When is the story in the subgroups? Strategies for interpreting and reporting intervention effects for subgroups.

This paper examines strategies for interpreting and reporting estimates of intervention effects for subgroups of a study sample. The paper considers: why and how subgroup findings are important for applied research, alternative ways to define subgroups, different research questions that motivate subgroup analyses, the importance of pre-specifying subgroups before analyses are conducted, the importance of using existing theory and prior research to distinguish between subgroups for whom study findings are confirmatory (hypothesis testing) as opposed to exploratory (hypothesis generating), and the conditions under which study findings should be considered confirmatory. Each issue is illustrated by selected empirical examples.

The effects of health care benefits on health care use and health: a randomized trial for disability insurance beneficiaries.

BACKGROUND: Under current law, most Social Security Disability Insurance (SSDI) beneficiaries are not eligible for Medicare until 29 months after the Social Security Administration determines the onset of their disability. During this waiting period, >1 in 5 lacks health insurance. This study investigated the effects of providing health care benefits on the health, employment, and other services of uninsured beneficiaries. METHODS: New SSDI beneficiaries without health insurance were randomly assigned to receive health care benefits, health care benefits plus additional supports, or a control group. RESULTS: Compared with a control group, those provided health care benefits used more health care, had fewer unmet medical needs, spent less out of pocket on health care, and reported improved health. In addition, those provided the additional supports were more likely to look for work, but the supports did not affect work or SSDI benefits at this very early period. CONCLUSIONS: The results provide rigorous evidence that health care benefits can increase health care use and health outcomes. Longer-term follow-up is needed to fully assess the program's effects on its ultimate benefits and costs, including its long-term effects on health, employment, and benefit receipt.

Explaining variation in the effects of welfare-to-work programs.

Evaluations of government-funded training programs often combine results from similar operations in multiple sites. Findings inevitably vary. It is common to relate site-to-site variations in outcomes to variations in program design, participant characteristics, and the local environment. Frequently, such connections are constructed in a narrative synthesis of multisite results. This article uses findings from the evaluations of California's Greater Avenues for Independence (GAIN) program and the National Evaluation of Welfare-to-Work Strategies (NEWWS) to illustrate why it is important to question the legitimacy of such syntheses. The discussion is carried out using a simple multilevel evaluation model that incorporates models of both individual outcomes within sites and variation in program effects across sites. The results indicate that tempting generalizations about GAIN and NEWWS effects are statistically unjustified but that significant progress might be made in identifying the determinants of program effects in future demonstrations with some changes in evaluation strategy.

Telephone care management's effectiveness in coordinating care for Medicaid beneficiaries in managed care: a randomized controlled study.

OBJECTIVE: To test the effectiveness of a telephone care management intervention to increase the use of primary and preventive care, reduce hospital admissions, and reduce emergency department visits for Medicaid beneficiaries with disabilities in a managed care setting. DATA SOURCE: Four years (2007-2011) of Medicaid claims data on blind and/or disabled beneficiaries, aged 20-64. STUDY DESIGN: Randomized control trial with an intervention group (n = 3,540) that was enrolled in managed care with telephone care management and a control group (n = 1,524) who remained in fee-for-service system without care management services. Multi-disciplinary care coordination teams provided telephone services to the intervention group to address patients' medical and social needs. DATA COLLECTION/EXTRACTION: Medicaid claims and encounter data for all participants were obtained from the state and the managed care organization. PRINCIPAL FINDINGS: There was no significant difference in use of primary care, specialist visits, hospital admissions, and emergency department between the intervention and the control group. Care managers experienced challenges in keeping members engaged in the intervention and maintaining contact by telephone. CONCLUSIONS: The lack of success for Medicaid beneficiaries, along with other recent studies, suggests that more intensive and more targeted interventions may be more effective for the high-needs population.

Does telephone care management help Medicaid beneficiaries with depression?

OBJECTIVES: While telephone care management has shown promise as a cost-effective approach to manage patients with depression, there is little evidence on the effectiveness of this method for Medicaid beneficiaries in managed care. This study examines a 1-year telephone care management intervention designed to help this low-income, hard-to-reach population enter and remain engaged with treatment. STUDY DESIGN: A randomized controlled trial of 499 Rhode Island Medicaid managed care beneficiaries with depression (all parents, average age of 35, and 90% women). Care managers conducted telephonic outreach with the intervention group to establish a relationship, initiate treatment, make referrals for in-person psychotherapy and/or medication treatment, and monitor treatment progress. The control group received usual care and was given a referral list of providers participating in the Medicaid program. METHODS: Primary outcomes were the use of health services and depression severity at 6 and 18 months. Administrative claims provided information on medical and mental health services use. Surveys of sample members provided information on depression severity. Analysis controlling for sociodemographic characteristics was done to assess the effectiveness of providing care management. RESULTS: Care managers contacted 91% of those assigned to the intervention group. The intervention was effective in enrolling participants into mental health services (42% in intervention group vs 31% in control; P = .05), but did not successfully reduce average depression severity. CONCLUSIONS: The intervention's lack of success in reducing depression severity for Medicaid beneficiaries suggests the need for more intensive interventions that strengthen telephone care management and potentially include in-person components as well.