Health Service Utilization Outcomes Research Articles

The Program Evaluation and Monitoring System: A Key Source of Data for Monitoring Evidence–Based HIV Prevention Program Processes and Outcomes

The Centers for Disease Control and Prevention (CDC) Division of HIV/AIDS Prevention (DHAP) has responded to the need for accurate and timely data to monitor and evaluate federally funded HIV prevention programs by designing and implementing the Program Evaluation and Monitoring System (PEMS). PEMS is a national data reporting system that includes a standardized set of HIV prevention data variables, Web-based software for data entry and management, data collection and evaluation guidance and training, and software implementation support services. This article discusses the purposes of evaluation and the need for and development of PEMS and also describes how PEMS strengthens the monitoring and evaluation of HIV prevention services nationally and program planning, management, and monitoring locally. PEMS data may be used by prevention stakeholders at all levels to examine program fidelity, adaptation and tailoring, and key program health service utilization and behavioral outcomes. PEMS provides a strong foundation to bring a program closer to its intended goals and to serve the needs of the clients and the community, provides a means for agencies to fulfill their reporting mandates and funding obligations, and enables the CDC to monitor HIV prevention efforts in a consistent, efficient, and effective manner across the United States.

Practice‐Level Effects of Interventions to Improve Asthma Care in Primary Care Settings: The Pediatric Asthma Care Patient Outcomes Research Team

To assess the practice-level effects of (1) a physician peer leader intervention and (2) peer leaders in combination with the introduction of asthma education nurses to facilitate care improvement. And, to compare findings with previously reported patient-level outcomes of trial enrollees. Data were included on children 5-17 years old with asthma in 40 primary care practices, affiliated with managed health care plans enrolled in the Pediatric Asthma Care Patient Outcomes Research Team (PORT) randomized trial. Primary care practices were randomly assigned to one of two care improvement arms or to usual care. Automated claims data were analyzed for 12-month periods using a repeated cross-sectional design. The primary outcome was evidence of at least one controller medication dispensed among patients with persistent asthma. Secondary outcomes included controller dispensing among all identified asthmatics, evidence of chronic controller use, and the dispensing of oral steroids. Health service utilization outcomes included numbers of ambulatory visits and hospital-based events. The proportion of children with persistent asthma prescribed controllers increased in all study arms. No effect of the interventions on the proportion receiving controllers was detected (peer leader intervention effect 0.01, 95 percent confidence interval [CI]: -0.07, 0.08; planned care intervention effect -0.03, 95 percent CI: -0.09, 0.02). A statistical trend was seen toward an increased number of oral corticosteroid bursts dispensed in intervention practices. Significant adjusted increases in ambulatory visits of 0.08-0.10 visits per child per year were seen in the first intervention year, but only a statistical trend in these outcomes persisted into the second year of follow-up. No differences in hospital-based events were detected. This analysis showed a slight increase in ambulatory asthma visits as a result of asthma care improvement interventions, using automated data. The absence of detectable impact on medication use at the practice level differs from the positive intervention effect observed in patient self-reported data from trial enrollees. Analysis of automated data on nonenrollees adds information about practice-level impact of care improvement strategies. Benefits of practice-level interventions may accrue disproportionately to the subgroup of trial enrollees. The effect of such interventions may be less apparent at the level of practices or health plans.

A Matched-Cohort Study of Health Services Utilization Outcomes for a Heart Failure Disease Management Program

Chronic disease is the leading cause of illness, disability, and death in the United States, affecting nearly 100 million Americans. Heart failure alone affects nearly 4.9 million Americans, with another 550,000 newly diagnosed cases each year. The aim of this study was to investigate the program effects of a heart failure care support program. A two-group cohort study matching on propensity scores was used to investigate 277 heart failure care support program participants and corresponding matched non-participants. Measures used were rates of hospitalizations, emergency department visits, physician office visits, and heart failure-related prescription drug use and procedures. Relative to the matched control group, program participants experienced 26.3% (p = 0.023) fewer inpatient admissions, 37.9% (p = 0.018) inpatient bed days, 33.3% (p = 0.059) more beta blocker use, 76.7% (p = 0.048) more alpha blocker use, 22.2% (p = 0.006) more lipid panels, 13.4% (p = 0.019) more electrocardiographies, 50.0% (p = 0.008) fewer cardiac catheterizations, and 94.6% (p = 0.014) more pneumonia vaccinations. The current study employs a propensity score matching methodology to select a subset of comparison patients most comparable to treatment patients, and documents the beneficial health services outcomes of participation in a heart failure care support program.

A matched-cohort study of health services utilization and financial outcomes for a heart failure disease-management program in elderly patients.

