Health Plan Information Research Articles

Comparison and validation of algorithms for asthma diagnosis in an electronic medical record system

BackgroundAsthma is one of the most common chronic health conditions, and to leverage the wealth of data in the electronic medical record (EMR), it is important to be able to accurately identify asthma diagnosis. ObjectiveWe aimed to determine the rule-based algorithm with the most balanced performance for sensitivity and positive predictive value of asthma diagnosis. MethodsWe performed a diagnostic accuracy study of multiple rule-based algorithms intended to identify asthma diagnosis in the EMR. Algorithm performance was validated by manual chart review of 795 charts of patients seen in a multisite, tertiary-level, pulmonary specialty clinic using explicit diagnostic criteria to distinguish asthma cases from controls. ResultsAn asthma diagnosis anywhere in the medical record had a 97% sensitivity and a 77% specificity for asthma (F-score 80) when tested on a validation set of asthma cases and nonasthma respiratory disease from a pulmonary specialty clinic. The most balanced performance was seen with asthma diagnosis restricted to an encounter, hospital problem, or problem list diagnosis with a sensitivity of 94% and specificity of 85% (F-score 84). High sensitivity was achieved with the modified Health Plan Employer Data and Information Set criteria and high specificity was achieved with the NUgene algorithm, an algorithm developed for identifying asthma cases by EMR for genome-wide association studies. ConclusionAsthma diagnosis can be accurately identified for research purposes by restricting to encounter, hospital problem, or problem list diagnosis in a pulmonary specialty clinic. Additional rules lead to steep drop-offs in algorithm sensitivity in our population.

Access to maternity and prenatal care services in rural Michigan.

The United States physician shortages affect rural health care access, including maternity care. Project aims were to identify and characterize prenatal and delivery care in Michigan's rural counties and to explore access to trial of labor after cesarean (TOLAC) services for women in rural Michigan. Descriptive, cross-sectional design used 2015 Medicaid claims data and public health plan information to identify maternity care services provided within Michigan's rural counties. Publicly available health plan information was used to identify rural maternity hospitals and prenatal care practitioners; findings were verified by Internet searches and telephone interviews. Medicaid claims data were used to determine services provided. High-risk geographic areas were defined as those where women needed to travel >30 miles for maternity-related care. Expected TOLAC rate was determined based on published national birth data; rural hospitals were stratified based on whether they met the expected TOLAC rate, delivered 20%-60% of expected rate, or billed ≤1 TOLAC birth to Medicaid in 2015. In Michigan's 57 rural counties, only 29 hospitals provide maternity care. Geographic high-risk areas were identified in the Upper Peninsula and northeast Lower Peninsula of Michigan. Only two rural hospitals billed for the expected rate of TOLAC births; six delivered at a lower rate, and the remaining 21 hospitals provided no TOLAC services, resulting in large areas of the state where women were not offered this option locally. Maternity care services are limited for many rural Michigan women. Findings can be used to target specific strategies to improve access to care for these women. Similar analyses, exploring patterns of maternity care delivery in other rural regions worldwide, may uncover similar or additional inequities.

The real-world economic impact of home-based video electroencephalography: the payer perspective

Aims: Electroencephalography (EEG) is an established method to evaluate and manage epilepsy; video EEG (VEEG) has significantly improved its diagnostic value. This study compared healthcare costs and diagnostic-related outcomes associated with outpatient vs inpatient VEEG among patients with epilepsy in the US.Materials and methods: This study used Truven MarketScan Commercial and Medicare Supplemental claims databases. Patients with a VEEG between July 1, 2013 and December 31, 2016 were identified. Index event was the first VEEG claim, which was used to determine inpatient and outpatient cohorts. Continuous health plan enrollment 6 months pre- and 12 months post-index VEEG was required. Primary outcomes were costs during the index event and 12 months post index. A generalized linear model with gamma distribution and a log link was used to estimate adjusted index and post-index costs.Results: Controlling for baseline differences, epilepsy-related cost of index VEEG was significantly lower for the outpatient ($4,098) vs the inpatient cohort ($13,821; p < 0.0001). The cost differences observed at index were maintained in the post-index period. The 12-month post-index epilepsy-related costs were lower in the outpatient cohort ($6,114 vs $12,733, p < 0.0001). Time from physician referral to index VEEG was significantly shorter in the outpatient cohort (30.6 vs 42.5 days). Patients in the inpatient cohort were also more likely to undergo an additional subsequent follow-up inpatient VEEG (p < 0.0001).Limitations: Administrative claims data have limitations, including lack of data on clinical presentation, disease severity, and comprehensive health plan information. Generalizability may be limited to a US insured population of patients who met study criteria.Conclusions: Index VEEG was less costly in an outpatient vs inpatient cohort, and costs were lower during the follow-up period of 12 months, suggesting that outpatient VEEG can be provided to appropriate patients as a less costly option. There were fewer follow-up tests in the outpatient cohort with similar pre- and post-index diagnoses.

