Teaching Hospitals See Largest Number of Homeless Emergency Room Patients

MedicalResearch.com Interview with:

Ruirui Sun, Ph.D. AHRQ

Dr. Sun

Ruirui Sun, Ph.D.
AHRQ

MedicalResearch.com: What is the background for this study?

Response: Homeless people are more likely than the members of the general public to use emergency department (ED) services, and it is usually at teaching hospitals when they seek medical care (Kushel et al., 2001; Bowdler and Barrell, 1987). This Healthcare Cost and Utilization Project (HCUP) Statistical Brief studies patient characteristics, insurance coverage and clinical profile of the ED visits among homeless individuals by hospital teaching status, during 2014 from eight States (AZ, FL, GA, MA, MD, MO, NY, and WI).

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Trends in Opioid-Related Inpatient Stays Shifted After Switch to ICD-10 Coding

MedicalResearch.com Interview with:

Anne Elixhauser, Ph.D. Senior Research Scientist Agency for Healthcare Research and Quality Rockville MD 20857

Dr. Elixhauser

Anne Elixhauser, Ph.D.
Senior Research Scientist
Agency for Healthcare Research and Quality
Rockville MD 20857

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Hospital inpatient data began using ICD-10-CM (I-10) codes on October 1, 2015.  We have been doing analysis using the new codeset to determine to what extent we can follow trends crossing the ICD transition—do the trends look consistent when we switch from I-9 to I-10?  Tracking the opioid epidemic is a high priority so we made this one of our first detailed analyses.  We were surprised to find that hospital stays jumped 14% across the transition, compared to a 5% quarterly increase before the transition (under I-9) and a 3.5% quarterly increase after the transition (under I-10).  The largest increase (63.2%) was for adverse effects in therapeutic use (side effects of legal drugs), whereas stays involving opioid abuse decreased 21% and opioid poisoning (overdose) decreased 12.4%.

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Changes in Hospital Inpatient Stays Over Ten Years: Less Cardiac Care, More Mental Health and Sepsis Admissions

MedicalResearch.com Interview with:
Ruirui Sun, Service Fellow, Economist
Center for Delivery, Organization and Markets
Agency for Healthcare Research and Quality

MedicalResearch.com: What is the background for this study?

Response: Hospital inpatient care has experienced changes due to factors such as population growth, rising of prevalence of chronic disease and efforts to reduce unnecessary hospitalizations. We generated information from the National Hospital Utilization and Costs path on Fast Stats (https://www.hcup-us.ahrq.gov/faststats/landing.jsp ), to present the trends on national hospitalization and costs from 2005 to 2014, as well as the most common diagnoses among inpatient stays over the 10-year period.

MedicalResearch.com: What are the main findings?

  • Between 2005 and 2014, the inflation-adjusted mean cost per inpatient stay increased by 12.7 percent, from $9,500 to $10,900.
  • Inflation-adjusted cost per stay for patients covered by private insurance or Medicaid increased 16-18 percent. Cost per stay for Medicare-covered patients and the uninsured changed minimally.
  • The rate of inpatient stays decreased the most among patients in the highest income quartiles (15-20 percent decrease).
  • The proportion of Medicaid-covered inpatient stays increased by 15.7 percent, whereas the proportion paid by private insurance and that were uninsured decreased by 12.5 and 13.0 percent, respectively.
  • Mental health/substance use accounted for nearly 6 percent of all inpatient stays in 2014, up 20.1 percent from 2005.
  • Between 2005 and 2014, septicemia and osteoarthritis became two of the five most common reasons for inpatient stays. Septicemia hospital stays almost tripled.
  • Nonspecific chest pain and coronary atherosclerosis decreased by more than 60 percent from 2005 to 2014, falling off the list of top 10 reasons for hospitalization. 

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Heart Disease, Trauma and Diabetes Incur Highest Cost Per Person Medical Expenses

MedicalResearch.com Interview with:

Anita Soni, PhD, MBA Survey Analyst/Statistician Agency for Healthcare Research and Quality

Dr. Anita Soni

Anita Soni, PhD, MBA
Survey Analyst/Statistician
Agency for Healthcare Research and Quality

MedicalResearch.com: What is the background for this study?

Response: This statistical brief uses the data from the Medical Expenditure Panel Survey (MEPS), which collects a broad range of data related to the health care of the U.S. civilian noninstitutionalized population including health insurance coverage, the number and types of health care events and the sources of payment and payment amounts for those events. The survey also gathers information on which medical conditions are associated with the reported health care events. Condition-specific health care expenditure information derived from MEPS data is useful for policy makers in determining where to focus health policies to improve the quality and efficiency of the health care system from the perspective of disease treatment and management.

This Statistical Brief presents data regarding medical expenditures for nine conditions for which an estimated 10 percent or more of the U.S. civilian noninstitutionalized population (individuals age 18 and older) received health care in 2013.

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Hospitals With Rigorous Quality Improvement Programs Penalized In Star Ratings

MedicalResearch.com Interview with:

John Oliver DeLancey, MD, MPH Resident, Department of Urology Research Fellow, Surgical Outcomes and Quality Improvement Center Northwestern University Feinberg School of Medicine

Dr. John Oliver DeLancey

John Oliver DeLancey, MD, MPH
Resident, Department of Urology
Research Fellow, Surgical Outcomes and Quality Improvement Center
Northwestern University Feinberg School of Medicine

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: We initially looked at the star ratings for hospitals that we considered to provide excellent care, and it did not seem that this was reflected in the star ratings. Therefore, we sought to examine which factors were associated with the likelihood of receiving a high or low star rating.

When we examined these associations, we found that academic and community hospitals, who reported nearly all of the measures included, had disproportionally lower star ratings than Critical Access or Specialty hospitals, who reported on average about half of the measures used to generate the star ratings.

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Growing Insurance Coverage Did Not Reduce Access To Care For Those Already Insured

MedicalResearch.com Interview with:

Salam Abdus, Ph.D. Agency for Healthcare Research and Quality

Dr. Salam Abdus

Salam Abdus, Ph.D.
Agency for Healthcare Research and Quality

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: When the ACA was passed, some people were concerned that access to care for people who already had insurance would decrease because there would be so many newly insured people trying to get care.

