Research on the Tufts Be Well at Work Program for Employees With Depression: 2005-2020.

OBJECTIVE: Although depression is a prevalent and costly health problem exacting a large toll on work productivity, interventions targeting occupational functioning are rare. This article describes the development of the Tufts Be Well at Work intervention, a brief telephonic program designed to improve occupational functioning among employees with depression and reduce depression symptom severity. Results from 15 years of research are summarized evaluating the occupational, clinical, and economic impact of Be Well at Work. METHODS: The design, methods, and results of all six Tufts Be Well at Work studies are reported. Studies included an initial workplace pilot study, two workplace randomized clinical trials (RCTs), one RCT in a health care system, and two pilot implementation studies conducted in a workplace and in an academic medical center. RCTs compared Tufts Be Well at Work to usual care. RESULTS: Tufts Be Well at Work consistently and significantly improved occupational functioning, work productivity, and depression symptom severity. Employees randomly assigned to usual care experienced smaller gains. The program also delivered a positive return on investment. CONCLUSIONS: Evidence suggests that Tufts Be Well at Work is an effective intervention for improving occupational and clinical functioning. Its relatively low cost and its impact on work productivity contribute to its positive economic impact.

A Population-Based Survey of the Workplace Costs for Caregivers of Persons With Treatment-Resistant Depression Compared With Other Health Conditions.

OBJECTIVE: To describe caregiving work outcomes and related indirect (ie, productivity) and direct (ie, caregiving hours and expenses) costs. METHODS: A national, population-based survey to identify employed caregivers assisting a person with treatment-resistant depression (TRD) and a comparison group of employed caregivers assisting others (No TRD). RESULTS: Screening identified 169 TRD caregivers and 1070 No TRD caregivers providing 23.3 and 14.6 mean weekly caregiving hours, respectively. Adjusted annual indirect cost estimates were $11,121 for caregivers of TRD and $7761 for caregivers in the No TRD group (P ≤ 0.0001). At-work productivity loss (presenteeism) was the largest component. Adjusted annual direct cost estimates were $29,805 for caregivers of TRD and $20,642 for caregivers in the No TRD group (P ≤ 0.0001). CONCLUSIONS: TRD exacts a toll on caregivers and their employers exceeding that for other caregivers.

Performance of a short, self-report adherence scale in a probability sample of persons using HIV antiretroviral therapy in the United States.

BACKGROUND: Excellent adherence to HIV antiretroviral therapy (ART) remains a cornerstone of HIV care. A three-item adherence self-report scale was recently developed and validated, but the scale has not been previously tested in a nationally representative sample. DESIGN: We administered the adherence scale to participants in the Centers for Disease Control and Prevention's Medical Monitoring Project, which is a probability sample of US adults with diagnosed HIV. METHODS: We combined sociodemographic and clinical participant data from three consecutive cycles of the Medical Monitoring Project (6/2015-5/2018). We used medical record reviews to determine most recent viral load, and whether viral loads were suppressed at all measurement points in the past 12 months. We describe the relationship between adherence scale score and two measures of viral load suppression (most recent and sustained), and estimate linear regression models using sampling weights to determine independent predictors of ART adherence scores. RESULTS: Of those using ART, the median adherence score was 93 (100 = perfect adherence), and the standardized Cronbach's alpha was 0.83. For both measures of viral load suppression, the relationship with the adherence score was generally linear; there was no 'cutoff' point indicating good vs. poor adherence. In the multivariable model, younger age, nonwhite race, poverty, homelessness, depression, binge-drinking, and both non-IDU and IDU were independently associated with lower adherence. CONCLUSION: The adherence measure had good psychometric qualities and a linear relationship with viral load, supporting its use in both clinical care and research. Adherence interventions should focus on persons with the highest risk of poor adherence.

Effect of Adding a Work-Focused Intervention to Integrated Care for Depression in the Veterans Health Administration: A Randomized Clinical Trial.

