Making a Dent in Undiagnosed and Untreated Depression among Older West Virginians.

IMPORTANCE: Depression, a serious and debilitating disease, remains under-diagnosed and inadequately treated among older adults. OBJECTIVE: To describe the prevalence of depression among older West Virginians and report the extent to which primary care providers screen Medicare beneficiaries for depression. METHODOLOGY: Descriptive analysis using 2014 Behavioral Risk Factor Surveillance System to estimate depression prevalence; Medicare Part B claims, 2012 - 2014, to measure depression screening. FINDINGS: In 2014, depression affected 10.1%, 95% CI [8.6%, 11.6%] of older West Virginians. While screening increased, less than 4% of Medicare beneficiaries seen in primary care that year were screened. CONCLUSION: We have a significant opportunity to improve diagnosis, treatment and quality of life for older West Virginians with depression, and Medicare reimbursement for screening is available to primary care providers. Although many older depressed patients can be treated in the primary care setting, integration of behavioral health and primary care has distinct benefits.

Persistent Distress after Water Contamination.

Background: A chemical spill contaminated the public water supply of Charleston, West Virginia in January 2014 for at least a week. Psychological distress is common after disasters. Methods: We surveyed the exposed population to assess psychological distress during and three months after the incident. We inquired about stressors that might predict distress, adequacy of communication from public officials, and use of the water supply and perceptions of its safety three months after the incident. Results: Twenty six percent of interviewees had persistent symptoms of distress. Female sex, negative household experiences during the episode (especially having someone sick), and poor perception of communication increased odds of persistent distress. Households of respondents without persistent distress were significantly more likely to report drinking tap water (RR=1.95) than those with persistent distress. Conclusions: Distress in Charleston area residents persisted and may have resulted in continuing mistrust of the water supply.

Correction: Self-Reported Household Impacts of Large-Scale Chemical Contamination of the Public Water Supply, Charleston, West Virginia, USA.

[This corrects the article DOI: 10.1371/journal.pone.0126744.].

Self-reported household impacts of large-scale chemical contamination of the public water supply, Charleston, West Virginia, USA.

A January 2014 industrial accident contaminated the public water supply of approximately 300,000 homes in and near Charleston, West Virginia (USA) with low levels of a strongly-smelling substance consisting principally of 4-methylcyclohexane methanol (MCHM). The ensuing state of emergency closed schools and businesses. Hundreds of people sought medical care for symptoms they related to the incident. We surveyed 498 households by telephone to assess the episode's health and economic impact as well as public perception of risk communication by responsible officials. Thirty two percent of households (159/498) reported someone with illness believed to be related to the chemical spill, chiefly dermatological or gastrointestinal symptoms. Respondents experienced more frequent symptoms of psychological distress during and within 30 days of the emergency than 90 days later. Sixty-seven respondent households (13%) had someone miss work because of the crisis, missing a median of 3 days of work. Of 443 households reporting extra expenses due to the crisis, 46% spent less than $100, while 10% spent over $500 (estimated average about $206). More than 80% (401/485) households learned of the spill the same day it occurred. More than 2/3 of households complied fully with "do not use" orders that were issued; only 8% reported drinking water against advice. Household assessments of official communications varied by source, with local officials receiving an average "B" rating, whereas some federal and water company communication received a "D" grade. More than 90% of households obtained safe water from distribution centers or stores during the emergency. We conclude that the spill had major economic impact with substantial numbers of individuals reporting incident-related illnesses and psychological distress. Authorities were successful supplying emergency drinking water, but less so with risk communication.

Exploratory analysis of the relationship between home health agency engagement in a national campaign and reduction in acute care hospitalization in US home care patients.

RATIONALE, AIMS AND OBJECTIVES: To determine whether US home health agencies that intensively engaged with the 2010 Home Health Quality Improvement National Campaign were more likely to reduce acute care hospitalization (ACH) rates than less engaged agencies. METHOD: We included all Medicare-certified agencies that accessed Campaign resources in the first month of the Campaign and also responded to an online survey of resource utilization at month two. We used the survey data and item response theory to estimate a latent construct we called engagement with the campaign. ACH rates were calculated from the Centers for Medicare & Medicaid Services Outcome and Assessment Information Set for pre- and post-intervention periods (March-November 2009 and 2010, respectively). RESULTS: Staff from 1077 agencies accessed resources in the first month of the Campaign. Of these, 382 provided information about resource use and had 10 or more monthly discharges throughout the measurement periods. Dividing these agencies into quartiles based on engagement score, we found an association between engagement and reduction in ACH rates, P=0.049 (χ(2) for trend). Exploratory path analysis revealed the effect of engagement score on reduction in ACH rate to be partially mediated through reduction in average length of service rates. CONCLUSION: We found evidence that early intensity of engagement with the Campaign, as measured through use of activities and resources, was positively associated with improvement. To continue the investigation of this relationship, future work in this and other campaigns should focus on further development of engagement measures.

