Impact of Physician Referral to Health Coaching on Patient Engagement and Health Risks: An Observational Study of UPMC's Prescription for Wellness

PURPOSE

Evaluate impact of physician referral to health coaching on patient engagement and health risk reduction.

DESIGN

Four-year retrospective, observational cohort study with propensity-matched pair comparisons.

SETTING

Integrated delivery and finance system in Pittsburgh, Pennsylvania.

SAMPLE

10 457 adult insured members referred to health coaching by their physician; 37 864 other members identified for health coaching through insurer-initiated outreach.

INTERVENTION

Practice-based, technology-supported workflow and process for physician prescribing of health coaching during regular office visit, with follow-up on patient's progress and implementation supports.

MEASURES

Patient engagement based on completion of pre-enrollment assessment, formal enrollment in health coaching, completion of required sessions, health risk levels, and number of health risks pre- and post-health coaching referral.

ANALYSIS

Difference-in-difference analysis to assess change in health risk levels and number of health risks pre- and post-health coaching and probability weighting to control for potential confounding between groups.

RESULTS

Members referred by a physician were significantly more likely to enroll in a health coaching program (21.0% vs 6.0%, P < .001) and complete the program requirements (8.5% vs 2.7%, P < .001) than when referred by insurer-initiated outreach; significant within group improvement in health risk levels from baseline (P < .001) was observed for both the groups.

CONCLUSIONS

Patients are significantly more likely to engage in health coaching when a referral is made by a physician; engagement in health coaching significantly improves health risk levels.

Using decision trees to manage hospital readmission risk for acute myocardial infarction, heart failure, and pneumonia

To improve healthcare quality and reduce costs, the Affordable Care Act places hospitals at financial risk for excessive readmissions associated with acute myocardial infarction (AMI), heart failure (HF), and pneumonia (PN). Although predictive analytics is increasingly looked to as a means for measuring, comparing, and managing this risk, many modeling tools require data inputs that are not readily available and/or additional resources to yield actionable information. This article demonstrates how hospitals and clinicians can use their own structured discharge data to create decision trees that produce highly transparent, clinically relevant decision rules for better managing readmission risk associated with AMI, HF, and PN. For illustrative purposes, basic decision trees are trained and tested using publically available data from the California State Inpatient Databases and an open-source statistical package. As expected, these simple models perform less well than other more sophisticated tools, with areas under the receiver operating characteristic (ROC) curve (or AUC) of 0.612, 0.583, and 0.650, respectively, but achieve a lift of at least 1.5 or greater for higher-risk patients with any of the three conditions. More importantly, they are shown to offer substantial advantages in terms of transparency and interpretability, comprehensiveness, and adaptability. By enabling hospitals and clinicians to identify important factors associated with readmissions, target subgroups of patients at both high and low risk, and design and implement interventions that are appropriate to the risk levels observed, decision trees serve as an ideal application for addressing the challenge of reducing hospital readmissions.

Long-term health outcomes of a decision aid: data from a randomized trial of adjuvant! In women with localized breast cancer

PURPOSE

Women with localized breast cancer face difficult decisions about adjuvant therapy. Several decision aids are available to help women choose between treatment options. Decision aids are known to affect treatment choices and may therefore affect patient survival. The authors aimed to model the effects of the Adjuvant! decision aid on expected survival in women with early stage breast cancer.

PATIENTS AND METHODS

Data were obtained from a randomized trial of Adjuvant! (n = 395). To calculate the effects of the decision aid on survival, the authors used the Adjuvant! survival predictions as a surrogate endpoint. Data from each arm were entered separately into statistical models to estimate change in survival associated with receiving the Adjuvant! decision aid.

RESULTS

Most women (approximately 85%) chose a treatment option that maximized predicted survival. The effects of the decision aid on outcome could not be modeled because a small number of women (n = 12, 3%) chose treatment options associated with a large (5%-14%) loss in survival. These women-most typically estrogen receptor positive but refusing hormonal therapy-were equally divided between Adjuvant! and control groups and were not distinguished by medical or demographic factors.

CONCLUSIONS

Expected benefit from treatment is a key variable in understanding patient behavior. A small number of women refuse adjuvant treatment associated with large increases in predicted survival, even when they are explicitly informed about the degree of benefit they would forgo. Investigation of the effects of decision aids on cancer survival is unlikely to be fruitful due to power considerations.