Importance: Thousands of working-age veterans with depression experience impaired occupational functioning. Objectives: To test whether the Veterans Health Administration (VHA) integrated care (IC) program combined with telephonic work-focused counseling, known as Be Well at Work (BWAW), is superior to IC alone for improving occupational functioning and depression, to determine whether these effects persist 4 months later, and to determine whether the return on investment is positive. Design, Setting, and Participants: In this randomized clinical trial conducted from October 21, 2014, to December 6, 2019, patients undergoing IC at VHA facilities were screened for eligibility and randomized to IC alone or IC plus BWAW. Blinded interviewers administered questionnaires before the intervention, immediately after completion of the intervention at month 4, and at month 8. Eligibility criteria were individuals 18 years or older who were working at least 15 hours per week in a job they had occupied for at least 6 months, were experiencing work limitations, and had current major depressive disorder or persistent depressive disorder. Exclusion criteria were individuals who could not read or speak English, had planned maternity leave, or had a history of bipolar disorder or psychosis. Data analyses were conducted from January 1, 2018, to December 6, 2019. Interventions: Integrated care is multidisciplinary depression care involving screening, clinical informatics, measurement-based care, brief behavioral interventions, and referral as needed to specialty mental health care. Be Well at Work counseling involves 8 biweekly telephone sessions and 1 telephone booster visit after 4 months. Doctoral-level psychologists helped patients to identify barriers to functioning and to adopt new work-focused cognitive-behavioral and work-modification strategies. Main Outcomes and Measures: The primary outcome was the adjusted mean group difference in changes from before to after intervention (hereafter, adjusted effect) in the percentage of at-work productivity loss, measured with the Work Limitations Questionnaire (range, 0%-25%). The secondary outcome was adjusted effect in the Patient Health Questionnaire 9-item symptom severity score (range, 0-27, with 0 indicating no symptoms and 27, severe symptoms). Results: Of 670 veterans referred for participation, 287 veterans (42.8%) consented and completed eligibility screening, and 253 veterans (37.8%) were randomized. Among these 253 patients (mean [SD] age, 45.7 [11.6] years; 218 [86.2%] men; 135 [53.4%] white), 114 (45.1%) were randomized to IC and 139 (54.9%) were randomized to IC plus BWAW. At the 4-month follow-up, patients who received IC plus BWAW had greater reductions in at-work productivity loss (adjusted effect, -1.7; 95% CI, -3.1 to -0.4; P = .01) and depression symptom severity (adjusted effect, -2.1; 95% CI, -3.5 to -0.7; P = .003). The improvements from IC plus BWAW persisted 4 months after intervention (at-work productivity loss mean difference, -0.5; 95% CI, -1.9 to 0.9; P = .46; depression symptom severity mean difference, 0.6; 95% CI -0.9 to 2.1; P = .44). The cost per patient participating in BWAW was $690.98, and the return on investment was 160%. Conclusions and Relevance: These findings suggest that adding this work-focused intervention to IC improves veterans' occupational and psychiatric outcomes, reducing obstacles to having a productive civilian life. Trial Registration: ClinicalTrials.gov Identifier: NCT02111811.

Analysis of the Full Economic Cost for Japanese Encephalitis Under Different Risk Scenarios for Business Travelers to Asia.

OBJECTIVE: Methods for assessing the costs and benefits of administering vaccines to international business/occupational travelers, assignees, and expatriates have neglected the impact of health and treatment on work productivity. The research objective is to evaluate the benefit to cost ratio of the Japanese encephalitis (JE) vaccine for international business/occupational travelers to Asia and other endemic areas incorporating a health and productivity approach. METHODS: Costs and benefits were estimated using actuarial methods with data obtained from secondary sources describing prevalence of infection risk and health outcomes, and business traveler demographic and travel characteristics. Results assumed 2018 salaries and prices, with employee time valued according to total compensation. RESULTS: Risks contracting JE vary widely on the basis of length of trip, season, and destination. The productivity benefits of vaccinating a traveler outweigh the vaccination costs for those staying 30 days or longer in endemic areas during one or more transmission seasons ($2009 vs $750 per traveler), and for business travelers to endemic areas during the transmission season with outdoor activities for the average 2-week/15.4-day international business trip ($502 to $815 vs $500). Vaccination costs outweigh the productivity benefits for short-term travelers who remain in urban areas or travel outside of the transmission season ($10 vs $500). CONCLUSION: JE Vaccination for business travelers in the active transmission season has a net benefit under certain conditions that are not commonly considered risky, such as average-length trips to peri-urban areas, in situations where contracting disease would result in significant business disruption, or when multiple trips are anticipated over several years.

