Performance tiers: Implementing comparative effectiveness analysis in the health care setting through operations research and spatial methods

This dissertation develops and tests a comparative effectiveness methodology utilizing a novel approach to the application of Data Envelopment Analysis (DEA) in health studies. The concept of performance tiers (PerT) is introduced as terminology to express a relative risk class for individuals within a peer group and the PerT calculation is implemented with operations research (DEA) and spatial algorithms. The analysis results in the discrimination of the individual data observations into a relative risk classification by the DEA-PerT methodology. The performance of two distance measures, kNN (k-nearest neighbor) and Mahalanobis, was subsequently tested to classify new entrants into the appropriate tier. The methods were applied to subject data for the 14 year old cohort in the Project HeartBeat! study.^ The concepts presented herein represent a paradigm shift in the potential for public health applications to identify and respond to individual health status. The resultant classification scheme provides descriptive, and potentially prescriptive, guidance to assess and implement treatments and strategies to improve the delivery and performance of health systems. ^

Identifying characteristics of mentally ill homeless individuals who are successfully linked to health and social services post-incarceration via the jail inreach project

Healthcare for the Homeless—Houston (HHH) received a research grant from The Medallion Foundation, Inc. in March 2006 to pilot The Jail Inreach Project, an intensive “inreach” initiative to assess the impact of providing continuity of mental and primary health care services for homeless individuals who suffer from mental illness and/or substance abuse being released from jail. This pilot project was initiated by HHH, in collaboration with the Harris County Sheriff’s Office and the Mental Health Mental Retardation Authority of Harris County (MHMRA). Those who are flagged as “frequent flyers” and who are diagnosed with a mental illness are referred to the Jail Inreach Project. In order to maximize the effectiveness of the discharge plan, case managers offer the option of meeting the client at the time of release and bring them to the HHH clinic located four blocks from the jail. Participation in both the program and the option for direct release to the care of a case manager are voluntary.^ The purpose of this study is to determine the outcomes of the Jail Inreach Project and addresses the following objectives: (1) to evaluate the characteristics of inmates that chose to be released from jail to the direct care of an HHH case manager versus those who opt for self release and (2) to determine the number and percent of inmates that are linked to services and relationship with type of release (direct versus indirect), (3) to determine if there is a relationship between outcomes and characteristics and (4) to determine what outcomes are a function of release, controlling for characteristics. Statistical analysis, including frequencies, cross tabulations, chi-square and logistical regression, found that those who opt for self release are six times less likely to be successfully linked to services and that gender is the most significant predictor of choosing self release. Men are far more likely to opt for self release than women engaged in this program. These findings help inform policy and program design and development that addresses the difference in service utilization and successful linkage to services post-incarceration. Successful linkage to services, thus continuity of and access to care, further impact the effects of the revolving door phenomenon of mentally ill homeless individuals cycling between the streets, jails and hospital emergency centers.^

Air Force Web Preventive Health Assessment (AF WEBPHA) mental health screening effectiveness

The U.S. Air Force assesses Active Duty Air Force (ADAF) health annually using the Air Force Web-based Preventative Health Assessment (AF WebPHA). The assessment is based on a self-administered survey used to determine the overall Air Force health and readiness, as well as, the individual health of each airman. Individual survey responses as well as groups of responses generate further computer generated assessment and result in a classification of 'Critical', 'Priority', or 'Routine', depending on the need and urgency for further evaluation by a health care provider. The importance of the 'Priority' and 'Critical' classifications is to provide timely intervention to prevent or limit unfavorable outcomes that may threaten an airman. Though the USAF has been transitioning from a paper form to the online WebPHA survey for the last three years it was not made mandatory for all airmen until 2009. The survey covers many health aspects including family history, tobacco use, exercise, alcohol use, and mental health. ^ Military stressors such as deployment, change of station, and the trauma of war can aggravate and intensify the common baseline worries experienced by the general population and place airmen at additional risks for mental health concerns and illness. This study assesses the effectiveness of the AF WebPHA mental health screening questions in predicting a mental health disorder diagnosis according to International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes generated by physicians or their surrogates. In order to assess the sensitivity, specificity, and positive predictive value of the AF WebPHA as a screening tool for mental health, survey results were compared to ascertain if they generated any mental health disorder related diagnosis for the period from January 1, 2009 to March 31, 2010. ^ Statistical analysis of the AF WebPHA mental health responses when compared with matching ICD-9-CM codes found that the sensitivity for 'Critical' or 'Priority' responses was only 3.4% and that it would correctly predict those who had the selected mental health diagnosis 9% of the time.^

