Healthcare Coinsurance Elasticity Coefficient Estimation Using Monthly Cross-sectional, Time-series Claims Data.

Published estimates of the healthcare coinsurance elasticity coefficient have typically relied on annual observations of individual healthcare expenditures even though health plan membership and expenditures are traditionally reported in monthly units and several studies have stressed the need for demand models to recognize the episodic nature of healthcare. Summing individual healthcare expenditures into annual observations complicates two common challenges of statistical inference, heteroscedasticity, and regressor endogeneity. This paper estimates the elasticity coefficient using a monthly panel data model that addresses the heteroscedasticity and endogeneity problems with relative ease. Healthcare claims data from employees of King County, Washington, during 2005 to 2011 were used to estimate the mean point elasticity coefficient: -0.314 (0.015 standard error) to -0.145 (0.015 standard error) depending on model specification. These estimates bracket the -0.2 point estimate (range: -0.22 to -0.17) derived from the famous Rand Health Insurance Experiment. Copyright © 2016 John Wiley & Sons, Ltd.

Racial and Ethnic Differences in Antipsychotic Medication Use Among Children Enrolled in Medicaid.

OBJECTIVE: The objective of this study was to detect and measure differences in antipsychotic drug use across racial-ethnic groups of children enrolled in Medicaid. METHODS: The main data sources were the Medicaid MAX Person Summary and the MAX Prescription Drug files for calendar years 2005-2009 and the Environmental Scanning and Program Characteristics Database. The analyses were based on the entire population (5.8 million) of Medicaid-enrolled children and adolescents, ages two to 20, from eight states. Proportional hazard and ordinary least-squares multivariate regressions were used to assess the effect of race-ethnicity on the likelihood of antipsychotic prescription fills and the use of any psychiatric services. RESULTS: The study found robust and statistically significant evidence of higher antipsychotic drug use among white children, especially relative to Hispanic and Asian children. When analyses held all variables constant, the probability of having an antipsychotic fill was lower compared with whites by 1.8 percentage points for African Americans, by 2.0 percentage points for Asians, and by 1.8 percentage points for Hispanics. These effects are large in light of the finding that the probability of an antipsychotic prescription fill across child-years was only 2.4%. Children from these minority groups were also less likely to receive psychiatric services. CONCLUSIONS: Substantial racial-ethnic differences were found in antipsychotic use. Explanations based on greater aversion to pharmacological treatment among minority groups are insufficient to explain the phenomenon.

The national response for preventing healthcare-associated infections: infrastructure development.

BACKGROUND: In 2009, the US Department of Health and Human Services (HHS) launched the Action Plan to Prevent Healthcare-associated Infections (HAIs). The Action Plan adopted national targets for reduction of specific infections, making HHS accountable for change across the healthcare system over which federal agencies have limited control. OBJECTIVES: This article examines the unique infrastructure developed through the Action Plan to support adoption of HAI prevention practices. RESEARCH DESIGN: Interviews of federal (n=32) and other stakeholders (n=38), reviews of agency documents and journal articles (n=260), and observations of interagency meetings (n=17) and multistakeholder conferences (n=17) over a 3-year evaluation period. MEASURES: We extract key progress and challenges in the development of national HAI prevention infrastructure--1 of the 4 system functions in our evaluation framework encompassing regulation, payment systems, safety culture, and dissemination and technical assistance. We then identify system properties--for example, coordination and alignment, accountability and incentives, etc.--that enabled or hindered progress within each key development. RESULTS: The Action Plan has developed a model of interagency coordination (including a dedicated "home" and culture of cooperation) at the federal level and infrastructure for stimulating change through the wider healthcare system (including transparency and financial incentives, support of state and regional HAI prevention capacity, changes in safety culture, and mechanisms for stakeholder engagement). Significant challenges to infrastructure development included many related to the same areas of progress. CONCLUSIONS: The Action Plan has built a foundation of infrastructure to expand prevention of HAIs and presents useful lessons for other large-scale improvement initiatives.

The national response for preventing healthcare-associated infections: data and monitoring.

BACKGROUND: Historically, the ability to accurately track healthcare-associated infections (HAIs) was hindered due to a lack of coordination among data sources and shortcomings in individual data sources. OBJECTIVES: This paper presents the results of the evaluation of the HAI data and the monitoring component of the Action Plan, focusing on context (goals), inputs, and processes. RESEARCH DESIGN: We used the Content-Input-Process-Product framework, together with the HAI prevention system framework, to describe the transformative processes associated with data and monitoring efforts. RESULTS: Six HAI priority conditions in the 2009 Action Plan created a focus for the selection of goals and activities. Key Action Plan decisions included a phased-in data and monitoring approach, commitment to linking the selection of priority HAIs to highly visible national 5-year prevention targets, and the development of a comprehensive HAI database inventory. Remaining challenges relate to data validation, resources, and the opportunity to integrate electronic health and laboratory records with other provider data systems. CONCLUSIONS: The Action Plan's data and monitoring program has developed a sound infrastructure that builds upon technological advances and embodies a firm commitment to prioritization, coordination and alignment, accountability and incentives, stakeholder engagement, and an awareness of the need for predictable resources. With time, and adequate resources, it is likely that the investment in data-related infrastructure during the Action Plan's initial years will reap great rewards.