The 2010-2011 home health quality improvement national campaign.

The purpose and goals of the 2010-2011 Home Health Quality Improvement (HHQI) National Campaign are outlined in this manuscript, including key campaign enhancements implemented since the first initiative began in 2007. A summary of the campaign's design and progress to date is also included, featuring HHQI educational and informational resources, participant incentives, and campaign evaluation.

Improving the home health acute-care hospitalization quality measure.

OBJECTIVES: (1) To demonstrate average length of service (ALOS) bias in the currently used acute-care hospitalization (ACH) home health quality measure, limiting comparability across agencies, and (2) to propose alternative ACH measures. DATA SOURCES/STUDY SETTING: Secondary analysis of Medicare home health service data 2004-2007; convenience sample of Medicare fee-for-service hospital discharges. STUDY DESIGN: Cross-sectional analysis and patient-level simulation. DATA COLLECTION/EXTRACTION METHODS: We aggregated outcome and ALOS data from 2,347 larger Medicare-certified home health agencies (HHAs) in the United States between 2004 and 2007, and calculated risk-adjusted monthly ACH rates. We used multiple regression to identify agency characteristics associated with ACH. We simulated ACH during and immediately after home health care using patient and agency characteristics similar to those in the actual data, comparing the existing measure with alternative fixed-interval measures. PRINCIPAL FINDINGS: Of agency characteristics studied, ALOS had by far the highest partial correlation with the current ACH measure (r(2)=0.218, p<.0001). We replicated the correlation between ACH and ALOS in the patient-level simulation. We found no correlation between ALOS and the alternative measures. CONCLUSIONS: Alternative measures do not exhibit ALOS bias and would be appropriate for comparing HHA ACH rates with one another or over time.

Impact of a national campaign on hospital readmissions in home care patients.

OBJECTIVE: Assess impact of nationwide home health quality improvement campaign to reduce acute care hospitalization of home health recipients. DESIGN: Observational pre-post comparison of self-selected participating and non-participating agencies' quality performance; survey to determine uptake of program materials. SETTING: US home health care agencies. PARTICIPANTS: A total of 147 agencies with 147 non-participating agencies matched on patient length of service, pre-intervention hospitalization rate and pre-intervention rate of change in hospitalization rate. INTERVENTION(S): Public events; provision of educational packages and technical assistance; quality measure feedback. MAIN OUTCOME MEASURE(S): Post-intervention difference in risk-adjusted acute care hospitalization rate between participants and non-participants; difference in self-reported campaign material use between agencies whose hospitalization rate declined 2% or more and those whose rates increased by 2% or more. RESULTS: Hospitalization rate had a negative trend beginning before the campaign. In the matched pairs studied, it did not differ significantly between participants and non-participants, or from pre- to post-intervention period (28% in every case). Agencies that improved were more likely to report activities consistent with the campaign and using campaign interventions than those not improving (P < 0.001), regardless of participation status. CONCLUSIONS: Merely agreeing to participate in the campaign did not improve performance, but effective participation through adoption of campaign methods did.

Quality of ambulatory care for diabetes and lower-extremity amputation.

Lower extremity amputation (LEA) is a serious complication of diabetes. We sought to determine whether quality of ambulatory care affects risk of LEA. We conducted a claims-based case-control study of 409 Medicare beneficiaries younger than age 75 with diabetes and LEA between January 1, 2003, and December 31, 2005. They were matched with controls with diabetes without LEA, on age, gender, number of diabetes outpatient visits, and (for those with hospital admissions between January 1, 2000, and December 31, 2002) number of comorbid conditions, diabetes complications, and peripheral vascular disease. Quality-of-care measures for cases and controls covered the period April 1, 1999, through March 31, 2001. LEA patients were less likely to have had lipid screening than controls (odds ratio = 0.73; 95% confidence interval = 0.53-0.99), and controls were more likely to use physicians with high performance in lipid screening (chi(2) = 6.631, P = .012) and hemoglobin A1c testing (chi(2) = 6.079, P = .014).

