Adjustment of physician profiles for patient socioeconomic status using aggregate geographic data

A systematic review of reasons for and against asking patients about their socioeconomic contexts

Background

People’s social and economic circumstances are important determinants of their health, health experiences, healthcare access, and healthcare outcomes. However, patients’ socioeconomic circumstances are rarely asked about or documented in healthcare settings. We conducted a systematic review of published reasons for why patients’ socioeconomic contexts (including education, employment, occupation, housing, income, or wealth) should, or should not, be enquired about.

Methods

Systematic review of literature published up to and including 2016. A structured literature search using databases of medicine and nursing (pubmed, embase, global health), ethics (Ethicsweb), social sciences (Web of Science), and psychology (PsychINFO) was followed by a ‘snowball’ search. Eligible publications contained one or more reasons for: asking patients about socioeconomic circumstances; collecting patients’ socioeconomic information; ‘screening’ patients for adverse socioeconomic circumstances; or linking other sources of individual socioeconomic data to patients’ healthcare records. Two authors conducted the screening: the first screened all references, the second author screened a 20% sample with inter-rater reliability statistically confirmed. ‘Reason data’ was extracted from eligible publications by two authors, then analysed and organised.

Results

We identified 138 eligible publications. Most offered reasons for why patients’ should be asked about their socioeconomic circumstances. Reasons included potential improvements in: individual healthcare outcomes; healthcare service monitoring and provision; population health research and policies. Many authors also expressed concerns for improving equity in health. Eight publications suggested patients should not be asked about their socioeconomic circumstances, due to: potential harms; professional boundaries; and the information obtained being inaccurate or unnecessary.

Conclusions

This first summary of literature on the subject found many published reasons for why patients’ social and economic circumstances should be enquired about in healthcare settings. These reasons include potential benefits at the levels of individuals, health service provision, and population, as well as the potential to improve healthcare equity. Cautions and caveats include concerns about the clinician’s role in responding to patients’ social problems; the perceived importance of social health determinants compared with biomedical factors; the use of average population data from geographic areas to infer the socioeconomic experience of individuals. Actual evidence of outcomes is lacking: our review suggests hypotheses that can be tested in future research.

Opportunities and Challenges for Measuring Cost, Quality, and Clinical Effectiveness in Health Care

Empirical studies of health care cost, productivity, and output have focused primarily on intermediate goods and services. Consumers are ultimately interested in final goods such as improved health or health-related quality of life, but health services research continues to address whether health services financing and delivery are structured in ways to maximize production of intermediate goods, regardless of the link between these services and final outcomes. Increasing rates of growth of health care cost and dissatisfaction with the quality of U.S. health care force us to reexamine how productivity and cost are analyzed so that research properly informs policy and practice. The authors examine recent changes in the U.S. health care sector that suggest the need to revise how health services research approaches analyses of cost, production, and output; consider alternative notions of final goods; and review the availability and quality of data necessary to conduct this research.

Longitudinal trajectory of sexual functioning after hematopoietic cell transplantation: impact of chronic graft-versus-host disease and total body irradiation

This prospective study described the trajectory of sexual well-being from before hematopoietic cell transplantation (HCT) to 3 years after in 131 allogeneic and 146 autologous HCT recipients using Derogatis Interview for Sexual Function and Derogatis Global Sexual Satisfaction Index. Sixty-one percent of men and 37% of women were sexually active pre-HCT; the prevalence declined to 51% (P = .01) in men and increased to 48% (P = .02) in women at 3 years post-HCT. After HCT, sexual satisfaction declined in both sexes (P < .001). All sexual function domains were worse in women compared with men (P ≤ .001). Orgasm (P = .002) and drive/relationship (P < .001) declined in men, but sexual cognition/fantasy (P = .01) and sexual behavior/experience (P = .01) improved in women. Older age negatively impacted sexual function post-HCT in both sexes (P < .01). Chronic graft-versus-host disease was associated with lower sexual cognition/fantasy (P = .003) and orgasm (P = .006) in men and sexual arousal (P = .05) and sexual satisfaction (P = .005) in women. All male sexual function domains declined after total body irradiation (P < .05). This study identifies vulnerable subpopulations that could benefit from interventional strategies to improve sexual well-being.