Factors associated with patient recall of key information in ambulatory specialty care visits: Results of an innovative methodology.

While some studies have assessed patient recall of important information from ambulatory care visits, none has done so recently. Furthermore, little is known about features of clinical interactions which are associated with patient understanding and recall, without which shared decision making, a widely shared ideal for patient care, cannot occur. Our objective was to evaluate characteristics of patients and outpatient encounters associated with patient recall of information after one week, along with observation of elements of shared decision making. This was an observational study based on coded transcripts of 189 outpatient encounters, and post-visit interviews with patients 1 week later. Coding used three previously validated systems, adopted for this study. Forty-nine percent of decisions and recommendations were recalled accurately without prompting; 36% recalled with a prompt; 15% recalled erroneously or not at all. Provider behaviors hypothesized to be associated with patient recall, such as open-questioning and "teach back," were rare. Patients with less than high school education recalled 38% of items freely and accurately, while patients with a college degree recalled 65% (p < .0001). In a multivariate model, the total number of items to be recalled per visit, and percentage of utterances in decision-making processes by the provider ("verbal dominance"), were significant predictors of poorer recall. The item count was associated with poorer recall for lower, but not higher, educated patients.

Psychological Distress Among Caregivers of Individuals With a Diagnosis of Schizophrenia or Schizoaffective Disorder.

OBJECTIVE: The aim was to quantify caregiver distress among informal caregivers of individuals with schizophrenia or schizoaffective disorder and identify its correlates. METHODS: From December 2014 through April 2015, ads posted with mental health advocates and the media recruited informal caregivers, age ≥21 years, to complete an online questionnaire. It included the ten-item Perceived Stress Scale (PSS) (0, no distress; 39, highest) and hypothesized distress correlates in four groups: caregiver and care recipient characteristics; caregiver role demands; caregiver social supports; and caregiver cognitive appraisals of caregiving. Three hypotheses were tested: first, distress is significantly related to variables from each group; second, social supports moderate the effects of role demands on distress; and third, cognitive appraisals mediate the effects of role demands on distress. Hypotheses were tested with multiple linear regression equations and structural equation models (SEMs). RESULTS: Of 2,338 Web site "hits," 1,708 individuals consented, 1,398 were eligible, and 1,142 had complete data. Most caregivers were women (83%), white (89%), and college educated (59%), with a mean±SD age of 55.6±13.0. Compared with U.S. norms on the PSS (13.4±6.5), mean caregiver distress was high (18.9±7.1). According to SEMs, variables from each group were associated with distress. Contributing most to greater distress were caregiver health problems, providing frequent caregiving assistance, monitoring medication, having limited social support, and appraising caregiving negatively. Cognitive appraisals mediated the effects of demands on distress. Social support had a significant direct effect only. CONCLUSIONS: Caregiver distress was relatively high and related to multiple variables, some of which are potentially modifiable.

Measuring the Work Impact of Caregiving for Individuals With Schizophrenia and/or Schizoaffective Disorder With the Caregiver Work Limitations Questionnaire (WLQ).

