Browsing by Subject "Health services research, policy and administration"

Now showing 1 - 5 of 5
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    Does process quality of inpatient care matter in potentially preventable readmission rates?
    (2012-08) Choi, Jae Young
    Objective: To examine the association between process quality of inpatient care and risk-adjusted, thirty-day potentially preventable hospital readmission (PPR) rates. Data Sources/Study Setting: This was an observational cross-sectional study of nonfederal acute-care hospitals located in two states California and Florida, discharging Medicare patients with a principal discharge diagnosis of heart failure, acute myocardial infarction, or pneumonia January through December 31, 2007. Data were obtained from the Healthcare Cost and Utilization Project State Inpatient Database of the Agency for Healthcare Research and Quality, Centers for Medicare and Medicaid Services Hospital Compare database, and the American Hospital Association Annual Survey of Hospitals.Study Design: The dependent variable of this study is condition-specific, risk-adjusted, thirty-day potentially preventable hospital readmission (PPR). 3M's PPR software was utilized to determine whether a readmission was potentially preventable. The independent variable of this study is hospital performance for process quality of inpatient care, measured by hospital adherence to recommended processes of care. We used multivariate hierarchical logistic models, clustered by hospitals, to examine the relationship between condition-specific, risk-adjusted, thirty-day PPR rates and process quality of inpatient care, after taking clinical and socio-demographic characteristics of patients and structural and operational characteristics of hospitals into account. Principal Findings: Better performance on the process quality metrics was associated with better patient outcome (i.e., low thirty-day PPR rates) in pneumonia, but not generally in two cardiovascular conditions (i.e., heart failure and acute myocardial infarction). We found no evidence of an interaction between process quality metrics and condition-specific hospital volume with respect to 30-day PPR. Conclusion: Adherence to the process quality metrics currently in use by CMS is associated with risk-adjusted, thirty-day PPR rates for patients with pneumonia, but not with cardiovascular conditions. More evidence-based process quality metrics closely linked to 30-day PPR rates, particularly for cardiovascular conditions, need to be developed.
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    The effects of health insurance loading fees on employment choice
    (2014-12) Graven, Peter F.
    This dissertation examines the impact of health insurance loading fees on the employment choices of individuals. Large firms are more likely to offer health insurance benefits and may be able to offer lower these benefits at a lower cost, or loading fee, to workers based on premium pricing practices. Individuals' sensitivity to these prices in their employment choice is largely unknown. The U.S. is undertaking significant and substantial reforms to the health insurance system including multiple reforms impacting loading fees, such as establishing federal medical loss ratio minimums and creating health insurance exchanges for the individual and employment markets. The Patient Protection and Affordable Care Act (PPACA) of 2010 introduces new options for the purchase of health insurance coverage that are not tied to employment. Using geographic variation in health insurance loading fees and individual variation in demand for healthcare, this study estimates an individual choice model between employment in large versus small firms to determine the impact of loading fees on employment decisions. It is hypothesized that individuals with greater healthcare demand may differentially prefer employment in larger firms due to the loading fees to which they are exposed.The study makes several contributions. First, it is the first study that uses the loading fee as a primary explanatory variable in an employment choice model. Second, it implements a novel method for estimating loading fees in the Medical Expenditure Panel Survey Household Component-Insurance Component (MEPS-HC-IC) Linked File through the use of an external actuarial value calculator. Third, it provides a theoretical structure to understand the economic impacts of loading fees. Finally, it contributes an econometric model structure well-suited to estimating and predicting incremental changes in loading fees. The study shows that individuals with high health demand are influenced by the loading fees in the market. The estimated loading fee gradient between small and large firms in a market area has an average marginal effect of 10.8 percentage points on the relationship between health demand and the probability of working at a large firm. This result suggests that policies that reduce the loading fee gradients between small and large firms, should expect to increase employment in small firms as a result of those with greater demands responding to the price changes. A policy simulation suggests that changes in the medical loss ratio observed in the individual market could lead to as much as 4 percentage point increase in small firm employment from 72.5% percent to 68.2% percent.
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    The experience of burnout among primary care physicians
    (2012-12) Gregory, Sean Thomas
    This dissertation addressed three specific aims, (1) the impact of an organizational change on the experience of burnout for primary care physicians, (2) the fit of a model for burnout in the primary care setting, and (3) modeling the trajectory of the three dimensions of burnout. The research was conducted with primary care physicians employed by a large integrated delivery system in the upper midwest United States, by observing a natural experiment occurring in the owned primary care practices.