To answer this question, we reviewed eight measures of access using data from the Agency for Healthcare Research and Quality’s Medical Expenditure Panel Survey (MEPS) and the Census Bureaus’ American Community Survey for the period 2008-2014 to study if change in local area insurance rate affected access to care of adults who were continuously insured for two years. Access measures that we looked at include whether they had a usual source of care, were unable to receive necessary medical care, were delayed in receiving necessary medical care, had a physical exam in the past year, had blood pressure checked, had a flu shot, experienced delays getting a doctor appointment, and problems seeing a specialist.

We found no consistent evidence of negative impacts on continuously insured adults. We also looked at two subgroups of vulnerable adults: Medicaid beneficiaries and adults living in health professional shortage areas. For both continuously insured subgroups we found no consistent evidence of negative impacts.

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Family and Individuals Directly Pay Less Than 14% of US Health Care Expenditures

MedicalResearch.com Interview with:
Marie Stagnitti, M.P.A.

Agency for Healthcare Research and Quality
Medical Expenditure Panel Survey Household Component Project Officer/Senior Survey Statistician

MedicalResearch.com: What is the background for this study?

Response: The Medical Expenditure Panel Survey (MEPS) – Household Component (HC) which began in 1996 and is administered annually collects data from a sample of families and individuals in selected communities across the United States, and is drawn from a nationally representative subsample of households that participated in the prior year’s National Health Interview Survey (conducted by the National Center for Health Statistics).

During the household interviews, MEPS collects detailed information for each person in the household on the following: demographic characteristics, health conditions, health status, use of medical services, charges and source of payments, access to care, satisfaction with care, health insurance coverage, income, and employment.

The panel design of the survey, which features several rounds of interviews covering two full calendar years, makes it possible to determine how changes in respondents’ health status, income, employment, eligibility for public and private insurance coverage, use of services, and payment for care are related. Continue reading

Out-of-Pocket Expenditures for Adults with Multiple Chronic Conditions

MedicalResearch.com Interview with:
Anita Soni, PhD, MBA
Survey Analyst/Statistician Agency for Healthcare Research and Quality
Rockville, MD

MedicalResearch.com: What is the background for this study?

Response: This statistical brief uses the data from the Medical Expenditure Panel Survey (MEPS), which is a nationally representative survey of the U.S. civilian noninstitutionalized population that collects data on the demographic characteristics, health conditions, health status, use of medical care services, charges and payments, access to care, satisfaction with care, health insurance coverage, income, and employment of Americans.

This brief focuses on adults 18 and older who received some medical care in 2014. Persons who have multiple chronic conditions—those who were treated for two or more conditions considered to be chronic during 2014 — are compared to those who, while they had medical care, reported use associated with only one or no chronic conditions.  Continue reading

Drop in Adverse Drug Events Linked to Meaningful Use of Electronic Records

MedicalResearch.com Interview with:
Michael Furukawa, Ph.D.

Senior Economist
Agency for Healthcare Research and Quality 

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Despite some progress, patient safety remains a serious concern in U.S. health care delivery, particularly in acute care hospitals. In part to support safety improvement, the Health Information Technology for Economic and Clinical Health (HITECH) Act promoted widespread adoption and use of certified electronic health record technology. To meet Meaningful Use (MU) requirements in the law, hospitals are required to adopt specific capabilities, such as computerized physician order entry, which are expected to reduce errors and promote safer care.

We found that, after the HITECH Act was made law, the occurrence of in-hospital adverse drug events (ADEs) declined significantly from 2010 to 2013, a decline of 19%. Hospital adoption of medication-related MU capabilities was associated with 11% lower odds of ADEs occurring, but the effects did not vary by the number of years of experience with these capabilities. Interoperability capability was associated with 19% lower odds of adverse drug events occurring. Greater exposure to MU capabilities explained about one-fifth of the observed reduction in ADEs.

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Opioid Emergencies Increased Almost 100% in Some States

MedicalResearch.com Interview with:
Claudia Steiner, M.D., MPH.

Agency for Healthcare Research and Quality (AHRQ)
Rockville, MD

MedicalResearch.com: What is the background for this study?

Response: The Agency for Healthcare Research and Quality (AHRQ) has a longstanding project and partnership, The Healthcare Cost and Utilization Project (HCUP, pronounced “H-Cup”). HCUP is a family of health care databases and related software tools and products developed through a Federal-State-Industry partnership. HCUP databases bring together the data collection efforts of State data organizations, hospital associations, and private data organizations (HCUP Partners) and the Federal government to create a national information resource of encounter-level health care data. HCUP includes the largest collection of longitudinal hospital care data in the United States, with all-payer, encounter-level information. These databases enable research on a broad range of health policy issues, including cost and quality of health services, medical practice patterns, access to health care programs, and outcomes of treatments at the national, State, and local market levels.

The HCUP Partners recognized the urgency of providing descriptive statistics to help inform the growing opioid epidemic in the U.S., and therefore agreed to supporting this statistical brief as well as the Opioid-Related Hospital Use path on Fast Stats: http://www.hcup-us.ahrq.gov/faststats/landing.jsp

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Health Care Spending Highly Concentrated Among a Small Group of People

MedicalResearch.com Interview with:

Emily Mitchell, Ph.D., Statistician Agency for Healthcare Research and Quality

Emily Mitchell,

Emily Mitchell, Ph.D., Statistician
Agency for Healthcare Research and Quality

MedicalResearch.com: What is the background for this study?

Response: The data for this study come from the Household Component of the Medical Expenditure Panel Survey (MEPS-HC), a nationally representative survey that is conducted annually by the Agency for Healthcare Research and Quality (AHRQ). The survey collects detailed information on health care utilization and expenditures, health insurance, and health status, as well as a wide variety of social, demographic, and economic characteristics for the U.S. civilian non-institutionalized population.

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Cesarean Section Rates Vary Across US Hospitals

MedicalResearch.com Interview with:
Kamila Mistry, PhD MPH
AHRQ

MedicalResearch.com: What is the background for this study?

Response: Although the overall cesarean section (C-section) rate in the United States has declined slightly in recent years, nearly a third of all births continue to be delivered by C-section—higher than in many other industrialized countries. A number of medical as well as nonmedical factors may contribute to high C-section rates.