Reductions in 30-day readmission, mortality, and costs with inpatient–to–community pharmacist follow-up

ObjectivesTo determine the impact of pharmacist-provided continuous care and electronic communication on readmissions among a group of high-risk patients. DesignPragmatic interventional study with 5:1 matched control. Setting and participantsPatients discharged from any of 4 hospitals with chronic obstructive pulmonary disease, pneumonia, heart failure, acute myocardial infarction, or diabetes within Pennsylvania. Patients in the intervention group received consultative services from inpatient pharmacists before discharge and inpatient–to–community pharmacist communication of hospitalization information facilitated with the use of a secure messaging system. After discharge, patients received up to 5 in-person or telephonic medication management consultations with their community pharmacists. Main outcome measuresThe principal end point was 30-day readmission. Secondary end points included time to event (readmission, emergency department [ED] visit, death, or composite of hospitalization, ED, or death) over 90 days after discharge. Financial feasibility and sustainability were also assessed with the use of a return-on-investment (ROI) model based on information within the subset of patients with health plan coverage. ResultsAmong patients who received inpatient intervention plus consultation with community pharmacists compared with matched control patients, we observed a lower 30-day readmission rate (9% vs. 15%, respectively; P = 0.02), 30-day all-cause mortality (2% vs. 5%; P = 0.04), and composite 30-day end point of readmission, ED visit, or death (22% vs. 28%; P = 0.09). Differences between the groups diminished and no longer maintained statistical significance at 90 days. An estimated average ROI of 8.1 was also observed among the subset with health plan information (worst base case range 1.9–16.3). ConclusionConnecting community pharmacists to inpatient pharmacists during the transitional hospital-to-home time frame is feasible and resulted in lower 30-day readmissions and significant ROI, that is, significant impact on health care utilization and total health care costs. Results of this study have broad implications for improving the care of high-risk patients moving from hospital to home, most notably in the engagement of community pharmacists after discharge to assure medication use and follow-up to reduce readmissions and total costs of care.

Big Data, Little Data, and Care Coordination for Medicare Beneficiaries with Medigap Coverage.

Most healthcare data warehouses include big data such as health plan, medical, and pharmacy claims information for many thousands and sometimes millions of insured individuals. This makes it possible to identify those with multiple chronic conditions who may benefit from participation in care coordination programs meant to improve their health. The objective of this article is to describe how large databases, including individual and claims data, and other, smaller types of data from surveys and personal interviews, are used to support a care coordination program. The program described in this study was implemented for adults who are generally 65 years of age or older and have an AARP(®) Medicare Supplement Insurance Plan (i.e., a Medigap plan) insured by UnitedHealthcare Insurance Company (or, for New York residents, UnitedHealthcare Insurance Company of New York). Individual and claims data were used first to calculate risk scores that were then utilized to identify the majority of individuals who were qualified for program participation. For efficient use of time and resources, propensity to succeed modeling was used to prioritize referrals based upon their predicted probabilities of (1) engaging in the care coordination program, (2) saving money once engaged, and (3) receiving higher quality of care. To date, program evaluations have reported positive returns on investment and improved quality of healthcare among program participants. In conclusion, the use of data sources big and small can help guide program operations and determine if care coordination programs are working to help older adults live healthier lives.

