Health Care-related Outcomes Research Articles

Operative Treatment of Rib Fractures in Flail Chest Injuries: A Meta-analysis and Cost-Effectiveness Analysis.

Flail chest is a common injury sustained by patients who experience high-energy blunt chest trauma and results in severe respiratory compromise because of altered mechanics of respiration. There has been increased interest in operative fixation of these injuries with the intention of restoring the mechanical integrity of the chest wall, and several studies have shown that ventilation requirements and pulmonary complications may be decreased with operative intervention. The purpose of this study was to evaluate fixation of rib fractures in flail chest injuries using cost-effectiveness analysis, supported by systematic review and meta-analysis. This was a 2-part study in which we initially conducted a systematic literature review and meta-analysis on outcomes after operative fixation of flail chest injuries, evaluating intensive care unit (ICU) stay, hospital length of stay (LOS), mortality, pneumonia, and need for tracheostomy. The results were then applied to a decision-analysis model comparing the costs and outcomes of operative fixation versus nonoperative treatment. The validity of the results was tested using probabilistic sensitivity analysis. Operative treatment decreased mortality, pneumonia, and tracheotomy (risk ratios of 0.44, 0.59, and 0.52, respectively), as well as time in ICU and total LOS (3.3 and 4.8 days, respectively). Operative fixation was associated with higher costs than nonoperative treatment ($23,682 vs. $8629 per case, respectively) and superior outcomes (32.60 quality-adjusted life year (QALY) vs. 30.84 QALY), giving it an incremental cost-effectiveness ratio of $8577/QALY. Surgical fixation of rib fractures sustained from flail chest injuries decreased ICU time, mortality, pulmonary complications, and hospital LOS and resulted in improved health care-related outcomes and was a cost-effective intervention. These results were sensitive to overall complication rates, and operations should be conducted by surgeons or combined surgical teams comfortable with both thoracic anatomy and exposures as well as with the principles and techniques of internal fixation. Economic Level III. See Instructions for Authors for a complete description of levels of evidence.

Asthma and asthma-related health care utilization among people without disabilities and people with physical disabilities

BackgroundPrevious research has shown that people with disabilities have higher rates of some chronic diseases and receive poorer disease-specific care than their counterparts without disabilities. Yet, little is known about the relationship between asthma and disability. ObjectiveThis study examines whether differences in the prevalence of asthma, asthma flare, and asthma-related measures of health care quality, utilization and cost exist among people with physical limitations (PL) and without any limitations. MethodsData from the 2004–2010 Medical Expenditure Panel Survey were pooled to compare outcomes for working-age adults (18–64) with PL to those with no limitations. ResultsPeople with PL had higher rates of asthma (13.8% vs. 5.9%, p < 0.001) and recent asthma flare (52.6% vs. 39.6%, p < 0.001) than people without limitations. There were no differences in health care quality, utilization or cost between people with PL and people without limitations in multivariate analyses. ConclusionsAlthough there are no differences in asthma-related quality or utilization of health care, people with PL have poorer asthma control than people without limitations. Research is needed to determine what factors (e.g., focus on other acute ailments, perceptions that asthma control cannot improve) are related to this outcome. Future research must also examine differences in asthma severity, and its impact on asthma control and health care-related outcomes, among people with and without disabilities.

How have state policies to expand dependent coverage affected the Affordable Care Act on healthcare-related outcomes?

Background: In the United States, prior to the implementation of the Affordable Care Act Dependent Coverage Expansion (ACA-DCE) in September 2010, many states had made similar expansion of coverage to young adults, although with varying requirements based on age limits, marital status, student status and other factors.Objective: To examine if healthcare-related changes among young adults after the ACA-DCE differed by the states’ prior reform status.Methods: Young adults aged 19-34 were identified from the 2004-2013 Medical Expenditure Panel Survey, a national household interview survey in the U.S. Quasi-experiment design and difference-in-differences analyses were conducted to examining the changes in insurance coverage, annual care utilization, and medical expenditures and self-reported after the implementation of the ACA-DEC among adults aged 19-25 years, using those aged 26-34 as controls; the analyses were stratified by states’ prior expansion status.Results: While insurance coverage increased nationwide among 19-25-year-olds after the implementation of the ACA-DCE, its spillover effects on dental insurance and prescription insurance and its effects on healthcare spending and overall health status were only seen for those residing in states that expanded dependent coverage prior to the ACA.Conclusions: State policies may have facilitated the effects from the ACA-DCE on healthcare delivery among young adults. Future studies evaluating effects of the ACA should consider state variations when possible, even for the provisions that apply to all states uniformly.Key words: Affordable Care Act, young adults, care utilization, medical expenditures, spillover effect.

