A Novel Rubric to Evaluate Wearable Cameras for Assessment of Interrater Reliability.

Research has reported on traditional methods of assessing interrater reliability but, currently, no such standard protocol exists for selection of alternative methods of assessing interrater reliability, such as wearable video cameras. The professions of occupational therapy and occupational science take a unique ecological perspective when evaluating individuals, which focuses on the naturalistic perspective of an individual, ideally resulting in optimal performance. Given current advancements in technology, wearable, low-cost, unobtrusive, first-person view digital video cameras are readily available for use in research. The researchers generated an original rubric for critiquing cameras, then trialed four cameras for use in a future interrater reliability study. This standardized protocol fills a gap in the field and can be used by future researchers searching for a standardized method of camera selection.

Doctor shopping by overweight and obese patients is associated with increased healthcare utilization.

OBJECTIVE: Negative interactions with healthcare providers may lead patients to switch physicians or "doctor shop." We hypothesized that overweight and obese patients would be more likely to doctor shop, and as a result, have increased rates of emergency department (ED) visits and hospitalizations as compared to normal weight nonshoppers. DESIGN AND METHODS: We combined claims data from a health plan in one state with information from beneficiaries' health risk assessments. The primary outcome was "doctor shopping," which we defined as having outpatient claims with ≥5 different primary care physicians (PCPs) during a 24-month period. The independent variable was standard NIH categories of weight by BMI. We performed multivariate logistic regression to evaluate the association between weight categories and doctor shopping. We conducted multivariate zero-inflated negative binominal regression to evaluate the association between weight-doctor shopping categories with counts of ED visits and hospitalizations. RESULTS: Of the 20,726 beneficiaries, the mean BMI was 26.3 kg m(-2) (SD 5.1), mean age was 44.4 years (SD 11.1) and 53% were female. As compared to normal weight beneficiaries, overweight beneficiaries had 23% greater adjusted odds of doctor shopping (OR 1.23, 95%CI 1.04-1.46) and obese beneficiaries had 52% greater adjusted odds of doctor shopping (OR 1.52, 95%CI 1.26-1.82). As compared to normal weight non-shoppers, overweight and obese shoppers had higher rates of ED visits (IRR 1.85, 95%CI 1.37-2.45; IRR 1.83, 95%CI 1.34-2.50, respectively), which persisted during within weight group comparisons (Overweight IRR 1.50, 95%CI 1.10-2.03; Obese IRR 1.54, 95%CI 1.12-2.11). CONCLUSION: Frequently changing PCPs may impair continuity and result in increased healthcare utilization.

Relationship of ethnicity and body mass index with the development of hypertension and hyperlipidemia.

OBJECTIVES: Studies primarily using prevalence data suggest the relationship between body mass index (BMI) and risk factors for cardiovascular disease may vary by ethnicity. The objective of this study was to examine longitudinally the associations of BMI and ethnicity with transitions from a baseline state without evidence of chronic disease to the onset of hypertension, hyperlipidemia, or both. DESIGN: The study population comprised members of a large insurer in Hawaii. Individuals were eligible if continuously enrolled for at least one year without evidence of major chronic disease. Analyses used multi-state models to measure the relative rates of transitions from the baseline state to developing hypertension, hyperlipidemia, or both. All analyses were adjusted for age, sex, education, number of office visits, and island of residence. RESULTS: Native Hawaiians had the highest prevalence of overweight and obesity followed by Caucasians, Filipinos, Japanese, Chinese, and Koreans. Relative rates of transitions by ethnicity, however, did not parallel the prevalence of overweight and obesity. Japanese and Filipino ethnicities had significantly faster transition rates than Whites for all four study transitions, rates that ranged from 20% to more than two-fold faster. Chinese and Koreans also had significantly higher rates of many transitions compared to Whites. Native Hawaiians, by contrast, had a slower transition rate than Whites to developing hyperlipidemia without hypertension, and relatively faster transitions to the other outcome states. CONCLUSIONS: The study offers longitudinal evidence of different patterns of risk for developing hypertension and hyperlipidemia among Asians, Whites, and Native Hawaiians.