The national response for preventing healthcare-associated infections: research and adoption of prevention practices.

BACKGROUND: Healthcare-associated infections (HAIs) have long been the subject of research and prevention practice. When findings show potential to significantly impact outcomes, clinicians, policymakers, safety experts, and stakeholders seek to bridge the gap between research and practice by identifying mechanisms and assigning responsibility for translating research to practice. OBJECTIVES: This paper describes progress and challenges in HAI research and prevention practices, as explained through an examination of Health and Human Services (HHS) Action Plan's goals, inputs, and implementation in each area. RESEARCH DESIGN: We used the Context-Input-Process-Product evaluation model, together with an HAI prevention system framework, to assess the transformative processes associated with HAI research and adoption of prevention practices. RESULTS: Since the introduction of the Action Plan, HHS has made substantial progress in prioritizing research projects, translating findings from those projects into practice, and designing and implementing research projects in multisite practice settings. Research has emphasized the basic science and epidemiology of HAIs, the identification of gaps in research, and implementation science. The basic, epidemiological, and implementation science communities have joined forces to better define mechanisms and responsibilities for translating HAI research into practice. Challenges include the ongoing need for better evidence about intervention effectiveness, the growing implementation burden on healthcare providers and organizations, and challenges implementing certain practices. CONCLUSIONS: Although these HAI research and prevention practice activities are complex spanning multiple system functions and properties, HHS is making progress so that the right methods for addressing complex HAI problems at the interface of patient safety and clinical practice can emerge.

The effect of Surgical Care Improvement Project (SCIP) compliance on surgical site infections (SSI).

BACKGROUND: The Surgical Care Improvement Project (SCIP) has developed a set of process compliance measures in an attempt to reduce the incidence of surgical site infections (SSIs). Previous research has been inconclusive on whether compliance with these measures is associated with lower SSI rates. OBJECTIVES: To determine whether hospitals with higher levels of compliance with SCIP measures have lower incidence of SSIs and to identify the measures that are most likely to drive this association. DATA AND METHODS: Analysis of linked SCIP compliance rates and SSIs on 295 hospital groups observed annually over the study period 2007-2010. A hospital group comprises all hospitals sharing identical categories for location by state, teaching status, bed size, and urban/rural location. We used a generalized linear model regression with logistic link and binomial family to estimate the association between 3 SCIP measures and SSI rates. RESULTS: Hospital groups with higher compliance rates had significantly lower SSI rates for 2 SCIP measures: antibiotic timing and appropriate antibiotic selection. For a hospital group of median characteristics, a 10% improvement in the measure provision of antibiotic 1 hour before intervention led to a 5.3% decrease in the SSI rates (P<0.05). Rural hospitals had effect sizes several times larger than urban hospitals (P<0.05). A third-core measure, Timely Antibiotic Stop, showed no robust association. CONCLUSIONS: This analysis supports a clinically and statistically meaningful relationship between adherence to 2 SCIP measures and SSI rates, supporting the validity of the 2 publicly available healthcare-associated infection metrics.

The national response for preventing healthcare-associated infections: system capacity and sustainability for improvement.

BACKGROUND: Strengthening capacity across the healthcare system for improvement is critical to ensuring that past efforts and investments establish a foundation for sustaining progress in patient safety. OBJECTIVES: The objective of this analysis was to identify key system capacity issues for sustainability from evaluation of the Action Plan to prevent healthcare-associated infections, a major national initiative launched by the US Department of Health and Human Services in 2009. RESEARCH DESIGN: The analysis involves the review and synthesis of results across the components of a 3-year evaluation of the Action Plan, as described in the evaluation framework and detailed in separate analyses elsewhere in this special issue. Data collection methods included interviews with government and private stakeholders, document and literature reviews, and observations of meetings and conferences at multiple time points. MEASURES: Key developments in healthcare-associated infection prevention system capacity were extracted on the basis of "major activities" identified through multiple methods and organized into the level of progress based on perspectives of multiple stakeholders. Activities within each level were then examined and compared according to our evaluation's framework of 4 system functions and 5 system properties. RESULTS: Key system capacity and sustainability issues for the Action Plan to be addressed centered on coordination and alignment (among participating agencies, with other federal initiatives, and across levels of healthcare), infrastructure for data and accountability (including more efficient technologies and unintended consequences), cultural embedding of prevention practices, and uncertainty and variability in resources. CONCLUSIONS: Sustainability depends on improvements across system functions and properties and how they reinforce each other. Change is more robust if different system elements support and incentivize behavior in similar directions.

