Characteristics Associated with Low-Value Cancer Screening Among Office-Based Physician Visits by Older Adults in the USA.

BACKGROUND: After a certain age, cancer screening may expose older adults to unnecessary harms with limited benefits and represent inefficient use of health care resources. OBJECTIVE: To estimate the frequency of cervical, breast, and colorectal cancer screening among adults older than US Preventive Services Task Force (USPSTF) age thresholds at which screening is no longer considered routine and to identify physician and patient factors associated with low-value cancer screening. DESIGN: Observational study using pooled cross-sectional data (2011-2016) from the National Ambulatory Medical Care Survey, a nationally representative probability sample of US office-based physician visits. PARTICIPANTS: Analyses for cervical and breast cancer screening were limited to visits by women over age 65 (N=37,818) and ages 75 and over (N=19,451), respectively. Analyses for colorectal cancer screening were limited to visits by patients over age 75 (N=31,543). MAIN MEASURES: Cancer screening procedures were coded as low value using USPSTF age thresholds. KEY RESULTS: Between 2011 and 2016, an estimated 509, 507, and 273 thousand potentially low-value Pap smears, mammograms, and colonoscopies/sigmoidoscopies, respectively, were ordered annually. Low-valuecervical cancer screening was less likely to occur for visits with older (vs. younger) patients. Compared to visits by non-HispanicWhite women, low-valuecervical and breast cancer screening was less likely to occur for visits by women whose race/ethnicitywas something other than non-HispanicWhite, non-HispanicBlack, or Hispanic. Obstetrician/gynecologistswere more likely to order low-valuePap smears and mammograms compared to family/generalpractice physicians. CONCLUSIONS: Thousands of cervical, breast, and colorectal cancer screenings at ages beyond routine guideline thresholds occur each year in the USA. Further research is needed to understand whether this pattern represents clinical inertia and resistance to de-adoption of previous screening practices, or whether physicians and/or patients perceive a higher value in these tests than that endorsed by experts writing evidence-based guidelines.

Impact of an Emergency Department-to-Home Transitional Care Intervention on Health Service Use in Medicare Beneficiaries: A Mixed Methods Study.

BACKGROUND: Hospital-based acute care [emergency department (ED) visits and hospitalizations] that is preventable with high-quality outpatient care contributes to health care system waste and patient harm. OBJECTIVE: To test the hypothesis that an ED-to-home transitional care intervention reduces hospital-based acute care in chronically ill, older ED visitors. RESEARCH DESIGN: Convergent, parallel, mixed-methods design including a randomized controlled trial. SETTING: Two diverse Florida EDs. SUBJECTS: Medicare fee-for-service beneficiaries with chronic illness presenting to the ED. INTERVENTION: The Coleman Care Transition Intervention adapted for ED visitors. MEASURES: The main outcome was hospital-based acute care within 60 days of index ED visit. We also assessed office-based outpatient visits during the same period. RESULTS: The Intervention did not significantly reduce return ED visits or hospitalizations or increase outpatient visits. In those with return ED visits, the Intervention Group was less likely to be hospitalized than the Usual Care Group. Interview themes describe a cycle of hospital-based acute care largely outside patients' control that may be difficult to interrupt with a coaching intervention. CONCLUSIONS AND RELEVANCE: Structural features of the health care system, including lack of access to timely outpatient care, funnel patients into the ED and hospital admission. Reducing hospital-based acute care requires increased focus on the health care system rather than patients' care-seeking decisions.

Service utilization in Medicaid HIV specialty plans versus standard plans among enrollees diagnosed with HIV/AIDS in Florida, U.S.A.