C-section is the most common surgical procedure performed in the United States. This operation carries additional risks compared with vaginal delivery, such as infection and postoperative pain. A C-section also may make it more difficult for the mother to establish breastfeeding and may complicate subsequent pregnancies.

Consensus guidelines from the American Congress of Obstetricians and Gynecologists and other national efforts to improve perinatal care have shown promise in reducing nonmedically indicated C-sections. However, recent research has found wide variation in hospital C-section rates even for low-risk deliveries.
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AHRQ Studies Find Large Declines in Number of Uninsured Adults

MedicalResearch.com Interview with:
Jessica Vistnes, Ph.D.
Senior Economist, Center for Financing, Access and Cost Trends
Agency for Healthcare Research and Quality

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: The Medical Expenditure Panel Survey – Household Component (MEPS-HC), sponsored by the Agency for Healthcare Research and Quality (AHRQ), is one of the few sources of nationally representative data that can assess changes in the percentage of Americans gaining and losing health insurance coverage between 2013 and 2014, the first year that many provisions of the Affordable Care Act (ACA) were implemented. The MEPS-HC is also one of the few data sources that can be used to assess changes in the rates at which Americans are uninsured for a full calendar year. Three new AHRQ studies use data from the MEPS-HC and show large declines from 2013 to 2014 in the percentage of non-elderly adults who were uninsured throughout the calendar year. They also show large increases in the likelihood of gaining health care coverage from 2013-2014 compared to 2012-2013 across demographic groups defined by age, race/ethnicity and education.

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Infections, Newborns and Heart Attacks Among Most Expensive Health Care Costs

MedicalResearch.com Interview with:

Celeste M. Torio, Ph.D., M.P.H Scientific Review Officer AHRQ

Dr. Celeste Torio

Celeste M. Torio, Ph.D., M.P.H
Scientific Review Officer
AHRQ

MedicalResearch.com: What is the background for this study? What are the main findings?

Dr. Torio: Hospital care expenditures constitute the largest single component of health care spending. These expenses are of significant concern to policymakers because of their impact on governments, consumers and insurers.

MedicalResearch.com: What are the main findings?

• Aggregate hospital costs for 35.6 million hospital stays totaled $381.4 billion in 2013.
• Septicemia, osteoarthritis, newborn infants, complication of device, and acute myocardial infarction are the five most expensive conditions, and account for 1/5 of the total aggregate costs for hospitalizations.
• Sixty-three percent of aggregate hospital costs were covered by Medicare and Medicaid, while 28 percent were covered by private insurance and 5 percent were covered by the uninsured.

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Fully Integrated Electronic Records Linked to Fewer Inpatient Adverse Effects

MedicalResearch.com Interview with:

Mr. Noel Eldridge Center for Quality Improvement and Patient Safety Agency for Healthcare Research and Quality

Mr. Noel Eldridge

Mr. Noel Eldridge
Center for Quality Improvement and Patient Safety
Agency for Healthcare Research and Quality

Medical Research: What is the background for this study? What are the main findings?

Mr. Eldridge: We used existing data on adverse events from the Medicare Patient Safety Monitoring System, which AHRQ, CMS, and Qualidigm have been analyzing for years, and focused on the question as to whether rates of the adverse event measures were higher or lower in patients whose charts indicated that they had been treated with a full electronic health record (EHR) or a partial EHR during their inpatient stay.

The main finding was that the adverse event rates were lower in the full EHR patients. We saw three different diagnosis groups of patients (cardiovascular, pneumonia, and major surgery), and looked at combined rates for all adverse event types, as well as for four combined subtypes separately: hospital-acquired infections, adverse drug events, post-procedural events, and falls and pressure ulcers combined. Not all of our findings were what people unfamiliar with our measures would have expected.

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Little Shift To Part Time Work As A Result of ACA So Far

Asako Moriya, Ph.D. Service economist Center for Financing, Access and Cost Trends Agency for Healthcare Research and Quality (AHRQ). Rockville, Maryland

Dr. Asako Moriya

MedicalResearch.com Interview with:
Asako Moriya, Ph.D
.
Service economist
Center for Financing, Access and Cost Trends
Agency for Healthcare Research and Quality (AHRQ).
Rockville, Maryland 

Medical Research: What is the background for this study?

Dr. Moriya: While the Affordable Care Act (ACA) has increased insurance coverage and improved access to care among millions of Americans, the law’s potential impacts on the labor market are also important policy considerations. There was speculation that employers would reduce work hours to avoid the ACA employer mandate and also that ACA coverage expansion through Medicaid and the Health Insurance Marketplace would create work disincentives. We wanted to test these speculations using data from a nationally representative sample of approximately 60,000 households interviewed monthly up until June 2015.

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AHRQ Study Finds Racial/Ethnic Groups Specifically Targeted By ACA

Kamila B. Mistry, PhD MPH Senior Advisor, Child Health and Quality Improvement Agency for Healthcare Research and Quality US Department of Health and Human Services Rockville, MD 20857

Dr. Kamila Mistry

MedicalResearch.com Interview with:
Kamila B. Mistry, PhD MPH

Senior Advisor, Child Health and Quality Improvement
Agency for Healthcare Research and Quality
US Department of Health and Human Services
Rockville, MD 20857 

Medical Research: What is the background for this study? What are the main findings?

Dr. Mistry: This study, conducted by researchers at the Agency for Healthcare Research and Quality (AHRQ), was seeking to explore what impact the Affordable Care Act (ACA) may have on the nation’s well-documented racial/ethnic disparities in insurance coverage, access to medical care, and preventive services utilization. We used pre-ACA (2005-2010) household data from AHRQ’s Medical Expenditure Panel Survey to examine patterns of coverage, access, and utilization, by race/ethnicity, for nonelderly adults who are targeted by ACA coverage expansion provisions.

Our analysis found that racial/ethnic minorities were disproportionately represented among groups targeted by the ACA. We also found that targeted groups had lower rates of coverage, access, and preventive services utilization, and some racial/ethnic disparities were widest within these groups.

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Schizophrenia, Chest Pain Top Longest Emergency Department Stays

Ernest Moy, MD, MPH Medical Officer Center for Quality Improvement and Patient Safety Agency for Healthcare Research and QualityMedicalResearch.com Interview with:
Ernest Moy, MD, MPH
Medical Officer
Center for Quality Improvement and Patient Safety
Agency for Healthcare Research and Quality

Medical Research: What is the background for this study?