The influence of race/ethnicity and socioeconomic status on end-of-life care in the ICU

BACKGROUND

There is conflicting evidence about the influence of race/ethnicity on the use of intensive care at the end of life, and little is known about the influence of socioeconomic status.

METHODS

We examined patients who died in the ICU in 15 hospitals. Race/ethnicity was assessed as white and nonwhite. Socioeconomic status included patient education, health insurance, and income by zip code. To explore differences in end-of-life care, we examined the use of (1) advance directives, (2) life-sustaining therapies, (3) symptom management, (4) communication, and (5) support services.

RESULTS

Medical charts were abstracted for 3,138/3,400 patients of whom 2,479 (79%) were white and 659 (21%) were nonwhite (or Hispanic). In logistic regressions adjusted for patient demographics, socioeconomic factors, and site, nonwhite patients were less likely to have living wills (OR, 0.41; 95% CI, 0.32-0.54) and more likely to die with full support (OR, 1.59; 95% CI, 1.30-1.94). In documentation of family conferences, nonwhite patients were more likely to have documentation that prognosis was discussed (OR, 1.47; 95% CI, 1.21-1.77) and that physicians recommended withdrawal of life support (OR, 1.57; 95% CI, 1.11-2.21). Nonwhite patients also were more likely to have discord documented among family members or with clinicians (OR, 1.49; 95% CI, 1.04-2.15). Socioeconomic status did not modify these associations and was not a consistent predictor of end-of-life care.

CONCLUSIONS

We found numerous racial/ethnic differences in end-of-life care in the ICU that were not influenced by socioeconomic status. These differences could be due to treatment preferences, disparities, or both. Improving ICU end-of-life care for all patients and families will require a better understanding of these issues.

TRIAL REGISTRY

ClinicalTrials.gov; No.: NCT00685893; URL: www.clinicaltrials.gov.

Will Pay-For-Performance And Quality Reporting Affect Health Care Disparities?

Pay-for-performance (P4P) and public quality-reporting programs can increase the quality of health care for the services being measured. However, unless carefully designed, these programs may have the unintended consequence of increasing racial and ethnic disparities. This paper describes ways in which P4P and public reporting programs may increase disparities and suggests ways in which programs might be designed that will make them likely to reduce, or at least not increase, disparities.

Adjusting for Patient Characteristics and Selection Effects in Assessment of Community Mental Health Centers

OBJECTIVE

The objective of this study was to determine the effect of patient socioeconomic characteristics and center selection of patients on measured performance of community mental health centers.

DATA SOURCE/STUDY SETTING

Data were taken from the administrative records of Indiana's public mental health system for 16,516 adults with severe, persistent mental illness treated in 30 community mental health centers. Center performance was compared using longitudinal information on patient functioning.

METHODS

A mixed random-effects model that is suitable for fitting data with a hierarchical structure was used to assess relative performance.

PRINCIPAL FINDINGS

Measured performance was found to depend significantly on patient education, income, marital status, race, ethnicity, and baseline health (P<0.05). Results also indicated centers that were more successful at maintaining patients in treatment were unfairly underranked by unadjusted performance scores.

CONCLUSIONS

Both the socioeconomic background of patients and patient selection by centers impact apparent performance in community mental health care. If observational data are used to evaluate community-based providers, analysts might need to account for both effects to ensure comparisons of relative performance are accurate.