In the United States (U.S.), to contain costs many state Medicaid programs offer specialty health insurance plans for costly conditions such as HIV/AIDS. This study compared service utilization between Florida Medicaid enrollees diagnosed with HIV/AIDS in standard Medicaid managed care plans to enrollees in HIV/AIDS specialty plans. We found lower mean utilization among HIV/AIDS enrollees in specialty plans compared to enrollees with HIV/AIDS in standard MMA plans for all services except inpatient which was approximately the same. While fewer emergency visits is a desired outcome, lower rates of other services may indicate suboptimal management of patients or lower engagement in care among enrollees in HIV/AIDS specialty plans. Continuous monitoring of experiences of patients in HIV/AIDS specialty plans is warranted to determine whether the observed utilization patterns represent better management through reductions in low value care or reduced engagement in care, and whether these utilization patterns persist.

The impact of nurse practitioner regulations on population access to care.

BACKGROUND: By 2025, experts estimate a significant shortage of primary care providers in the United States, and expansion of the nurse practitioner (NP) workforce may reduce this burden. However, barriers imposed by state NP regulations could reduce access to primary care. PURPOSE: The objectives of this study were to examine the association between three levels of NP state practice regulation (independent, minimum restrictive, and most restrictive) and the proportion of the population with a greater than 30-min travel time to a primary care provider using geocoding. METHODS: Logistic regression models were conducted to calculate the adjusted odds of having a greater than 30-min drive time. FINDINGS: Compared with the most restrictive NP states, states with independent practice had 19.2% lower odds (p = .001) of a greater than 30-min drive to the closest primary care provider. DISCUSSION: Allowing NPs full autonomy to practice may be a relatively simple policy mechanism for states to improve access to primary care.

A value proposition for early physical therapist management of neck pain: a retrospective cohort analysis.

BACKGROUND: Neck pain is one of the most common reasons for entry into the healthcare system. Recent increases in healthcare utilization and medical costs have not correlated with improvements in health. Therefore there is a need to identify management strategies for neck pain that are effective for the patient, cost efficient for the payer and provided at the optimal time during an episode of neck pain. METHODS: One thousand five hundred thirty-one patients who underwent physical therapist management with a primary complaint of non-specific neck pain from January 1, 2008 to December 31, 2012 were identified from the Rehabilitation Outcomes Management System (ROMS) database at Intermountain Healthcare. Patients reporting duration of symptoms less than 4 weeks were designated as undergoing "early" management and patients with duration of symptoms greater than 4 weeks were designated as receiving "delayed" management. These groups were compared using binary logistic regression to examine odds of achieving Minimal Clinically Important Difference (MCID) on the Neck Disability Index (NDI) and Numerical Pain Rating Scale (NPRS). Separate generalized linear modeling examined the effect of timing of physical therapist management on the metrics of value and efficiency. RESULTS: Patients who received early physical therapist management had increased odds of achieving MCID on the NDI (aOR = 2.01, 95 % CI 1.57, 2.56) and MCID on the NPRS (aOR = 1.82, 95 % CI 1.42, 2.38), when compared to patients receiving delayed management. Patients who received early management demonstrated the greatest value in decreasing disability with a 2.27 percentage point change in NDI score per 100 dollars, best value in decreasing pain with a 0.38 point change on the NPRS per 100 dollars. Finally, patients receiving early management were managed more efficiently with a 3.44 percentage point change in NDI score per visit and 0.57 point change in NPRS score per visit. CONCLUSIONS: These findings suggest that healthcare systems that provide pathways for patients to receive early physical therapist management of neck pain may realize improved patient outcomes, greater value and higher efficiency in decreasing disability and pain compared to delayed management. Further research is needed to confirm this assertion.

Description of Common Clinical Presentations and Associated Short-Term Physical Therapy Clinical Outcomes in Patients With Neck Pain.

