Quality of hospital care of children with asthma: Medicaid versus privately insured patients.

Asthma is an important condition to study in the Medicaid population because it is the most frequent reason for hospital admission of Medicaid children, with rates substantially higher than those of non-Medicaid children. This study addressed how the quality of hospital care provided to children with asthma on Medicaid compares with that provided to privately insured children. Children inpatient records were studied in California, Georgia, and Michigan, comparing the care that was provided to standards created by a national panel of physician experts. Process-of-care analysis showed that Medicaid children in each state were more likely than privately insured children to be discharged on suboptimal medication regimens. This study concluded that hospitals serving Medicaid children, at least in these three states, are providing asthma inpatient care of fairly comparable quality to that of privately insured children. However, there remain significant problems surrounding outpatient medication regimens and follow-up care.

Developing episodes of care for adult asthma patients: a cautionary tale.

An episodes of care methodology examines the contiguous cluster of services related to a particular health condition. We developed an episodes methodology for evaluating the quality of health care delivery to privately insured adult asthma patients. Computer algorithms were used for episode construction beginning with an index asthma diagnosis and ending with a final clinical event, yielding a sample of 30,553 episodes. Only service claims with an asthma diagnosis were assigned to an episode. We used a database of private insurance claims from 1992 to 1993. Disease staging served as the framework for evaluating episodes with similar severity and resource use. We found that episodes of care can be constructed from claims data and have the potential for use in physician profiling and as quality screens. Certain limitations in using this methodology suggest that caution needs to be exercised in applying this approach to evaluation of health care services.

Repeated emergency department use by HIV-infected persons: effect of clinic accessibility and expertise in HIV care.

Repeated emergency department (ED) visits by HIV-infected persons may signify poor access to care or treatment from inexperienced ambulatory providers. We examined features of 157 clinics following 6820 HIV-infected patients and associations with repeated (> or =2) ED visits by these patients in the year before their first AIDS diagnosis. Patient clinical and health care data came from 1987-1992 New York State (NYS) Medicaid files and clinic data came from interviews of clinic directors. The HIV/AIDS experience of each study patient's clinic was measured as the annual number of Medicaid enrollees newly diagnosed with AIDS who were contemporaneously followed by the patient's clinic. Repeated ED use was observed for 24%. The adjusted odds ratio (AOR) of repeated ED visits was reduced for patients in clinics with a physician on-call (0.77; 95% confidence interval [CI] = 0.65, 0.92), evening or weekend clinic hours (0.77; 95% CI = 0.64, 0.93), or >50 AIDS patients/year in 1987-1988 (0.56; 95% CI = 0.44, 0.71) versus fewer patients in those years. Patients in clinics with more than one feature promoting accessibility or HIV expertise had a greater reduction in their AOR of repeated ED use. HIV-infected patients in clinics with greater accessibility and HIV expertise rely less on the ED for care.

Clinic services for persons with AIDS. Experience in a high-prevalence state.

OBJECTIVE: To profile characteristics of clinics caring for persons with advanced HIV infection. DESIGN AND SETTING: Survey of clinic directors in New York State. PARTICIPANTS: Newly diagnosed Medicaid-enrolled AIDS patients in New York state in federal fiscal years 1987-1992 (n = 6,184) managed by 62 HIV specialty, 53 hospital-based general medicine/primary care, 36 community-based primary care, and 28 other clinics. MEASUREMENTS AND MAIN RESULTS: Telephone survey about clinic hours, emphasis on HIV, staffing, procedures, and directors' rating of care. Estimates of the number of newly diagnosed, Medicaid-enrolled AIDS patients treated in surveyed clinics were obtained from claims data. We found that community-based clinics were significantly more likely to have longer hours, a physician on call, or to accommodate unscheduled care than were hospital-based general medicine/ primary care or other types of clinics. Compared with HIV specialty clinics, general medicine/primary care clinics were less likely to have HIV-specific care attributes such as a director of HIV care (98% vs 72%), multidisciplinary conferences on HIV care (83% vs 32%), or a standard initial HIV workup (90% vs 70%). Of general medicine/primary care clinics, most (83%) were staffed by residents and fellows compared with only 68% of HIV or 25% of community-based clinics (p < .001). General medicine/primary care clinics were less likely than community-based clinics to perform Pap smears (75% vs 94%) or to have case managers on payroll (21% vs 81%). CONCLUSIONS: In this sample of clinics, hospital-based general medicine/primary care clinics managing the care of Medicaid enrollees with AIDS appeared to have more limited hours and availability of specific services than HIV specialty or community-based clinics.

