Search

To complement the current process measures for treating patients with heart attacks and with heart failure, which target gaps in quality but do not capture patient outcomes, the Centers for Medicare and Medicaid Services (CMS) has proposed the public reporting of hospital-level thirty-day mortality for these conditions in 2007. We present the case for including measurements of outcomes in the assessment of hospital performance, focusing on the care of patients with heart attacks and with heart failure. Recent developments in the methodology and standards for outcomes measurement have laid the groundwork for incorporating outcomes into performance monitoring efforts for these conditions. [ABSTRACT FROM AUTHOR]

Objective: To examine whether availability of cardiac services at the admitting hospital affects case-selection for angiography and one-year survival following angiography, within groups of patients who have similar clinical need for angiography according to published criteria.Study Setting: Elderly Medicare beneficiaries (37,788) discharged with a diagnosis of acute myocardial infarction (AMI) from hospitals in seven U.S. states between February 1994 and July 1995. We focused on patients who were eligible to receive angiography 12 or more hours after symptom onset.Data Collection: Data were abstracted from patient's medical records, Medicare National Claims Standard Analytic Files, Health Care Financing Administration (HCFA) Provider of Service File and Health Insurance Master File.Methods: Admitting hospitals were classified as offering no cardiac services, angiography only, or revascularization. Case-selection differences across these three types of hospitals were examined by comparing relative risk of receiving angiography for various patient and hospital characteristics. Relative differences in one-year survival rate, comparing patients who received angiography to those who did not, were estimated within each hospital type and clinical need category (necessary, appropriate, or uncertain) after matching on propensity to receive angiography.Principal Findings: Compared to patients for whom angiography was deemed necessary, the relative risk of receiving angiography among those for whom it was deemed of uncertain benefit was 0.58, 0.79, and 0.92 (p-value of homogeneity test < 0.001) at hospitals offering no cardiac services, angiography only, and revascularization, respectively. There was no significant difference in survival following angiography across hospital types, overall as well as within clinical need categories.Conclusions: Despite increased case selection at hospitals with on-site cardiac services, there was no evidence of increase in the survival rate associated with angiography use at these hospitals. [ABSTRACT FROM AUTHOR]

Objective: To develop a prediction model of death within 30 days of hospital admission for Medicare patients with acute myocardial infarction that would permit use of risk-adjusted mortality rates as hospital quality measures.Design: Retrospective cohort study using data created from medical charts and administrative files.Setting: All acute care hospitals in Alabama, Connecticut, Iowa, or Wisconsin.Patients: A cohort of 14,581 patients with acute myocardial infarction covered by Medicare in 1993.Results: The unadjusted 30-day mortality rate was 21%, ranging from 18% in Connecticut to 23% in Alabama. The 4 largest contributors to variability in mortality rates were mean arterial pressure, age, respiratory rate, and serum urea nitrogen level. The area under the receiver operator characteristic curve was 0.79 in a developmental sample of 10 936 patients and 0.78 in a validation sample of 3645 patients. Based on admission variables, we were able to explain 27% of the variability in 30-day mortality rates. During the index admission, aspirin, beta-blockers, angiotensin-converting enzyme inhibitors, and thrombolytic agents were used in 72%, 39%, 32%, and 15% of patients, respectively. Explained variation increased by 6 percentage points to 33% when drug therapies and revascularization procedures performed during the index admission were added to the model predictors.Conclusions: Short-term mortality remains high for elderly patients with acute myocardial infarction, and a large percentage of variation remains unexplained after controlling for admission severity. Part of the unexplained variability can be explained by the location of the admitting hospital; some of the remaining unexplained variation may reflect differences in quality of care or unmeasured differences in disease severity. Researchers should develop quality indicators based on process measures for acute myocardial infarction and should incorporate these measures into mortality models to determine whether quality accounts for variation in 30-day mortality rates beyond that explained by clinical status at admission. [ABSTRACT FROM AUTHOR]

The value of mental health services is regularly questioned in health policy debates. Although all health services are being asked to demonstrate their value, there are special concerns about this set of services because spending on mental health care has grown markedly over the past twenty years. We propose a method for using administrative data to develop a comprehensive assessment of value for mental health care, which we call systems cost-effectiveness (SCE). We apply the method to acute-phase treatment of depression in a large insured population. Our results show that SCE of treatment for depression has improved during the 1990s. [ABSTRACT FROM AUTHOR]

