This issue of CHP/PCOR's Quarterly Update covers news from the Fall 2007 quarter and includes articles about:

• the 2007 Eisenberg Legacy Lecture event, featuring CHP/PCOR core faculty member Victor R. Fuchs;
• annual meeting and conference coverage, including the Society for Medical Decision Meeting's Annual Meeting, and the Freeman Spogli Institute for International Studies conference;
• two Research in Brief selections -- one highlights differences in gender use care in the VA system, and the second examines health risk assessment tools;
• how the Geriatrics Research team at the VA is using informatics to improve quality of health care;
• international health features from the field and from a research perspective;
• a Q & A with senior scholar Dena M. Bravata, who led a popular pedometer that received lots of media attention in past months.

The newsletter also contains various other news items that may be of interest to our readers.

Note to the reader:

The newsletter is fully-navigational. Any text that is surrounded by a dashed box is clickable and will allow the reader to navigate the newsletter more efficiently. The end of each article contains a special symbol (§) that, when clicked, will take the reader back to the table of contents. Please feel free to contact Amber Hsiao with any questions.

The main aim of this paper is to describe and estimate a new decomposition of disability trends among working age populations into two parts -- the part of the trend explained by changes in the prevalence of chronic disease and obesity and the part of the trend explained by changes in the prevalence of disability among people with chronic diseases. If most of the changes in disability in this population are due to change in chronic disease prevalence, then there is little room for statutory incentives as an explanation for ADL disability trends. More importantly, such a result would suggest that recent changes in disability in this population are permanent for the affected age cohorts. If this cohort survives to old age, the use of medical care by this group will place great demands on Medicare financing.

On the other hand, if an increase in disability prevalence among those with chronic disease is the explanation, then there arise two possibilities: that chronic diseases have become more severe over time, or that the incidence of even ADL-style disabilities are dependent on cultural, social, and economic determinants such as the disability insurance payments. Such a result would suggest that the increases in ADL disability seen among working age populations might not be permanent.

Access to Early Intervention (EI) services may improve cognitive and behavioral outcomes in very low birth weight infants, but few states have population-based data to evaluate EI outreach efforts. We analyzed Massachusetts (MA) infants born weighing <1,200 g to identify maternal and birth characteristics that predicted EI referral and timing of referral.

METHODS: MA birth and hospital discharge records (Jan. 1998-Sept. 2000) were linked to EI referral records (Jan. 1998-Sept. 2003) via probabilistic and deterministic methods (88% linkage). Timing of EI referral among infants weighing <1,200 g was examined by infant and maternal characteristics using categorical (0-12 months, 12-36 months, or no referral) time comparisons in the crude analysis. Survival functions calculating median time to referral, and adjusted hazard ratios (HR) with 95% confidence intervals (CI) were calculated for continuous time comparisons of EI referral from birth to 36 months.

RESULTS: Of 1,233 infants weighing <1,200 g, 93.2% were referred to EI. After risk adjustment, referral was more likely among multiple-birth infants (HR = 1.17, 95%CI 1.06-1.30) and less likely among infants <28 weeks (HR = 0.70; 95%CI 0.64-0.77) or with low Apgar scores (<5 at 5 min; HR = 0.75; 95%CI 0.62-0.92). EI referrals were lower for infants of black non-Hispanic mothers, and mothers without private insurance (HR = 0.85; 95%CI 0.74-0.98 and HR = 0.77; 95%CI 0.68-0.86, respectively).

CONCLUSIONS: In MA, most infants born <1,200 g are referred to EI, but disparities exist. Analysis of linked population-based health and developmental services can inform programs in order to reduce disparities and improve access for all high-risk infants.

BACKGROUND: Recent work has shown that rates of severe disability, measured by the inability to perform basic activities of daily living, have been rising in working age populations. At the same time, the prevalence of important chronic diseases has been rising, while others falling, among working age populations. Chronically ill individuals are more likely than others to have activity of daily living limitations.

OBJECTIVE: We examine the extent to which chronic disease trends can explain these disability trends. DATA: We use nationally representative survey data from the 1984-1996 National Interview Survey, which posed a consistent set of questions regarding limitations in activities of daily living over that period.

METHODS: We decompose trends in disability into 2 parts-1 part due to trends in the prevalence of chronic disease and the other due to trends in disability prevalence among those with chronic disease.

RESULTS:: Our primary findings are that for working age populations between 1984 and 1996: (1) disability prevalence fell dramatically among the nonchronically ill; (2) rising obesity prevalence explains about 40% of the rise in disability attributable to trends chronic illness; and (3) rising disability prevalence among the chronically ill explains about 60% of the rise in disability attributable to trends in chronic illness.

CONCLUSIONS: Disability prevention efforts in working age populations should focus on reductions in obesity prevalence and limiting disability among chronically ill populations. Given the rise in disability among these population subgroups, it is unclear whether further substantial declines in elderly disability can be expected.

