A model of factors determining levels of public support for health care policy in the United States

Public preferences for policy are formed in a little-understood process that is not adequately described by traditional economic theory of choice. In this paper I suggest that U.S. aggregate support for health reform can be modeled as tradeoffs among a small number of behavioral values and the stage of policy development. The theory underlying the model is based on Samuelson, et al.'s (1986) work and Wilke's (1991) elaboration of it as the Greed/Efficiency/Fairness (GEF) hypothesis of motivation in the management of resource dilemmas, and behavioral economics informed by Kahneman and Thaler's prospect theory. ^ The model developed in this paper employs ordered probit econometric techniques applied to data derived from U.S. polls taken from 1990 to mid-2003 that measured support for health reform proposals. Outcome data are four-tiered Likert counts; independent variables are dummies representing the presence or absence of operationalizations of each behavioral variable, along with an integer representing policy process stage. Marginal effects of each independent variable predict how support levels change on triggering that variable. Model estimation results indicate a vanishingly small likelihood that all coefficients are zero and all variables have signs expected from model theory. ^ Three hypotheses were tested: support will drain from health reform policy as it becomes increasingly well-articulated and approaches enactment; reforms appealing to fairness through universal health coverage will enjoy a higher degree of support than those targeted more narrowly; health reforms calling for government operation of the health finance system will achieve lower support than those that do not. Model results support the first and last hypotheses. Contrary to expectations, universal health care proposals did not provide incremental support beyond those targeted to “deserving” populations—children, elderly, working families. In addition, loss of autonomy (e.g. restrictions on choice of care giver) is found to be the “third rail” of health reform with significantly-reduced support. When applied to a hypothetical health reform in which an employer-mandated Medical Savings Account policy is the centerpiece, the model predicts support that may be insufficient to enactment. These results indicate that the method developed in the paper may prove valuable to health policy designers. ^

Risk factors for developing complications while awaiting a cholecystectomy

Background. Laparoscopic Cholecystectomy is the gold standard for patients who are diagnosed with biliary colic (NIH, 1993). It has been demonstrated that individuals who wait a longer time between diagnosis and treatment are at increased risk of having complications (Rutledge et al., 2000; Contini et al., 2004; Eldar et al., 1999). County hospitals, such as Ben Taub General Hospital (BTGH), have a particularly high population of uninsured patients and consequently long surgical wait periods due to limited resources. This study evaluates patients the risk factors involved in their progression to complications from gallstones in a county hospital environment. ^ Methods. A case-control study using medical records was performed on all patients who underwent a cholecystectomy for gallstone disease at BTGH during the year of 2005 (n=414). The risk factors included in the study are obesity, gender, age, race, diabetes, and amount of time from diagnosis to surgery. Multivariate analysis and logistical regression were used to assess factors that potentially lead to the development of complications. ^ Results. There were a total of 414 patients at BTGH who underwent a cholecystectomy for gallstone disease during 2005. The majority of patients were female, 84.3% (n=349) and Hispanic, 79.7% (n=330). The median wait time from diagnosis to surgery was 1.43 weeks (range: 0-184.71). The majority of patients presented with complications 72.5% (n=112). The two factors that impacted development of complications in our study population were Hispanic race (OR=1.81; CI 1.02, 3.23; p=0.04) and time from diagnosis to surgery (OR=0.98; CI 0.97, 0.99; p<0.01). Obesity, gender, age, and diabetes were not predictive of development of complications. ^ Conclusions. An individual's socioeconomic status potentially influences all aspects of their health and subsequent health care. The patient population of BTGH is largely uninsured and therefore less likely to seek care at an early stage in their disease process. In order to decrease the rate of complications, there needs to be a system that increases patient access to primary care clinics. Until the problem of access to care is solved, those who are uninsured will likely suffer more severe complications and society will bear the cost. ^

A process evaluation of a health literacy intervention targeting pediatric providers' communication skills at the Texas Children's Health Plan