OBJECTIVE: To determine the effect of clinical presentations of neck pain on short-term physical therapy outcomes. DESIGN: Retrospective analysis of pair-matched groups from a clinical cohort. SETTING: Thirteen outpatient physical therapy clinics in 1 health care system. PARTICIPANTS: Patients (N=1069) grouped by common clinical presentations of neck pain: nonspecific neck pain (NSNP) with duration <4 weeks; NSNP with duration >4 weeks; neck pain with arm pain; neck pain with headache; and neck pain from whiplash. INTERVENTION: Conservative interventions provided by physical therapists. MAIN OUTCOME MEASURES: Neck Disability Index (NDI) and numerical pain rating scale (NPRS) recorded at the initial and last visits. The main outcome of interest was achieving recovery status on the NDI. Changes in NDI and NPRS were compared between clinical presentation groups. RESULTS: Compared with patients presenting with NSNP >4 weeks, patients with NSNP <4 weeks had increased odds of achieving recovery status on the NDI (P<.0001) and demonstrated the greatest changes in clinical outcomes of pain (P≤.0001) and disability (P≤.0001). Patients with neck pain and arm pain demonstrated an increased odds of achieving recovery status on the NDI (P=.04) compared with patients presenting with NSNP >4 weeks. CONCLUSIONS: Treating patients with NSNP within <4 weeks of onset of symptoms may lead to improved clinical outcomes from physical therapy compared with other common clinical presentations.

Opioid prescribing by physicians with and without electronic health records.

BACKGROUND: Physicians in the U.S. are adopting electronic health records (EHRs) at an unprecedented rate. However, little is known about how EHR use relates to physicians' care decisions. Using nationally representative data, we estimated how using practice-based EHRs relates to opioid prescribing in primary care. METHODS: This study analyzed 33,090 visits to primary care physicians (PCPs) in the 2007-2010 National Ambulatory Medical Care Survey. We used logistic regression to compare opioid prescribing by PCPs with and without EHRs. RESULTS: Thirteen percent of all visits and 33 % of visits for chronic noncancer pain resulted in an opioid prescription. Compared to visits without EHRs, visits to physicians with EHRs had 1.38 times the odds of an opioid prescription (95 % CI, 1.22-1.56). Among visits for chronic noncancer pain, physicians with EHRs had significantly higher odds of an opioid prescription (adj. OR = 1.39; 95 % CI, 1.03-1.88). Chronic pain visits involving electronic clinical notes were also more likely to result in an opioid prescription compared to chronic pain visits without (adj. OR = 1.51; 95 % CI, 1.10-2.05). Chronic pain visits involving electronic test ordering were also more likely to result in an opioid prescription compared to chronic pain visits without (adj. OR = 1.31; 95 % CI, 1.01-1.71). CONCLUSIONS: We found higher levels of opioid prescribing among physicians with EHRs compared to those without. These results highlight the need to better understand how using EHR systems may influence physician prescribing behavior so that EHRs can be designed to reliably guide physicians toward high quality care.

How do high cost-sharing policies for physician care affect total care costs among people with chronic disease?

OBJECTIVE: This study examines whether high cost-sharing in physician care is associated with a differential impact on total care costs by health status. Total care includes physician care, emergency room (ER) visits and inpatient care. BACKGROUND: Since high cost-sharing policies can reduce needed care as well as unneeded care use, it raises the concern whether these policies are a good strategy for controlling costs among chronically ill patients. METHODS: This study used the 2007 Medical Expenditure Panel Survey data with a cross-sectional study design. Difference in difference (DID), instrumental variable technique, two-part model, and bootstrap technique were employed to analyze cost data. RESULTS: Chronically ill individuals' probability of reducing any overall care costs was significantly less than healthier individuals (beta = 2.18, p = 0.04), while the integrated DID estimator from split results indicated that going from low cost-sharing to high cost-sharing significantly reduced costs by $12,853.23 more for sick people than for healthy people (95% CI: -$17,582.86, -$8,123.60). CONCLUSIONS: This greater cost reduction in total care among sick people likely resulted from greater cost reduction in physician care, and may have come at the expense of jeopardizing health outcomes by depriving patients of needed care. Thus, these policies would be inappropriate in the short run, and unlikely in the long run to control health plans costs among chronically ill individuals. A generous benefit design with low cost-sharing policies in physician care or primary care is recommended for both health plans and chronically ill individuals, to save costs and protect these enrollees' health status.

The Relationship of Chronic Disease Burden and Racial-Ethnic Disparities in Depression Treatment.

