John Hsu

Publications of John Hsu

• COBRA ARRA Subsidies: Was the Carrot Enticing Enough?

  Authors: Ilana Graetz, Mary Reed, Vicki Fung, William H Dow, Joseph P Newhouse, John Hsu

  Health services research. 04/2012;

  OBJECTIVE: To help preserve continuity of health insurance coverage during the recent recession, the American Recovery and Reinvestment Act provided a 65 percent Consolidated Omnibus BudgetOBJECTIVE: To help preserve continuity of health insurance coverage during the recent recession, the American Recovery and Reinvestment Act provided a 65 percent Consolidated Omnibus Budget Reconciliation Act (COBRA) premium subsidy for workers laid off in 2008-2010. We examined COBRA enrollment levels with the subsidy and the health, access, and financial consequences of enrollment decisions. STUDY DESIGN/DATA COLLECTION: Telephone interviews linked with health system databases for 561 respondents who were laid off in 2009 and eligible for the COBRA subsidy (80 percent response rate). PRINCIPAL FINDINGS: Overall, 38 percent reported enrolling in COBRA and 54 percent reported having some gaps in insurance coverage since being laid off. After adjustments, we found that those who had higher cost-sharing, who had higher incomes, were older, or were sicker were more likely to enroll in COBRA. COBRA enrollees less frequently reported access problems or that their health suffered because of poor access, but they reported greater financial stress due to health care spending. CONCLUSION: Despite the substantial subsidy, a majority of eligible individuals did not enroll in COBRA, and many reported insurance coverage gaps. Nonenrollees reported more access problems and that their health worsened. Without a mandate, subsidies may need to be widely publicized and larger to encourage health insurance enrollment among individuals who suffer a negative income shock.

• Consumer-directed Health Plans With Health Savings Accounts: Whose Skin is in the Game and How do Costs Affect Care Seeking?

  Authors: Mary Reed, Ilana Graetz, Huihui Wang, Vicki Fung, Joseph P Newhouse, John Hsu

  Medical care. 02/2012;

  BACKGROUND:: Employers are increasingly offering high-deductible health insurance plans with associated health savings accounts (HSAs), but there is limited information on account contributions orBACKGROUND:: Employers are increasingly offering high-deductible health insurance plans with associated health savings accounts (HSAs), but there is limited information on account contributions or effects on patient care seeking. OBJECTIVE:: We examined HSA contributions and their source, patient-reported effects of costs on care seeking, and reports of financial burden. RESEARCH DESIGN:: We conducted telephone interviews with 488 adult members of small group of employer-sponsored HSA-eligible plans within an integrated delivery system. PRINCIPAL FINDINGS:: HSA contribution sources and amounts varied with 32% receiving an employer contribution and also making their own employee contribution, 35% only receiving an employer contribution (no employee contribution), 19% only making their own contribution (no employer contribution), and 14% with no HSA contribution from either source. After adjustment for respondent characteristics, those who made their own HSA contributions in addition to their employer's contribution were significantly more likely to report that costs affected their care-seeking behavior, compared with those with only employer contributions (39% vs. 31% for emergency department and 60% vs. 49% for office visits, all P<0.05). Respondents who contributed to their HSA or who paid out-of-pocket for care were significantly more likely to report financial burdens than those with only employer contributions (P<0.05). CONCLUSIONS:: The majority of consumers receive employer contributions to their HSA, but few have fully funded accounts. Those with only an employer contribution reported fewer changes in their care-seeking behavior and were less likely to report experiencing financial burdens.

• Something is amiss in Denmark: a comparison of preventable hospitalisations and readmissions for chronic medical conditions in the Danish Healthcare system and Kaiser Permanente.

  Authors: Michaela Schiøtz, Mary Price, Anne Frølich, Jes Søgaard, Jette K Kristensen, Allan Krasnik, Murray N Ross, Finn Diderichsen, John Hsu

  BMC health services research. 12/2011; 11:347.

