Evaluation of electronic measurement of capillary refill for Sepsis screening at ED triage.

OBJECTIVE: To evaluate the association between capillary refill time (CRT) measured by a medical device and sepsis among patients presenting to the Emergency Department (ED). METHODS: This prospective observational study enrolled adult and pediatric patients during ED triage when sepsis was considered a potential diagnosis by the triage nurse. Patients were enrolled at an academic medical center between December 2020 and June 2022. CRT was measured by a research assistant using an investigational medical device. The outcomes included sepsis and septic shock defined using sep-3 criteria, septic shock defined as IV antibiotics and a vasopressor requirement, ICU admission, and hospital mortality. Other measures included patient demographics and vital signs at ED triage. We evaluated univariate associations between CRT and sepsis outcomes. RESULTS: We enrolled 563 patients in the study, 48 met Sep-3 criteria, 5 met Sep-3 shock criteria, and 11 met prior septic shock criteria (IV antibiotics and vasopressors to maintain mean arterial pressure of 65). Sixteen patients were admitted to the ICU. The mean age was 49.1 years, and 51% of the cohort was female. The device measured CRT was significantly associated with the diagnosis of sepsis by sep-3 criteria (OR 1.23, 95% CI 1.06-1-43), septic shock by sep-3 criteria (OR 1.57, 95% CI 1.02-2.40), and septic shock defined as receipt of IV antibiotics and a vasopressor requirement (OR 1.37, 95% CI 1.03-1.82). Patients with CRT >3.5 s measured by the DCR device had an odds ratio of 4.67 (95%CI 1.31-16.1) of septic shock (prior definition), and an odds ratio of 3.97 (95% CI 1.99-7.92) of ICU admission, supporting the potential for the 3.5-s cutoff of the DCR measurement. CONCLUSIONS: CRT measured by a medical device at ED triage was associated with the diagnosis of sepsis. Objective CRT measurement using a medical device may be a relatively simple way to improve sepsis diagnosis during ED triage.

Emergency Department Pediatric Readiness and Short-term and Long-term Mortality Among Children Receiving Emergency Care.

Importance: Emergency departments (EDs) with high pediatric readiness (coordination, personnel, quality improvement, safety, policies, and equipment) are associated with lower mortality among children with critical illness and those admitted to trauma centers, but the benefit among children with more diverse clinical conditions is unknown. Objective: To evaluate the association between ED pediatric readiness, in-hospital mortality, and 1-year mortality among injured and medically ill children receiving emergency care in 11 states. Design, Setting, and Participants: This is a retrospective cohort study of children receiving emergency care at 983 EDs in 11 states from January 1, 2012, through December 31, 2017, with follow-up for a subset of children through December 31, 2018. Participants included children younger than 18 years admitted, transferred to another hospital, or dying in the ED, stratified by injury vs medical conditions. Data analysis was performed from November 1, 2021, through June 30, 2022. Exposure: ED pediatric readiness of the initial ED, measured through the weighted Pediatric Readiness Score (wPRS; range, 0-100) from the 2013 National Pediatric Readiness Project assessment. Main Outcomes and Measures: The primary outcome was in-hospital mortality, with a secondary outcome of time to death to 1 year among children in 6 states. Results: There were 796 937 children, including 90 963 (11.4%) in the injury cohort (mean [SD] age, 9.3 [5.8] years; median [IQR] age, 10 [4-15] years; 33 516 [36.8%] female; 1820 [2.0%] deaths) and 705 974 (88.6%) in the medical cohort (mean [SD] age, 5.8 [6.1] years; median [IQR] age, 3 [0-12] years; 329 829 [46.7%] female, 7688 [1.1%] deaths). Among the 983 EDs, the median (IQR) wPRS was 73 (59-87). Compared with EDs in the lowest quartile of ED readiness (quartile 1, wPRS of 0-58), initial care in a quartile 4 ED (wPRS of 88-100) was associated with 60% lower in-hospital mortality among injured children (adjusted odds ratio, 0.40; 95% CI, 0.26-0.60) and 76% lower mortality among medical children (adjusted odds ratio, 0.24; 95% CI, 0.17-0.34). Among 545 921 children followed to 1 year, the adjusted hazard ratio of death in quartile 4 EDs was 0.59 (95% CI, 0.42-0.84) for injured children and 0.34 (95% CI, 0.25-0.45) for medical children. If all EDs were in the highest quartile of pediatric readiness, an estimated 288 injury deaths (95% CI, 281-297 injury deaths) and 1154 medical deaths (95% CI, 1150-1159 medical deaths) may have been prevented. Conclusions and Relevance: These findings suggest that children with injuries and medical conditions treated in EDs with high pediatric readiness had lower mortality during hospitalization and to 1 year.