OBJECTIVE: The aim of this study was to test the reliability, validity, and responsiveness of the Caregiver Work Limitations Questionnaire (WLQ) for employed caregivers of individuals with schizophrenia and/or schizoaffective disorder. METHODS: A cross-sectional web-based survey with test/retest and responsiveness test components was administered to informal caregivers. Using data from employed caregivers, psychometric tests were performed of the questionnaire's four at-work limitation scales and work absence score. RESULTS: Of 1142 eligible caregivers, 710 (62.2%) were employed. On the basis of the 4-week recall period, caregivers were limited in performing work tasks approximately between 20% and 30% of the time on average and absent a mean of 2 to 3 days. With few exceptions, the Caregiver WLQ demonstrated scale homogeneity, test/retest reliability, construct validity, and responsiveness to change. CONCLUSION: The Caregiver WLQ provides new information about the impact of caregiving on employment.

Prescriber and pharmacy variation in patient adherence to five medication classes measured using implementation during persistent episodes.

PURPOSE: The objective of this study was to determine the fraction of variance in patient-level medication adherence accounted for by prescribers and pharmacies. METHODS: We used prescription drug claims paid between January 2010 and July 2011 to a national pharmacy benefits manager to define implementation during persistent episodes. Patients in Massachusetts or Rhode Island covered by Blue Cross Blue Shield of Rhode Island and their prescribers were included. Five drug classes were analyzed: angiotensin converting enzyme (ACE) inhibitors, antihyperglycemics (ANHGs), drugs for prostatic hyperplasia (PH), statins, and levothyroxine (THYR). We performed mixed models with random intercepts (drug, patient, prescriber, and pharmacy) and examined the fraction of variance explained at each level using intraclass correlations. RESULTS: Overall implementation ranged from 87 to 91%. The fraction of the explained variance in implementation to ACEs, ANHG, PH, statins, and THYR accounted for by prescribers was 16.4%, 12.6%, 14.6%, 15.6%, and 15% respectively; and for pharmacies 20.4%, 20%, 15.2%, 10.6%, and 9.4%, respectively. CONCLUSIONS: Prescriber and pharmacy effects accounted for a substantial amount of the explained variance in implementation across all five drug classes. Adherence interventions for chronic conditions that target prescribers and pharmacies, in addition to patients, could be effective and efficient. Copyright © 2016 John Wiley & Sons, Ltd.

Validation of a New Three-Item Self-Report Measure for Medication Adherence.

Few self-report measures of medication adherence have been rigorously developed and validated against electronic drug monitoring (EDM). Assess the validity of the 3-item self-report scale by comparing it with a contemporaneous EDM measure. We conducted an observational study in which adherence assessments were done monthly for up to 4 months for 81 patients with HIV who were taking antiretroviral medications. We report results for both HIV antiretroviral medications, and also for other, non-HIV-related medications. Raw and calibrated self-report adherence measures, electronic drug monitoring adherence measures, and sociodemographic variables. The mean age of patients was 46 years, 37 % were female, 49 % had some education beyond high school, 22 % were Black, and 22 % were Hispanic. Cronbach's alphas for the 3-item scale for HIV and non-HIV medications were 0.83 and 0.87, respectively. The mean differences (raw/uncalibrated self-report scale minus EDM) for HIV and non-HIV medications were 7.5 and 5.2 points on a 100-point scale (p < 0.05 for both). Pearson correlation coefficients between the calibrated 3-item scale and the EDM for HIV and non-HIV medications were 0.47 and 0.59, respectively. The c-statistics for the ROC curves for the calibrated scale, using cut-offs of 0.8 and 0.9 for the EDM gold standard measure to define non-adherence, were between 0.74 and 0.76 for HIV and non-HIV medications. This 3-item adherence self-report scale showed good psychometric characteristics and good construct validity when compared with an EDM standard, for both HIV and non-HIV medications. In clinical care it can be a useful first-stage screener for non-adherence. In clinical research and quality improvement settings it can be a useful tool when more complex and expensive methods such as EDM or pharmacy claims are impractical or unavailable.

Improving work outcomes of dysthymia (persistent depressive disorder) in an employed population.