Cancer perceptions: Implications from the 2007 Health Information National Trends Survey

Background. Research has demonstrated associations between sociodemographic characteristics and illness perceptions; however, the impact of cancer exposure through personal or family diagnoses is not well-studied. The purposes of this study were to examine the prevalence of different cancer beliefs and the disparity in cancer beliefs across groups of individuals with distinct cancer histories; and to identify whether, when adjusted for sociodemographic characteristics, cancer history predicts a set of cancer beliefs.^ Methods. Using Leventhal’s Common Sense Model and data from the 2007 Health Information National Trends Survey (N=7172), we constructed multivariable logistic regressions to evaluate the effect of different stimuli, including cancer experience, on cancer perceptions (e.g., risk, worry, causation, outcome).^ Results. Findings indicate significant associations between cancer history and cancer perceptions. Individuals with family and personal cancer histories were more likely than individuals without any cancer history to worry about getting cancer (OR=3.55, P<0.01), agree they will develop cancer in the future (OR=8.81, P<0.01), and disagree that cancer is most often caused by a person’s behavior or lifestyle (OR=1.24, P=0.03). Additionally, results support education’s role in forming cancer perceptions. Individuals with high levels of education were more likely to endorse cancer prevention (OR=1.68, P<0.01) and higher 5-year survival rates (OR=1.41, P<0.01). ^ Conclusions. Results indicate cancer history affects cancer perceptions throughout the cancer continuum. Additionally, cancer history may influence coping behaviors and outcomes related to cancer.^ Impact. Cancer education and survivorship programs should assess important variables (e.g., cancer history) to more effectively tailor services and monitor evolving needs throughout cancer care.^

Analysis of participation in the federally mandated coal workers' health surveillance program

The Federal Coal Mine Health and Safety Act of 1969 required that periodic chest radiographs be offered to underground coal miners to protect the miners from the development of Coal Workers' Pneumoconiosis (CWP) and progression of the disease to progressive massive fibrosis (PMF). These examinations are administered by the National Institute for Occupational Safety and Health (NIOSH) through the Coal Workers' Health Surveillance Program (CWHSP). The mine operator is required to provide each miner with the opportunity to have the chest radiograph at no cost to the miner.^ Three rounds of examinations have been conducted since 1969 and the fourth is underway. The decrease in participation over rounds is of great concern if the incidence and progression of CWP are to be understood and controlled.^ This study developed rates of participation for each of 558 West Virginia underground coal mines who submitted or had NIOSH assigned plans for making chest radiographs available during the third round, July 1978 through December 1980. These rates were analyzed in relation to desired levels of participation and to reinforcing, predisposing and enabling factors presumed to affect rates of participation in disease prevention and surveillance programs.^ Two reinforcing factors, size of mine and inclusion of the mine in the National Coal Study (NCS) epidemiology research program, and the enabling factor, use of an on-site radiograph facility, demonstrated highly significant relationships to participation rates.^ The major findings of the study were: (1) Participation in the CWHSP is even lower than previously estimated; (2) CWHSP program evaluation is not systematic and program data base is not complete and comprehensive; and (3) NIOSH program policy is not clear and administration of the CWHSP is fragmented and lacks adequate fiscal and personnel resources. ^

Social network size and perceived network sufficiency as predictors of perceived health status

This study focused on the relationship between social network size (number of friends and relatives), perceived sufficiency of the network and self-rated health utilizing data from the National Survey of Personal Health Practices and Consequences, 1979. For men neither perceived sufficiency nor number of relatives were associated with self-rated health status. The number of friends was positively associated with health status. For women perceived network sufficiency was positively and significantly related to health status, independent of network size. The number of friends and relatives was not associated with self-rated health status. The sociodemographic variables accounted for most of the explained variance in health status for both males and females. Social networks may hold different meanings for women and men, and may require qualitative as well as quantitative analysis. There may have been insufficient variance in the major variables to produce meaningful results. ^