Emergency Department Pediatric Readiness Among US Trauma Centers: A Machine Learning Analysis of Components Associated With Survival.

OBJECTIVE: We used machine learning to identify the highest impact components of emergency department (ED) pediatric readiness for predicting in-hospital survival among children cared for in US trauma centers. BACKGROUND: ED pediatric readiness is associated with improved short-term and long-term survival among injured children and part of the national verification criteria for US trauma centers. However, the components of ED pediatric readiness most predictive of survival are unknown. METHODS: This was a retrospective cohort study of injured children below 18 years treated in 458 trauma centers from January 1, 2012, through December 31, 2017, matched to the 2013 National ED Pediatric Readiness Assessment and the American Hospital Association survey. We used machine learning to analyze 265 potential predictors of survival, including 152 ED readiness variables, 29 patient variables, and 84 ED-level and hospital-level variables. The primary outcome was in-hospital survival. RESULTS: There were 274,756 injured children, including 4585 (1.7%) who died. Nine ED pediatric readiness components were associated with the greatest increase in survival: policy for mental health care (+8.8% change in survival), policy for patient assessment (+7.5%), specific respiratory equipment (+7.2%), policy for reduced-dose radiation imaging (+7.0%), physician competency evaluations (+4.9%), recording weight in kilograms (+3.2%), life support courses for nursing (+1.0%-2.5%), and policy on pediatric triage (+2.5%). There was a 268% improvement in survival when the 5 highest impact components were present. CONCLUSIONS: ED pediatric readiness components related to specific policies, personnel, and equipment were the strongest predictors of pediatric survival and worked synergistically when combined.

Cross-sectional analysis of the Myasthenia Gravis Patient Registry: Disability and treatment.

INTRODUCTION: The Myasthenia Gravis Patient Registry (MGR) is a voluntary, patient-submitted database dedicated to improve understanding of care/burden of myasthenia gravis (MG). METHODS: In this study we present analyses of baseline records through July 2017 (n = 1140) containing data on the MG-Activities of Daily Living (MG-ADL) and the MG 15-item Quality of Life (MG-QOL15) instruments, two validated scales assessing quality of life in MG patients at sign-up into the MGR. RESULTS: Most registrants reported moderate to severe impairment of health-related quality of life, with a median MG-ADL score of 6 and a median MG-QOL15 score of 21. Seventy-one percent of the patients had received pyridostigmine. Corticosteroids, mycophenolate mofetil, and azathioprine were the most common immunomodulators/immunosuppressants, with 85% of participants having ever using one of these agents. Forty-seven registrants reported receiving intravenous immunoglobulin, and 30% received plasma exchange. Twelve percent reported other treatments, and 40% were unsure whether they received less common therapies. Forty percent had undergone thymectomy. DISCUSSION: The MGR data correlate well with other MG cohorts. Many MG patients remain negatively impacted despite treatment.

Employment in refractory myasthenia gravis: A Myasthenia Gravis Foundation of America Registry analysis.

INTRODUCTION: Labor-market participation is potentially very difficult for patients with refractory myasthenia gravis (MG). In this study, employment status and work absences are compared between refractory and nonrefractory MG. METHODS: Adults (aged 18-64 years, all diagnosed ≥2 years previously) were included if enrolled in the Myasthenia Gravis Foundation of America Patient Registry during July 2013 to February 2018. RESULTS: Seventy-six patients (9.2%) had refractory and 749 (90.8%) had nonrefractory disease; demographic data did not differ between groups. Relative to the nonrefractory group, the refractory group patients were more than twice as likely to work fewer hours per week (odds ratio [95% confidence interval]: currently employed, 2.777 [1.640-4.704]; employed over previous 6 months, 2.643 [1.595-4.380]), but those employed were not more likely to be absent from work. DISCUSSION: Because absence from the labor market adversely affects quality of life and personal finances, these findings reaffirm the considerable disease burden associated with refractory MG.