Impact of the 2004 influenza vaccine shortage on repeat immunization rates.

PURPOSE: We assessed the impact of the severe influenza vaccine shortage of 2004 on individual physicians' immunization performance. METHODS: Using 1998-2004 Medicare claims data, we monitored the physician continuity rate (proportion of patients receiving influenza immunization from a physician in 1 year who received a subsequent immunization from the same physician the subsequent year) and other clinician rate (proportion of patients with claims from 1 physician in 1 year with a claim from another clinician the subsequent year) in West Virginia Medicare beneficiaries from 2000-2004. We examined vaccine claim trends by clinician and surveys of self-reported immunization to determine whether patients received vaccine from nonphysician clinicians or went without immunization each year. RESULTS: Claims-based influenza vaccination rates increased from 35.5% to 41.3% from 2000-2003, reflecting historical trends, before declining 14.1% in 2004. Median continuity rates among the 723 to 849 physicians claiming 25 or more influenza immunizations from 2000-2003 increased from 47% in 2000-2001 to 54% in 2002-2003; then fell to 3% in 2003-2004. The number of physicians filing 100 or more claims declined from 337 in 2003 to 130 in 2004. More than 25% of physicians had no repeat vaccinations of the same beneficiaries in 2004. Trends in clinician type and survey data indicated a shift of many beneficiaries to mass vaccinators and institutional providers; however, compared with previous years, there was an estimated 8% increase in 2004 in the number of West Virginia beneficiaries who did not receive vaccine. CONCLUSIONS: The 2004 vaccine shortage had a severe impact on influenza immunization rates in private physician's offices, disrupting continuity of care.

Improving self-reporting of adverse drug events in a West Virginia hospital.

Adverse drug events significantly increase length of stay and costs of hospitalization but are underreported in health care institutions. We hypothesized that hospitals could improve the accuracy of adverse drug event self-reporting by comparing adverse drug events recorded in an occurrence reporting tool with those detected by surveillance of "rescue" drugs administered to treat adverse drug events. We conducted a prospective cohort study of all adult inpatient discharges from a 200-bed rural acute care hospital in West Virginia during a 6-month period. We performed 3572 chart audits, of which 1011 included rescue drug administration. Our outcome measure was the proportion of adverse drug events in the rescue drug surveillance that were found in the occurrence reporting tool. We found that less than 4% of all adverse drug events involving use of rescue drugs were reported. We concluded that underreporting of preventable adverse drug events in this hospital is comparable to published rates and that surveillance of adverse drug events to detect underreporting is feasible.

e-Prescribing, efficiency, quality: lessons from the computerization of UK family practice.

Nearly all general practice physicians (GPs) in the United Kingdom (UK) have electronic health record (EHR) systems in their practices compared with perhaps 15% of primary care physicians in the United States (U.S.). Based on interviews of 13 general GPs and review of current literature, the authors argue that the historical experience of widespread electronic health record uptake in the UK provides insight into features that might motivate broad adoption in the United States. These features include electronic prescribing, improved quality and consistency of care, practice efficiencies that have both timesaving and revenue generating effects, and potential shielding from malpractice claims.

ACE inhibitor use and mortality reduction: do controlled trial results equal clinical practice?

Randomized trials have shown that angiotensin converting enzyme inhibitors (ACEIs) reduce mortality and morbidity and improve symptoms in many patients with heart failure. However, recent data show that the rate of ACEI prescriptions in West Virginia Medicare beneficiaries diagnosed with heart failure is not increasing. Data from the charts of patients who were discharged from 44 acute care hospitals during 2000 and 2001 were obtained, and these data were matched with current beneficiary data to determine if and when the patient died subsequent to the hospitalization of record. We examined data from 5,144 patients with heart failure for whom we had information on ACEI use, comorbidities, and contraindications, in addition to basic demographics. Patients who received angiotensin receptor blockers (ARBs) were excluded. Of these patients, 863 were eligible for ACEls, and 716 (83%) were discharged on an ACEI. Logistic regression showed that being discharged on an ACEI had a significant negative association with mortality one year later (P = .0009), reducing mortality in patients with heart failure by about one third.

Promoting influenza and pneumococcal immunization in older adults.