Heart failure patients receiving ACEIs/ARBs were less likely to be hospitalized or to use emergency care in the following year.

Angiotensin-converting enzyme inhibitors (ACEIs) have been shown to decrease morbidity and mortality in heart failure (HF) patients in randomized-controlled trials; observational studies have confirmed this benefit among patients discharged with HF. Investigating the benefit of ACEIs or angiotensin receptor blockers (ARBs) among general HF patients has important implications for quality-of-care measurement and quality initiatives. The objective of this study is to assess the impact of receipt of ACEIs/ARBs among patients with HF on hospitalization, emergency care, and healthcare cost during the following year. Using administrative data, we identified HF patients between 2000 and 2005 in a large health plan (n=2,396 patients). We conducted multivariate analysis to assess the impact of receipt of an ACEI/ARB on likelihood of hospitalization and emergency care, and on total healthcare cost. We found that patients who received ACEIs/ARBs were less likely to be hospitalized (odds ratio [OR]=0.82, p<.05) or use emergency care (OR=0.82, p<.05) in the following year. Receipt of ACEIs/ARBs was not associated with significantly increased cost. Incentivizing the receipt of ACEIs/ARBs in a general population with HF may be a suitable target for pay-for-performance programs, disease management programs, or newer complementary frameworks, such as value-based insurance design.

Does pay for performance improve cardiovascular care in a "real-world" setting?

The objective was to investigate the impact of a pay-for-performance program (P4P) on quality care and outcomes among cardiovascular disease (CVD) patients. Claims data were used to identify CVD patients in a commercial plan in 1999-2006. Multivariate analyses were employed to examine the impact of P4P on quality care (lipid monitoring and treatment) and quality care on outcomes (new coronary events, hospitalizations, and lipid control). Patients who were treated by physicians participating in P4P were more likely to receive quality care than patients who were not. Patients who received quality care were less likely to have new coronary events (odds ratio [OR] = 0.80; 95% confidence interval [CI] = 0.69-0.92), be hospitalized (OR = 0.76; 95% CI = 0.69-0.83), or have uncontrolled lipids (OR = 0.67; 95% CI = 0.61-0.73) than patients who did not. A P4P program was associated with increased lipid monitoring and treatment. Receipt of this quality care was associated with improved lipid control and reduced likelihood of new coronary events and hospitalizations.

Impact of a pay-for-performance program on low performing physicians.

Studies have shown that the lowest performing physicians in pay-for-performance (P4P) programs improved the most; however, it is unclear whether this would occur without the P4P program or be sustained. The objective of this study is to investigate the impact of P4P in a Preferred Provider Organization (PPO) on low performing physicians over a 4-year period. We used administrative claims data from a PPO health plan in Hawaii, which implemented a P4P program, and a PPO plan in the South, which did not implement a P4P program. The difference-indifference model was used to compare the quality scores between the two physician groups in preventive measures, a heart failure measure, and an HbA1c testing measure. We found that P4P programs may be effective in incentivizing low performing physicians to improvement quality of care and sustain improvement, and the positive benefit of the P4P program may not be realized until the 3rd or 4th year of the program.

The effect of a PPO pay-for-performance program on patients with diabetes.

