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Background: Congress, veterans' groups, and the press have expressed concerns that access to care and quality of care in Department of Veterans Affairs (VA) settings are inferior to access and quality in non-VA settings.Objective: To assess quality of outpatient and inpatient care in VA at the national level and facility level and to compare performance between VA and non-VA settings using recent performance measure data.Main Measures: We assessed Patient Safety Indicators (PSIs), 30-day risk-standardized mortality and readmission measures, and ORYX measures for inpatient safety and effectiveness; Healthcare Effectiveness Data and Information Set (HEDIS®) measures for outpatient effectiveness; and Consumer Assessment of Healthcare Providers and Systems Hospital Survey (HCAHPS) and Survey of Healthcare Experiences of Patients (SHEP) survey measures for inpatient patient-centeredness. For inpatient care, we used propensity score matching to identify a subset of non-VA hospitals that were comparable to VA hospitals.Key Results: VA hospitals performed on average the same as or significantly better than non-VA hospitals on all six measures of inpatient safety, all three inpatient mortality measures, and 12 inpatient effectiveness measures, but significantly worse than non-VA hospitals on three readmission measures and two effectiveness measures. The performance of VA facilities was significantly better than commercial HMOs and Medicaid HMOs for all 16 outpatient effectiveness measures and for Medicare HMOs, it was significantly better for 14 measures and did not differ for two measures. High variation across VA facilities in the performance of some quality measures was observed, although variation was even greater among non-VA facilities.Conclusions: The VA system performed similarly or better than the non-VA system on most of the nationally recognized measures of inpatient and outpatient care quality, but high variation across VA facilities indicates a need for targeted quality improvement. [ABSTRACT FROM AUTHOR]

This highlight describes the characteristics and inpatient utilization of under age 65 disabled California Medicare beneficiaries by dual eligible status (i.e., Medicaid State buy-in coverage or not). More disabled dually eligible beneficiaries are younger, non-White, and in fee-for-service (FFS) than non-dually eligible beneficiaries. Disabled dually eligible beneficiaries experienced consistently higher hospitalization rates and average length of stay (LOS) than non-dually eligible beneficiaries from 1996 to 2001. Inpatient days remain higher among dually eligible beneficiaries when stratified by the system of care, age, sex, or race. In addition, the hospitalization rate of disabled dually eligible beneficiaries was higher for most diagnoses, but how much higher varied by condition. [ABSTRACT FROM AUTHOR]

Measures of medication adherence have become common parameters with which disease management (DM) programs are being evaluated, leading to the question of how this concept should be measured in the particular context of a DM intervention. We hypothesize that DM improves adherence to prescriptions more than the rate with which prescriptions are being filled. We used health plan claims data to construct 13 common measures of medication adherence for five chronic conditions. The measures were operationalized in three different ways: the Prescription Fill Rate (PFR), which requires only one prescription; the Medication Possession Ratio (MPR), which requires a supply that covers at least 80% of the year; and the Length of Gap (LOG), which requires no gap greater than 30 days between prescriptions. We compared results from a baseline year to results during the first year of a DM program. Changes in adherence were quite small in the first year of the intervention, with no changes greater than six percentage points. In the intervention year, three measures showed a significant increase based on all three operational definitions, but two measures paradoxically decreased based on the PFR. For both, the MPR and the LOG suggested either no change or significant improvement. None of the MPR and LOG measures pointed toward significantly lower compliance in the intervention year. Different ways to operationalize the concept of medication adherence can lead to fundamentally different conclusions. While more complex, MPR- and LOG-based measures could be more appropriate for DM evaluation. Our initial results, however, need to be confirmed by data covering longer term follow-up. (Disease Management 2007;10:91–100) [ABSTRACT FROM AUTHOR]

