The heart of NYU Wagner's programs is our faculty. An amalgam of full-time, clinical/research/visiting, and adjunct professors, they are outstanding teachers, expert researchers and committed practitioners.
Blustein, Jan, Teresa M Attina, Laura Cox, Mengling Liu, Andrew M Ryan, Martin M Blaser, Leonardo Trasande. 2013. Association of Caesarean Delivery with Child Adiposity from Age 6 Weeks to 15 Years. International Journal of Obesity, in press.
Trasande, Leonardo, Teresa M Attina, S Sathyanarayana, Adam J Spanier, Jan Blustein. 2013. Race/Ethnicity-Specific Associations of Urinary Phthalates with Childhood Body Mass in a Nationally Representative Sample. Environmental Health Perspectives, in press.
Transande, Leonardo, Teresa Attina, Adam Spanier, Shella Sathyanarayana, Jan Blustein 2013. Urinary Phthalates and Increased Insulin Resistance in Adolescents. Pediatrics, in press.
Ryan, Andrew M. and Jan Blustein. 2012. Making the Best of Hospital Pay for Performance. New England Journal of Medicine. 366(17):1557-9.
Ryan, Andrew M., Jan Blustein, Lawrence P. Casalino. 2012. Medicare’s Flagship Test Of Pay-For-Performance Did Not Spur More Rapid Quality Improvement Among Low-Performing Hospitals. Health Affairs; 31(4):797-805.
Medicare’s flagship hospital pay-for-performance program, the Premier Hospital Quality Incentive Demonstration, began in 2003 but changed its incentive design in late 2006. The goals were to encourage greater quality improvement, particularly among lower-performing hospitals. However, we found no evidence that the change achieved these goals. Although the program changes were intended to provide strong incentives for improvement to the lowest-performing hospitals, we found that in practice the new incentive design resulted in the strongest incentives for hospitals that had already achieved quality performance ratings just above the median for the entire group of participating hospitals. Yet during the course of the program, these hospitals improved no more than others. Our findings raise questions about whether pay-for-performance strategies that reward improvement can generate greater improvement among lower performing providers. They also cast some doubt on the extent to which hospitals respond to the specific structure of economic incentives in pay-for-performance programs.
Borden, William and Jan Blustein. 2012. Valuing Improvement in Value Based Purchasing. Circulation: Cardiovascular Quality and Outcomes. 5:163-170
Medicare will soon implement hospital value-based purchasing (VBP), using a scoring system that rewards both achievement (absolute performance) and improvement (performance increase over time). However, improvement is defined so as to give less credit to initial low performers than initial high performers. Since initial low performers are disproportionately hospitals in socioeconomically disadvantaged areas, these institutions stand to lose under Medicare’s VBP proposal.
We developed an alternative improvement scale, and applied it to hospital performance throughout the US. Using 2005-2008 Medicare process measures for acute myocardial infarction (AMI) and heart failure (HF), we calculated hospital scores using Medicare’s proposal and our alternative. Hospital performance scores were compared across 5 locational dimensions of socioeconomic disadvantage: poverty, unemployment, physician shortage, high school and college graduation rates.
Medicare’s proposed scoring system yielded higher overall scores for the most locationally advantaged hospitals for 4 out of 5 dimensions in AMI and 2 out of 5 for HF. Using our alternative, differences in overall scores between hospitals in the most and least advantaged areas were attenuated, with locationally advantaged hospitals having higher overall scores for 3 out of 5 dimensions in AMI and 1 out of 5 dimensions for HF.
Using an alternative VBP formula that reflects the principle of “equal credit for equal improvement,” resulted in a more equitable distribution of overall payment scores, which could allow hospitals in both socioeconomically advantaged and disadvantaged areas to succeed under VBP.
Trasande, Leonardo, Teresa M Attina, and Jan Blustein 2012. Association Between Urinary Bisphenol A Concentration and Obesity Prevalence in Children and Adolescents. Journal of the American Medical Assocation (JAMA). 2012;308(11):1113-1121.
Context Bisphenol A (BPA), a manufactured chemical, is found in canned food, polycarbonate-bottled liquids, and other consumer products. In adults, elevated urinary BPA concentrations are associated with obesity and incident coronary artery disease. BPA exposure is plausibly linked to childhood obesity, but evidence is lacking to date.
Objective To examine associations between urinary BPA concentration and body mass outcomes in children.
Design, Setting, and Participants Cross-sectional analysis of a nationally representative subsample of 2838 participants aged 6 through 19 years randomly selected for measurement of urinary BPA concentration in the 2003-2008 National Health and Nutrition Examination Surveys.
Main Outcome Measures Body mass index (BMI), converted to sex- and age-standardized z scores and used to classify participants as overweight (BMI ≥85th percentile for age/sex) or obese (BMI ≥95th percentile).
Results Median urinary BPA concentration was 2.8 ng/mL (interquartile range, 1.5-5.6). Of the participants, 1047 (34.1% [SE, 1.5%]) were overweight and 590 (17.8% [SE, 1.3%]) were obese. Controlling for race/ethnicity, age, caregiver education, poverty to income ratio, sex, serum cotinine level, caloric intake, television watching, and urinary creatinine level, children in the lowest urinary BPA quartile had a lower estimated prevalence of obesity (10.3% [95% CI, 7.5%-13.1%]) than those in quartiles 2 (20.1% [95% CI, 14.5%-25.6%]), 3 (19.0% [95% CI, 13.7%-24.2%]), and 4 (22.3% [95% CI, 16.6%-27.9%]). Similar patterns of association were found in multivariable analyses examining the association between quartiled urinary BPA concentration and BMI z score and in analyses that examined the logarithm of urinary BPA concentration and the prevalence of obesity. Obesity was not associated with exposure to other environmental phenols commonly used in other consumer products, such as sunscreens and soaps. In stratified analysis, significant associations between urinary BPA concentrations and obesity were found among whites (P < .001) but not among blacks or Hispanics.