Healthcare Stereotype Threat in Older Adults in the Health and Retirement Study.

Healthcare stereotype threat is the threat of being personally reduced to group stereotypes that commonly operate within the healthcare domain, including stereotypes regarding unhealthy lifestyles and inferior intelligence. The objective of this study was to assess the extent to which people fear being judged in healthcare contexts on several characteristics, including race/ethnicity and age, and to test predictions that experience of such threats would be connected with poorer health and negative perceptions of health care. Data were collected as part of the 2012 Health and Retirement Study (HRS). A module on healthcare stereotype threat, designed by the research team, was administered to a random subset (n=2,048 of the total 20,555) of HRS participants. The final sample for the present healthcare stereotype threat experiment consists of 1,479 individuals. Logistic regression was used to test whether healthcare stereotype threat was associated with self-rated health, reported hypertension, and depressive symptoms, as well as with healthcare-related outcomes, including physician distrust, dissatisfaction with health care, and preventative care use. Seventeen percent of respondents reported healthcare stereotype threat with respect to one or more aspects of their identities. As predicted, healthcare stereotype threat was associated with higher physician distrust and dissatisfaction with health care, poorer mental and physical health (i.e., self-rated health, hypertension, and depressive symptoms), and lower odds of receiving the influenza vaccine. The first of its kind, this study demonstrates that people can experience healthcare stereotype threat on the basis of various stigmatized aspects of social identity, and that these experiences can be linked with larger health and healthcare-related outcomes, thereby contributing to disparities among minority groups.

Development and validation of a questionnaire assessing the perceived control in health care among older adults with care needs in the Netherlands.

Purpose In response to the increased emphasis placed on older people’s self-reliance in many welfare societies, we aimed to develop and validate a measurement instrument, assessing perceived control in health care among older adults with care needs. The target group consists of older people who live (semi-)independently and use professional health care, with or without informal care.MethodsPhase I (development) of the study consisted of the construction of the instrument based on the input from a variety of stakeholders. Phase II (validation) entailed a quantitative study in a sample of 247 respondents selected from the Longitudinal Aging Study Amsterdam, to assess the instrument’s construct validity (structural validity and hypotheses testing) and reliability (internal consistency).ResultsThe questionnaire consists of 29 items, related to organizing professional care, communication with care professionals, health management in the home situation, planning (more) complex care in the future, and perceived support from the social network. Based on a factor analysis, we identified three subscales: (I.) ‘perceived personal control in health care’; (II.) ‘anticipated personal control regarding future health care’; and (III.) ‘perceived support from the social network,’ with internal consistencies varying from Cronbach’s α = .71 to .90. Factor I was associated with mastery, self-efficacy, self-esteem (r = .31–.35) and factor III with social loneliness (r = −.42). Factor II correlated less strongly with mastery, self-efficacy, and self-esteem (r < .30).ConclusionOur questionnaire revealed sufficient construct validity and internal consistency. The instrument provides a basis for further quantitative research regarding control, especially in relation to health care-related outcomes.

Adaptation of the chronic disease self-management program for cancer survivors: feasibility, acceptability, and lessons for implementation.

