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Mentors: Mark D. Neuman MD Susmita Pati MD, MPH FINAL PRESENTATION Presenter: Ambar La Forgia Swarthmore College SUMR August 2009.

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Presentation on theme: "Mentors: Mark D. Neuman MD Susmita Pati MD, MPH FINAL PRESENTATION Presenter: Ambar La Forgia Swarthmore College SUMR August 2009."— Presentation transcript:

1 Mentors: Mark D. Neuman MD Susmita Pati MD, MPH FINAL PRESENTATION Presenter: Ambar La Forgia Swarthmore College SUMR August 2009

2 An Analysis of Hip Fracture Care in Pennsylvania Mark Neuman MD Ambar La Forgia

3 Hip fracture is a common and disabling event in older adults, occurring 340,000 times each year in the United States 10% of patients die by 30 days and 24%-33% die by one year 30% are re-admitted to an acute care hospital within six months of hip fracture, and between 25% and 75% of survivors fail to return to their pre-fracture level of ambulation BACKGROUND

4 PROCESSOUTCOME EVALUATING QUALITY IN HEALTH CARE STRUCTURE Conceptual Framework (Donabedian, 1989) The attributes of the settings in which care occurs What is actually done in giving and receiving care The effects of care on the health status of patients and populations

5 CAN HOSPITAL STRUCTURES IMPACT HIP FRACTURE OUTCOMES? Clinical pathways: written tools detailing steps in the care of a patient with a specific condition and describing the expected progress of the patient – –Meta-analysis: associated with reduced inpatient complications (Neuman et al, 2009, in press) Geriatric co-management: team approach to care involving orthopedic and geriatric physicians – –Associated with decreased length of stay and re-admission rates (Friedman et al, 2008)

6   To describe variations in hospital structures relevant to hip fracture care in a population- based sample – –1. Estimate the prevalence of inpatient geriatrics consultation – –2. Estimate the prevalence of pathways for inpatient hip fracture care – –3. Estimate the prevalence of protocols related to selected quality measures for geriatric care OBJECTIVES

7 Telephone and Web-based survey of key informants at hospitals in Pennsylvania Survey instrument: 18 items focusing on structures   Availability of inpatient geriatrics consultation   Presence of a hip fracture pathway   Presence of guidelines or protocols for 11 quality measures   Availability of social work or care coordination services Standardized questionnaire and interview script developed and revised through:   Consultation with experts   Pilot testing (8 NJ facilities June 3-17, 2009) Additional hospital-level data gathered from existing data bases (PHC4, DOH) METHODS

8 Target both rural and urban settings Pennsylvania Healthcare Cost Containment Council (PHC4) has defined 3 regions of PA (Southeast, Central, Western) All hospitals from Southeast and Central Pennsylvania with 10 or more hip fracture admissions in 2007 (n=93) STUDY SAMPLE

9 Criteria for Interviewee - Extensive knowledge regarding hospitals’ clinical policies - Unique to each hospital - Knowledge of practices over time - Potentially accessible via telephone or e-mail Focus on Nurse Administrators: – Chief Nursing Officer – Director of Nursing – Other potential responders: Nurse-in-Charge, Vice President of Patient Services, Vice President of Nursing FINDING THE RIGHT INFORMANT

10 Interviews conducted (June 17-July 31) by PI and two trained RA’s Separate databases for entry of tracking information and survey responses Recruitment process:   1. Initial telephone call to hospital directory; administrator contact information obtained; invited to participate via phone message, e-mail, or fax   2. Repeat telephone contact, with e-mails sent where respondent address available. Web-based survey link included in follow-up e-mail   3. Third telephone contact with attempt to schedule interview; e-mail re-sent on request   4. Final telephone contact planned for September 2009 RECRUITMENT AND ADMINSTRATION (ONGOING)

11 90/93 hospitals successfully contacted – –2 closed – –1 does not have a nurse administrator 82/93 Received emails with survey link 51/93 (55%) Completed survey – –23/93 Responded to survey link – –18/93 Responded via telephone INTERVAL RESULTS

12 VariableRespondents (51)Non-Respondents (42) χ2χ2 Region 0.197 SE26 (51.0%)27 (64.3%) CN25 (49.0%)15 (35.7 %) Number of Beds 0.790 <12913 (25.5%)10 (23.8%) 129-19510 (19.6%)12 (28.6%) 196-30414 (27.5%)10 (23.8%) 305 or more12 (27.5%)10 (23.8%) Hip Fracture Cases 0.964 <4212 (23.7%)11 (26.2%) 42 to 7713 (25.5%)10 (23.8%) 78 to 11212 (23.5%)11 (26.2%) 133 or More12 (27.5%)10 (23.8%)

13 Geriatrics Consult# of Obs = 49 Answered NProportion95% CI Yes190.388(0.246, 0.529) No280.571(0.428, 0.715) Don't Know20.041(-0.016, 0.098) Hip Fracture Pathway# of Obs = 44 AnsweredNProportion95 % CI Yes300.682(0.539, 0.825) No100.227(0.098, 0.356) Don't Know40.092(0.002, 0.179) INTERVAL RESULTS

