicians or internists for the remainder of their cancer screening and general medical care. Thus, the majority of women expressed preferences for physicians of different specialties to provide their medical care.

Increasing breast and cervical cancer screening in low-income women.

OBJECTIVE: To determine if women would have higher breast and cervical cancer screening rates if lay health advisers recommended screening and offered a convenient screening opportunity. DESIGN: Controlled trial. SETTING: Urban county teaching hospital. PARTICIPANTS: Women aged 40 years and over attending appointments in several non-primary-care outpatient clinics. INTERVENTIONS: Lay health advisers assessed the participants' breast and cervical cancer screening status and offered women in the intervention group who were due for screening an appointment with a female nurse practitioner. MEASUREMENTS AND MAIN RESULTS: Screening rates at baseline and at follow-up 1 year after the intervention were determined. At follow-up, the mammography rate was 69% in the intervention group versus 63% in the usual care group (p = .009), and the Pap smear rate was 70% in the intervention group versus 63% in the usual care group (p = .02). In women who were due for screening at baseline, the mammography rate was 60% in the intervention group versus 50% in the usual care group (p = .006), and the Pap smear rate was 63% in the intervention group versus 50% in the usual care group (p = .002). The intervention was effective across age and insurance payer strata, and was particularly effective in Native American women. CONCLUSIONS: Breast and cervical cancer screening rates were improved in women attending non-primary-care outpatient clinics by using lay health advisers and a nurse practitioner to perform screening. The effect was strongest in women in greatest need of screening.

The effect of the Utah Prepaid Mental Health Plan on structure, process, and outcomes of care.

Capitation reduced Medicaid costs but had limited effects on most measures of process and outcome. Clients under capitation with the poorest mental health at baseline performed more poorly over time on some measures.

Monitoring the consequences of uninsurance: a review of methodologies.

The proportion of the United States population without health insurance continues to grow. How will this affect the health of the nation? Prior research suggests that the uninsured are at risk for poor health outcomes. They use fewer medical services and have higher mortality rates than do insured persons. The episodic nature of uninsurance and its prevalence among disadvantaged groups makes it difficult to ascertain the health effects of uninsurance. The goal of this review is to assist researchers and policy makers in choosing methodologies to assess the effects of uninsurance. It provides a compendium of methods that have been used to examine the health consequences of uninsurance, the populations in which these methods have been used, and the strengths and weaknesses of different approaches. The review highlights the need for more longitudinal studies that focus on community-based samples of the uninsured.

Accuracy of self-report of mammography and Pap smear in a low-income urban population.

BACKGROUND: Cancer screening history can often be obtained only by self-report, particularly for disadvantaged populations. We examined the accuracy of self-report of mammography and Pap smear for an urban, low-income population. METHODS: Women attending non-primary care clinics (mostly surgery and orthopedics) at a large public teaching hospital in Minneapolis between July 1992 and May 1993 were queried about their screening history (n = 477). The women were interviewed by a trained peer-recruiter and asked whether they had ever heard of a Pap smear or mammogram, whether they had ever had one, where it was done, and when the last one was. We verified self-report by checking medical records where the test was performed. RESULTS: The positive and negative predictive value of recall of mammography in the previous year was 72.4% and 90.6%, respectively. The figures for Pap smear recall were somewhat lower, 65.5% and 85.9%, respectively. We found a record of a mammogram in 88% of women able to recall the year. Of these, slightly over two-thirds recalled their mammogram in the same year as their record indicated. Inaccurate recalls were more commonly of the "telescoping" type, i.e., tests were recalled as having occurred more recently than was the case. Recall was substantially better for recent tests. Results for Pap smear recalls were broadly similar. CONCLUSIONS: The accuracy of self-report of mammography and Pap smear is relatively poor for medical practice but is acceptable in population surveys with appropriate correction for overreporting.

Hunger in an adult patient population.

CONTEXT: Although clinical observations suggest that some patients experience hunger and food insecurity, there are limited data on the prevalence of hunger in adult patients. OBJECTIVE: To determine the prevalence of hunger and food insecurity in adult patients at an urban county hospital. DESIGN: Cross-sectional survey conducted in 1997. PATIENTS: The primary survey included all patients aged 18 years or older who were admitted to the medicine, surgery, and neurology services during a 2-week period, and all patients who attended the hospital's general medicine clinic during 1 week. A second survey included primary care patients who received insulin from the hospital pharmacy during a 1-month period. MAIN OUTCOME MEASURES: Rates of hunger and food insecurity. RESULTS: Of 709 eligible patients, 567 (participation rate, 80%) were interviewed in either the clinic (n=281) or hospital (n=286). An additional 170 patients who received insulin were interviewed by telephone (response rate, 75%). Of the primary sample, 68 (12%) respondents reported not having enough food, 75 (13%) reported not eating for an entire day, and 77 (14%) reported going hungry but not eating because they could not afford food. A total of 222 (40%) had received food stamps in the previous year and of those, 113 (50%) had their food stamps reduced or eliminated. Recipients whose food stamps had been eliminated or reduced were more likely to report not having enough food (18% vs 13%, P=.006), not eating for a whole day (20% vs 16%, P=.01), going hungry but not eating (20% vs 16%, P=.08), and cutting down on the size of meals or skipping meals (33% vs 27%, P=.01). In multivariate analysis, independent predictors of hunger included an annual income of less than $10000 (odds ratio [OR], 7.55; 95% CI, 3.01-18.92), drug use (OR, 3.56; 95% CI, 1.46-8.66), and a reduction in food stamp benefits (OR, 1.73; 95% CI, 1.01-2.96). Predictors of food insecurity included an annual income of less than $10000 (OR, 4.12; 95% confidence interval [CI], 1.98-8.58), drug use (OR, 2.11; 95% CI, 1.66-5.08), and a reduction in food stamps (OR, 2.02; 95% CI, 1.23-3.32). In addition, 103 (61%) patients in the sample of diabetics reported hypoglycemic reactions; 32 (31%) of these were attributed to inability to afford food. CONCLUSION: Hunger and food insecurity are common among patients seeking care at an urban county hospital.