The Cost-Effectiveness of Dextranomer/Hyaluronic Acid Copolymer for the Management of Vesicoureteral Reflux. 2. Reflux Correction at the Time of Diagnosis as a Substitute for Traditional Management

PURPOSE

The use of dextranomer/hyaluronic acid copolymer has become increasingly popular as an alternative to ureteral reimplantation in the treatment of vesicoureteral reflux. We compared the cost-effectiveness of performing dextranomer/hyaluronic acid injection at the time of diagnosis of reflux to that of traditional management.

MATERIALS AND METHODS

A model to estimate the costs of managing vesicoureteral reflux has previously been created. We updated the model to compare the costs of managing vesicoureteral reflux by traditional methods with the costs of managing reflux if dextranomer/hyaluronic acid injection is performed at the time of diagnosis. The success rate required for dextranomer/hyaluronic acid injection at diagnosis to be as cost effective as traditional management was estimated. We used 2 models of dextranomer/hyaluronic acid injection at diagnosis-injection at diagnosis proceeding to traditional management if injection failed (scenario 1), and injection at diagnosis proceeding to ureteral reimplantation if injection failed (scenario 2).

RESULTS

If reflux is stratified by grade in scenario 1, for grades III, IV and V respective success rates of 88.5%, 66.6%, and 55.6% for unilateral reflux and 97.5%, 89.7% and 91.4% for bilateral reflux must be achieved to have equal cost-effectiveness to traditional management, while grades I and II reflux can never achieve equal cost-effectiveness. Stratified by grade for scenario 2, for grades III, IV and V respective success rates of 86.9%, 70.8% and 55.8% for unilateral reflux, and 97.6%, 89.8% and 89.8% for bilateral reflux must be achieved to attain equal cost-effectiveness compared to traditional management. In scenario 2 dextranomer/hyaluronic acid injection at diagnosis for grades I and II unilateral and bilateral reflux can never achieve equal cost-effectiveness compared to traditional management.

CONCLUSIONS

Based on the results of this study, in most clinical situations dextranomer/hyaluronic acid injection at the time of diagnosis is unlikely to be as cost effective as traditional management of vesicoureteral reflux.

The cost-effectiveness of dextranomer/hyaluronic acid copolymer for the management of vesicoureteral reflux. 1: substitution for surgical management

PURPOSE

We examined the cost-effectiveness of dextranomer/hyaluronic acid copolymer injection in patients who would otherwise undergo ureteral reimplantation.

MATERIALS AND METHODS

A model for managing vesicoureteral reflux has previously been created. We now update the model to compare the costs of treating vesicoureteral reflux using standard methods (ie ureteral reimplantation after failed medical therapy) with the costs of dextranomer/hyaluronic acid injection.

RESULTS

In the first scenario created dextranomer/hyaluronic acid injection is substituted for ureteral reimplantation when surgical intervention would be performed for treatment of breakthrough infection or failure of the reflux to resolve. For dextranomer/hyaluronic acid injection to have equal cost-effectiveness compared to ureteral reimplantation in this scenario success rates for dextranomer/hyaluronic acid injection would need to be 57.8% per ureter for patients with unilateral reflux and 75.3% per ureter for patients with bilateral reflux. However, if increasing grades of reflux require increasing volumes of dextranomer/hyaluronic acid, success rates would need to be 72.5% for patients with unilateral reflux and 93.8% for patients with bilateral reflux. In the second scenario created dextranomer/hyaluronic acid injection is repeated if it fails to resolve the reflux after the first injection. Success rates to obtain equal cost-effectiveness for the repeat dextranomer/hyaluronic acid injection would need to be 0%, 11.4% and 60.3% in patients with unilateral reflux if the respective success rates of the initial injection were 85%, 70% and 55%. Success rates for the second dextranomer/hyaluronic acid injection would need to be 0%, 29.1% and 76.7% per ureter in patients with bilateral reflux if the respective success rates of the initial injection were 85%, 70% and 55%. If increasing volumes of dextranomer/hyaluronic acid were required for increasing grades of reflux, a second dextranomer/hyaluronic acid injection would not be a viable option.

CONCLUSIONS

Based on our results, dextranomer/hyaluronic acid injection may be more cost-effective than ureteral reimplantation for children who meet standard criteria for surgical therapy, especially for lower grades of reflux. If increasing grades of reflux require an increased volume of dextranomer/hyaluronic acid, then injection would likely be cost-effective only for grades I and II unilateral and bilateral reflux, and perhaps unilateral grade III reflux.

Quality of patient referral information for open-access endoscopic procedures

BACKGROUND

Increased demand for endoscopic procedures has led to the provision of these services without prior consultation (open access). The need for accurate medical referral information for these patients is vital for patient safety.

