All Publications

  • The association between Asian patient race/ethnicity and lower satisfaction scores. BMC health services research Liao, L., Chung, S., Altamirano, J., Garcia, L., Fassiotto, M., Maldonado, B., Heidenreich, P., Palaniappan, L. 2020; 20 (1): 678


    BACKGROUND: Patient satisfaction is increasingly being used to assess, and financially reward, provider performance. Previous studies suggest that race/ethnicity (R/E) may impact satisfaction, yet few practices adjust for patient R/E. The objective of this study is to examine R/E differences in patient satisfaction ratings and how these differences impact provider rankings.METHODS: Patient satisfaction survey data linked to electronic health records from two large outpatient centers in northern California - a non-profit organization of community-based clinics (Site A) and an academic medical center (Site B) - was collected and analyzed. Participants consisted of adult patients who received outpatient care at Site A from December 2010 to November 2014 and Site B from March 2013 to August 2014, and completed Press-Ganey Medical Practice Survey questionnaires (N=216,392 (Site A) and 30,690 (Site B)). Self-reported non-Hispanic white (NHW), Black, Latino, and Asian patients were studied. For six questions each representing a survey subdomain, favorable ratings were defined as top-box ("very good") compared to all other categories ("very poor," "poor," "fair," and "good"). Using multivariable logistic regression with provider random effects, we assessed whether the likelihood of giving favorable ratings differed by patient R/E, adjusting for patient age and sex.RESULTS: Asian, younger and female patients provided less favorable ratings than other R/E, older and male patients. After adjustment, Asian patients were less likely than NHW patients to provide top-box ratings to the overall assessment question "likelihood of recommending this practice to others" (Site A: Asian predicted probability (PP) 0.680, 95% confidence interval (CI): 0.675-0.685 compared to NHW PP 0.820, 95% CI: 0.818-0.822; Site B: Asian PP 0.734, 95% CI: 0.733-0.736 compared to NHW PP 0.859, 95% CI: 0.859-0.859). The effect sizes for Asian R/E were greater than the effect sizes for older age and female sex. An absolute 3% decrease in mean composite score between providers serving different percentages of Asian patients translated to an absolute 40% drop in national ranking.CONCLUSIONS: Patient satisfaction scores may need to be adjusted for patient R/E, particularly for providers caring for high panel percentages of Asian patients.

    View details for DOI 10.1186/s12913-020-05534-6

    View details for PubMedID 32698825

  • Patient-Centric Scheduling With the Implementation of Health Information Technology to Improve the Patient Experience and Access to Care: Retrospective Case-Control Analysis. Journal of medical Internet research Chung, S., Martinez, M. C., Frosch, D. L., Jones, V. G., Chan, A. S. 2020; 22 (6): e16451


    BACKGROUND: Cancellations and rescheduling of doctor's appointments are common. An automated rescheduling system has the potential to facilitate the rescheduling process so that newly opened slots are promptly filled by patients who need and can take the slot. Building on an existing online patient portal, a large health care system adopted an automated rescheduling system, Fast Pass, that sends out an earlier appointment offer to patients via email or SMS text messaging and allows patients to reschedule their appointment through the online portal.OBJECTIVE: We examined the uptake of Fast Pass at its early stage of implementation. We assessed program features and patient and visit characteristics associated with higher levels of Fast Pass utilization and the association between Fast Pass use and no-show and cancellation rates.METHODS: This study was a retrospective analysis of Fast Pass offers sent between July and December 2018. Multivariable logistic regression was used to assess the independent contribution of program, patient, and visit characteristics on the likelihood of accepting an offer. We then assessed the appointment outcome (completion, cancellation, or no-show) of Fast Pass offered appointments compared to appointments with the same patient and visit characteristics, but without an offer.RESULTS: Of 177,311 Fast Pass offers sent, 14,717 (8.3%) were accepted. Overall, there was a 1.3 percentage point (38%) reduction in no-show rates among Fast Pass accepted appointments compared to other appointments with matching characteristics (P<.001). The offers were more likely to be accepted if they were sent in the evening (versus early morning), the first (versus repeated) offer for the same appointment, for a slot 1-31 days ahead (versus same-day), for later in a day (versus before 10am), for a primary care (versus specialty) visit, sent via SMS text messaging (versus email only), for an appointment made through the online patient portal (versus via phone call or in-person), or for younger adults aged 18-49 years (versus those aged 65 years or older; all at P<.001). Factors negatively associated with offer acceptance were a higher number of comorbidities (P=.02) and visits scheduled for chronic conditions (versus acute conditions only; P=.002).CONCLUSIONS: An automated rescheduling system can improve patients' access by reducing wait times for an appointment, with an added benefit of reducing no-shows by serving as a reminder of an upcoming appointment. Future modifications, such as increasing the adoption of SMS text messaging offers and targeting older adults or patients with complex conditions, may make the system more patient-centered and help promote wider utilization.

    View details for DOI 10.2196/16451

    View details for PubMedID 32519970

  • Smoking-Cessation Interventions After Lung Cancer Screening Guideline Change. American journal of preventive medicine Li, J., Chung, S., Martinez, M. C., Luft, H. S. 2020


    INTRODUCTION: Recent guideline changes for lung cancer screening with low-dose computed tomography recommend smoking-cessation interventions be done in parallel with screening. The purpose of this study is to determine the post-guideline rates of smoking-cessation interventions among patients eligible and ineligible for lung cancer screening.METHODS: Using electronic health records collected from a large ambulatory care system in northern California between 2010 and 2017, authors identified new patients who were current smokers aged 55-80 years visiting a primary care provider, and grouped patients into lung cancer screening-eligible heavy smokers, screening-ineligible moderate smokers, and screening-ineligible light smokers. Screening-eligible smokers versus screening-ineligible smokers were compared in receipt of smoking-cessation interventions before (2010-2013) and after (2014-2017) the guideline change, overall and by intervention type (formal counseling, informal counseling, pharmacotherapy) using hierarchical generalized linear models. Analyses were conducted in 2018-2019.RESULTS: After the guideline change, the likelihood of receiving any smoking-cessation intervention (OR=1.44, 95% CI=1.28, 1.61, p<0.05), informal counseling (OR=1.29, 95% CI=1.15, 1.46, p<0.05), and pharmacotherapy (OR=1.24, 95% CI=1.02, 1.50, p<0.05) during a new patient visit significantly increased, with the increase not varying by level of smoking. For formal counseling, the post-guideline increase was greater for screening-eligible heavy smokers (OR=3.15, 95% CI=1.18, 8.36, p<0.05) and moderate smokers (OR=3.58, 95% CI=1.29, 9.95, p<0.05) relative to light smokers.CONCLUSIONS: Smoking-cessation interventions increased after new lung cancer screening guidelines. Given the sizable adverse impacts of smoking on morbidity and mortality, small increases in the implementation of smoking-cessation interventions could have substantial public health benefits.

