Recent Research Summaries

from News at http://bit.ly/1OIc0Sw on April 30, 2015 at 09:00AM

Optimization Modeling to Maximize Population Access to Comprehensive Stroke Centers

Michael T. Mullen, Charles C. Branas, Scott E. Kasner, Catherine Wolff, Justin C. Williams, Karen C. Albright and Brendan G. Carr

In Neurology, Michael Mullen, Charles Branas, Brendan Carr and colleagues share results of a virtual simulation focused on access to comprehensive stroke centers (CSCs), which are critical to ensuring access to stroke treatment. For their virtual trial, the authors selectively converted primary stroke centers (PSCs) to CSCs. Up to 20 PSCs per state were selected for conversion to CSCs, attempting to maximize the amount of the population with 60-minute CSC access by ground or air. Access was then compared across states. In 2010, the Joint Commission Survey found that 65.8 percent of the U.S. population had 60-minute ground access to a PSC. The simulation raised that to 63.1 percent with ground access to a CSC and 86.0 percent with ground or air access to a PSC. Access was lower in states without emergency service routing policies, as well as in the southeastern United States – a region known as the Stroke Belt for its high incidence of stroke and other cardiovascular disease. The authors conclude that even under the optimal conditions that their trial simulated, a large proportion of the U.S. population will be unable to access a CSC within 60 minutes.


The Role of Training Environment Care Intensity in US Physician Cost Consciousness

Kira L. Ryskina, Scott D. Halpern, Nancy S. Minyanouc, Susan D. Goold, Jon C. Tilburt

In Mayo Clinical Proceedings, Kira Ryskina and colleagues, including Scott Halpern, evaluate the impact of training environment on physicians’ levels of cost-consciousness. The authors analyzed results from the Physicians, Health Care Costs, and Society survey, administered to physicians across the country in 2012. Using responses from physicians for whom information was available about the care intensity of the hospitals where they did their residency, the authors evaluated the degree to which training environment influenced the views expressed in the survey. Training intensity was evaluated using the Dartmouth Atlas of Health Care – Hospital Care Intensity, and cost-consciousness by an 11 point scale. The authors find that the mean cost-consciousness score was lower among physicians trained in the highest quartile of intensity than among physicians trained in hospitals rated in the lowest quartile. The authors therefore conclude that the intensity of care utilization during residency does affect physicians’ levels of cost-consciousness later in their careers.


Location of HIV Diagnosis Impacts Linkage to Medical Care

Baligh R. Yehia, Elizabeth Ketner, Florence Momplaisir, Alisa J. Stephens-Shields, Nadia Dowshen, Michael G. Eberhart, Kathleen A. Brady

In the Journal of Acquired Immune Deficiency Syndromes, Baligh Yehia and colleagues investigate the importance of HIV diagnosis location for determining whether a person starts treatment in a timely manner. The U.S. National HIV/AIDS Strategy includes a goal to increase the proportion of persons linked to care within 3 months of diagnosis, which is critical to achieving HIV viral suppression. Baligh and colleagues analyze data on 1359 patients in Philadelphia newly diagnosed with HIV in 2010-2011. Diagnosis locations ranged from medical clinics and testing centers to inpatient settings and correctional facilities. Of the patients analyzed for the study, 60 percent were linked to care within three months and a further 20 percent after three months from the diagnosis. Twenty percent did not link to care. The rates varied greatly depending on diagnosis location. While 86 percent of patients diagnosed in medical clinics were linked to care, the rate was 75 percent among inpatients, 62 percent in counseling and testing centers, and just 44 percent among patients in correctional facilities.

See the LDI blog post on this study.


Comparison of HIV Outcomes for Patients Linked at Hospital Versus Community-Based Clinics

Asher J. Schranz, Kathleen A. Brady, Florence Momplaisir, Joshua P. Metlay, Alisa J. Stephens-Shields, Baligh R. Yehia

In AIDS Patient Care and STDs, Asher Schranz (New York University) and colleagues, including Baligh Yehia, compare HIV treatment outcomes for patients in hospital-based clinics versus those accessing care in a community clinic. The authors studied 2008-2011 data on HIV-infected adults in Philadelphia, assessing treatment outcomes in terms of retention in care, use of antiretroviral therapy, and viral suppression. Controlling for differences in patient and clinic characteristics, the authors find no difference in treatment outcomes between patients in hospital-based and community-based clinics. The authors find that 59 percent of patients meet outcome goals in both settings. They conclude that this may reflect advances in HIV therapy and the wide availability of HIV care resources.

See the LDI blog post on this study.


Suggestibility of Oncologists’ Clinical Estimates

David I. Shalowitz, John O. Schorge

In JAMA Oncology, David Shalowitz and John Schorge (Massachusetts General Hospital), assess the degree to which oncologists’ clinical estimates might be biased by extraneous information. For their study the authors sent surveys of different clinical scenarios to members of the New England and Mid-Atlantic Association of Gynecological Oncologists. Respondents were asked to assess the scenarios and provide an estimated life expectancy, evaluate other providers’ assessments, and indicate what treatments they would opt for. Results of the study show that clinicians are influenced by anchoring bias, meaning they rely too much on initial pieces of information, irrespective of relevance or reliability. The authors stress that their study was limited by low response rate and small sample size. Nevertheless, the results suggest that extensive training and availability of data may not protect clinicians from non-rational clinical decision-making. The authors caution that awareness of the phenomenon alone will not be enough to avoid bias, as there is potential for cognitive bias whenever there is clinical uncertainty, but it is still important for clinicians to consider potential anchors in making clinical decisions. They point to demonstrated success in asking providers to "consider the opposite" when making decisions.