OBJECTIVE: To test the effectiveness of a work-focused intervention (WFI) on the work outcomes of employed adults with dysthymia. METHOD: This subgroup analysis from a randomized controlled trial compares an initial sample of 167 employees (age: ≥45 years), screened for dysthymia using the PC-SAD without current major depressive disorder randomized to WFI (n=85) or usual care (UC) (n=82). Study sites included 19 employers and five additional organizations. Telephone-based WFI counseling (eight, twice monthly 50-min sessions) provided work coaching and modification, care coordination and cognitive behavioral therapy. Adjusted mixed effects models compared the WFI vs. UC group preintervention to 4-month postintervention change in at-work limitations measured by the Work Limitations Questionnaire. Secondary outcome analysis compared the change in self-reported absences and depression symptom severity (Patient Health Questionnaire PHQ-9 scores). RESULTS: Work productivity loss scores improved 43.0% in the WFI group vs. 4.8% in UC (difference in change: P<.001). Absence days declined by 58.3% in WFI vs. 0.0% in UC (difference in change: P=.09). Mean PHQ-9 depression symptom severity declined 44.2% in WFI vs. 5.3% in UC (difference in change: P<.001). CONCLUSION: At 4 months, the WFI was more effective than UC on two of the three outcomes. It could be an important mental and functional health improvement resource for the employed dysthymic population.

A randomized clinical trial of a telephone depression intervention to reduce employee presenteeism and absenteeism.

OBJECTIVES: The study tested an intervention aimed at improving work functioning among middle-aged and older adults with depression and work limitations. METHODS: A randomized clinical trial allocated an initial sample of 431 eligible employed adults (age ≥45) to a work-focused intervention (WFI) or usual care. Inclusion criteria were depression as measured by the Patient Health Questionnaire-9 (PHQ-9) and at-work limitations indicated by a productivity loss score ≥5% on the Work Limitations Questionnaire (WLQ). Study sites included 19 employers and five related organizations. Telephone-based counseling provided three integrated modalities: care coordination, cognitive-behavioral therapy strategy development, and work coaching and modification. Effectiveness (change in productivity loss scores from preintervention to four months postintervention) was tested with mixed models adjusted for confounders. Secondary outcomes included change in WLQ work performance scales, self-reported absences, and depression. RESULTS: Of 1,227 eligible employees (7% of screened), 431 (35%) enrolled and 380 completed the study (12% attrition). At-work productivity loss improved 44% in the WFI group versus 13% in usual care (difference in change, p<.001). WFI group scores on the four WLQ scales improved 44% to 47%, significantly better than in usual care (p<.001 for each scale). Absence days declined by 53% in the WFI group versus 13% in usual care (difference in change, p<.001). Mean PHQ-9 depression symptom severity scores declined 51% for WFI versus 26% for usual care (difference in change, p<.001). CONCLUSIONS: The WFI was more effective than usual care at four-month follow-up. Given increasing efforts to provide more patient-centered, value-based care, the WFI could be an important resource.

The health care and productivity costs of back and neck pain in a multi-employer sample of utility industry employees.

OBJECTIVE: To determine the cost of back and/or neck (B/N) pain among predominantly rural employees insured through an employee benefits trust. METHODS: Eligible employees had 1 year or more of medical coverage and completed a survey subsequently linked to their claims data. B/N pain costs consisted of medical and pharmacy claims, over-the-counter expenses, and presenteeism and absenteeism costs valued according to median occupational earnings. RESULTS: Of 1342 eligible employees, 52.7% currently had B/N pain of which 87.9% was chronic. The average annualized cost of B/N pain per employee was $1727; 56.1% was due to lost productivity. Covered medical care was utilized by 35.6% of employees, 55.7% used pharmacy care, and 71.6% purchased uncovered over-the-counter pain medication. CONCLUSIONS: Many covered employees did not use formal care. The effect of care choices on productivity costs requires closer scrutiny.

Four types of barriers to adherence of antiretroviral therapy are associated with decreased adherence over time.