Association of maternal HIV infection with low birth weight.

We evaluated factors associated with low birth weight (LBW) in an HIV-infected cohort (n = 772) and a general sample (n = 2,377) of women delivering a live singleton in federal fiscal years 1989 and 1990 while enrolled in New York State Medicaid. The association of LBW and HIV infection was studied in logistic models, controlling for illicit drug use, demographic characteristics, adequacy of prenatal care, and medical risk factors. Overall, 29% of the HIV-infected women had a LBW infant compared to 9.3% of the general sample (p < 0.001). The adjusted odds of LBW for HIV-infected women were twofold higher than for uninfected women [odds ratio (OR) = 2.04 and 95% confidence interval (Cl) = 1.54, 2.69]. Odds of LBW were also increased for illicit drug users (OR = 2.16; 95% CI = 1.59, 2.94), cigarette smokers (OR = 1.81; 95% CI = 1.37, 2.39), and African-American versus non-Hispanic white women (OR = 1.89; 95% CI = 1.31, 2.72). Lower odds appeared for women with adequate prenatal care (OR = 0.54; 95% CI = 0.42, 0.68). Among only women with full-term deliveries, the association of HIV with LBW remained strong as we found nearly threefold greater odds of LBW for HIV-infected women. This study indicates that HIV-infected women have an increased risk of bearing a L.BW infant, even after adjusting for the effects of drug use, health care delivery, and other social and medical risk factors.

Health care delivery, zidovudine use, and survival of women and men with AIDS.

The aim of this study was to define predictors of survival for women and men after AIDS diagnosis. We examined health care delivery and drug therapy in the year before AIDS diagnosis for continuously enrolled New York State Medicaid beneficiaries with AIDS in 1988-1990. We examined the association of these factors with survival after AIDS diagnosis. Of 1,077 women and 1,871 men, 60% of both gender groups were drug users. In both risk groups, women had more outpatient visits than men but were equally likely to visit an AIDS specialist. In those who were not drug users, men were twice as likely as women to receive either zidovudine or Pneumocystis carinii pneumonia prophylaxis. No difference appeared among drug users. Survival after AIDS diagnosis was similar by gender for those who were not drug users (RR = 1.09; 95% CI = 0.90-1.33). In drug users, women had a slightly lower risk of death than men (RR = 0.84; 95% CI = 0.72-0.98). Risk of death after AIDS diagnosis was higher for persons starting zidovudine earlier in both risk groups. Among drug users, women received more ambulatory care and survived slightly longer than men. Among those who were not drug users, survival was similar by gender even after adjusting for differences in care.

Patterns of ambulatory care for AIDS patients, and association with emergency room use.

OBJECTIVE: We examined the association of patterns of ambulatory care for AIDS patients with any use of the emergency room (ER) and the monthly rate of ER visits in the six months after AIDS diagnosis. DATA SOURCES/STUDY SETTING: The study population was obtained from the New York State Medicaid HIV/AIDS Research Data Base and includes patients diagnosed with AIDS from 1983 to 1990. DATA COLLECTION/EXTRACTION METHODS: To examine patterns of care and ER use not leading to hospitalization, we studied patients who survived at least six months after their first AIDS-defining diagnosis. The data base included person level information on visits to different provider sites and patient demographic and clinical characteristics. STUDY DESIGN: We defined the dominant provider as the site delivering the majority of ambulatory care for patients with a minimum of four ambulatory visits in the six months after AIDS diagnosis. Dominant providers were classified by specialty and setting: generalist physician; general medicine clinic; AIDS specialty clinic; and other specialty clinic or physician (e.g., cardiology). Patients without a dominant provider were grouped into those with four or more visits and those with fewer than four visits. Regression analysis was used to estimate relationships between ER use and patterns of ambulatory care and patient demographic and severity of illness characteristics. PRINCIPAL RESULTS: The study population included 9,155 AIDS patients aged 13 to 60 years at diagnosis, continuously Medicaid-enrolled, and surviving at least six months after AIDS diagnosis. Among those with four or more visits (56 percent), over 70 percent had a dominant provider. Overall, 39 percent of the study population visited the ER while, in the group with four or more visits, 53 percent of those without a dominant provider had an ER visit. Patients without a dominant provider were estimated to have 32 percent higher odds of ER use than patients with a dominant provider. Among patients with a dominant provider, patients with a generalist or primary care clinic dominant site of care were estimated respectively to have 18 percent and 23 percent lower odds than patients with an AIDS specialty clinic as the dominant site of care. Drug users had higher odds of ER use, as did women. CONCLUSIONS: In this Medicaid AIDS population, a dominant provider delivering the majority of a patient's care was associated with less use of the ER by the patient. Among patients with a dominant provider, ER use was lowest for those with a primary care provider. Further examination of the type and availability of ambulatory services in AIDS specialty clinics and primary care settings, as well as more detailed information on patient characteristics, may reveal reasons for these patterns of ER use.