Switching health insurers: the role of price, quality and consumer information search.

We examine the impact of price, service quality and information search on people’s propensity to switch health insurers in the competitive Dutch health insurance market. Using panel data from annual household surveys and data on health insurers’ premiums and quality ratings over the period 2006–2012, we estimate a random effects logit model of people’s switching decisions. We find that switching propensities depend on health plan price and quality, and on people’s age, health, education and having supplementary or group insurance. Young people (18–35 years) are more sensitive to price, whereas older people are more sensitive to quality. Searching for health plan information has a much stronger impact on peoples’ sensitivity to price than to service quality. In addition, searching for health plan information has a stronger impact on the switching propensity of higher than lower educated people, suggesting that higher educated people make better use of available health plan information. Finally, having supplementary insurance significantly reduces older people’s switching propensity.

Potentially Inappropriate Medication Use in Veterans Residing in Community Living Centers: Have We Gotten Better?

To evaluate the use of medications classified as inappropriate according to the Health Plan Employer Data and Information Set (HEDIS) in elderly veterans residing in Department of Veterans Affairs (VA) nursing homes from 2004 to 2009 and to identify participant-specific correlates of use. Retrospective, cross-sectional study using VA administrative data merged with participant-specific data from the Minimum Data Set. VA nursing homes (community living centers (CLCs)). Veterans aged 65 and older residing in CLCs at the time of the prescribed medication use (N = 176,168). The number of exposed veterans aged 65 and older per facility receiving at least one HEDIS high-risk medication was determined. Between 2004 and 2009, 28,970 of 176,168 (mean 16.4 ± 9.5%) veterans received at least one HEDIS high-risk medication. Over the period, the number of veterans receiving high-risk medications decreased steadily from 23.9 ± 10.0% in 2004 to 10.0 ± 6.6% in 2009. Nevertheless, large facility variations remained in 2009, with rates from 0% to 44.4%. Certain characteristics were also associated with HEDIS high-risk medication use, including female sex (odds ratio (OR) = 1.6; 95% confidence interval (CI) = 1.25-2.04), cancer (OR = 1.19, 95% CI = 1.08-1.32), renal disease (OR = 1.16, 95% CI = 1.01-1.33), chronic obstructive pulmonary disease (OR = 1.16, 95% CI = 1.05-1.28), and diabetes mellitus (OR = 1.11, 95% CI = 1.02-1.22). Protective characteristics included age 75 and older (OR = 0.81, 95% CI = 0.73-0.90) and having a diagnosis of moderate (OR = 0.72, 95% CI = 0.64-0.82) or severe (OR = 0.72, 95% CI = 0.61-0.85) cognitive impairment. The use of HEDIS medications among elderly veterans residing in VA nursing homes has markedly improved. Nevertheless, significant variations between facilities and certain subpopulations remain. A low percentage of women at VA CLCs make comparisons with community nursing homes difficult.

Inappropriate drug use in hospitalized elderly patients of medicine and cardiology departments at a tertiary care hospital of Northeast India

BackgroundNational committee on quality assurance, USA convened an expert consensus panel and identified the list of drugs which should be avoided in the elderly people. This resulting list of drugs after 2003 beers criteria were added to the 2006 Health Plan Employer Data and Information Set (HEDIS) to assess the drug prescribing in elderly people. MethodsThe objective of this study was to determine the prevalence of inappropriate drug use and assess their predictors in the hospitalized elderly patients of tertiary care hospital by using HEDIS 2006 criteria. A 6-month prospective study was conducted in medicine & cardiology inpatient department of tertiary care hospital by reviewing prescriptions of 502 elderly patients. The patients of either sex having age more than 60 year were included in this study. ResultsIt is found that (2.39%) 12 patients received at least 1 inappropriate drug by 2006 HEDIS measure. Out of 12 inappropriate drugs, short acting nifedipine was prescribed to 4 elderly patients followed by dicyclomine to 2 patients and ketorolac to 2 patients each. Increased number (≥11) of concurrent medications use during hospital stay (OR: 0.015, CI: 0.001–0.199, P = 0.001) and prolonged (≥5 days) length of stay (OR: 0.039, CI: 0.005–0.291, P = 0.002) were found as a predictors of inappropriate medication use. ConclusionIn this study, low prevalence (2.39%) of inappropriate drug prescribing was found. Multiple medications and long duration of hospital stay were the risk factors for inappropriate medication use.