Conclusions Urinary BPA concentration was significantly associated with obesity in this cross-sectional study of children and adolescents. Explanations of the association cannot rule out the possibility that obese children ingest food with higher BPA content or have greater adipose stores of BPA.
Trasande, Leonardo, Jan Blustein, Mengling Liu, Elise Corwin, Laura M Cox, Martin J Blaser 2012. Infant Antibiotic Exposures and Early-Life Body Mass. International Journal of Obesity , (21 August 2012) | doi:10.1038/ijo.2012.132.
To examine the associations of antibiotic exposures during the first 2 years of life and the development of body mass over the first 7 years of life.
Longitudinal birth cohort study.
Exposures to antibiotics during three different early-life time windows (
Antibiotic exposure during the earliest time window (
Exposure to antibiotics during the first 6 months of life is associated with consistent increases in body mass from 10 to 38 months. Exposures later in infancy (6–14 months, 15–23 months) are not consistently associated with increased body mass. Although effects of early exposures are modest at the individual level, they could have substantial consequences for population health. Given the prevalence of antibiotic exposures in infants, and in light of the growing concerns about childhood obesity, further studies are needed to isolate effects and define life-course implications for body mass and cardiovascular risks.
Ryan, Andrew M, Jan Blustein, Tim Doran, Marilyn Michelew and Lawrence P. Casalino. 2012. The Effect of Phase 2 of the Premier Hospital Quality Incentive Demonstration on Incentive Payments to Hospitals Caring for Disadvantaged Patients. Health Services Research. 47(4):1418-1426.
Objective. The Medicare and Premier Inc. Hospital Quality Incentive Demonstration (HQID), a hospital-based pay-for-performance program, changed its incentive design from one rewarding only high performance (Phase 1) to another rewarding high performance, moderate performance, and improvement (Phase 2). We tested whetherthis design change reduced the gap in incentive payments among hospitals treating patients across the gradient of socioeconomic disadvantage.
Data. To estimate incentive payments in both phases, we used data from the Premier Inc. website and from Medicare Provider Analysis and Review Files.We used data from the American Hospital Association Annual Survey and Centers for Medicare and Medicaid Services Impact File to identify hospital characteristics.
Study Design. Hospitals were divided into quartiles based on their Disproportionate Share Index (DSH) , from lowest disadvantage (Quartile 1) to highest disadvantage (Quartile 4). In both phases of the HQID, we tested for differences across the DSH quartiles for three outcomes: (1) receipt of any incentive payments; (2) total incentive payments; and (3) incentive payments per discharge. For each of the study outcomes,we performed a hospital-level difference-in-differences analysis to test whether the gap between Quartile 1 and the other quartiles decreased from Phase 1 to Phase 2.
Principal Findings. In Phase 1, there were significant gaps across the DSH quartiles for the receipt of any payment and for payment per discharge. In Phase 2, the gap was not significant for the receipt of any payment, but remained significant for payment perdischarge. For the receipt of any incentive payment, difference-in-difference estimates showed significant reductions in the gap between Quartile 1 and the other quartiles (Quartile 2, 17.5 percentage points [p < .05]; Quartile 3, 18.1 percentage points [p < .01]; Quartile 4, 28.3 percentage points [p < .01]). For payments per discharge, the gap was also signi_cantly reduced between Quartile 1 and the other quartiles (Quartile 2, $14.92 per discharge [p < .10]; Quartile 3, $17.34 per discharge [p < .05]; Quartile 4, $21.31 per discharge [p < .01]). There were no significant reductions in the gap for total payments.
Conclusions. The design change in the HQID reduced the disparity in the receipt of any incentive payment and for incentive payments per discharge between hospitals caring for the most and least socioeconomically disadvantaged patient populations.
Blustein, Jan. 2011. Geographic Variations in Health Care Workforce Training in the US: The Case of Registered Nurses (RNs). Med Care. 2011 Aug;49(8):769-74.
Background: In the United States, registered nurses [RNs] are trained through one of three educational pathways: a diploma course; an associate's degree, or a baccalaureate degree in nursing (the BSN). A national consensus has emerged that the proportion of RNs that are baccalaureate-trained should be substantially increased. Yet achieving that goal may be difficult in areas where college graduates are unlikely to reside.
Conclusions: Nationwide, there are substantial geographic variations in the training of hospital RNs. Educational segregation (the tendency for educated people to cluster geographically) may make it more difficult to achieve a BSN-rich nursing workforce in some areas of the US. Further work is needed to assess whether educational segregation similarly influences the distribution of other health care professionals, and whether it leads to variations in the local quality of care.
Blustein, Jan, Joel Weissman, Andrew M Ryan, Tim Doran and Romana Hasnain-Wynia. 2011. Massachusetts Links Pay for Performance to the Reduction of Racial and Ethnic Disparities. Health Affairs. 30(6):1165-1175.