An examination of longitudinal CAUTI, SSI, and CDI rates from key HHS data systems.

BACKGROUND: In response to the growing concern about healthcare-associated infections (HAIs), US Department of Health and Human Services (HHS) developed the National Action Plan to Prevent Healthcare-associated Infections. A key focus of the Action Plan is the setting of HAI metrics and targets and the enhancement and development of data systems to support HAI surveillance. OBJECTIVES: To identify and assess the strengths and weaknesses of HHS data systems available for surveillance of catheter-associated urinary tract infections, surgical site infections, and Clostridium difficile infections. To present national data from each of the data systems and assess concordance in trends over time. RESEARCH DESIGN: Literature review on data system characteristics and HAI measurement. Graphical and descriptive analyses of longitudinal HAI rates from HHS data systems. MEASURES: HAI rate information expressed as prevalence rates or standardized infection ratios. RESULTS: We identified four HHS data systems--Medicare claims data, Healthcare Cost and Utilization Project, Medicare Patient Safety Monitoring System, and National Healthcare Safety Network--capable of surveillance of at least one of the HAIs under study. Surgical site infection and Clostridium difficile infection rates display concordance in trends, although there is no evidence of concordance in catheter-associated urinary tract infections rates. We have identified a number of desirable HAI data system characteristics: clinically valid; provide information on a broad range of HAIs; have large sample size to support statistical inference; be representative of the United States; and display consistency in cohort, surveillance protocols, and data collection methodology. CONCLUSIONS: Although the data systems included in this study vary along the desirable data system dimensions we identified, trends in HAI rates are generally concordant across the data systems. This increases confidence in observed trends.

Approach for conducting the longitudinal program evaluation of the US Department of Health and Human Services National Action Plan to prevent healthcare-associated infections: roadmap to elimination.

BACKGROUND: In response to mounting evidence about skyrocketing morbidity, mortality, and costs associated with healthcare-associated infections (HAIs), in 2009, the US Department of Health and Human Services (HHS) issued the HHS HAI Action Plan to enhance collaboration and coordination and to strengthen the impact of national efforts to address HAIs. To optimize timely understanding of the Action Plan's approach and outcomes, as well as improve the likely success of this effort, HHS requested an independent longitudinal and formative program evaluation. OBJECTIVES: This article describes the evaluation approach to assessing HHS's progress and the challenges encountered as HHS attempted to transform the national strategy to HAI elimination. RESEARCH DESIGN: The Context-Input-Process-Product (CIPP) model, a structured-yet-flexible formative and summative evaluation tool, supported the assessment of: (1) the Context in which the Action Plan developed, (2) the Inputs and decisions made about selecting activities for implementation, (3) Processes or implementation of selected activities, and (4) Products and outcomes. MEASURES: A system framework consisting of 4 system functions and 5 system properties. RESULTS: The CIPP evaluation model provides a structure for tracking the components of the program, the relationship between components, and the way in which components change with time. The system framework allows the evaluation team to understand what the Action Plan is doing and how it aims to facilitate change in the healthcare system to address the problem of HAIs. CONCLUSIONS: With coordination and alignment becoming increasingly important among large programs within healthcare and other fields, program evaluations like this can inform the policy community about what works and why, and how future complex large-scale programs should be evaluated.

From research to nationwide implementation: the impact of AHRQ's HAI prevention program.

INTRODUCTION: The Agency for Healthcare Research and Quality (AHRQ's) Patient Safety Program is responsive to AHRQ's mission of quality improvement in healthcare. As part of this program, AHRQ has invested in projects to prevent healthcare-associated infections (HAIs), and funding has increased significantly over the last decade. AHRQ-funded projects have focused on generating new knowledge and promoting the nationwide implementation of proven HAI prevention measures in diverse healthcare settings. OBJECTIVES: To provide insight to AHRQ's HAI prevention strategies by: first, discussing the context and structure of AHRQ's HAI research portfolio and funding decisions; secondly, describing the process of prevention practice implementation and lessons learned; and third, explaining the outcomes and national impact of the AHRQ program. RESULTS AND CONCLUSIONS: In the early 2000s, AHRQ identified HAIs as an important and preventable public health threat and built their HAI-prevention portfolio based on National Action Plan priorities, available resources, advice from experts, and the state of science. This paper describes major contributions that have emerged from AHRQ-funded HAI projects. The projects examined, many of which focus on implementation of HAI prevention practices, yield useful lessons learned for future implementation and research endeavors and show significant impact of AHRQ's program in reducing HAIs.