  As many other European healthcare systems the Danish healthcare system (DHS) has targeted chronic condition care in its reform efforts. Benchmarking is a valuable tool to identify areas forAs many other European healthcare systems the Danish healthcare system (DHS) has targeted chronic condition care in its reform efforts. Benchmarking is a valuable tool to identify areas for improvement. Prior work indicates that chronic care coordination is poor in the DHS, especially in comparison with care in Kaiser Permanente (KP), an integrated delivery system based in the United States. We investigated population rates of hospitalisation and readmission rates for ambulatory care sensitive, chronic medical conditions in the two systems. Using a historical cohort study design, age and gender adjusted population rates of hospitalisations for angina, heart failure, chronic obstructive pulmonary disease, and hypertension, plus rates of 30-day readmission and mortality were investigated for all individuals aged 65+ in the DHS and KP. DHS had substantially higher rates of hospitalisations, readmissions, and mean lengths of stay per hospitalisation, than KP had. For example, the adjusted angina hospitalisation rates in 2007 for the DHS and KP respectively were 1.01/100 persons (95%CI: 0.98-1.03) vs. 0.11/100 persons (95%CI: 0.10-0.13/100 persons); 21.6% vs. 9.9% readmission within 30 days (OR = 2.53; 95% CI: 1.84-3.47); and mean length of stay was 2.52 vs. 1.80 hospital days. Mortality up through 30 days post-discharge was not consistently different in the two systems. There are substantial differences between the DHS and KP in the rates of preventable hospitalisations and subsequent readmissions associated with chronic conditions, which suggest much opportunity for improvement within the Danish healthcare system. Reductions in hospitalisations also could improve patient welfare and free considerable resources for use towards preventing disease exacerbations. These conclusions may also apply for similar public systems such as the US Medicare system, the NHS and other systems striving to improve the integration of care for persons with chronic conditions.

• Does primary stroke center certification change ED diagnosis, utilization, and disposition of patients with acute stroke?

  Authors: Dustin W Ballard, Mary E Reed, Jie Huang, Barbara J Kramer, John Hsu, Uli Chettipally

  The American journal of emergency medicine. 11/2011;

  BACKGROUND AND PURPOSE: We examined the impact of primary stroke center (PSC) certification on emergency department (ED) use and outcomes within an integrated delivery system in which EDs underwentBACKGROUND AND PURPOSE: We examined the impact of primary stroke center (PSC) certification on emergency department (ED) use and outcomes within an integrated delivery system in which EDs underwent staggered certification. METHODS: A retrospective cohort study of 30 461 patients seen in 17 integrated delivery system EDs with a primary diagnosis of transient ischemic attack (TIA), intracranial hemorrhage, or ischemic stroke between 2005 and 2008 was conducted. We compared ED stroke patient visits across hospitals for (1) temporal trends and (2) pre- and post-PSC certification-using logistic and linear regression models to adjust for comorbidities, patient characteristics, and calendar time, to examine major outcomes (ED throughput time, hospital admission, radiographic imaging utilization and throughput, and mortality) across certification stages. RESULTS: There were 15 687 precertification ED visits and 11 040 postcertification visits. Primary stroke center certification was associated with significant changes in care processes associated with PSC certification process, including (1) ED throughput for patients with intracranial hemorrhage (55 minutes faster), (2) increased utilization of cranial magnetic resonance imaging for patients with ischemic stroke (odds ratio, 1.88; 95% confidence interval, 1.36-2.60), and (3) decrease in time to radiographic imaging for most modalities, including cranial computed tomography done within 6 hours of ED arrival (TIA: 12 minutes faster, ischemic stroke: 11 minutes faster), magnetic resonance imaging for patients with ischemic stroke (197 minutes faster), and carotid Doppler sonography for TIA patients (138 minutes faster). There were no significant changes in survival. CONCLUSIONS: Stroke center certification was associated with significant changes in ED admission and radiographic utilization patterns, without measurable improvements in survival.

• Timely detection of localized excess influenza activity in Northern California across patient care, prescription, and laboratory data.

  Authors: Sharon K Greene, Martin Kulldorff, Jie Huang, Richard J Brand, Kenneth P Kleinman, John Hsu, Richard Platt

  Statistics in medicine. 02/2011; 30(5):549-59.

  Timely detection of clusters of localized influenza activity in excess of background seasonal levels could improve situational awareness for public health officials and health systems. However, noTimely detection of clusters of localized influenza activity in excess of background seasonal levels could improve situational awareness for public health officials and health systems. However, no single data type may capture influenza activity with optimal sensitivity, specificity, and timeliness, and it is unknown which data types could be most useful for surveillance. We compared the performance of 10 types of electronic clinical data for timely detection of influenza clusters throughout the 2007/08 influenza season in northern California. Kaiser Permanente Northern California generated zip code-specific daily episode counts for: influenza-like illness (ILI) diagnoses in ambulatory care (AC) and emergency departments (ED), both with and without regard to fever; hospital admissions and discharges for pneumonia and influenza; antiviral drugs dispensed (Rx); influenza laboratory tests ordered (Tests); and tests positive for influenza type A (FluA) and type B (FluB). Four credible events of localized excess illness were identified. Prospective surveillance was mimicked within each data stream using a space-time permutation scan statistic, analyzing only data available as of each day, to evaluate the ability and timeliness to detect the credible events. AC without fever and Tests signaled during all four events and, along with Rx, had the most timely signals. FluA had less timely signals. ED, hospitalizations, and FluB did not signal reliably. When fever was included in the ILI definition, signals were either delayed or missed. Although limited to one health plan, location, and year, these results can inform the choice of data streams for public health surveillance of influenza.