    View details for DOI 10.1016/j.amepre.2020.01.031

    View details for PubMedID 32417022

  • Heterogeneity of Treatment and Outcomes Among Asians With Coronary Artery Disease in the United States. Journal of the American Heart Association Manjunath, L., Chung, S., Li, J., Shah, H., Palaniappan, L., Yong, C. M. 2020: e014362


    Background Prior data demonstrate significant heterogeneity regarding coronary artery disease risk factors and outcomes among Asians in the United States, but no studies have yet examined coronary artery disease treatment patterns or outcomes among disaggregated Asian American subgroups. Methods and Results From a total of 772882 patients with known race/ethnicity and sex who received care from a mixed-payer healthcare organization in Northern California between 2006 and 2015, a retrospective analysis was conducted on 6667 adults with coronary artery disease. Logistic regression was used to examine medical and procedural therapies and outcomes by race/ethnicity, with adjustment for age, sex, income, and baseline comorbidities. Compared with non-Hispanic whites, Chinese were more likely to undergo stenting (50.9% versus 60.8%, odds ratio [OR] 1.39 [95% CI, 1.04-1.87], p=0.005), whereas Filipinos were more likely to receive bypass surgery (6.9% versus 20.5%, OR 2.65 [95% CI, 1.75-4.01], P<0.0001). After stenting, Chinese, Filipinos, and Japanese were more likely than non-Hispanic whites to be prescribed clopidogrel (86.2%, 83.0%, and 91.4% versus 74.5%, ORs 1.86 [95% CI, 1.13-3.04], 1.86 [95% CI, 1.01-3.44], and 4.37 [95% CI, 1.02-18.67], respectively, P<0.0001). Lastly, Chinese and Asian Indians were more likely than non-Hispanic whites to be diagnosed with a myocardial infarction within 1year postangiography (15.6% and 17.4% versus 11.2%, ORs 1.49 [95% CI, 1.02-2.19] and 1.68 [95% CI, 1.21-2.34], respectively, P<0.0001). Conclusions Disaggregation of Asian Americans with coronary artery disease into individual racial/ethnic subgroups reveals significant variability in treatment patterns and outcomes. Further investigation into these differences may expose important opportunities to mitigate disparities and improve quality of care in this diverse population.

    View details for DOI 10.1161/JAHA.119.014362

    View details for PubMedID 32390539

  • Primary care physician practice styles and quality, cost, and productivity. The American journal of managed care Luft, H. S., Liang, S., Eaton, L. J., Chung, S. 2020; 26 (4): e127–e134


    OBJECTIVES: To assess quality, cost, physician productivity, and patient experience for 2 primary care physician (PCP) practice styles: the focused, who typically address only the patient's acute problem, versus the max-packers, who typically address additional conditions also.STUDY DESIGN: Retrospective observational study using administrative data, electronic health record (EHR) data, and patient surveys. Data represent 285 PCPs (779 PCP-years) in a large, multispecialty group practice during 2011, 2012, and 2013.METHODS: PCPs were ranked each year by their number of additional conditions addressed during acute care visits. The top one-third (max-packers) addressed 25.4% more"other problems" than expected, while focused PCPs (bottom one-third) addressed 20.3% fewer than expected. Outcomes were resource use, clinical quality metrics, patient-reported experience, physician time using the EHR, and physician productivity. All measures were risk-adjusted to account for patient mix. T tests were used to compare measures.RESULTS: Relative to a focused pattern of care, max-packing was associated with 3.4% lower overall resource use, consistently better scores for the available clinical quality metrics, and comparable patient experience (except for worse wait time ratings). Patients of focused PCPs used 7.3% more specialist services, in terms of costs, than patients of max-packers ($1218 vs $1136; P <.001). Max-packers spent 40 minutes more per clinical day using the EHR. PCPs with less appointment availability and who used a mix of appointment slots were more likely to be max-packers.CONCLUSIONS: Max-packing behavior yields desirable outcomes at lower overall cost but involves more conventionally uncompensated PCP time. Alternatives to compensation just for face-to-face visits and using more flexible scheduling may be needed to support max-packing.

    View details for DOI 10.37765/ajmc.2020.42840

    View details for PubMedID 32270990

  • STATIN USE FOR SECONDARY PREVENTION OF CARDIOVASCULAR DISEASE IN THE ELDERLY Spencer-Bonilla, G., Chung, S., Heidenreich, P. A., Palaniappan, L. P., Rodriguez, F. ELSEVIER SCIENCE INC. 2020: 1891
  • The Relationship Between Primary Care Physician Burnout and Patient-Reported Care Experiences: a Cross-sectional Study. Journal of general internal medicine Chung, S., Dillon, E. C., Meehan, A. E., Nordgren, R., Frosch, D. L. 2020


    BACKGROUND: Primary care physician (PCP) burnout is prevalent and on the rise. Physician burnout may negatively affect patient experience of care.OBJECTIVE: To identify the direct impact of PCP burnout on patient experience in various domains of care.DESIGN: A cross-sectional observational study using physician well-being (PWB) surveys collected in 2016-2017, linked to responses from patient experience of care surveys. Patient demographics and practice characteristics were derived from the electronic health record. Linked data were analyzed at the physician level.SETTING: A large non-profit multi-specialty ambulatory healthcare organization in northern California.PARTICIPANTS: A total of 244 physicians practicing internal medicine or family medicine who responded to the PWB survey (response rate 72%), and 30,701 completed experience surveys from patients seeing these physicians.MEASUREMENTS: Burnout was measured with a validated single-item question with a 5-point scale ranging from (1) enjoy work to (5) completely burned out and seeking help. Patient experience of patient-provider communication, access, and overall rating of provider was measured with Clinician & Group Consumer Assessment of Healthcare Providers & Systems (CG-CAHPS) survey. Patient experience scores (0-100 scale) were adjusted for age, gender, race/ethnicity, and English proficiency.RESULTS: Physician burnout had a negative impact on patient-reported experience of patient-provider communication but not on access or overall rating of providers. A one-level increase in burnout was associated with 0.43 decrease in adjusted patient-provider communication experience score (P<0.01).LIMITATIONS: Data came from a single large healthcare organization. Patterns may differ for small- and mid-sized practices.CONCLUSION: Physician burnout adversely affects patient-provider communication in primary care visits. Efforts to improve physician work environments could have a meaningful positive impact on patient experience as well as physician well-being.