Background: Many people 65 years of age and older are at risk for functional decline and death. However, the resource-intensive medical care provided to this group has received little evaluation. Previous studies have focused on general medical conditions aimed at prolonging life, not on geriatric issues important for quality of life. Objective: To measure the quality of medical care provided to vulnerable elders by evaluating the process of care using Assessing Care of Vulnerable Elders quality indicators (QIs). Design: Observational cohort study. Setting: Managed care organizations in the northeastern and southwestern United States. Patients: Vulnerable older patients identified by a brief interview from a random sample of community-dwelling adults 65 years of age or older who were enrolled in 2 managed care organizations and received care between July 1998 and July 1999. Measurements: Percentage of 207 QIs passed, overall and for 22 target conditions; by domain of care (prevention, diagnosis, treatment, and follow-up); and by general medical condition (for example, diabetes and heart failure) or geriatric condition (for example, falls and incontinence). Results: Patients were eligible for 10 711 QIs, of which 55% were passed. There was no overall difference between managed care organizations. Wide variation in adherence was found among conditions, ranging from 9% for end-of-life care to 82% for stroke care. More treatment QIs were completed (81%) compared with other domains (follow-up, 63%; diagnosis, 46%; and prevention, 43%). Adherence to QIs was lower for geriatric conditions than for general medical conditions (31% vs. 52%; P < 0.001). Conclusions: Care for vulnerable elders falls short of acceptable levels for a wide variety of conditions. Care for geriatric conditions is much less optimal than care for general medical conditions. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To develop a simple method for identifying community-dwelling vulnerable older people, defined as persons age 65 and older at increased risk of death or functional decline. To assess whether self-reported diagnoses and conditions add predictive ability to a function-based survey. DESIGN: Analysis of longitudinal survey data. SETTING: A nationally representative community-based survey. PARTICIPANTS: Six thousand two hundred five Medicare beneficiaries age 65 and older. MEASUREMENTS: Bivariate and multivariate analyses of the Medicare Current Beneficiary Survey; development and comparison of scoring systems that use age, function, and self-reported diagnoses to predict future death and functional decline. RESULTS: A multivariate model using function, self-rated health, and age to predict death or functional decline was only slightly improved when self-reported diagnoses and conditions were included as predictors and was significantly better than a model using age plus self-reported diagnoses alone. These analyses provide the basis for a 13-item function-based scoring system that considers age, self-rated health, limitation in physical function, and functional disabilities. A score of ≥3 targeted 32% of this nationally representative sample as vulnerable. This targeted group had 4.2 times the risk of death or functional decline over a 2-year period compared with those with scores <3. The receiver operating characteristics curve had an area of .78. An alternative scoring system that included self-reported diagnoses did not substantially improve predictive ability when compared with a function-based scoring system. CONCLUSIONS: A function-based targeting system effectively and efficiently identifies older people at risk of functional decline and death. Self-reported diagnoses and conditions, when added to the system, do not enhance predictive ability. The function-based targeting system relies on self-report and is easily transported across care... [ABSTRACT FROM AUTHOR]

Objective. To examine the evaluation process for the CHAMPUS Reform Initiative (CRI) both to highlight issues that evaluators must consider when undertaking such projects and to provide policymakers with tools to better assess demonstration project evaluations. Data Sources. The CRI evaluation. Study Design. Case study. Data Collection. Review of CRI evaluation reports. Principal Findings. Although policymakers increasingly rely on the evaluations of demostration projects to determine whether to extend the scope and funding of many public programs, the results of these evaluations are often difficult to assess. Despite its analytical sophistication, the CRI evaluation was no exception. The somewhat artificial time constraints imposed by policymakers made projection of the CRI's performance beyond the demonstration period particularly difficult. Conclusions. Much uncertainty generally remains even after well-planned and well-executed evaluations of demonstration projects. [ABSTRACT FROM AUTHOR]

Context: Continuing changes in the health care delivery system make it essential to monitor underuse of needed care, even for relatively well-insured populations. Traditional approaches to measuring underuse have relied on patient surveys and chart reviews, which are expensive, or simple single-condition claims-based indicators, which are not clinically convincing.Objective: To develop a comprehensive, low-cost system for measuring underuse of necessary care among elderly patients using inpatient and outpatient Medicare claims.Design: A 7-member, multispecialty expert physician panel was assembled and used a modified Delphi method to develop clinically detailed underuse indicators likely to be associated with avoidable poor outcomes for 15 common acute and chronic medical and surgical conditions. An automated system was developed to calculate the indicators using administrative data.Setting and Subjects: A total of 345,253 randomly selected elderly US Medicare beneficiaries in 1994-1996.Main Outcome Measures: Proportion of beneficiaries receiving care, stratified by indicators of necessary care (n = 40, including 3 for preventive care), and avoidable outcomes (n = 6).Results: For 16 of 40 necessary care indicators (including preventive care indicators), beneficiaries received the indicated care less than two thirds of the time. Of all indicators, African Americans scored significantly worse than whites on 16 and better on 2; residents of poverty areas scored significantly lower than nonresidents on 17 and higher on 1; residents of federally defined Health Professional Shortage Areas scored significantly lower than nonresidents on 16 and higher on none (P<.05 for all).Conclusions: This claims-based method detected substantial underuse problems likely to result in negative outcomes in elderly populations. Significantly more underuse problems were detected in populations known to receive less-than-average medical care. The method can serve as a reliable, valid tool for monitoring trends in underuse of needed care for older patients and for comparing care across health care plans and geographic areas based on claims data. JAMA. 2000;284:2325-2333. [ABSTRACT FROM AUTHOR]