BACKGROUND: Reducing the risk of influenza and pneumococcal disease in older adults is a long-standing goal of Medicare's Quality Improvement Organization (QIO) program and parallels the Joint Commission's National Patient Safety Goal 10. ADDRESSING THE GOAL: Since 1999 the West Virginia Medical Institute has worked with a statewide partnership of health organizations on a program to improve influenza and pneumonia vaccination rates in hospitalized Medicare beneficiaries. Methods included education, audit and feedback, toolkits, and training meetings. RESULTS: During the first three years (1999-2001) of the effort, the rate of assessment for pneumococcal immunization at discharge increased from < 10% to 74.1% statewide and for influenza immunization from near zero to 63.4% statewide. Since 2002 pneumococcal immunization administration has increased from 16.1% to 41.1%, with similar improvement in influenza measures. LESSONS LEARNED/NEXT STEPS: Hospitals--and, by extension, long term care facilities--can make dramatic improvements in quality performance in a relatively short time when key staff receive feedback about the need to improve and the tools to assist in improving.

Do mass media affect Medicare beneficiaries' use of diabetes services?

BACKGROUND: Appropriate secondary preventive care for people with diabetes can reduce complications and premature death, yet many people with diabetes do not get these services. Mass media may influence individual health behavior. METHODS: In 1999, the West Virginia Medical Institute (WVMI) began a long-term radio and television campaign to educate West Virginia Medicare beneficiaries with diabetes about the importance of foot exams, eye exams, HbA1c testing, and influenza and pneumonia immunizations using messages with an "Ask your doctor about..." formula. To assess campaign efficacy, WVMI commissioned a telephone survey of 1500 randomly selected beneficiaries likely to have diabetes in two groups of counties with differing exposure to the messages. The survey asked whether the beneficiary had heard the messages and responded to them, by message topic. RESULTS: Nearly everyone (90%) in both survey groups said they had seen or heard the diabetes ads. However, high-exposure group members were about 1.2 times more likely to recall hearing most messages than low-exposure group members, and were 1.2 to 1.8 times more likely to say that they did what the messages suggested. CONCLUSIONS: Media campaigns with preventive health messages targeted to Medicare beneficiaries with diabetes can reach them and may induce appropriate responses.

Physician supply in key medical specialties in West Virginia hospitals, 2001-2004.

This article describes the development, implementation and analysis of an ongoing prospective physician supply survey of the largest acute care hospitals in West Virginia. This survey was designed to assess changes in availability of physicians in key specialties from 2001-2004, a period of years that included a "malpractice insurance crisis." The malpractice crisis in this article describes the period of time in 2001-2002 when medical malpractice insurance rates increased abruptly in West Virginia and a number of physicians publicized their departure from practice in the state. We calculated the absolute and relative percentage change in the median number of physicians in each specialty between 2001-2004, calculated percentage change for each specialty by year, and performed univariate analysis on the percentage changes among all hospitals. We also calculated univariate analysis on the percentage changes among all hospitals. The median number of staff physicians in these hospitals declined steadily from 2001-2004. Declines in the number of specialists (some statistically significant) occurred, especially early in the three-year period, notably among surgical specialties. The availability of nephrologists increased significantly from 2003-2004. Decreases in staff physician numbers may have leveled off, but there is no evidence of sustained growth.

Using statewide audit and feedback to improve hospital care in West Virginia.

BACKGROUND: Audit and feedback systems have significantly improved medical care in numerous settings, and they appear to work by stimulating competition rather than through command and control. METHODS: The West Virginia Medical Institute (WVMI), a Medicare-designated Quality Improvement Organization (QIO), periodically collected quality information on five common conditions (acute myocardial infarction [AMI], heart failure, pneumonia, stroke, and atrial fibrillation) that cause hospitalization in Medicare beneficiaries. All 44 acute care hospitals in West Virginia were offered written and orally presented reports of quality performance from 1998 through 2001. RESULTS: All indicators appeared to improve statewide. Several--for example, aspirin at discharge for AMI patients and pneumococcal vaccine for pneumonia patients--improved by more than 10 absolute percentage points. Fourteen of 15 quality indicators showed significant improvement (p < .05, paired t-test) in all hospitals between the before- and after-feedback periods. Seven of 13 indicators assessed during the entire study in the largest hospitals showed no significant trends in quality before feedback but significant increases (p < .05, chi-square for trend) in the after-feedback period. DISCUSSION: The quality indicator changes reported can represent important health gains for West Virginia Medicare beneficiaries. Most of the improvement did not occur until after hospitals received feedback.