Patient Dissatisfaction With Primary Care and Nonurgent Emergency Department Use.

A well-functioning primary care system will have the capacity to provide timely, adequate, and effective care for patients to avoid nonurgent emergency department (ED) use. This study advances academic discussion by examining whether patient negative experiences during their encounter with a primary care physician (PCP) are associated with nonurgent ED use nationwide in the United States. This retrospective cohort study used data from the 2010-2011 Medical Expenditure Panel Survey. The independent measures were patient perceptions of PCPs' communication and care quality in 2010. The multivariate logit model was employed to analyze the nonurgent ED use as opposed to no ED use in 2011, after controlling for age, gender, race and ethnicity, rural/urban location, marital status, and education levels in 2010. All predictors were treated as dummy variables. We employed the lagged time effect and controlled health status to account for the endogeneity between outcomes and the main independent variables. The weights and variance were adjusted using the survey procedures to yield nationally representative results. The study sample consisted of 5242 adults, which represented 131 317 908 weighted people in the total population. While the measure of patient satisfaction with providers' communication was not associated with nonurgent ED use (P = .750), patient perceived poor and intermediary levels of primary care quality had higher odds of a nonurgent ED visit (OR = 1.75, P = .049, and OR = 1.48, P = .050, respectively) compared with high levels of care quality. For PCPs, endeavors may be considered in improving health care quality to reduce nonurgent ED use. Whenever possible, PCPs' efforts may want to be devoted to both communication and care quality to improve patients' health outcomes and satisfaction and to reduce nonurgent ED use.

Examining the Impact of Refractory Myasthenia Gravis on Healthcare Resource Utilization in the United States: Analysis of a Myasthenia Gravis Foundation of America Patient Registry Sample.

BACKGROUND AND PURPOSE: Patients with refractory myasthenia gravis (MG) experience ongoing disease burden that might be reflected in their healthcare utilization. Here we examine the impact of refractory MG on healthcare utilization. METHODS: The 825 included participants were aged 18-64 years, enrolled in the Myasthenia Gravis Foundation of America Patient Registry between July 2013 and February 2018, and had been diagnosed with MG ≥2 years previously. RESULTS: Participants comprised 76 (9.2%) with refractory MG and 749 (90.8%) with nonrefractory MG. During the 6 months before enrollment, participants with refractory MG were significantly more likely than those with nonrefractory MG to have experienced at least one exacerbation [67.1% vs. 52.0%, respectively, p=0.01; odds ratio (OR)=1.882, 95% confidence interval (CI)=1.141-3.104], visited an emergency room at least once [43.4% vs. 27.1%, p<0.01; OR=2.065, 95% CI=1.276-3.343], been hospitalized overnight at least once (32.9% vs. 20.5%, p=0.01; OR=1.900, 95% CI=1.140-3.165), ever been admitted to an intensive care unit (ICU) (61.8% vs. 33.4%, p<0.01; OR=3.233, 95% CI=1.985-5.266), or ever required a feeding tube (21.1% vs. 9.1%, p<0.01; OR=2.671, 95% CI=1.457-4.896). A total of 75.8% younger females with refractory disease (<51 years, n=33) experienced at least one exacerbation, 69.7% had been admitted to an ICU, and 30.3% had required a feeding tube. For older females with refractory disease (≥51 years, n=33), 60.6%, 54.6%, and 6.1% experienced these outcomes, respectively (between-group differences were not significant). CONCLUSIONS: Refractory MG is associated with higher disease burden and healthcare utilization than nonrefractory MG.

Impact of Refractory Myasthenia Gravis on Health-Related Quality of Life.