14 Accuracy of nurse reports unknown and may vary by item Potential differences in responses via web vs. via telephone Response rate Limited information regarding actual care delivered LIMITATIONS/DIFFICULTIES

15 Success in accessing nurse administrators as reporters of hospital structures Availability of selected hospital resources for hip fracture care varies within PA hospitals – –Geriatrics consult available in 25-53% – –Clinical pathway for hip fracture present in 54-83% PRELIMINARY INSIGHTS

16 Extension of sample to Western PA: Sept-Oct 2009 Analysis for associations between survey responses and other hospital level variables Linking survey elements to patient-level discharge data for PA hip fracture cases in 2007 and 2008 Multivariable analyses of associations between hospital structures, processes of care, and patient outcomes NEXT STEPS

17 THANK YOU! Funding: John Eisenberg Research Scholar Award (MDN); LDI SUMR Scholars Program Our survey respondents! Mark D. Neuman, M.D. George Stein Judy Shea, Ph.D. Lee A. Fleisher, M.D. Samir Mehta, M.D. Joanne Levy, M.S. Shanta Layton

18  PHC4 Administrative Dataset: patient level variables and facility level variables  Pennsylvania Department of Health Death Records: on mortality within 180 days of admission for hip fracture for all patients  Pennsylvania Department of Health Hospital Information Website: hospital level variables including bed count, teaching status, number of orthopedic surgeons per facility, number of physical therapists per facility DATA SOURCES

19 Susmita Pati MD, MPH Jane Kavanagh Ambar La Forgia Medicaid Churning: A Study on Medicaid Retention Rates Among Children in the United States A Study on Medicaid Retention Rates Among Children in the United States

20   Medicaid Churning: Occurs when individuals lose and regain coverage in a short period of time.   Nearly 14% (9 million) children experience gaps in Medicaid coverage in any given year   These gaps are relatively brief, lasting usually from 1- 3 months BACKGROUND

21   Causes of Churning:   Valid change in eligibility   Misconceptions of eligibility - - Former beneficiaries believe that you cannot have a job and still qualify for Medicaid   Barriers to recertification through complicated paperwork and/or interviews - - meeting deadlines, compiling recertification materials, and tracking down the necessary documents are more than working parents can handle   Not knowing Medicaid was terminated - - “For some reason [Medicaid] cut my son off without telling me and when I went with him to the doctor, the doctor told me that he didn’t have health insurance.” Perry, Michael. “Reducing Enrollee Churning in Medicaid, Child Health Plus, and Family Health Plus.” NYS Health Foundation. February 2009 BACKGROUND

22   Consequences of Churning:   Costs to reenroll in Medicaid ranges from $160 to $300 per child - - Majority administrative: extra paperwork, system updates, extra mailings   Unstable health insurance coverage causes disruption in care management and health care itself - - Children go without preventive check-ups, and do not fill prescriptions - - Dangerous for young children and those with chronic conditions   Children experience fewer ambulatory visits, less utilization of preventive services, more unnecessary emergency room visits, more avoidable hospitalizations   Adverse retention occurs as only the very ill determinedly seek reenrollment BACKGROUND

23   To inform policymakers on the effects of Medicaid renewal practices on children as well as provide descriptive state Medicaid data   Determine total number of disenrollments and length of disenrollment for all children in Medicaid   Specifically analyze retention rates by: 1. State 2. Race and Ethnicity 3. Sex 4. Chronic Conditions   Determine barriers to Medicaid renewal as observed through state renewal processes and enrollee perspectives OBJECTIVES

24   Our sample size includes all fifty states and the District of Columbia   The focus age group of 0-18 was chosen as these are the age parameters defined the majority of state Medicaid programs   Data collection: – –The Center for Medicare and Medicaid Services national administrative database containing information on all children covered by Medicaid at any point in 2001 or 2002 – –12-month continuous eligibility status, renewal form characteristics and interview policy were obtained from the Henry J. Kaiser Foundation State Data STUDY DESIGN

25   Medicaid retention rate determined through longitudinal analysis - - retention defined as percentage of Medicaid enrollees covered from January 1, 2001 to December 31, 2002   Medicaid renewal applications found online - - in absence of internet information, staff contacted each Medicaid organization and the data was obtained from individual county offices   Readability Studio software analyzed each renewal application’s literacy level using New Fog, FORCAST and Flesh-Kincaid tests. METHODS





30   The data available omits household income and size, parental employment and disenrollment explanation   Delayed release of files: working with 2001-2002 data   Size of files requires gargantuan data server to manage and computing time is VERY long   States differ drastically on their Medicaid policies and reporting – –Florida especially problematic! LIMITATIONS/DIFFICULTIES

31   Continue examining data to find predictors of Medicaid churning among different groups   Randomized trial of simplified Medicaid renewal application at a 4 th grade reading level   Compile recommendations to end Medicaid churning   Continue refining graphical portrayal of data NEXT STEPS

32 Susmita Pati MD, MPH Jane Kavanagh Kathleen Noonan JD Lihai Song Zeinab Mohamad Joanne Levy MBA Shanta Layton THANK YOU!

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