• Using medicare data for comparative effectiveness research: opportunities and challenges.

  Authors: Vicki Fung, Richard J Brand, Joseph P Newhouse, John Hsu

  The American journal of managed care. 01/2011; 17(7):488-96.

  With the introduction of Part D drug benefits, Medicare began to collect information on diagnoses, treatments, and clinical events for millions of beneficiaries. These data are a promising resourceWith the introduction of Part D drug benefits, Medicare began to collect information on diagnoses, treatments, and clinical events for millions of beneficiaries. These data are a promising resource for comparative effectiveness research (CER) on treatments, benefit designs, and delivery systems. To explore the data available for researchers and approaches that could be used to enhance the value of Medicare data for CER. CHALLENGES AND OPPORTUNITIES: Using currently available Medicare data for CER is challenging; as with all administrative data, it is not possible to capture every factor that contributes to prescribing decisions and patients are not randomly assigned to treatments. In addition, Part D plan selection and switching may influence treatment decisions and contribute to selection bias. Exploiting certain program aspects could address these limitations. For example, ongoing changes in Medicare or plan policies and the random assignment of beneficiaries with Part D low-income subsidies into plans with different formularies could yield natural experiments. Refining policies for time to data release, provision of additional data elements, and linkage with more beneficiary level information would improve the value and usability of these data. Improving the transparency and reproducibility of findings, and potential open access for qualified stakeholders are also important policy considerations. Data needs must be reconciled with current policies and goals. Medicare data provide a rich resource for CER. Leveraging existing program elements, combined with some administrative changes in data availability, could create large data sets for evaluating treatment patterns, spending, and coverage decisions.

• Fixing flaws in Medicare drug coverage that prompt insurers to avoid low-income patients.

  Authors: John Hsu, Vicki Fung, Jie Huang, Mary Price, Richard Brand, Rita Hui, Bruce Fireman, William H Dow, John Bertko, Joseph P Newhouse

  Health affairs (Project Hope). 10/2010; 29(12):2335-43.

  Since 2006 numerous insurers have stopped serving the low-income segment of the Medicare Part D program, forcing millions of beneficiaries to change prescription drug plans. Using data fromSince 2006 numerous insurers have stopped serving the low-income segment of the Medicare Part D program, forcing millions of beneficiaries to change prescription drug plans. Using data from participating plans, we found that Medicare payments do not sufficiently reimburse insurers for the relatively high medication use among this population, creating perverse incentives for plans to avoid this part of the Part D market. Plans can accomplish this by increasing their premiums for all beneficiaries to an amount above regional benchmarks. We demonstrate that improving the accuracy of Medicare's risk and subsidy adjustments could mitigate these perverse incentives.

• Generic-only drug coverage in the Medicare Part D gap and effect on medication cost-cutting behaviors for patients with diabetes mellitus: the translating research into action for diabetes study.

  Authors: O Kenrik Duru, Carol M Mangione, John Hsu, W Neil Steers, Elaine Quiter, Norman Turk, Susan L Ettner, Julie A Schmittdiel, Chien-Wen Tseng

  Journal of the American Geriatrics Society. 05/2010; 58(5):822-8.

  To examine the association between drug coverage during the Medicare Part D coverage gap and medication cost-cutting behaviors of beneficiaries with diabetes mellitus who use and do not useTo examine the association between drug coverage during the Medicare Part D coverage gap and medication cost-cutting behaviors of beneficiaries with diabetes mellitus who use and do not use insulin. The study was cross-sectional. A network-model health system. 2007 survey of Medicare Advantage Part D (MAPD) and Prescription Drug Plan (PDP) beneficiaries who entered the gap by October 2006 (N=1,468, 57% response rate). The primary predictor variable was no gap coverage versus generic-only gap coverage. Seven cost-cutting behaviors were examined as dependent variables, including cost-related nonadherence (CRN) to any medication. Covariates included race or ethnicity, education, health status, income, and comorbidities, as well as generic medication use in the first quarter. Logistic regression models were constructed using nonresponse weights to generate predicted percentages. In multivariate analyses, beneficiaries taking insulin were less likely to report CRN if they had generic-only gap coverage than if they had no gap coverage (16% vs 29%, P=.03). No differences in CRN according to type of gap coverage were seen between beneficiaries not taking insulin. Medicare beneficiaries using insulin are at high risk of CRN. Generic-only coverage during the gap is associated with an attenuated risk of CRN in insulin users, possibly because of savings on other, generic medications. Future research should evaluate CRN within alternative benefit designs covering selected brand name medications, such as insulin, during the gap.

• Falling into the coverage gap: Part D drug costs and adherence for Medicare Advantage prescription drug plan beneficiaries with diabetes.

