Treatment patterns among adult patients with asthma: factors associated with overuse of inhaled beta-agonists and underuse of inhaled corticosteroids.

BACKGROUND: Overuse of inhaled beta-agonists and underuse of inhaled corticosteroids by patients with asthma may have adverse consequences. This study was performed to identify factors associated with misuse of these types of asthma medication. METHODS: We examined baseline data from a longitudinal survey of adult patients with asthma. The setting was a consortium of 15 national managed care organizations serving 11 large employers. Baseline surveys were completed by 6612 health plan enrollees at least 18 years old who had had at least 2 visits with a diagnostic code for asthma in the preceding 2 years. The main outcome measures were the overuse of inhaled beta-agonists and the underuse of inhaled corticosteroids. Independent variables were patient and process of care factors. RESULTS: Among patients with moderate or severe asthma, 16% of users of inhaled beta-agonists reported overuse (>8 puffs per day on days of use), and 64% of users of inhaled corticosteroids reported underuse (use on < or =4 days/wk or < or =4 puffs per day). Overuse of inhaled beta-agonists was most strongly associated with concomitant treatment with inhaled corticosteroids or anticholinergic agents, increased asthma symptom severity, problems in obtaining asthma medication, and male sex. Underuse of inhaled corticosteroids was associated with nonwhite race, younger age (18 to 34 years), lower use of inhaled beta-agonist, lower symptom severity, and not possessing a peak flow meter. Rates of misuse of medication also varied by speciality of the patient's provider (generalist, allergist, or pulmonologist). CONCLUSIONS: Overuse of inhaled beta-agonists may be caused by symptom severity, while underusers of corticosteroids may interrupt use as symptoms abate. This study demonstrated an important opportunity to improve medication use among patients with asthma.

Mental health service utilization by African Americans and Whites: the Baltimore Epidemiologic Catchment Area Follow-Up.

OBJECTIVE: To compare mental health service utilization and its associated factors between African Americans and whites in the 1980s and 1990s. DESIGN: Household-based longitudinal study with baseline interviews in 1981 and follow-up interviews from 1993 to 1996. SETTING: The Baltimore Epidemiologic Catchment Area (ECA) Follow-Up. SUBJECTS: Subjects included 1,662 adults (590 African Americans and 1,072 whites). MAIN OUTCOME VARIABLE: Use of mental health services, defined as talking to any health professional about emotional or nervous problems or alcohol or drug-related problems within the 6 months preceding each interview. RESULTS: In 1981, crude rates of mental health service use in general medical (GM) settings and specialty mental health settings were similar for African Americans and whites (11.7%). However, after adjustment for predisposing, need, and enabling factors, individuals receiving mental health services were less likely to be African American. Mental health service use increased by 6.5% over follow-up, and African Americans were no longer less likely to report receiving any mental health services in the 1990s. African Americans were more likely than whites to report discussing mental health problems in GM settings without having seen a mental health specialist. They were less likely than whites to report use of specialty mental health services, but this finding was not statistically significant, possibly because of low rates of specialty mental health use by both race groups. Psychiatric distress was the strongest predictor of mental health service use. Attitudes positively associated with use of mental health services were more prevalent among African Americans than whites. CONCLUSIONS: Mental health service use increased in the past decade, with the greatest increase among African Americans in GM settings. Although it is possible that the racial disparity in use of specialty mental health services remains, the GM setting may offer a safety net for some mental health concerns of African Americans.

A comparison of ambulatory Medicaid claims to medical records: a reliability assessment.

