Healthcare costs associated with antiretroviral adherence among medicaid patients.

BACKGROUND: The relationship of antiretroviral therapy (ART) adherence to total healthcare expenditures for Medicaid-insured people living with HIV or AIDS (PLWHA) is not well understood, especially among asymptomatic HIV-positive patients. OBJECTIVE: This study examined Medicaid-insured HIV-positive and AIDS-diagnosed patient groups to determine the association of ART adherence to mean monthly total healthcare expenditures in the 24-month measurement period, controlling for demographic, geographic, insurance, and clinical factors. The present study extends the existing literature by analyzing the relationship of ART adherence to total healthcare costs for asymptomatic HIV-positive patients separately from those patients with AIDS-defining conditions. METHODS: This retrospective study utilized claims data from Florida Medicaid claims from July 2006 through June 2011. All patients (n = 502) were HIV-positive, aged 18-64 years, non-pregnant, and ART naïve for at least 12 months prior to the measurement period. Each patient was categorized, based on medication possession ratios, as adherent (≥90 %) or non-adherent (<90 %), and were divided into two groups: HIV positive (n = 232) and AIDS diagnosed (n = 270). Generalized linear models predicted the mean monthly total expenditures for the non-adherence group versus the adherence group. RESULTS: For the HIV-positive group, the adjusted mean monthly expenditures for the non-adherent group were US$1,291; the adherent group adjusted mean monthly expenditures were US$1,926. The HIV-positive non-adherent group adjusted mean monthly expenditures were significantly less than the adherent group (-40 %, p < 0.001). However, for the AIDS-diagnosed group, there was not a statistically significant association of ART adherence to total healthcare expenditures (p = 0.29). CONCLUSION: The results show that the relationship of ART adherence to healthcare costs is more complex than previously reported.

Characteristics of all, occasional, and frequent emergency department visits due to ambulatory care-sensitive conditions in Florida.

We studied characteristics of all, occasional, and frequent emergency department (ED) visits due to ambulatory care-sensitive conditions (ACSCs). We used a cross-sectional, split-sample design with multivariate logistic regressions using encounter-level, all-payer ED data from all Florida hospitals for the year of 2005. We evaluated associations of key patient characteristics, characteristics of ED utilization, and availability of primary care physicians in the area, with ED visits for ACSCs. We concluded that factors associated with ED use for ACSCs were similar for occasional and frequent ED users. Therefore, universal strategies for reduction of ED overutilization by increasing access to, timeliness, and quality of primary care for all patients likely to experience ACSCs should be used.

Physician and practice characteristics associated with longitudinal increases in electronic health records adoption.

This article identifies practice- and physician-related characteristics associated with the increased use of EHRs by physicians in outpatient practices. Two Florida surveys conducted in 2005 and 2008 on physician use of EHRs were examined to determine the practice and physician characteristics associated with increased EHR use over time. Based on multivariate analysis, several variables were found to influence increased EHR adoption. Practice variables included participation in a single-specialty practice and percentage of Medicare patients in the practice, but not percentage of Medicaid patients in the practice. Physician characteristics included younger physician age, but not specialty nor years practicing in the community. Factors associated with EHR adoption at any given point in time did not necessarily predict longitudinal increases in EHR adoption. These results are important for physicians to consider in their potential adoption of EHRs and should also be considered by policymakers interested in promoting increased use of EHRs by physicians.

The use of physician-patient email: a follow-up examination of adoption and best-practice adherence 2005-2008.

