Measuring value in cancer-related health care: A case study in head and neck cancer

In the current climate of escalating health care costs, defining value and accurately measuring it are two critical issues affecting not only the future of cancer care in particular but also the future of health care in general. Specifically, measuring and improving value in cancer-related health care are critical for continued advancements in research, management, and overall delivery of care. However, in oncology, most of this research has focused on value as it relates to insurance industry and payment reform, with little attention paid to value as the output of clinical interventions that encompass integrated clinical teams focusing on the entire cycle of care and measuring objective outcomes that are most relevant to patients. ^ In this study, patient-centered value was defined as health outcomes achieved per dollar spent, and calculated using objective functional outcomes and total care costs. The analytic sample comprised patients diagnosed with three common head and neck cancers—cancer of the larynx, oral cavity, and oropharynx—who were treated in an integrated tertiary care center over an approximately 10-year period. The results of this study provide initial empirical data that can be used to assess and ultimately to help improve the quality and value of head and neck cancer care, and more importantly they can be used by patients and clinicians to make better-informed decisions about care, particularly what therapeutic services and outcomes matter the most to patients.^

Shifting the focus: Addressing breast cancer disparities at the health care organization level

The purpose of this study was to understand the scope of breast cancer disparities within the Texas Medical Center. The goal was to increase the awareness of breast cancer disparities at the health care organization level, and to foster the development of organizational interventions to reduce breast cancer disparities. The study seeks to answer the following questions: 1. Are hospitals in the Texas Medical Center implementing interventions to reduce breast cancer disparities? 2. What are their interventions for reducing the effects of non clinical factors on breast cancer treatment disparities? 3. What are their measures for monitoring, continuously improving, and evaluating the success of their interventions? ^ This research project was designed as a mixed methods case study. Quantitative breast cancer data for the years 2000-2009 was obtained from the Texas Cancer Registry (TCR). Qualitative data collection and analysis was done by conducting a total of 20 semi-structured interviews of administrators, physicians and nurses at five hospitals (A, B, C, D and E) in the Texas Medical Center (TMC). For quantitative analysis, the study was limited to early stage breast cancer patients: local and regional. The dependent variable was receipt of standard treatment: Surgery (Yes/No), BCS vs Mastectomy, Chemotherapy (Yes/No) and Radiation after BCS (Yes/No). The main independent variable was race: non-Hispanic White (NHW) , non-Hispanic Black (NHB), and Hispanic. Other covariates included age at diagnosis, diagnosis date, percent poverty, grade, stage, and regional nodes. Multivariate logistic regression was used to test the adjusted association between receipt of standard care and race. Qualitative data was analyzed with the Atlas.ti7 software (ATLAS.ti GmbH, Berlin). ^ Though there were significant differences by race for all dependent variables when the data was analyzed as a single group of all hospitals; at the level of the individual hospitals the results were not consistent by race/ethnicity across all dependent variables for hospitals A, B, and E. There were no racial differences in adjusted analysis for receipt of chemotherapy for the individual hospitals of interest in this study. For hospitals C and D, no racial disparities in treatment was observed in adjusted multivariable analysis. All organizations in this study were aware of the body of research which shows that there are disparities in breast cancer outcomes for patient population groups. However, qualitative data analysis found that there were differences in interest among hospitals in addressing breast cancer disparities in their patient population groups. Some organizations were actively implementing directed measures to reduce the breast cancer disparity gap in outcomes for patients, and others were not. Despite the differences in levels of interest, quantitative data analysis showed that organizations in the Texas Medical Center were making progress in reducing the burden of breast cancer disparities in the patient populations being served.^

Attitudes of health-care workers toward pregnant, HIV -positive women

The management of HIV infection with antiretroviral drugs has succeeded in increasing survival rates, but the subject of pregnancy in HIV-positive women continues to garner debate. Discrimination and stigma have been identified as barriers to health care, suggesting that women with HIV may be disinclined to seek prenatal care if health-care workers exhibit negative attitudes toward the women's pregnancies. To optimize prenatal and medical care for women with HIV infection, it is important to understand the general social conditions and cultural context in which these women have children. Goffman's treatise on stigma, Foucault's discussion of the knowledge/power matrix, and Bandura's Social Cognitive Theory offer theoretical perspectives by which we can evaluate the gender, race, and class issues that are inherent in pregnancy decision-making for women with HIV infection. It is also necessary to evaluate prevailing attitudes on childbearing toward HIV-positive women and to review the historical background of prejudice in which HIV-positive women make decisions regarding childbearing. ^ This qualitative study used a survey instrument and one-on-one interviews with HIV-infected women to elicit their perceptions of how they were treated by care providers when they became pregnant. It also included interviews with health-care workers to determine what their feelings are about pregnancy within the context of HIV infection. Results of the ethnographic inquiry reveal that most of the women had negative experiences at some point during a pregnancy, but that the situation improved when they sought care from a provider who was familiar with HIV infection. The health-care providers interviewed were firm in their belief that HIV-positive women deserved optimal care and treated the women with respect, but these are individuals who are also experts in providing care to HIV-positive patients. The question remains as to what kind of care HIV-positive women are receiving generally and what types of attitudes they are being subjected to if they see less experienced providers. Further research is also needed to determine whether HIV-positive women from a broader ethnic representation and higher socioeconomic status experience similar negative attitudes. ^