    View details for DOI 10.1007/s11606-020-05770-w

    View details for PubMedID 32206992

  • Machine learning and atherosclerotic cardiovascular disease risk prediction in a multi-ethnic population. NPJ digital medicine Ward, A., Sarraju, A., Chung, S., Li, J., Harrington, R., Heidenreich, P., Palaniappan, L., Scheinker, D., Rodriguez, F. 2020; 3: 125


    The pooled cohort equations (PCE) predict atherosclerotic cardiovascular disease (ASCVD) risk in patients with characteristics within prespecified ranges and has uncertain performance among Asians or Hispanics. It is unknown if machine learning (ML) models can improve ASCVD risk prediction across broader diverse, real-world populations. We developed ML models for ASCVD risk prediction for multi-ethnic patients using an electronic health record (EHR) database from Northern California. Our cohort included patients aged 18 years or older with no prior CVD and not on statins at baseline (n = 262,923), stratified by PCE-eligible (n = 131,721) or PCE-ineligible patients based on missing or out-of-range variables. We trained ML models [logistic regression with L2 penalty and L1 lasso penalty, random forest, gradient boosting machine (GBM), extreme gradient boosting] and determined 5-year ASCVD risk prediction, including with and without incorporation of additional EHR variables, and in Asian and Hispanic subgroups. A total of 4309 patients had ASCVD events, with 2077 in PCE-ineligible patients. GBM performance in the full cohort, including PCE-ineligible patients (area under receiver-operating characteristic curve (AUC) 0.835, 95% confidence interval (CI): 0.825-0.846), was significantly better than that of the PCE in the PCE-eligible cohort (AUC 0.775, 95% CI: 0.755-0.794). Among patients aged 40-79, GBM performed similarly before (AUC 0.784, 95% CI: 0.759-0.808) and after (AUC 0.790, 95% CI: 0.765-0.814) incorporating additional EHR data. Overall, ML models achieved comparable or improved performance compared to the PCE while allowing risk discrimination in a larger group of patients including PCE-ineligible patients. EHR-trained ML models may help bridge important gaps in ASCVD risk prediction.

    View details for DOI 10.1038/s41746-020-00331-1

    View details for PubMedID 33043149

    View details for PubMedCentralID PMC7511400

  • Factors Associated With Accuracy of Self-Assessment Compared With Tested Non-English Language Proficiency Among Primary Care Providers MEDICAL CARE Diamond, L., Bejarano, M., Chung, S., Ferguson, W., Gonzalez, J., Garzon, M., Mujawar, I., Gany, F. 2019; 57 (5): 385–90


    There are no accepted best practices for clinicians to report their non-English language (NEL) fluencies. Language discordance between patients with limited English proficiency and their clinicians may contribute to suboptimal quality of care.To compare self-assessed clinician NEL proficiency with a validated oral language proficiency test. To identify clinician characteristics associated with self-assessment accuracy.Primary care providers from California and Massachusetts.We surveyed 98 clinicians about demographics and their NEL self-assessment using an adapted version of the Interagency Language Roundtable (ILR) scale followed by an oral proficiency interview: The Clinician Cultural and Linguistic Assessment (CCLA). We compared the ILR to the CCLA and analyzed factors associated with the accuracy of self-assessment.Ninety-eight primary care providers participated: 75.5% were women, 62.2% were white, and Spanish was the most common NEL reported (81.6%). The average CCLA score was 78/100 with a 70% passing-rate. There was a moderate correlation between the ILR and CCLA (0.512; P<0.0001). Participants whose self-reported levels were "fair" and "poor" had a 0% pass-rate and 100% who self-reported "excellent" passed the CCLA. Middle ILR levels showed a wider variance. Clinicians who reported a NEL other than Spanish and whose first language was not English were more likely to accurately self-assess their abilities.Self-assessment showed a moderate correlation with the validated CCLA test. Additional testing may be required for clinicians at the middle levels. Clinicians whose native languages were not English and those using languages other than Spanish with patients may be more accurate in their self-assessment.

    View details for DOI 10.1097/MLR.0000000000001105

    View details for Web of Science ID 000465997400011

    View details for PubMedID 30844905

    View details for PubMedCentralID PMC6459717

  • Patient-Reported Experiences in Discussing Prescribed Medications with a Health Care Provider: Evidence for Racial/Ethnic Disparities in a Large Health Care Delivery System. Population health management Chung, S., Huang, Q., LaMori, J., Doshi, D., Romanelli, R. J. 2019


    The objective was to understand patient-reported experiences in communicating with a health care provider about prescribed medications in a health care setting serving diverse racial/ethnic groups. Adult patients who completed a patient-experience survey and received a prescription for a hypertension, hyperlipidemia, or diabetes medication at the surveyed encounter were studied (N=19,006). Data were collected in a large mixed-payer outpatient health care system in northern California between 2011 and 2014. Surveys were linked to the electronic health records of the office visit to which the survey refers, with detailed information on visit content, provider, and patient characteristics. The focus was on 2 survey questions asking about providers' efforts to include patients in treatment decisions and the information received about medications. Logistic regression was used to assess factors associated with survey responses, which were dichotomized as very good or not (ie, good, fair, poor, very poor). Chinese (OR: 0.59; 95% CI: 0.50-0.70), Asian Indians (0.68; 0.54-0.84), Japanese (0.74; 0.57-0.98), Koreans (0.46; 0.25-0.83), Vietnamese (0.51; 0.27-0.98), and African Americans (0.74; 0.55-0.99) vs. non-Hispanic whites (NHWs) reported poorer experiences of involvement in treatment decisions. Similarly, Chinese (0.59; 0.49-0.70), Asian Indians (0.67; 0.54-0.83), Koreans (0.38; 0.21-0.70), Vietnamese (0.46; 0.25-0.87), African Americans (0.65; 0.49-0.87), and Mexicans (0.77; 0.61-0.98) vs. NHWs reported poorer experiences for information received about medications. Almost all racial/ethnic groups report poorer experiences with involvement in treatment decisions and information received about medications than NHWs in the same clinical setting, which may contribute to poorer adherence and outcomes among racial/ethnic minority groups.