BACKGROUND: Improved communication from physician- patient emailing is an important element of patient centeredness. Physician-patient email use has been low; and previous data from Florida suggest that physicians who email with patients rarely implement best-practice guidelines designed to protect physicians and patients. OBJECTIVE: Our objective was to examine whether email use with patients has changed over time (2005-2008) by using two surveys of Florida physicians, and to determine whether physicians have more readily embraced the best-practice guidelines in 2008 versus 2005. Lastly, we explored the 2008 factors associated with email use with patients and determined whether these factors changed relative to 2005. METHODS: Our pooled time-series design used results from a 2005 survey (targeting 14,921 physicians) and a separate 2008 survey (targeting 7003 different physicians). In both years, physicians practicing in the outpatient setting were targeted with proportionally identical sampling strategies. Combined data from questions focusing on email use were analyzed using chi-square analysis, Fisher exact test, and logistic regression. RESULTS: A combined 6260 responses were available for analyses, representing a participation rate of 28.2% (4203/14,921) in 2005 and 29.4% (2057/7003) in 2008. Relative to 2005, respondents in 2008 were more likely to indicate that they personally used email with patients (690/4148, 16.6% vs 408/2001, 20.4%, c(2) (1) = 13.0, P < .001). However, physicians who reported frequently using email with patients did not change from 2005 to 2008 (2.9% vs 59/2001, 2.9%). Interest among physicians in future email use with patients was lower in 2008 (58.4% vs 52.8%, c(2) (2) = 16.6, P < .001). Adherence to email best practices remained low in 2008. When comparing 2005 and 2008 adherences with each of the individual guidelines, rates decreased over time in each category and were significantly lower for 4 of the 13 guidelines. Physician characteristics in 2008 that predicted email use with patients were different from 2005. Specifically, in multivariate analysis female physicians (OR 1.48, 95% CI 1.12-1.95), specialist physicians (OR 1.43, 95% CI 1.12-1.84), and those in a multispecialty practice (OR 1.76, 95% CI 1.30-2.37) were more likely than their counterparts to email with patients. Additionally, self-reported computer competency levels (on a 5-point Likert scale) among physicians predicted email use at every level of response. CONCLUSIONS: Email use between physicians and patients has changed little between 2005 and 2008. However, future physician interest in using email with patients has decreased. More troubling is the decrease in adherence to best practices designed to protect physicians and patients when using email. Policy makers wanting to harness the potential benefits of physician-patient email should devise plans to encourage adherence to best practices. These plans should also educate physicians on the existence of best practices and methods to incorporate these guidelines into routine workflows.

Strategy, structure, and patient quality outcomes in ambulatory surgery centers (1997-2004).

The purpose of this study was to examine potential associations among ambulatory surgery centers' (ASCs) organizational strategy, structure, and quality performance. The authors obtained several large-scale, all-payer claims data sets for the 1997 to 2004 period. The authors operationalized quality performance as unplanned hospitalizations at 30 days after outpatient arthroscopy and colonoscopy procedures. The authors draw on related organizational theory, behavior, and health services research literatures to develop their conceptual framework and hypotheses and fitted fixed and random effects Poisson regression models with the count of unplanned hospitalizations. Consistent with the key hypotheses formulated, the findings suggest that higher levels of specialization and the volume of procedures may be associated with a decrease in unplanned hospitalizations at ASCs.

The influence of payer mix on electronic prescribing by physicians.

BACKGROUND: Limited studies have examined electronic prescribing (e-prescribing) adoption in physician office practices. Specifically, none have explored the influence of payer mix on e-prescribing adoption among physicians. PURPOSE: This study examines the impact of practice composition of Medicare, Medicaid, and private insurance on e-prescribing adoption among physicians. METHODOLOGY/APPROACH: Logistic regression was used to analyze data collected from a large-scale information technology-related survey of Florida physicians. FINDINGS: After controlling for practice and physician characteristics, physicians with the highest (odds ratio = 1.67, 95% confidence interval = 1.01-2.78) and above-average (odds ratio [OR] = 1.83, 95% confidence interval = 1.04-3.22) volume of Medicare patients were significantly more likely to e-prescribe as compared with those in the low-volume category. No differences in adoption were found across all Medicaid and private insurance practice composition categories. PRACTICE IMPLICATIONS: Our findings support the notion that direct incentives, such as those in the Medicare Modernization Act of 2003, may influence physician adoption of e-prescribing.

EHR adoption among doctors who treat the elderly.

OBJECTIVES: The purpose of this study is to examine Electronic Health Record (EHR) adoption among Florida doctors who treat the elderly. This analysis contributes to the EHR adoption literature by determining if doctors who disproportionately treat the elderly differ from their counterparts with respect to the utilization of an important quality-enhancing health information technology application. METHODS: This study is based on a primary survey of a large, statewide sample of doctors practising in outpatient settings in Florida. Logistic regression analysis was used to determine whether doctors who treat a high volume of elderly (HVE) patients were different with respect to EHR adoption. RESULTS: Our analyses included responses from 1724 doctors. In multivariate analyses controlling for doctor age, training, computer sophistication, practice size and practice setting, HVE doctors were significantly less likely to adopt EHR. Specifically, compared with their counterparts, HVE doctors were observed to be 26.7% less likely to be utilizing an EHR system (OR=0.733, 95% CI 0.547-0.982). We also found that doctor age is negatively related to EHR adoption, and practice size and doctor computer savvy-ness is positively associated. CONCLUSIONS: Despite the fact that EHR adoption has improved in recent years, doctors in Florida who serve the elderly are less likely to adopt EHRs. As long as HVE doctors are adopting EHR systems at slower rates, the elderly patients treated by these doctors will be at a disadvantage with respect to potential benefits offered by this technology.