Factors associated with home health care costs

Characteristics of Medicare-certified home health agencies in Texas and the contributions of selected agency characteristics on home health care costs were examined. Cost models were developed and estimated for both nursing and total visit costs using multiple regression procedures. The models included home health agency size, profit status, control, hospital-based affiliation, contract-cost ratio, service provision, competition, urban-rural input-price differences, and selected measures of patient case-mix. The study population comprised 314 home health agencies in Texas that had been certified at least one year on July, 1, 1986. Data for the analysis were obtained from Medicare Cost Reports for fiscal year ending between July 1, 1985 to June 30, 1986.^ Home health agency size, as measured by the logs of nursing and total visits, has a statistically significant negative linear relationship with nursing visit and total visit costs. Nursing and total visit costs decrease at a declining rate as size increases. The size-cost relationship is not altered when controlling for any other agency characteristic. The number of visits per patient per year, a measure of patient case-mix, is also negatively related to costs, suggesting that costs decline with care of chronic patients. Hospital-based affiliation and urban location are positively associated with costs. Together, the four characteristics explain 19 percent of the variance in nursing visit costs and 24 percent of the variance in total visit costs.^ Profit status and control, although correlated with other agency characteristics, exhibit no observable effect on costs. Although no relationship was found between costs and competition, contract cost ratio, or the provision on non-reimburseable services, no conclusions can be made due to problems with measurement of these variables. ^

Social support, health status and health services utilization among the noninstitutionalized elderly: An analysis of the Supplement on Aging to the 1984 national health interview survey

The association between Social Support, Health Status, and Health Services Utilization of the elderly, was explored based on the analysis of data from the Supplement on Aging to the National Health Interview Survey, 1984 (N = 11,497) using a modified framework of Aday and Andersen's Expanded Behavioral Model. The results suggested that Social Support as operationalized in this study was an independent determinant of the use of health services. The quantity of social activities and the use of community services were the two most consistent determinants across different types of health services use.^ The effects of social support on the use of health services were broken down into three components to facilitate explanations of the mechanisms through which social support operated. The Predisposing and Enabling component of Social Support had independent, although not uniform, effects on the use of health services. Only slight substitute effects of social support were detected. These included the substitution of the use of senior centers for longer stay in the hospital and the substitution of help with IADL problems for the use of formal home care services.^ The effect of financial support on the use of health services was found to be different for middle and low income populations. This differential effect was also found for the presence of intimate networks, the frequencies of interaction with children and the perceived availability of support among urban/rural, male/female and white/non-white subgroups.^ The study also suggested that the selection of appropriate Health Status measures should be based on the type of Health Services Utilization in which a researcher is interested. The level of physical function limitation and role activity limitation were the two most consistent predictors of the volume of physician visits, number of hospital days, and average length of stay in the hospital during the past year.^ Some alternative hypotheses were also raised and evaluated, when possible. The impacts of the complex sample design, the reliability and validity of the measures and other limitations of this analysis were also discussed. Finally, a revised framework was proposed and discussed based on the analysis. Some policy implications and suggestions for future study were also presented. ^

Determinants of participation in worksite health risk appraisal (HRA) programs

The purpose of this study was to apply the Behavioral Model of Health Services Utilization to examine an existing worksite HRA program to identify and examine the roles of determinants of participation in HRA programs. The program consisted of three activities: questionnaire, physical examination, and group interpretation sessions. All of the 1821 employees were eligible for the program; 523 (29%) participated in at least one activity. Results from bivariate analyses suggest that being female, being white, having fewer dependents, and having higher medical claims for the past year were positively associated with participation. Results of logistic regression suggest that Age, Sex, Race, Marital, Number of Dependents, Job Title, Months with the Company, and a log transformed value of Employee's Total Medical Claims were all significant determinants of participation. Applications of the logistic regression models, other factors that should be investigated in future studies, and the limitations of the study were discussed. ^

A study of the determinants of the utilization of preventive health care service among Chicanos