OBJECTIVE

To assess the accuracy of endoscopic referral information.

DESIGN

Over a 4-month study period, patient referral forms were evaluated to determine the accuracy of medical information on patient referral forms by using direct interview with the patient and/or the caregiver. Inconsistencies were validated against medical records.

SETTING

Large academic medical clinic.

PATIENTS

A total of 868 open-access patient referrals for upper endoscopy and colonoscopy services.

MAIN OUTCOME MEASUREMENTS

Referral information about medical diagnoses, medications, allergies, need for antibiotic administration, and current coagulopathies.

RESULTS

Inaccurate medical referral information was provided to the endoscopist in 8.8% of referrals (n = 76). Among referrals containing errors, there were a total of 95 significant medical information errors, which, if left undetected by preprocedure review, could have resulted in serious adverse consequences for patients undergoing endoscopy.

LIMITATIONS

Study limited to an academic clinical setting.

CONCLUSIONS

Patient referrals for endoscopic services in an open-access referral system contain unacceptably high numbers of errors, which place patients at risk for adverse outcomes from endoscopic procedures.

Decreased Use of Adjuvant Breast Cancer Therapy in a Randomized Controlled Trial of a Decision Aid with Individualized Risk Information

Objective. Oncology patients often seek involvement in their medical consultations. Such involvement is endorsed by most health care providers and mirrored in practice guidelines. However, oncologists exhibit great variation in how they provide patients with disease-relevant information, and many remain reluctant to do so at all. The authors examined the impact of a patient-specific decision aid on women’s decisions about adjuvant therapy for breast cancer. Method. 386 women with breast cancer were randomized to receive either an informational pamphlet about adjuvant therapy (usual care) or a patient-specific, evidence-based decision aid about adjuvant therapy. The authors compared rates of adjuvant therapy between the groups controlling for age, education, marital status, race, tumor severity, and practice type of their physician (university-based or community-based). Results. Among women with low tumor severity, only 58% (35/60) of women in the decision aid group chose adjuvant therapy, compared to 87% (33/38) of their counterparts in usual care (P < 0.01). Conclusions. This study illustrates the important impact of medical decision aids on treatment choices, particularly for patients for whom treatment has little benefit. In the case of adjuvant therapy for breast cancer, providing individualized, evidence-based risk information for shared decision making resulted in fewer women with low tumor severity choosing adjuvant treatment.

Depression and Occupational Injury: Results of a Pilot Investigation

OBJECTIVE

Even mild clinical depression can cause decreased vigilance, attention span, increased irritability, and insomnia-all well-known precursors to occupational injury. This pilot project explores the relationship between occupational injury and depression.

METHOD

One hundred twenty-one individuals with recent work-related injuries and 140 without work-related injuries completed a self-administered depression screening instrument (PHQ-9). We compared the two groups using bivariate analyses. The impact of depression on injury was examined using logistic regression analysis controlling for employment history, marital status, age, and sex.

RESULTS

Overall, injured workers in this study were not more likely to be depressed than a comparison group of uninjured workers. However, injured women had significantly higher depression scores than non-injured women (P = 0.04); no such difference was found for men.

CONCLUSIONS

These data suggest that depression may serve as a precursor to occupational injury for women.

Use of medical and behavioral health services by adolescents with bipolar disorder

OBJECTIVE

This study compared use of medical and behavioral health care by adolescents with bipolar disorder and other adolescents and identified areas in need of more clinical attention.

METHODS

Medical and behavioral health insurance claims from 1996 for 100,880 adolescents were examined and categorized. Differences between and among various categories of disease were explored by using multivariate analyses.

RESULTS

Among the 10,970 adolescents who used at least one behavioral health service, adolescents with bipolar disorder (N=326) had significantly higher behavioral health costs than those with mood or non-mood disorders, a result driven by these adolescents' significantly higher hospital admission rates for behavioral health care. Adolescents with bipolar disorder also had significantly higher medical admission rates compared with adolescents who had other behavioral health diagnoses. More than half of the 14 medical admissions for adolescents with bipolar disorder were due to drug overdose.

CONCLUSIONS

Reallocation of medical and behavioral health resources to improve ambulatory treatment of bipolar disorder among adolescents has the potential to decrease the use and costs of health care while improving the welfare of these adolescents and their families.

Insurance expenditures on bipolar disorder: clinical and parity implications

OBJECTIVE

This study assessed treatment rates and expenditures for behavioral health care by employers and behavioral health care patients in a large national database of employer-sponsored health insurance claims.