Hospital Employment of Supplemental Registered Nurses and Patients’ Satisfaction With Care

Karen B. Lasater, Douglas M. Sloane, Linda H. Aiken

In the Journal of Nursing Administration, Linda Aiken and Penn colleagues from the Center for Health Outcomes and Policy Research (CHOPR) examine whether the use of supplemental registered nurses (SRNs), temporary nurses often used by hospitals to alleviate staffing shortages, has an impact on overall patient satisfaction. Using survey data from nurses and patients, they found little evidence that temporary nurses affect patient satisfaction with the hospital or with nursing care in particular. After other hospital and nursing characteristics were controlled, greater use of SRNs was not associated with patients’ global satisfaction, including whether they would rank their hospital highly or recommend their hospital, nor was it associated with nurse communication, medication explanation, or pain control. This study adds to a growing research base suggesting that the use of SRNs is safe and satisfactory to patients and offers hospitals a reasonable strategy for ensuring that adequate nurse staffing is available to hospitalized patients at all times.


An “Intention-Focused” Paradigm for Improving Bystander CPR Performance

Ashish R. Panchal, Jessica Fishman, Teresa Camp-Rogers, Roksolana Starodub, Raina M. Merchant

In the journal Resuscitation, Raina Merchant and colleagues from Penn, Ohio State University and the University of Texas propose a new way to improve the rate of bystander CPR performed on people suffering from cardiac arrest. The authors’ approach involves an “intention-focused” model in place of the current “training-based” model, along with insights from behavior theory, to increase people’s motivation to use CPR. The authors propose to test the model through population surveys to evaluate differences in the intention to perform CPR. From this, subgroups can be identified which have strong or weak intentions to perform CPR and evaluated for whether the bulk of their intentions are explained by personal attitudes, perceived norms of the subgroup, self-efficacy, or a combination. The intention-focused model for CPR performance allows for an understanding of determinants of lay bystanders’ decision-making. Interventions can then be designed to target specific modifiable variables that can increase the likelihood of CPR performance.


The Quality of Hospital Work Environments and Missed Nursing Care is Linked to Heart Failure Readmissions: a Cross-Sectional Study of U.S. Hospitals

J. Margo Brooks Carthon, Karen B. Lasater, Douglas M. Sloane, Ann Kutney-Lee

In BMJ Quality & Safety, J. Margo Brooks Carthon and colleagues from Penn Nursing’s Center for Health Outcomes and Policy Research (CHOPR) look at the effect of missed nursing care on 30-day readmissions for heart failure patients. Missed care are those services that nurses regard as necessary but were left undone on their last shift due to a lack of time. The authors linked nurse survey data, hospital administrative data, and patient discharge data from three states to evaluate hospital-level nursing work environments, missed care, and readmissions. They found that missed care was an independent predictor of readmissions. However, this relationship is attenuated by adjusting for the quality of the nurse work environment. This suggests a link between structural or environmental factors — staffing and resource adequacy, participation in hospital affairs, nursing leadership, and relationship with physicians — and the likelihood of readmission for heart failure. Improvements in nurses’ working conditions may be one strategy to reduce care omissions and improve patient outcomes.


Cross-Border Effects of State Health Technology Regulation

Jill R. Horwitz, Daniel Polsky

In the American Journal of Health Economics, LDI Executive Director Daniel Polsky and Jill R. Horwitz (UCLA School of Law) explore whether state Certificate of Need (CON) laws have an effect on the supply of medical technology in neighboring states. They studied whether MRI providers disproportionately locate in unregulated states in counties that border states regulated by CON licensing laws. They found a sizable cross-border effect: among counties located on state borders where one state regulates MRI entry and the other state does not, there is more likely to be an MRI provider in the unregulated county than in the regulated county. Of note, these effects are linked to the relative ease of traveling across state borders; the difference between regulated and unregulated border counties stems almost exclusively on state borders that are not separated by rivers, borders that are presumably easier for potential patients and staff to cross. The authors suggest that these spillover effects be considered when evaluating the effectiveness of CON laws.


Cost outcomes of supplemental nurse staffing in a large medical center

Ying Xue, Linda H. Aiken, Andre R. Chappel, Deborah A. Freund, Katia Noyes

In the Journal of Nursing Care Quality, Ying Xue (University of Rochester) and colleagues, including Linda Aiken, assess the effects of using agency-employed supplemental nursing staff on overall personnel costs at large academic medical centers. Through analysis of data from 19 medical centers, the investigators find that the modest use of supplemental nursing staff is a cost-efficient way to keep up with demand for personnel during peak periods. However, heavy reliance on supplemental nurses to meet staffing needs is not cost-efficient in terms of overall personnel costs.


Prescription Drug Use under Medicare Part D: A Linear Model of Nonlinear Budget Sets

Jason Abaluck, Jonathan Gruber, Ashley Swanson

In a NBER Working Paper, Jason Abaluck (Yale University), Jonathan Gruber (MIT) and LDI’s Ashley Swanson analyze the complicated decision problem faced by Medicare Part D enrollees in their use of prescription drugs. Enrollees must respond to prices that are difficult to find, and that may change as they spend more over time. As in other settings such as income taxation and electricity and cellular telephone markets, these sorts of nonlinear prices make it difficult to estimate behavior, as consumers may not follow rational models of consumption. The authors use Medicare Part D claims data from 2006-2009 to estimate a flexible model of consumption that accounts for these complex prices, that allows enrollees to be imperfectly forward-looking about price changes, and that allows some prices to be more salient than others. They develop methods for estimating consumption behavior using changes in Part D prices between years of enrollment. Their estimates suggest that consumers do respond to price increases by slightly reducing their prescription drug consumption. They also find that consumers are not perfectly forward-looking in choosing their consumption and that more salient plan characteristics affect consumption beyond their effect on out-of-pocket prices. These results suggest that policymakers designing prescription drug plans must account not only for what prices are, but also when consumers encounter them in the year and how they are presented.