Background. Health literacy is an important determinant for quality health care, and affects communication between patients and physicians. Poor communication may result in negative effects in health. Improved communication between patients and physicians could positively affect health outcomes. Communication skills are teachable.^ Objectives. (1) to evaluate the process involved in the design and implementation of a health literacy intervention targeting pediatric providers’ communication skills at the Texas Children’s Health Plan in Houston, Texas; and (2) to describe lessons learned from this process that may be used in future attempts to address the issue of health literacy and health communication. ^ Design/methods. The process evaluation of the implementation of a health literacy strategy at the Texas Children’s Health Plan (TCHP) consisted of a critical analysis of all documents and minutes from meetings of the team of investigators. It also involved a secondary analysis of data collected between December 2006 and June 2007. Descriptive statistics, paired t-test and Wilcoxon-signed-rank test were employed in analyzing the data. This information was complemented with a limited review of existing literature on communication skills training programs. ^ Results. The design of the educational intervention followed recommendations from experts in the field of health literacy. The delivery of the intervention was possible and benefited from existing resources and logistics within the TCHP. Very few targeted providers participated in two offerings of the workshop (6.6% and 1.7% respectively). After the educational intervention, providers showed increased knowledge of health literacy facts and its effects in health (p=0.001); increased awareness of the low health literacy problem (p=0.003); increased expectations for change in practice (p=0.002), and intent to use health literacy strategies for communication immediately following the intervention (p=0.001). Low participation indicated the need for further investigation of barriers to, and means for successful implementation of programs aimed to improving health communication. ^ Conclusions. A short, focused intervention utilizing health literacy strategies for communication appeared effective in increasing knowledge and intentions for change in a small group of pediatric providers. ^

Depression care for the old-old in a primary care setting

Objective. Although those age 75 and older are the fastest growing age group in the U.S., few studies focus on the course and treatment of depression in this age group. This study examines the differences between the young-old (age 60 to 74) and the old-old (age 75 and older) in regards to their response to a collaborative care model for depression in primary care. We hypothesized that old-old participants would have more severe depression and have a lower rate of treatment response compared to young-old participants. ^ Methods. The sample consisted of 906 participants (n = 606 young-old; n = 300 old-old) who were randomized to receive the intervention with a depression care manager in the IMPACT trial. This study compared young-old and old-old patients on process of care and outcome variables to identify potential differences between the two age groups. Process of care was determined by the type of treatment and level of stepped care received. Clinical outcomes included SCL-20 depression scores, treatment response (defined as a ≥50% decrease in SCL-20 score from baseline) and complete remission (defined as a SCL-20 score <0.5) at 3-, 6-, and 12-months follow-up. ^ Results. The process of care variables did not differ between the two age groups. SCL-20 depression scores did not significantly differ between the two age groups at all follow-up intervals. Treatment response was significantly different between young-old and old-old participants at 6- and 12-months. Complete remission rates were significantly different between the two age-groups at 12-months follow-up. ^ Conclusions. Young-old and old-old patients have a similar clinical response to initial collaborative depression care in a primary care setting, but old-old patients may have lower rates long-term treatment response and complete remission. These findings will help guide future clinical and public health approaches to treat old-old patients with depression. ^

Health care policy analysis of Medicaid's early and periodic screening, diagnosis, and treatment (EPSDT) benefit in Colorado