OBJECTIVES: To investigate the effectiveness of a pay-for-performance program (P4P) to increase the receipt of quality care and to decrease hospitalization rates among patients with diabetes mellitus. STUDY DESIGN: Longitudinal study of patients with diabetes enrolled in a preferred provider organization (PPO) between January 1, 1999, and December 31, 2006. METHODS: We used multivariate analyses to assess the effect of seeing P4P-participating physicians on the receipt of quality care (ie, glycosylated hemoglobin and low-density lipoprotein cholesterol testing) and on hospitalization rates, controlling for patient characteristics. RESULTS: Patients with diabetes who saw P4P-participating physicians were more likely to receive quality care than those who did not (odds ratio, 1.16; 95% confidence interval, 1.11-1.22; P <.001). Patients with diabetes who received quality care were less likely to be hospitalized than those who did not (incident rate ratio, 0.80; 95% confidence interval, 0.80-0.85; P <.001). During 1 year, there was no difference in hospitalization rates between patients with diabetes who saw P4P-participating physicians versus those who did not. However, patients with diabetes who saw P4P-participating physicians in 3 consecutive years were less likely to be hospitalized than those who did not (incident rate ratio, 0.75; 95% confidence interval, 0.61-0.93; P <.01). CONCLUSIONS: A P4P can significantly increase the receipt of quality care and decrease hospitalization rates among patients with diabetes in a PPO setting. Although it is possible that the differences observed between P4P-participating physicians and non-P4P-participating physicians were due to selection bias, we found no significant difference in the receipt of quality care between patients with diabetes who saw new P4P-participating physicians versus non-P4P-participating physicians during the baseline year. Further research should focus on defining the effect of P4Ps on intermediate outcomes such as glycosylated hemoglobin and low-density lipoprotein cholesterol levels.

Diabetes incidence based on linkages with health plans: the multiethnic cohort.

OBJECTIVE: Using the Hawaii component of the Multiethnic Cohort (MEC), we estimated diabetes incidence among Caucasians, Japanese Americans, and Native Hawaiians. RESEARCH DESIGN AND METHODS: After excluding subjects who reported diabetes at baseline or had missing values, 93,860 cohort members were part of this analysis. New case subjects were identified through a follow-up questionnaire (1999-2000), a medication questionnaire (2003-2006), and linkage with two major health plans (2007). We computed age-standardized incidence rates and estimated hazard ratios (HRs) for ethnicity, BMI, education, and combined effects of these variables using Cox regression analysis. RESULTS: After a total follow-up time of 1,119,224 person-years, 11,838 incident diabetic case subjects were identified with an annual incidence rate of 10.4 per 1,000 person-years. Native Hawaiians had the highest rate with 15.5, followed by Japanese Americans with 12.5, and Caucasians with 5.8 per 1,000 person-years; the adjusted HRs were 2.65 for Japanese Americans and 1.93 for Native Hawaiians. BMI was positively related to incidence in all ethnic groups. Compared with the lowest category, the respective HRs for BMIs of 22.0-24.9, 25.0-29.9, and > or =30.0 kg/m(2) were 2.10, 4.12, and 9.48. However, the risk was highest for Japanese Americans and intermediate for Native Hawaiians in each BMI category. Educational achievement showed an inverse association with diabetes risk, but the protective effect was limited to Caucasians. CONCLUSIONS: Within this multiethnic population, diabetes incidence was twofold higher in Japanese Americans and Native Hawaiians than in Caucasians. The significant interaction of ethnicity with BMI and education suggests ethnic differences in diabetes etiology.

Major depression associated with rates of cardiovascular disease state transitions.

OBJECTIVE: To compare patients with and without major depression with respect to their rates of transition to several stages of cardiovascular disease progression. STUDY DESIGN: Retrospective observational study. METHODS: The study used administrative data from a large insurer in Hawaii to evaluate associations of major depression with cardiovascular progression. Analyses used competing-risks models, models that allow more than 1 type of possible outcome event at the transition stages. All analyses were adjusted for age and sex. RESULTS: Among nearly 600,000 healthy members, those with major depression in the past year were 50% to 100% more likely than controls to develop hypertension or dyslipidemia. Rates were increased to a similar magnitude (1) among patients with hypertension or dyslipidemia who subsequently developed either the other condition or coronary artery disease and (2) among patients with hypertension and dyslipidemia who developed coronary artery disease or congestive heart failure. Transition rates to coronary artery disease or congestive heart failure also were increased 50% to 100% among patients with diabetes, hypertension, and dyslipidemia. The sequence of associations remained as strong examining depression 1-2 years in the past as with depression in the past year. CONCLUSIONS: The results show a pattern of faster transitions for patients with major depression compared with patients without major depression across both the early and later stages of cardiovascular progression. Health plans offer a setting where patients with depression can be identified and where interventions might be undertaken to minimize the possible effects of depression on transition rates.