Using Social Media to Engage Adolescents and Young Adults with Their Health

Charlene A. Wong, Raina M. Merchant, Megan A. Moreno

In Healthcare, Charlene Wong and Raina Marchant, along with Megan Moreno of the University of Washington, discuss how to improve health-related communication with young people through the use of social media. With relatively low health care utilization, while at the same time being ubiquitous users and often the earliest adopters of social media, many adolescents and young adults might be better reached via social media than through traditional channels. The authors suggest that social media could be used for everything from providing information on issues like sexual and mental health to communicating with young patients between office visits. Currently no payment models exist to reimburse providers for social media-based health care delivery, which presents a barrier to widespread adoption. Additional challenges include the maintenance of records of online interaction, as well as privacy concerns with sharing health information on social media.


Effects of Tailored Risk Communications for Skin Cancer Prevention and Detection: The PennSCAPE Randomized Trial

Karen Glanz, Kathryn Volpicelli, Christopher Jepson, Michael E. Ming, Lynn M. Schuchter; Katrina Armstrong

In Cancer Epidemiology, Biomarkers and Prevention, Karen Glanz and colleagues investigate whether personalized print materials are more effective than generic ones in promoting preventive behavior among patients at high risk for skin cancer. Their study measures adherence to sun protection behaviors, like sunscreen use and self-examination, as well as reported recent sunburns among 192 Caucasian adults at risk for skin cancer. Participants were randomized to receive either personalized or generic print materials. The authors find that the tailored communications are associated with improved adherence in six sun protection metrics, suggesting that personalized interventions may be more effective in promoting patient preventive behavior.


Oculomotor and Neurocognitive Assessment of Youth Ice Hockey Players: Baseline Associations and Observations After Concussion

Brian T. Vernau, Matthew F. Grady, Arlene Goodman, Douglas J. Wiebe, Luke Basta, Yong Park, Kristy B. Arbogast, Christina L. Master

In Developmental Neuropsychology, Brian Vernau and colleagues, including Douglas Wiebe, evaluate several cognitive assessment tools designed to evaluate patients pre- and post-concussion. The study enrolled 180 youth hockey players, all of whom underwent three neurocognitive assessments: the K-D test, ImPACT, and SCAT 3 or Child SCAT 3 depending on the participant’s age. Over the course of the season, several of the players sustained a concussion and underwent standard post-injury clinical assessment. Analyzing the data from the different assessment tools, the authors find a correlation between poor scores on the reaction time and visual motor skills sections of the K-D and ImPACT tests. They find no correlation between their baseline metrics, although prior studies have demonstrated a link for adult athletes. The authors conclude that further research is needed to determine the ideal metrics and frequency of cognitive assessment for children. They suggest that an annual screening, as recommended by current guidelines, may be too infrequent.


Wearable Devices as Facilitators, Not Drivers, of Health Behavior Change

Mitesh S. Patel, David A. Asch, Kevin G. Volpp

In a commentary in the Journal of the American Medical Association, Mitesh Patel, David Asch, and Kevin Volpp discuss the validity of claims that wearable devices promote long-term healthy behaviors. The authors contend that, although they may be useful in facilitating behavioral change in individuals already motivated to do so, using wearable devices to motivate people to instigate healthy changes is a challenge. Relatively high prices, potential inaccuracy of metrics, inconsistency of use, and difficulties in sustaining motivation are all significant barriers to success. Getting patients with chronic conditions – those for whom wearable devices have the most potential utility – to use the device regularly and to maintain behavioral changes in the long term will be challenging. The authors conclude that successful use of wearable health devices will depend more on the design of engagement strategies than the technology itself.


Wage, Work Environment, and Staffing: Effects on Nurse Outcomes

Matthew McHugh, Chenjuan Ma

In Policy, Politics, and Nursing Practice, Matthew McHugh and Penn Nursing colleague Chenjuan Ma look at the effects of wages on better nursing outcomes – less burnout, job dissatisfaction, and intention to leave the job. While prior studies have found links between work environment and staffing levels on nurse outcomes, they did not investigate the effects of wages. McHugh and Ma cross-analyze administrative data with a four-state survey. Logistic regression models, both with and without wage included, show that wage is associated with reported job dissatisfaction and intent to leave, but not with burnout. The analysis also shows that work environment and nurse-to-patient ratio have stronger effects on the measured outcomes. The authors conclude that wage is important for good nurse outcomes, but it does not diminish the significant influence of work environment and staffing.


Development, implementation, and impact of an automated early warning and response system for sepsis

Craig Umscheid, Joel Betesh, Christine VanZandbergen, Asaf Hanish, Gordon Tait, Mark Mikkelsen, Benjamin French, Barry Fuchs.