A STUDY OF THE ATTITUDES OF ELDERLY CONSUMERS TOWARD DENTAL CARE AND ORAL HEALTH

This paper describes a study of the attitudes of elderly consumers toward dental care and oral health. Four hundred and two respondents ages 60-97 were interviewed with a 62 item questionnaire. Attitudes were measured regarding: quality of care, sufficient utilization of care, priority of oral health, patient-provider interaction, individual control over health, powerful others control of health, and chance as the locus of control over health. Analysis of variance was performed on the sample of males and females separately. Fifty-four hypotheses were tested on each sex. Race and self-concept were excellent predictors of attitude for both sexes and SES (socioeconomic status) and self-reported health were good predictors for females. There was no statistically significant relationship between the frequency with which the elderly utilize dental care and their attitudes toward the quality of care they receive. Foremost reason for non-utilization was that of no felt need. Those selecting this reason were likely to be Anglo females, wearers of dentures, in good health. Those selecting cost as the foremost reason for non-utilization were Black, in fair health, of either sex, missing some teeth, but with no dentures. Overall attitudes toward quality of dental care were positive, despite the fact that this group was exposed to dental care in its infancy. This may suggest that the elderly recognize the importance of technological advances in dentistry. Women with low income and education levels were more likely to have positive attitudes about quality of care than other females. Attitudes about interaction between patient and provider were overall negative. The sample scored high on individual control over health, and scored lower, but nonetheless positively, on feelings that persons other than themselves are most essential to maintaining health. Overall these elderly persons did not agree that they relied on chance in matters of health. Those who did choose this locus were female, with lower SES and health status. Though males scored high on internal control of health, those with lowest scores were Mexican-American or had never been married. Sex and ethnicity were the best predictors of attitude across all measures in the study.^

Development and formative evaluation of an obesity prevention intervention for the pediatric primary care setting: Helping HAND (Healthy Activity and Nutrition Directions)

As the obesity epidemic continues to increase, the pediatric primary care office setting remains a relatively unexplored arena to offer obesity prevention interventions for children. The increased risk for adult obesity among 10 to 14 year-old children who are overweight, suggests obesity prevention programs should be introduced just before this age or early in this age period. Research is also accumulating on the importance of targeting parents along with children, since parents are in charge of the home environment for children. Therefore, the aim of this project was to develop an obesity prevention program called Helping HAND (Healthy Activity and Nutrition Directions) based on Social Cognitive Theory and authoritative parenting techniques for the pediatric primary care setting and conduct one-on-one interviews with parents as the initial formative evaluation of the intervention material for the obesity prevention intervention. A secondary aim of the project was to determine the feasibility of identifying appropriate subjects for the intervention, and conducting qualitative evaluations of the materials through recruitment through pediatric primary care settings. ^

Effect of primary care availability and health insurance coverage on risk and cost of Preventable Hospitalizations in Harris County

Preventable Hospitalizations (PHs) are hospitalizations that can be avoided with appropriate and timely care in the ambulatory setting and hence are closely associated with primary care access in a community. Increased primary care availability and health insurance coverage may increase primary care access, and consequently may be significantly associated with risks and costs of PHs. Objective. To estimate the risk and cost of preventable hospitalizations (PHs); to determine the association of primary care availability and health insurance coverage with the risk and costs of PHs, first alone and then simultaneously; and finally, to estimate the impact of expansions in primary care availability and health insurance coverage on the burden of PHs among non-elderly adult residents of Harris County. Methods. The study population was residents of Harris County, age 18 to 64, who had at least one hospital discharge in a Texas hospital in 2008. The primary independent variables were availability of primary care physicians, availability of primary care safety net clinics and health insurance coverage. The primary dependent variables were PHs and associated hospitalization costs. The Texas Health Care Information Collection (THCIC) Inpatient Discharge data was used to obtain information on the number and costs of PHs in the study population. Risk of PHs in the study population, as well as average and total costs of PHs were calculated. Multivariable logistic regression models and two-step Heckman regression models with log-transformed costs were used to determine the association of primary care availability and health insurance coverage with the risk and costs of PHs respectively, while controlling for individual predisposing, enabling and need characteristics. Predicted PH risk and cost were used to calculate the predicted burden of PHs in the study population and the impact of expansions in primary care availability and health insurance coverage on the predicted burden. Results. In 2008, hospitalized non-elderly adults in Harris County had 11,313 PHs and a corresponding PH risk of 8.02%. Congestive heart failure was the most common PH. PHs imposed a total economic burden of $84 billion at an average of $7,449 per PH. Higher primary care safety net availability was significantly associated with the lower risk of PHs in the final risk model, but only in the uninsured. A unit increase in safety net availability led to a 23% decline in PH odds in the uninsured, compared to only a 4% decline in the insured. Higher primary care physician availability was associated with increased PH costs in the final cost model (β=0.0020; p<0.05). Lack of health insurance coverage increased the risk of PH, with the uninsured having 30% higher odds of PHs (OR=1.299; p<0.05), but reduced the cost of a PH by 7% (β=-0.0668; p<0.05). Expansions in primary care availability and health insurance coverage were associated with a reduction of about $1.6 million in PH burden at the highest level of expansion. Conclusions. Availability of primary care resources and health insurance coverage in hospitalized non-elderly adults in Harris County are significantly associated with the risk and costs of PHs. Expansions in these primary care access factors can be expected to produce significant reductions in the burden of PHs in Harris County.^