The Institute of Medicaid has identified equity as a key dimension of quality. Recently, Massachusetts’ Medicaid program (MassHealth) took the unusual step of linking pay-for-performance (P4P) to the reduction of racial/ethnic disparities for hospital care. We report on early experience with the program, describing the challenges of implementing an ambitious program in a short time frame, with limited resources. Our findings raise questions about whether P4P as currently constituted is a suitable tool for addressing disparities in hospital care.
Ryan, Andrew M and Jan Blustein. 2011. The Effect of the MassHealth Hospital Pay-for-Performance Program on Quality. Health Services Research. 2011:46(3);712-728.
Objective. To test the effect of Massachusetts Medicaid's (MassHealth) hospital-based pay-for-performance (P4P) program, implemented in 2008, on quality of care for pneumonia and surgical infection prevention (SIP). Data. Hospital Compare process of care quality data from 2004 to 2009 for acute care hospitals in Massachusetts (N=62) and other states (N=3,676) and American Hospital Association data on hospital characteristics from 2005. Study Design. Panel data models with hospital fixed effects and hospital-specific trends are estimated to test the effect of P4P on composite quality for pneumonia and SIP. This base model is extended to control for the completeness of measure reporting. Further sensitivity checks include estimation with propensity-score matched control hospitals, excluding hospitals in other P4P programs, varying the time period during which the program was assumed to have an effect, and testing the program effect across hospital characteristics. Principal Findings. Estimates from our preferred specification, including hospital fixed effects, trends, and the control for measure completeness, indicate small and nonsignificant program effects for pneumonia (-0.67 percentage points, p>.10) and SIP (-0.12 percentage points, p>.10). Sensitivity checks indicate a similar pattern of findings across specifications. Conclusions. Despite offering substantial financial incentives, the MassHealth P4P program did not improve quality in the first years of implementation.
Blustein, J., Borden, W.B., Valentine, M. 2010. Hospital Performance, the Local Economy, and the Local Workforce: Findings from a US National Longitudinal Study. PLoS Med 7(6): e1000297. doi:10.1371/journal.pmed.1000297.
Background: Pay-for-performance is an increasingly popular approach to improving health care quality, and the US government will soon implement pay-for-performance in hospitals nationwide. Yet hospital capacity to perform (and
improve performance) likely depends on local resources. In this study, we quantify the association between hospital performance and local economic and human resources, and describe possible implications of pay-for-performance for socioeconomic equity.
Methods and Findings: We applied county-level measures of local economic and workforce resources to a national sample of US hospitals (n = 2,705), during the period 2004–2007. We analyzed performance for two common cardiac conditions (acute myocardial infarction [AMI] and heart failure [HF]), using process-of-care measures from the Hospital Quality Alliance [HQA], and isolated temporal trends and the contributions of individual resource dimensions on performance, using multivariable mixed models. Performance scores were translated into net scores for hospitals using the Performance Assessment Model, which has been suggested as a basis for reimbursement under Medicare’s ‘‘Value-Based Purchasing’’ program. Our analyses showed that hospital performance is substantially associated with local economic and workforce resources. For example, for HF in 2004, hospitals located in counties with longstanding poverty had mean HQA composite scores of 73.0, compared with a mean of 84.1 for hospitals in counties without longstanding poverty (p,0.001). Hospitals located in counties in the lowest quartile with respect to college graduates in the workforce had mean HQA composite scores of 76.7, compared with a mean of 86.2 for hospitals in the highest quartile (p,0.001). Performance on AMI measures showed similar patterns. Performance improved generally over the study period. Nevertheless, by 2007—4 years after public reporting began—hospitals in locationally disadvantaged areas still lagged behind their locationally advantaged counterparts. This lag translated into substantially lower net scores under the Performance Assessment Model for hospital reimbursement.
Conclusions: Hospital performance on clinical process measures is associated with the quantity and quality of local economic and human resources. Medicare’s hospital pay-for-performance program may exacerbate inequalities across regions, if implemented as currently proposed. Policymakers in the US and beyond may need to take into consideration the balance between greater efficiency through pay-for-performance and socioeconomic equity.
Please see later in the article for the Editors’ Summary.
Palmas, W., Shea, S., Starren, J., Teresi, J.E., Ganz, M.L., Burton, T.M., Pashos, C.L., Blustein, J., Field, L., Morin, P.C., Izquierdo, R.E., Silver, S., Eimicke, J.P., Langiua, R.A. & Weinstock, S. 2010. Medicare Payments, Health Care Services Use, and Telemedicine Implementation Cost in Randomized Trial Comparing Telemedicine Case Management With Usual Care in Medically Underserved Patients With Diabetes Mellitus. Journal of the American Medical Informatics Association.
Silver D, J Blustein, BC Weitzman. 2010. Transportation to Clinic: Findings from a Pilot Clinic-Based Survey of Low-Income Suburbanites. Journal of Immigrant and Minority Health 2010. DOI: 10.1007/s10903-010-9410-0.
Health care policymakers have cited transportation barriers as key obstacles to providing health care to low-income suburbanites, particularly because suburbs have become home to a growing number of recent immigrants who are less likely to own cars than their neighbors. In a suburb of New York City, we conducted a pilot survey of low income, largely immigrant clients in four public clinics, to find out how much transportation difficulties limit their access to primary care. Clients were receptive to the opportunity to participate in the survey (response rate = 94%). Nearly one-quarter reported having transportation problems that had caused them to miss or reschedule a clinic appointment in the past. Difficulties included limited and unreliable local bus service, and a tenuous connection to a car. Our pilot work suggests that this population is willing to participate in a survey on this topic. Further, since even among those attending clinic there was significant evidence of past transportation problems, it suggests that a population based survey would yield information about substantial transportation barriers to health care.