In the Journal of Hospital Medicine, Craig Umscheid, Benjamin French, and other Penn colleagues investigate electronic health record (EHR)-based interventions aimed at reducing sepsis-related mortality. Severe sepsis affects as many as three million patients in the U.S. annually and kills 750,000. Earlier intervention could help to lower the mortality rate, but identifying at-risk patients is a challenge. Umscheid and colleagues propose that a better screening mechanism would help providers recognize and treat sepsis right away. To test this, they conduct a study where the EHRs of adult non-ICU patients in acute inpatient units are programmed to alert the provider, nurse, and rapid response coordinators whenever a patient’s vital signs and laboratory metrics show certain predetermined abnormalities. The use of this automatic prediction tool was found to promote a statistically significant increase in early sepsis care, ICU transfer, and sepsis documentation. The authors also find a related decrease in sepsis mortality, but this data was not statistically significant.


Predictors of Community Therapists’ Use of Therapy Techniques in a Large Public Mental Health System

Rinad S. Beidas, Steven Marcus, Gregory A. Aarons, Kimberly E. Hoagwood, Sonja Schoenwald, Arthur C. Evans, Matthew O. Hurford, Trevor Hadley, Frances K. Barg, Lucia M. Walsh, Danielle R. Adams, David S. Mandell

In JAMA Pediatrics, Rinad Beidas and colleagues explore the effects of individual and organizational characteristics on therapists’ self-reported use of different therapy techniques – cognitive behavioral therapy (CBT), family therapy, and psychodynamic therapy techniques. The study focuses on the Philadelphia public mental health system, currently engaged in a large-scale effort to increase the use of CBT. The study results show that although both individual and organizational factors are important, the relative significance of the factors varies by treatment type. Key findings include that older therapists and therapists with more open attitudes are more likely to endorse use of CBT. Women are more likely to endorse use of family therapy techniques, as are those in organizations employing more fee-for-service staff and with more stressful climates. Therapists with more divergent attitudes and less knowledge about evidence-based practices were more likely to use psychodynamic therapy techniques. The authors recommend focusing on changing organizational factors in order to drive adherence to evidence-based practice, but that efforts should also include convincing individual therapists to cease outdated practices.


Patient Demands and Requests for Cancer Tests and Treatments

Keerthi Gogineni, Katherine L. Shuman, Derek Chinn, Nicole B. Gabler, Ezekiel J. Emanuel

In JAMA Oncology, Keerthi Gogineni and colleagues, including Ezekiel Emanuel, investigate how frequently patients demand or request medical tests or treatments, what types they demand, the clinical appropriateness of their demands, and how frequently clinicians comply. The authors interviewed more than 60 clinicians at three outpatient cancer treatment facilities in the Philadelphia area. They find that just one percent of encounters involve patients’ making demands for what are deemed clinically inappropriate services, frequently imaging, lab tests or palliative treatments. Physicians comply with less than one sixth of the inappropriate demands, meaning that just 0.14 percent of encounters result in physician compliance with clinically inappropriate demands from patients. The authors conclude that at least in oncology, “demanding patients” seem infrequent and may not account for a significant proportion of costs.


Psychological Language on Twitter Predicts County-Level Heart Disease Mortality

Authors: Johannes C. Eichstaedt, Hansen Andrew Schwartz, Margaret L. Kern, Gregory Park, Darwin R. Labarthe, Raina M. Merchant, Sneha Jha, Megha Agrawal, Lukasz A. Dziurzynski, Maarten Sap, Christopher Weeg, Emily E. Larson, Lyle H. Ungar, Martin E. P. Seligman

In the journal Psychological Science, Johannes C. Eichstaedt and colleagues, including Raina Merchant, analyze Twitter language to look for correlation with community-level mortality from atherosclerotic heart disease (AHD). Using a ‘social media language model’, a cross-sectional regression, they find statistically significant relationships between negative sentiment and higher mortality – and protective effects of positive sentiment. Most of the relationships remain significant after controlling for income and education. The authors posit that their model predicts AHD mortality significantly better than does a model that combines 10 common demographic, socioeconomic, and health risk factors, including smoking, diabetes, hypertension, and obesity. They conclude that capturing community psychological characteristics through social media is feasible, and these characteristics are strong markers of cardiovascular mortality at the community level.


Addressing Cost Barriers to Medications: A Survey of Patients Requesting Financial Assistance

Authors: David Grande, Margaret Lowenstein, Madeleine Tardif, Carolyn Cannuscio

In the American Journal of Managed Care, David Grande and colleagues assess decision-making preferences of patients who face cost-related barriers to care or medication. Specifically, the authors evaluate which health care actors patients trust most to evaluate cost-efficacy tradeoffs and screen for cost barriers using administrative records. The authors conducted a survey of 1,400 patients (adults with a chronic disease seeking financial assistance) who rated a clinical vignette describing how a clinical decision was made in the context of a cost-efficacy tradeoff. Results show that patients most trust personal physicians to screen for cost barriers, with pharmacists, nurses and trained volunteers less preferred but still trusted. Results also reveal that patients value ‘patient-directed’ decision-making about cost barriers rather than unilateral decision-making by physicians. The study highlights the significance of shared patient-physician decision-making regarding cost-efficacy tradeoffs, especially as more patients enroll in plans with higher cost-sharing arrangements.