Predictors of physician satisfaction among electronic health record system users.

Electronic health records (EHRs) have experienced slow adoption rates but play an important role in improving ambulatory quality of care. Sustained use of EHRs is closely related to physician satisfaction, however little research exists on this issue. We focused on physician EHR users to determine factors that are related to satisfaction with the level of computerization in their office practice. After controlling for various factors, physicians with more robust EHRs, and those who adopted their system two or more years ago, were more likely to be satisfied. Lastly, several individual EHR functionalities were independently related to improved satisfaction.

Quality improvement in local health departments: results of the NACCHO 2008 survey.

OBJECTIVES: To assess the current status of quality improvement (QI) within local health departments (LHDs) and examine the characteristics associated with such QI efforts. METHODS: A QI module was administered to a representative sample of 545 LHDs along with the core instrument in the 2008 NACCHO Profile survey of all LHDs nationally. Using the Profile survey data set, a quantitative approach was employed to determine the current status of QI within LHDs. Statistical analysis was performed to identify characteristics of LHDs associated with QI. The response rate to the QI module was 82 percent. RESULTS: Of the 448 LHDs that responded to the QI Module, 55 percent reported conducting formal QI efforts during the previous 2 years. Forty-four percent of these LHDs used a specific framework for QI, 56 percent used at least one of four commonly employed QI tools or techniques, and customer focus and satisfaction was the most frequently reported area (76%) of QI efforts. LHDs with large size of jurisdiction population and those with centralized governance were more likely to have engaged in quality or performance improvement, have managers who received formal QI training, and have provided QI training to staff. CONCLUSION: The 2008 NACCHO Profile QI module furnishes an excellent baseline for measuring progress of health department QI activities as accreditation and other related activities intensify. A clear definition of QI in public health that is understood by practitioners will greatly increase our ability to measure the adoption of QI by LHDs. Further research is necessary to identify and explore some of the predictors and possible barriers to increasing the application of QI by LHDs.

Quality improvement in local health departments: progress, pitfalls, and potential.

OBJECTIVES: To assess the current deployment of quality improvement (QI) approaches within local health departments (LHDs) and gain a better understanding of the depth and intensity of QI activities. METHODS: A mixed quantitative and qualitative approach was employed to determine the current status of QI utilization within LHDs. All respondents from the 2005 NACCHO Profile QI module questionnaire who indicated that their LHD was involved in some kind of QI activity received a follow-up Web-based survey in 2007. A smaller convenience sample of 30 LHDs representing all groups of respondents was selected for the follow-up interview to validate and expound upon survey data. RESULTS: Survey response rate was 62 percent (181/292). Eighty-one percent of LHDs reported QI programmatic activities, with 39 percent occurring agency-wide. Seventy-four percent of health departments had staff trained in QI methods. External funding sources for QI were infrequent (28%). LHDs that were serving large jurisdictions and LHDs that were subunits of state health agencies (centralized states) were more likely to engage in most QI activities. However, interview responses did not consistently corroborate survey results and noted a need for shared definitions. CONCLUSION: Multiple factors, including funders and accreditation, may be driving the increase of QI for public health. Additional research to confirm and validate these findings is necessary. A common QI vocabulary is also recommended.

The relationship between local hospital IT capabilities and physician EMR adoption.

In light of new federal policies allowing hospitals to subsidize the cost of information systems for physicians, we examine the relationship between local hospital investments in information technology (IT) and physician EMR adoption. Data from two Florida surveys were combined with secondary data from the State of Florida and the Area Resource File (ARF). Hierarchal logistic regression was used to examine the effect of hospital adoption of clinical information systems on physician adoption of EMR systems after controlling for confounders. In multivariate analysis, each additional clinical IT application adopted by a local hospital was associated with an 8% increase in the odds of EMR adoption by physicians practicing in that county. Given this existing relationship between hospital IT capabilities and physician adoption patterns, federal policies designed to encourage this more directly will positively promote the proliferation of EMR systems.