  Authors: Vicki Fung, Carol M Mangione, Jie Huang, Norman Turk, Elaine S Quiter, Julie A Schmittdiel, John Hsu

  Health services research. 04/2010; 45(2):355-75.

  To compare drug costs and adherence among Medicare beneficiaries with the standard Part D coverage gap versus supplemental gap coverage in 2006. Pharmacy data from Medicare Advantage PrescriptionTo compare drug costs and adherence among Medicare beneficiaries with the standard Part D coverage gap versus supplemental gap coverage in 2006. Pharmacy data from Medicare Advantage Prescription Drug (MAPD) plans. Parallel analyses comparing beneficiaries aged 65+ with diabetes in an integrated MAPD with a gap versus no gap (n=28,780); and in a network-model MAPD with a gap versus generic-only coverage during the gap (n=14,984). Drug spending was 3 percent (95 percent confidence interval [CI]: 1-4 percent) and 4 percent (CI: 1-6 percent) lower among beneficiaries with a gap versus full or generic-only gap coverage, respectively. Out-of-pocket expenditures were 189 percent higher (CI: 185-193 percent) and adherence to three chronic drug classes was lower among those with a gap versus no gap (e.g., odds ratio=0.83, CI: 0.79-0.88, for oral diabetes drugs). Annual out-of-pocket spending was 14 percent higher (CI: 10-17 percent) for beneficiaries with a gap versus generic-only gap coverage, but levels of adherence were similar. Among Medicare beneficiaries with diabetes, having the Part D coverage gap resulted in lower total drug costs, but higher out-of-pocket spending and worse adherence compared with having no gap. Having generic-only coverage during the gap appeared to confer limited benefits compared with having no gap coverage.

• Is the Kaiser Permanente model superior in terms of clinical integration?: a comparative study of Kaiser Permanente, Northern California and the Danish healthcare system.

  Authors: Martin Strandberg-Larsen, Michaela L Schiøtz, Jeremy D Silver, Anne Frølich, John S Andersen, Ilana Graetz, Mary Reed, Jim Bellows, Allan Krasnik, Thomas Rundall, John Hsu

  BMC health services research. 04/2010; 10:91.

  Integration of medical care across clinicians and settings could enhance the quality of care for patients. To date, there is limited data on the levels of integration in practice. Our objective wasIntegration of medical care across clinicians and settings could enhance the quality of care for patients. To date, there is limited data on the levels of integration in practice. Our objective was to compare primary care clinicians' perceptions of clinical integration and three sub-aspects in two healthcare systems: Kaiser Permanente, Northern California (KPNC) and the Danish healthcare system (DHS). Further, we examined the associations between specific organizational factors and clinical integration within each system. Comparable questionnaires were sent to a random sample of primary care clinicians in KPNC (n = 1103) and general practitioners in DHS (n = 700). Data were analysed using multiple logistic regression models. More clinicians in KPNC perceived to be part of a clinical integrated environment than did general practitioners in the DHS (OR = 3.06, 95% CI: 2.28, 4.12). Further, more KPNC clinicians reported timeliness of information transfer (OR = 2.25, 95% CI: 1.62, 3.13), agreement on roles and responsibilities (OR = 1.79, 95% CI: 1.30, 2.47) and established coordination mechanisms in place to ensure effective handoffs (OR = 6.80, 95% CI: 4.60, 10.06). None of the considered organizational factors in the sub-country analysis explained a substantial proportion of the variation in clinical integration. More primary care clinicians in KPNC reported clinical integration than did general practitioners in the DHS. Focused measures of clinical integration are needed to develop the field of clinical integration and to create the scientific foundation to guide managers searching for evidence based approaches.

• PS1-32: Doctor's Role in Their Patient's Healing: Practices of the Highest Performing Physicians by Patient Survey.

  Authors: Elizabeth Sutherland, Nancy Vuckovic, John Hsu, Karen Tallman, Richard Frankel, Terry Stein, Sue Hee Sung

  Clinical medicine & research. 03/2010; 8(1):47.