Optimizing the Patient Handoff Between Emergency Medical Services and the Emergency Department

Authors: Zachary Meisel; Judy A. Shea; Nicholas J. Peacock; Edward T. Dickinson; Breah Paciotti; Roma Bhatia; Egor Buharin; Carolyn C. Cannuscio

In Annals of Internal Medicine, LDI’s Zachary Meisel and colleagues examine patient handoffs from emergency medical services (EMS) to hospital emergency departments to learn more about what can be done to improve the structure and process of these high-risk events. The authors conducted focus group interviews with EMS providers around the country to learn more about their perspectives on the professional and interpersonal factors that contribute to the effectiveness of handoffs. EMS providers identified four potential way of improving the handoff system: communicating directly with the patient’s ED provider upon arrival, increasing interdisciplinary feedback and transparency between hospital-based providers and EMS providers, standardizing some aspects of the handoff, and utilizing technology to promote better exchange of information. The study’s findings suggest that these reforms could help to reduce the risk of medical error in patient transitions.


State of Emergency Preparedness for U.S. Health Insurance Plans

Authors: Raina M. Merchant; Kristen Finne; Barbara Lardy; German Veselovskiy; Casey Korba; Gregg S. Margolis, Nicole Lurie

In the American Journal of Managed Care, Raina Merchant and collaborators from the Centers for Medicare & Medicaid Services, Deloitte, and America’s Health Insurance Plans evaluate the collective readiness of health insurance plans to respond to natural disasters and public health crises. The study evaluates 86 health plans, representing 80 percent of the insurance market, on the dimensions of infrastructure, adaptability, connectedness and best practices. The findings show that all respondents had emergency plans for business continuity, and most had infrastructure for emergency teams. Some health plans also had established benchmarks for preparedness (eg, response time). On adaptability, most had protocols to extend claim filing time and could temporarily suspend prior medical authorization rules. On connectedness, many plans shared their contingency plans with health officials, but often cited challenges in identifying regulatory agency contacts. The authors suggest six policy modifications that health insurance plans could undertake to potentially improve healthcare system preparedness: establishing metrics and benchmarks for emergency preparedness; identifying disaster-specific policy modifications, enhancing stakeholder connectedness, considering digital strategies to enhance communication, improving support and access for special-needs individuals, and developing regular forums for knowledge exchange about emergency preparedness.


The Role of Technical Advances in the Adoption and Integration of Patient-Reported Outcomes in Clinical Care

Authors: Roxanne E. Jensen, Nan E. Rothrock, Esi M. DeWitt, Brennan Spiegel, Carole A. Tucker, Heidi M. Crane, Christopher B. Forrest, Donald L. Patrick, Rob Frederickson, Lisa M. Shulman, David Cella, Paul K. Crane

In Medical Care, Roxanne E. Jensen (Georgetown University) and colleagues, including LDI’s Christopher Forrest, explore the changing role of patient-reported outcomes (PROs) in clinical treatment. PROs, assessments of a patient’s experiences in a structured and standardized format directly from the patient themselves, are gaining recognition as key measures for improving the quality of patient care in clinical care settings. The authors examine five case studies across diverse health care settings and patient populations to explore how implementation barriers were addressed to promote the successful integration of PRO collection into the clinical workflow. The case studies address selecting and reporting of relevant content, workflow integration, pre-visit screening, effective evaluation, and electronic health record integration. The case studies exemplify elements of well-designed electronic systems, including response automation, tailoring of item selection and reporting algorithms, flexibility of collection location, and integration with patient health care data elements. They also highlight emerging logistical barriers in this area, such as the need for specialized technological and methodological expertise, and design limitations of current electronic data capture systems.


Presentation of Prescription and Nonprescription Opioid Overdoses to U.S. Emergency Departments

Authors: Michael A. Yokell, M. Kit Delgado, Nicholas D. Zaller, N. Ewen Wang, Samuel K. McGowan, Traci Craig Green

In JAMA Internal Medicine, Kit Delgado and colleagues investigate characteristics of opioid overdose presentations to emergency departments. Opioid overdose is a leading cause of injury-related mortality in the United States. They analyze data from 2010 on 135,971 patients with opioid overdoses who were treated in emergency departments. The authors evaluate opioid type, patient characteristics, care utilization and clinical outcomes. They find that: two thirds of overdose cases involved prescription opioids, mortality was higher for overdoses with multiple opioids, most overdoses of prescription opioids occurred in urban environments and in the south, and patients with overdoses had high rates of chronic comorbidities. The authors suggest targeted interventions such as prescription monitoring programs and concomitantly prescribed opioid overdose treatment as methods to prevent and address overdoses.


The Use of Health Information Technology to Improve Care and Outcomes for Older Adults

Authors: Kathryn H. Bowles, Patricia Dykes, George Demiris

In a commentary in Research in Gerontological Nursing, Kathryn Bowles and colleagues look at how nurse scientists are using health information technology, such as electronic health records (EHR) and decision support, to improve care. They highlight positive research findings, including that integrated EHR systems reduced hospital-acquired pressure ulcers by 13 percent. Or how the use of a discharge decision support system helped to identify whether older adults were likely to need post-acute services, such as skilled home care or skilled nursing facility care. Use of the system, which is based on an algorithm analyzing how a patient answers a series of questions, achieved a 26% relative reduction in both 30- and 60-day readmissions. The article includes suggestions on how gerontological nurses can make best use of health IT and outlines future challenges that can be addressed with adoption and implementation research.