Abstract

The authors examined how the association between quality improvement (QI) implementation in hospitals and hospital clinical quality is moderated by hospital organizational and environmental context. The authors used Ordinary Least Squares regression analysis of 1,784 community hospitals to model seven quality indicators as a function of four measures of QI implementation and a variety of control variables. They found that forces that are external and internal to the hospital condition the impact of particular QI activities on quality indicators: specifically data use, statistical tool use, and organizational emphasis on Continuous Quality Improvement (CQI). Results supported the proposition that QI implementation is unlikely to improve quality of care in hospital settings without a commensurate fit with the financial, strategic, and market imperatives faced by the hospital.

Abstract

BACKGROUND:

Only 31% of Americans with hypertension have their blood pressure (BP) under effective control. We describe a study that tests 3 different interventions in a randomized controlled trial using home BP telemedicine monitoring.

METHODS:

A sample of hypertensive patients with poor BP control at baseline (N = 600) are randomized to 1 of 4 arms: (1) control group--a group of hypertensive patients who receive usual care; (2) nurse-administered tailored behavioral intervention; (3) nurse-administered medication management according to a hypertension decision support system; (4) combination of the 2 interventions. The interventions are triggered based on home BP values transmitted via telemonitoring devices over standard telephone lines. The tailored behavioral intervention involves promoting adherence with medication and health behaviors. Patients randomized to the medication management or the combined arm have their hypertension regimen changed by the study team using a validated hypertension decision support system based on evidence-based hypertension treatment guidelines and individualized to patients' comorbid illnesses. The primary outcome is BP control: < or = 140/90 mm Hg (nondiabetic) and < or = 130/80 mm Hg (diabetics) measured at 6-month intervals over 18 months (4 total measurements).

CONCLUSIONS:

Given the increasing prevalence of hypertension and our inability to achieve adequate BP control using traditional models of care, testing novel interventions in patients' homes may improve access, quality, and outcomes.

Black patients receiving dialysis for end-stage renal disease in the United States have lower mortality rates than white patients. Whether racial differences exist in mortality after acute renal failure is not known. We studied acute renal failure in patients hospitalized between 2000 and 2003 using the Nationwide Inpatient Sample and found that black patients had an 18% (95% confidence interval [CI] 16 to 21%) lower odds of death than white patients after adjusting for age, sex, comorbidity, and the need for mechanical ventilation. Similarly, among those with acute renal failure requiring dialysis, black patients had a 16% (95% CI 10 to 22%) lower odds of death than white patients. In stratified analyses of patients with acute renal failure, black patients had significantly lower adjusted odds of death than white patients in settings of coronary artery bypass grafting, cardiac catheterization, acute myocardial infarction, congestive heart failure, pneumonia, sepsis, and gastrointestinal hemorrhage. Black patients were more likely than white patients to be treated in hospitals that care for a larger number of patients with acute renal failure, and black patients had lower in-hospital mortality than white patients in all four quartiles of hospital volume. In conclusion, in-hospital mortality is lower for black patients with acute renal failure than white patients. Future studies should assess the reasons for this difference.

BACKGROUND: The elderly constitute the fastest-growing segment of the end-stage renal disease (ESRD) population, but the epidemiology and outcomes of dialysis among the very elderly, that is, those 80 years of age and older, have not been previously examined at a national level. OBJECTIVE: To describe recent trends in the incidence and outcomes of octogenarians and nonagenarians starting dialysis. DESIGN: Observational study. SETTING: U.S. Renal Data System, a comprehensive, national registry of patients with ESRD. PARTICIPANTS: Octogenarians and nonagenarians initiating dialysis between 1996 and 2003. MEASUREMENTS: Rates of dialysis initiation and survival. RESULTS: The number of octogenarians and nonagenarians starting dialysis increased from 7054 persons in 1996 to 13,577 persons in 2003, corresponding to an average annual increase in dialysis initiation of 9.8%. After we accounted for population growth, the rate of dialysis initiation increased by 57% (rate ratio, 1.57 [95% CI, 1.53 to 1.62]) between 1996 and 2003. One-year mortality for octogenarians and nonagenarians after dialysis initiation was 46%. Compared with octogenarians and nonagenarians initiating dialysis in 1996, those starting dialysis in 2003 had a higher glomerular filtration rate and less morbidity related to chronic kidney disease but no difference in 1-year survival. Clinical characteristics strongly associated with death were older age, nonambulatory status, and more comorbid conditions. LIMITATIONS: Survival of patients with incident ESRD who did not begin dialysis could not be assessed. CONCLUSIONS: The number of octogenarians and nonagenarians initiating dialysis has increased considerably over the past decade, while overall survival for patients on dialysis remains modest. Estimates of prognosis based on patient characteristics, when considered in conjunction with individual values and preferences, may aid in dialysis decision making for the very elderly.