Mortalidade hospitalar e tempo de permanência: comparação entre hospitais públicos e privados na região de Ribeirão Preto, São Paulo, Brasil

A avaliação de desempenho dos serviços de saúde é essencial. A comparação de indicadores de desempenho requer o uso de estratégias de ajuste de risco. O objetivo deste artigo é avaliar variações no desempenho clínico, mensurado pela mortalidade e pelo tempo de permanência, entre hospitais públicos e privados, levando em conta diferenças nas características dos pacientes tratados. Este estudo é limitado à região de Ribeirão Preto, São Paulo, Brasil. Entre os anos de 1996 e 1998, 32.906 pacientes admitidos com diagnósticos cardiovasculares e respiratórios foram estudados. As variáveis usadas para o ajuste de risco dos indicadores de desempenho foram: sexo, idade, diagnóstico principal e medidas de gravidade baseada em comorbidade. Os resultados mostraram que o desempenho clínico dos hospitais públicos, mensurado pela mortalidade hospitalar ajustada (razão de chance = 0,41), é superior ao dos privados. Os hospitais públicos e privados não foram estatisticamente diferentes com relação ao tempo de permanência dos pacientes. Ainda que problemas conceituais e metodológicos devam ser resolvidos, taxa de mortalidade e outros indicadores de desempenho ajustados devem ser considerados como instrumentos úteis para identificar problemas de desempenho dos serviços de saúde.

Effects of patient and physician practice socioeconomic status on the health care of privately insured managed care patients

BACKGROUND

Previous research shows that patient socioeconomic status (SES) affects health care, but little is known about the relative effects of patient and physician practice SES among privately insured patients.

OBJECTIVE

To examine the effects of patient and physician practice SES on prevention, disease management, utilization, and cost expenditures.

DESIGN

Cross-sectional analyses of claims data.

SUBJECTS

Primary care physicians (568) and their adult managed care organization patients (437,743) in the Rochester, New York, area.

MEASURES

Pap smears, mammograms, glycohemoglobins, and eye examinations for diabetics, physician visits, referrals, hospitalizations, costs standardized expenditures (diagnostic testing, office visits, and total), patient zip code-based SES, and physician practice SES (mean SES of patients in practice).

RESULTS

After adjustment, lower SES patients had lower compliance with Pap smears, mammograms, and diabetic eye exams, and were less likely to have a referral or make any office visit, but were more likely to be hospitalized, and generated higher testing standardized expenditures. Lower physician practice SES was associated with lower adjusted Pap, mammogram, and glycohemoglobin compliance, lower office visit standardized expenditures, but higher diagnostic testing and total standardized expenditures. Patient SES effects were stronger for mammography, whereas physician practice SES effects were stronger for diagnostic testing costs. For the utilization indicators, the SES effects on utilization exhibited a linear gradient, whereas there was a threshold effect for costs.

CONCLUSIONS

Patient and practice SES are independently associated with care among privately insured patients. These effects are not confined to the poorest patients but span the entire socioeconomic spectrum. Interventions to address these disparities need to be broad-based, but should also address the needs of practices with predominantly lower SES patients.

Effect of patient socioeconomic status on physician profiles for prevention, disease management, and diagnostic testing costs

BACKGROUND

Previous research shows patient socioeconomic status (SES) affects physician profiles for health status and satisfaction, but effects on other aspects of care are not known.

OBJECTIVE

To examine the effect of patient SES on physician profiles for preventive care, disease management, and diagnostic testing costs.

RESEARCH DESIGN

Cross-sectional analysis of a managed care claims data.

SUBJECTS

Five hundred sixty-eight physicians and 600,618 patients.

MEASURES

Patient age, gender, case-mix, and SES based on zip code, likelihood of having a Papanicolaou smear, mammogram, for diabetics having had a glycosylated hemoglobin, diabetic eye exam, and diagnostic testing costs.

RESULTS

For each performance indicator, except glycosylated hemoglobin, there was a statistically significant effect of adjusting for patient SES. For diabetic eye checks, mammograms and Papanicolaou tests respectively, 5%, 16%, and 21% of physicians who were outliers (in the top or bottom 5% of rankings) were no longer outliers after socioeconomic adjustment. For all performance measures the change in physician ranking was strongly correlated with the mean practice SES.

CONCLUSIONS

Patient SES, as measured by zip code, appreciably affects physician profiles for preventive care and diabetes management. Monitoring patient SES using patient zip codes could be used to target resources to improve outcomes for higher risk patients.