BACKGROUND: Chronic disease and depression are closely related, and depression, if left untreated, can worsen physical disease symptoms. Furthermore, treating depression can improve patient outcomes. Generally, treatment for depression is lower in minority groups. OBJECTIVE: The aim of this study was to determine the relationship between chronic disease burden and depression treatment and whether that relationship differs between white to non-white patient visits to primary care physicians. DESIGN: We conducted a quantitative secondary data analysis using data from 2014-2019 National Ambulatory Medical Care Survey (NAMCS). PARTICIPANTS: Visits by adults with depression to primary care physicians (n = 3832). MAIN MEASURES: Logistic regressions estimated the odds of medication treatment, mental health counseling treatment, and any treatment. KEY RESULTS: Visits by patients with 3 or more chronic conditions had 1.39 times the odds of receiving medication treatment (p-value = 0.06). However, when examining treatment by race, visits by white patients with 1-2 chronic conditions had 3.04 times the odds of receiving mental health treatment (p-value = 0.09) compared to visits by non-white patients and 2.09 times the odds of receiving any treatment (p-value = 0.08) compared to visits by non-white patients. CONCLUSIONS: Although not significant at the p < .05 level, the results suggest that the odds of depression treatment is greater during visits by patients with multiple co-occurring chronic conditions compared to visits by people without chronic conditions. It appears that this effect is larger for visits by white patients compared to visits by non-white patients. Further research is needed to confirm these findings and determine how this association impacts minorities distinctly and what could be the reason behind the disparity. These findings could help physicians be aware of ongoing disparities in depression treatment and provide more equitable depression treatment.

Effects of Practice Ownership and Integration of Health Services on Adherence to Diabetes Guidelines.

OBJECTIVE: There has been a trend toward hospital systems and insurers acquiring privately owned physician practices and subsequently converting them into vertically integrated practices. The purpose of this study is to observe whether this change in ownership of a medical practice influences adherence to clinical guidelines for the management of type 1 and type 2 diabetes. METHODS: This is an observational study using pooled cross-sectional data (2014-2016 and 2018-2019) from the National Ambulatory Medical Care Survey, a nationally representative probability sample of US office-based physician visits. A total of 7499 chronic routine follow ups and preventative care visits to non-integrated (solo and group physician practices) and integrated practices were analyzed to see whether guideline concordant care was provided. Measures included 7 services that are recommended annually for individuals with type 1 and type 2 diabetes (HbA1c, lipid panel, serum creatinine, depression screening, influenza immunization, foot examination, and BMI). RESULTS: Compared to non-integrated physician practices, vertically integrated practices had higher rates of hemoglobin A1C testing (odds ratio 1.58 [95% CI 1.07-2.33], P < .05), serum creatine testing (odds ratio 1.53 [95% CI 1.02-2.29], P < .05), foot examinations (odds ratio 2.03 [95% CI 0.98-4.22], P = .058), and BMI measuring (odds ratio 1.54 [95% CI 0.99-2.39], P = .054). There was no significant difference in lipid panel testing, depression screenings, or influenza immunizations. CONCLUSIONS: Our results show that integrated medical practices have a higher adherence to diabetes practice guidelines than non-integrated practices. However, rates of services provided regardless of ownership were low.

Racial and Ethnic Disparities in Emergency Department Wait Times for Headache.

Headache is a common complaint of individuals seeking treatment in the emergency department (ED). Because pain is subjective, medical evaluation is susceptible to implicit bias that can lead to disparities in wait times. The aim of this study was to determine whether there are racial and ethnic disparities in ED wait times for headache. Our study used the 2015-2018 National Hospital Ambulatory Care Surveys (NHAMCS), a nationally representative sample of ambulatory care visits to EDs. Our sample consisted of visits made by adults for headaches, which were identified using ICD-10 diagnosis codes and NHAMCS reason for visit codes. There were 12,301,655 ED visits for headache represented by our sample. The mean wait time for headache visits was 38.1 min (95%CI: 31.1, 45.0). The mean wait time for Non-Hispanic White patients, non-Hispanic Black patients, Hispanic patients, and the other race and ethnicity groups were 34.7 min (95%CI: 27.5, 42.0), 46.4 min (95%CI: 26.5, 66.4), 37.9 min (95%CI: 19.4, 56.3), and 21.0 min (95%CI: 6.3, 35.7) respectively. After controlling for patient- and hospital-level covariates, visits by non-Hispanic Black patients had 40% (95%CI: -0.01, 0.81, p = 0.056) longer wait times and visits by Hispanic patients had 39% (95%CI: -0.03, 0.80, p = 0.068) longer wait times than visits by non-Hispanic White patients. While our findings suggest that there may be longer wait times for visits by non-Hispanic Black and Hispanic patients compared to visits by non-Hispanic White patients, further research is needed to confirm these findings and determine causes of wait times disparities in the ED.