OBJECTIVES: Myasthenia gravis (MG) may be refractory to traditional therapies. Quality of life (QOL) and disease burden in patients with refractory and nonrefractory MG were compared using Myasthenia Gravis Foundation of America MG Patient Registry data. METHODS: Adults aged 18 years or older with MG diagnosed ≥2 years before enrollment were included. Participants with refractory MG had received ≥2 previous and 1 current MG treatment and had MG Activities of Daily Living Scale total score ≥6 at enrollment; other participants had nonrefractory MG. MG QOL 15-item scale (MG-QOL15) scores were compared. RESULTS: In total, 56 participants with refractory and 717 participants with nonrefractory MG enrolled. Participants with refractory MG had significantly higher mean (SD) MG-QOL15 total scores [31.4 (11.1) vs. 20.8 (15.0), P < 0.0001] and were more likely to have had exacerbations, emergency department visits, and recent hospitalizations. CONCLUSIONS: Participants with refractory MG experience worse QOL and greater clinical burden than those with nonrefractory disease.

High-cost sharing policies and non-urgent emergency department visits.

PURPOSE: The purpose of this paper is to examine whether high-cost-sharing ambulatory care policies affect non-urgent emergency department (ED) care utilization differently among individuals with and without chronic conditions. DESIGN/METHODOLOGY/APPROACH: This retrospective cohort study used 2010-2011 US Medical Expenditure Panel Survey data. Difference-in-difference methods, multivariate logit model and survey procedures were employed. Time lag effect was used to address endogeneity concerns. FINDINGS: The sample included 4,347 individuals. Difference in non-urgent ED visits log odds between high- and low-cost-sharing policies was not significantly different between chronically ill and non-chronically ill individuals ( ß=-0.48, p=0.42). Sensitivity analysis with 15 and 25 percent cost-sharing levels also generated consistent insignificant results ( p=0.33 and p=0.31, respectively). Ambulatory care incidence rates were not significantly different between high- and low-cost-sharing groups among chronically ill people (incidence rate ratio=0.849, p=0.069). PRACTICAL IMPLICATIONS: High-cost-sharing ambulatory care policies were not associated with increased non-urgent ED care utilization among chronically ill and healthy people. The chronically ill patients may have retained sizable ambulatory care that was necessary to maintain their health. Health plans or employers may consider low-level cost-sharing policies for ambulatory care among chronically ill enrollees or employees. ORIGINALITY/VALUE: Findings contribute to insurance benefit design; i.e., whether high-cost-sharing ambulatory care policies should be implemented among chronically ill enrollees to maintain their health and save costs for health plans.

Gender and quality of life in myasthenia gravis patients from the myasthenia gravis foundation of America registry.

INTRODUCTION: Quality of life (QOL) has been poorly characterized among patients with myasthenia gravis (MG) other than assessments performed within the clinical setting. METHODS: Patients age ≥ 18 years who were diagnosed with MG and registered with the MG patient registry between July 1, 2013, and June 30, 2016, were included. Demographic information, disease related history, and QOL were compared between men and women using multivariable analysis. RESULTS: A total of 1,315 subjects (827 women) were included. Women were significantly younger, had a younger age at symptom onset, and were more likely to have thymoma and thymectomy. The 15-item Myasthenia Gravis Quality of Life scale (MG-QOL15) was significantly worse in women. MG-QOL15 score was comparable between women who had thymectomy and men with or without thymectomy. DISCUSSION: QOL among MG patients is worse in women compared with men, but this disparity is eliminated in women who have undergone thymectomy. Muscle Nerve, 2018.

Racial Disparity in Localized Prostate Cancer Mortality.

This study aims to examine racial differences in all-cause mortality between African American (AA) and non-African American localized prostate cancer patients. This study advances academic discussion by being among the first to use a sample more representative of the general population that is different from certain subpopulations examined in literature. This study adopted a retrospective cohort study design using the Florida Cancer Data System. The hierarchical logistic regression was employed to analyze mortality in 2004 among living patients with localized prostate cancer from baseline 2000. Among 9617 patients, the odds of mortality in AAs were 57.6% higher than the non-AAs (Adjusted OR = 1.576, 95% CI: 1.243-1.999). Among prostate cancer patients, AA, older age, unmarried status, conservative treatment, Medicaid, and tumor grade III diagnosis predicted higher mortality relative to the reference group. Screening programs at a younger age can be considered, family and community support and aggressive treatments are suggested to prevent AA against adverse health outcomes.