This study compares the documentation of ambulatory care visits and diagnoses in Medicaid paid claims and in medical records. Data were obtained from Maryland Medicaid's 1988 paid claims files for 2407 individuals who were continuously enrolled for the fiscal year, had at least one billed visit for one of six indicator conditions, and had received the majority of their care from one provider. The patients sampled were also stratified on the basis of the case-mix adjusted cost of their usual source of care. The medical records for these individuals as maintained by their usual source of care were abstracted by trained nurse reviewers to compare claims and record information. Linked claim and medical record data for sampled patients were used to calculate: (i) the percent of billed visits documented in the record, (ii) the percent of medical record visits where both the date and the diagnosis agreed with the claims data, and (iii) the ratio of medical record visits to visits from billed claims. Included in the analysis were independent variables specifying place of residence, type and costliness of usual care source, level of patient utilization, and indicator condition on which patient was sampled. Ninety percent of the visits chronicled in the paid claims were documented in the medical record with 82% agreeing on both date and diagnosis. Compared to the medical records kept by private physicians and community health centers, a significantly lower percent of hospital medical records agreed with the claims data. Total volume of visits was 2.6% higher in the medical records than in the claims. Claims data substantially understated visits in the medical record by 25% for low cost providers and by 41% for patients with low use rates (based on claims information). Conversely, medical records substantially understated billed visits by 19% for rural patients and by 10% for persons with high visit rates. Although Medicaid claims are relatively accurate and useful for examining average ambulatory use patterns, they are subject to significant biases when comparing subgroups of providers classified by case-mix adjusted cost and patients classified by utilization rates. Medicaid programs are using claims data for profiling and performance assessment need to understand the limitations of administrative data.

Translating research into practice: the Schizophrenia Patient Outcomes Research Team (PORT) treatment recommendations.

Beginning in 1992, the Agency for Health Care Policy and Research and the National Institute of Mental Health funded the Schizophrenia Patient Outcomes Research Team (PORT) to develop and disseminate recommendations for the treatment of schizophrenia based on existing scientific evidence. These Treatment Recommendations, presented here in final form for the first time, are based on exhaustive reviews of the treatment outcomes literature (previously published in Schizophrenia Bulletin, Vol. 21, No. 4, 1995) and focus on those treatments for which there is substantial evidence of efficacy. The recommendations address antipsychotic agents, adjunctive pharmacotherapies, electroconvulsive therapy, psychological interventions, family interventions, vocational rehabilitation, and assertive community treatment/intensive case management. Support for each recommendation is referenced to the previous PORT literature reviews, and the recommendations are rated according to the level of supporting evidence. The PORT Treatment Recommendations provide a basis for moving toward "evidence-based" practice for schizophrenia and identify both the strengths and limitations in our current knowledge base.

Patterns of usual care for schizophrenia: initial results from the Schizophrenia Patient Outcomes Research Team (PORT) Client Survey.

To examine the conformance of current patterns of usual care for persons with schizophrenia to the Schizophrenia Patient Outcomes Research Team (PORT) Treatment Recommendations, the PORT surveyed a stratified random sample of 719 persons diagnosed with schizophrenia in two States. The types of treatment settings surveyed included acute inpatient programs and continuing outpatient programs in urban and rural locales. Using data from medical record reviews and patient interviews, the PORT assessed the conformance of current care with 12 of the Treatment Recommendations. The rates at which patients' treatment conformed to the recommendations were modest at best, generally below 50 percent. Conformance rates were higher for pharmacological than for psychosocial treatments and in rural areas than in urban ones. Rates of Treatment Recommendation conformance for minority patients were lower than those for Caucasians, and patterns of care varied between the two States. The findings indicate that current usual treatment practices likely fall substantially short of what would be recommended based on the best evidence on treatment efficacy. This disparity underscores the need for greater efforts to ensure that treatment research results are translated into practice.

Principles for assessment of patient outcomes in mental health care.

With the dramatic changes that are occurring in mental health and substance abuse treatment systems, it is imperative that the field keep its focus on the patient and the patient's outcomes of care. Outcomes management systems that measure the processes of care, the patient's characteristics, and the patient's outcomes of care can be helpful in maintaining this focus. To facilitate the development of these systems, the Outcomes Roundtable, a group of mental health consumer, professional, service, and policy-making organizations, has articulated a set of 12 broadly applicable principles of outcomes assessment. The principles call for outcomes assessments that are appropriate to the question being answered, that use tools with demonstrated validity and reliability and sensitivity to clinically important changes over time, and that always include the consumer perspective. In addition, the principles recommend outcomes assessments that create minimal burden for respondents and are adaptable to different health care systems, that include general health status as well as mental health status, and that include consumers' evaluation of treatment and outcomes. Outcomes assessment tools should quantify the type and extent of treatment, should include generic and disorder-specific information, and should measure areas of personal functioning affected by the disorder. Outcomes should be reassessed at clinically meaningful points in time. Outcomes assessment should use appropriate scientific design and representative samples and should examine outcomes of consumers who prematurely leave treatment as well as those who continue in treatment.

Building research capacity into a national physician database.