The purpose of this thesis is to identify "best practice" recommendations for successful implementation of the EPSDT outreach program at Memorial Health System's Hospital for Children in Colorado Springs through a policy analysis of Medicaid EPSDT services in Colorado. A successful program at Memorial will increase education and awareness of EPSDT services, enrollment, and access to and utilization of health care services for eligible children. Methodology utilized in this study included questionnaires designed for the EPSDT contract administrator and outreach coordinators/workers; analysis of current federal and state policies; and studies conducted at the federal and state level, and by various advocacy groups. The need for this analysis of EPSDT came about in part through an awareness of increasingly high numbers of children in poverty and who are uninsured. Though the percentage of children living in poverty in Colorado is slightly below the national average (see Table 2), according to data analyzed by The Annie E. Casey Foundation, the percentage of children (0-18) living in poverty in Colorado increased from 10% in 2000 to 16% in 2006, a dramatic increase of 60% surpassed by only one other state in the nation (The Annie E. Casey Foundation, 2008). By comparison, the U.S. percentage of children in poverty during the same time frame rose from 17% to 18% (The Annie E. Casey Foundation, 2008). What kind of health care services are available to this vulnerable and growing group of Coloradans, and what are the barriers that affect their enrollment in, access to and utilization of these health care services? Barriers identified included difficulty with the application process; system and process issues; a lack of providers; and a lack of awareness and knowledge of EPSDT. Fiscal restraints and legislation at the federal and state level are also barriers to increasing enrollment and access to services. Outreach services are a critical component of providing EPSDT services, and there were several recommendations regarding outreach and case management that will benefit the program in the future. Through this analysis and identification of a broad range of barriers, a clearer picture emerged of current challenges within the EPSDT program as well as a broad range of strategies and recommendations to address these challenges. Through increased education and advocacy for EPSDT and the services it encompasses; stronger collaboration and cooperation between all groups involved, including providing a Medical Home for all eligible children; and new legislation putting more money and focus on comprehensive health care for low-income uninsured children; enrollment, access to and utilization of developmentally appropriate and quality health care services can be achieved. ^

A qualitative analysis of leadership styles and the selection of quality improvement in primary care practice

In the Practice Change Model, physicians act as key stakeholders, people who have both an investment in the practice and the capacity to influence how the practice performs. This leadership role is critical to the development and change of the practice. Leadership roles and effectiveness are an important factor in quality improvement in primary care practices.^ The study conducted involved a comparative case study analysis to identify leadership roles and the relationship between leadership roles and the number and type of quality improvement strategies adopted during a Practice Change Model-based intervention study. The research utilized secondary data from four primary care practices with various leadership styles. The practices are located in the San Antonio region and serve a large Hispanic population. The data was collected by two ABC Project Facilitators from each practice during a 12-month period including Key Informant Interviews (all staff members), MAP (Multi-method Assessment Process), and Practice Facilitation field notes. This data was used to evaluate leadership styles, management within the practice, and intervention tools that were implemented. The chief steps will be (1) to analyze if the leader-member relations contribute to the type of quality improvement strategy or strategies selected (2) to investigate if leader-position power contributes to the number of strategies selected and the type of strategy selected (3) and to explore whether the task structure varies across the four primary care practices.^ The research found that involving more members of the clinic staff in decision-making, building bridges between organizational staff and clinical staff, and task structure are all associated with the direct influence on the number and type of quality improvement strategies implemented in primary care practice.^ Although this research only investigated leadership styles of four different practices, it will offer future guidance on how to establish the priorities and implementation of quality improvement strategies that will have the greatest impact on patient care improvement. ^

Effectiveness of Texas Children's Hospital's Saturday Wellness Program for Children with special health care needs