    View details for DOI 10.1089/pop.2018.0206

    View details for PubMedID 31013464

  • Comparison of Outpatient Satisfaction Survey Scores for Asian Physicians and Non-Hispanic White Physicians JAMA NETWORK OPEN Garcia, L. C., Chung, S., Liao, L., Altamirano, J., Fassiotto, M., Maldonado, B., Heidenreich, P., Palaniappan, L. 2019; 2 (2)
  • Atherosclerotic Cardiovascular Disease Risk Prediction in Disaggregated Asian and Hispanic Subgroups Using Electronic Health Records. Journal of the American Heart Association Rodriguez, F., Chung, S., Blum, M. R., Coulet, A., Basu, S., Palaniappan, L. P. 2019; 8 (14): e011874


    Background Risk assessment is the cornerstone for atherosclerotic cardiovascular disease ( ASCVD ) treatment decisions. The Pooled Cohort Equations ( PCE ) have not been validated in disaggregated Asian or Hispanic populations, who have heterogeneous cardiovascular risk and outcomes. Methods and Results We used electronic health record data from adults aged 40 to 79 years from a community-based, outpatient healthcare system in northern California between January 1, 2006 and December 31, 2015, without ASCVD and not on statins. We examined the calibration and discrimination of the PCE and recalibrated the equations for disaggregated race/ethnic subgroups. The cohort included 231 622 adults with a mean age of 53.1 (SD 9.7) years and 54.3% women. There were 56 130 Asian (Chinese, Asian Indian, Filipino, Japanese, Vietnamese, and other Asian) and 19 760 Hispanic (Mexican, Puerto Rican, and other Hispanic) patients. There were 2703 events (332 and 189 in Asian and Hispanic patients, respectively) during an average of 3.9 (SD 1.5) years of follow-up. The PCE overestimated risk for NHW s, African Americans, Asians, and Hispanics by 20% to 60%. The extent of overestimation of ASCVD risk varied by disaggregated racial/ethnic subgroups, with a predicted-to-observed ratio of ASCVD events ranging from 1.1 for Puerto Rican patients to 1.9 for Chinese patients. The PCE had adequate discrimination, although it varied significantly by race/ethnic subgroups (C-indices 0.66-0.83). Recalibration of the PCE did not significantly improve its performance. Conclusions Using electronic health record data from a large, real-world population, we found that the PCE generally overestimated ASCVD risk, with marked heterogeneity by disaggregated Asian and Hispanic subgroups.

    View details for DOI 10.1161/JAHA.118.011874

    View details for PubMedID 31291803

  • Racial/ethnic differences in reporting versus rating of healthcare experiences. Medicine Chung, S., Mujal, G., Liang, L., Palaniappan, L. P., Frosch, D. L. 2018; 97 (50): e13604


    Asians are reported to have poorer healthcare experience than non-Hispanic Whites (NHWs), but the sources of the differences are not understood. One explanation is Asian's reluctance to choose extreme responses in survey. We thus sought to compare NHW-Asian differences in responses to healthcare experience surveys when asked to report versus rate their experiences. Patients of an outpatient care system in 2013 to 2014 in the United States were studied. Patient experience surveys were sent after randomly selected clinic visits. Responses from 6 major Asian subgroups and NHWs were included (N = 61,115). The surveys used a combined questionnaire of Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) and Press Ganey surveys. CG-CAHPS questions are framed as "reporting" and Press Ganey questions as "rating" of experiences. We compared the proportion of favorable (or top box) responses to 2 related questions, one from CG-CAHPS and another from Press Ganey, and assessed racial/ethnic differences when using each of the 2 related questions, using a Pearson chi-squared test for independence. All Asian subgroups were less likely to select top box than NHWs for all questions. The Asian-NHW differences in 'rating" questions were larger than the difference in related "reporting" questions. Of those who chose top box to CG-CAHPS questions (e.g., "Yes" on a question asking "Waited < 15 minutes"), their responses to related Press Ganey questions varied widely: 47% to 57% of Asian subgroups versus 67% of NHWs rated wait time as "Very good." The extent of racial/ethnic differences in patient-reported experiences varies based on how questions are framed. The observed poorer experiences by Asians are in part explained by their worse rating of similar objectively measurable experiences.

    View details for PubMedID 30558033

  • Preventive visit among older adults with Medicare's introduction of Annual Wellness Visit: Closing gaps in underutilization PREVENTIVE MEDICINE Chung, S., Romanelli, R. J., Stults, C. D., Luft, H. S. 2018; 115: 110–18


    Preventive visit rates are low among older adults in the United States. We evaluated changes in preventive visit utilization with Medicare's introduction of Annual Wellness Visits (AWVs) in 2011. We further assessed how coverage expansion differentially affected older adults who were previously underutilizing the service. The study included Medicare beneficiaries aged 65 to 85 from a mixed-payer multispecialty outpatient healthcare organization in northern California between 2007 and 2016. Data from the electronic health records were used, and the unit of analysis was patient-year (N = 456,281). Multivariable logistic regression models were used to assess determinants of "any preventive visit" use. Prior to the AWV coverage (2007-2010), Medicare beneficiaries who were older, with serious chronic conditions, and with a fee-for-services (FFS) plan underutilized preventive visits such that odds ratio (OR) for age groups (vs. age 65-69) ranges from 0.826 (age 70-74) to 0.522 (age 80-85); for Charlson comorbidity index (CCI) (vs. 0 CCI) ranges from 0.77 (1 CCI) to 0.65 (≥2 CCI); and for FFS (vs. HMO) is 0.236. With the Medicare coverage (2011-2016), the age-based gap reduced substantially, but the difference persisted, e.g., OR for age 80-85 (vs. 65-69) is 0.628, and FFS (vs. HMO) beneficiaries still have far lower odds of using a preventive visit (OR = 0.278). The gap based on comorbidity was not reduced. Medicare's coverage expansion facilitated the use of preventive visit particularly for older adults with more advanced age or with FFS, thereby reducing disparities in preventive visit use.

    View details for DOI 10.1016/j.ypmed.2018.08.018

    View details for Web of Science ID 000444003100017

    View details for PubMedID 30145346

  • Patients' Medication-Related Experience of Care Is Associated with Adherence to Cardiometabolic Disease Therapy in Real-World Clinical Practice POPULATION HEALTH MANAGEMENT Romanelli, R. J., Huang, Q., LaMori, J., Doshi, D., Chung, S. 2018; 21 (5): 409–14


    Adherence to cardiometabolic disease (CMD) medications is typically suboptimal. This study sought to evaluate the relationship between patients' medication-related experiences of care and adherence to CMD therapy. This study was conducted using electronic health records and administrative data from an ambulatory care setting. It included adult managed care beneficiaries with a prescription for CMD medications (antihyperlipidemic, antihypertensive, or antihyperglycemic agents) between 2010 and 2014, written ±14 days of an office encounter linked to a completed patient experience survey. Outcomes were primary and overall adherence. Primary adherence was defined as ever filling a CMD medication and overall adherence as ≥80% days covered over 365 days among those with an initial fill. Survey items ("inclusion in treatment decisions" and "information about medications") are measured on a scale from 1 (very poor) to 5 (very good). Logistic regression was used to assess associations between ratings on each item (5 vs. <5) and primary or overall adherence. Eligibility criteria were met by 7368 patients; 5865 had ≥1 fill. After adjusting for confounders, better patient experiences with "inclusion in treatment decisions" (adjusted odds ratio [OR]:1.16; P = 0.049) and "information about medications" (OR:1.22; P = 0.009) were associated with greater odds of overall adherence to therapy. No significant associations were found between patient experience and primary adherence. Better patient medication-related experience of care is associated with improved adherence to CMD therapy. Efforts to include patients in treatment decision making and to provide better education on medications are simple, modifiable solutions to improve adherence and resultant outcomes of CMD treatment.