  Background: The MD Patient Communication Study aims were to improve the best practice communication behaviors of physicians during outpatient clinic visits and to collect physician perspectives ofBackground: The MD Patient Communication Study aims were to improve the best practice communication behaviors of physicians during outpatient clinic visits and to collect physician perspectives of communication behaviors. Researchers have consistently found the top predictors of overall patient satisfaction are quality of the physician-patient relationship and contributing communications. There is limited understanding however, of the range of specific behaviors in the interaction associated with positive and negative patient perceptions and reactions. Methods: In phase 1, we conducted a naturalistic, observational study of 55 Kaiser Permanente Primary Care physician-patient visits using videotape recordings, and incorporating patient and physician reactions to the tape. The physicians, who practiced in Los Angeles and Honolulu, spanned the three strata of high, medium, and low historical patient satisfaction scores. In phase 2, a standardized six-question set was posed in semi-structured, 60-minute interviews to 77 of the highest-performing physicians on this patient survey, including 20 of the highest performers (top 5%) from the LA and Honolulu groups and 42 and 15, respectively, of the highest performing physicians in Portland and Oakland. These interviews were audio taped with permission, transcribed and coded for patterns. Results: This abstract addresses the 4th question: What role do you feel you play in your patients' healing? Do you think you, as a doctor, contribute to your patients' healing through non-technical, non-physical, or non-scientific ways? All physicians agreed but varied in their role. Representative quotes: Giving people the confidence to go through something. People feel better coming in and seeing/talking to you. People realizing they have the power to heal themselves their involvement is essential. Our relationship: Interpersonal connection is so powerful. The art of medicine is the art of healing. These narratives provide deep, coherent learning about physicians' role in healing: relationship, education, empowerment, emotion, personal connection, hope. Conclusions: With primary care in crisis nationally, and specialists increasingly procedure-focused, understanding physicians' role in patients' healing, especially as it creates high patient satisfaction, is of great importance to sustaining the highest quality medical care and service.

• Meaningful variation in performance: what does variation in quality tell us about improving quality?

  Authors: Joseph V Selby, Julie A Schmittdiel, Janelle Lee, Vicki Fung, Sean Thomas, Nancy Smider, Francis J Crosson, John Hsu, Bruce Fireman

  Medical care. 02/2010; 48(2):133-9.

  Variance reduction is sometimes considered as a goal of clinical quality improvement. Variance among physicians, hospitals, or health plans has been evaluated as the proportion of total variance (orVariance reduction is sometimes considered as a goal of clinical quality improvement. Variance among physicians, hospitals, or health plans has been evaluated as the proportion of total variance (or intraclass correlation, ICC) in a quality measure; low ICCs have been interpreted to indicate low potential for quality improvement at that level. However, the absolute amount of variation, expressed in clinically meaningful units, is less frequently reported. Moreover, changes in variance components have not been studied as quality improves. To examine changes in variance components at primary care physician and medical facility levels as performance improved for 4 quality indicators: systolic blood pressure levels in hypertension; low-density lipoprotein-cholesterol levels in hyperlipidemia; patient-reported care experience scores after primary care visits; and mammography screening rates. Adult members (n = 62,596-410,976) of Kaiser Permanente in Northern California, served by more than 1000 primary care physicians in 35 facilities, from 2001 to 2006. Multilevel linear and logistic regression to examine the interphysician and interfacility variances in 4 quality indicators over 6 years, after case-mix adjustment. ICCs were low for all 4 indicators at both levels (0.0021-0.086). Nevertheless, variances at both levels were statistically and clinically significant. For systolic blood pressure and the care experience score, interfacility and interphysician variance as well as ICCs decreased further as quality improved; declines were greater at the facility level. For low-density lipoprotein-cholesterol, variability at both levels increased with quality improvement; and for screening mammography, small declines were not statistically significant for either physicians or facilities. Low proportions of variance do not predict low potential for quality improvement. Despite low ICCs for facilities, quality improvement efforts directed primarily at facilities improved quality for all 4 indicators.

• Meaningful variation in performance: a systematic literature review.

  Authors: Vicki Fung, Julie A Schmittdiel, Bruce Fireman, Aabed Meer, Sean Thomas, Nancy Smider, John Hsu, Joseph V Selby

  Medical care. 02/2010; 48(2):140-8.

  Recommendations for directing quality improvement initiatives at particular levels (eg, patients, physicians, provider groups) have been made on the basis of empirical components of variance analysesRecommendations for directing quality improvement initiatives at particular levels (eg, patients, physicians, provider groups) have been made on the basis of empirical components of variance analyses of performance. To review the literature on use of multilevel analyses of variability in quality. Systematic literature review of English-language articles (n = 39) examining variability and reliability of performance measures in Medline using PubMed (1949-November 2008). Variation was most commonly assessed at facility (eg, hospital, medical center) (n = 19) and physician (n = 18) levels; most articles reported variability as the proportion of total variation attributable to given levels (n = 22). Proportions of variability explained by aggregated levels were generally low (eg, <19% for physicians), and numerous authors concluded that the proportion of variability at a specific level did not justify targeting quality interventions to that level. Few articles based their recommendations on absolute differences among physicians, hospitals, or other levels. Seven of 12 articles that assessed reliability found that reliability was poor at the physician or hospital level due to low proportional variability and small sample sizes per unit, and cautioned that public reporting or incentives based on these measures may be inappropriate. The proportion of variability at levels higher than patients is often found to be "low." Although low proportional variability may lead to poor measurement reliability, a number of authors further suggested that it also indicates a lack of potential for quality improvement. Few studies provided additional information to help determine whether variation was, nevertheless, clinically meaningful.

