Abstract: National health surveys have played an important role in the development of health services research. They have contributed to the advancement of concepts, methods, and the policy relevance of the field. One product of these surveys was the Behavioral Model of Health Services Use. This article documents a 75-year legacy by reviewing the series of national studies that have given to the form and function of health services research. It further examines the Behavioral Model through 40 years of considerable application and alteration.

Abstract: Background: In the United States, $50,000 per Quality-Adjusted Life-Year (QALY) is a decision rule that is often used to guide interpretation of cost-effectiveness analyses. However, many investigators have questioned the scientific basis of this rule, and it has not been updated. Methods: We used 2 separate approaches to investigate whether the $50,000 per QALY rule is consistent with current resource allocation decisions. To infer a lower bound for the decision rule, we estimated the incremental cost-effectiveness of recent (2003) versus pre-“modern era” (1950) medical care in the United States. To infer an upper bound for the decision rule, we estimated the incremental cost-effectiveness of unsubsidized health insurance versus self-pay for nonelderly adults (ages 21‐64) without health insurance. We discounted both costs and benefits, following recommendations of the Panel on Cost-Effectiveness in Health and Medicine. Results: Our base case analyses suggest that plausible lower and upper bounds for a cost-effectiveness decision rule are $183,000 per life-year and $264,000 per life-year, respectively. Our sensitivity analyses widen the plausible range (between $95,000 per life-year saved and $264,000 per life-year saved when we considered only health care’s impact on quantity of life, and between $109,000 per QALY saved and $297,000 per QALY saved when we considered health care’s impact on quality as well as quantity of life) but it remained substantially higher than $50,000 per QALY. Conclusions: It is very unlikely that $50,000 per QALY is consistent with societal preferences in the United States.

Abstract: Background:Recent reports speculate that provider implicit attitudes about race may contribute to racial/ethnic health care disparities.Objectives:We hypothesized that implicit racial bias exists among pediatricians, implicit and explicit measures would differ and implicit measures may be related to

Abstract: Background:No current consensus exists on the causal effect of gaining or losing health insurance on health care utilization and health outcomes.Objective:To systemically search and review available evidence of estimated causal effects of health insurance on health care utilization and/or health out

Abstract: Background:Overuse of antibiotics in ambulatory care persists despite many efforts to address this problem. We performed a systematic review and quantitative analysis to assess the effectiveness of quality improvement (QI) strategies to reduce antibiotic prescribing for acute outpatient illnesses fo

Abstract: Background:Despite the surge of recent research on the association between perceived discrimination and health-related outcomes, few studies have focused on race-based discrimination encountered in health care settings. This study examined the prevalence of such discrimination, and its association w

Abstract: Objectives:To estimate the actual cost savings that could be achieved through reductions in intensive care unit (ICU) length of stay and duration of mechanical ventilation by determining the short-run marginal variable cost of an ICU and ventilator day.Research Design:Retrospective cohort study in a

Abstract: Background.The therapeutic misconception occurs when a research subject fails to appreciate the distinction between the imperatives of clinical research and of ordinary treatment, and therefore inaccurately attributes therapeutic intent to research procedures. The therapeutic misconception is a seri

Abstract: Objective:To compare the predictive validity of 8 different adherence measures by studying the variability explained between each measure and 2 outcome measures: hospitalization episodes and total nonpharmacy cost among Medicaid eligible persons diagnosed with diabetes.Research Design:This study was

Abstract: Background: The Institute of Medicine has identified care transitions as a priority area for performance measurement. Objectives: To examine the performance of the Care Transitions Measure (CTM) in more diverse populations and to introduce a 3-item CTM. Research Design: Cross-sectional study with purposive sampling of traditionally underserved populations. Confirmatory factor analyses, internal consistency reliability analyses, and differential item function tests were performed to explore the stability and performance of the 15-item CTM. Regression assessed the ability of the 3-item CTM to predict the 15-item CTM total score. Analysis of variance tests were conducted to explore CTM performance in different populations with respect to health and demographics. Subjects: A total of 225 patients age 18‐90 who were hospitalized in the past 12 months and were African American, Hispanic American, or rural-dwelling. Measures: CTM-15, CTM-3, age, gender, education, and health status. Results: Mplus confirmatory factor analysis supported the CTM-15 factor structure in more diverse population (Comparative Fit Index CFI 0.954). The 3-item CTM explained 88% of the variance in the 15-item CTM score. Differential item function analysis did not reveal any differential item difficulty by age, gender, education, self-rated health, or group (African American, Hispanic American, and rural-dwelling). Conclusions: Following endorsement by National Quality Forum, findings support use of the CTM in national public reporting efforts. The 3-item CTM closely approximates the 15-item instrument and may be attractive to purchasers and health care organizations that want to assess quality in this area while minimizing cost and response burden.