Patterns of Medicaid expenditures after AIDS diagnosis.

This article examines average monthly Medicaid expenditures after diagnosis of acquired immunodeficiency syndrome (AIDS) for the diagnosis, mid-illness, and death intervals, as well as Kaplan-Meier estimates of expenditures from AIDS diagnosis to death. A clinical severity measure (the Severity Index for Adults with AIDS [SIAA]) designed to be predictive of patient survival was applied to a population of continuously enrolled New York State Medicaid patients who survived at least 6 months after being diagnosed with AIDS. Our findings suggest that groups of more seriously ill patients who appear to have more intense demand for health care services, especially over the diagnosis and mid-illness intervals, can be identified using the SIAA.

Survival experience of 789 children with the acquired immunodeficiency syndrome.

To define predictors of survival we studied longitudinal histories of 789 New York State Medicaid-enrolled children diagnosed with acquired immunodeficiency syndrome (AIDS) from 1983 to 1989 and followed through 1990. Median survival times for 3 severity groups of AIDS-defining conditions were 66, 48 and 9 months. In a proportional hazards model, the relative risk of death for the most vs. least severe group was 3.33 (95% confidence interval, 2.53, 4.37) and the relative risk for children < 6 months old at diagnosis vs. older children was 1.81 (95% confidence interval, 1.41, 2.34). We increased our ability to predict death by using a 4-category severity index that assesses both the AIDS-defining diagnosis and clinical complications within 3 months of diagnosis (relative risk, 5.27; 95% confidence interval, 3.16, 8.78 for most vs. least severe). These analyses offer new clinical severity measures and reveal that, regardless of the AIDS-defining diagnosis, children with AIDS who are < 6 months old have a poor prognosis.

Predicting hospital choice for rural Medicare beneficiaries: the role of severity of illness.

Previous research has confirmed that desirable hospital attributes as well as increased distance, or travel time, have an impact on hospital choice. These studies have become increasingly sophisticated in modeling choice. This study adds to the existing literature by estimating the effect of both hospital and individual characteristics on hospital choice, using McFadden's conditional logit model. Some patient characteristics have not previously been accounted for in this type of analysis. In particular, the effect of a patient's complexity of illness (as measured by Disease Staging) on the choice of hospital is taken into account. The data consist of over 12,000 Medicare discharges in three overlapping rural market areas during 1986. The hospital choice set was aggregated into seven groups of urban and rural hospitals. Results indicate that rural Medicare beneficiaries tend to choose hospitals with a large scope of service and with teaching activity over those with a lower scope of service and no teaching activity, holding other factors constant. Distance is a deterrent to hospital choice, especially for older Medicare beneficiaries. The more complex cases tend to choose larger urban and rural hospitals over small rural hospitals more often than less complex cases do.

The AIDS-defining diagnosis and subsequent complications: a survival-based severity index.

To define a survival-based severity measure for AIDS, we convened a panel of AIDS experts who identified factors influencing AIDS prognosis and estimated the impact of prognostic factors on survival time. The resulting conceptual model included 19 AIDS-defining conditions and 80 subsequent AIDS-related complications. This model was tested on longitudinal disease histories of 3,937 AIDS patients in the New York State Medicaid Program diagnosed between 1983 and 1986 and followed through 1988. The initial AIDS diagnosis and complications within 3 months of AIDS onset were identified from coded diagnoses recorded on inpatient and outpatient claims. Three AIDS-defining diagnosis groups were created; survival times from least to most severe group were 25, 10, and 7 months. To determine the influence of subsequent complications on risk of death, the survival times associated with combinations of defining diagnosis groups and four severity levels of subsequent complications were determined. Median survival ranged from 43 months for the least severe defining diagnosis group without early complications to 12 months for the group with severe defining diagnoses and serious complications. The matrix of AIDS-defining diagnoses and complications was divided into four severity categories with significantly different survival curves. This severity measure uses longitudinal data commonly available to clinicians and researchers to create distinct AIDS prognostic categories.