Health Service Use and Expenditure Patterns of Dual Eligibles in Michigan

Objective: The objective is to provide a statewide population-based comparison of Michigan beneficiaries dually eligible for Medicare and Medicaid (duals) to Medicare-only beneficiaries, including the public health expenditures by service type, and to focus on the LTC service use patterns of elderly duals receiving care in various settings. Data Sources: Data sources were linked 2005 and 2006 individual Medicaid and Medicare claims from all Michigan duals. Methods: CMS provided Medicare claims and beneficiary data. Michigan Department of Community Health provided Medicaid claims data. Design: We compared characteristics and health expenditures across various categories of beneficiaries and LTC care settings. Principal Findings: The 13% duals accounted for 33% of total Medicare and Medicaid expenditures. Eight percent of elderly beneficiaries were duals in 2005, accounting for 26% of public health expenditures in the aged. The average monthly expenditures of elderly duals were: $4,896 in institutional LTC,$2,921 for those served through HCBS waiver programs, and $1,488 for those in the community. Conclusions: Duals in Michigan account for a disproportionate large share of state and federal health expenditures. Michigan’s experience suggests that LTC services can be offered in home and community-based settings, at lower costs compared to institutional LTC. The shift in prescription drug coverage from Medicaid to Medicare increased the drug expenditures for some duals and had limited impact on overall dual expenditures. Results may be pertinent within the context of impending healthcare reforms

Preventive Primary Care Screening Patterns after Provider EHR Adoption for Michigan Medicaid Adults

Introduction It remains largely unknown how use of electronic health records (EHR) impacts ordering of preventive/screening services (PSS). These analyses examined the influence of confirmed Medicaid provider EHR adoption on primary care ordering rates of five major PSS. Sample was comprised of 10,149 continuously enrolled Michigan Medicaid adults linked to 6,587 providers. Methods The authors obtained complete office-based billing claims data from the Michigan Medicaid Data Warehouse for adults with 29 or more months of continuous state Medicaid coverage. PSS claims data were linked to patients’ Medicaid-assigned providers who either had, or had not, EHR-attested during the 60-month analytic window. Results Final predictive models with consistent EHR provider-patient dyads demonstrated both significant increases and decreases in order rates for office-based PSS compared to non-EHR dyads. Similar to the authors’ earlier work, the authors conclude that while EHR modules prompted many providers to increase some PSS ordering, their improved access to historical documentation also decreased redundant or premature orders. Conclusions Based on these results, future controlled studies examining the apparent mixed influences derived from increased use of different EHR technologies on PSS ordering rates are certainly required

"Concordance between comorbidity data from patient self-report interviews and medical record documentation"

<p>Abstract</p> <p>Background</p> <p>Comorbidity is an important adjustment measure in research focusing on outcomes such as health status and mortality. One recurrent methodological issue concerns the concordance of comorbidity data obtained from different reporting sources. The purpose of these prospectively planned analyses was to examine the concordance of comorbidity data obtained from patient self-report survey interviews and hospital medical record documentation.</p> <p>Methods</p> <p>Comorbidity data were obtained using survey interviews and medical record entries from 525 hospitalized Acute Coronary Syndrome patients. Frequencies and descriptive statistics of individual and composite comorbidity data from both sources were completed. Individual item agreement was evaluated with simple and weighted kappas, Spearman Rho coefficients for composite scores.</p> <p>Results</p> <p>On average, patients reported more comorbidities during their patient survey interviews (mean = 1.78, SD = 1.99) than providers had documented in medical records (mean = 1.27, SD = 1.43). Higher proportions of positive responses were obtained from self-reports compared to medical records for all conditions except congestive heart failure and renal disease. Older age and higher depressive symptom levels were significantly associated with poorer levels of data concordance.</p> <p>Conclusion</p> <p>These results demonstrate that survey comorbidity data from ACS patients may not be entirely concordat with medical record documentation. In the absence of a gold standard, it is possible that hospital records did not include all pre-admission comorbidities and these patient survey interview methods may need to be refined. Self-report methods to facilitate some patients' complete recall of comorbid conditions may need to be refined by health services researchers.</p> <p>Trial Registration</p> <p>ClinicalTrials.gov NCT00416026.</p

Changes in practice patterns affecting in-hospital and post-discharge survival among ACS patients