Associations of adverse childhood events with disordered eating behaviors among US adolescents.

The purpose of our study was to use recent nationally-representative data to 1) determine whether reported adverse childhood experiences (ACEs) were associated with individual disordered eating behaviors (DEBs) for the US- based early and middle adolescent population; and 2) the extent to which individual ACE categories were associated with DEBs for this population. The study used cross-sectional data from the 2022 National Survey of Children's Health, which used parent-reported data. Inclusion criteria included all early (10-13 years of age) and middle-aged adolescents (14-17 years of age) (n = 24,173). Multiple logistic regressions were used to test the association between ACEs and DEBs while controlling for covariates. Both categories for ACEs (i.e. 1-2 ACEs and 3+ ACEs) exhibited a statistically significant association with three specific DEBs: skipping meals or fasting, low interest in food, and binge eating. Additionally, six of the seven ACE categories exhibited a statistically significant association with DEBs which included parent or guardian divorced, parent or guardian time in jail, adults slap, hit, kick, punch others, victim of violence, lived with mentally ill, and lived with person with alcohol/drug problem. Further studies are needed to examine mechanisms contributing to the increased risk of DEBs among those with ACE exposure.

Private equity ownership and nursing home financial performance.

BACKGROUND: Private equity has acquired multiple large nursing home chains within the last few years; by 2009, it owned nearly 1,900 nursing homes. Private equity is said to improve the financial performance of acquired facilities. However, no study has yet examined the financial performance of private equity nursing homes, ergo this study. PURPOSE: The primary purpose of this study is to understand the financial performance of private equity nursing homes and how it compares with other investor-owned facilities. It also seeks to understand the approach favored by private equity to improve financial performance-for instance, whether they prefer to cut costs or maximize revenues or follow a mixed approach. METHODOLOGY/APPROACH: Secondary data from Medicare cost reports, the Online Survey, Certification and Reporting, Area Resource File, and Brown University's Long-term Care Focus data set are combined to construct a longitudinal data set for the study period 2000-2007. The final sample is 2,822 observations after eliminating all not-for-profit, independent, and hospital-based facilities. Dependent financial variables consist of operating revenues and costs, operating and total margins, payer mix (census Medicare, census Medicaid, census other), and acuity index. Independent variables primarily reflect private equity ownership. The study was analyzed using ordinary least squares, gamma distribution with log link, logit with binomial family link, and logistic regression. FINDINGS: Private equity nursing homes have higher operating margin as well as total margin; they also report higher operating revenues and costs. No significant differences in payer mix are noted. PRACTICE IMPLICATIONS: Results suggest that private equity delivers superior financial performance compared with other investor-owned nursing homes. However, causes for concern remain particularly with the long-term financial sustainability of these facilities.

Do Medicaid incentive payments boost quality? Florida's direct care staffing adjustment program.

Beginning in April 2000 and continuing for 21 months, Florida's legislature allocated $31.6 million (annualized) to nursing homes through a Medicaid direct care staffing adjustment. Florida's legislature paid the highest incentives to nursing homes with the lowest staffing levels and the greatest percentage of Medicaid residents--the bottom tier of quality. Using Donabedian's structure-process-outcomes framework, this study tracks changes in staffing, wages, process of care, and outcomes. The incentive payments increased staffing and wages in nursing home processes (decreased restraint use and feeding tubes) for the facilities receiving the largest amount of money but had no change on pressure sores or decline in activities of daily living. The group receiving the lowest incentives payment (those highest staffed at baseline) saw significant improvement in two quality measures: pressure sores and decline in activities of daily living. All providers receiving more resources improved on deficiency scores, suggesting more Medicaid spending improves quality of care regardless of total incentive payments.

