Listening to the nurse pays off: an integrated Nurse HealthLine programme was associated with significant cost savings.

AIM: To estimate the relationship between adherence to nurse recommendations about where to seek care and expenditures for health-care services received by callers to a Nurse HealthLine telephone-based triage programme. METHODS: Health-care utilization and claims data from callers to the Nurse HealthLine were included. Adherent callers were those who followed the nurse recommendations, while those who did not were classified as non-adherent. Programme-related savings were estimated using differences in downstream health-care expenditures between adherent and non-adherent callers after using multivariate modelling to adjust for between-group differences. RESULTS: Fifty-five per cent of callers were adherent. Nurses were over three times as likely (41% vs. 13%) to recommend seeking a higher level of care (e.g. emergency room vs. urgent care). Regression analyses showed that the impact of getting members to the appropriate place of care was associated with significant annual savings of $13.8 million (P < 0.05), attributable mostly to Medicare, generating a positive return on investment of $1.59. CONCLUSIONS: This is the first known Nurse HealthLine triage programme exclusively for Medicare beneficiaries with supplemental coverage. IMPLICATIONS FOR NURSING MANAGEMENT: Nurse managers should consider promoting telephone-based triage programmes as complementary to clinical nursing, which has a direct impact on health-care utilization and costs.

Barriers to managing coronary artery disease among older women.

Numerous barriers to managing coronary artery disease (CAD) among older women are reported in the literature; however, few studies adjust for demographic and health status differences. A survey assessing barriers and other factors was distributed to a stratified random sampling of older women with CAD. Factor analysis and multiple logistic regression procedures were used to estimate the impact of these issues on receiving a CAD-related office visit. The most problematic barriers included denial and low health literacy. Efforts to promote patient awareness of heart health and better communication between patients and clinicians may alleviate these barriers.

Melding regulatory, pharmaceutical industry, and U.S. payer perspectives on improving approaches to heterogeneity of treatment effect in research and practice.

Effective pursuit of the science and management of heterogeneity of treatment effect (HTE) relies on the mutual understanding of the perspectives of, and collaboration among, the various stakeholders in health care. In this article, we compare, contrast, and endeavor to find areas of alignment across the perspectives of three such stakeholders -regulators, the biopharmaceutical and device industry, and U.S. payers. First, we discuss how evidence of HTE is generated and could be improved upon. For pharmaceuticals, much of the initial research is conducted by the pharmaceutical industry, guided by basic science but also delimited by potential markets, regulatory approval requirements, trial size considerations, and payer expectations for evidence of value. Once a drug is marketed, further evidence can be generated via combining trial data, conducting meta-analysis, and analyzing real-world results through observational research designs; we explore how these efforts can benefit from cooperation across these stakeholders. Second, we discuss the equally important utilization of HTE evidence so that physicians and patients have access to and can benefit from the learnings from this research. Research findings must be translated into actionable information and guidelines that can be incorporated into everyday practice. Doing so requires interaction and collaboration among all involved, based on facilitated communication as well as further evaluation research. We provide examples of several cross-sectorial initiatives that are under way in this area. Finally, we explore some economic aspects of HTE research as part of the drug development, marketing, and treatment process. Understanding the economic incentives present is fundamental to aligning those incentives to improve the availability and utilization of HTE evidence. Clear understandings among regulators, pharma, and payers about high-value targets, methods to efficiently generate and communicate information, and value propositions can lead to "win-win" scenarios for patients, individual payers, the health care system overall, and the future of drug development in producing new medicines.

The impact of pain on physical and mental quality of life in adults 65 and older.

Pain is a frequent and debilitating problem among older adults, decreasing quality of life (QOL) both physically and mentally. The burden of arthritis, sciatica, and back pain on QOL was estimated using ordinary least squares regression techniques to estimate the impact of each of these types of pain on QOL, controlling for patient demographic, socioeconomic, and health status characteristics. For individuals with arthritis, sciatica, and back pain, the adjusted average physical component scores were 4.19, 1.39, and 6.75 points lower, respectively (all p < 0.0001), than those without pain. Adjusted average mental component scores were 1.33, 0.47, and 2.93 points lower (all p < 0.01) for individuals with arthritis, sciatica, and back pain, respectively. The impact of pain on QOL was greater than that for many other commonly treated medical conditions. Clinicians should discuss pain with their patients to maximize their QOL.

The burden of depressive symptoms and various chronic conditions and health concerns on the quality of life among those with Medicare Supplement Insurance.