Self-management in chronic disease has been shown to improve patient-reported and health care-related outcomes. However, relatively little information about its utility in cancer survivorship is known. We evaluated the feasibility and acceptability of the delivery of an adaptation of the evidence-based Chronic Disease Self-management Program (Stanford) called Cancer Thriving and Surviving (CTS). Triangulated mixed methods were used to capture baseline characteristics and post-program experiences using a combination of closed- and open-ended survey items; emergent coding and simple descriptive statistics were used to summarize the data. Twenty-seven workshops were delivered by 22 CTS leaders to 244 participants between August 2011 and January 2013 in a variety of settings (48 % community, 30 % health care, 22 % regional/community cancer center). Representing a variety of cancer types, about half the participants were 1-3 years post-diagnosis and 45 % were 4 or more years from diagnosis. Program attendance was high with 84 % of participants attending four or more of the six sessions in the workshop. Overall, 95 % of the participants were satisfied with the program content and leaders, and would recommend the program to friends and family. These results confirm the feasibility and acceptability of delivery of a high-fidelity, peer-led model for self-management support for cancer survivors. Expansion of the CTS represents a powerful tool toward improving health-related outcomes in this at-risk population.

Comparing Hospitals on Stroke Care

STROKE IS A LEADING CAUSE OF MORBIDITY AND MORtality in the United States and worldwide and is associated with enormous health care expenditures. Approximately 800 000 new or recurrent strokes occur annually in the United States, and of these, about 87% are ischemic cerebral infarctions. Since 1996, when the use of intravenous tissue plasminogen activator was approved by the US Food and Drug Administration (FDA) for the treatment of patients with acute ischemic stroke within 3 hours of symptom onset, there has been a sea change in the approach to identification and management of stroke patients to improve their outcomes. Parallel to these advances, there has been an equally important move toward a systems-based approach to stroke care. The very short time window needed for acute therapies to reverse brain injury has inspired several national and statewide initiatives to improve hospital care of the stroke patient. The Brain Attack Coalition criteria for primary stroke centers, first recommended in 2000 and revised in 2011, have formed the basis for Joint Commission certification for stroke center status. Additional certification for comprehensive stroke centers begins in July 2012. These efforts are rooted in a developing evidence base demonstrating that organized, systems-based care, informed by guidelines and quality assurance efforts, can improve outcomes. There is evidence, for example, that patients with acute stroke are more likely to survive, return home, and regain independence if treated in hospital units specializing in the care of patients with stroke. The restructuring of health insurance in the United States, with the focus on increasing efficiency, improving outcomes, and providing value to the public, has stimulated efforts to provide valid measures of health care quality. One such measure includes assessment and ranking of hospital performance in the care of commonly encountered and significant illnesses, of which stroke is a good example. Approaches to the measurement of such outcomes, however, are potentially fraught with biases and other complexities. Although the implications of such measures are substantial, both for the individual hospital and the health care system as a whole, targeted research about health care–related outcomes is a relatively new field and optimal analytic approaches are still being developed. In this issue of JAMA, Fonarow and colleagues evaluate the influence of including or excluding stroke severity in prognostic stroke outcome models in a large Medicare insurance database. The authors used data from almost 128 000 patients with ischemic stroke from 782 Get With The Guidelines–Stroke participating hospitals. For all patients included in the analysis, information on the severity of the stroke was available in the form of the National Institutes of Health Stroke Scale (NIHSS) score. The primary outcome was 30-day mortality, and prognostic models were evaluated for their overall model discrimination as well as for differences in rankings of the hospital performance when including or excluding information on stroke severity. The main prognostic model included information on age, sex, prior stroke or transient ischemic attack, and a large number of comorbid conditions and was compared with a model that additionally included information on stroke severity. All statistical measures of model performance showed that the model including stroke severity was superior, indicating that stroke severity substantially improved the prediction of 30-day mortality above and beyond other clinical predictors. Considered at the level of the individual patient, this result does not seem surprising: a patient who has a relatively more severe stroke is at increased risk of death. Moreover, when the prediction models were used to classify and rank hospitals based on 30-day mortality, the model including stroke severity demonstrated substantially more accurate classification and substantially changed hospital rankings. Of the 782 participating hospitals, the absolute change of the median hospital rank position was 79 places. More than half (58%) of hospitals first classified as having higher than expected mortality were reclassified to having the expected mortality rate after incorporating severity into

CPNP position paper released: Integration of psychiatric pharmacy expertise into primary care is essential to our patients care