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    The medicare hospice benefit: peering into the black box
    (2013-12) Jarosek, Stephanie L.
    The Medicare Hospice Benefit (MHB) provides terminally ill Medicare beneficiaries with a program of care specifically targeted to shifting the goals of medical care from curative to palliative care. The American Society of Clinical Oncologists (ASCO) considers hospice to be the optimal system of care for patients with cancer who are dying.This research evaluates use of the MHB among patients with cancer using the Surveillance, Epidemiology and End Results (SEER)-Medicare linked database. We use novel methodologies and data fields which have only recently become available to understand whether these patients are using the MHB as expected given its design. The Peters-Belson method is used to understand the disparity in hospice use between blacks and whites over time in patients with terminal cancer diagnoses (pancreatic, lung and advanced gastric cancers). We find that while use of hospice has grown for both groups, the observed disparity has increased from 1992 to 2008 while the difference between the observed and expected disparity (based on differences in population factors between the groups) has increased over time from <-1% to 33%. We also find that patients with lung cancer who use no cancer directed treatment use hospice at the same rate as patients who use three or more cancer directed treatments (adjusted odds ratio (OR) of 0.892 (95% CI: 0.775-1.026)). Patients who use two or more treatments are significantly less likely than patients with three or more treatments to use hospice (OR=0.838, 95% CI: 0.728-0.965). Finally, we find that 30% of hospice patients with cancer do not die at home, despite the home-based design of the benefit. Almost half of hospice users who died in the hospital had a total length of stay of 3 days or fewer, and two-thirds had a length of stay less than 1 week, suggesting a shift to the hospice payment system without time to benefit from the system of care.Our results demonstrate the continuing importance of monitoring and investigating disparities in hospice use, expanding access to palliative care for patients who use cancer directed treatment, and reforming payment incentives for hospice care provided in institutions.
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    Reconstructing research: exploring the intersections of race, gender and socioeconomic status in medical education
    (2014-01) Hardeman, Rachel Renee
    This dissertation is based on the notion that understanding the early years of medical training is vital to gaining perspective on the socialization of future physicians. I find that the medical school socialization process is a complex and multidimensional one. Studies of this process over the years have failed to explore how the role of diverse social positions fits into the process. It is the premise of this dissertation that the medical school socialization process is likely one in which certain students (e.g. White, male, upper-middle class) will thrive while its effect on non-whites, women and lower income groups may be less beneficial. This, combined with the fact that members of marginalized social positions may begin their medical training with different resources and vulnerabilities than their counterparts who are part of the majority suggests that medical school socialization processes has the potential to be harmful to certain groups. In this dissertation, I use social position (race, gender, SES) to explore and understand three aspects of the medical school socialization process--psychological well-being, identity and attitudes towards patient care. I believe that these are three important elements that can have a profound impact on the experience of medical trainees and ultimately the type of physicians they will become. All analyses come from the Medical Student CHANGES Study. The first manuscript assesses whether there are race and gender disparities in mental and physical health in a national sample of first-year medical students; if there are race and gender differences in factors known to increase resiliency to stress (e.g. coping, mastery, social support, self esteem); and how race and gender intersect to impact depression and anxiety. The second manuscript examines if racial identity is a protective factor for depression and anxiety among African American first year medical students. It also explores the interaction between gender and racial identity and SES and racial identity and their impact on depressive and anxiety symptoms. The third manuscript explores the relationship between socio-demographic characteristics (gender, race and SES) and attitudes towards patient-centered care among African American and White first year medical students.In manuscript one, African American and female students were found to be at greater risk for depression and anxiety. African American students were also at greater risk of lacking psychosocial resources such as social support. In manuscript two, findings suggested that a high racial identity is not protective of depression and anxiety. Instead, I found that students with high racial identity were at greater risk for depression and anxiety. In manuscript three, I found that female gender and SES (low-middle income) were significant predictors of positive attitudes towards patient-centered care. Conclusions:This dissertation provides insight into the potential impact of the medical socialization process on students from marginalized social positions, more specifically; how the process impacts their psychological well-being, identity and attitudes towards patient care of students. The findings of this dissertation have practical implications for medical education, clinical care and health disparities.