The 2023 AcademyHealth Annual Research Meeting in Seattle had three poster sessions in the Seattle Convention Center. (Photos: Hoag Levins). Click images for larger.
The poster exposition hall of the AcademyHealth Annual Research Meeting (ARM) is always one of its most popular–and crowded–features. In this year’s expo, more than a thousand posters of the latest health services research were on display and scientists from the University of Pennsylvania’s Leonard Davis Institute of Health Economics (LDI) were well represented. This is what some of the research and posters were about:
Racially biased disbelief linguistics was the subject of the poster detailing a study by LDI Associate Fellow Courtney Lee, MD, MPH, Fellow in the Division of General Internal Medicine at the Perelman School of Medicine, and Student in the Master of Science in Health Policy Research program. Her team used electronic health records (EHR) text mining methods to analyze 54,936 physician admission notes for the presence of subtle “disbelief terms” conveying doubt about a patient’s description of their symptoms or condition. Compared to non-Hispanic white patients, Black patients had higher odds of their permanent record containing these terms. “Equity and justice are something that we as a community want to advance, so understanding how we perpetuate stigma or bias in health records is important to advancing that goal,” said Lee. LDI Senior Fellows Jaya Aysola, MD, MPH, and Gary Weissman, MD, MSHP, were part of the research team.
LDI Senior Fellow Gary Weissman, MD, MSHP, explains his study to Murtaza Mogri of the Kaiser Permanente Division of Research and Vincent Liu of Stanford University. The work was an effort to build an artificial intelligence-based (AI) diagnostic decision support system for primary care clinicians. “There are a lot of barriers to building these systems in this space because primary care clinicians deal with hundreds or even thousands of diagnoses and it’s hard to train an AI model to predict that many different diagnoses,” said Weissman. The research team included LDI Senior Fellows David Asch, MD, MBA and Matthew Press, MD, MSc.
Kerry Meltzer, MD, LDI Associate Fellow and Fellow in the National Clinician Scholars Program at the Perelman School of Medicine, discusses her study that matched NASA geocoded disaster data with hospital markets to determine which hospitals were most affected. “Within markets most impacted by natural disasters, it was smaller public hospitals in the South that were most affected,” Meltzer said. “This is going to have grave implications and future investigations are needed to further understand what this means for those hospitals and their patients.” LDI Senior Fellows Rachel M. Werner, MD, PhD, and Paula Chatterjee, MD, MPH, were members of the research team.
Bundled with her 2-month-old daughter Sadie, Rebecca Clark, PhD, RN, LDI Senior Fellow and Assistant Professor at the Penn School of Nursing and its Center for Health Outcomes and Policy Research (CHOPR), explains her study to Laura Faherty, MD, MPH, of the Rand Corporation. The work was a survey of all actively licensed registered nurses in New York and Illinois in 2019 and 2020 that asked “What helps (or hinders) your ability to provide quality care to vulnerable populations?” Most nurses cited hospital organizational factors including staffing, staffing diversity, resource adequacy, bias, and things like not enough social workers or interpreters.
Daniel Cullen, PhD, of Elevance Health at the poster of a study conducted in partnership with LDI Executive and LDI Senior Fellow Rachel M. Werner, MD, PhD, and LDI Associate Fellow Eric Bressman, MD, MSHP. The work looked at the differences in telemedicine care-seeking in states where pandemic waivers remained in force compared to states where they expired. They found that waivers allowed better access to telemedicine across state lines and that the country needs a permanent cross-state regulatory framework for telemedicine. In 2017, LDI and Elevance (formerly Anthem, Inc., the country’s second largest health insurance company) began a long-term research partnership.
Norma Coe, PhD, LDI Senior Fellow and Co-Director of the Penn Population Aging Research Center (PARC), Courtney Van Houtven, PhD, of the Duke University’s Department of Population Health Sciences, and Chuxuan Sun, MPA, Statistical Analyst in the Penn Department of Medical Ethics and Health Policy, discuss the changing trends in living arrangements for persons with dementia. Coe and Sun were co-investigators. “The average number of difficulties in residential facilities was higher because of the lack of federal oversight and because the care is not paid for by Medicare or Medicaid,” said Sun. “The policy implications of our findings are that more federal oversight is needed to ensure the quality of care in residential facilities.”
Robert Burke, MD, MS, LDI Senior Fellow and Associate Division Chief for Research in the Penn Medicine Division of General Internal Medicine and Indrakshi Roy, PhD, Assistant Research Professor at Northern Arizona University, discuss their study of county-level Medicare Advantage (MA) utilization. They found that counties that had the highest levels of MA enrollment also had the highest rates of hospital utilization, but the lowest rates of post-acute skilled nursing facility use. The goal of the work, they said, was to better understand what is being done to achieve lower skilled nursing facility use and how those methods might be extended to traditional Medicare.