Explores Medicare risk adjustment for children's capitation rate for the 35 percent of the variance in annual outpatient expenditures. Maximum explainable variance; Dependent variables; Potential adjusters; Estimation method.

Abstract: U sing data from the National Health Interview Survey and the RAND Health Insurance Experiment, we estimated the external costs (costs borne by others) of a sedentary life-style. External costs stem from additional payments received by sedentary individuals from collectively financed programs such as health insurance, sick-leave coverage, disability insurance, and group life insurance. Those with sedentary life-styles incur higher medical costs, but their life expectancy at age 20 is 10 months less so they collect less public and private pensions. The pension costs come late in life, as do some of the medical costs, and so the estimate of the external cost is sensitive to the discount rate used. At a 5 percent rate of discount, the lifetime subsidy from others to those with a sedentary life style is $1,900. Our estimate of the subsidy is also sensitive to the assumed effect of exercise on mortality. The subsidy is a rationale for public support of recreational facilities such as parks and swimming pools and employer support of programs to increase exercise. (Am J Public Health 1989; 79:975-981.) [ABSTRACT FROM AUTHOR]

Attempts to estimate the lifetime, discounted costs that smokers and drinkers impose on others through collectively financed health insurance, pensions, disability insurance, group life insurance, fires, motor-vehicle accidents, and the criminal justice system in the U.S. Excise taxes on cigarettes and alcohol; Internal and external costs of smoking and alcohol drinking.

In a previous comparison of persons between 14 and 62 years of age randomly assigned to receive care through a fee-for-service system (n = 784) or through a health maintenance organization (HMO) (n = 738) in Seattle, Washington, persons in the HMO had much lower hospital expenditures and admissions, more bed days, a higher prevalence of serious symptoms, and less satisfaction with care. We report an examination of 20 additional health status measures. Our results are consistent with a hypothesis of no differences in health status measures between the two systems. In addition, a comparison of nine health practices between the systems also indicated no overall differences. Most physiologic measures and health practices for a typical person were not affected by care received through the fee-for-service system or the HMO. However, we are less certain of this result in specific subgroups, such as persons of lower income initially at elevated risk, because confidence intervals are necessarily wider. We conclude that the cost savings achieved by this HMO through lower hospitalization rates were not reflected in lower levels of health status. [ABSTRACT FROM AUTHOR]

An association between cigarette smoking and menstrual disorders was observed during 1981 in a sample of 1367 women between the ages of 18 and 44 years in selected communities of Los Angeles County. Relevant questions were asked as part of a survey conducted to investigate the general health status of women living in these communities. The five-year period prevalence of physician-attended menstrual disorders, as reported in the survey, was 20.3%; the prevalence of menstrual disorders was higher among smokers (25.1%) than among nonsmokers (1 8.6%). Women who smoked 1½ packs of cigarettes or more per day were twice as likely to report past menstrual disorders as women who were nonsmokers. The results, though inconclusive, warrant further investigation. [ABSTRACT FROM PUBLISHER]

Recently, the U.S. Department of Defense replaced its traditional fee-for-service insurance plan for military health care beneficiaries with an HMO/PPO hybrid. Using survey and claims data, a comparison is made of changes in costs over two years at sites that implemented this CHAMPUS Reform Initiative (CRI) with changes at matched control sites. Results indicate that CRI substantially raised per beneficiary government costs for providing benefits (as compared to predicted costs in the absence of CRI). This difference is attributed to the higher overhead of managed care and the increased expenditures by HMO participants. [ABSTRACT FROM AUTHOR]

Replies to the comments of a reader concerning the authors' article about the effect to infants of smoking in pregnant women.