    View details for DOI 10.1089/pop.2017.0163

    View details for Web of Science ID 000446682600012

    View details for PubMedID 29649391

  • New recommendation and coverage of low-dose computed tomography for lung cancer screening: uptake has increased but is still low BMC HEALTH SERVICES RESEARCH Li, J., Chung, S., Wei, E. K., Luft, H. S. 2018; 18: 525


    In 2013, the US Preventive Services Task Force (USPSTF) issued recommendations for low-dose computed tomography for lung cancer screening (LDCT-LCS), but there continues to be a dearth of information on the adoption of LDCT-LCS in healthcare systems. Using a multilevel perspective, our study aims to assess referrals for LDCT-LCS and identify facilitators and barriers to adoption following recent policy changes.A retrospective analysis of electronic medical record data from patients aged 55-80 years with no history of lung cancer who visited a primary care provider in a large healthcare system in California during 2010-2016 (1,572,538 patient years). Trends in documentation of smoking history, number of eligible patients, and lung cancer screening orders were assessed. Using Hierarchical Generalized Linear Models, we also evaluated provider-level and patient-level factors associated with lung cancer screening orders among 970 primary care providers and 12,801 eligible patients according to USPSTF guidelines between January 1st, 2014 and December 31st, 2016.Documentation of smoking history to determine eligibility (59.2% in 2010 to 77.8% in 2016) and LDCT-LCS orders (0% in 2010 to 7.3% in 2016) have increased since USPSTF guidelines. Patient factors associated with increased likelihood of lung cancer screening orders include: younger patient age (78-80 vs. 55-64 years old: OR, 0.4; 95% CI, 0.3-0.7), Asian race (vs. Non-Hispanic White: OR, 1.6; 95% CI, 1.1-2.4), reported current smoking (vs. former smoker: OR, 1.7; 95% CI, 1.4-2.0), no severe comorbidity (severe vs. no major comorbidity: OR = 0.2, 95% CI = 0.1-0.3; moderate vs. no major comorbidity: OR = 0.5; 95% CI = 0.4-0.7), and making a visit to own primary care provider (vs. other primary care providers: OR, 2.4; 95% CI, 1.7-3.4). Appropriate referral for lung cancer screening varies considerably across primary care providers. Provider factors include being a female physician (vs. male: OR, 1.6; 95% CI, 1.1-2.3) and receiving medical training in the US (foreign vs. US medical school graduates: OR = 0.4, 95% CI = 0.3-0.7).Future interventions to improve lung cancer screening may be more effective if they focus on accurate documentation of smoking history and target former smokers who do not regularly see their own primary care providers.

    View details for DOI 10.1186/s12913-018-3338-9

    View details for Web of Science ID 000437414900002

    View details for PubMedID 29976189

    View details for PubMedCentralID PMC6034213

  • Geographic Variations in Cardiovascular Disease Mortality Among Asian American Subgroups, 2003-2011 JOURNAL OF THE AMERICAN HEART ASSOCIATION Pu, J., Hastings, K. G., Boothroyd, D., Jose, P. O., Chung, S., Shah, J. B., Cullen, M. R., Palaniappan, L. P., Rehkopf, D. H. 2017; 6 (7)


    There are well-documented geographical differences in cardiovascular disease (CVD) mortality for non-Hispanic whites. However, it remains unknown whether similar geographical variation in CVD mortality exists for Asian American subgroups. This study aims to examine geographical differences in CVD mortality among Asian American subgroups living in the United States and whether they are consistent with geographical differences observed among non-Hispanic whites.Using US death records from 2003 to 2011 (n=3 897 040 CVD deaths), age-adjusted CVD mortality rates per 100 000 population and age-adjusted mortality rate ratios were calculated for the 6 largest Asian American subgroups (Asian Indian, Chinese, Filipino, Japanese, Korean, and Vietnamese) and compared with non-Hispanic whites. There were consistently lower mortality rates for all Asian American subgroups compared with non-Hispanic whites across divisions for CVD mortality and ischemic heart disease mortality. However, cerebrovascular disease mortality demonstrated substantial geographical differences by Asian American subgroup. There were a number of regional divisions where certain Asian American subgroups (Filipino and Japanese men, Korean and Vietnamese men and women) possessed no mortality advantage compared with non-Hispanic whites. The most striking geographical variation was with Filipino men (age-adjusted mortality rate ratio=1.18; 95% CI, 1.14-1.24) and Japanese men (age-adjusted mortality rate ratio=1.05; 95% CI: 1.00-1.11) in the Pacific division who had significantly higher cerebrovascular mortality than non-Hispanic whites.There was substantial geographical variation in Asian American subgroup mortality for cerebrovascular disease when compared with non-Hispanic whites. It deserves increased attention to prioritize prevention and treatment in the Pacific division where approximately 80% of Filipinos CVD deaths and 90% of Japanese CVD deaths occur in the United States.

    View details for PubMedID 28701306

  • Can Secure Patient-Provider Messaging Improve Diabetes Care? Diabetes care Chung, S., Panattoni, L., Chi, J., Palaniappan, L. 2017; 40 (10): 1342–48


    Internet-based secure messaging between patients and providers through a patient portal is now common in the practice of modern medicine. There is limited evidence on how messaging is associated with use and clinical quality measures among patients with type 2 diabetes. We examine whether messaging with physicians for medical advice is associated with fewer face-to-face visits and better diabetes management.Patients with diabetes who were enrolled in an online portal of an outpatient health care organization in 2011-2014 were studied (N= 37,762 patient-years). Messages from/to primary care physicians or diabetes-related specialists for medical advice were considered. We estimated the association of messaging with diabetes quality measures, adjusting for patient and provider characteristics and patient-level clustering.Most patients (72%) used messaging, and those who made frequent visits were also more likely to message. Given visit frequency, no (vs. any) messaging was negatively associated with the likelihood of meeting an HbA1ctarget of <8% (64 mmol/mol) (odds ratio [OR] 0.83 [95% CI 0.77, 0.90]). Among message users, additional messages (vs. 1) were associated with better outcome (two more messages: OR 1.17 [95% CI 1.06, 1.28]; three more messages: 1.38 [1.25, 1.53]; four more messages: 1.55 [1.43, 1.69]). The relationship was stronger for noninsulin users. Message frequency was also positively associated, but to a smaller extent, with process measures (e.g., eye examination). Physician-initiated messages had effects similar to those for patient-initiated messages.Patients with diabetes frequently used secure messaging for medical advice in addition to routine visits to care providers. Messaging was positively associated with better diabetes management in a large community outpatient practice.

