LDI Poster Spotlight at AcademyHealth
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Poster Presenter: JAYA AYSOLA, MD, MPH, Assistant Professor of Medicine at Penn's Perelman School of Medicine and LDI Senior Fellow.
Verbal Synopsis: "We looked at practice organizational processes that out-patient primary practices adopt to become patient-centered medical homes. We wanted to know which of those processes were related to patient-reported care experiences because practices and providers are now being graded on patient experience. So, what factors, if any, could they adopt or change and are they moving the needle on patient-reported care experiences? Main findings: In the aggregate for all primary care patients, we found that nothing the practices were doing was related to patient-reported experiences of care. Among a very sick subset of patients we did find there were processes that practices adopted to move the needle on patient experience. The policy implication is that we need a targeted approach; adoption of all these processes takes a lot of time and effort and maybe we don't need to do it for the entire patient panel."
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Poster Presenter: JEFFREY SILBER, MD, PhD, Director of the Center for Outcomes Research at Children's Hospital of Philadelphia, Professor of Pediatrics, Anesthesiology and Critical Care, Penn's Perelman School of Medicine, and LDI Senior Fellow.
Verbal Synopsis: "We looked at Medicare claims -- 25,000 patients with general surgery at a Magna hospital that had good nurse-to-bed ratios and matched them to 25,000 patients at non-Magna hospitals with poor nurse-to-bed ratios. Main findings: There was a huge difference in outcomes between those with the better nursing environments and those with the worst nursing environments. In better environments, you have better value with lower cost and lower mortality in general surgical procedures. We find there's a certain group of patients that benefit the most in better nursing environments: the patients who are very sick but not the very sickest. We also found the better way was also cheaper because CMS pays less after you take away for indirect medical education expenses and geographic adjustments. There's a very strong case for better nursing environments in this sample for general surgical procedures."
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Poster Presenter: NORA BECKER, University of Pennsylvania PhD Student and LDI Fellow.
Verbal Synopsis: "The Affordable Care Act mandates that preventive services be covered by private health plans with no consumer cost sharing. That means no co-pays, no deductibles. This mandate includes FDA-approves contraceptives. The goal of this project is to quantify the impact of this mandate on the utilization of prescription contraceptives. I used descriptive times series and a regression analysis that I would describe as a dose-response difference-in-difference analysis testing whether women in employer plans where the price changed more, changed their utilization more in response. Main finding: Very little change in utilization as found in response to the mandate. There were some very small price responses that suggest that in general, women in private health insurance are pretty price insensitive, at least in the short term. These are preliminary findings; the major limitation of this work is that I only have about a year of post-mandate data and in future work I hope to examine longer-term impact on utilization."
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Poster Presenter: HILARY BARNES, PhD, CRNP, Postdoctoral Research Fellow, Center for Health Outcomes and Policy, University of Pennsylnvania School of Nursing, and LDI Fellow.
Verbal Synopsis: "This work looked at the distribution of nurse practitioners (NPs) to primary care in terms of scope of practice. Main findings: NPs were 13% more likely to work in primary care practices in states that had full scope of practice. That number increased to 20% when the state also had 100% Medicaid reimbursement for NP services. This is important as more Americans gain health insurance and seek primary care, particularly Medicaid patients. States should consider ways to distribute providers to higher-needs areas and increase out-patient care for those patients. The research needs to continue. We would like to look longitudinally to see how scope-of-practice changes in the laws may affect how the distribution of the work force occurs."
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Poster Presenter: CHARLENE WONG, MD, University of Pennsylvania Robert Wood Johnson Clinical Scholar and LDI Fellow.
Verbal Synopsis: "We were interested in looking at the decision support and choice environments that were created on the health insurance marketplaces, not just Healthcare.gov but across all the different state-based exchanges, both in the first and second enrollment period. We audited all these different sites. Main finding: More was being done in the second open enrollment period as far as having tools available like total cost estimators which allow people to put in how they anticipate using their health insurance. The estimator does the math and spits out estimated out-of-pocket costs taking into account the deductible, the co-insurance and co-pays. Other tools included an integrated provider lookup that allows you to see your provider's in-network plans. A lot more could be done because those sorts of tools are still available only on a few sites and Healthcare.gov really had a lot of room for improvement as far as providing additional tools that can help people make what are sometimes very complex and difficult decisions in choosing a health insurance plan."
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Poster Presenter: BRANDON MAUGHAN, MD, MHS, Penn Robert Wood Johnson Clinical Scholar and LDI Fellow.