Dr. Moy: The amount of time that a patient spends in the emergency department (ED) has become increasingly viewed as a quality measure, because length of stay and ED crowding have been linked to quality of care, patient safety, and treatment outcomes. However, current ED length-of-stay measures publicly reported by the Centers for Medicare & Medicaid Services (CMS) combine lengths of stay across all conditions. We suspected that ED length of stay is influenced by the clinical condition of the patient, but didn’t know how disparate times might be. Of course, such stays will certainly be influenced by other factors, which we describe in the paper. Previous studies have helped guide decisions about where to focus resources to improve emergency department services. However, many studies about ED length of stay focus on a single condition, a single or few hospitals, or both, which limits what we can conclude across different conditions.  We were fortunate to find one state, Florida, in the Healthcare Cost and Utilization Project database that provides entry and exit times for a census of emergency department visits for both released and admitted patients to measure length of ED stays by patients’ conditions and dispositions.

Medical Research: What are the main findings?

Dr. Moy: For the 10 most common diagnoses, patients with relatively minor injuries (e.g., sprains and strains, superficial injuries and contusions, skin and subcutaneous tissue infections, open wounds of the extremities) typically required the shortest mean stays (3 hours or less). Conditions involving pain with nonspecific or unclear etiologies (e.g., chest, abdomen, or back pain; headache, including migraine), generally resulted in mean stays of 4 hours or more. However, there were substantial clinical differences among patients released, admitted, and transferred. Conditions resulting in admission or transfer tended to be more serious, resulting in longer stays. Patients requiring the longest stays, by disposition, had discharge diagnoses of nonspecific chest pain (mean 7.4 hours among discharged patients), urinary tract infections (4.8 hours among admissions), and schizophrenia (9.6 hours among transfers) among the top 10 diagnoses.

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Hospital Improvements Have Led To Marked Decreased In Inpatient Mortality Over Ten Years

MedicalResearch.com Interview with:
Kevin Heslin, Ph.D.
, Staff Service Fellow, Center for Delivery, Organization and Markets, Agency for Healthcare Research and Quality

Medical Research: What is the background for this study?

Dr. Heslin: Previous trends in inpatient mortality suggest that rates have been decreasing for acute myocardial infarction (AMI), congestive heart failure (CHF), stroke, and pneumonia (Hines et al., 2010; Stepanova et al., 2013).  Continued study of these trends can help researchers and policymakers assess the impact of health care quality efforts.  Further, examining trends across patient and hospital subgroups may inform strategies for addressing disparities in health care quality by identifying groups that are leading and lagging in improvement.

Medical Research: What is the background for this study

Dr. Heslin: From 2002 to 2012, inpatient mortality decreased among patients admitted to U.S. hospitals for pneumonia (45 percent decrease, from 65.0 to 35.8 deaths per 1,000 admissions), AMI (41 percent decrease, from 94.0 to 55.9 deaths per 1,000 admissions), CHF (29 percent decrease, from 44.4 to 31.4 deaths per 1,000 admissions), and stroke (27 percent decrease, from 112.6 to 82.6 deaths per 1,000 admissions).  The inpatient mortality rate for all four conditions decreased among both younger and older patients, and among men and women.

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5% of US Population Accounts For 50% of Health Care Costs

 

H. Joanna Jiang, Ph.D. Agency for Healthcare Research and QualityMedicalResearch.com Interview with:
H. Joanna Jiang, Ph.D.
Agency for Healthcare Research and Quality

MedicalResearch: What is the background for this study? What are the main findings?

Dr. Jiang: A large proportion of health care resources in the United States are consumed by a relatively small number of individuals, who have been dubbed super-utilizers. Approximately 25% of U.S. health care expenses are incurred by 1% of the U.S. population, and 50% of expenses are incurred by 5% of the population.

Our study found that across all types of payers of medical care (Medicare, Medicaid, and private insurance), super-utilizers on average had approximately 4 times as many hospital stays as other patients, and the 30-day hospital readmission rate for super-utilizers was 4 to 8 times higher than for other patients. Among Medicaid and privately insured patients, super-utilizers had longer hospital stays and higher average hospital costs than other patients.

We also found that patients with multiple chronic conditions, such as diabetes, hypertension, and congestive heart failure, accounted for a greater share of hospital stays among super-utilizers than among other hospitalized patients. Mental health and substance use disorders were among the top 10 principal diagnoses for super-utilizers aged 1 to 64 years regardless of payer.

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High-Performance Work Practices Can Reduce Central Line Infections

Ann Scheck McAlearney, Sc.D., M.S. Professor, Family Medicine Vice Chair for Research, Department of Family Medicine College of Medicine Ohio State University Columbus, OhioMedicalResearch.com Interview with:
Ann Scheck McAlearney, Sc.D., M.S.
Professor, Family Medicine
Vice Chair for Research, Department of Family Medicine
College of Medicine Ohio State University
Columbus, Ohio

MedicalResearch: What is the background for this study? What are the main findings?

Dr. McAlearney: In this study, we sought to explore the potential role high-performance work practices (HPWPs) may play in explaining differences in the success of central line-associated blood stream infection (CLABSI) reduction efforts involving otherwise similar organizations and approaches. We analyzed data from 194 key informant interviews across eight hospitals participating in the federally funded ‘‘On the CUSP: Stop BSI’’ initiative. We found evidence that at sites more successful at reducing central line-associated blood stream infection, HPWPs facilitated the adoption and consistent application of practices known to prevent CLABSIs; these HPWPs were virtually absent at lower performing sites.

In this paper we present examples of management practices and illustrative quotes categorized into four HPWP subsystems:
(a) staff engagement,
(b) staff acquisition/development,
c) frontline empowerment, and
(d) leadership alignment/development. Continue reading

No Knee-Jerk Antibiotics Campaign Aims To Reduce Antibiotic Overusage

Barbara W. Trautner, MD, PhD Houston Veterans Affairs Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center Section of Infectious Diseases, Department of Medicine Baylor College of Medicine, Houston, TexasMedicalResearch.com Interview with:
Barbara W. Trautner, MD, PhD
Houston Veterans Affairs Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center
Section of Infectious Diseases
Department of Medicine
Baylor College of Medicine, Houston, Texas

Medical Research: What is the background for this study? What are the main findings?