To investigate the utilization and financial outcomes of a telephonic nursing disease-management program for elderly patients with heart failure. A 1-year concurrent matched-cohort study employing propensity score matching. Medicare+Choice recipients residing in Ohio, Kentucky, and Indiana. A total of 533 program participants aged 65 and older matched to nonparticipants. Disease-management heart failure program employing a structured, evidence-based, telephonic nursing intervention designed to provide patient education, counseling, and monitoring services. Medical service utilization, including hospitalizations, emergency department visits, medical doctor visits, skilled nursing facility (SNF) days, selected clinical indicators, and financial effect. The intervention group had considerably and significantly lower rates of acute service utilization than the control group, including 23% fewer hospitalizations, 26% fewer inpatient bed days, 22% fewer emergency department visits, 44% fewer heart failure hospitalizations, 70% fewer 30-day readmissions, and 45% fewer SNF bed days. Claims costs were 1,792 dollars per person lower in the intervention group than in the control group (inclusive of intervention costs), and the return on investment was calculated to be 2.31. The study demonstrates that a commercially delivered heart failure disease-management program significantly reduced hospitalizations, emergency department visits, and SNF days. The intervention group had 17% lower costs than the control group; when intervention costs were included, the intervention group had 10% lower costs.

Processes and outcomes of care for diabetic acute myocardial infarction patients in Ontario: do physicians undertreat?

To compare the health service utilization and long-term outcomes of acute myocardial infarction (AMI) patients with and without diabetes in Ontario. We examined 25,697 patients from Ontario (6,052 and 19,645 patients with and without diabetes, respectively) who were hospitalized because of AMI between 1 April 1992 and 31 December 1993. Using linked administrative databases, we determined the use of invasive cardiac procedures at 1 year as well as the intensity of specialty follow-up care and use of evidence-based pharmacotherapies (among elderly individuals) within the first 90 days of hospital discharge. Outcomes examined included mortality and recurrent cardiac admissions at 30 days and 5 years post AMI. Multivariable analyses adjusted for sociodemographic and case-mix characteristics, attending physician specialty, and admitting hospital characteristics. Despite being at significantly higher risk for death at baseline, diabetic patients were less likely to be followed-up by a cardiologist (22.2 vs. 25.6%, P < 0.001), to receive myocardial revascularization (12.6 vs. 14.9%, P < 0.001), to receive beta-blockers (34.2 vs. 44.0%, P < 0.001), and to receive aspirin therapy (59.7 vs. 63.5%, P < 0.001) after AMI than their nondiabetic counterparts. Diabetes was an important independent predictor of 5-year morbidity (adjusted hazard ratio 1.52, 95% CI 1.45-1.59) and 5-year mortality outcomes (1.57, 1.50-1.63). Variations in processes of care were marginally associated with higher nonfatal complication rates for diabetic patients. When managing AMI patients with diabetes in Ontario, physician treatment aggressiveness does not correspond appropriately to the baseline risk of patients.

Clinical and economic outcomes associated with olanzapine for the treatment of psychotic symptoms in a county mental health population

Background: The comparatively high acquisition costs of the newer antipsychotic medications have caused the mental health community to look closely at their potential benefits.Objective: The purpose of this study was to perform a naturalistic analysis of changes in mental health service utilization, economic costs, and clinical outcomes after the initiation of olanzapine therapy for psychotic symptoms in an indigent patient population from a large county-operated mental health care system.Methods: This was a prospective, uncontrolled investigation using a mirror-image cohort design. All captured costs from patients who began olanzapine therapy between November 1, 1996, and April 30, 1998, were analyzed in an intent-to-treat fashion to compare resource utilization in the 12 months immediately before and after the intervention. Clinical function was assessed at baseline and 6 months using the Positive and Negative Syndrome Scale (PANSS). In a subgroup analysis, the baseline characteristics of patients who completed 12 months of olanzapine treatment were compared with those of patients who (1) changed medication or (2) changed payor source or were lost to follow-up.Results: One hundred eighty-nine patients were started on olanzapine treatment during the 18-month study entry phase. Patients were primarily male (63.5%) and had a mean age of 35.9 years. Most (66.3%) had a formal diagnosis of thought disorder. Fifty-six patients received olanzapine for 12 consecutive months, and 22 were switched to other psychotropic medications. Of the remaining 111 patients, 70 changed payors (ie, qualified for Medicaid), and 41 were lost to follow-up. In the subgroup analysis, patients who completed 12 months of treatment (ie, responders) had significantly lower mean PANSS total scores at baseline compared with those who changed payors or were lost to follow-up (P = 0.047), and were significantly more likely to have a formal diagnosis of thought disorder (P = 0.039). Responders demonstrated a significant reduction in PANSS total and negative subscale scores at 6-month follow-up (both measures, P < 0.001). In the intent-to-treat analysis of resource utilization in all patients with complete data sets (n = 78), hospitalization costs and crisis costs decreased significantly during the 12-month follow-up period (P = 0.003 and P = 0.009, respectively), and both outpatient and medication costs increased significantly (P = 0.035 and P < 0.001, respectively). Overall, the change in total annual resource utilization during the 12 months after initiation of olanzapine was not statistically significant (mean decrease per patient, $1991; 95% CI, −$5258 to $1122).Conclusions: Initiation of olanzapine therapy was associated with favorable clinical outcomes in this population, particularly in patients with a formal diagnosis of thought disorder. Overall, there was a cost shift away from hospital and crisis costs toward medication and outpatient services costs. The decline in total resource utilization was not statistically significant, although it may be of practical importance.