Electronic medical record availability and primary care depression treatment.

BACKGROUND: Electronic medical records (EMR) are commonly believed to improve quality of care. Primary care patients with multiple chronic conditions have potentially greater opportunity to benefit from receiving care at practices with EMRs if these systems help coordinate complex care. OBJECTIVE: To examine how chronic conditions impact the odds that depressed patients receive depression treatment in primary care practices with EMRs compared to practices without EMRs. DESIGN: The study uses logistic regression to analyze cross-sectional data of primary care physician office visits in freestanding, office-based practices from the 2006-2008 National Ambulatory Medical Care Surveys. PATIENTS: All visits to primary care providers made by patients ages 18 and older with physician-identified depression (N = 3,467). MAIN MEASURES: Outcomes include depression treatment which is defined as receipt or ordering of antidepressant medication and/or mental health counseling. KEY RESULTS: EMRs were associated with significantly lowered odds that depressed patients received depression treatment (OR = 0.75, p = 0.009, 95% CI: 0.61-0.93); however when stratified by the number of chronic conditions, this association was observed only in patients with three or more chronic conditions (OR = 0.50, p > 0.001, 95% CI: 0.36-0.70). EMRs did not have a significant association with depression treatment for patients with two or fewer chronic conditions. CONCLUSIONS: EMRs appear to have an unintended negative association with depression care provided during visits made by primary care patients with multiple chronic conditions.

Obesity and postpartum depression: does prenatal care utilization make a difference?

To identify (1) the association between pre-pregnancy BMI (PP-BMI) and PPD symptoms, and (2) the association between PP-BMI and PPD symptoms after considering PNC utilization as a moderating variable. Data from the 2004 and 2005 Pregnancy Risk Assessment Monitoring System (PRAMS) were analyzed from 15 states. The study design utilized two risk-adjustment approaches. One approach included all women in the dataset and used statistical analyses to risk-adjust for pregnancy risk status, and the other approach, through a sensitivity analysis, modified the design of the study by truncating the sample to include only women with healthy pregnancies. An initial association was seen between obesity and PPD symptoms, and PNC and PPD symptoms in the multivariate analyses. However, the inclusion of case-mix variables into the multivariate models removed these associations. Overall, for both approaches, there was no indication of a moderating effect of PNC utilization. Results also revealed that many of the women were significantly affected by a variety of high-risk maternal morbidity (case-mix) variables. Although PNC is important for the health of mothers and babies, it does not appear to moderate the association of PP-BMI and PPD symptoms. However, since this study revealed associations between several high-risk maternal morbidities (included as case-mix variables), and PPD symptoms, it is recommended that future research further investigate the possible association of these morbidities with PPD symptoms. For practice, it is suggested that PNC providers focus on their patients, and establish suitable interventions accordingly.

Racial inequities in emergency department wait times for pregnancy-related concerns.

OBJECTIVE: Emergency department care is common among US pregnant women. Given the increased likelihood of serious and life-threatening pregnancy-related health conditions among Black mothers, timeliness of emergency department care is vital. The objective of this study was to evaluate racial/ethnic variations in emergency department wait times for receiving obstetrical care among a nationally representative population. METHODS: The study used pooled 2016-2018 data from the National Hospital Ambulatory Medical Care Survey, a nationally representative sample of emergency department visits. Regression models were estimated to determine whether emergency department wait time was associated with the race/ethnicity of the perinatal patient. Adjusted models controlled for age, obesity status, insurance type, whether the patient arrived by ambulance, triage status, presence of a patient dashboard, and region. RESULTS: There were a total of 821 reported pregnancy-related visits in the National Hospital Ambulatory Medical Care Survey sample of emergency department visits. Of those 821 visits, 40.6% were among White women, 27.7% among Black women, and 27.5% among Hispanic women. Mean wait times differed substantially by race/ethnicity. After adjusting for potential confounders, Black women waited 46% longer than White women with emergency department visits for pregnancy problems (p < .05). Those reporting another race waited 95% longer for pregnancy problems in the emergency department than White women (p < .05). CONCLUSION: Findings from this study document significant racial/ethnic differences in wait times for perinatal emergency department care. Although inequities in wait times may emerge across the spectrum of care, documenting the factors influencing racial disparities in wait times are critical to promoting equitable perinatal health outcomes.