The range of physician financial arrangements with managed care and insurers, as well as practice arrangements, is becoming increasingly complex. Little is known systematically about these changes, yet there is growing evidence that financial arrangements, utilization management, and other practice characteristics make a substantial difference in treatment patterns, patient mix, and costs of care. Current data systems and surveys frequently do not capture the new information needed to track these changes. New elements of information should be included in national surveys and in a national physician database. A list of recommended data items for a national data base is provided as a starting point for identifying a minimal data set to be included in national statistical systems.

Systemwide provider performance in a Medicaid program. Profiling the care of patients with chronic illnesses.

OBJECTIVES: This study illustrates how claims data can be applied to examine cost and clinical performance of providers in the Medicaid program. METHODS: The authors conducted a cross-sectional analysis of Medicaid beneficiaries in Maryland with diabetes mellitus, hypertension, and asthma treated on an ambulatory basis by hospital-based outpatient departments, physician office-based providers, and community health centers. The study year was July 1987 to June 1988. The authors defined the cost performance (high, medium, or low) of providers in the management of each of the three chronic illnesses, both before and after casemix adjustment, using a classification system based on ambulatory diagnoses (ambulatory care groups). The authors constructed claims-based clinical performance indicators for each of the three conditions. These included the number of patients admitted to acute-care hospitals for any and specific (diabetes mellitus, hypertension, and asthma) causes, the number of patients without a follow-up visit within 30 days of being discharged from the hospital, and the number of patients with consecutive emergency room visits during the study period. RESULTS: The ambulatory care group casemix classification system explained 23%, 33%, and 36% of the variation in total payments for patients with hypertension, diabetes, and asthma, respectively. Without adjustment for casemix, 35% to 50% of providers would be misclassified regarding their cost performance. Forty-one (19.4%) of 211 providers who treated all three illnesses were in the same cost group for all three illnesses and 95 (43%) of 223 providers who treated two of the three illnesses were in the same cost group for both illnesses. Among office-based physicians, for all three chronic illnesses, high-cost providers had more admissions (P < 0.01) for ambulatory care-sensitive conditions than low-cost providers. Among hospital outpatient departments, only high-cost providers of asthma had more admissions (P < 0.05) for asthma than low-cost providers. There was no statistically significant (P > 0.05) difference in the clinical performance indicators between high-cost and low-cost hospital outpatient department providers of primary care for hypertensive and diabetic Medicaid beneficiaries. For the other clinical performance indicators, the results were not consistent across the three illnesses or across the different types of providers. CONCLUSIONS: Without adjustments for casemix, a large number of providers are misclassified regarding to cost performance. In addition, most providers are not equally efficient in managing different chronic illnesses. Provider cost performance is not associated consistently with clinical performance, although severity differences not captured by the casemix adjustment may account for these observations. These measurement methods and relationships between provider performance measures may be useful to state Medicaid programs that seek to contain costs, enhance coordination of care, and improve health.

Ambulatory care practice variation within a Medicaid program.

STUDY QUESTIONS: What is the extent of variation in patterns of ambulatory care practice across one state's Medicaid program once case mix is controlled for? How much of this variation in resource consumption is explained by factors linked to the provider, patient, and geographic subarea? DATA SOURCES/STUDY SETTING: Practices of all providers delivering care to persons who were continuously enrolled in the Maryland Medicaid program during FY 1988 were studied. A computerized summary of all services received during this year for 134,725 persons was developed using claims data. We also obtained data from the state's beneficiary and provider files and the American Medical Association's masterfile. Each patient was assigned a "usual source of care" (primary provider) based on the actual patterns of service. The Ambulatory Care Group (ACG) measure was used to help control for case mix. STUDY DESIGN: This was a cross-sectional study based on the universe of continuously enrolled Medicaid enrollees in one state. PRINCIPAL FINDINGS: After controlling for case mix, the variation in patient resource use by type of primary provider was 19 percent for ambulatory visits, 46 percent for ancillary testing, 61 percent for prescriptions, and 81 percent for hospitalizations. Across Maryland counties, comparing the low- to high-use jurisdiction, there was 41 percent variation in case mix-adjusted visit rates, 72 percent variation in pharmacy use, and 325 percent variation in hospital days. At the individual practice level, physician characteristics explain up to 17 percent of ambulatory resource use and geographic area explains only a few percent, while patient characteristics explain up to 60 percent of variation. CONCLUSIONS: Since a large proportion of variation was explained by patient case mix, it is evident that risk adjustment is essential for these types of analyses. However, even after adjustment, resource use varies considerably across types of ambulatory care provider and region, with consequent implications for efficiency of health services delivery.