Blustein, J., Valentine, M., Mead, H. & Regenstein, M. 2008. Race/Ethnicity and Patient Confidence to Self-manage Cardiovascular Disease. Medical Care. 2008; 46(9):924-9.
Background: Minority populations bear a disproportionate burden of chronic disease, due to higher disease prevalence and greater morbidity and mortality. Recent research has shown that several factors, including confidence to self-manage care, are associated with better health behaviors and outcomes among those with chronic disease.
Objective: To examine the association between minority status and confidence to self-manage cardiovascular disease (CVD).
Study Sample: Survey respondents admitted to 10 hospitals participating in the Expecting Success program, with a diagnosis of CVD, during January-September 2006 (n = 1107).
Results: Minority race/ethnicity was substantially associated with lower confidence to self-manage CVD, with 36.5% of Hispanic patients, 30.7% of Black patients, and 16.0% of white patients reporting low confidence (P < 0.001). However, in multivariate analysis controlling for socioeconomic status and clinical severity, minority status was not predictive of low confidence.
Conclusions: Although there is an association between race/ethnicity and confidence to self-manage care, that relationship is explained by the association of race/ethnicity with socioeconomic status and clinical severity.
Blustein, J. 2008. Who Is Accountable for Racial Equity in Health Care? Journal of the American Medical Association. Vol. 299 No.7, February 20: 814-816.
Racial disparities are a ubiquitous feature of the US medical landscape, with health care delivery substantially segregated by race/ethnicity. Recent evidence from hospitals,1-3 nursing homes,4-5 and physicians' offices6 suggests that those caring for minority patients do not perform as well as those who care for nonminority patients, on average. This evidence is troubling but hardly surprising because the limited resources of those who care for the poor have helped to create and sustain racial disparities. As the United States enters an era of accountability in health care, it is time to consider these familiar circumstances from a new perspective.
Blustein, J., Regenstein, M., Seigel, B. & Billings, J. 2007. Notes from the Field: Jumpstarting the IRB Approval Process in Multicenter Studies. Health Services Research, Volume 42, Number 4, August 2007 , pp. 1773-1782(10) Blackwell Publishing.
Objective. To identify strategies that facilitate readiness for local Institutional Review Board (IRB) review, in multicenter studies.
Study Setting. Eleven acute care hospitals, as they applied to participate in a foundation-sponsored quality improvement collaborative.
Study Design. Case series.
Data Collection/Extraction. Participant observation, supplemented with review of written and oral communications.
Principal Findings. Applicant hospitals responded positively to efforts to engage them in early planning for the IRB review process. Strategies that were particularly effective were the provisions of application templates, a modular approach to study description, and reliance on conference calls to collectively engage prospective investigators, local IRB members, and the evaluation/national program office teams. Together, these strategies allowed early identification of problems, clarification of intent, and relatively timely completion of the local IRB review process, once hospitals were selected to participate in the learning collaborative.
Conclusions. Engaging potential collaborators in planning for IRB review may help expedite and facilitate review, without compromising the fairness of the grant-making process or the integrity of human subjects protection.
Many studies have explored the extent to which physicians’ characteristics and Medicaid program factors influence physicians’ decisions to accept Medicaid patients. In this article, we turn to patient race/ethnicity and residential segregation as potential influences. Using the 2000/2001 Community Tracking Study and other sources we show that physicians are significantly less likely to participate in Medicaid in areas where the poor are nonwhite and in areas that are racially segregated. Surprisingly—and contrary to the prevailing Medicaid participation theory—we find no link between poverty segregation and Medicaid participation when controlling for these racial factors. Accordingly, this study contributes to an accumulating body of circumstantial evidence that patient race influences physicians’ choices, which in turn may contribute to racial disparities in access to health care.
Blustein, J. 2005. Toward a More Public Discussion of the Ethics of Federal Social Program Evaluation. Journal of Policy Analysis and Management, Vol. 24, No. 4, pp 824-852.
Federal social program evaluation has blossomed over the past quarter century. Despite this growth, there has been little accompanying public debate on research ethics. This essay explores the origins and the implications of this relative silence on ethical matters. It reviews the federal regulations that generally govern research ethics, and recounts the history whereby the evaluation of federal programs was specifically exempted from the purview of those regulations. Through a discussion of a recent evaluation that raised ethical concerns, the essay poses - but does not answer - three questions: (1) Are there good reasons to hold federal social program evaluations to different standards than those that apply to other research?; (2) If so, what ethical standards should be used to access such evaluations?; and (3) Should a formal mechanism be developed to ensure that federal social program evaluations are conducted ethically?
Greene, J., Blustein, J. & Remler, D. 2005. The Impact of Medicaid Managed Care on Primary Care Physician Participation in Medicaid. Medical Care, Vol. 43, No. 9, pp 911-920, September.
Objectives: Medicaid managed care has been touted as an important vehicle for increasing physician participation in Medicaid. Although there is anecdotal evidence that the opportunity to participate in Medicaid via managed care increases physician participation, no empirical study has validated the claim. This study explores the relationship between Medicaid managed care penetration at the county-level and the likelihood that a physician practicing in that county will participate in Medicaid.