Dr. Trautner: Reducing antimicrobial overuse, or antimicrobial stewardship, is a national imperative. If we fail to optimize and limit use of these precious resources, we may lose effective antimicrobial therapy in the future. CDC estimates that more than $1 billion is spent on unnecessary antibiotics annually, and that drug-resistant pathogens cause 2 million illnesses and 23,000 deaths in the U.S. each year. The use of antibiotics to treat asymptomatic bacteriuria (ASB) is a significant contributor to antibiotic overuse in hospitalized and nursing home patients, especially among patients with urinary catheters. In catheterized patients, ASB is very often misdiagnosed and treated as catheter-associated urinary tract infection (CAUTI). Therefore, we designed the “Kicking CAUTI: The No Knee-Jerk Antibiotics Campaign intervention” to reduce overtreatment of ASB and to reduce the confusion about distinguishing CAUTI from asymptomatic bacteriuria.

This study evaluated the effectiveness of the Kicking CAUTI intervention in two VAMCs between July 2010 and June 2013. The primary outcomes were urine cultures ordered per 1,000 bed-days (inappropriate screening for ASB) and cases of ASB receiving antibiotics (overtreatment). The study included 289,754 total bed days, with 170,345 at the intervention site and 119,409 at the comparison site. Through this campaign, researchers were able to dramatically decrease the number of urine cultures ordered. At the intervention site, the total number of urine cultures ordered decreased by 71 percent over the course of the intervention. Antibiotic treatment of asymptomatic bacteriuria decreased by more than 75 percent during the study. No significant changes occurred at the comparison site over the same time period. Failure to treat catheter-associated urinary tract infection when indicated did not increase at either site. Continue reading

CDC Discusses Best Practices and Resources For Childhood ADHD

Susanna N. Visser, DrPH Epidemiologist at the National Center on Birth Defects and Developmental Disabilities CDCMedicalResearch.com Interview with:
Susanna N. Visser, DrPH

Epidemiologist at the National Center on Birth Defects and Developmental Disabilities
CDC

 

Medical Research: What is the background for this study? What are the main findings?

Dr. Visser: Attention-Deficit/Hyperactivity Disorder, or ADHD is one of the most common chronic conditions of childhood. It often persists into adulthood.   When children diagnosed with ADHD receive proper treatment, they have the best chance of thriving at home, doing well at school, and making and keeping friends.

In 2011, the American Academy of Pediatrics (AAP) updated their guidelines for ADHD treatment. The new guidelines give this advice to healthcare providers, psychologists, educators, and parents of children with ADHD:

  • For preschoolers ages 4-5 with ADHD, use behavioral therapy before medication.
  • For older children and teens with ADHD, use behavioral therapy along with medication.

In order to learn more about ADHD treatment patterns, CDC researchers looked at data from a national sample of children with special health care needs, ages 4-17 years, collected in 2009-10 just before the release of the 2011 guidelines.

We found that most children with ADHD received either medication treatment or behavioral therapy. However, we also found that many children were not receiving treatment in the way it was outlined in the 2011 best practice guidelines.

  • Less than 1 in 3 children with ADHD received both medication treatment and behavioral therapy, the preferred treatment approach for children ages 6 and older.
  • Only half of preschoolers (4-5 years of age) with ADHD received behavioral therapy, which is now the recommended first-line treatment for this group.
  • About half of preschoolers with ADHD were taking medication for ADHD, and about 1 in 4 were treated only with medication.

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Back Pain: Early Imaging Of Older Adults Results in More Costs, Not Better Outcomes

Jeffrey (Jerry) G. Jarvik MD MPH Professor, Radiology, Neurological Surgery and Health Services Adjunct Professor, Pharmacy and Orthopedics & Sports Medicine Director, Comparative Effectiveness, Cost and Outcomes Research Center University of Washington Seattle, WA  98104-2499MedicalResearch.com Interview with:
Jeffrey (Jerry) G. Jarvik MD MPH
Professor, Radiology, Neurological Surgery and Health Services
Adjunct Professor, Pharmacy and Orthopedics & Sports Medicine
Director, Comparative Effectiveness, Cost and Outcomes Research Center University of Washington Seattle, WA

Medical Research: What is the background for this study?

Dr. Jarvik: 
When I arrived at the Univ of WA over 20 years ago, my mentor, Rick Deyo, had just finished leading a project that was responsible for developing one of the first set of guidelines for the diagnosis and treatment of acute low back pain. These guidelines, published in a booklet by AHRQ (then called AHCPR), recommended that patients with acute low back pain not undergo imaging for 4-6 weeks unless a red flag was present. One of the exceptions was that patients older than 50 could get imaged immediately, the rationale being that older adults had a higher prevalence of potentially serious conditions such as cancer, infections, etc, that would justify the early imaging. As a practicing neuroradiologist, it was clear that a potential problem with this strategy is that the prevalence of age-related changes, which may or may not be related to back pain, also increases with age. So earlier imaging of older adults would almost certainly reveal findings, and these could easily start a series of unfortunate events leading to potentially poor outcomes and more healthcare resource use. Thus this policy of early imaging of older adults didn’t entirely make sense.

About 5 years ago, these guidelines hit home when I developed acute low back pain and since I was over 50 (barely) my doctor recommended that I get an imaging study. Being a knowledgeable patient and having a reasonable doctor, we mutually agreed not to get the study. I improved but that wasn’t the end of it. When we had the chance to apply for one of the CHOICE ARRA awards funded by AHRQ, we made answering this question of early imaging in older adults one of our primary goals.

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Hispanic and Uninsured Adults May Experience Barriers To Blood Pressure Control

Stella Yi, Ph.D., MPH, Assistant Professor Department of Population Health New York University School of MedicineMedicalResearch.com Interview with:
Stella Yi, Ph.D., MPH, Assistant Professor
Department of Population Health
New York University School of Medicine

MedicalResearch: What is the background for this study? What are the main findings?

