The role of data in health care disparities in medicaid managed care

BACKGROUND: The Affordable Care Act includes provisions to standardize the collection of data on health care quality that can be used to measure disparities. We conducted a qualitative study among leaders of Medicaid managed care plans, that currently have access to standardized quality data stratified by race and ethnicity, to learn how they use it to address disparities. METHODS: We conducted semi-structured interviews with 21 health plan leaders across 9 Medicaid managed care plans in California. We used purposive sampling to maximize heterogeneity in geography and plan type (e.g., non-profit, commercial). We performed a thematic analysis based on iterative coding by two investigators. RESULTS: We found 4 major themes. Improving overall quality was tightly linked to a focus on standardized metrics that are integral to meeting regulatory or financial incentives. However, reducing disparities was not driven by standardized data, but by a mix of factors. Data were frequently only examined by race and ethnicity when overall performance was low. Disparities were attributed to either individual choices or cultural and linguistic factors, with plans focusing interventions on recently immigrated groups. CONCLUSIONS: While plans' efforts to address overall quality were often informed by standardized data, actions to reduce disparities were not, at least partly because there were few regulatory or financial incentives driving meaningful use of data on disparities. Standardized data, as envisaged by the Affordable Care Act, could become more useful for addressing disparities if they are combined with policies and regulations that promote health care equity

Developing a complex intervention to improve prescribing safety in primary care:mixed methods feasibility and optimisation pilot study

Objectives (A) To measure the extent to which different candidate outcome measures identified high-risk prescribing that is potentially changeable by the data-driven quality improvement in primary care (DQIP) intervention.(B) To explore the value of reviewing identified high-risk prescribing to clinicians.(C) To optimise the components of the DQIP intervention.  Design Mixed method study.  Setting General practices in two Scottish Health boards.  Participants 4 purposively sampled general practices of varying size and socioeconomic deprivation.  Outcome measures Prescribing measures targeting (1) high-risk use of the non-steroidal anti-inflammatory drugs (NSAIDs) and antiplatelets; (2) ‘Asthma control’ and (3) ‘Antithrombotics in atrial fibrillation (AF)’.  Intervention The prescribing measures were used to identify patients for review by general practices. The ability of the measures to identify potentially changeable high-risk prescribing was measured as the proportion of patients reviewed where practices identified a need for action. Field notes were recorded from meetings between researchers and staff and key staff participated in semistructured interviews exploring their experience of the piloted intervention processes.  Results Practices identified a need for action in 68%, 25% and 18% of patients reviewed for prescribing measures (1), (2) and (3), respectively. General practitioners valued being prompted to review patients, and perceived that (1) ‘NSAID and antiplatelet’ and (2) ‘antithrombotics in AF’ were the most important to act on. Barriers to initial and ongoing engagement and to sustaining improvements in prescribing were identified.  Conclusions ‘NSAIDs and antiplatelets’ measures were selected as the most suitable outcome measures for the DQIP trial, based on evidence of this prescribing being more easily changeable. In response to the barriers identified, the intervention was designed to include a financial incentive, additional ongoing feedback on progress and reprompting review of patients, whose high-risk prescribing was restarted after a decision to stop.  Trial registration number Clinicaltrials.govNCT01425502

Quality and Outcomes Framework: what have we learnt?

Martin Roland and Bruce Guthrie assess the successes and failures of the pay-for-performance scheme and what its future should beThis is the final version of the article. It first appeared from BMJ Publishing Group via http://dx.doi.org/10.1136/bmj.i406

A study of B-type stars

The effect of rotation on quantities used in classifying B -type stars is discussed. The tendency for stars with high rotational velocities to have weaker Balmer lines for the same (U - B)₀ has been investigated using published data. Abt's explanation of the affect in terms of the change in effective surface gravity due to rotation is confirmed. A correction term in Crawford's method of determining ages of clusters and field stars from Balmer line intensities and UBV photometry is derived. It is shown that errors in age determinations due to rotation are much smaller when the wavelength λ₁ of the Balmer discontinuity is used instead of Balmer line intensities. A colour index sensitive to λ₁ is discussed. Methods of determining the inclinations of the axes of rotation are suggested. It is shown that the "cosmic dispersion" in the relation between Balmer line intensities and absolute magnitudes is largely caused , by rotation. A scheme of two -dimensional spectral classification using measurements of the position and size of the Balmer discontinuity on low dispersion objective prism plates is outlined. Rotational velocities for 18 stars have been derived from slit spectrograms; several lines including five Balmer lines were measured for each star