Research Design: We used 3 waves of a large, nationally representative sample of primary care physicians from the Community Tracking Study followed across time (1996-2001) to estimate the impact of changing Medicaid managed care penetration levels on physician participation in the program. County-level Medicaid managed care penetration rates were collected directly from state Medicaid agencies for the study.
Findings: In cross-sectional bivariate and multivariate analyses, Medicaid managed care penetration is significantly associated with physician participation in Medicaid; however, the relationship is nonmonotonic, of small magnitude and generally not in the anticipated direction. Our analyses indicate that a 10 percentage point increase in managed care penetration would reduce the likelihood that physicians participate in Medicaid on average by 2.9 percentage points. Although commercial MCO penetration exhibited a small positive, linear relationship with physician participation, this was not sufficient to offset the effects of Medicaid-dominant MCO penetration. Panel data analysis supported these findings.
Conclusions: This study failed to find that increases in Medicaid managed care lead to increased primary care physician participation in Medicaid during the period 1996-2001.
Blustein, J., Chan, S. & Aguiair, F.C. 2004. Elevated Depressive Symptoms Among
Caregiving Grandparents. Health Services Research, Vol. 28, No. 6p1, pp. 1671-1690.
The objective is to determine whether caregiving grandparents are at an increased risk for depressive symptoms.
Blustein, J. 2004. Should Capstone Activities Be Subject to the Human Subjects Review Process? Journal of Policy Analysis and Management, Vol. 23, No. 4, pp. 921-927.
Like many schools of public policy and management, New York University's Wagner School offers a capstone course in which teams of MPA students provide consultation to client organizations, This year, as the they began to assign students to teams, some members of the faculty sounded an alarm. Several of the projects might involve interviewing service recipients about sensitive issues. Other projects would give teams access to confidential information. Faculty members experience with their university human subjects review board knew that such projects, where they to be undertaken in a research context, would require lengthy and cumbersome review. Did the capstone projects need to go through the human subjects review process? If the answer was yes, the program would come to a grinding halt, given the open-endness of a capstone assignments and the bureaucratic nature of the committee application and approval process.
Carlson, M. & Blustein, J. 2003. Access to Care Among Vulnerable Populations Enrolled in Commercial HMOs. Journal of Health Care for the Poor and Underserved, Volume 14, Number 3, pages 372-385.
This cross-sectional study compares self-reported access to care among a representative sample of 13,952 HMO enrollees in New Jersey. Using multivariate logistic regression, this study found that compared with college graduates, those with less than a high school education reported more difficulty obtaining tests or treatment. Compared with whites, Hispanics were more likely to report difficulty seeing their primary care provider, and African Americans reported greater difficulty seeing a specialist and obtaining tests and treatment. Enrollees in poor health were more likely to report problems seeing a specialist and obtaining tests and treatment than enrollees in excellent health. Income was not a consistent predictor of access. Nonfinancial barriers appear to be more influential than financial barriers for predicting access problems in commercial HMOs. More work is needed to identify the source of nonfinancial barriers to care among vulnerable populations.
Cantor, J., Blustein, J., Carlson, M. & Gould, D. 2003. Next of Kin Perceptions of Physician Responsiveness to Symptoms of Hospitalized Patients Near Death. Journal of Palliative Medicine, Volume 6, pages 531-541.
Many different medical providers visit critically ill patients during a hospitalization, and patients and family members may not feel any physician is truly in charge of care. This study explores whether perceiving that a physician was clearly in charge is associated with reports by surviving next of kin about the responsiveness of physicians to symptoms in hospitalized patients near the end of life. We conducted telephone interviews with surviving next of kin of adult patients (n = 1107) who died in one of five New York City teaching hospitals between April 1998 and June 1999 after a minimum 3-day inpatient stay. Next-of-kin ratings of whether physicians did "all they could" all or most of the time in response to patient pain, dyspnea, and affective distress (confusion, depression or emotional distress) were compared by whether the next of kin reported one or more physicians "clearly in charge" of care, adjusting for patient and next-of-kin characteristics. More than 80% of patients were reported to have experienced often serious pain, dyspnea, or affective distress. Physicians were rated as responsive to pain by 79.1% of respondents, to dyspnea by 84.9%, and to affective distress by 66.6%. Ratings of physician responsiveness to pain (p = 0.001) and affective distress (p = 0.001) were significantly lower among patients for whom no physician was seen as clearly in charge of care. This finding is consistent with the view that ensuring that a physician coordinates the care of seriously ill, hospitalized patients may improve symptom management. Further research is warranted to establish causality and identify optimal models of care.
Greene, J.K., Blustein, J. & Laflamme, K.B. 2001. Use of Preventive Care Services, Beneficiary Characteristics, and Medicare HMO Performance. Health Care Financing Review, Summer 2001, 22 (4).
The superior performance of HMOs in providing preventive care--both in the population at-large (Miller and Luft, 1994), and within the elderly Medicare population (Ballard et al., 1997; Potosky et al., 1998; Retchin and Brown, 1990)--may be due to the favorable organizational, infrastructural, or cultural characteristics of managed care systems. For example, HMOs have historical roots in a health maintenance and wellness orientation (Lawrence, Mattingly, and Ludden, et al., 1997). HMOs also encourage patients to have a primary care provider, and they have been leaders in the use of technologies like computerized reminder systems, which are effective in promoting the regular use of preventive care services (Mandelson and Thompson, 1998). However, other factors may also contribute to HMO successes in the preventive care arena. Managed care enrollees typically face few financial barriers to care. To the extent that HMOs offer no-cost or low-cost preventive care services, and to the extent that cost is a barrier to receiving preventive care in the FFS sector, HMOs are likely to perform better. It is also possible that those who enroll in HMOs are attitudinally and behaviorally more receptive to preventive care. For example, some studies have found HMO enrollees to be better educated, healthier, and more optimistic about the benefits of preventive care than their FFS counterparts (Bernstein, Thompson, and Harlan, 1991; Porrell and Turner, 1990; Lichtenstein et al., 1992).