The objectives of this study were to understand how different types of barriers to adherence to antiretroviral therapy (ART) were related and their differential impact on objectively measured adherence over time. Data from 151 patients taking ART were used to describe four sub-types of self-reported adherence barriers: medication and health concerns (MHC), stigma (S), family responsibilities (FR), and problems with schedule and routine (PSR). Generalized linear models with generalized estimating equations (GEE) were used to examine the impact of barriers on adherence over time. The sample was 23 % female, mean age 42 years, with 26 % African-American and 20 % Hispanic. The overall average adherence was 73 %. Patients reported at least one PSR barrier in 66 % of study visits, MHC in 40 %, S in 17 %, and FR in 6 %. In 40 % of visits, patients reported two or more barrier sub-types. There were statistically significant (p ≤ 0.05) decreases of 3.9, 2.5, and 2.4 in percent adherence, for MHC, PSR, and S, respectively, per unit increase in barrier score. Interventions to address different types of patient-identified barriers to ART adherence using targeted approaches are needed.

Provider-patient communication about adherence to anti-retroviral regimens differs by patient race and ethnicity.

Disparities in HIV care and outcomes negatively affect Black and Hispanic patients. Features of clinical communication may be a factor. This study is based on coding transcripts of 404 routine outpatient visits by people with HIV at four sites, using a validated system. In models adjusting for site and patient characteristics, with provider as a random effect, providers were more "verbally dominant" with Black patients than with others. There was more discussion about ARV adherence with both Black and Hispanic patients, but no more discussion about strategies to improve adherence. Providers made more directive utterances discussing ARV treatment with Hispanic patients. Possible interpretations of these findings are that providers are less confident in Black and Hispanic patients to be adherent; that they place too much confidence in their White, non-Hispanic patients; or that patients differentially want such discussion. The lack of specific problem solving and high provider directiveness suggests areas for improvement.

Cognitive and field testing of a new set of medication adherence self-report items for HIV care.

We conducted four rounds of cognitive testing of self-report items that included 66 sociodemographically diverse participants, then field tested the three best items from the cognitive testing in a clinic waiting room (N = 351) and in an online social networking site for men who have sex with men (N = 6,485). As part of the online survey we conducted a randomized assessment of two versions of the adherence questionnaire-one which asked about adherence to a specific antiretroviral medication, and a second which asked about adherence to their "HIV medicines" as a group. Participants were better able to respond using adjectival and adverbial scales than visual analogue or percent items. The internal consistency reliability of the three item adherence scale was 0.89. Mean scores for the two different versions of the online survey were similar (91.0 vs. 90.2, p < 0.05), suggesting that it is not necessary, in general, to ask about individual medications in an antiretroviral therapy regimen when attempting to describe overall adherence.

Blending group and practice site scores to increase the reliability of physician quality information.

OBJECTIVE: To use an empirical Bayesian approach, blending practice, and group quality data with physician results to increase the accuracy of quality of care measures. DATA SOURCES: Performance data on diabetes glycemic screening for 8,357 physicians collected from multiple payers as part of a statewide physician performance reporting initiative. STUDY DESIGN: A variance components analysis assessed the strength of group, practice, and physician effects compared with random error. We derived formulas to describe reliability and measurement error variances and calculated the optimal blend of physician, practice, and group data. We constructed a simulation to show what various methods can achieve. The value of blending strategies was assessed by simulating a common pay-for-performance criterion-performance in the top 25 percent. We estimated the proportion of physicians whose true percentage would place them in the top 20 percent but who would not receive payment based on the observed success rate. PRINCIPAL FINDINGS: Blending reduced the error rate from 29.7 to 22.7 percent. Simpler empirical Bayes estimates using shrinkage alone produced no gains over simple doctor percentages. CONCLUSIONS: When good structural data about physician groups and practices exist, gains from blending can be substantial.

Stages of change for adherence to antiretroviral medications.