Continuity of Care and Adherence to Antidepressant Treatment Among Medicaid-Covered Youth

Continuity of care is a critical indicator of quality of care and key to effective antidepressant medication management in children and adolescents. Little is known about the characteristics associated with receiving guidelines concordant care. Using a retrospective, longitudinal cohort design of youth with a new episode of depression, this study reviewed records and pre-existing data to (1) examine rates of conformance to continuity of care treatment guidelines (Health Plan Employer Data and Information Set [HEDIS]) for antidepressant management; (2) identify individual- and community-level characteristics associated with continuity of antidepressant treatment; and (3) investigate the relationship between continuity of care and antidepressant adherence. Two-thirds of youth met the HEDIS optimum contact criteria of three outpatient mental health contacts during the first 3 months of treatment. Good continuity of care was associated with prior outpatient treatment and taking other psychotropic medications while inadequate follow-up was associated with older adolescents, disabled children, and youths living in rural areas. Guidelines concordant follow-up was associated with better antidepressant adherence. Findings underscore the need to deliver guidelines concordant care, particularly among vulnerable subgroups.

Racial/Ethnic Differences in Medicare Experiences and Immunization

Although Medicare provides beneficiaries with primary access to the health care system, racial/ethnic disparities in health care experiences and preventive care are well documented in the Medicare population. To investigate disease burden and its possible impact on racial/ethnic health disparities for measures of secondary and tertiary access to health care, such as access to health plan information, obtaining recommended care in a timely manner, and immunization. A total of 355,874 beneficiaries over the age of 64 years who responded to the 2008 Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey. We fit a series of linear, case-mix adjusted models predicting Medicare CAHPS measures of patient experience and immunization from race/ethnicity, a 0 to 6 count of disease burden, and their interaction. Disparities between non-Hispanic whites and other racial/ethnic groups are largest among beneficiaries with no major health conditions. Disparities between whites and other racial/ethnic groups on getting care quickly and immunization are mitigated at higher levels of disease burden. Disparities persist at higher levels of disease burden for getting information from one's health plan. Whites have better overall access to care than other beneficiaries with Medicare in the absence of major health conditions. Disparities in getting care quickly and immunizations are smaller among beneficiaries with greater disease burden, perhaps as a function of integration into the health care system gained through management of health issues. These results underscore the importance of outreach to minorities with low utilization and few or no major health conditions.