Carlson, M., Blustein, J., Fiorentino, N.& Prestianni, F. 2000. Socioeconomic Status and Dissatisfaction Among HMO Enrollees. Medical Care. 2000, Volume 38, pages 506-516.
Objectives. Member satisfaction is commonly used as an indicator of the quality of care delivered by health plans. Yet few contemporary studies have explored the extent to which individual patient characteristics influence dissatisfaction in HMOs. We sought to determine whether socioeconomic status is associated with enrollee dissatisfaction.
Methods. Data are from a cross-sectional, telephone survey of a probability sample of adults enrolled in New Jersey HMOs in 1998 (n = 7,983). Health plan ratings were elicited as part of the Consumer Assessment of Health Plans Study (CAHPS) survey, along with income, education, and race/ethnicity. Other factors known to influence satisfaction (age, gender, health status, extent of plan choice, and payment for plan) were also ascertained.
Results. Socioeconomically advantaged enrollees were more likely to give low ratings to their health plans. In a multivariate logistic regression model, those with incomes exceeding $100,000 had 1.65 times the odds of being dissatisfied compared with those with family incomes less than $25,000 (P <0.001); those with a college education had 2.53 times the odds of being dissatisfied than those who had not completed high school (P <0.001). However, among enrollees in their plans for >=5 years, those in the lowest income group were significantly more dissatisfied than higher-income enrollees.
Conclusions. Among New Jersey HMO enrollees, higher socioeconomic status (SES) is associated with greater dissatisfaction. Although based on cross-sectional data and thus preliminary, the evidence presented here also suggests that the SES-dissatisfaction relationship varies as a function of duration of enrollment. Further research using longitudinal data could shed additional light on the SES-dissatisfaction link.
Blustein, J. 2000. Drug Coverage and Drug Purchases by Medicare Beneficiaries with Hypertension. Health Affairs. 2000, Volume 19, pages 219-230.
Research has shown that older Americans with prescription drug coverage purchase more medications; however, it is unclear whether they are more likely to purchase essential medications. This study addresses that question by examining the relationship between drug coverage and medication purchases among older Americans with hypertension. It finds that drug coverage has a significant impact: It lowers the likelihood that persons with hypertension will go without antihypertensive drugs, and it raises the number of tablets purchased among those who purchase these essential drugs.
Blustein, J. 2000. Medicare and Drug Coverage: A Women's Health Issue. Women's Health Issues. 2000, Volume 10, pages 47-53.
The lack of prescription drug coverage under the Medicare program translates into high out-of-pocket drug costs for seniors. This nationwide study of older Americans with hypertension (''high blood pressure'') demonstrates that women bear the disproportionate burden of this gap in Medicare coverage. Women form the majority of older people with hypertension, and are less likely to have supplemental policies to cover the cost of the prescription drugs that are needed to treat the disease. Moreover, women have substantially lower incomes. Despite their economic vulnerability, older women with hypertension spend substantially more on prescription drugs than men.
Blustein, J., Hoy, E.C. 2000. Who is Enrolled in For-Profit vs. Nonprofit Medicare HMOs? Health Affairs. 2000;19:210-220.
We compare the characteristics of enrollees in for-profit and nonprofit Medicare health plans using nationwide data from the 1996 Medicare Current Beneficiary Survey. We find few differences in overall health status, limitations in activities of daily living (ADLs), or history of chronic disease. However, older Americans enrolled in for-profit plans are substantially poorer and less educated than those enrolled in nonprofit plans, are more likely to have joined their plan recently, and are more likely to have joined a plan with the expectation of reducing their out-of-pocket health care costs.
Blustein, J., Hanson, K. & Shea, S. 1998. Preventable Hospitalizations and Socioeconomic Status. Health Affairs. 1998;17:177-189.
"Preventable" hospitalizations have been proposed as indicators of poor health plan performance. In this study of elderly Medicare beneficiaries, however, we found that preventable hospitalizations are also more common among elders of lower socioeconomic status (SES). The relationship persisted even when an up-to-date severity-of-illness adjustment system was used. To the extent that indicators of health plan "performance" reflect enrollees' characteristics, plans will be rewarded for marketing their services to wealthier, healthier, and better-educated patients. Further work is needed to clarify issues of accountability for preventable hospitalizations and other putative indices of health plan performance.
Knickman, J.R. & Blustein, J. 1998. The Organization and Use of Services by the Chronically Medically Ill. V Mor and S Allen, eds., Living in the Community with Disability: Service Needs, Use and Systems. New York: Springer Publishing; .
Text discussing disability research from a life course perspective and emphasizing the reality that people of all ages are at risk of being disabled. For policy makers and researchers.
Blustein, J. & Weiss, L.J. 1998. Use of Mammography by Women Aged 75 and Over: Factors Related to Health, Functioning and Age. J American Geriatrics Society. 1998;46:1-6.