Children with Special Health Care Needs comprise approximately 13% of children within the state of Texas. In addition to their primary diagnosis, it is estimated that approximately 18% of these children with special health care needs are overweight. Many times parents of children with special health care needs are extremely busy dealing with the daily responsibilities required to care for a child with a chronic illness, and thus, lose connections with their local communities and available resources for health needs such as obesity. Texas Children’s Hospital’s Wellness Program for Children with Special Health Care Needs is a family-centered wellness program to prevent obesity in this population; however, no formal evaluation of the program has been conducted. The purpose of this study was to assess the effectiveness of the Texas Children’s Saturday Wellness Program on weight status, nutrition knowledge, and the frequency of physical activity of children who participated in the program. A secondary data analysis was conducted with 50 children with special health care needs and their families who participated in the program during 2007 and 2008. A pre post-test study design was used with data collected immediately before and after participation in the 4 week program. Data measures included demographics (age, race, etc.), anthropometrics (height and weight), a quality of life survey focusing on nutrition and physical activity behaviors, and a knowledge survey on physical activity and nutrition. Of 50 participants, 33 (66%) completed the program. Children participating in the program showed a significant decrease in BMI (mean=29.83 to mean=29.22, BMI z score p<0.01), as well as frequency of physical activity (p<0.05) and knowledge (p<0.01). Texas Children’s Hospital’s wellness program for children with special health care needs provided a promising structure for a wellness program within a multi-ethnic special needs population; however, long term effect research is needed with a larger sample size and more comprehensive outcomes and process measures. Nonetheless, this program indicates the effectiveness and feasibility of a family-based approach to weight loss in children with special needs.^

Efforts of hospital system wound care teams to reduce hospital acquired pressure ulcers

New reimbursement policies developed by the Centers for Medicare and Medicaid Services (CMS) are revolutionizing the health care landscape in America. The policies focus on clinical quality and patient outcomes. As part of the new policies, certain hospital acquired conditions have been identified by Medicare as "reasonably preventable". Beginning October 1, 2008, Medicare will no longer reimburse hospitals for these conditions developed after admission, pressure ulcers are among the most common of these conditions.^ In this practice-based culminating experience the objective was to provide a practical account of the process of program development, implementation and evaluation in a public health setting. In order to decrease the incidence of pressure ulcers, the program development team of the hospital system developed a comprehensive pressure ulcer prevention program using a "bundled" approach. The pressure ulcer prevention bundle was based on research supported by the Institute for Healthcare Improvement, and addressed key areas of clinical vulnerability for pressure ulcer development. The bundle consisted of clinical processes, policies, forms, and resources designed to proactively identify patients at risk for pressure ulcer development. Each element of the bundle was evaluated to ensure ease of integration into the workflow of nurses and clinical ancillary staff. Continued monitoring of pressure ulcer incidence rates will provide statistical validation of the impact of the prevention bundle. ^

Hemodynamic changes associated with manual and automated lateral rotation in mechanically ventilated intensive care patients

Objective: To investigate hemodynamic responses to lateral rotation. ^ Design: Time-series within a randomized controlled trial pilot study. ^ Setting: A medical intensive care unit (ICU) and a medical-surgical ICU in two tertiary care hospitals. ^ Patients: Adult patients receiving mechanical ventilation. ^ Interventions: Two-hourly manual or continuous automated lateral rotation. ^ Measurements and Main Results: Heart rate (HR) and arterial pressure were sampled every 6 seconds for > 24 hours, and pulse pressure (PP) was computed. Turn data were obtained from a turning flow sheet (manual turn) or with an angle sensor (automated turn). Within-subject ensemble averages were computed for HR, mean arterial pressure (MAP), and PP across turns. Sixteen patients were randomized to either the manual (n = 8) or automated (n = 8) turn. Three patients did not complete the study due to hemodynamic instability, bed malfunction or extubation, leaving 13 patients (n = 6 manual turn and n = 7 automated turn) for analysis. Seven patients (54%) had an arterial line. Changes in hemodynamic variables were statistically significant increases ( p < .05), but few changes were clinically important, defined as ≥ 10 bpm (HR) or ≥ 10 mmHg (MAP and PP), and were observed only in the manual-turn group. All manual-turn patients had prolonged recovery to baseline in HR, MAP and PP of up to 45 minutes (p ≤ .05). No significant turning-related periodicities were found for HR, MAP, or PP. Cross-correlations between variables showed variable lead-lag relations in both groups. A statistically, but not clinically, significant increase in HR of 3 bpm was found for the manual-turn group in the back compared with the right lateral position ( F = 14.37, df = 1, 11, p = .003). ^ Conclusions: Mechanically ventilated critically ill patients experience modest hemodynamic changes with manual lateral rotation. A clinically inconsequential increase in HR, MAP, and PP may persist for up to 45 minutes. Automated lateral rotation has negligible hemodynamic effects. ^