OBJECTIVE: This study aims to estimate the burden of currently having depressive symptoms on quality of life independently and in combination with various chronic conditions/health concerns among adults with Medicare Supplement Insurance (i.e., Medigap) coverage. METHODS: Data were obtained from the Health Update Survey (HUS). The HUS contains questions on demographics, comorbid conditions, and all of the questions on the Veterans RAND 12-item (VR-12) health status/quality of life survey. The survey was mailed to a random sample of 30,000 insureds from 10 states between 2008 and 2009. On the basis of relevant questions from the survey, respondents were categorized into two groups: those currently suffering from current depressive symptoms (N = 2283) and those who never had depressive symptoms (N = 7058). Multiple regression modeling was used to test the impact on quality of life of depressive symptoms independently or as an interaction of depressive symptoms with various chronic conditions/health concerns. RESULTS: Depressive symptoms were common, with an estimated prevalence of 24.4%. The greatest impact of depressive symptoms in combination with various chronic conditions/health concerns on quality of life was on the ability to handle emotional roles, bodily pain, social functioning, and ability to handle physical roles. Most of the significant interactions between depressive symptoms and various chronic conditions/health concerns were demonstrated for those chronic conditions contributing to functional impairment (e.g., difficulty walking, falls, chronic pain, and diabetes). CONCLUSIONS: Although depressive symptoms independently reduced quality of life, having depressive symptoms in addition to other chronic conditions/health concerns had a greater impact on quality of life.

The prevalence of hearing impairment and its burden on the quality of life among adults with Medicare Supplement Insurance.

PURPOSE: To estimate the impact of hearing impairment on quality of life from a physical and mental standpoint. METHODS: Data were obtained from the Health Update Survey, which contains questions on demographics, comorbid conditions, and the Veterans RAND 12-item health status/quality of life survey. It was fielded on a random sample of 15,000 adults with an AARP(®) Medicare Supplement plan, insured by UnitedHealthcare. Respondents were divided into those with hearing impairments and others, based on their response to a survey question. Univariate and multivariate analyses were conducted to estimate the likelihood of hearing impairment and its impact on quality of life while controlling for respondent demographics and comorbid conditions. RESULTS: Of the 5,515 eligible respondents, 10.4% reported having hearing impairments. The strongest predictor of hearing impairment was older age, while those with 4 years of college or more were least likely to have hearing impairments. Those with hearing impairments averaged significantly lower physical component and mental component scores, exceeding those of numerous other chronic conditions. CONCLUSIONS: This is the first known study of hearing impairment among those with Medigap coverage. Hearing impairment was strongly associated with lower quality of life from both a physical and mental health standpoint.

The prevalence of urinary incontinence and its burden on the quality of life among older adults with medicare supplement insurance.

PURPOSE: Estimate the prevalence and burden of urinary incontinence (UI) on the quality of life (QOL) among adults (65 or older) with Medigap insurance. METHODS: Data were obtained from the health update survey (HUS), which contains questions on demographics, comorbid conditions, and the Veteran's RAND 12-item health status survey. The mail survey was fielded on a random sample of 15,000 insureds from 10 states in 2008. Respondents were divided into those with UI and others, based on their response to a question about leaking urine during the last six months. Univariate and multivariate analyses were conducted to estimate the likelihood of UI and its impact on QOL while controlling for respondent demographics and comorbid conditions. RESULTS: Of the 5,530 eligible respondents, 37.5% reported having UI. The strongest predictors of UI were female gender, advancing age, and obesity. All the QOL estimates were significantly lower for those with UI (P < 0.001). Further, UI had a stronger influence on QOL than did diabetes, cancer, and arthritis, particularly from a mental health standpoint. CONCLUSIONS: Consistent with other Medicare populations (e.g. Medicare managed care), UI was common in Medigap insureds, strongly associated with lower QOL affecting mental, physical, and social well-being, and is often untreated.

The burden of falling on the quality of life of adults with Medicare supplement insurance.

To study the impact of falling or risk of falling on quality of life (QOL) outcomes, a survey was mailed to a random sample of 15,000 adults with an AARP® Medicare Supplement plan insured by UnitedHealthcare from 10 states in 2008. Approximately 21% had fallen in the past year; 17% did not fall but reported balance or walking problems (i.e., at high risk of falling); and 62% were in the low-risk, no-falls comparison group. Multiple regression analyses showed the strongest predictors of falling or being at high risk of falling were advancing age, female gender, heart conditions, stroke, digestive disorders, arthritis, sciatica, diabetes, and hearing problems. Average physical and mental component scores were significantly lower for both those who fell and those at risk of falling than the comparison group, indicating that falling or being at risk of falling had a stronger negative influence on QOL than most of the comorbidities measured. Clinicians, patients, and families should be aware of the potential negative impact of falling and fear of falling on the QOL of older adults.

Using Propensity to Succeed Modeling to Increase Utilization and Adherence in a Nurse HealthLine Telephone Triage Program.

Propensity to succeed modeling was used to identify characteristics associated with higher utilization of a telephone triage program and adherence to nurse recommendations among callers. Characteristics significantly associated with calling the telephone triage service and engaging in triage services were being female and having an elevated health risk score. Callers most likely to adhere to nurse recommendations were younger than 85 years of age, had called on a weekday, and had received a recommendation to seek care at an emergency department or a doctor's office visit. Additional analyses suggest the propensity to succeed modeling is stable and valid.

Propensity to Succeed: Prioritizing Individuals Most Likely to Benefit from Care Coordination.