• Is the Kaiser Permanente model superior in terms of clinical integration?: a comparative study of Kaiser Permanente, Northern California and the Danish healthcare system

  Authors: Martin Strandberg-Larsen, Michaela Schiøtz, Jeremy Silver, Anne Frølich, John Andersen, Ilana Graetz, Mary Reed, Jim Bellows, Allan Krasnik, Thomas Rundall, John Hsu

  BMC Health Services Research. 01/2010;

  Abstract Background Integration of medical care across clinicians and settings could enhance the quality of care for patients. To date, there is limited data on the levels of integration inAbstract Background Integration of medical care across clinicians and settings could enhance the quality of care for patients. To date, there is limited data on the levels of integration in practice. Our objective was to compare primary care clinicians' perceptions of clinical integration and three sub-aspects in two healthcare systems: Kaiser Permanente, Northern California (KPNC) and the Danish healthcare system (DHS). Further, we examined the associations between specific organizational factors and clinical integration within each system. Methods Comparable questionnaires were sent to a random sample of primary care clinicians in KPNC (n = 1103) and general practitioners in DHS (n = 700). Data were analysed using multiple logistic regression models. Results More clinicians in KPNC perceived to be part of a clinical integrated environment than did general practitioners in the DHS (OR = 3.06, 95% CI: 2.28, 4.12). Further, more KPNC clinicians reported timeliness of information transfer (OR = 2.25, 95% CI: 1.62, 3.13), agreement on roles and responsibilities (OR = 1.79, 95% CI: 1.30, 2.47) and established coordination mechanisms in place to ensure effective handoffs (OR = 6.80, 95% CI: 4.60, 10.06). None of the considered organizational factors in the sub-country analysis explained a substantial proportion of the variation in clinical integration. Conclusions More primary care clinicians in KPNC reported clinical integration than did general practitioners in the DHS. Focused measures of clinical integration are needed to develop the field of clinical integration and to create the scientific foundation to guide managers searching for evidence based approaches.

• Patient-provider communication regarding drug costsin Medicare Part D beneficiaries with diabetes: a TRIAD Study

  Authors: Julie Schmittdiel, Neil Steers, Duru O Kenrik, Susan Ettner, Arleen Brown, Vicki Fung, John Hsu, Elaine Quiter, Chien-Wen Tseng, Carol Mangione

  BMC Health Services Research. 01/2010;

  Abstract Background Little is known about drug cost communications of Medicare Part D beneficiaries with chronic conditions such as diabetes. The purpose of this study is to assess Medicare Part DAbstract Background Little is known about drug cost communications of Medicare Part D beneficiaries with chronic conditions such as diabetes. The purpose of this study is to assess Medicare Part D beneficiaries with diabetes' levels of communication with physicians regarding prescription drug costs; the perceived importance of these communications; levels of prescription drug switching due to cost; and self-reported cost-related medication non-adherence. Methods Data were obtained from a cross-sectional survey (58% response rate) of 1,458 Medicare beneficiaries with diabetes who entered the coverage gap in 2006; adjusted percentages of patients with communication issues were obtained from multivariate regression analyses adjusting for patient demographics and clinical characteristics. Results Fewer than half of patients reported discussing the cost of medications with their physicians, while over 75% reported that such communications were important. Forty-eight percent reported their physician had switched to a less expensive medication due to costs. Minorities, females, and older adults had significantly lower levels of communication with their physicians regarding drug costs than white, male, and younger patients respectively. Patients with < $25 K annual household income were more likely than higher income patients to have talked about prescription drug costs with doctors, and to report cost-related non-adherence (27% vs. 17%, p < .001). Conclusions Medicare Part D beneficiaries with diabetes who entered the coverage gap have low levels of communication with physicians about drug costs, despite the high perceived importance of such communication. Understanding patient and plan-level characteristics differences in communication and use of cost-cutting strategies can inform interventions to help patients manage prescription drug costs.

• Patient-provider communication regarding drug costs in Medicare Part D beneficiaries with diabetes: a TRIAD Study.

  Authors: Julie A Schmittdiel, Neil Steers, O Kenrik Duru, Susan L Ettner, Arleen F Brown, Vicki Fung, John Hsu, Elaine Quiter, Chien-Wen Tseng, Carol M Mangione

  BMC health services research. 01/2010; 10:164.