The role of information technology usage in physician practice satisfaction.

BACKGROUND: Despite the growing use of information technology (IT) in medical practices, little is known about the relationship between IT and physician satisfaction. PURPOSE: The objective of this study was to examine the relationship between physician IT adoption (of various applications) and overall practice satisfaction, as well as satisfaction with the level of computerization at the practice. METHODS: Data from a Florida survey examining physicians' use of IT and satisfaction were analyzed. Odds ratios (ORs), adjusted for physician demographics and practice characteristics, were computed utilizing logistic regressions to study the independent relationship of electronic health record (EHR) usage, PDA usage, use of e-mail with patients, and the use of disease management software with satisfaction. In addition, we examined the relationship between satisfaction with IT and overall satisfaction with the current medical practice. RESULTS: In multivariate analysis, EHR users were 5 times more likely to be satisfied with the level of computerization in their practice (OR = 4.93, 95% CI = 3.68-6.61) and 1.8 times more likely to be satisfied with their overall medical practice (OR = 1.77, 95% CI = 1.35-2.32). PDA use was also associated with an increase in satisfaction with the level of computerization (OR = 1.23, 95% CI = 1.02-1.47) and with the overall medical practice (OR = 1.30, 95% CI = 1.07-1.57). E-mail use with patients was negatively related to satisfaction with the level of computerization in the practice (OR = 0.69, 95% CI = 0.54-0.90). Last, physicians who were satisfied with IT were 4 times more likely to be satisfied with the current state of their medical practice (OR = 3.97, 95% CI = 3.29-4.81). IMPLICATIONS: Physician users of IT applications, especially EHRs, are generally satisfied with these technologies. Potential adopters and/or policy makers interested in influencing IT adoption should consider the positive impact that computer automation can have on medical practice.

Bypassing the local rural hospital for outpatient procedures.

PURPOSE: To assess the amount of local rural hospital outpatient department (HOPD) bypass for outpatient procedures. METHODS: We analyzed data on colonoscopies and upper gastrointestinal endoscopies performed in the state of Florida over the period 1997-2004. FINDINGS: Approximately, 53% of colonoscopy and 45% of upper gastrointestinal endoscopy patients bypassed their local rural hospital for treatment at either a free-standing ambulatory surgical center (ASC) or a nonlocal hospital outpatient department. Independent predictors of bypass included risk-adjusted severity of the patient's medical condition, insurance status, and race. Patients treated in ASCs were predominately healthier, white and commercially insured. Nonlocal HOPDs tend to treat a sicker cohort of patients who were publicly insured or under managed care. CONCLUSIONS: The results indicate that patients who bypass their local HOPD to an ASC differ from those bypassing to a nonlocal HOPD, and that patient factors influencing bypass for outpatient procedures differ from those influencing inpatient bypass. From a policy perspective, as procedures continue to migrate from the inpatient to the outpatient setting, bypassing the local rural hospital for treatment elsewhere could create conditions that negatively impact rural hospital operations.

Aligning public health financing with essential public health service functions and National Public Health Performance Standards.

The purpose of this study was to assess the alignment of state and local health department financing with the 10 essential public health service (10EPHS) categories and National Public Health Performance Standards (NPHPS). To determine this, we collected primary data from the Florida Department of Health (FDOH) for fiscal year 2005-2006 and compared it with secondary data collected in the same year through NPHPS survey instruments. A structured interview technique was used to collect primary budget data from each program office at the FDOH and assign each program budget to 10EPHS categories. Local county health department (CHD) expenditures were assessed through an interview with the director and budget chief of one small, medium, and large CHD, and results were then extrapolated for other local CHDs. It was possible for almost 98 percent of the FDOH budget to be allocated into the 10EPHS categories. A majority of resources (68.7%) were used for individual healthcare services, category 7b (assuring provision of services) and category 7a (linking people to needed services). No direct correlation was found between the level of funding by 10EPHS category and the performance standards scores at state or local levels. Public health continues to utilize a majority of its available resources for individual healthcare services, despite increasing requests for improved population-based programs.

Reducing the impact of the health care access crisis through volunteerism: a means, not an end.