Is Access to and Use of Primary Care Practices that Patients Perceive as Having Essential Qualities of a Patient-Centered Medical Home Associated With Positive Patient Experience? Empirical Evidence From a U.S. Nationally Representative Sample.

OBJECTIVE: The patient-centered medical home (PCMH) has emerged as an innovative healthcare delivery model that holds the conceptual promise to improve healthcare quality and patient experience. This study examined how patient perceived PCMH is related to patient satisfaction and experience nationwide. This study advances academic discussion in that it is among the first to examine empirical evidence using a U.S. nationally representative sample. METHODS: This retrospective cohort study used data from the 2010 to 2011 Medical Expenditure Panel Survey. This study focused on insured individuals aged 18 and older. We measured and identified cohorts for a "full PCMH," a "partial PCMH" (i.e., with a usual source of care but not a PCMH), and an "unknown PCMH," with the reference group being the "no regular provider" group and the partial PCMH group, respectively. Using logit models, we assessed patient experiences of the PCMH use controlling for covariates in 2010. Given the nature of the complex survey design, the weights and variance were adjusted using the survey procedures to yield nationally representative results. RESULTS: The final study sample consisted of 7,743 individuals, representing 191 million individuals in the weighted population. After controlling for covariates in 2010, the full PCMH group was consistently observed to have higher odds of positive patient experience than individuals with no usual source of care: odds ratio (OR) = 1.89 (p = .003) for providers "listened carefully to you"; OR = 1.81 (p = .001) for providers "spent enough time with you"; OR = 1.85 (p = .007) for providers "showed respect for what you had to say"; and OR = 1.89 (p < .001) for the composite patient experience. Similarly, compared with the partial PCMH group, consistently higher odds of patient satisfaction among all patient experience measures were observed for the full medical home group: OR = 1.45 (p = .070, significant at α = 0.1 level) for providers "explained things so you understood"; OR = 1.69 (p = .002) for providers "listened carefully to you"; OR = 1.57 (p = .003) for providers "spent enough time with you"; OR = 1.48 (p = .039) for providers "showed respect for what you had to say"; and OR = 1.56 (p = .001) for the composite patient experience. CONCLUSIONS: Overall, the PCMH model was associated with improved patient satisfaction nationwide. Findings from this study have shed light on strategies of innovative healthcare delivery models in improving patient experience, which in turn, may translate to patients' compliance to treatment regimen and improved health outcomes.

Is Access to and Use of Patient Perceived Patient-Centered Medical Homes Associated With Reduced Nonurgent Emergency Department Use?

This study examined whether access to and use of patient-centered medical home (PCMH) practices is associated with reduced nonurgent emergency department (ED) use, especially among the uninsured population. This retrospective study used 2010-2011 Medical Expenditure Panel Survey data. Difference-in-difference methods, multivariate logit model, marginal effect, and survey procedures were employed. A total of 1287 adults had any ED visit in 2011, which represented weighted 29 463 684 people in the population. Reductions in odds of nonurgent ED use between the full PCMH group and the "no regular provider" group was significantly larger for the uninsured group than publicly and privately insured groups (ß = -1.70, P = .009, and ß = -1.04, P = .040, respectively). Similar results were found between the partial PCMH group and the "no regular provider" group for the uninsured group compared to the public group (ß = -1.67, P = .019). PCMH models demonstrate higher odds of reduced nonurgent ED use among uninsured individuals compared to public and private enrollees nationwide.

Experiences and Lessons from Urban Health Insurance Reform in China.

Health care systems often face competing goals and priorities, which make reforms challenging. This study analyzed factors influencing the success of a health care system based on urban health insurance reform evolution in China, and offers recommendations for improvement. Findings based on health insurance reform strategies and mechanisms that did or did not work can effectively inform improvement of health insurance system design and practice, and overall health care system performance, including equity, efficiency, effectiveness, cost, finance, access, and coverage, both in China and other countries. This study is the first to use historical comparison to examine the success and failure of China's health care system over time before and after the economic reform in the 1980s. This study is also among the first to analyze the determinants of Chinese health system effectiveness by relating its performance to both technical reasons within the health system and underlying nontechnical characteristics outside the health system, including socioeconomics, politics, culture, values, and beliefs. In conclusion, a health insurance system is successful when it fits its social environment, economic framework, and cultural context, which translates to congruent health care policies, strategies, organization, and delivery. No health system can survive without its deeply rooted socioeconomic environment and cultural context. That is why one society should be cautious not to radically switch from a successful model to an entirely different one over time. There is no perfect health system model suitable for every population-only appropriate ones for specific nations and specific populations at the right place and right time. (Population Health Management 2016;19:291-297).