Abstract: for coverage recommendations to the National Health Service 2 ; some observers have inferred that explicit criteria such as £30,000 per QALY may be used to guide these recommendations. 3 The World Health Organization has proposed that developing countries might use a cost-per-QALY threshold of 3 times the per-capita gross domestic product to guide their health care resource allocations. 4 Despite widespread use elsewhere in the world, cost-effectiveness analysis has gained only limited traction in the United States as an explicit guide to clinical practice, insurance coverage, and policy decisions. It seems that Americans do not have the inclination to focus on the fact that even in the wealthiest country in the world, resources are limited, and not all beneficial health services can be provided to everyone who might potentially benefit from them. Rationing among health services occurs largely by default and not by design. In the United States, cost per QALY is sometimes cited as part of the justification for guidelines for clinical practice or preventive services, and a decade ago a panel was convened by the US Public Health Service to provide guidance to practitioners of cost-effectiveness analysis. 5 However, despite the attention given to cost-effectiveness analysis in medical journals, The Centers for Medicare and Medicaid Services have avoided explicit use of cost-effectiveness criteria in coverage decisions, and it is unclear to what degree cost-effectiveness is used to guide coverage decisions in the private sector. 6 Because cost per QALY is not used in any systematic or consistent way in the United States, it should not be surprising that there is no consensus as to the appropriate value of cost per QALY that should guide health care decisions and policies. The number $50,000 per QALY has become a mythical benchmark for cost per QALY in this country, although it is impossible to trace its origins. Some authors of cost-effectiveness studies refer to this number when reporting subgroup analyses or sensitivity analyses 7 ; these kinds of statements should not be interpreted as endorsements of a $50,000 per QALY threshold, but rather as a convenient way of representing the conclusion that the intervention in question is good value for money even under pessimistic assumptions. With that interpretation, the reference to the $50,000 threshold could be interpreted as an implied lower bound on the value of a QALY. Braithwaite et al, in this issue of Medical Care, 8 set out to deduce lower and upper bounds on the value Americans place on quality-adjusted life years by analyzing the implications of aggregate decisions that citizens of this country have made—to pay for the increase in the cost of medical care services since 1950; or have not made—to insure the uninsured. They argue that because the gains in life expectancy since 1950 have been bought at an estimated average cost of $183,000 per year of life expectancy gained, on average Americans must be willing to pay at least that much for a year of life. When optimistic imputations of quality of life gains are also considered, the implied lower bound on the value of a QALY drops to $109,000. The number drops below $100,000 when they

Abstract: Background:Incorporating patients’ preferences into colorectal cancer (CRC) screening recommendations has been identified as a potential mechanism for increasing adherence. This study used conjoint analysis to describe variation in CRC screening preferences among racially/ethnically diverse primary

Abstract: Background:Recent reports by the Medicare Payment Advisory Commission have highlighted sharp increases in the use of advanced diagnostic imaging procedures among the Medicare fee-for-service population. Little research has examined whether such trends also exist among persons with generous private i

Abstract: Background: Mental disorders constitute a significant public health problem in active military populations. However, very little is known about patterns of mental health service use in these populations. Objectives: The primary objective of this study was to examine the patterns and predictors of mental health service use in active Canadian Force members. Additional objectives included identification of barriers to service use. Design: A cross-sectional analysis was conducted using data from the Canadian Community Health Survey-Canadian Forces Supplement. Subjects and Measures: Participants were assessed for mood, anxiety, and substance use disorders using the World Health Organization's Composite International Diagnostic Interview. Those who met criteria for at least 1 disorder in the past year (n = 1220) were included in the analyses. Results: Of military members with a 12-month diagnosis, 42.6% used services in the past year. Predictors of service use included mental health indicators, gender, marital status, and military rank. Of military members who failed to use services, only a small percentage (3.5–16.0%) acknowledged a need for services. These members perceived a number of barriers to services, foremost among which was lack of trust in military health, administrative, and social services. Conclusions: Despite recent efforts to de-stigmatize mental health problems and treatments, unmet need for mental health services remains a significant problem in active militaries. Our findings indicate that military institutions should continue public education campaigns to de-stigmatize mental health problems and should make necessary changes in health delivery systems to gain the trust of military members.