The Effects of Medicare on Health Care Utilization and Outcomes

Medicare, which provides health insurance to Americans over the age of 65 and to Americans living with disabilities, is one of the governments largest social programs. It accounts for 12 percent of federal on- and off-budget outlays, and in fiscal year 1999,$212 billion in Medicare benefits were paid. The largest shares of spending are for inpatient hospital services (48 percent) and physician services (27 percent). In thirty years, the number of Americans covered by Medicare will nearly double to 77 million, or 22 percent of the U.S. population.Perhaps the most important question we can ask about the Medicare program is, What impact does it have on the health of the U.S. population? One feature of the Medicare program can be exploited to shed light on its impacts: its age specificity. Most people become eligible for Medicare suddenly, the day they turn 65. Consequently, the age profiles of health services utilization and health outcomes (morbidity and mortality) can provide revealing evidence about Medicares impacts.My objective is to obtain precise estimates of medical utilization and outcomes, by single year of age, for ages close to age 65. The most precise estimates can be obtained by using information obtained from medical providers (hospitals and doctors) pooled over several years.Utilization of ambulatory care and, to a much smaller extent, inpatient care increases suddenly and significantly at age 65, presumably due to Medicare eligibility. The evidence points to a structural change in the frequency of physician visits precisely at age 65. Attainment of age 65 marks not only an upward shift but also the beginning of a rapid upward trend (up until age 75) of about 2.8 percent per year in annual visits per capita. The number of physician visits in which at least one drug is prescribed also jumps up at age 65. Reaching age 65 has a strong positive impact on the consumption of hospital services, but most of this impact appears to be the result of postponement of hospitalization in the prior two years.We also examine whether this increase in utilization leads to an improvement in outcomes--a reduction in morbidity and mortality--relative to what one would expect given the trends in outcomes prior to age 65. The estimates are consistent with the hypothesis that the Medicare-induced increase in health care utilization leads to a reduction in days spent in bed of about 13 percent and to slower growth in the probability of death after age 65. Physician visits are estimated to have a negative effect on the male death rate, conditional on age and the death rate in the previous year. The short-run elasticity of the death rate with respect to the number of physician visits is -.095, and the long-run elasticity is -.497: a permanent or sustained 10 percent increase in the number of visits ultimately leads to a 5 percent reduction in the death rate.Data on age-specific death probabilities every 10 years since 1900, i.e., before as well as after Medicare was enacted, provide an alternative way to test for the effect of Medicare on longevity. They also provide strong support for the hypothesis that Medicare increased the survival rate of the elderly by about 13 percent.

The Effects of Medicare on Health Care Utilization and Outcomes

Medicare, which provides health insurance to Americans over the age of 65 and to Americans living with disabilities, is one of the government’s largest social programs. It accounts for 12 percent of federal on- and off-budget outlays, and in fiscal year 1999,$212 billion in Medicare benefits were paid. The largest shares of spending are for inpatient hospital services (48 percent) and physician services (27 percent). In thirty years, the number of Americans covered by Medicare will nearly double to 77 million, or 22 percent of the U.S. population.Perhaps the most important question we can ask about the Medicare program is, What impact does it have on the health of the U.S. population? One feature of the Medicare program can be exploited to shed light on its impacts: its age specificity. Most people become eligible for Medicare suddenly, the day they turn 65. Consequently, the age profiles of health services utilization and health outcomes (morbidity and mortality) can provide revealing evidence about Medicare’s impacts.My objective is to obtain precise estimates of medical utilization and outcomes, by single year of age, for ages close to age 65. The most precise estimates can be obtained by using information obtained from medical providers (hospitals and doctors) pooled over several years.Utilization of ambulatory care and, to a much smaller extent, inpatient care increases suddenly and significantly at age 65, presumably due to Medicare eligibility. The evidence points to a structural change in the frequency of physician visits precisely at age 65. Attainment of age 65 marks not only an upward shift but also the beginning of a rapid upward trend (up until age 75) of about 2.8 percent per year in annual visits per capita. The number of physician visits in which at least one drug is prescribed also jumps up at age 65. Reaching age 65 has a strong positive impact on the consumption of hospital services, but most of this impact appears to be the result of postponement of hospitalization in the prior two years.We also examine whether this increase in utilization leads to an improvement in outcomes--a reduction in morbidity and mortality--relative to what one would expect given the trends in outcomes prior to age 65. The estimates are consistent with the hypothesis that the Medicare-induced increase in health care utilization leads to a reduction in days spent in bed of about 13 percent and to slower growth in the probability of death after age 65. Physician visits are estimated to have a negative effect on the male death rate, conditional on age and the death rate in the previous year. The short-run elasticity of the death rate with respect to the number of physician visits is -.095, and the long-run elasticity is -.497: a permanent or sustained 10 percent increase in the number of visits ultimately leads to a 5 percent reduction in the death rate.Data on age-specific death probabilities every 10 years since 1900, i.e., before as well as after Medicare was enacted, provide an alternative way to test for the effect of Medicare on longevity. They also provide strong support for the hypothesis that Medicare increased the survival rate of the elderly by about 13 percent.