Outcomes assessment: information for improving mental health care.

Findings from ongoing assessments in two states illustrate strategies for using outcomes information.

Do ophthalmologists, anesthesiologists, and internists agree about preoperative testing in healthy patients undergoing cataract surgery?

To assess variation in reported use of preoperative medical tests in patients undergoing cataract surgery and to identify factors that influence test use by different physician groups we performed a national survey of ophthalmologists, anesthesiologists, and internists. Participants included randomly selected members of American professional societies who provided care to one or more patients undergoing cataract surgery in 1991. Responses were obtained from 538 (82%) of 655 eligible ophthalmologists, 109 (76%) of 143 anesthesiologists, and 54 (44%) of 122 internists. Fifty percent of ophthalmologists, 40% of internists, and 33% of anesthesiologists frequently or always obtained a chest x-ray film, while 20% of ophthalmologists, 27% of internists, and 37% of anesthesiologists never obtained a chest x-ray film for patients being considered for cataract surgery who had no history of major medical problems (P < .01 for differences between ophthalmologists and the other groups). Similarly, 70% to 90% of ophthalmologists, 73% to 79% of internists, and 41% to 79% of anesthesiologists frequently or always obtained a complete blood cell count, electrolyte panel, and electrocardiogram, while 4% to 11% of ophthalmologists, 13% to 17% of internists, and 9% to 28% of anesthesiologists never obtained these tests for such patients. Many respondents (32% to 80%) believed tests were unnecessary but cited multiple reasons for obtaining tests (eg, medicolegal concerns and institutional requirements). Many physicians in each group viewed preoperative evaluations as screening opportunities or believed that one of the other two types of physicians "required" tests. We conclude that marked variation exists within and across physician specialties in the use and rationale for use of medical tests in patients undergoing cataract surgery.

Extended coverage for preventive services for the elderly: response and results in a demonstration population.

OBJECTIVES: This study was undertaken to test the acceptability of preventive services under Medicare waivers to a community-dwelling population aged 65 and over and to examine the effect of such services on health. METHODS: Medicare beneficiaries and designated primary care providers were sampled, and beneficiaries were screened and surveyed. A total of 4195 individuals were then randomized into intervention or control groups. Those in the intervention group were offered free preventive visits (under waivers) to their physicians. A follow-up survey of the entire group was administered after completion of the intervention. RESULTS: Sixty-three percent of the intervention group made a preventive clinical visit, and about half of them a counseling visit. For men, being married and having a solo practitioner were positively associated with accepting the intervention services, while for women, having had a mammogram, having a confidant, having a high school education, and having a female practitioner were so associated. The intervention group showed a greater health benefit than did the control group and had a significantly lower death rate: 8.3% vs 11.1%. CONCLUSIONS: Older individuals will respond to preventive programs, and such services will result in modest health gains.

Preventive services for the elderly: would coverage affect utilization and costs under Medicare?

OBJECTIVES: This study was undertaken to determine whether adding a benefit for preventive services to older Medicare beneficiaries would affect utilization and costs under Medicare. METHODS: The demonstration used an experimental design, enrolling 4195 older, community-dwelling Medicare recipients. Medicare claims data for the 2 years in which the preventive visits occurred were compared for the intervention (n = 2105) and control (n = 2090) groups. Monthly allowable charges for Part A and Part B services and number of hospital discharges and ambulatory visits were compared. RESULTS: There were no significant differences in the charges between the groups owing to the intervention, although total charges were somewhat lower for the intervention group even when the cost of the intervention was included. Charges for both groups rose significantly as would be expected for an aging population. A companion paper describes a modest health benefit. CONCLUSIONS: There appears to be a modest health benefit with no negative cost impact. This finding gives an early quantitative basis for the discussion of whether to extend Medicare benefits to include a general preventive visit from a primary care clinician.

Geographic variation in utilization of cataract surgery.