Primary Care Appointment Availability and Preventive Care Utilization: Evidence From an Audit Study

Authors: Brendan Saloner, Daniel Polsky, Ari Friedman, Karin Rhodes

In Medical Care Research and Review, Brendan Saloner (Johns Hopkins University), and Penn colleagues Dan Polsky, Ari Friedman and Karin Rhodes, analyzes adult preventive care utilization and primary care appointment availability. The authors link individual-level, cross-sectional data on adult preventive care utilization from the 2011-2012 Behavioral Risk Factor Surveillance System to novel county-level measures of primary care appointment availability collected from an experimental audit study conducted in 10 states in 2012 to 2013 and other county-level health service and demographic measures. They find that in counties with more available primary care appointments, adults with private insurance used less preventive care; however, counties with more Medicaid appointment availability saw higher utilization of preventive care among Medicaid populations. The authors conclude that the relationship between primary care appointment availability and utilization of preventive care differs based on whether non-elderly adults are on private insurance or Medicaid. They suggest that policymakers look past merely increasing the supply of providers and ensure that providers are available in lower-resource areas where the newly expanded Medicaid population lives.


Insurance Decision-Making For Rare Events: The Role Of Emotions

Authors: Howard Kunreuther, Mark Pauly

In a NBER working paper, Howard Kunreuther and Mark Pauly analyze an individual’s decision to purchase insurance when given information about “low-probability high-consequence” events such as a hurricane. The authors conducted a web-based multi-period insurance purchasing experiment. Participants were told the probability and resulting losses of a hurricane occurring and were informed that these were stable from period to period. The authors contrast the model of informed expected utility maximization with alternative behavioral models of choice as explanations for what they observe. The majority of individuals (63 percent) behaved in ways that were consistent with expected utility theory, although the authors stipulate that they do not know whether these individuals were utilizing other decision rules. A sizeable number of uninsured individuals decided to purchase insurance after learning that they had suffered a loss and revealing that they were unhappy about having been uninsured. The study shows that a loss coupled with emotions is likely to play an important role in convincing an uninsured person to buy coverage. In contrast, insured individuals who did not suffer a loss rarely dropped coverage.


Comparison of Pediatric and Adult Hospice Patients Using Electronic Medical Record Data from Nine Hospices in the United States, 2008–2012

Authors: Laura Dingfield, Laura Bender, Pamela Harris, Kristina Newport, Margo Hoover-Regan, Chris Feudtner, Sheila Clifford, and David Casarett

In the Journal of Palliative Medicine, David Casarett and colleagues from Penn Medicine look at pediatric and adult hospice patients and analyze differences in their characteristics and outcomes. In the study of over 126,000 hospice patients, children (18 years of age or younger) make up less than one percent of the hospice population. The authors posit that characteristics and needs of children in hospice are very different to that of adults. Despite this, pediatric patients are in general receiving services designed for adults, with only one third of hospice agencies running formal pediatric programs. Looking at retrospective cohort data, the authors find that children in hospice are less likely to have cancer, less likely to need oxygen, and less likely to have a do-not-resuscitate order. Children in hospice are more likely to have an enteral feeding tube. The data shows that average hospice length of stay for pediatric patients is longer than that of adults. Children are more likely to leave hospice care, but among patients who died while enrolled in hospice, pediatric patients are more likely to die at home. The study has important implications for hospice managers and caregivers, especially those that do not have formal pediatric programs in place.


Effectiveness of Androgen-Deprivation Therapy and Radiotherapy for Older Men With Locally Advanced Prostate Cancer

Authors: Justin E. Bekelman, Nandita Mitra, Elizabeth A. Handorf, Robert G. Uzzo, Stephen A. Hahn, Daniel Polsky and Katrina Armstrong

In the Journal of Clinical Oncology, Justin Bekelman and colleagues analyze whether treating locally advanced prostate cancer in older men with hormone therapy plus radiation improves chances of survival relative to hormone therapy alone. Earlier trials have shown that the combined course of treatment improves chances of survival for younger men. Bekelman and colleagues’ study tests whether this holds true for the treatment of older men with advanced prostate cancer. The authors compared the treatment of 31,541 men with prostate cancer ranging in age from 65 years to 85 years. Among men age 65 to 75 years old, radiation plus hormone therapy was associated with a reduction in prostate cancer deaths of 57 percent relative to hormone therapy alone (from 9.8 percent to 4.4 percent of patients at 7 years follow up). Similarly, among men age 76 to 85 years old, radiation plus hormone therapy was associated with a reduction in prostate cancer deaths of 49 percent relative to hormone therapy alone (from 9.8 percent to 5.0 percent of patients at 7 years follow-up). In both groups, radiation plus hormone therapy was also associated with about one-third fewer deaths from any cause.


Presentation on US Hospital Websites of Risks and Benefits of Transcatheter Aortic Valve Replacement Procedures

Authors: Mariah L. Kincaid, Lee A. Fleisher, Mark D. Neuman

In JAMA Internal Medicine, Mariah Kincaid (Tufts University) and Penn colleagues Lee Fleisher and Mark Neuman assess how risks and benefits of transcatheter aortic valve replacement (TAVR) are communicated on hospital websites. TAVR was recently approved by the U.S. Food and Drug Administration for the treatment of severe aortic stenosis among carefully selected patients. Recent randomized clinical trials have identified important positive and negative outcomes of TAVR, including twice the risk of stroke for patients undergoing TAVR vs those undergoing open aortic valve replacement. The study by Kincaid and colleagues assessed the information on TAVR made available to the public on the websites of 317 US hospitals currently performing the procedure. They find that although U.S. hospital websites universally discuss the benefits of TAVR, they rarely present information on the potential risks of this procedure. Moreover, numerical quantitative information was provided more frequently for benefits than for risks. The authors conclude that web-based advertising of TAVR to the public by hospitals may understate the established risks of this procedure and provide little context for the magnitude of those risks to inform patient decision-making. Hospitals may promote appropriate use of TAVR by presenting more balanced information regarding its risks and benefits.