Moral distress among nurses during the pandemic became particularly acute in hospitals serving patient populations that were disproportionately Black. This negatively affected job outcomes for the nurses and health outcomes for the patients, according to this study. LDI Fellows Eileen Lake, PhD, RN (above), Connie Ulrich, PhD, RN, and Vaneh Hovsepian, PhD, RN, all of Penn Nursing’s Center for Health Outcomes and Policy Research (CHOPR), studied disparities in hospital nurse outcomes during COVID-19. “Nurses in middle- and high-minority hospitals had significantly greater moral distress,” said Lake, who is CHOPR’s Associate Director. Moral distress occurs when a clinician knows the ethically correct action that needs to be taken but is constrained from taking it.
LDI Associate Fellow Jane Muir, PhD, APRN, a Postdoctoral Fellow in the National Clinician Scholars Program and Penn Nursing School’s Center for Health Outcomes and Policy Research (CHOPR), explained her study of nursing working conditions and the quality of care in emergency departments (EDs). The survey of ED registered nurses in New York and Illinois found that 50% reported high burnout, 39% reported job dissatisfaction, 27% reported an intent to leave their job, and 25% rated the quality of care provided in their own EDs as “poor.” “What we found is that if hospitals are investing in better interprofessional collaboration, integrating nursing in decision-making on committees, and staffing adequately on their units, it really impacts the quality of the care patients receive in a very important place in our health care system,” Muir said.
LDI Associate Fellow Grace Ng, an MD/MSHP student at the Perelman School of Medicine, presented a poster on an analysis of outcomes in bundled payment episodes in the Bundled Payments for Care Improvement-Advanced program (BPCI-A) program. In 2018, bundled payments were introduced for a series of procedures including Back and Neck Except Spinal Fusion, Cardiac Defibrillator, and Percutaneous Coronary Intervention. But there hadn’t been any peer-reviewed evaluations of the costs and quality of those bundled procedures for outpatient episodes of care. Overall, the findings of this first evaluation indicate that participation in outpatient BPCI-A was not associated with differential changes in spending, 90-day readmission, or 90-day mortality. Other LDI Fellows involved in this research were Austin Kilaru, MD, MSHP; Joshua Liao, MD, MSc; and Amol Navathe, MD, PhD.
Manning the poster of a study on which LDI Senior Fellow Wade Berrettini, MD, PhD was a researcher, Geisinger Commonwealth School of Medicine student Sophie Roe (above, left) noted the study focused on administrators, providers and care coordinators’ perspectives of the barriers and facilitators to successful engagement in a health system’s medication for opioid use disorder (MOUD) program. “A lot of studies have looked at the patient perspective of MOUD engagement but haven’t looked at clinical stakeholder perspectives,” said Roe. “We found that integrating MOUD in a health system came with the advantages of resources but also with stigma from other providers and departments.”
Speaking with Vanderbilt University Department of Health Policy PhD student Dennis Lee, Perelman School of Medicine master’s candidate Samuel Cohen explains the project done with LDI Senior Fellow Kira Ryskina, MD, MSHP. The work used Medicaid data–rather than Hospital Service Area (HSA) or Hospital Referral Region (HRR) data–to define Philadelphia nursing home markets. “We tried to define markets by how nursing home patients actually behaved and where they went from where they lived,” said Cohen. He said this produced more precise nursing market definitions than HSA or HRR data because both of those are essentially based on hospital data.
LDI Associate Fellow Sara Handley, MD, MSCE, details her study for Caitlin Ellis, MPA, of the National Institute for Health Care Management. The work was a survey of the Children’s Hospital of Philadelphia’s (CHOP) newborn care network of 11 of 14 hospitals. The goal was to develop and validate a resuscitation-specific organizational culture instrument for the implementation of evidence-based practices in delivery room resuscitation. The findings were that higher team scores in role clarity, shared-mental models, and closed-loop communications indicated a higher level of implementation readiness. Also involved in the research were LDI Senior Fellows Ingrid Nembhard, PhD, MS, of The Wharton School, and Christopher Bonafide, MD, MSCE, of the Perelman School of Medicine.
Aiden Crowley, A MD-PhD Student at the Perelman School of Medicine and the Wharton School, and a Research Assistant at LDI, explained the poster of her study done with LDI Senior Fellow Amol Navathe, MD, PhD and LDI Adjunct Senior Fellow Joshua Liao, MD, MSc. The work found that hospitals in communities with higher shares of marginalized populations are less likely to participate in the latest Medicare bundled payment program. That voluntary program, Bundled Payments for Care Improvement-Advanced (BPCI-A), has been demonstrated to have beneficial effects on the cost and quality of care. The findings indicate that voluntary BPCI-A programs may not result in uniform representation across socioeconomic groups in ways that could hinder the development of practice redesign tailored to marginalized populations.