METHOD

Insurance claims from 1996 from approximately 1.66 million individuals were examined. Average annual charges per person and payments for behavioral health care were calculated along with patient out-of-pocket expenses and inpatient hospital admission rates. Behavioral health care expenditures for bipolar disorder were compared to expenditures for other behavioral health care diagnoses in these same insurance plans.

RESULTS

A total of 7.5% of all covered individuals filed a behavioral health care claim. Of those, 3.0% were identified as having bipolar disorder, but they accounted for 12.4% of total plan expenditures. Patients with bipolar disorder incurred annual out-of-pocket expenses of $568, more than double the $232 out-of-pocket expenses incurred by all claimants. The inpatient hospital admission rate for patients with bipolar disorder was also higher (39.1%) compared to 4.5% for all other behavioral health care claimants. Furthermore, annual insurance payments were higher for covered medical services for individuals with bipolar disorder than for patients with other behavioral health care diagnoses.

CONCLUSIONS

Bipolar disorder is the most expensive behavioral health care diagnosis, both for patients with bipolar disorder and for their insurance plans. For every behavioral health care dollar spent on outpatient care for patients with bipolar disorder, $1.80 is spent on inpatient care, suggesting that better prevention management could decrease the financial burden of bipolar disorder.

Diabetes in employer-sponsored health insurance

OBJECTIVE

To examine medical and mental health care expenditures for large numbers of individuals with diabetes enrolled in employment-sponsored insurance plans.

RESEARCH DESIGN AND METHODS

Health insurance billing data for approximately 1.3 million individuals enrolled in health insurance plans sponsored by 862 large self-insured employers nationwide were used to examine employer expenditures and consumer out-of-pocket payments for 20,937 people identified with diabetes. These expenditures were compared with expenditures for individuals with other chronic illnesses. Main outcome measures were covered charges, insurance plan reimbursements, and estimated consumer out-of-pocket payments for both medical and mental health services.

RESULTS

A total of 1.7% of enrollees were identified as having diabetes and approximately 11% of those used at least one mental health service during 1996. Health care expenditures were three times higher for those with diabetes compared with all health care consumers in these insurance plans, but when compared with individuals with other chronic illnesses such as heart disease, HIV/AIDS, cancer, and asthma, those with diabetes were not more expensive for employers' insurance plans. Diabetes accounts for 6.5% of total health plan expenditures.

CONCLUSIONS

Diabetes is not more expensive for either consumers or their employer-sponsored insurance plans than other chronic illnesses.

An exploratory analysis of behavioral health care use within families

OBJECTIVES

The authors studied enrollees in employer-sponsored managed health plans to determine the extent of multiple behavioral health consumers within families, use of behavioral health services by employees who have another family member using such services, congruence of diagnoses between two family members using behavioral health services, and the effect on covered charge per behavioral health consumer when other family members use behavioral health services.

METHODS

Claims data from 911 plans sold or managed by a single managed behavioral health care company were examined. The plans provided coverage for 724,789 employees and covered about 1.7 million lives. Family members of employees were identified by the relationship codes on the claims. Service utilization rates were calculated for employees overall and for employees who had spouses or children who used behavioral health services. Mean and median covered charges were determined and were examined by number and type of consumers in the family.

RESULTS

The use of behavioral health services was greater among employees whose children or spouses used behavioral health services. Utilization rates varied by the child's or spouse's diagnoses. More than 50 percent of male employees whose children received treatment for a depressive disorder also received such treatment. Congruence of diagnoses within families was noted. Covered charges per person generally increased with the number of family members who used behavioral health services.

CONCLUSION

Greater knowledge about patterns of use of behavioral health services within families may help in improving access to care and developing more effective family interventions.

Exclusions and limitations in children's behavioral health care coverage

OBJECTIVE

The objective of this study was to identify benefit limits, diagnostic exclusions, and service exclusions of private behavioral health care plans that can influence the delivery of care to children.

METHODS

A total of 128 commercial, employment-based behavioral health plans were examined for types of benefit limits, service exclusions, and diagnostic exclusions applicable to children.

RESULTS

Almost half of the plans had restrictions on the number of outpatient visits, with limits ranging from 12 to 60 clinic visits a year. More than half of the plans had limitations on the number of inpatient days, ranging from 20 to 60 days a year. Diagnoses excluded from coverage included autism, mental retardation, problems related to child abuse, and impulse control disorders, such as kleptomania and pyromania. Half of the services excluded could be categorized as either social and human services or complementary medicine rather than as mental health care.