Process to develop a State Model Law to reduce prescription drug trafficking while protecting pain management

This paper will discuss the intersection of pill mills and the under-treatment of pain, while addressing the unintended consequence that cracking down on pill mills actually has on medical professionals' treatment of legitimate pain in clinical settings. Moreover, the impact each issue has on the spectrum of related policy, regulatory issues and legislation will be analyzed while addressing the national impact on medical care. Lastly, this paper will outline a process to develop a State Model Law on this subject. This process will include suggestions for the future and how we can move forward to adequately address public safety needs and how we can attempt to mitigate the unintended impact prescription drug trafficking has had on a patient's right to appropriate pain management. This balance is achievable and this paper will address ways we can find this elusive balancing point through the development of a State Model Law. ^

Perceptions of work engagement of nurses in Taiwan

Purpose. The purpose of this study was to determine the perceptions of work engagement of Taiwanese nurses with 3 specific aims: (1) understand Taiwanese nurses' perceptions of work engagement; (2) explore the factors influencing work engagement, and (3) examine how work engagement impacts nursing care for patients. ^ Design. The study used an ethnographic approach with participant observation and semi-structured interviews with RNs. ^ Setting. The study was conducted in the highest and lowest nurse turnover medical surgical units at a regional teaching hospital in southwestern Taiwan. ^ Sample. Purposive sampling resulted in 28 formal interviews with RNs who provided direct patient care, had at least 3 months experience in nursing, and were full-time employees. ^ Methods. Descriptive data were collected through participant observation in each unit. Observations were made while attending meetings, continuing education sessions, and informal conversations with RNs. Field notes and audio recorded semi-structured interviews were analyzed using qualitative thematic analytic techniques. ^ Findings. Findings revealed perceptions of work engagement spanned four domains: patients ("wholehearted care"), work (positive attitude), self (fulfillment and happiness), and others (relationships with colleagues). Providing "wholehearted care" toward patients was the foundation of work engagement for nurses in Taiwan. Engaged nurses felt fulfilled, happy, and found "meaning" through the process of patient care. The study revealed five factors that influenced work engagement: personal, organizational, social, patient, and professional. The impact of work engagement on nurse and patient outcomes are confirmed. ^ Conclusions. Taiwanese nurses connect work engagement with patients, the job, oneself, and colleagues. "Wholehearted patient care" is the core manifestation of work engagement among these nurses. In contrast, studies in western business only focused on work attitudes. Losing interest and "heart" lead to work routines which can lead to individual unhappiness. Findings from this study validate the multiple factors contributing to work engagement of nurses. Job demands and resources can only partially explain what hinders work engagement. Work disengagement and burnout share some commonality but should be measured differently. An understanding of RNs' perceptions of work engagement may provide direction for strategies that improve work engagement leading to decreased RN turnover. ^

Perinatal mortality and quality of care at the National Institute of Perinatology: A 3-year analysis