  Little is known about drug cost communications of Medicare Part D beneficiaries with chronic conditions such as diabetes. The purpose of this study is to assess Medicare Part D beneficiaries withLittle is known about drug cost communications of Medicare Part D beneficiaries with chronic conditions such as diabetes. The purpose of this study is to assess Medicare Part D beneficiaries with diabetes' levels of communication with physicians regarding prescription drug costs; the perceived importance of these communications; levels of prescription drug switching due to cost; and self-reported cost-related medication non-adherence. Data were obtained from a cross-sectional survey (58% response rate) of 1,458 Medicare beneficiaries with diabetes who entered the coverage gap in 2006; adjusted percentages of patients with communication issues were obtained from multivariate regression analyses adjusting for patient demographics and clinical characteristics. Fewer than half of patients reported discussing the cost of medications with their physicians, while over 75% reported that such communications were important. Forty-eight percent reported their physician had switched to a less expensive medication due to costs. Minorities, females, and older adults had significantly lower levels of communication with their physicians regarding drug costs than white, male, and younger patients respectively. Patients with < $25 K annual household income were more likely than higher income patients to have talked about prescription drug costs with doctors, and to report cost-related non-adherence (27% vs. 17%, p < .001). Medicare Part D beneficiaries with diabetes who entered the coverage gap have low levels of communication with physicians about drug costs, despite the high perceived importance of such communication. Understanding patient and plan-level characteristics differences in communication and use of cost-cutting strategies can inform interventions to help patients manage prescription drug costs.

• Validation of an Algorithm for Categorizing the Severity of Hospital Emergency Department Visits.

  Authors: Dustin Ballard, Mary Price, Vicki Fung, Richard Brand, Mary Reed, Bruce Fireman, Joseph Newhouse, Joseph Selby, John Hsu

  Medical care. 11/2009;

  BACKGROUND:: Differentiating between appropriate and inappropriate resource use represents a critical challenge in health services research. The New York University Emergency Department (NYU ED)BACKGROUND:: Differentiating between appropriate and inappropriate resource use represents a critical challenge in health services research. The New York University Emergency Department (NYU ED) visit severity algorithm attempts to classify visits to the ED based on diagnosis, but it has not been formally validated. OBJECTIVE:: To assess the validity of the NYU algorithm. RESEARCH DESIGN:: A longitudinal study in a single integrated delivery system from January 1999 to December 2001. SUBJECTS:: A total of 2,257,445 commercial and 261,091 Medicare members of an integrated delivery system. MEASURES:: ED visits were classified as emergent, nonemergent, or intermediate severity, using the NYU ED algorithm. We examined the relationship between visit-severity and the probability of future hospitalizations and death using a logistic model with a general estimating equation approach. RESULTS:: Among commercially insured subjects, ED visits categorized as emergent were significantly more likely to result in a hospitalization within 1-day (odds ratio = 3.37, 95% CI: 3.31-3.44) or death within 30-days (odds ratio = 2.81, 95% CI: 2.62-3.00) than visits categorized as nonemergent. We found similar results in Medicare patients and in sensitivity analyses using different probability thresholds. ED overuse for nonemergent conditions was not related to socio-economic status or insurance type. CONCLUSIONS:: The evidence presented supports the validity of the NYU ED visit severity algorithm for differentiating ED visits based on need for hospitalization and/or mortality risk; therefore, it can contribute to evidence-based policies aimed at reducing the use of the ED for nonemergencies.

• Evolving health information technology and the timely availability of visit diagnoses from ambulatory visits: A natural experiment in an integrated delivery system.

  Authors: Naomi Bardach, Jie Huang, Richard Brand, John Hsu

  BMC medical informatics and decision making. 08/2009; 9(1):35.

  ABSTRACT: BACKGROUND: Health information technology (HIT) may improve health care quality and outcomes, in part by making information available in a timelier manner. However, there are few studiesABSTRACT: BACKGROUND: Health information technology (HIT) may improve health care quality and outcomes, in part by making information available in a timelier manner. However, there are few studies documenting the changes in timely availability of data with the use of a sophisticated electronic medical record (EMR), nor a description of how the timely availability of data might differ with different types of EMRs. We hypothesized that timely availability of data would improve with use of increasingly sophisticated forms of HIT. METHODS: We used an historical observation design (2004-2006) using electronic data from office visits in an integrated delivery system with three types of HIT: Basic, Intermediate, and Advanced. We calculated the monthly percentage of visits using the various types of HIT for entry of visit diagnoses into the delivery system's electronic database, and the time between the visit and the availability of the visit diagnoses in the database. RESULTS: In January 2004, when only Basic HIT was available, 10% of office visits had diagnoses entered on the same day as the visit and 90% within a week; 85% of office visits used paper forms for recording visit diagnoses, 16% used Basic at that time. By December 2006, 95% of all office visits had diagnoses available on the same day as the visit, when 98% of office visits used some form of HIT for entry of visit diagnoses (Advanced HIT for 67% of visits). CONCLUSIONS: Use of HIT systems is associated with dramatic increases in the timely availability of diagnostic information, though the effects may vary by sophistication of HIT system. Timely clinical data are critical for real-time population surveillance, and valuable for routine clinical care.