Dr. Yi: Self-blood pressure monitoring has been shown to be an effective tool for improving blood pressure control, however most studies have only included white race participants. We were interested in assessing whether distribution of self-blood pressure monitors (intervention) would improve blood pressure and hypertension control over usual care (control) in a 9-month period in a predominantly Hispanic, uninsured population. Systolic blood pressure improved over time in both the intervention (n=409) and the control (n=419) arms by 14.7 mm Hg and 14.1 mm Hg, respectively, as did hypertension control; 39% of study participants overall achieved control at the end of follow-up. However there were no statistical differences between the outcomes in the intervention and usual care groups. Continue reading

1% of US Population Accounts for Over 22% of Health Care Costs

Steven B. Cohen, Ph.D. Director, Center for Financing, Access and Cost Trends Agency for Healthcare Research and Quality Rockville, Maryland 20850MedicalResearch.com Interview with:
Steven B. Cohen, Ph.D.
Director, Center for Financing, Access and Cost Trends
Agency for Healthcare Research and Quality
Rockville, Maryland 20850

MedicalResearch: What is the background for this study?

Dr. Cohen: Health care expenditures represent more than one-sixth of the U.S. gross domestic product, exhibit a rate of growth that exceeds other sectors of the economy, and constitute one of the largest components of the federal budget and states’ budgets. Although the rate of growth in health care spending has slowed in the past few years, costs continue to rise. As a result, an evaluation of the current health care system requires an understanding of the patterns and trends in the use of health care services and their associated costs and sources of payment. Studies that examine the concentration and persistence of high levels of expenditures over time are essential to help discern the factors most likely to drive health care spending and the characteristics of the individuals who incur them.

MedicalResearch: What are the main findings?

Dr. Cohen: Using information from the Household Component of the Medical Expenditure Panel Survey (MEPS-HC) sponsored by the Agency for Healthcare Research and Quality (AHRQ), this study provides detailed estimates of the concentration and persistence in the level of health care expenditures in the United States. Attention is given to identifying the characteristics of individuals with the highest levels of medical expenditures, in addition to those factors that are associated with low medical expense profiles.

In 2011, 1 percent of the population accounted for 21.5 percent of total health care expenditures, and in 2012, the top 1 percent accounted for 22.7 percent of total expenditures with an annual mean expenditure of $97,956. The lower 50 percent of the population ranked by their expenditures accounted for only 2.8 percent and 2.7 percent of the total for 2011 and 2012 respectively. Of those individuals ranked at the top 1 percent of the health care expenditure distribution in 2011 (with a mean expenditure of $92,825), 19.6 percent maintained this ranking with respect to their 2012 health care expenditures.

In both 2011 and 2012, the top 10 percent of the population accounted for 65.3 percent of overall health care expenditures in 2011 (with a mean expenditure of $27,927), and 41.5 percent of this subgroup retained this top decile ranking with respect to their 2012 health care expenditures. Those who were in the top decile of spenders in both 2011 and 2012 differed by age, race/ethnicity, sex, health status, and insurance coverage (for those under 65) from those who were in the lower half in both years. Continue reading

Education Remains Strong Predictor of Longevity

MedicalResearch.com Interview with:
Robert M. Kaplan

Office of Behavioral and Social Sciences Research
National Institutes of Health
Bethesda, MD 20892

Medical Research: What is the background for this study? What are the main findings?

Response: Years of formal education is one of the strongest correlates of life expectancy. The purpose of this study was to examine the relationship between educational attainment and life expectancy with adjustments for other social, behavioral, and biological factors. Using data from a large cohort of nearly 30,000 adults, we found that education was a very strong predictor of survival and that biological and behavioral factors only partially explained the relationship.

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Study shows families could save more than $1,000 on average if states expanded Medicaid.

Steven C. Hill, PhD Center for Financing, Access and Cost Trends Agency for Healthcare Research and Quality Rockville, MD 2085MedicalResearch.com Interview with:
Steven C. Hill, PhD
Center for Financing, Access and Cost Trends
Agency for Healthcare Research and Quality
Rockville, MD 20850

MedicalResearch: What is the background for this study?

Dr. Hill: The Affordable Care Act offers two major ways to extend health coverage to more Americans: through expanding state Medicaid programs and through the Marketplace. States can expand Medicaid coverage to adults with family incomes at or below 138 percent of the federal poverty guidelines (approximately $16,242 for an individual and $33,465 for a family of four in 2015).

At the time of the study, 23 states had not yet expanded their Medicaid programs. In those states, poor adults typically continue to have very limited access to Medicaid. However, adults with incomes at or above the poverty guidelines who lack access to affordable insurance elsewhere are eligible for premium tax credits in the Marketplace. If these low-income adults purchase silver plans, then they are also generally eligible for cost sharing reductions.

MedicalResearch: What was the methodology for study?

Dr. Hill: The study used data from then Agency for Healthcare Research and Quality’s Medical Expenditure Panel Survey (MEPS) to determine family out-of-pocket health care spending in 2005 – 2010 for uninsured, low-income adults who lived in the states that had not yet expanded Medicaid under the Affordable Care Act at the time of the study. The study focused on those who would have been eligible for Medicaid if their states expanded eligibility (income at or below 138 percent of poverty guideline), and whose incomes were high enough to be eligible for premium tax credits and cost sharing reductions through the Health Insurance Marketplace (at or above poverty guidelines). The study then compared those data with the following simulated scenarios for these adults: coverage in a Marketplace silver plan with financial assistance; and enrolling in expanded Medicaid.

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Hospital Utilization Patterns For Medicaid and Uninsured Patients Differ From Insured

Raynard E. Washington, PhD, MPH Center for Delivery, Organization, and Markets Agency for Healthcare Research and Quality Rockville, MD 20850MedicalResearch.com Interview with:
Raynard E. Washington, PhD, MPH

Center for Delivery, Organization, and Markets
Agency for Healthcare Research and Quality
Rockville, MD 20850

Medical Research: What is the background for this study? What are the main findings?

Dr. Washington: Many individuals with low income who require a hospital stay are uninsured or covered by Medicaid, a joint Federal-State health insurance program for eligible individuals and families with low income. The difference in hospital utilization among patients covered by Medicaid and those who are uninsured may reflect differences in the characteristics of these populations and their level of access to health care. This HCUP Statistical Brief describes 2012 hospital stays with a primary expected payer of Medicaid and stays that were uninsured.