Abstract: Physician and patient gender both influence medical communication. Nonverbal behavior is generally under-researched in the medical encounter but plays an important role for patient outcomes such as satisfaction. This article aims at identifying how specific physician nonverbal behaviors predict analogue patient satisfaction depending on physician and patient gender. Eleven physicians in a real medical encounter were videotaped and analogue patients indicated their satisfaction with each physician while viewing the videotapes. One hundred sixty-three university students participated (analogue patients). From the videotapes, 17 physician nonverbal behaviors (related to face, body, voice/speech), 2 physician appearance cues, 2 characteristics of the examination room, and 1 patient behavior were coded. For each analogue patient, the correlation between each of these coded characteristics and the patient's satisfaction was calculated, across all physicians and across male and female physicians separately. There was no main effect for patient gender but most coded characteristics showed different relations to patient satisfaction according to physician gender. Analogue patients were most satisfied with female physicians who behaved in line with the female gender role (eg, more gazing, more forward lean, softer voice) while still stressing their professionalism (laboratory coat, medical-looking examination room). For male physicians, satisfaction was high for a broader range of behaviors, partly related to their gender role (eg, louder voice, more distance to patient). To be satisfied, patients expect female and male physicians to show different patterns of nonverbal behavior. Awareness of these gender-specific expectations should be taken into account in medical training.

Abstract: BACKGROUND:: Injury is a major cause of death in adults. Although racial disparities in healthcare access and health outcomes are well documented for medical conditions, the influence of race on access to emergent care after injury has received little scrutiny. OBJECTIVES:: We sought to determine whether race was associated with risk of in-hospital death after injury. RESEARCH DESIGN:: Data from the Healthcare Cost and Utilization Project (1998-2002) were used to estimate multivariate models of in-hospital mortality, controlling for age, race, gender, comorbid conditions, injury severity, primary payer, median income of zip code of residence, and hospital type. Additional multivariate models were estimated among stratified subsets of patients, including injury severity and hospital type. SUBJECTS:: Patients age 18-64 with a primary diagnosis of injury. RESULTS:: Relative to injured white patients, black and Asian patients had a higher risk of death [1.5% vs. 2.1% and 2.0%, multivariate odds ratios (OR) = 1.14 and 1.39]. Other racial/ethnic groups showed no significant mortality difference from white patients. In stratified analyses, we found large black-white mortality disparities among mild to moderately injured patients (OR = 1.40, 95% confidence interval: 1.18-1.66), whereas Asian-white disparities were concentrated among more severely injured patients (OR = 1.37, 95% confidence interval: 1.03-1.80). CONCLUSIONS:: Black and Asian patients have a higher risk of death after injury than white patients. These data raise important questions about access to quality trauma care for racial minority patients. Language: en

Abstract: Background:Electronic health records (EHRs) have been promoted as an important tool to improve quality of care. We examined the association between EHR components, a complete EHR, and the quality of care.Methods:Using data from the 2005 National Ambulatory Medical Care Survey and the National Hospit

Abstract: Background:The Agency for Healthcare Research and Quality (AHRQ) has constructed Inpatient Quality Indicator (IQI) mortality measures to measure hospital quality using routinely available administrative data. With the exception of California, New York State, and Wisconsin, administrative data do not

Abstract: Background Unplanned hospitalization often represents a costly and hazardous event for the older population.

Abstract: Background:Identifying moderators of the effects of self-efficacy enhancing interventions could facilitate their refinement and more targeted, cost-effective delivery. Current theories and data concerning the potential moderating effect of depressive symptoms on interventions to enhance patient chro

Abstract: Background Colorectal cancer (CRC) screening is underutilized. Effective methods to increase screening use are needed. This study sought to determine the impact of tailored navigation on CRC screening in primary care. Methods The study included 154 primary care practice patients who were 50 or more years of age, were eligible for CRC screening, and had an office visit within 2 years before study initiation. Baseline telephone survey data were collected on participant sociodemographic characteristics, psychosocial factors, and screening test [fecal occult blood test (FOBT) or colonoscopy] decision stage. By comparing decision stage data, we identified that test with the highest decision stage (ie, preferred screening test). Participants who preferred FOBT were sent an FOBT kit and a reminder. Those preferring colonoscopy were sent colonoscopy instructions. After this mailing, a study patient navigator made a telephone call to guide participants towards screening. Six-month end point survey and medical records data were obtained. Univariable and multivariable analyses were performed to identify predictors of screening and of change in preferred screening test decision stage. Results At end point, 63 (41%) study participants had screened. From baseline to end point, overall screening preference increased for 75 (63%) participants. Age and perceived salience and coherence (ie, screening is important and sensible) were positive, significant predictors of screening use (P = 0.02 and P = 0.05, respectively); while only age predicted change in overall screening preference (P = 0.03). Conclusions Study participant screening use and preference increased. Age and attitudes predicted outcomes. Randomized trials are needed to determine intervention impact at the population level.