Making Health Care Reform Work

PHYSICIANS AND BUSINESSES SHARE A COMMON goal—to advance better health. Employers are finding that it makes business sense to promote workforce health and productivity, recently linked to $576 billion in costs due to medical and pharmaceutical use, lost productivity, and wage replacement. Many mediumand large-sized employers, motivated by their self-insured status and by responsibility for much of these costs, are investing in an ever-expanding array of initiatives for fostering the good health of the healthy and health improvements for those who have or are at risk for disease or other impairment. In addition, the therapeutic value of work and its beneficial effects on health and wellbeing are becoming clearer to physicians. The longer people are off work, the lower their chances of returning to work. Evidence is mounting that links long periods of unemployment to poor mental and physical health and increased use of health services. Berwick acknowledged this growing alignment when he recently called for greater business involvement in health care reform. Business buy-in has often played a key role in the success or failure of major initiatives to reform US health care. For example, employer support has been pivotal to the evolution of the National Committee for Quality Assurance’s Healthcare Effectiveness Data Information Set (originally, the Health Plan Employer Data and Information Set) as the standard by which health plan performance is measured. Conversely, efforts to establish regional health information centers for clinical data exchange have largely stalled because employer support has been far short of expectations. Yet the business community maintains a low profile in health care reform under the Affordable Care Act (ACA), a development for which the business community bears some responsibility given its apparent, continuing decision to distance itself from the legislation. This is true even in those instances in which a higher business profile would strengthen the employers’ influence in better aligning reform with company objectives but also boost the sustainability of the changes being sought. Fortunately, the ACA’s emphasis on measurement, if broadened in a new direction, offers a path that will benefit both stakeholder groups in the current reform environment. This path should bring new empowerment to employers and thereby advance the staying power of ACA’s reforms. If well managed, it would also yield a major collateral benefit for physicians—better measures of the value of their care for the outcomes-oriented compensation schemes mandated by the ACA. Several examples illustrate missed opportunities for strengthening employer linkages vis-a-vis the ACA. For instance, accountable care organizations (ACOs) represent a major delivery reform that is now targeting both Medicare and commercial populations. With their buying power, businesses will heavily affect the long-term viability of many, if not most, commercially insured ACOs. Yet the ACA has no regulatory or incentive provisions for shaping the interface of business with ACOs and thus leaves largely untouched the capacity of businesses to influence ACOs in the marketplace. Another example involves ACA provisions for valuebased purchasing. Value-based purchasing consists of proven strategies that pay for care based on value, not volume, by rewarding physicians for more efficient and effective care. While advancing value-based purchasing on several fronts, the ACA overlooks a key extension for businesses. Fee-forservice remains by far the most prominent payment method for private sector health care. Appropriate tax incentives and rebates have much promise for accelerating businesses’ transition to value-based purchasing. However, the ACA contains no such provisions. A third example is the Patient-Centered Outcomes Research Institute. As the ACA’s entity for comparative effectiveness research, its focus includes quality of life, quality of care, and improved treatment adherence. Recent developments suggest that this focus is being expanded to consider the full range of evidence on direct and indirect benefits to society and patient differences in responses to treatment. This expansion only partially meets employer priorities. These priorities center on total health burden–both

Measuring chronic care delivery: patient experiences and clinical performance

To assess the relationship between clinical care metrics and patient experiences of care among patients with chronic disease. Cross-sectional survey and clinical performance data. Eighty-nine medical groups across California caring for patients with chronic disease. Using patient surveys, we identified 51 129 patients with a chronic disease. Using patient surveys, we produced five composite measures of patient experiences of care and self-management support (scale 0-100). Using Health Plan Employer Data and Information Set data, we analyzed care for asthma, diabetes and cardiovascular disease, producing one composite summarizing clinical processes of care and one composite summarizing outcomes of care. We calculated adjusted Spearman's correlation coefficients to assess the relationship between patient experiences of care, clinical processes and clinical outcomes. Clinical performance was higher for process measures compared with outcomes measures, ranging from 91% for appropriate asthma medication use to 59% for controlling low-density lipoprotein cholesterol in the presence of diabetes. Performance on patient experiences of care measures was the highest for the quality of clinical interactions (88.5) and the lowest for delivery of self-management support (68.8). Three of the 10 patient experience-clinical performance composite correlations were statistically significant. These three correlations involved composites summarizing integration of care and quality of clinical interactions, and ranged from a low of 0.30 to a high of 0.39. Chronic care delivery is variable across diseases and domains of care. Improving care integration processes and communication between health-care providers and their patients may lead to improved clinical outcomes.

Comparison of tools for the assessment of inappropriate prescribing in hospitalized older people

RATIONAL, AIMS AND OBJECTIVE: The aim of the present study was to compare the ease of use and the capability of four approaches [Medication Appropriateness Index (MAI), the Beers' criteria 2003, the Improved Prescribing in the Elderly Tool (IPET) and Health Plan Employer Data and Information Set (HEDIS)] in assessing changes in medication appropriateness in elderly patients over a period of hospitalization. A retrospective observational study in two hospitals in Northern Ireland using the four measures was undertaken, involving a cohort of 192 patients (aged > 65 years). Medication appropriateness assessments were made at three stages during the patients' hospital 'journey', that is, at admission, during their inpatient stay and at discharge. The identifying rates of inappropriate prescribing in elderly patients in hospital used validated screening tools: MAI, the Beers' criteria 2003, the IPET and HEDIS. The MAI was the most comprehensive approach but was also the most time consuming to apply. Data derived using the MAI indicated clearly that there was improved medication appropriateness over the three hospital stay stages (P < 0.001). Although this trend was also significant for the Beers' criteria 2003 (P < 0.05) and the IPET (P < 0.05) approaches, the HEDIS was unable to differentiate changes in appropriateness over time. There was a good correlation between data derived using the MAI and the Beers' criteria 2003 and the IPET approaches; this correlation was not evident for the HEDIS. The MAI is the most convincing tool in evaluating medication appropriateness, but is very time consuming to apply. Beers' criteria 2003 and the IPET perform to an acceptable standard within the clinical setting and are more practical in their application. The HEDIS, although simplest to apply, does not have the sensitivity to measure change in appropriateness over time.