Part D plan enrollment by uninsured medicare beneficiaries.

OBJECTIVES: The objective of the study was to examine the patient factors and medication acquisition strategies that impacted PDP enrollment in early 2006 by Medicare beneficiaries without prior drug coverage. RESEARCH DESIGN AND SUBJECTS: A retrospective cohort study identified 2282 Medicare beneficiaries without prior drug coverage from the 2005 Access to Care Module of the Medicare Current Beneficiary Survey. MEASURES: Bivariate statistics (eg, chi and t-tests) were used to compare beneficiaries without drug coverage in 2005 who enrolled or did not enroll in a PDP in early 2006. A logistic regression was estimated to examine which patient factors were associated with PDP enrollment, controlling for demographic, socioeconomic, and health status variables, as well as medication purchasing strategies and size of the PDP choice set. RESULTS: In early 2006, 44% of Medicare beneficiaries without prior drug coverage enrolled in a standalone PDP. Beneficiaries without prior drug coverage were more likely to enroll if they were younger (age 65-74), female, non-Hispanic white, married or widowed, had more self-reported conditions, requested prescription drug samples from their provider, or compared medication prices prior to purchase. Seniors without prior drug coverage were less likely to enroll if they had incomes <$50,000 or obtained medication via mail or the internet. CONCLUSIONS: Enrollment in PDPs by beneficiaries without prior drug coverage was fairly low in early 2006, and vulnerable subgroups of these beneficiaries who did not enroll require follow-up to ensure that they realized the benefits of the Medicare Part D program.

Association of Health Plans' Healthcare Effectiveness Data and Information Set (HEDIS) performance with outcomes of enrollees with diabetes.

BACKGROUND: Few quality of care evaluations examine the relationship between clinical processes and patient outcomes. OBJECTIVE: To determine the association between health plan performance on Healthcare Effectiveness Data and Information Set (HEDIS) clinical processes and intermediate outcome measures and Health Outcomes Survey (HOS) self-reported physical and mental health scores among Medicare plan enrollees with diabetes. RESEARCH DESIGN: Secondary data analysis of 2002 HEDIS and 2001-2003 HOS data. SUBJECTS: This study focused on Medicare plan enrollees with self-reported diabetes (N = 8184). MEASURES: Plan-level HEDIS diabetes care measures for 2002 and longitudinal, patient-level 2001-2003 HOS physical and mental health outcomes scores. Hierarchical linear models estimated the relationship between plan HEDIS performance on diabetes process of care and intermediate outcome measures and 2-year changes in enrollee HOS physical and mental health scores. RESULTS: Each 10% point improvement in plan performance on HEDIS intermediate outcomes (ie, the proportion of well-controlled diabetes) was related to significant positive increase in the probability of being healthy as measured by both enrollee physical health scores (7 percentage point increase, P < 0.05) and mental health scores (11 percentage point increase, P < 0.01). Similar increases in plan process of care measures were associated with increases in the probability of being healthy as measured by enrollee mental health scores (11 percentage point increase, P < 0.001). CONCLUSIONS: This study represents one of the first attempts to link plan HEDIS performance to changes in enrollee health. The results suggest that improved quality of care, as measured by process and intermediate outcomes measures for diabetes, can result in better health among patients with diabetes. Further research should address whether this relationship exists in other quality measures, clinical conditions, and populations.