BACKGROUND: Adherence to clinical practice guidelines for the treatment of specific illnesses may result in unexpected outcomes, given that multiple therapies must often be given to patients with diverse medical conditions. Yet, few studies have presented empirical evidence that quality improvement (QI) programs both change practice by improving adherence to guidelines and improve patient outcomes under the conditions of actual practice. Thus, we focus on patient survival, following hospitalization for acute coronary syndrome in three successive patient cohorts from the same community hospitals, with a quality improvement intervention occurring between cohorts two and three. METHODS: This study is a comparison of three historical cohorts of Acute Coronary Syndrome (ACS) patients in the same five community hospitals in 1994–5, 1997, 2002–3. A quality improvement project, the Guidelines Applied to Practice (GAP), was implemented in these hospitals in 2001. Study participants were recruited from community hospitals located in two Michigan communities during three separate time periods. The cohorts comprise (1) patients enrolled between December 1993 and April 1995 (N = 814), (2) patients enrolled between February 1997 and September 1997 (N = 452), and (3) patients enrolled between January 14, 2002 and April 13, 2003 (N = 710). Mortality data were obtained from Michigan's Bureau of Vital Statistics for all three patient cohorts. Predictor variables, obtained from medical record reviews, included demographic information, indicators of disease severity (ejection fraction), co-morbid conditions, hospital treatment information concerning most invasive procedures and the use of ace-inhibitors, beta-blockers and aspirin in the hospital and as discharge recommendations. RESULTS: Adjusted in-hospital mortality showed a marked improvement with a HR = 0.16 (p < 0.001) comparing 2003 patients in the same hospitals to those 10 years earlier. Large gains in the in-hospital mortality were maintained based on 1-year mortality rates after hospital discharge. CONCLUSION: Changes in practice patterns that follow recommended guidelines can significantly improve care for ACS patients. In-hospital mortality gains were maintained in the year following discharge

Quality Improvement Intervention associated with Improved Lung Protective Ventilation Settings in an Emergency Department.

INTRODUCTION: Patients requiring endotracheal intubation and mechanical ventilation in the emergency department (ED) are critically ill, and their ventilator management is crucial for their subsequent clinical outcomes. Lung-protective ventilation (LPV) setting strategies are key considerations for this care. The objectives of this 2019-2020 community-based quality improvement project were to: a) identify patients at greater risk of not receiving LPV, and b) evaluate the effectiveness of a series of brief quality improvement educational sessions to improve LPV setting protocol adherence rates. METHODS: A 15-month retrospective chart review of ventilator settings and subject characteristics (N = 200) was conducted before and after a series of 10-15-minute educational sessions were delivered to improve LPV adherence. This information was presented at a series of four educational sessions for 25 attending physicians (n = two sessions) and 27 residents at conferences (n = two sessions). Two additional materials (e.g., LPV reference charts, tape measures to gauge patients\u27 heights) were also posted in three ED resuscitation rooms and on cabinets containing emergency airway equipment. The pre and post-intervention occurrence rates of LPV setting orders were inferentially compared before and after educational sessions. RESULTS: Patients ventilated using LPV increased from 70% to 82% after the educational sessions (p = 0.04). All patients who were 67 inches or greater in height were ventilated appropriately before and after sessions. For patients under 65 inches in height, post-session LPV adherence increased from 13% to 53% (p = 0.01). CONCLUSIONS: Based on these results, a brief ED provider educational intervention can significantly improve the utilization of LPV guideline-based settings. Patients under 65 inches in height may also be especially at risk of receiving non-LPV ventilator setting orders

Contemporary Adult Diabetes Mellitus Management Perceptions

Background: Over 180 million people have been diagnosed with diabetes mellitus worldwide, with this number expected to more than double by 2030. Due to the increasing mortality and morbidity associated with this epidemic, the improved primary-care management of diabetes during routine office visits remains an emerging international challenge. Objective: To report the results of a series of exploratory semi-structured group interview sessions with a sample of 44 American adults with type 2 diabetes, concerning their diabetes management perceptions and office-based diabetes care processes. Methods: A total of 44 adults from a Midwest Internal Medicine Clinic were interviewed during 2004 and 2005 before starting a larger, quantitative, shared decision-making intervention study. During group interviews, participants offered their perceptions of their self-management practices, interactions with office clinicians, and diabetes-related health outcomes to date. A total of 178 audio-taped interview comments (across 44 participants) were transcribed and analyzed for core themes and sub-themes. Results: Many participants reported frustrating experiences regarding the relationship between their personal diabetes self-management practices and typical office visit interactions with clinicians. Most participants perceived these diabetes management processes as inherently different from each other. Many participants were intrigued with the proposed shared decision-making management approach of the larger intervention study. Conclusions: Primary-care clinicians should assess how patients may perceive their self-management strategies relate to office-based diabetes care processes. Patients' self-management beliefs and practices should be routinely evaluated since they frequently affect the nature of key diabetes care office visit decisions. These qualitative results suggest that clinicians should convey the increasing interdependence between their patients' daily diabetes self-management practices and contemporary office visit decision-making discussions.Decision-making, Diabetes-mellitus, treatment, Disease-management-programmes, Patient-preference