Factors Associated with Antidepressant Adherence for Medicaid-Enrolled Children and Adolescents

Antidepressants have been shown to be efficacious for the treatment of pediatric depression. However, many youths do not receive an adequate duration of treatment, and factors associated with nonadherence in this population remain poorly understood. To examine rates of antidepressant adherence for depressed youth and identify factors associated with adherence during the acute and continuation phases of treatment. A retrospective cohort analysis was conducted using claims data from a state Medicaid-enrolled population of 1650 youths (aged 5-17 years) with new episodes of depression between January 1, 2005, and December 30, 2007. These patients were treated with selective serotonin reuptake inhibitors or newer antidepressants and followed for 6 months from the first prescription fill date. Adherence measures were derived from the Health Plan Employer Data and Information Set (HEDIS) quality indicators on antidepressant management (3 months of continuous treatment for the acute phase and 6 months for the continuation phase) and assessed using the medication possession ratio. Multivariate logistic regression analyses evaluated the association between demographic, clinical, medication, and treatment factors, and adherence. About half (49.5%) of the youths were adherent to antidepressant medication during the acute phase, and 42% of these were adherent during the continuation phase; 21% were adherent across both treatment phases. Optimal follow-up visits and adequate antidepressant dosing was associated with better adherence during both treatment phases, as was use of other psychotropic medications. Youths prescribed trazodone for sleep had higher adherence rates during the acute phase. Minority youths and adolescents had lower adherence rates during the acute phase. Youths in foster care had higher adherence rates during both treatment phases. Nonadherence with antidepressant medications is common among Medicaid-covered children and adolescents. Study findings underscore the need for clinicians to deliver guideline-concordant care, assess adherence, and develop interventions that improve adherence, particularly for vulnerable subgroups.

P1-S4.09 Validation of the HEDIS measure of sexual activity in adolescents

BackgroundThe proportion of sexually active young women who are screened annually for chlamydia is a Health Plan Employer Data and Information Set (HEDIS) performance measure. The accuracy of this measure,...

Impact of Accreditation on the Quality of Healthcare Services: a Systematic Review of the Literature

BACKGROUND AND OBJECTIVE:Accreditation is usually a voluntary program in which trained external peer reviewers evaluate a healthcare organization's compliance and compare it with pre-established performance standards. The aim of this study was to evaluate the impact of accreditation programs on the quality of healthcare servicesMETHODS:We did a systematic review of the literature to evaluate the impact of accreditation programs on the quality of healthcare services. Several databases were systematically searched, including Medline, Embase, Healthstar, and Cinhal.RESULTS:Twenty-six studies evaluating the impact of accreditation were identified. The majority of the studies showed general accreditation for acute myocardial infarction (AMI), trauma, ambulatory surgical care, infection control and pain management; and subspecialty accreditation programs to significantly improve the process of care provided by healthcare services by improving the structure and organization of healthcare facilities. Several studies showed that general accreditation programs significantly improve clinical outcomes and the quality of care of these clinical conditions and showed a significant positive impact of subspecialty accreditation programs in improving clinical outcomes in different subspecialties, including sleep medicine, chest pain management and trauma management.CONCLUSIONS:There is consistent evidence that shows that accreditation programs improve the process of care provided by healthcare services. There is considerable evidence to show that accreditation programs improve clinical outcomes of a wide spectrum of clinical conditions. Accreditation programs should be supported as a tool to improve the quality of healthcare services.