BACKGROUND AND OBJECTIVES: Mammographic screening for breast cancer is of uncertain clinical benefit for women 75 years of age and older. Some have argued against instituting routine screening in this age group, noting that disability and shorter life expectancy may diminish the desirability and cost-effectiveness of screening. We sought to determine the extent to which health, functioning, and age influence mammography use in this cohort. DESIGN, SETTING, AND PARTICIPANTS: A retrospective cohort study of a representative sample of women in the US aged 75 and older (n = 2352) who participated in the Medicare Current Beneficiary Survey. MEASURES: Information about general health, level of functioning, medical history, age, and various sociodemographic characteristics elicited in the survey was linked with subjects' Medicare bills for 1991 and 1992 to ascertain patterns of mammography use. RESULTS: Overall, 26.7% of the women had mammograms during the 2-year period. Advanced age was associated with a decreased likelihood of receiving a mammogram. This did not reflect simply the decline in health and functioning that may accompany aging; those aged 85 and older were less likely to receive mammograms than those in the 75 to 79 age group, controlling for general health, medical history, functional status, and sociodemographic factors (adjusted OR = .41; 95% CI = 0.27 to 0.64). ADL limitations were also associated independently with decreased mammography use. For example, controlling for age, women with any limitations in Activities of Daily Living were 0.71 times as likely to have mammograms as women without ADL limitations (95% CI = 0.59 to 0.85). However, several comorbid conditions, including hypertension, diabetes mellitus, and a history of myocardial infarction were not significantly related to mammography use. CONCLUSIONS: Within the cohort of women aged 75 and older, more advanced age and impaired functional status both substantially reduce the likelihood of mammography use. The extent to which this reflects patients' informed decisions, physicians' judgments, or other factors remains to be explored.
Blustein, J. & Weiss, L.J. 1998. Visits to Specialists Under Medicare: Socioeconomic Advantage and Access to Care. J Health Care for the Poor and Underserved. 1998;9:153-169.
This study examines the relationship between socioeconomic advantage and the likelihood of receiving specialty care in a nationally representative sample of older Americans participating in fee-for-service Medicare. In 1992, 62.9 percent of Americans aged 65 and older visited a specialist physician at least once. Being white, having more education, and having a higher income were each independently associated with a higher likelihood of visiting a specialist. Having insurance to supplement basic Medicare coverage was also independently associated with an increased likelihood of visiting a specialist; disadvantaged elders are less likely to have such supplemental insurance. Therefore, based both upon socioeconomic disadvantage and a lack of insurance to supplement the basic Medicare benefit, black, less educated and low-income elders are less likely to receive specialty services under fee-for-service Medicare. As the program evolves, it will be important to continue to monitor access to specialty care in vulnerable, socioeconomically disadvantaged populations.
Pablos-Mendez, A., Blustein, J. & Knirsch, C.A. 1997. The Role of Diabetes Mellitus in the Higher Prevalence of Tuberculosis Among Hispanics. American J Public Health. 1997;87:574-579.
OBJECTIVES: This research studied the relative contribution of diabetes mellitus to the increased prevalence of tuberculosis in Hispanics. METHODS: A case-control study was conducted involving all 5290 discharges from civilian hospitals in California during 1991 who had a diagnosis of tuberculosis, and 37,366 control subjects who had a primary discharge diagnosis of deep venous thrombosis, pulmonary embolism, or acute appendicitis. Risk of tuberculosis was estimated as the odds ratio (OR) across race/ethnicity, with adjustment for other factors. RESULTS: Diabetes mellitus was found to be an independent risk factor for tuberculosis. The association of diabetes and tuberculosis was higher among Hispanics (adjusted OR [ORadj] = 2.95: 95% confidence interval [CI] = 2.61, 3.33) than among non-Hispanic Whites (ORadj = 1.31: 95% CI = 1.19. 1.45): among non-Hispanic Blacks, diabetes was not found to be associated with tuberculosis (ORadj = 0.93: 95% CI = 0.78, 1.09). Among Hispanics aged 25 to 54, the estimated risk of tuberculosis attributable to diabetes (25.2%) was equivalent to that attributable to HIV infection (25.5%). CONCLUSIONS: Diabetes mellitus remains a significant risk factor for tuberculosis in the United States. The association is especially notable in middle-aged Hispanics.
Weiss, L.J. & Blustein, J. 1996. Faithful Patients: The Effect of Long-Term Physician--Patient Relationships on the Costs and Use of Health Care by Older Americans. American J Public Health. 1996;86:1742-1747.
OBJECTIVES: This study examined the impact of duration of physician-patient ties on the processes and costs of medical care. METHODS: The analyses used a nationally representative sample of Americans 65 years old or older who participated in the Medicare Current Beneficiary Survey in 1991 and had a usual source of care. RESULTS: Older Americans have long-standing ties with their physicians; among those with a usual source of care, 35.8% had ties enduring 10 years or more. Longer ties were associated with a decreased likelihood of hospitalization and lower costs. Compared with patients with a tie of 1 year or less, patients with ties of 10 years or more incurred $316.78 less in Part B Medicare costs, after adjustment for key demographic and health characteristics. However, substantial impacts on the use of selected preventive care services and the adoption of certain healthy behaviors were not observed. CONCLUSIONS: This preliminary study suggests that long-standing physician-patient ties foster less expensive, less intensive medical care. Further studies are needed to confirm these findings and to understand how duration of tie influences the processes and outcomes of care.