Economic evaluations of community-based care: lessons from twelve studies in Ontario.

A series of 12 studies (five historic cohort and seven randomized trials) examined clients in community settings in Southern Ontario suffering from a variety of chronic physical and mental health conditions. These studies are appraised using a framework for evaluating possible outcomes of economic evaluation. In the 12 studies, sample composition and size varied. Each study was designed to quantify the well-being outcomes and expenditures associated with different community-based approaches to care provided in the context of a system of national health insurance. As a collective, these studies represent increasing methodological rigour. Multiple-perspective client well-being outcome measures were used. In two studies, caregiver burden also was analysed. A common approach to quantification and evaluation of expenditures for service consumption was used in all 12 studies. The nature of community-based health services (health vs. disease care orientation) was found to have direct and measurable impact on total expenditures for health service utilization and client well-being outcomes. In most cases, a recurring pattern of equal or better client outcomes, yet lower expenditures for use of community based health services, was associated with well-integrated health oriented services. Integrated services aimed at factors which determine health are superior when compared to individual, fragmented, disease oriented, and focused approaches to care. The main lessons from the 12 studies are that it is as or more effective and as or less expensive to offer complete, proactive, community health services to persons living with chronic circumstance than to provide focused, on-demand, piecemeal services. Complete services would have a psychosocial and mental health focus included with the physical care approach. Furthermore, people with coexisting risk factors (age, living arrangements, mental distress and problem-solving ability) are the ones who most benefit at lower expense from health oriented, proactive interventions.

More effective and less expensive: lessons from five studies examining community approaches to care

Does the nature of community health services used by chronically ill clients and their caregivers have an impact on utilization of services, expenditure and well-being outcomes? A series of five studies, (four historic cohort and one randomized trial) examined clients suffering from a variety of chronic conditions in a number of community settings in different regions of Southern Ontario. Study sample composition and size varied. Each study was designed to quantify the well-being outcomes, and expenditure associated with different community approaches is covered under a nation-wide system of health insurance plans. As a collective, these studies represent increasing methodological rigor. Multiple-perspective client well-being outcome measures were used. Caregiver burden was also analyzed. A common approach to quantification and evaluation of expenditure for service consumption was applied across all five studies. The nature of community health services (proactive versus reactive approaches to care) was found to have direct and measurable impact on total expenditure for health service utilization and client well-being outcomes. A recurring pattern of lower expenditure for community health service utilization and equal or better client outcomes was associated with well-integrated proactive services when compared with individual fragmented, reactive approaches to care. The main lesson emerging from examining the five studies on approaches to community care is that it is as, or more, effective and less expensive to offer complete proactive health care services to chronically ill people in the early stages of their illness than to provide services on demand in a piecemeal manner.

Racial differences in treatment of psychiatric inpatients.

The study examined several aspects of inpatient psychiatric treatment to determine if differences existed between treatment of African-American and white patients. Using a structured chart review, data were collected on 76 African-American and 88 white patients consecutively admitted to an acute inpatient setting with a principal axis I diagnosis of a major mood or psychotic disorder. Racial differences in treatment were examined using analysis of variance and logistic regression to assess the effects of diagnosis and socioeconomic status. Nonpsychotic African-American patients had shorter lengths of stay than white patients with similar disorders. White patients were more likely to be on one-to-one observational status. Clinicians were more likely to order urine drug screens for African-American patients with high socioeconomic status than for comparable white patients. African-American patients with schizophrenic disorders received higher neuroleptic dosages than white patients with similar diagnoses. Most racial differences cited in earlier studies of psychotic patients were not found or were not statistically significant once socio-economic status and diagnosis were accounted for. However, racial differences related to the detection, phenomenology, treatment, and course of psychotic disorders and the diagnosis and management of alcohol and drug use disorders and personality disorders were found.