    View details for PubMedID 28807977

  • Effect of Organizational Culture on Patient Access, Care Continuity, and Experience of Primary Care JOURNAL OF AMBULATORY CARE MANAGEMENT Hung, D., Chung, S., Martinez, M., Tai-Seale, M. 2016; 39 (3): 242–52


    This study examined relationships between organizational culture and patient-centered outcomes in primary care. Generalized least squares regression was used to analyze patient access, care continuity, and reported experiences of care among 357 physicians in 41 primary care departments. Compared with a "Group-oriented" culture, a "Rational" culture type was associated with longer appointment wait times, and both "Hierarchical" and "Developmental" culture types were associated with less care continuity, but better patient experiences with care. Understanding the unique effects of organizational culture can enhance the delivery of more patient-centered care.

    View details for DOI 10.1097/JAC.0000000000000116

    View details for Web of Science ID 000402649400007

    View details for PubMedID 27232685

  • Clocks Moving at Different Speeds Cultural Variation in the Satisfaction With Wait Time for Outpatient Care MEDICAL CARE Chung, S., Johns, N., Zhao, B., Romanelli, R., Pu, J., Palaniappan, L. P., Luft, H. 2016; 54 (3): 269-276


    To explore racial/ethnic differences in satisfaction with wait time of scheduled office visits by comparing electronic health record (EHR)-based, patient-reported, and patient satisfaction with wait time: A large multispecialty ambulatory care organization in Northern California. Patient experience surveys were collected between 2010 and 2014. Surveys were mailed after randomly selected nonurgent visits. Returned survey data were linked to EHR data for surveyed visits.Observational, retrospective study designed to assess differences in patient-reported wait time, wait-time satisfaction, and actual EHR-recorded wait time with respect to self-reported race/ethnicity. Multivariate regression models with provider random effects were used to evaluate differences.Asian subgroups (Chinese, Asian Indian, Filipino, Japanese, Korean, and Vietnamese) and Latinos gave poorer ratings for wait time than non-Hispanic whites (NHWs). The average wait time reported by Asians was longer than that reported by NHWs. On the basis of EHR data, however, no minority group was likely to wait longer, and all, except for Japanese (10%), were more likely to be late for the appointment (16%: Filipino and 23%: Asian Indian), than NHWs (13%).Given actual wait times, Asians perceive longer wait time and were less satisfied with wait times. Asians may have different expectations about wait time at the clinic.

    View details for DOI 10.1097/MLR.0000000000000473

    View details for Web of Science ID 000372935400008

  • Racial/Ethnic Differences in Gestational Diabetes Prevalence and Contribution of Common Risk Factors PAEDIATRIC AND PERINATAL EPIDEMIOLOGY Pu, J., Zhao, B., Wang, E. J., Nimbal, V., Osmundson, S., Kunz, L., Popat, R. A., Chung, S., Palaniappan, L. P. 2015; 29 (5): 436-443


    The White House, the American Heart Association, the Agency for Healthcare Research and Quality, and the National Heart, Lung and Blood Institute have all recently acknowledged the need to disaggregate Asian American subgroups to better understand this heterogeneous racial group. This study aims to assess racial/ethnic differences in relative contribution of risk factors of gestational diabetes mellitus (GDM) among Asian subgroups (Asian Indian, Chinese, Filipino, Japanese, Korean, and Vietnamese), Hispanics, non-Hispanic blacks, and non-Hispanic whites.Pregnant women in 2007-2012 were identified through California state birth certificate records and linked to the electronic health records in a large mixed-payer ambulatory care organisation in Northern California (n = 24 195). Relative risk and population attributable fraction (PAF) for specific racial/ethnic groups were calculated to assess the contributions of advanced maternal age, overweight/obesity (Centers for Disease Control and Prevention (CDC) standards and World Health Organization (WHO)/American Diabetes Association (ADA) body mass index cut-offs for Asians), family history of type 2 diabetes, and foreign-born status.GDM was most prevalent among Asian Indians (19.3%). Relative risks were similar across all race/ethnic groups. Advanced maternal age had higher PAFs in non-Hispanic whites (22.5%) and Hispanics (22.7%). Meanwhile family history (Asian Indians 22.6%, Chinese 22.9%) and foreign-borne status (Chinese 40.2%, Filipinos 30.2%) had higher PAFs in Asian subgroups. Overweight/obesity was the most important GDM risk factor for non-Hispanic whites, Hispanics, Asian Indians, and Filipinos when the WHO/ADA cut-off points were applied. Advanced maternal age was the only risk factor studied that was modified by race/ethnicity, with non-Hispanic white and Hispanic women being more adversely affected than other racial/ethnic groups.Overweight/obesity, advanced maternal age, family history of type 2 diabetes, and foreign-borne status are important risk factors for GDM. The relative contributions of these risk factors differ by race/ethnicity, mainly due to differences in population prevalence of these risk factors.

    View details for DOI 10.1111/ppe.12209

    View details for Web of Science ID 000359633400009

    View details for PubMedID 26201385

  • Impact of Education on Weight in Newly Diagnosed Type 2 Diabetes: Every Little Bit Helps PLOS ONE Azar, K. M., Chung, S., Wang, E. J., Zhao, B., Linde, R. B., Lederer, J., Palaniappan, L. P. 2015; 10 (6)


    Highly structured, intensive behavioral lifestyle interventions have been shown to be efficacious in research settings for type 2 diabetes management and weight loss. We sought to evaluate the benefit of participation in more limited counseling and/or education among individuals with newly diagnosed type 2 diabetes in more modest real-world clinical settings.Electronic Health Records of newly diagnosed type 2 diabetes patients age 35-74 from a large ambulatory group practice were analyzed (n = 1,314). We examined participation in clinic-based lifestyle counseling/education and subsequent weight loss.Of the total cohort, 599 (45.6%) patients received counseling/education with (26.2%) and without (19.4%) medication, 298(22.7%) patients received a prescription for medication alone, and 417(31.7%) patients were only monitored. On average, those who participated in counseling/education attended 2.5 sessions (approximately 2-3 hours). The average weight loss of patients who received counseling/education alone during the follow-up period (up to three years post-exposure to participation) was 6.3 lbs. (3.3% of body weight), and, if received with medication prescription, 8.1 lbs. (4.0% of body weight) (all at P<0.001). The weight loss associated with medication was only 3.5 lbs. (P<0.001). No significant weight change was observed in the monitoring only group.While efforts to improve both the short-term and long-term effectiveness of behavioral lifestyle interventions in real-world settings are ongoing, it is important for clinicians to continue to utilize less intensive, existing resources. Even relatively small "doses" of health education may help in promoting weight loss and may potentially reduce cardiometabolic risk.