As psychiatric pharmacy practitioners, we are all acutely aware that persons with severe and persistent mental illnesses often do not receive adequate general medical care for a variety of reasons. According to work published by Dross and colleagues, sponsored by the Robert Woods Johnson Foundation, more than 68 percent of adults with a mental illness have at least one medical disorder, and 29% of people with medical disorders have a comorbid mental health condition. Further, comorbid mental health and medical conditions are associated with substantial decreased quantity and quality of life, increased symptom burden, and increased healthcare costs. It is increasingly clear that optimizing healthcare outcomes requires effective management of medical and psychiatric illness.Recognizing the significance of this matter, and the pace of change in the national healthcare landscape with multiple converging factors that make the advancement of pharmacy practice a real possibility, the CPNP Board of Directors appointed a task force to develop a position statement on integrating pharmacists with psychiatric and neurologic training into primary care settings. In this edition of the Mental Health Clinician, we are sharing this position with the membership. The goal of this position statement on integration of psychiatric pharmacists into the medical home model is to encourage the medical and pharmacy community to work together to improve access to care, improve healthcare-related outcomes, and decrease overall healthcare costs for patients with mental illness and medical comorbidities by taking purposeful action to move towards integrated care. Further, CPNP believes that this position statement will give guidance to our members regarding what is important in this rapidly evolving arena of behavioral health integration into the primary care medical home setting. By supporting healthcare reform in the manner outlined in the position statement, including recognizing pharmacists as providers, high quality, cost effective care can be more effectively delivered to this high risk patient group.It is clear from well-established models that psychiatric pharmacists can provide holistic patient-centered care by integrating mental health and primary care. In this model, psychiatric pharmacists provide comprehensive medication management, consistent with the principles outlined by the Patient Centered Primary Care Collaborative Medication Management Taskforce, as part of an integrated health care team. Board-certified psychiatric pharmacists are uniquely positioned to partner with primary care providers and generalist pharmacists to target complex patients who are high users of resources and optimize outcomes.Our ultimate goal in promoting collaboration between mental health and medical care is to improve the lives of persons with chronic mental illness and their families. This position statement has been endorsed by NAMI, as a partner advocacy group seeking appropriate services for persons with mental diseases. Similar such positions on moving pharmacy practice forward have recently been taken by the United States Public Health Service and endorsed by the Surgeon General. Clearly, more effective utilization of pharmacists in healthcare to the benefit of patients is an idea whose time has arrived. George Bernard Shaw has a famous line that goes “Those who say it cannot be done get in the way of those who are doing it.” I believe we are the doers.View the position paper

SP1-90 Socio-demographic and geographic differences in healthcare related outcomes in a cohort of diabetes patients in the Lazio Region, Italy

IntroductionThe Italian health system guarantees care to all citizens. Previous research reported socio-demographic differences in access to evidence-based therapies, whereas studies evaluating differences in healthcare related outcomes are scarce.ObjectivesAnalysing socio-demographic...

Measures and measurement of high-performance work systems in health care settings

Given that non-health care research has demonstrated many positive outcomes for organizations using high-performance work systems (HPWSs), a closer examination of HPWSs in health care settings is warranted. We conducted a narrative review of the literature to understand how previous researchers have measured HPWSs in health care settings and what relationships exist between HPWSs and outcomes. Articles that examined HPWSs in health care settings were identified and summarized. Key discrepancies and agreements in the existing HPWS research, including definitional, conceptual, and analytical areas of interest to health services researchers, are included. The findings demonstrate that although HPWSs might be a valuable predictor of health care-related outcomes, opportunities exist for improving HPWS measurement in health care settings. Suggestions are provided to help guide future health services researchers in conducting research on HPWSs. Practice implications are provided for health care managers.

Uniform national numerator definitions for infection control clinical indicators: surgical site infection and health-care related bloodstream infection

The concept of national surveillance of health-care-related infection is not new - programs have been implemented in the USA and a number of European countries over the past two decades. Proposals for a similar program in Australia have been hampered by a lack of government support. However, recent interest in adverse health-care related outcomes, both federally and in many of the states, has encouraged moves toward a national surveillance strategy.