Hospital utilization in chronic spinal injury and primary physicians' adherence to clinical guidelines: three approaches to answering health services questions
Waddimba, Anthony Claret
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The first study was a prospective observation of predictors of cardiopulmonary hospitalization in a cohort of spinal cord injury (SCI) patients at Veterans Affairs (VA) centers at least one year post-SCI. Baseline data were linked to longitudinal 1996-2003 VA hospitalization data. Predictors of admission with circulatory or respiratory system illness, the outcome, were assessed by multivariate Cox regression. 143 cardiopulmonary hospitalizations were observed. Independent predictors were greater age (3% increase/year), hypertension, lowest body mass index (BMI) quintile (<22.4kg/m^2), and reduced lung function. SCI severity / neurological level did not significantly predict the outcome independent of covariates. Cardiopulmonary hospitalization risk in chronic SCI is related to greater age and medical factors that could result in strategies for reducing such hospitalizations. The second study investigated factors associated with risk-adjusted length of stay (LOS) for VA and Medicare-reimbursed hospitalizations prospectively observed in the same cohort. We merged 1999-2003 admissions in the Medicare Provider Analysis and Review (MEDPAR) dataset with the 1996-2003 VA hospitalizations. Risk-adjusted LOS was assessed in a multivariable Gaussian identity-linked generalized estimating equation (GEE) adjusting for repeated events. Unadjusted median LOS was 6 days for Medicare versus 8 days for the VA. Adjusting for repeated events and geographical location, LOS was significantly associated with ICU days, SCI severity, comorbidities, and surgical procedures. Risk-adjusted LOS did not differ between the Medicare and VA. Reducing LOS across both healthcare systems requires alleviating illness burden, lessening comorbidity, preventing skin ulcers, increasing mobility, and decreasing inpatient procedures. The third study was a cross-sectional observation of managed care attitudes and adherence to evidence-based clinical guidelines among primary care physicians (PCPs) enrolled in a pay-for-performance (P4P) collaboration. Participants were 186 survey respondents with complete adherence data for a panel-representative medical condition targeted by P4P incentives. Guideline adherence, defined as the percent of recommended services actually delivered, was the outcome. Provider attitudes that were significantly associated with top-tertile adherence, independent of specialty and prior behavior, were financial salience, peer cooperation, control, and autonomy. The most adherent PCPs found the P4P incentives salient and felt peer-supported, but high-autonomy providers found early-stage incentives intrinsically demoralizing and they reduced work effort.
Thesis (Sc.D.)--Boston University
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