Rotation and chemical composition of early-type stars

Some early-type stars with abnormal line strengths for their intrinsic colours are investigated in order to determine their structure and the chemical composition of their atmospheres. The abnormal line strengths in several B-type stars (αScl, 36 Lyn, 20 Tau and HD 175156) are shown to be probably due to large ranges of surface temperature such as would be observed in rapidly rotating stars of normal chemical composition, if viewed pole-on. These stars differ from the peculiar A stars, which rotate slowly and have abnormal chemical composition. Members of the Mn group of peculiar A stars rotate more slowly than those of the Si-4200 group, although the mean intrinsic colours of the two groups are similar.Previous work on abundance determination in peculiar A stars is reviewed. The chemical composition of the manganese star 53 Tau is studied by a refined differential curve-of-growth method with αLyr as the comparison star. Groups of lines of similar mean excitation and ionisation potentials and wavelengths are used so that the results are independent of the structure of 53 Tau, which is shown to be abnormal. A new double-line peculiar A spectroscopic binary HR 4072 was discovered, and it was found that excesses of Sr and Y are common to both components. Spectral variations in some peculiar A stars are described.Well established abundance abnormalities in peculiar A stars may be explained on a modified form of van den Heuvel's theory that peculiar A stars have been secondaries of binary systems with initial separations in the range 10 a.u. to 100 a.u. approximately. The primaries, initially earlier than spectral type B8, have evolved and exploded as type II supernovae. During the explosions material enriched in heavy elements by interior nuclear reactions was transferred to the surfaces of the secondaries, which are now observed as peculiar A stars and are still on the main sequence. Excesses of Be and Si and deficiencies of 0 are caused by surface nuclear reactions on the secondaries after the explosions of the primaries. Ln stars differ from other peculiar A stars in many respects; the differences may be due to the primaries expanding beyond the Roche limits before they explode. On the oblique rotator theory, spectrum variables result from irregular distributions of surface nuclear reactions and ion migration on the secondaries. Some other theories of peculiar A stars are reviewed and shown to be in conflict with observation

Protocol for the effective feedback to improve primary care prescribing safety (EFIPPS) study : a cluster randomised controlled trial using ePrescribing data

High-risk prescribing in primary care is common and causes considerable harm. Feedback interventions to improve care are attractive because they are relatively cheap to widely implement. There is good evidence that feedback has small to moderate effects, but the most recent Cochrane review called for more high-quality, large trials that explicitly test different forms of feedback. The study is a three-arm cluster-randomised trial with general practices being randomised and outcomes measured at patient level. 262 practices in three Scottish Health Board areas have been randomised (94% of all possible practices). The two active arms receive different forms of prescribing safety data feedback, with rates of high-risk prescribing compared with a ‘usual care’ arm. Sample size estimation used baseline data from participating practices. With 85 practices randomised to each arm, then there is 93% power to detect a 25% difference in the percentage of high-risk prescribing (from 6.1% to 4.5%) between the usual care arm and each intervention arm. The primary outcome is a composite of six high-risk prescribing measures (antipsychotic prescribing to people aged ≥75 years; non-steroidal anti-inflammatory drug (NSAID) prescribing to people aged ≥75 without gastroprotection; NSAID prescribing to people prescribed aspirin/clopidogrel without gastroprotection; NSAID prescribing to people prescribed an ACE inhibitor/angiotensin receptor blocker and a diuretic; NSAID prescription to people prescribed an oral anticoagulant without gastroprotection; aspirin/clopidogrel prescription to people prescribed an oral anticoagulant without gastroprotection). The primary analysis will use multilevel modelling to account for repeated measurement of outcomes in patients clustered within practices. The study was reviewed and approved by the NHS Tayside Committee on Medical Research Ethics B (11/ES/0001). The study will be disseminated via a final report to the funder with a publicly available research summary, and peer reviewed publications