This study examines the individual and health care system determinants of two types of preventive health care practice behaviors, having a routine physical exam or a preventive dental exam, in the past year among Chicanos in the Southwestern United States. The study utilizes the Health System Model, developed by Aday and Andersen in 1974, to analyze the relative effect of education, income and occupation on the use of discretionary health care, controlling for other individual and health care system determinants.^ The study is based on a sample of 4,111 Mexican origin adults, drawn from the Hispanic Health and Nutrition Examination Survey (HHANES). This sample is representative of Mexican American residing in the Southwestern United States.^ The study tests the hypothesis that education is the most important social class predictor of preventive health care practice behavior. The fully elaborated model tests the hypothesis that individual determinants alone are insufficient to explain the use of preventive health care services among Chicanos.^ The study found that education and income are statistically significant social class indicators only as it relates to having a preventive dental exam. Education is not the most important social class predictor of either preventive health care practice behavior. Health care system determinants are key predictors of both behaviors. Need, as measured by self-perceived health status of teeth and gender, is as important a determinant as having dental insurance coverage as it relates to having a preventive dental exam. Implications for health programs to effectively reach Chicano target groups and remove access barriers to their use of discretionary health care services are discussed. ^

Patient satisfaction in government health facilities in the state of Qatar

This study provides data which can contribute to improving services and delivering quality health care in government health facilities in the state of Qatar. To measure the satisfaction with current care of selected patients who receive care in Hamad General Hospital and the Khalifa Town Health Center in the city of Doha, a cross-sectional survey and a self-administered questionnaire were used.^ Analysis was performed on data from 444 patients on eight dimensions of patient satisfaction with medical care. These include: general satisfaction, availability of services, convenience of services, facilities, humaneness of doctors, quality of care, continuity of care, and aspects of the last visit. Patient satisfaction parameters were compared for males vs. females, for citizens vs. non-citizens, and for patients seen in the hospital vs. those seen in the health center.^ Results indicate that patients seen in the hospital were more satisfied with care than patients seen in the health center, that non-citizens were more satisfied than citizens, and that males were slightly more satisfied than females with medical services. ^

For health's sake: Cervical and breast cancer screening

African-Americans make up twelve percent of the United States population, yet they experience morbidity and mortality at a rate that, in some cases, is disproportionate to their numbers. There are numerous health areas, including cancer, in which disparities exist. There are also numerous reasons which have been suggested to explain the high rates of cancer morbidity and mortality experienced by African-Americans. Among the reasons given to explain these differences are lack of knowledge and lack of access to medical care (1). This study sought to increase the knowledge, attitudes, and behavioral intentions of African-American women attending a Baptist church in Houston with regard to cervical cancer, breast cancer, Pap smear, and mammography. It was hypothesized that a church-based cancer education program would produce the desired change in knowledge, attitudes, and behavioral intentions.^ The quasi-experimental design of the study was untreated control group with pretest and posttest and untreated control group with posttest only. Female members of Mount Ararat Baptist Church took part in an eight-week, cancer education program based on social cognitive theory. Baseline data were collected before the start of the program at Mount Ararat and at Solid Rock Baptist Church, control group one. At the end of the program, the follow-up survey was administered at the program church, control church one, and in a third church, Damascus Missionary Baptist Church, which served as the posttest only group. The data were analyzed by Fisher's exact and paired t-test to determine if the program supported the project's hypotheses.^ Results of data analyses supported the major study hypotheses, the exception being behavioral intention to have Pap smear performed. Although the program appeared to have generally influenced changes in the desired direction, the results are limited due to the quasi-experimental design and small sample size. Longer term studies with larger sample sizes are needed to more fully develop and evaluate programs which impact the health of African-Americans. ^

Infectious diseases, immune status, and health insurance among child care providers in Houston, Texas