Appointment Availability after Increases in Medicaid Payments for Primary Care

Authors: Daniel Polsky, Michael Richards, Simon Basseyn, Douglas Wissoker, Genevieve M. Kenney, Stephen Zuckerman and Karin V. Rhodes

In the New England Journal of Medicine, LDI Executive Director Dan Polsky and colleagues show that the increase in Medicaid reimbursement for primary care providers, a key provision of the Affordable Care Act (ACA), was associated with a 7.7 percentage point increase in new patient appointment availability without longer wait times. The results are from a new 10-state study and provide the first research-based evaluation of the association between the ACA’s two-year Medicaid fee bump — for which federal funding expired on December 31, 2014 — and appointment availability for Medicaid patients seeking new patient primary care appointments at physician offices that participate in Medicaid.

See the LDI blog post on this study which provides further analysis on states’ decisions of whether to keep the fee bump.


Healthcare System Supports for Young Adult Patients with Pediatric Onset Chronic Conditions: A Qualitative Study

Authors: Dava E. Szalda, Manuel E. Jimenez, Jeremiah E. Long, Amelia Ni, Judy A. Shea, Sophia Jan

In the Journal of Pediatric Nursing, Dava Szalda and colleagues examine how adult primary care teams can facilitate the transition and ongoing care of adults with pediatric onset chronic illness. Currently, over 90% of pediatric patients with chronic medical conditions are living into adulthood. For some pediatric onset chronic conditions there are more adults living with an illness than children. This qualitative study explores practice supports and barriers to care for this population, comparing them to other patients with chronic illness in order to identify facilitators that may be used or adapted. Using in depth interviews with twenty-two healthcare providers, practice supports identified include: formalizing intake processes, interoperable electronic medical records, and leveraging care coordination. Barriers identified included: definition of the medical team, lack of appropriate medical records, time and administrative burden, lack of training, and financial constraints. Themes may be utilized to design interventions and improve care coordination for patients with pediatric-onset chronic conditions.


The ACA’s Pediatric Essential Health Benefit Has Resulted In A State-By-State Patchwork Of Coverage With Exclusions

Authors: Aimee M. Grace, Kathleen G. Noonan, Tina L. Cheng, Dorothy Miller, Brittany Verga, David Rubin and Sara Rosenbaum

In Health Affairs, Kathleen Noonan, co-director of the CHOP PolicyLab, and colleagues investigate how the Affordable Care Act’s (ACA) pediatric essential health benefit has been implemented by states. They look at how state benchmark plans – the base plan chosen in each state as the standard or benchmark of coverage in that state under ACA rules – address pediatric coverage in plans governed by the essential health benefits standard. The review of summaries of all the state benchmark plans found that no state specified a distinct pediatric services benefit class. Furthermore, although benchmark plans explicitly included multiple pediatric conditions, many plans also specifically excluded services for children with special health care needs. This benchmarking approach resulted in a state-by-state patchwork of coverage for children and adolescents. Noonan has written a blog about the paper and it has also been included in the NY Times’ Upshot column.


Measuring Consumer Valuation of Limited Provider Networks

Authors: Keith Marzilli Ericson, Amanda Starc

In a National Bureau of Economic Research Working Paper, Amanda Starc and Keith Marzilli Ericson (Boston University) examine how much consumers value network breadth by measuring and comparing insurance plans, and plan choice, on the Massachusetts health insurance exchange. ‘Limited’ or ‘narrow’ network plans are growing in popularity yet there is currently little evidence on consumer valuation of breadth as a plan attribute. Using data from the Massachusetts exchange and the Massachusetts All-Payer Claims Database, Starc and Marzilli quantify the breadth of insurer-hospital networks through calculating the fraction of population hospital admissions that would be covered by the network.

To examine consumer valuation of these networks they look at the provider demand system method where consumers’ value of a network is built up from a model of consumer demand for providers. They also use the ‘insurance choice’ method, which measures consumers’ demand directly from their choice of insurance plans that vary in network breadth. Results of the study indicate that simple measures of network breadth can predict consumer choices, with willingness-to-pay for network breadth varying by age. 60-year-olds value the broadest network approximately $1200-1400/year more than the narrowest network, while 30-year-olds value it about half as much. Consumers place additional value on star hospitals, and there is significant geographic heterogeneity in the value of network breadth.


Lessons for Providers and Hospitals from Philadelphia’s Obstetric Services Closures and Consolidations, 1997-2012

Authors: Scott A. Lorch, Ashley E. Martin, Richa Ranade, Sindhu K. Srinivas, and David Grande

In Health Affairs, Scott Lorch and colleagues suggest that the way in which hospitals respond to disruptions caused by the closure of nearby facilities could influence patient outcomes. They look at the example of obstetric services in Philadelphia, where 13 of 19 hospital obstetric units closed between 1997 and 2012. This led to a "severely strained obstetric care system," according to interviews with key informants in hospitals with units still open. The authors conclude that policymakers need to do more to anticipate reductions in supply and monitor patient outcomes.

See the LDI blog post on this study.