The objective was to develop a propensity to succeed (PTS) process for prioritizing outreach to individuals with Medicare Supplement (ie, Medigap) plans who qualified for a high-risk case management (HRCM) program. Demographic, socioeconomic, health status, and local health care supply data from previous HRCM program participants and nonparticipants were obtained from Medigap membership and health care claims data and public data sources. Three logistic regression models were estimated to find members with higher probabilities of engaging in the HRCM program, receiving high quality of care once engaged, and incurring enough monetary savings related to program participation to more than offset program costs. The logistic regression model intercepts and coefficients yielded the information required to build predictive models that were then applied to generate predicted probabilities of program engagement, high quality of care, and cost savings a priori for different members who later qualified for the HRCM program. Predicted probabilities from the engagement and cost models were then standardized and combined to obtain an overall PTS score, which was sorted from highest to lowest and used to prioritize outreach efforts to those newly eligible for the HRCM program. The validity of the predictive models also was estimated. The PTS models for engagement and financial savings were statistically valid. The combined PTS score based on those 2 components helped prioritize outreach to individuals who qualified for the HRCM program. Using PTS models may help increase program engagement and financial success of care coordination programs.

An emergency room decision-support program that increased physician office visits, decreased emergency room visits, and saved money.

The objective of this study was to evaluate an Emergency Room having a Decision-Support (ERDS) program designed to appropriately reduce ER use among frequent users, defined as 3 or more visits within a 12-month period. To achieve this, adults with an AARP Medicare Supplement Insurance plan insured by UnitedHealthcare Insurance Company (for New York residents, UnitedHealthcare Insurance Company of New York) were eligible to participate in the program. These included 7070 individuals who elected to enroll in the ERDS program and an equal number of matched nonparticipants who were eligible but either declined or were unreachable. Program-related benefits were estimated by comparing the difference in downstream health care utilization and expenditures between engaged and not engaged individuals after using propensity score matching to adjust for case mix differences between these groups. As a result, compared with the not engaged, engaged individuals experienced better care coordination, evidenced by a greater reduction in ER visits (P=0.033) and hospital admissions (P=0.002) and an increase in office visits (P<0.001). The program was cost-effective, with a return on investment (ROI) of 1.24, which was calculated by dividing the total program savings ($3.41 million) by the total program costs ($2.75 million). The ROI implies that for every dollar invested in this program, $1.24 was saved, most of which was for the federal Medicare program. In conclusion, the decrease in ER visits and hospital admissions and the increase in office visits may indicate the program helped individuals to seek the appropriate levels of care.

Why do older adult women fall short of the recommended follow-up care for coronary artery disease?

BACKGROUND: Many women with coronary artery disease (CAD), commonly referred to as coronary heart disease, do not receive an annual office visit to manage their disease. We set out to determine what barriers factor into women not receiving an office visit to manage their disease. METHODS: A purposive sample of 26 eligible women (≥65 years of age) diagnosed with CAD completed in-depth, qualitative interviews. Systematic analysis of the content of interviews was performed on transcripts from these interviews. Participants with an AARP Medicare Supplement Insurance Plan insured by UnitedHealthcare insurance company that did not receive an annual office visit were eligible. In addition, we surveyed 100 physicians to obtain their thoughts about why women may not schedule at least one annual visit to manage their CAD. RESULTS: The most common barriers identified were skepticism of heart problems, having to take the initiative to schedule the appointment, and dealing with seemingly more pressing health problems. Many of these barriers identified were substantiated in a survey of physicians that treat women with CAD, but the relative rankings of the importance of these problems differed somewhat. CONCLUSIONS: Many women were skeptical about their heart health and often lacked the initiative to schedule a follow-up appointment. Most agreed that they would make an appointment if contacted by their doctor's office. Many of these women were receptive to the idea of receiving educational information by mail. Active involvement by doctors' offices to schedule appointments may help improve care, as might mail-based reminders.

Disparities in major joint replacement surgery among adults with Medicare supplement insurance.

The objective of this study was to determine if disparities in hip and knee replacement surgery exist among osteoarthritis patients with AARP-branded Medicare supplement plan (ie, Medigap) coverage provided by UnitedHealthcare. Patients were selected into the study if they had 1 or more medical claims with a diagnosis of osteoarthritis from July 1, 2006 to June 30, 2007. Logistic regression analyses tested for age-, sex-, race-, or income-related differences in the likelihood of receiving a hip or knee replacement surgery. The regression models controlled for socioeconomics, health status, type of supplement plan, and residential location. Of the 2.2 million Medigap insureds eligible for this study, 529,652 (24%) had osteoarthritis. Of these, 32,527 (6.1%) received a hip or knee replacement. Males were 6% (P < 0.001) more likely than females to have a replacement surgery. Patients living in minority or lower income neighborhoods were less likely to receive a hip or knee replacement. Supplement plan type was not a strong predictor of the likelihood of hip or knee replacement. Disparities were much greater by comorbid condition and residential location. Disparities in hip and knee replacement surgery existed by age, sex, race, and income levels. Larger disparities were found by residential location and comorbid condition. Interventions are being considered to address these disparities.