Can Nonurgent Emergency Department Care Costs be Reduced? Empirical Evidence from a U.S. Nationally Representative Sample.

BACKGROUND: A well-functioning primary care system has the capacity to provide effective care for patients to avoid nonurgent emergency department (ED) use and related costs. OBJECTIVE: This study examined how patients' perceived deficiency in ambulatory care is associated with nonurgent ED care costs nationwide. METHODS: This retrospective cohort study used data from the 2010-2011 Medical Expenditure Panel Survey. This study chose usual source of care, convenience of needed medical care, and patient evaluation of care quality as the main independent variables. The marginal effect following a multivariate logit model was employed to analyze the urgent vs. nonurgent ED care costs in 2011, after controlling for covariates in 2010. The endogeneity was accounted for by the time lag effect and controlling for education levels. Sample weights and variance were adjusted with the survey procedures to make results nationally representative. RESULTS: Patient-perceived poor and intermediate levels of primary care quality had higher odds of nonurgent ED care costs (odds ratio [OR] = 2.22, p = 0.035, and OR = 2.05, p = 0.011, respectively) compared to high-quality care, with a marginal effect (at means) of 13.0% and 11.5% higher predicted probability of nonurgent ED care costs. Costs related to these ambulatory care quality deficiencies amounted to $229 million for private plans (95% confidence interval [CI] $100 million-$358 million), $58.5 million for public plans (95% CI $33.9 million-$83.1 million), and an overall of $379 million (95% CI $229 million-$529 million) nationally. CONCLUSIONS: These findings highlight the improvement in ambulatory care quality as the potential target area to effectively reduce nonurgent ED care costs.

How do high cost-sharing policies for physician care affect inpatient care use and costs among people with chronic disease?

Rapidly rising health care costs continue to be a significant concern in the United States. High cost-sharing strategies thus have been widely used to address rising health care costs. Since high cost-sharing policies can reduce needed care as well as unneeded care use, it raises the concern whether these policies for physician care are a good strategy for controlling costs among chronically ill patients, especially whether utilization and costs in inpatient care will increase in response. This study examined whether high cost sharing in physician care affects inpatient care utilization and costs differently between individuals with and without chronic conditions. Findings from this study will contribute to the insurance benefit design that can control care utilization and save costs of chronically ill individuals. Prior studies suffered from gaps that limit both internal validity and external validity of their findings. This study has its unique contributions by filling these gaps jointly. The study used data from the 2007 Medical Expenditure Panel Survey, a nationally representative sample, with a cross-sectional study design. Instrumental variable technique was used to address the endogeneity between health care utilization and cost-sharing levels. We used negative binomial regression to analyze the count data and generalized linear models for costs data. To account for national survey sampling design, weight and variance were adjusted. The study compared the effects of high cost-sharing policies on inpatient care utilization and costs between individuals with and without chronic conditions to answer the research question. The final study sample consisted of 4523 individuals; among them, 752 had hospitalizations. The multivariate analysis demonstrated consistent patterns. Compared with low cost-sharing policies, high cost-sharing policies for physician care were not associated with a greater increase in inpatient care utilization (P = .86 for chronically ill people and P = .67 for healthy people, respectively) and costs (P = .38 for chronically ill people and P = .68 for healthy people, respectively). The sensitivity analysis with a 10% cost-sharing level also generated consistent insignificant results for both chronically ill and healthy groups. Relative to nonchronically ill individuals, chronically ill individuals may increase their utilization and expenditures of inpatient care to a similar extent in response to increased physician care cost sharing. This may be due to cost pressure from inpatient care and short observation window. Although this study did not find evidence that high cost-sharing policies for physician care increase inpatient care differently for individuals with and without chronic conditions, interpretation of this finding should be cautious. It is possible that in the long run, these sick people would demonstrate substantial demands for medical care and there could be a total cost increase for health plans ultimately. Health plans need to be cautious of policies for chronically ill enrollees.