Potentially inappropriate medication use among older adults in the USA in 2007

• Potentially inappropriate medication (PIM) use is a major patient safety concern for the elderly. • Using explicit criteria, previous studies found that 23.5% and 21.3% of the U.S. communitydwelling elderly used at least one PIM in 1987 and 1996, respectively.1 • The Beers criteria, Zhan criteria, and Health Plan Employer Data and Information Set (HEDIS) quality measure have been widely used for evaluation of health care quality and medication safety in older population.1-6

Racial and Ethnic Disparities in the Quality of Diabetes Care for the Elderly in a Nationally Representative Sample

Minority elderly patients with diabetes receive lower quality of care based on an array of quality measures across various health care settings. However, the documentation of racial/ethnic disparities in quality of care for elderly patients with diabestes relies on a few major data sets such as claims data from Medicare beneficiaries, the Veterans Health Administration (VHA) databases, or the Health Plan Employer Data and Information Set (HEDIS) databases. The current study examines if racial/ethnic disparities in the quality of diabetes care found among elderly patients have begun to abate by using data from a nationally representative survey not frequently used in the literature. Using pooled data from the 2002–2007 Medical Expenditure Panel Survey, we found that elderly black patients with diabetes were less likely to receive appropriate quality of care as reported by patients, or eye examination and more likely to receive a foot examination compared to their white counterparts. Similarly, elderly Asian patients with diabetes were less likely to report receiving appropriative quality of care compared to their white counterparts. These results have important implication for future research that would seek to understand the mechanisms through which racial minority status is associated with poorer quality of diabetes care.

The impact of information disclosure on quality of care in HMO markets

To examine the impact of voluntary information disclosure on quality of care in Health Maintenance Organization (HMO) markets in the USA. Commercial HMOs that collected a set of standardized quality meausures, Health Plan Employer Data and Information Set (HEDIS), between 1997 and 2000 in the USA (1062 HMO-years). After collecting the HEDIS data, some HMOs disclosed their HEDIS-quality scores to the public (disclosing HMOs), whereas some HMOs declined to disclose the information (non-disclosing HMOs). A secondary data analysis based on 4 years of quality scores of HMOs. The study uses non-disclosing plans as a control group. A treatment-effects model is used to address a potential bias associated with voluntary disclosure decisions by HMOs. The study focuses on 13 HEDIS clinical indicators. On the basis of these indicators, a plan-level composite score and four domain scores were constructed. The four domains are childhood immunizations, treatments/exams for chronic conditions, screening tests and maternity services. Public disclosure leads to an increase of 0.72 composite score units, which corresponds to ∼7% points in original quality scale (0-100%). The degree of quality improvement differed by the type of services. Public release of quality information had a significant and positive effect on quality in HMO markets during the earlier years of the voluntary disclosure program; however, the improvement was not universal across all quality measures.

Partnership Research

Translational research is increasingly important as academic health centers transform themselves to meet new requirements of National Institutes of Health funding. Most attention has focused on T1 translation studies (bench to bedside) with considerable uncertainty about how to enhance T2 (effectiveness trials) and especially T3 (implementation studies). To describe an innovative example of a T3 study, conducted as partnership research with the leaders of a major natural experiment in Minnesota to improve the primary care of depression. All health plans in the state have agreed on a new payment model to support clinics that implement the well-evidenced collaborative care model for depression in the Depression Improvement Across Minnesota: Offering a New Direction initiative. The Depression Improvement Across Minnesota: Offering a New Direction study was developed in an ongoing partnership with the Initiative leaders from 7 health plans, 85 clinics, and a regional quality improvement collaborative to evaluate the implementation and its impacts on patients and other stakeholders. We agreed on a staggered implementation, multiple baseline research design, using the concepts of practical clinical trials and engaged scholarship and have collaborated on all aspects of conducting the study, including joint identification of patient and clinic survey recipients. Complex study methods have worked well through 20 months because of the commitment of all stakeholders to both the Initiative and the Study. Over 1500 subjects have been recruited from health plan information delivered weekly, and 99.7% of 316 physicians and administrators from all participating clinical organizations have completed the Study surveys. Partnership research can greatly facilitate translational research studies.