Kahn, L.H., Blustein, J., Arons, R.R., Yee, R.Y. & Shea, S. 1996. The Validity of Hospital Administrative Data in Monitoring Variations in Breast Cancer Surgery. American J Public Health. 1996;86:243-245.
To assess the validity of using hospital administrative data to measure variations in surgery for early-stage breast cancer, ICD-9-CM coded information was compared with corresponding tumor registry data for 1293 breast cancer patients undergoing lumpectomy or mastectomy at a tertiary referral center from January 1989 to October 1993. Relative to "gold standard" tumor registry data, the administrative data proved 83.4% sensitive and 80.4% specific in identifying women with localized disease who would be potential candidates for lumpectomy. The proportion of women with localized disease undergoing lumpectomy in groups defined by race and insurance status was nearly identical, whichever data were used. Administrative data, which is often readily and publicly available, may be useful in studying variations in breast cancer treatment in key demographic groups.
Blustein, J. & Weitzman, B.C. 1995. Access to Hospitals with High-Technology Cardiac Services: How is Race Important? American J Public Health. 1995;85:345-351.
OBJECTIVES. Relatively few hospitals in the United States offer high-technology cardiac services (cardiac catheterization, bypass surgery, or angioplasty). This study examined the association between race and admission to a hospital offering those services. METHODS. Records of 11,410 patients admitted with acute myocardial infarction to hospitals in New York State in 1986 were analyzed. RESULTS. Approximately one third of both White and Black patients presented to hospitals offering high-technology cardiac services. However, in a multivariate model adjusting for home-to-hospital distance, the White-to-Black odds ratio for likelihood of presentation to such a hospital was 1.68 (95% confidence interval = 1.42, 1.98). This discrepancy between the observed and "distance-adjusted" probabilities reflected three phenomena: (1) patients presented to nearby hospitals; (2) Blacks were more likely to live near high-technology hospitals; and (3) there were racial differences in travel patterns. For example, when the nearest hospitals did not include a high-technology hospital, Whites were more likely than Blacks to travel beyond those nearest hospitals to a high-technology hospital. CONCLUSIONS. Whites and Blacks present equally to hospitals offering high-technology cardiac services at the time of acute myocardial infarction. However, there are important underlying racial differences in geographic proximity and tendencies to travel to those hospitals.
Blustein, J. 1995. Medicare Coverage, Supplemental Insurance, and the Use of Mammography in Older Women. New England Journal of Medicine. 1995;332:1138-43.
BACKGROUND. On January 1, 1991, the Medicare program began offering reimbursement for screening mammography every two years. This study examined the use of mammography in women covered by Medicare during the first two years that the screening benefit was offered. METHODS. Medicare bills for 1991 and 1992 from a nationally representative sample of 4110 women 65 years of age or older were examined to determine the degree of compliance with recognized guidelines for screening mammography and the extent to which the use of mammography was associated with having supplemental insurance, which shields patients from the out-of-pocket costs associated with using Medicare benefits. RESULTS. A total of 36.9 percent of older U.S. women had mammography during the first two years of the Medicare benefit for screening mammography. Only 14.4 percent of the women lacking supplemental insurance had mammography, as compared with 44.7 percent of those with employer-sponsored supplemental insurance, 40.1 percent of those with self-purchased supplemental insurance, and 23.9 percent of those with Medicaid supplemental insurance. These differences persisted in the stratified and multivariate analyses. As compared with women lacking supplemental insurance, women with employment-based supplemental insurance were more likely to undergo mammography (adjusted odds ratio, 3.03; 95 percent confidence interval, 2.17 to 4.23), as were women with self-purchased supplemental insurance (adjusted odds ratio, 2.97; 95 percent confidence interval, 2.13 to 4.15) and women with Medicaid supplemental insurance (adjusted odds ratio, 1.99; 95 percent confidence interval, 1.30 to 3.07). CONCLUSIONS. The use of mammography was substantially below recommended levels during the first two years of Medicare coverage for screening mammography. Women lacking supplemental health insurance were at particularly high risk of failing to undergo mammography. Requiring copayments for preventive services is an obstacle to the effective mass screening of older women for breast cancer.
Blustein, J., Arons, R.R. & Shea, S. 1995. Sequential Events Contributing to Variations in Cardiac Revascularization Rates. Medical Care. 1995;33:864-880.
Numerous studies have demonstrated the importance of race, payor, and gender in determining the use of cardiac services, including revascularization procedures (bypass surgery and angioplasty). However, there has been less investigation into where and when in the process of care differences in utilization arise. In this report, the authors examined the sequence of events leading to the use of revascularization procedures, identifying four phases of care (prehospital, intrahospital, interhospital, and posthospital). Following a cohort of 5857 patients admitted to California hospitals with acute myocardial infarction in 1991, the authors found differences in treatment probabilities during nearly every phase for different racial and payor groups. For example, compared with patients who are uninsured, patients with private insurance were more likely to be admitted initially to a hospital offering revascularization (adjusted odds ratio [OR] = 1.40, 95% confidence interval [CI] 1.30 to 1.51). Moreover, once admitted to such a hospital, private patients were more likely to undergo revascularization (adjusted OR = 2.30; 95% CI 1.80 to 2.94). They were also more likely to undergo transfer to receive revascularization (adjusted OR = 1.22; 95% CI 1.03 to 1.45), and to be readmitted for revascularization (adjusted OR = 1.60; 95% CI 1.13 to 2.27). Previously reported discrepancies in service use represent the cumulative effects of multiple phases during which different racial and payor groups experience different processes of care.