Verbal Synopsis: "Prescription opioid abuse has been a major problem in the U.S. and nearly all states have adopted prescription drug monitoring programs to try to reduce 'doctor shopping.' But there's not been a lot of evidence that these programs work or decrease opioid-related mortality. We thought mortality might not be the best outcome to look at. There are many thousands of opioid-related ER visits each year, so, in this work we looked see if we could find an effect; perhaps the states that have adopted these monitoring progams had fewer opioid-related ER visits. Main findings: We found no evidence that prescription drug monitoring programs have had an impact on reducing opioid-related ER visits and this reinforces the idea that although many states have these programs, there's a paucity of data showing they have any actual effect on safety."
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Poster Presenter: MATTHEW MCHUGH, PhD, JD, MPH, Associate Director of Penn's Center for Health Outcomes and Policy Research at the University of Pennsylania's School of Nursing.
Verbal Synopsis: "We looked at Kaiser Permanente Hospitals in California known to have good environments for nurses to work in and good outcomes. We compared them to another set of hospitals -- Magna Hospitals -- which are known to have a very good nursing environment and good outcomes. Accomplishing the kinds of integration required to become like Kaiser is a very expensive proposition: owning your own physician groups and running your own health insurance company. Well, what we find here is that the benefit, at least on hospital outcomes, is similar to that of going through a Magna certification process, which is much more attainable by a broader range of hospitals. On the hospital outcome side, we look at mortality, failure to rescue, nurse satisfaction and turn over. Main finding: You get the same benefit. It's a cheaper pathway to the same outcomes."
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Poster Presenter: KARIN RHODES, MD, Associate Professor, Emergency Medicine, University of Pennsylvania Perelman School of Medicine, and LDI Senior Fellow.
Verbal Synopsis: "We evaluated whether Pennsylvania's Chronic Care Initiative decreased utilization and cost for the highest risk patients; those with comorbid chronic health conditions and a behavioral health condition, i.e., substance abuse or serious mental illness. Main finding: For almost 20,000 comorbid Medicaid patients (using claims data) that there was a decrease in emergency department utilization and in-patient utilization with a resulting cost o $3,700 per person on average which, if you extrapolate that to the full Medicaid population, would be a savings of about $70 million in the year after the start of the Chronic Care Initiative. This is preliminary work and there's more work that needs to be done, so this is not the final bottom line."
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Poster Presenter: MITESH PATEL, MD, MBA, Assistant Professor of Medicine at the University of Pennsylvania's Perelman School of Medicine and LDI Senior Fellow.
Verbal Synopsis: "More than half the adults in the United States don't get enough physical activity to achieve health benefits. And there's a lot of interest in using financial incentives and making team designs more social in an employer setting. We did a four-arm randomized controlled trial to compare financial incentives versus social feedback, either framed at the 50th percentile or the median or the 75th percentile, which is the top quartile. Main finding: What we found was that the 50th percentile with financial incentive was significantly better than the 75th percentile without financial incentive. It was so much more that they walked about 1,300 steps per day over a three-month intervention than the 50th percentiile without incentives."
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Poster Presenter: ZACHARY MEISEL, MD, Assistant Professor of Emergeny Medicine at the University of Pennsylvania Perelman School of Medicine and LDI Senior Fellow.
Verbal Synopsis: "This was the first phase of our SPIN trial. We interviewed 60 emergency physicians around how they use state prescription drug monitoring programs. Those are databases designed to prevent 'doctor shopping.' We learned that there are a lot of barriers to use; in particular, these systems often make it hard to sign up and are difficult to use. On the other hand, we found that once the physicians use them, they often use them more as a communication tool to communicate with patients and are more likely to continue using it in that way then they are to determine whether or not the patient is going to get the medication. Main finding: We found that the tool is not being used in the way it was designed. It's being used as a communication tool -- which raises an interesting policy question about how these databases could actually be used to help improve communications with patients."
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Poster Presenter: ALEXANDER BAIN, 3rd Year University of Pennsylvania medical student and CHARLENE WONG, MD, Penn Robert Wood Johnson Clinical Scholar and LDI Fellow.
Verbal Synopsis: "The use of urgent care centers and retail-based clinics has been increasing but there's little data to show how patients use those sites or how much they are charged for the care provided there. We used the OPTUM Insight database for the first half of 2013 to see what services were being used and focused specifically on the differences in use by age group. Main findings: Adolescents and young adults are much more likely to use both urgent care centers and retail-based clinics for common ambulatory concerns like upper respiratory infection. Retail-based clinics are providing preventive care, mostly in the form of vaccinations. The other finding was that among all insured beneficiaries -- children, adolescents and young adults -- the out-of-pocket expense was significantly lower at retail-based clinics compared to physician offices; urgent care centers were significantly more expensive out-of-pocket when compared to physician offices."