Comprehensive Versus Consultative Rehabilitation Services Postacute Stroke: Outcomes Differ

Authors: Margaret Stineman, Dawei Xie, Jibby Kurichi, Pui Kwong, W. Bruce Vogel, Diane Cowper Ripley, Barbara Bates

In the Journal of Rehabilitation Research & Development, Margaret Stineman and colleagues compare outcomes of postacute stroke patients provided with comprehensive rehabilitation with those provided with consultative rehabilitation services. Of the nearly 3000 patients in the study, 23 percent received comprehensive rehabilitation while the remaining patients received consultative services. The researchers found that those who received comprehensive rehabilitation compared with consultative gained on average 12.8 more points of physical independence on a 78-point scale and gained 1.5 more points of cognitive independence on a 30-point scale. Additionally, the likelihoods of discharge to home from the hospital and one-year post hospital discharge survival were significantly higher among those who received comprehensive rehabilitation.

The researchers conclude that:

These findings have implications to the care of patients with stroke in both the VHA and Medicare-reimbursed settings. Movement to bundled payments appears to be accelerating in response to passage of the Patient Protection and Affordable Care Act in 2010. The "minimal essential coverage" for tens of millions of patients in Medicare will include entitlement for rehabilitation services. Details about what constitutes "rehabilitation" are unclear. Cost containment efforts by necessity will move toward less comprehensive rehabilitation. It is thus essential to identify those conditions where comparative evidence supports comprehensive rehabilitation. Evidence is growing for stroke.


Hidden in Plain Sight: A Crowdsourced Public Art Contest to Make Automated External Defibrillators More Visible

Authors: Raina Merchant, Heather Griffis, Yoonhee Ha, Austin Kilaru, Allison Sellers, John Hershey, Shawndra Hill, Emily Kramer-Golinkoff, Lindsay Nadkarni, Margaret Debski, Kevin Padrez, Lance Becker, David Asch

Raina Merchant and colleagues want to raise awareness about automated external defibrillators (AEDs) and use artwork to make AED locations more memorable. In a recent article in the American Journal of Public Health, Merchant et al use an online crowdsourcing design contest — the Defibrillator Design Challenge — to engage the public to this end. The goal of the project was not to install designs submitted as part of the contest, but to test whether the public would create them, vote on them, and share them. It is a follow-up to MyHeartMap Challenge, a crowdsourcing contest that engaged the public to locate and report the locations of AEDs. The Defibrillator Design Challenge expands on the location work to explore ways of making AEDs more visible and noticeable in their physical space. Over a two month period, the competition engaged more than 13,000 individuals to participate and disseminate information about AEDs, including through social media. Those who submitted designs could win cash prizes by popularity or expert panel acknowledgment.

Key conclusions of the study include:

  • Twenty percent of participants were older than 40, illustrating the potential to access multiple age groups through a crowdsourcing project.
  • The authors identified themes in the submitted designs that may be useful for future public health campaigns or initiatives that seek to raise awareness about AEDs.
  • The authors defined and collected several crowdsourcing metrics (e.g., participation demographics, motivations for participation) that could be useful for designing subsequent public health contests.
  • The authors suggest that monetary rewards may be unnecessary in crowdsourcing contests. When asked, the majority of the designers reported that they participated to contribute to an important cause (44%) rather than to win the prize money (0.8%).

Food Insecurity, Neighborhood Food Access, and Food Assistance in Philadelphia

Authors: Victoria L. Mayer, Amy Hillier, Marcus A. Bachhuber, Judith A. Long

In the Journal of Urban Health, a group of LDI Senior Fellows and Fellows study the relationship between food insecurity, neighborhood food access, and receipt of food assistance. They analyze 2008, 2010, and 2012 household health survey data from Southeastern Pennsylvania. They were particularly interested in respondents’ answers to questions about the difficulty of finding fruit and vegetables in their neighborhood, the overall quality of neighborhood grocery stores, and whether or not they were receiving food assistance. The researchers find an association between better neighborhood food access and lower risk of food insecurity. Additionally, people receiving food assistance are significantly more likely to be food insecure, meaning they are unable to obtain enough food for an active and healthy life. However, more than half of the respondents who reported food insecurity were not receiving any food assistance. Most food insecure individuals report good access to food but that it is too expensive. Thus, improving the diet of people who are food insecure must take into account both improving access and affordability.


HIV Testing Among Adults with Mental Illness in the United States

Authors: Baligh Yehia, Wanjun Cui, William Thompson, Matthew Zack, Lela McKnight-Eily, Elizabeth DiNenno, Charles E. Rose, and Michael B. Blank

In AIDS Patient Care and STDs, Baligh Yehia and colleagues explore the difference in rates of HIV testing for the mentally ill and the rest of the U.S. population. HIV infection and mental illness are frequently co-occurring health conditions, and nearly half of the people living with HIV have a psychiatric disorder. The researchers analyzed National Health Interview Survey (NHIS) data, and found that the mentally ill population is tested at a significantly higher rate than the rest of the U.S. population. However, the rates of HIV testing are still low, with less than half of the at-risk, mentally ill population being tested. The researchers suggest implementing routine HIV testing at mental health centers, targeting the mentally ill in HIV awareness campaigns, and screening the mentally ill who use illegal drugs for HIV when they initiate treatment for substance abuse.

Association of the 2011 ACGME Resident Duty Hour Reforms With Mortality and Readmissions Among Hospitalized Medicare Patients

Authors: Mitesh S. Patel, Kevin G. Volpp, Dylan S. Small, Alexander S. Hill, Orit Even-Shoshan, Lisa Rosenbaum, Richard N. Ross, Lisa Bellini, Jingsan Zhu, and Jeffrey H. Silber

In JAMA, Mitesh Patel, Kevin Volpp and colleagues evaluate patient outcomes associated with 2011 limits on resident work hours, and find no change in 30-day mortality rates or 30-day all-cause readmission rates.

See the LDI blog post on this study.