CONCLUSIONS

Plans commonly had service and diagnostic exclusions that could disrupt children's health care. The results of the study emphasize a need to address the types of treatment covered by mental health insurance.

Managed care in workers' compensation plans

Workers' compensation plans have lagged behind most public and private health care plans in the adoption of managed care techniques. This is largely attributable to the underlying differences between workers' compensation and group health plans. Managed care techniques were developed within group health plans with the objective of health at the lowest cost. In workers' compensation, managed care must address a different objective-restoring a worker to health and productivity at the lowest cost. It is this fundamental difference that makes the application of managed care techniques to workers' compensation plans contentious and at times inappropriate. Research on the impact of managed care on the health and welfare of injured workers is sparse, and important questions remain about the appropriateness of care delivered under workers' compensation managed care plans. In this paper, we discuss the application of managed care to workers' compensation, and highlight the barriers to effective implementation.

Effect of different recruitment sources on the composition of a bipolar disorder case registry

BACKGROUND

Conducting research on low-prevalence conditions presents an ongoing challenge for clinical and services researchers. Recruitment through health professionals versus other forms of self-referral may affect study group composition.

METHODS

We compared members of a voluntary case registry for bipolar disorder who were recruited through a variety of sources including health professionals, support groups, an Internet website, and mailings, brochures, and other general public relations activities. We also compared the cost of recruitment methods. We hypothesized that self-referred registry members would be of higher socioeconomic status and less likely to be in treatment compared to members recruited through health professionals.

RESULTS

Registrants referred through the Internet and patient support groups were better educated and more likely to be married than other registrants. However, Internet registrants were younger, had fewer lifetime hospitalizations and were more likely to be working. Nearly all registrants were in treatment with a psychiatrist. Local registrants were predominantly recruited through health professionals and public presentations. Registrants outside of the local region most often learned about the registry from patient support groups and the Internet. Local registrants were less likely to be using non-lithium mood stabilizers. Recruitment through public relations efforts was the most expensive method of recruitment, and the Internet website was the cheapest.

CONCLUSIONS

Diverse recruitment methods can expand the population available for clinical trials. For services research, the Internet and patient support groups are less expensive ways to identify persons served in diverse settings and health plans, but these recruitment methods yield a sample that is better educated than the remainder of the population. It remains a difficult task to identify minorities and persons not in treatment.

Employer-sponsored health insurance: are employers good agents for their employees?

Employers in the United States provide many welfare-type benefits, such as life insurance, disability insurance, health insurance, and pensions, to their employees. Employers can be viewed as performing an agency role in purchasing pension, health, and other welfare benefits for their employees. An exploration of their competence in this role as agents for their employees indicates that large employers are very helpful to their employees in this arena. They seem to contribute to individual employees' welfare by providing them with valued services in purchasing health insurance.

Benefit limits in managed behavioral health care: do they matter?

More than half of Americans with insurance coverage for mental health services are enrolled in plans that carve out behavioral health care services with a vendor specializing in the management of these services. However, utilization management has not taken the place of benefit limitations. Do benefit limits matter? This article reports the percentage of enrollees in managed behavioral health care carve-out plans that encounter benefit limits. Estimates are provided on the impact and savings of imposing benefit limits on enrollees in unrestricted plans. Costs to eliminate benefit limits are estimated to be very small. This study finds that benefit limits do matter but only to a very small number of plan enrollees. Furthermore, the results of this study show that for inpatient limits, children are especially vulnerable. These issues have important implications for discussions about the impact of managed care in mental health and for discussions concerning parity legislation.

Evaluating welfare losses in the health care market

According to traditional welfare analysis, consumers facing a price increase forego consumption of the least valued units of a commodity. Studies, such as the Rand HIE, show that patients decrease their consumption of all types of health care when faced with a price increase for health care. From this observation, Thomas Rice (1992) concludes that traditional welfare analysis is inadequate for evaluating insurance-related welfare losses in health care. In this note, I argue that it is not traditional welfare analysis which is inadequate, but the method of assigning marginal valuations to units of health care.

A new technique for interpreting the BAER in cochlear disease

We found, by studying 20 normal ears and 34 ears with cochlear disease, that the brainstem auditory evoked response (BAER) wave I latency was a good predictor of the I-V interval (r = -0.67, p less than 0.001), whereas hearing loss had little predictive value. The normal and hearing-loss groups generated regression lines (wave I latency vs I-V latency) that did not differ significantly from each other. A normal range of I-V intervals can be established for any wave I latency, increasing the sensitivity of the BAER.