Context: The Centers for Medicare & Medicaid Services (CMS) and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) measure and report quality process measures for acute myocardial infarction (AMI), but little is known about how these measures are correlated with each other and the degree to which inferences about a hospital's outcomes can be made from its performance on publicly reported processes.Objective: To determine correlations among AMI core process measures and the degree to which they explain the variation in hospital-specific, risk-standardized, 30-day mortality rates.Design, Setting, and Participants: We assessed hospital performance in the CMS/JCAHO AMI core process measures using 2002-2003 data from 962 hospitals participating in the National Registry of Myocardial Infarction (NRMI) and correlated these measures with each other and with hospital-level, risk-standardized, 30-day mortality rates derived from Medicare claims data.Main Outcome Measures: Hospital performance on AMI core measures; hospital-specific, risk-standardized, 30-day mortality rates for AMI patients aged 66 years or older.Results: We found moderately strong correlations (correlation coefficients > or =0.40; P values <.001) for all pairwise comparisons between beta-blocker use at admission and discharge, aspirin use at admission and discharge, and angiotensin-converting enzyme inhibitor use, and weaker, but statistically significant, correlations between these medication measures and smoking cessation counseling and time to reperfusion therapy measures (correlation coefficients <0.40; P values <.001). Some process measures were significantly correlated with risk-standardized, 30-day mortality rates (P values <.001) but together explained only 6.0% of hospital-level variation in risk-standardized, 30-day mortality rates for patients with AMI.Conclusions: The publicly reported AMI process measures capture a small proportion of the variation in hospitals' risk-standardized short-term mortality rates. Multiple measures that reflect a variety of processes and also outcomes, such as risk-standardized mortality rates, are needed to more fully characterize hospital performance. [ABSTRACT FROM AUTHOR]

Background. Drop-out, often accompanied by treatment non-compliance, is common in psychiatric trials. Methodologists have criticized the use of a traditional intention-to-treat (ITT) approach in such cases, and have proposed alternative methods. We set out to describe and assess methods for estimation of a treatment effect when the trial is 'broken'.Method. We describe a stratified method of moments (SMOM) estimator that assesses treatment effects on subjects who are willing to comply with all the treatments under study. A simulation study and a re-analysis of data from an antipsychotics trial are used to compare SMOM to ITT, as-treated, and adequate estimators.Results. The new estimator retains good statistical properties under different levels of non-compliance and drop-out mechanisms. The re-analysis indicates that SMOM yields more precise results.Conclusions. Although the traditional ITT approach provides a valid method to estimate treatment effects, it can be biased in the presence of treatment non-compliance and drop-out. It is critical that researchers move beyond traditional approaches when trials are broken. A key first step is to consider non-compliance and drop-out as two independent phenomena, tracking and reporting rates separately. [ABSTRACT FROM AUTHOR]

OBJECTIVE: The Federal Employees Health Benefits Program implemented full mental health and substance abuse parity in January 2001. Evaluation of this policy revealed that parity increased adult beneficiaries' financial protection by lowering mental health and substance abuse out-of-pocket costs for service users in most plans studied but did not increase rates of service use or spending among adult service users. This study examined the effects of full mental health and substance abuse parity for children. METHODS: Employing a quasiexperimental design, we compared children in 7 Federal Employees Health Benefits plans from 1999 to 2002 with children in a matched set of plans that did not have a comparable change in mental health and substance abuse coverage. Using a difference-in-differences analysis, we examined the likelihood of child mental health and substance abuse service use, total spending among child service users, and out-of-pocket spending. RESULTS: The apparent increase in the rate of children's mental health and substance abuse service use after implementation of parity was almost entirely due to secular trends of increased service utilization. Estimates for children's mental health and substance abuse spending conditional on this service use showed significant decreases in spending per user attributable to parity for 2 plans; spending estimates for the other plans were not statistically significant. Children using these services in 3 of 7 plans experienced statistically significant reductions in out-of-pocket spending attributable to the parity policy, and the average dollar savings was sizeable for users in those 3 plans. In the remaining 4 plans, out-of-pocket spending also decreased, but these decreases were not statistically significant. CONCLUSIONS: Full mental health and substance abuse parity for children, within the context of managed care, can achieve equivalence of benefits in health insurance coverage and improve financial protection without adversely affecting health care costs but may not expand access for children who need these services. [ABSTRACT FROM AUTHOR]