Quality of medical care has been indirectly assessed through the collection of negative outcomes. A preventable death is one that could have been avoided if optimum care had been offered. The general objective of the present project was to analyze the perinatal mortality at the National Institute of Perinatology (located in Mexico City) by social, biological and some available components of quality of care such as avoidability, provider responsibility, and structure and process deficiencies in the delivery of medical care. A Perinatal Mortality Committee data base was utilized. The study population consisted of all singleton perinatal deaths occurring between January 1, 1988 and June 30, 1991 (n = 522). A proportionate study was designed.^ The population studied mostly corresponded to married young adult mothers, who were residents of urban areas, with an educational level of junior high school or more, two to three pregnancies, and intermediate prenatal care. The mean gestational age at birth was 33.4 $\pm$ 3.9 completed weeks and the mean birthweight at birth was 1,791.9 $\pm$ 853.1 grams.^ Thirty-five percent of perinatal deaths were categorized as avoidable. Postnatal infection and premature rupture of membranes were the most frequent primary causes of avoidable perinatal death. The avoidable perinatal mortality rate was 8.7 per 1000 and significantly declined during the study period (p $<$.05). Preventable perinatal mortality aggregated data suggested that at least part of the mortality decline for amenable conditions was due to better medical care.^ Structure deficiencies were present in 35% of avoidable deaths and process deficiencies were present in 79%. Structure deficiencies remained constant over time. Process deficiencies consisted of diagnosis failures (45.8%) and treatment failures (87.3%), they also remained constant through the years. Party responsibility was as follows: Obstetric (35.4%), pediatric (41.4%), institutional (26.5%), and patient (6.6%). Obstetric responsibility significantly increased during the study period (p $<$.05). Pediatric responsibility declined only for newborns less than 1500 g (p $<$.05). Institutional responsibility remained constant.^ Process deficiencies increased the risk for an avoidable death eightfold (confidence interval 1.7-41.4, p $<$.01) and provider responsibility ninety-fivefold (confidence interval 14.8-612.1, p $<$.001), after adjustment for several confounding variables. Perinatal mortality due to prematurity, barotrauma and nosocomial infection, was highly preventable, but not that due to transpartum asphyxia. Once specific deficiencies in the quality of care have been identified, quality assurance actions should begin. ^

DISCHARGE PLANNING: A PROCESS MODEL

As the requirements for health care hospitalization have become more demanding, so has the discharge planning process become a more important part of the health services system. A thorough understanding of hospital discharge planning can, then, contribute to our understanding of the health services system. This study involved the development of a process model of discharge planning from hospitals. Model building involved the identification of factors used by discharge planners to develop aftercare plans, and the specification of the roles of these factors in the development of the discharge plan. The factors in the model were concatenated in 16 discrete decision sequences, each of which produced an aftercare plan.^ The sample for this study comprised 407 inpatients admitted to the M. D. Anderson Hospital and Tumor Institution at Houston, Texas, who were discharged to any site within Texas during a 15 day period. Allogeneic bone marrow donors were excluded from the sample. The factors considered in the development of discharge plans were recorded by discharge planners and were used to develop the model. Data analysis consisted of sorting the discharge plans using the plan development factors until for some combination and sequence of factors all patients were discharged to a single site. The arrangement of factors that led to that aftercare plan became a decision sequence in the model.^ The model constructs the same discharge plans as those developed by hospital staff for every patient in the study. Tests of the validity of the model should be extended to other patients at the MDAH, to other cancer hospitals, and to other inpatient services. Revisions of the model based on these tests should be of value in the management of discharge planning services and in the design and development of comprehensive community health services.^

Differences in performance for quality of care indicators for acute myocardial infarction (AMI) across various hospital categories in Texas

The study analyzed Hospital Compare data for Medicare Fee-for-service patients at least 65 years of age to determine whether hospital performance for AMI outcome and processes of care measures differ amongst Texas hospitals with respect to ownership status (for profit vs. not-for-profit), academic status (teaching vs. non-teaching) and geographical setting (rural vs. urban). ^ The study found a statistically significant difference between for-profit and not-for-profit hospitals in four process-of-care measures (aspirin at discharge, P=0.028; ACE or ARB inhibitor for LSVD, P=0.048; Smoking cessation advice: P=0.034; outpatients who got aspirin with 24 hours of arrival in the ED, P=0.044). No significant difference in performance was found between COTH-member teaching and non-teaching hospitals for any of the eight process-of-care measures or the two outcome measures for AMI. The study was unable to compare performance based on geographic setting of hospitals due to lack of sufficient data for rural hospitals. ^ The results of the study suggest that for-profit Texas hospitals might be slightly better than not-for –profit hospitals at providing possible heart attack patients with certain processes of care.^