Changes in practice patterns affecting in-hospital and post-discharge survival among ACS patients

Abstract Background Adherence to clinical practice guidelines for the treatment of specific illnesses may result in unexpected outcomes, given that multiple therapies must often be given to patients with diverse medical conditions. Yet, few studies have presented empirical evidence that quality improvement (QI) programs both change practice by improving adherence to guidelines and improve patient outcomes under the conditions of actual practice. Thus, we focus on patient survival, following hospitalization for acute coronary syndrome in three successive patient cohorts from the same community hospitals, with a quality improvement intervention occurring between cohorts two and three. Methods This study is a comparison of three historical cohorts of Acute Coronary Syndrome (ACS) patients in the same five community hospitals in 1994–5, 1997, 2002–3. A quality improvement project, the Guidelines Applied to Practice (GAP), was implemented in these hospitals in 2001. Study participants were recruited from community hospitals located in two Michigan communities during three separate time periods. The cohorts comprise (1) patients enrolled between December 1993 and April 1995 (N = 814), (2) patients enrolled between February 1997 and September 1997 (N = 452), and (3) patients enrolled between January 14, 2002 and April 13, 2003 (N = 710). Mortality data were obtained from Michigan's Bureau of Vital Statistics for all three patient cohorts. Predictor variables, obtained from medical record reviews, included demographic information, indicators of disease severity (ejection fraction), co-morbid conditions, hospital treatment information concerning most invasive procedures and the use of ace-inhibitors, beta-blockers and aspirin in the hospital and as discharge recommendations. Results Adjusted in-hospital mortality showed a marked improvement with a HR = 0.16 (p Conclusion Changes in practice patterns that follow recommended guidelines can significantly improve care for ACS patients. In-hospital mortality gains were maintained in the year following discharge.</p

COMPARISON OF MIDDLE-AGED WOMEN WITH AND WITHOUT TYPE 2 DIABETES ON DEMOGRAPHIC, CLINICAL, AND SOCIAL-COGNITIVE FACTORS ASSOCIATED WITH MODERATE- TO VIGOROUS-INTENSITY PHYSICAL ACTIVITY

Aims: The purpose of this cross-sectional, exploratory study was to compare demographic, clinical, and social cognitive factors associated with minutes per day of moderate- to vigorous-intensity physical activity (MVPA) in middle-aged women with and without Type 2 diabetes. Methods: The theoretical framework was based on both the Social Cognitive Theory and the Theory of Planned Behavior used to depict the demographic, clinical, and social-cognitive factors shown to be associated with physical activity. Forty-two middle-aged women with Type 2 diabetes and 67 without diabetes met inclusion criteria at four urban primary care clinics.. Enrolled women received an accelerometer to wear for seven consecutive days and completed a survey including questions exploring various demographic, clinical, and social-cognitive factors. Height and weight were measured to calculate body mass index (BMI). After the one week of wear-time, women returned the accelerometer and completed the International Physical Activity Questionnaire (IPAQ) short-form. Data were analyzed using independent t-tests and chi-squared tests. Results: Ninety-three (86.1%) of the women were overweight or obese. A higher proportion of non-Whites was noted for women with Type 2 diabetes, compared to women without diabetes. The mean values for women with Type 2 diabetes were higher for BMI and comorbidity index, lower for perceived benefits and self-efficacy related to physical activity, and fewer for minutes per day of vigorous-intensity physical activity. Conclusions: Tailored nursing interventions are needed to enhance perceived benefits and self-efficacy of physical activity, especially in middle-aged women with Type 2 diabetes, as a means for increasing MVPA