Of the 36.5 million total hospital inpatient stays in 2012, 20.9 percent had an expected primary payer of Medicaid and 5.6 percent were uninsured; 30.6 percent were covered by private insurance. Patients covered by Medicaid were on average younger and more likely to live in low-income areas than were patients with private insurance. Patients who were uninsured were more likely to be male and to live in low-income communities than were patients with private insurance. The majority of the top 10 diagnoses for Medicaid hospitalizations were ambulatory care sensitive conditions. Cholecystectomy (gall bladder removal) was the most common operating room procedure for Medicaid and uninsured stays.

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Spending on Cancer Rises Sharply Over Ten Year Period

MedicalResearch.com Interview with:
Anita Soni, PhD, MBA

Survey Analyst/Statistician
Project Officer, AHRQ Healthcare Data Analytics and Statistical Products Contract
Center for Financing, Access and Cost Trends
Agency for Healthcare Research and Quality
Rockville, MD 20850

Medical Research: What is the background for this study? What are the main findings?

Dr. Soni: The data used for this comes from Medical Expenditure Panel Survey, which is a household respondent survey. The expenditures reported for the treatment of cancer in 2001 were converted in to 2011 dollars and compared with expenditures reported by households respondents in 2011.Main findings of the study are that in 2011, approximately 15.8 million adults or 6.7 percent of the adult U.S. population received treatment for cancer. This represents an increase from 2001, when 10.2 million  adults or 4.8 percent of the population reported receiving treatment for cancer. Medical spending to treat cancer increased from $56.8 billion in 2001 (in 2011 dollars) to $88.3 billion in 2011. Ambulatory expenditures for care and treatment of cancer increased from $25.5 billion in 2001 to $43.8 billion in 2011. Expenditures on retail prescription medications for cancer increased from $2.0 billion in 2001 to $10.0 billion in 2011. Mean annual retail prescription drug expenditures for those with an  expense related to cancer increased more than three times, from $201 per person in 2001 (in 2011 dollars) to $634 per person in 2011. Inpatient hospital expenditures accounted for 47 percent of total spending for cancer treatment in 2001, but fell to 35 percent of the total by 2011.

Based on these numbers, the spending on cancer has risen in all aspects, number of people receiving treatment, spending on prescription drugs, medical visits as well as the hospital stays.

Citation:

Trends in Use and Expenditures for Cancer Treatment among Adults 18 and Older, U.S. Civilian Noninstitutionalized Population, 2001 and 2011
AHRQ Agency For Healthcare Research and Quality June 2014

Anita Soni, PhD, MBA

Sepsis-Sniffer Tool Better Identifies Patients Requiring Advance Care

Craig A Umscheid, MD, MSCE, FACP Assistant Professor of Medicine and Epidemiology Director, Center for Evidence-based Practice Medical Director, Clinical Decision Support Chair, Department of Medicine Quality Committee Senior Associate Director, ECRI-Penn AHRQ Evidence-based Practice Center University of Pennsylvania, Philadelphia, PA 19104MedicalResearch.com Interview with:
Craig A Umscheid, MD, MSCE, FACP
Assistant Professor of Medicine and Epidemiology
Director, Center for Evidence-based Practice
Medical Director, Clinical Decision Support
Chair, Department of Medicine Quality Committee
Senior Associate Director, ECRI-Penn AHRQ Evidence-based Practice Center, University of Pennsylvania Philadelphia, PA 19104

Medical Research: What are the main findings of the study?

Dr. Umscheid: We developed an automated early warning and response system for sepsis that has resulted in a marked increase in sepsis identification and care, transfer to the ICU, and an indication of fewer deaths due to sepsis.

Sepsis is a potentially life-threatening complication of an infection; it can severely impair the body’s organs, causing them to fail. There are as many as three million cases of severe sepsis and 750,000 resulting deaths in the United States annually. Early detection and treatment, typically with antibiotics and intravenous fluids, is critical for survival.

The Penn prediction tool, dubbed the “sepsis sniffer,” uses laboratory and vital-sign data (such as body temperature, heart rate, and blood pressure) in the electronic health record of hospital inpatients to identify those at risk for sepsis. When certain data thresholds are detected, the system automatically sends an electronic communication to physicians, nurses, and other members of a rapid response team who quickly perform a bedside evaluation and take action to stabilize or transfer the patient to the intensive care unit if warranted.

We developed the prediction tool using 4,575 patients admitted to the University of Pennsylvania Health System (UPHS) in October 2011.  We then validated the tool during a pre-implementation period from June to September 2012, when data on admitted patients was evaluated and alerts triggered in a database, but no notifications were sent to providers on the ground.  Outcomes in that control period were then compared to a post-implementation period from June to September 2013.  The total number of patients included in the pre and post periods was 31,093.

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Patient Safety Indicators Likely To Change Under New ICD-10 Coding

Yves A. Lussier, MD, Fellow ACMI Professor of Medicine Associate Vice President for Health Sciences (Chief Knowledge Officer) The University of ArizonaMedicalResearch.com Interview with:
Yves A. Lussier, MD, Fellow ACMI
Professor of Medicine
Associate Vice President for Health Sciences (Chief Knowledge Officer)
The University of Arizona

Medical Research: What are the main findings of the study?

Dr. Lussier:  The main finding is that reporting patient safety using ICD-10-CM coding schema rather than ICD-9-CM will change the reported percentage of adverse events reported for half the specific “patient safety indicators” (PSIs), even with a true unaltered frequency of reported events in the medical center. For some patient safety indicators, the reported frequency will appear to increase substantially and for others, it will appear to decrease.  The latter is particularly  worrisome as it may erroneously appease administrators and prospective clients (patients) as their apparent trend is improving, while their institution may inadvertently be under-reporting adverse events.