In the absence of meaningful health reform, Florida implemented a volunteer health care program to strengthen the existing safety net. Since program implementation in 1992, over $1 billion of services have been provided to uninsured and underserved populations. Currently, over 20,000 volunteers participate statewide. Key incentives for provider participation have been an organized framework for volunteering and liability protection through state-sponsored sovereign immunity. Volunteerism, although not a solution to the health care crisis, serves as a valuable adjunct pending full-scale health care reform.

Use of health information technology by children's hospitals in the United States.

OBJECTIVE: The purpose of this study was to examine the adoption of health information technology by children's hospitals and to document barriers and priorities as they relate to health information technology adoption. METHODS: Primary data of interest were obtained through the use of a survey instrument distributed to the chief information officers of 199 children's hospitals in the United States. Data were collected on current and future use of a variety of clinical health information technology and telemedicine applications, organizational priorities, barriers to use of health information technology, and hospital and chief information officer characteristics. RESULTS: Among the 109 responding hospitals (55%), common clinical applications included clinical scheduling (86.2%), transcription (85.3%), and pharmacy (81.9%) and laboratory (80.7%) information. Electronic health records (48.6%), computerized order entry (40.4%), and clinical decision support systems (35.8%) were less common. The most common barriers to health information technology adoption were vendors' inability to deliver products or services to satisfaction (85.4%), lack of staffing resources (82.3%), and difficulty in achieving end-user acceptance (80.2%). The most frequent priority for hospitals was to implement technology to reduce medical errors or to promote safety (72.5%). CONCLUSION: This first national look at health information technology use by children's hospitals demonstrates the progress in health information technology adoption, current barriers, and priorities for these institutions. In addition, the findings can serve as important benchmarks for future study in this area.

Influence of pay-for-performance programs on information technology use among child health providers: the devil is in the details.

OBJECTIVE: Pay-for-performance programs are used to promote improved health care quality, often through increased use of health information technology. However, little is known about whether pay-for-performance programs influence the adoption of health information technology, especially among child health providers. This study explored how various pay-for-performance compensation methods are related to health information technology use. METHODS: Survey data from 1014 child health providers practicing in Florida were analyzed by using univariate and multivariate techniques. Questions asked about the adoption of electronic health records and personal digital assistants, as well as types of activities that affected child health provider compensation or income. RESULTS: The most common reported method to affect respondents' compensation was traditional productivity or billing (78%). Of the pay-for-performance-related methods of compensation, child health providers indicated that measures of clinical care (41%), patient surveys and experience (34%), the use of health information technology (29%), and quality bonuses or incentives (27%) were a major or minor factor in their compensation. In multivariate logistic regression analyses, only pay-for-performance programs that compensated directly for health information technology use were associated with an increased likelihood of electronic health record system adoption. Pay-for-performance programs linking measures of clinical quality to compensation were positively associated with personal digital assistant use among child health providers. CONCLUSIONS: Pay-for-performance programs that do not directly emphasize health information technology use do not influence the adoption of electronic health records among Florida physicians treating children. Understanding how different pay-for-performance compensation methods incentivize health information technology adoption is important for improving quality.

How well does diagnosis-based risk-adjustment work for comparing ambulatory clinical outcomes?

This paper examines the empirical consistency of the Diagnosis Cost Groups/Hierarchical Condition Categories (DCG/HCC) risk-adjustment method for comparing 7-day mortality between hospital-based outpatient departments (HOPDs) and freestanding ambulatory surgery centers (ASCs). We used patient level data for the three most common outpatient procedures provided during the 1997-2004 period in Florida. We estimated base-line logistic regression models without any diagnosis-based risk adjustment and compared them to logistic regression models with the DCG/HCC risk-adjustment, and to conditional logit models with a matched cohort risk-adjustment approach. We also evaluated models that adjusted for primary diagnoses only, and then for all available diagnoses, to assess how the frequently absent secondary diagnoses fields in ambulatory surgical data affect risk-adjustment. We found that risk-adjustment using both diagnosis-based methods resulted in similar 7-day mortality estimates for HOPD patients in comparison with ASC patients in two out of three procedures. We conclude that the DCG/HCC risk-adjustment method is relatively consistent and stable, and recommend this risk-adjustment method for health policy research and practice with ambulatory surgery data. We also recommend using risk-adjustment with all available diagnoses.