Providers do not predict reliably which of their HIV-positive patients are having difficulty adhering to antiretroviral therapy (ART). The transtheoretical, or stages of change model, may be a useful tool to help providers identify patients who are having difficulty with ART adherence. The objective of the current study was to determine the relationship between stages of change and ART adherence among patients who were actively taking ART. Data from a randomized trial of a provider-focused intervention were used to examine the relationship between the stages of change and adherence, measured using electronic monitoring devices in the 30 days following the stages of change assessment. Individuals were eligible for inclusion if they were taking ART and had detectable plasma viral load (HIV-RNA). Repeated measures analysis of covariance was used to determine the impact of stages of change on adherence after controlling for potential confounders. The sample of 137 participants was 22% female, 48% white, 28% African-American, with a mean age of 42 years. Fifty-eight percent reported sex with a man as an HIV risk factor, while 13% reported sex with a woman, 14% reported injecting drugs and 15% reported other risk factors. In adjusted models, those in earlier stages of change (i.e., contemplation and preparation) had significantly lower adherence (-9.8%, p=0.04) compared to those in the action and maintenance phases. No demographic characteristics predicted adherence. The stages of change model may function as a screening tool for clinicians to discover patients at-risk of lower adherence.

Development and validation of a cystic fibrosis patient and family member experience of care survey.

OBJECTIVE: The purpose of this study was to develop a cystic fibrosis (CF)-specific patient and family experience of care survey that CF care centers could use to inform quality improvement efforts. METHODS: A literature search and query of CF care centers was conducted to identify existing surveys. Individuals with CF, their families, and health care professionals were also asked what to include. Following this process, a draft survey was developed and then reviewed by focus groups. Finally, a version was piloted at 25 CF care centers to validate and further refine the instrument. RESULTS: No CF-specific surveys were found in the literature. Focus group participants stated that they understood the survey questions and that they covered important aspects of care, particularly infection control. The pilot test of the instrument with 485 participants supported its validity by demonstrating significant differences across centers and that most of the 3 care dimensions had acceptable internal consistency (Cronbach α: adults, 0.71-0.85; children, 0.68-0.79). CONCLUSION: A CF-specific patient and family experience of care survey was developed with input from individuals with CF, their families, and health care professionals. The instrument was validated and has been deployed to CF care centers.

Guideline-recommended medications: variation across Medicare Advantage plans and associated mortality.

OBJECTIVES: To evaluate variation in the prescription of guideline-recommended medications across Medicare Advantage (MA) plans and to determine whether such variation is associated with increased mortality. METHODS: Observational study of 111,667 patients aged 65 years or older receiving care in 203 MA plans. We linked data from the Medicare Health Outcomes (HOS) Survey cohort 9 (April 2006-May 2008) with the Medicare Part D prescription benefit files (January 1, 2006-December 31, 2007) to examine variation in treatment across MA plans and its association with differences in observed (O)/expected (E) mortality ratio for 5 high-volume chronic conditions: diabetes, coronary artery disease (CAD), congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD)/asthma, and depression. RESULTS: Analysis of variance confirmed that the 203 MA plans differed significantly in their use of guideline-recommended treatment (P≤0.02). Those MA plans with higher use of angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers (r=-0.40; P<0.0001) and beta-blockers (r=-0.27; P<0.0001) in patients with CHF were significantly associated with lower O/E mortality ratios. Those MA plans with higher use of multiple guideline-recommended medications were significantly associated with lower O/E mortality ratios in CHF (r=-0.45; P<0.0001) and diabetes (r=-0.14; P<0.042). There were no significant associations between the variation in performance indicators and mortality ratios in patients with CAD and COPD/asthma. Those MA plans with higher use of antidepressant medications had significantly higher O/E mortality ratios (r=0.28, P<0.0001). CONCLUSIONS: There was wide variation across MA plans in the prescription of guideline-recommended medications that had a measurable relationship to the mortality of elderly patients with CHF and diabetes. These findings can serve to both motivate and target quality improvement programs.