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Electronic Health Record Alerts Reduced Urinary Tract Infections

Craig A Umscheid, MD, MSCE, FACP Assistant Professor of Medicine and Epidemiology Director, Center for Evidence-based Practice Medical Director, Clinical Decision Support Chair, Department of Medicine Quality Committee Senior Associate Director, ECRI-Penn AHRQ Evidence-based Practice Center University of Pennsylvania, Philadelphia, PA 19104MedicalResearch.com Interview with:
Craig A Umscheid, MD, MSCE, FACP
Assistant Professor of Medicine and Epidemiology
Director, Center for Evidence-based Practice
Medical Director, Clinical Decision Support
Chair, Department of Medicine Quality Committee

Senior Associate Director, ECRI-Penn AHRQ Evidence-based Practice Center
University of Pennsylvania, Philadelphia, PA 19104

Medical Research: What are the main findings of the study?

Dr. Umscheid: We found that targeted automated alerts in electronic health records significantly reduce urinary tract infections in hospital patients with urinary catheters. In addition, when the design of the alert was simplified, the rate of improvement dramatically increased.

Approximately 75 percent of urinary tract infections acquired in the hospital are associated with a urinary catheter, which is a tube inserted into the bladder through the urethra to drain urine.  According to the Centers for Disease Control and Prevention, 15 to 25 percent of hospitalized patients receive urinary catheters during their hospital stay. As many as 70 percent of urinary tract infections in these patients may be preventable using infection control measures such as removing no longer needed catheters resulting in up to 380,000 fewer infections and 9,000 fewer deaths each year.

Our study has two crucial, applicable findings.  First, electronic alerts do result in fewer catheter-associated urinary tract infections. Second, the design of the alerts is very important. By making the alert quicker and easier to use, we saw a dramatic increase in the number of catheters removed in patients who no longer needed them. Fewer catheters means fewer infections, fewer days in the hospital, and even, fewer deaths. Not to mention the dollars saved by the health system in general.

In the first phase of the study, two percent of urinary catheters were removed after an initial “off-the-shelf” electronic alert was triggered (the stock alert was part of the standard software package for the electronic health record). Hoping to improve on this result in a second phase of the study, we developed and used a simplified alert based on national guidelines for removing urinary catheters that we previously published with the CDC. Following introduction of the simplified alert, the proportion of catheter removals increased more than seven-fold to 15 percent.

The study also found that catheter associated urinary tract infections decreased from an initial rate of .84 per 1,000 patient days to .70 per 1,000 patient-days following implementation of the first alert and .50 per 1,000 patient days following implementation of the simplified alert. Among other improvements, the simplified alert required two mouse clicks to submit a remove-urinary-catheter order compared to seven mouse clicks required by the original alert.

The study was conducted among 222,475 inpatient admissions in the three hospitals of the University of Pennsylvania Health System between March 2009 and May 2012. In patients’ electronic health records, physicians were prompted to specify the reason (among ten options) for inserting a urinary catheter. On the basis of the reason selected, they were subsequently alerted to reassess the need for the catheter if it had not been removed within the recommended time period based on the reason chosen.
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Electronic Medical Records: Tool to Identify Readmission Risk

Craig A Umscheid, MD, MSCE, FACP Assistant Professor of Medicine and Epidemiology Director, Center for Evidence-based Practice Medical Director, Clinical Decision Support Chair, Department of Medicine Quality Committee Senior Associate Director, ECRI-Penn AHRQ Evidence-based Practice Center University of Pennsylvania Philadelphia, PA 19104MedicalResearch.com Interview with:
Craig A Umscheid, MD, MSCE, FACP
Assistant Professor of Medicine and Epidemiology
Director, Center for Evidence-based Practice
Medical Director, Clinical Decision Support
Chair, Department of Medicine Quality Committee
Senior Associate Director, ECRI-Penn AHRQ Evidence-based Practice Center
University of Pennsylvania Philadelphia, PA 19104

MedicalResearch.com: What are the main findings of the study?

Dr. Umscheid: We developed and successfully deployed into the electronic health record of the University of Pennsylvania Health System an automated prediction tool which identifies newly admitted patients who are at risk for readmission within 30 days of discharge.  Using local data, we found that having been admitted to the hospital two or more times in the 12 months prior to admission was the best way to predict which patients are at risk for being readmitted in the 30 days after discharge. Using this finding, our automated tool identifies patients who are “high risk” for readmission and creates a “flag” in their electronic health record (EHR). The flag appears next to the patient’s name in a column titled “readmission risk.” The flag can be double-clicked to display detailed information relevant to discharge planning.  In a one year prospective validation of the tool, we found that patients who triggered the readmission alert were subsequently readmitted 31 percent of the time. When an alert was not triggered, patients were readmitted only 11 percent of the time.  There was no evidence for an effect of the intervention on 30-day all-cause readmission rates in the 12-month period after implementation.
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Children’s Use of Asthma Controller Drugs Has Doubled

Released: 10/17/2011 8:00 AM EDT
Source: Agency for Healthcare Research and Quality (AHRQ)

Newswise — The proportion of children who used a prescribed controller drug to treat their asthma doubled from 29 percent in 1997–1998 to 58 percent in 2007–2008, according to the latest News and Numbers from the Agency for Healthcare Research and Quality.

Asthma controller drugs, such as cortisteroids, control inflammation thereby reducing the likelihood of airway spasms; asthma reliever drugs, such as short-acting beta-2-agonists, make breathing easier; and leukotrienes help prevent asthma symptoms from occurring.

AHRQ also found that during the 1997–1998 and 2007–2008 timeframes:

• Use of inhaled corticosteroids, a type of controller drug increased from 15.5 percent to 40 percent. Use of other controller drugs also increased: beta agonists (from 3 percent to 13 percent); and leukotriene (from 3 percent to 34 percent).

• Use of reliever and oral corticosteroid drugs declined from 44 percent to 30 percent and from 17 percent to 9 percent, respectively.

• Average annual total spending for all asthma drugs more than quadrupled from $527 million to $2.5 billion. Specifically, spending for controller drugs grew from $280 million to $2.1 billion and for reliever drugs, the increase was $222 million to $352 million (all in 2008 dollars).

• Spending for oral corticosteroids fell from $25 million to $8 million (2008 dollars).

The data in this AHRQ News and Numbers summary are taken from the Medical Expenditure Panel Survey (MEPS), a detailed source of information on the health services used by Americans, the frequency with which they are used, the cost of those services, and how they are paid. For more information, go to Statistical Brief #341: Changes in Children’s Use and Expenditures for Asthma Medications, United States, 1997–1998 to 2007–2008