Abstract: Background:Recent work has shown that rates of severe disability, measured by the inability to perform basic activities of daily living, have been rising in working age populations. At the same time, the prevalence of important chronic diseases has been rising, while others falling, among working ag

Abstract: Background:Current recommendations advise patients to participate in the decision-making for selecting a colorectal cancer (CRC) screening option. The degree to which providers communicate the information necessary to prepare patients for participation in this process is not known.Objective:To asses

Abstract: Background:The case-mix system Resource Utilization Groups version III for Home Care (RUG-III/HC) was derived using a modest data sample from Michigan, but to date no comprehensive large scale validation has been done.Objectives:This work examines the performance of the RUG-III/HC classification usi

Abstract: Background: Older adults who are discharged from the emergency department (ED) may be at risk for subsequent adverse outcomes; however, this has not been fully investigated in national, population-based samples. The goal of this study was to determine the frequency and predictors of adverse outcomes among older adults discharged from the ED. Design: Secondary analysis of data from the Medicare Current Beneficiary Survey. Subjects: A total of 1851 community-dwelling, Medicare fee-for-service enrollees, ≥65 years old who were discharged from the ED between January 2000 and September 2002. Measures: The primary dependent variable was time to first adverse outcome defined as any repeat outpatient ED visit, hospital admission, nursing home admission or death within 90 days of the index ED visit. Results: Six hundred twenty-three of 1851 subjects (32.9%) discharged from the ED experienced an adverse outcome within 90 days of the index visit; 17.2% returned to the ED but were not admitted, 18.3% were hospitalized, 2.6% were admitted to a nursing home, and 4.1% died. Patients who were older [hazard ratios (HR), 1.01; confidence interval (CI), 1.00–1.02], with more chronic health conditions (HR, 1.12; CI, 1.07–1.19), Medicaid insurance (HR, 1.42; CI, 1.11–1.82), and recent ED (HR, 1.46; CI, 1.17–1.82) or hospital use (HR, 1.80; CI, 1.50–2.17) were at particularly high risk. Conclusions: A substantial proportion of older Medicare beneficiaries in this study experienced an adverse outcome after ED discharge. Further study is needed to determine whether simple prediction tools based on these identified risk factors may be useful in predicting adverse outcomes in this vulnerable population.

Abstract: Background:Mandatory hospital nurse staffing ratios are under consideration in a number of states without strong empirical evidence of the optimal ratio.Objective:To determine whether increases in medical-surgical licensed nurse staffing levels are associated with improvements in patient outcomes fo

Abstract: Background:Although physician-owned specialty hospitals have become increasingly prevalent in recent years, little research has examined whether the financial incentives linked to ownership influence physicians’ referral rates for services performed at the specialty hospital.Objective:We compared th

Abstract: Background: The relationship between process and outcome measures among patients with stroke is unclear. Objectives: To examine the association between quality of care and mortality among patients with stroke in a nationwide population-based follow-up study. Methods: Using data from The Danish National Indicator Project, a quality improvement initiative with participation of all Danish hospital departments caring for patients with stroke, we identified 29,573 patients hospitalized with stroke between January 13, 2003 and October 31, 2005. Quality of care was measured in terms of 7 specific criteria: early admission to a stroke unit, early initiation of antiplatelet or oral anticoagulant therapy, early examination with computed tomography/magnetic resonance imaging scan, and early assessment by a physiotherapist, an occupational therapist, and of nutritional risk. Data on 30- and 90-day mortality rates were obtained through the Danish Civil Registration System. Results: Six of 7 of these criteria were associated with lower 30- and 90-day mortality rates. Adjusted mortality rate ratios corrected for clustering by department ranged from 0.41 to 0.83. We found indication of an inverse dose-response relationship between the number of quality of care criteria met and mortality; the lowest mortality rate was found among patients whose care met all criteria compared with patients whose care failed to meet any criteria (ie, adjusted 30-day mortality rate ratios: 0.45, 95% confidence interval: 0.24–0.66). When analyses were stratified by age and sex, the dose-response relationship was found in all subgroups. Conclusions: Higher quality of care during the early phase of stroke was associated with substantially lower mortality rates.

Abstract: Background:The Centers for Medicare and Medicaid Services (CMS) publish a report card for nursing homes with 19 clinical quality measures (QMs). These measures include minimal risk adjustment.Objectives:To develop QMs with more extensive risk adjustment and to investigate the impact on quality ranki