How do high cost-sharing policies for physician care affect total care costs among people with chronic disease?

OBJECTIVE: This study examines whether high cost-sharing in physician care is associated with a differential impact on total care costs by health status. Total care includes physician care, emergency room (ER) visits and inpatient care. BACKGROUND: Since high cost-sharing policies can reduce needed care as well as unneeded care use, it raises the concern whether these policies are a good strategy for controlling costs among chronically ill patients. METHODS: This study used the 2007 Medical Expenditure Panel Survey data with a cross-sectional study design. Difference in difference (DID), instrumental variable technique, two-part model, and bootstrap technique were employed to analyze cost data. RESULTS: Chronically ill individuals' probability of reducing any overall care costs was significantly less than healthier individuals (beta = 2.18, p = 0.04), while the integrated DID estimator from split results indicated that going from low cost-sharing to high cost-sharing significantly reduced costs by $12,853.23 more for sick people than for healthy people (95% CI: -$17,582.86, -$8,123.60). CONCLUSIONS: This greater cost reduction in total care among sick people likely resulted from greater cost reduction in physician care, and may have come at the expense of jeopardizing health outcomes by depriving patients of needed care. Thus, these policies would be inappropriate in the short run, and unlikely in the long run to control health plans costs among chronically ill individuals. A generous benefit design with low cost-sharing policies in physician care or primary care is recommended for both health plans and chronically ill individuals, to save costs and protect these enrollees' health status.

Evaluating the Reliability of EHR-Generated Clinical Outcomes Reports: A Case Study.

INTRODUCTION: Quality incentive programs, such as Meaningful Use, operate under the assumption that clinical quality measures can be reliably extracted from EHRs. Safety Net providers, particularly Federally Qualified Health Centers and Look-Alikes, tend to be high adopters of EHRs; however, recent reports have shown that only about 9% of FQHCs and Look-Alikes were demonstrating meaningful use as of 2013. Our experience working with the Crescent City Beacon Community (CCBC) found that many health centers relied on chart audits to report quality measures as opposed to electronically generating reports directly from their EHRs due to distrust in the data. This paper describes a step-by-step process for improving the reliability of data extracted from EHRs to increase reliability of quality measure reports, to support quality improvement, and to achieve alignment with national clinical quality reporting requirements. BACKGROUND: Lack of standardization in data capture and reporting within EHRs drives distrust in EHR-reported data. Practices or communities attempting to achieve standardization may look to CCBC's experience for guidance on where to start and the level of resources required in order to execute a data standardization project. During the time of this data standardization project, CCBC was launching an HIE. Lack of trust in EHR data was a driver for distrust in the HIE data. METHODS: We present a case study where a five-step process was used to harmonize measures, reduce data errors, and increase trust in EHR clinical outcomes reports among a community of Safety Net providers using a common EHR. Primary outcomes were the incidence of reporting errors and the potential effect of error types on quality measure percentages. The activities and level of resources required to achieve these results were also documented by the CCBC program. FINDINGS: Implementation of a community-wide data reporting project resulted in measure harmonization, reduced reporting burden, and error reduction in EHR-generated clinical outcomes reporting across participating clinics over a nine-month period. Increased accuracy of clinical outcomes reports provided physicians and clinical care teams with better information to guide their decision-making around quality improvement planning. DISCUSSION: A number of challenges exist to achieving reliable population level quality reporting from EHRs at the practice, vendor, and community levels. Our experience demonstrates that quality measure reporting from EHRs is not a straightforward process, and it requires time and close collaboration between clinics and vendors to improve reliability of reports. Our experience found that practices valued the opportunity and step-wise process to validate their data locally (out of their EHRs) prior to reporting out of the HIE. CONCLUSION AND NEXT STEPS: Communities can achieve higher levels of confidence in quality measure reporting at the population level by establishing collaborative user groups that work with EHR vendors as partners and use technical assistance to build relationships and trust in EHR-generated reports. While this paper describes the first phase of our work around improving standardization and reliability of EHR reports, vendors should continue to explore modifications for improving data capture (at the front-end) via standardized data entry templates.