    View details for DOI 10.1371/journal.pone.0129348

    View details for Web of Science ID 000355955300121

    View details for PubMedID 26052698

    View details for PubMedCentralID PMC4459994

  • Racial/Ethnic differences in hypertension prevalence, treatment, and control for outpatients in northern california 2010-2012. American journal of hypertension Zhao, B., Jose, P. O., Pu, J., Chung, S., Ancheta, I. B., Fortmann, S. P., Palaniappan, L. P. 2015; 28 (5): 631-639


    Hypertension (HTN) is a known major cardiovascular disease risk factor, but prevalence, treatment, and control of HTN among rapidly growing minority groups such as Asian Americans and Hispanics are unknown largely due to either underrepresentation in epidemiologic studies or aggregation of Asian American subgroups.A three-year cross-section (2010-2012) of patients from a large ambulatory care setting in northern California was examined in the following subgroups: Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese, Mexicans, non-Hispanic Blacks (NHBs), and non-Hispanic Whites (NHWs). We defined HTN as two separate nonemergent office visit blood pressure measurements ≥140/90mm Hg, physician diagnosis of HTN, or use of antihypertensive medications.A total of 208,985 patients were included in the study. Age-adjusted HTN prevalence ranged from 30.0% in Chinese women to 59.9% in Filipino men. Most minority subgroups had lower or similar odds of having HTN compared with NHWs, except for Filipinos and NHBs whose odds were significantly higher after adjusting for patient demographic and clinical characteristics. Asian Americans and NHBs were more likely to be treated for HTN compared with NHWs. Achievement of blood pressure control was lower among Filipino women (odds ratio = 0.82, 99% confidence interval 0.70-0.96) and NHB men (odds ratio = 0.73, 99% confidence interval 0.58-0.91), compared with NHW women and men.Substantial racial/ethnic variation in HTN prevalence, treatment, and control was found in our study population. Filipino and NHB women and men are at especially high risk for HTN and may have more difficulty in achieving adequate blood pressure control.

    View details for DOI 10.1093/ajh/hpu189

    View details for PubMedID 25352230

  • Comparative effectiveness of early versus delayed metformin in the treatment of type 2 diabetes DIABETES RESEARCH AND CLINICAL PRACTICE Romanelli, R. J., Chung, S., Pu, J., Nimbal, V., Zhao, B., Palaniappan, L. 2015; 108 (1): 170-178


    The purpose of this study was to evaluate the effectiveness of early versus delayed initiation of metformin in type 2 diabetes.We identified 2925 new users of metformin with type 2 diabetes between 2005 and 2012 in the electronic health records of an integrated health system in Northern California. Patients were matched 1:1 on the propensity for receiving early treatment (defined as ≤6 months from first evidence of diabetes). We evaluated the effectiveness of early versus delayed metformin treatment on intermediate clinical outcomes indicated by changes in hemoglobin A1c (HbA1c) and body mass index (BMI), as well as the incidence of therapy intensification (addition or substitution of a second antihyperglycemic agent).A total of 2144 propensity-score matched patients were included in the early or delayed treatment group (n=1072, in each). Early treatment was associated with significantly larger decreases in HbA1c (-0.36%; 95% confidence intervals [CI]: -0.44 to -0.27%; P<0.001) and BMI (-0.46kg/m(2); 95% CI: -0.64 to -0.29kg/m(2); P<0.001) relative to delayed treatment. Patients receiving early treatment also had a greater likelihood of attaining an HbA1c<7% (<53mmol/mol) (odds ratio: 2.00; 95% CI: 1.63-2.45; P<0.001) and a reduced risk of therapy intensification (hazard ratio: 0.72; 95% CI: 0.61-0.85; P<0.001).Treatment with metformin earlier in the course of type 2 diabetes is associated with better glycemic control, more pronounced weight reduction, and a lower risk for therapy intensification than delayed treatment. Antihyperglycemic therapy should be initiated early after diagnosis to achieve optimal outcomes.

    View details for DOI 10.1016/j.diabres.2014.12.019

    View details for Web of Science ID 000352274900031

    View details for PubMedID 25661984

    View details for PubMedCentralID PMC4388779

  • Patients Report Better Satisfaction with Part-Time Primary Care Physicians, Despite Less Continuity of Care and Access JOURNAL OF GENERAL INTERNAL MEDICINE Panattoni, L., Stone, A., Chung, S., Tai-Seale, M. 2015; 30 (3): 327–33


    The growing number of primary care physicians (PCPs) reducing their clinical work hours has raised concerns about meeting the future demand for services and fulfilling the continuity and access mandates for patient-centered care. However, the patient's experience of care with part-time physicians is relatively unknown, and may be mediated by continuity and access to care outcomes.We aimed to examine the relationships between a physicians' clinical full-time equivalent (FTE), continuity of care, access to care, and patient satisfaction with the physician.We used a multi-level structural equation estimation, with continuity and access modeled as mediators, for a cross-section in 2010.The study included family medicine (n = 104) and internal medicine (n = 101) physicians in a multi-specialty group practice, along with their patient satisfaction survey responses (n = 12,688).Physician level FTE, continuity of care received by patients, continuity of care provided by physician, and a Press Ganey patient satisfaction with the physician score, on a 0-100 % scale, were measured. Access to care was measured as days to the third next-available appointment.Physician FTE was directly associated with better continuity of care received (0.172% per FTE, p < 0.001), better continuity of care provided (0.108% per FTE, p < 0.001), and better access to care (-0.033 days per FTE, p < 0.01), but worse patient satisfaction scores (-0.080% per FTE, p = 0.03). The continuity of care provided was a significant mediator (0.016% per FTE, p < 0.01) of the relationship between FTE and patient satisfaction; but overall, reduced clinical work hours were associated with better patient satisfaction (-0.053 % per FTE, p = 0.03).These results suggest that PCPs who choose to work fewer clinical hours may have worse continuity and access, but they may provide a better patient experience. Physician workforce planning should consider these care attributes when considering the role of part-time PCPs in practice redesign efforts and initiatives to meet the demand for primary care services.

    View details for DOI 10.1007/s11606-014-3104-6

    View details for Web of Science ID 000350886500013

    View details for PubMedID 25416600

    View details for PubMedCentralID PMC4351271

  • Initiation of treatment for incident diabetes: evidence from the electronic health records in an ambulatory care setting. Primary care diabetes Chung, S., Zhao, B., Lauderdale, D., Linde, R., Stafford, R., Palaniappan, L. 2015; 9 (1): 23-30


    We examined patterns and predictors of initiation of treatment for incident diabetes in an ambulatory care setting in the US.Data were extracted from electronic health records (EHR) for active patients ≥35 years in a multispecialty, multiclinic ambulatory care organization with 1000 providers. New onset type 2 diabetes and subsequent treatment were identified using lab, diagnosis, medication prescription, and service use data. Time from the first evidence of diabetes until initial treatment, either medication or education/counseling, was examined using a Kaplan-Meier hazards curve. Potential predictors of initial treatment were examined using multinomial logistic models accounting for physician random effects.Of 2258 patients with incident diabetes, 55% received either medication or education/counseling (20% received both) during the first year. Of the treated patients, 68% received a treatment within the first four weeks, and 13% after initial 16 weeks. Strong positive predictors (P<0.01) of combined treatment were younger age, higher fasting glucose at diagnosis, obesity, and visits with an endocrinologist.Among insured patients who have a primary care provider in a multispecialty health care system, incident diabetes is treated only half the time. Improved algorithms for identifying incident diabetes from the EHR and team approach for monitoring may help treatment initiation.