Cataract surgery is the most frequently performed surgical procedure on Medicare beneficiaries, with an annual cost to the Medicare program of more than $3.4 billion. In this study, the relationship between demographic, environmental, and provider-related factors, and the likelihood that cataract surgery will be performed on a Medicare beneficiary were assessed. The association between likelihood of cataract surgery and patient age, sex, race, income, and latitude of residence was examined, as was the association with the supply of ophthalmologists and optometrists in each region, and the allowed charge for cataract surgery and cost of practice in a region. This cross-sectional, population-based study used administrative data. Both regional models, using least-squares regression and person-based models, using logistic regression were employed. A random 5% sample of 1986 and 1987 Medicare beneficiaries, 65 years of age and older, were included in the study. Medicare beneficiaries who lacked continuous Part A and Part B coverage during 1986 and 1987, or who were enrolled in a health maintenance organization at any time during this 2-year period of observation were excluded from the study to make certain that complete utilization data were available for each individual. Rate of cataract surgery per 1,000 Medicare beneficiaries in each Bureau of Economic Analysis Economic Area (BEAEA) and the likelihood of an individual with particular characteristics undergoing cataract surgery were determined in separate regression models. The mean annual rate of cataract surgery during 1986 and 1987 in the 181 BEAEAs was 25.4 surgeries per 1,000 persons 65 years of age or older (standard deviation = 6.2, coefficient of variation = 0.24). Both the regional model and the person-based model detected an association between a higher rate of and personal likelihood of cataract surgery and female gender, more southerly latitude, higher concentration of optometrists per 1,000 Medicare beneficiaries, and higher allowed charge for cataract surgery, after adjusting for variation in practice expense. The person-based model additionally demonstrated that increased likelihood of undergoing cataract surgery was associated with increasing age from 65 to 94 years, white race, and living in a zip-code area with mean income greater than $15,000. Neither analysis detected a statistically significant association between the concentration of ophthalmologists per 1,000 Medicare beneficiaries and the regional rate of, or an individual's likelihood of, cataract surgery. Compared with the geographic variation in provision of other surgical procedures, the variation in cataract surgery across large geographic areas observed in this analysis was relatively low.(ABSTRACT TRUNCATED AT 400 WORDS)

Treatment outcomes in schizophrenia: implications for practice, policy, and research.

Outcomes research on treatments for schizophrenia has identified a number of efficacious interventions. The degree to which such scientific knowledge influences the care delivered in everyday practice depends on a large number of patient, practitioner, service system, and other social factors. The current atmosphere for change in the health care delivery system poses both risks and opportunities to improve care for persons with this disorder. Scientific knowledge about treatment outcomes must inform this rapid evolution of practice, policy, and research to ensure that effective treatments are preserved and available for all who need them and that new treatments continue to be developed, evaluated, and disseminated.

Variation in cataract surgery practice and clinical outcomes.

PURPOSE: To examine associations between surgical technique, patient and surgeon characteristics, and clinical outcomes of cataract surgery. METHODS: Seventy-five ophthalmologists were recruited from three cities based on a sampling scheme stratified by surgeon-reported annual volume of cataract surgery. Seven hundred seventy-two patients undergoing first eye cataract surgery were enrolled, with complete preoperative, perioperative, and 4-month postoperative clinical data on 717 patients (93%). RESULTS: Sixty-five percent of surgery was performed by phacoemulsification and 35% by standard extracapsular (ECCE) techniques. Performance of ECCE was associated with the presence of ocular comorbidity and 21 or more years in practice of the surgeon. Performance of phacoemulsification was associated with annual volume of cataract surgery, wherein high-volume (201-399 patients annually) and very high-volume (> 400 patients annually) surgeons had 3.7 and 3.9 times the likelihood of performing phacoemulsification compared with moderate-volume (51-200 cases annually) surgeons. The rates of intraoperative, perioperative, and 4-month postoperative adverse events and the amount of improvement in visual acuity did not differ either by surgical technique or volume stratum. The reported occurrence of posterior capsular opacification within 4 months of surgery was increased in the presence of cortical opacification, one city, and patients operated on by either high- or very high-volume surgeons. CONCLUSIONS: In this cohort, no difference in clinical outcomes, as measured by change in visual acuity or occurrence of postoperative adverse events (except for posterior capsular opacification), can be attributed to performance of phacoemulsification versus ECCE or to the reported annual volume of cataract surgery of the surgeon. Self-reported high and very high annual volume of cataract surgery is associated independently with performance of phacoemulsification and surgeon's report of posterior capsular opacification at 4 months after cataract surgery.