The objectives of this study were to compare female child-care providers with female university workers and with mothers of children in child-care centers for: (1) frequency of illness and work loss days due to infectious diseases, (2) prevalence of antibodies against measles, rubella, mumps, hepatitis B, hepatitis A, chickenpox and cytomegalovirus (CMV), and (3) status regarding health insurance and job benefits.^ Subjects from twenty child-care centers and twenty randomly selected departments of a university in Houston, Texas were studied in a cross-sectional fashion.^ A cluster sample of 281 female child-care providers from randomly selected child-care centers, a cluster sample of 286 university workers from randomly selected departments and a systematic sample of 198 mothers of children from randomly selected child-care centers.^ Main outcome measures were: (1) self-reported frequency of infectious diseases and number of work-days lost due to infectious diseases; (2) presence of antibodies in blood; and (3) self-reported health insurance and job benefits.^ In comparison to university workers, child-care providers reported a higher prevalence of infectious diseases in the past 30 days; lost three times more work-days due to infectious diseases; and were more likely to have anti-core antibodies against hepatitis B (odds ratio = 3.16 95% CI 1.27-7.85) and rubella (OR 1.88, 95% CI 1.02-3.45). Child-care providers had less health insurance and job-related benefits than mothers of children attending child-care centers.^ Regulations designed to reduce transmission of vaccine and non-vaccine preventable diseases in child-care centers should be strictly enforced. In addition policies to improve health insurance and job benefits of child-care providers are urgently needed. ^

Health status of Saudi women, the case of Yanbu al-Sinaiya

Detailed data on the health status of Saudi women are lacking. This cross sectional study attempts to provide a comprehensive description of the health status of Saudi females between the ages of 15-45 residing in Yanbu Al-Siniyah. The purpose is to assess women's needs for health services. The health status indicators are chronic tracer conditions, reported symptoms and multidimensional functioning levels. The generic functioning instrument of the Medical Outcome Study was used to estimate physical, social, and role functioning; degree of pain and health perceptions. The information was obtained by interviewing subjects and abstracting facts from their medical records. The results show functioning scores are in the "well health" range for physical, social, role and pain. Crowding and education have an equal or stronger effect of reducing functioning levels than the diagnosed tracer conditions. The highest prevalence conditions having a definite functional impact and diagnosed adequately in primary care are anemia, urinary tract infection, hemorrhoids, rheumatoid arthritis, caries and gingivitis. Reported symptoms strongly reducing function levels in this study are dyspnea, heart pain, incontinence, eye and skin problems, and joint ache. The impact of the reliability and validity of the measures used and other limitations of the results are discussed. Finally, some policy implications and suggestions for future study are presented. ^

Cross-culture perspectives on fear of HIV disease and AIDS in health care workers

Health care workers have been known to carry into the workplace a variety of judgmental and negative attitudes towards their patients. In no other area of patient care has this issue been more pronounced as in the management of patients with AIDS. Health care workers have refused to treat or manage patients with AIDS and have often treated them more harshly than identically described leukemia patients. Some health care institutions have simply refused to admit patients with AIDS and even recent applicants to medical colleges and schools of nursing have indicated a preference for schools in areas with low prevalence of HIV disease. Since the attitudes of health care workers do have significant consequences on patient management, this study was carried out to determine the differences in clinical practice in Nigeria and the United States of America as it relates to knowledge of a patient's HIV status, determine HIV prevalence and culture in each of the study sites and how they impact on infection control practices, determine the relationship between infection control practices and fear of AIDS, and also determine the predictors of safe infection control practices in each of the study sites.^ The study utilized the 38-item fear of AIDS scale and the measure of infection control questionnaire for its data. Questionnaires were administered to health care workers at the university teaching hospital sites of Houston, Texas and Calabar in Nigeria. Data was analyzed using a chi-square test, and where appropriate, a student t-tests to establish the demographic variables for each country. Factor analysis was done using principal components analysis followed by varimax rotation to simple structure. The subscale scores for each study site were compared using t-tests (separate variance estimates) and utilizing Bonferroni adjustments for number of tests. Finally, correlations were carried out between infection control procedures and fear of AIDS in each study site using Pearson-product moment correlation coefficients.^ The study revealed that there were five dimensions of the fear of AIDS in health care workers, namely fear of loss of control, fear of sex, fear of HIV infection through blood and illness, fear of death and medical interventions and fear of contact with out-groups. Fear of loss of control was the primary area of concern in the Nigerian health care workers whereas fear of HIV infection through blood and illness was the most important area of AIDS related feats in United States health care workers. The study also revealed that infection control precautions and practices in Nigeria were based more on normative and social pressures whereas it was based on knowledge of disease transmission, supervision and employee discipline in the United States, and thus stresses the need for focused educational programs in health care settings that emphasize universal precautions at all times and that are sensitive to the cultural nuances of that particular environment. ^