• A Retrospective Analysis of Health Systems in Denmark and Kaiser Permanente.

  Authors: Anne Frolich, Michaela Schiotz, Martin Strandberg-Larsen, John Hsu, Allan Krasnik, Finn Diderichsen, Jim Bellows, Jes Sogaard, Karen White

  BMC health services research. 01/2009; 8(1):252.

  ABSTRACT: BACKGROUND: To inform Danish health care reform efforts, we compared health care system inputs and performance and assessed the usefulness of these comparisons for informing policy.ABSTRACT: BACKGROUND: To inform Danish health care reform efforts, we compared health care system inputs and performance and assessed the usefulness of these comparisons for informing policy. METHODS: Retrospective analysis of secondary data in the Danish Health Care System (DHS) with 5.3 million citizens and the Kaiser Permanente integrated delivery system (KP) with 6.1 million members in California. We used secondary data to compare population characteristics, professional staff, delivery structure, utilisation and quality measures, and direct costs. We adjusted the cost data to increase comparability. RESULTS: A higher percentage of KP patients had chronic conditions than did patients in the DHS: 6.3% vs. 2.8% (diabetes) and 19% vs. 8.5% (hypertension), respectively. KP had fewer total physicians and staff compared to DHS, with134 physicians/100,000 individuals versus 311 physicians/100,000 individuals. KP physicians are salaried employees; in contrast, DHS primary care physicians own and run their practices, remunerated by a mixture of capitation and fee-for-service payments, while most specialists are employed at largely public hospitals. Hospitalisation rates and lengths of stay (LOS) were lower in KP, with mean acute admission LOS of 3.9 days versus 6.0 days in the DHS, and, for stroke admissions, 4.2 days versus 23 days. Screening rates also differed: 93% of KP members with diabetes received retinal screening; only 46% of patients in the DHS with diabetes did. Per capita operating expenditures were PPP$1,951 (KP) and PPP $1,845 (DHS). CONCLUSIONS: Compared to the DHS, KP had a population with more documented disease and higher operating costs, while employing fewer physicians and resources like hospital beds. Observed quality measures also appear higher in KP. However, simple comparisons between health care systems may have limited value without detailed information on mechanisms underlying differences or identifying translatable care improvement strategies. We suggest items for more in-depth analyses that could improve the interpretability of findings and help identify lessons that can be transferred.

• Comparative Effectiveness of Different {beta}-Adrenergic Antagonists on Mortality Among Adults With Heart Failure in Clinical Practice.

  Authors: Alan S Go, Jingrong Yang, Jerry H Gurwitz, John Hsu, Kimberly Lane, Richard Platt

  Archives of internal medicine. 01/2009; 168(22):2415-2421.

  BACKGROUND: Randomized trials have demonstrated the efficacy of selected beta-blockers in systolic heart failure, but the comparative effectiveness of different beta-blockers in practice is poorlyBACKGROUND: Randomized trials have demonstrated the efficacy of selected beta-blockers in systolic heart failure, but the comparative effectiveness of different beta-blockers in practice is poorly understood. METHODS: We compared mortality associated with different beta-blockers following hospitalization for heart failure between 2001 and 2003. Longitudinal exposure to beta-blockers was ascertained from pharmacy databases. Patient characteristics and other medication use were identified from administrative, hospitalization, outpatient, and pharmacy databases. Death was identified from administrative, state mortality, and Social Security Administration databases. Multivariate Cox regression was used to examine the association between different beta-blockers and death. RESULTS: Among 11 326 adults surviving a hospitalization for heart failure, 7976 received beta-blockers (atenolol, 38.5%; metoprolol tartrate, 43.2%; carvedilol, 11.6%; and other, 6.7%) during follow-up. The rate (per 100 person-years) of death during the 12 months after discharge varied by exposure and type of beta-blocker (atenolol, 20.1; metoprolol tartrate, 22.8; carvedilol, 17.7; and no beta-blockers, 37.0). After adjustment for confounders and the propensity to receive carvedilol, the risk of death compared with atenolol was higher for metoprolol tartrate (adjusted hazard ratio [HR], 1.16; 95% confidence interval [CI], 1.01-1.34) and no beta-blockers (HR, 1.63; 95% CI, 1.44-1.84) but was not significantly different for carvedilol (HR, 1.16; 95% CI, 0.92-1.44). CONCLUSIONS: Compared with atenolol, the adjusted risks of death were slightly higher with shorter-acting metoprolol tartrate but did not significantly differ for carvedilol in adults with heart failure. Our results should be interpreted cautiously and they suggest the need for randomized trials within real-world settings comparing a broader spectrum of beta-blockers for heart failure.