    View details for DOI 10.1016/j.pcd.2014.04.005

    View details for PubMedID 24810147

    View details for PubMedCentralID PMC4221568

  • Medicare annual preventive care visits: use increased among fee-for-service patients, but many do not participate. Health affairs Chung, S., Lesser, L. I., Lauderdale, D. S., Johns, N. E., Palaniappan, L. P., Luft, H. S. 2015; 34 (1): 11-20


    Under the Affordable Care Act (ACA), Medicare coverage expanded in 2011 to fully cover annual preventive care visits. We assessed the impact of coverage expansion, using 2007-13 data from primary care patients of Medicare-eligible age at the Palo Alto Medical Foundation (204,388 patient-years), which serves people in four counties near San Francisco, California. We compared trends in preventive visits and recommended preventive services among Medicare fee-for-service and Medicare health maintenance organization (HMO) patients as well as non-Medicare patients ages 65-75 who were covered by private fee-for-service and private HMO plans. Among Medicare fee-for-service patients, the annual use of preventive visits rose from 1.4 percent before the implementation of the ACA to 27.5 percent afterward. This increase was significantly larger than was seen for patients in the other insurance groups. Nevertheless, rates of annual preventive care visit use among Medicare fee-for-service patients remained 10-20 percentage points lower than was the case for people with private coverage (43-44 percent) or those in a Medicare HMO (53 percent). ACA policy changes led to increased preventive service use by Medicare fee-for-service beneficiaries, which suggests that Medicare coverage expansion is an effective way to increase seniors' use of preventive services.

    View details for DOI 10.1377/hlthaff.2014.0483

    View details for PubMedID 25561639

  • AGING & HEALTH Medicare Annual Preventive Care Visits: Use Increased Among Fee-For-Service Patients, But Many Do Not Participate HEALTH AFFAIRS Chung, S., Lesser, L. I., Lauderdale, D. S., Johns, N. E., Palaniappan, L. P., Luft, H. S. 2015; 34 (1): 11-20


    Under the Affordable Care Act (ACA), Medicare coverage expanded in 2011 to fully cover annual preventive care visits. We assessed the impact of coverage expansion, using 2007-13 data from primary care patients of Medicare-eligible age at the Palo Alto Medical Foundation (204,388 patient-years), which serves people in four counties near San Francisco, California. We compared trends in preventive visits and recommended preventive services among Medicare fee-for-service and Medicare health maintenance organization (HMO) patients as well as non-Medicare patients ages 65-75 who were covered by private fee-for-service and private HMO plans. Among Medicare fee-for-service patients, the annual use of preventive visits rose from 1.4 percent before the implementation of the ACA to 27.5 percent afterward. This increase was significantly larger than was seen for patients in the other insurance groups. Nevertheless, rates of annual preventive care visit use among Medicare fee-for-service patients remained 10-20 percentage points lower than was the case for people with private coverage (43-44 percent) or those in a Medicare HMO (53 percent). ACA policy changes led to increased preventive service use by Medicare fee-for-service beneficiaries, which suggests that Medicare coverage expansion is an effective way to increase seniors' use of preventive services.

    View details for DOI 10.1377/hlthaff.2014.0483

    View details for Web of Science ID 000351716000003

  • Patient and Provider Characteristics Associated with Colorectal, Breast, and Cervical Cancer Screening among Asian Americans CANCER EPIDEMIOLOGY BIOMARKERS & PREVENTION Thompson, C. A., Gomez, S. L., Chan, A., Chan, J. K., McClellan, S. R., Chung, S., Olson, C., Nimbal, V., Palaniappan, L. P. 2014; 23 (11): 2208-2217


    Routinely recommended screening for breast, cervical, and colorectal cancers can significantly reduce mortality from these types of cancer, yet screening is underutilized among Asians. Surveys rely on self-report and often are underpowered for analysis by Asian ethnicities. Electronic health records (EHR) include validated (as opposed to recall-based) rates of cancer screening. In this article, we seek to better understand cancer screening patterns in a population of insured Asian Americans.We calculated rates of compliance with cervical, breast, and colorectal cancer screening among Asians from an EHR population and compared them with non-Hispanic whites. We performed multivariable modeling to evaluate potential predictors (at the provider- and patient-level) of screening completion among Asian patients.Aggregation of Asian subgroups masked heterogeneity in screening rates. Asian Indians and native Hawaiians and Pacific Islanders had the lowest rates of screening in our sample, well below that of non-Hispanic whites. In multivariable analyses, screening completion was negatively associated with patient-physician language discordance for mammography [OR, 0.81; 95% confidence interval (CI), 0.71-0.92] and colorectal cancer screening (OR, 0.79; CI, 0.72-0.87) and positively associated with patient-provider gender concordance for mammography (OR, 1.16; CI, 1.00-1.34) and cervical cancer screening (OR, 1.66; CI, 1.51-1.82). In addition, patient enrollment in online health services increased mammography (OR, 1.32; CI, 1.20-1.46) and cervical cancer screening (OR, 1.31; CI, 1.24-1.37).Language- and gender-concordant primary care providers and culturally tailored online health resources may help improve preventive cancer screening in Asian patient populations.This study demonstrates how the use of EHR data can inform investigations of primary prevention practices within the healthcare delivery setting.

    View details for DOI 10.1158/1055-9965.EPI-14-0487

    View details for Web of Science ID 000345279600003

    View details for PubMedCentralID PMC4221799

  • Reconsidering the Age Thresholds for Type II Diabetes Screening in the U.S. AMERICAN JOURNAL OF PREVENTIVE MEDICINE Chung, S., Azar, K. M., Baek, M., Lauderdale, D. S., Palaniappan, L. P. 2014; 47 (4): 375-381


    Type II diabetes and its complications can sometimes be prevented, if identified and treated early. One fifth of diabetics in the U.S. remain undiagnosed. Commonly used screening guidelines are inconsistent.To examine the optimal age cut-point for opportunistic universal screening, compared to targeted screening, which is recommended by U.S. Preventive Services Task Force (USPSTF) and American Diabetes Association (ADA) guidelines.Cross-sectional analysis of a nationally representative sample from the National Health and Nutrition Examination Survey, 2007-2010. Number of people needed to screen (NNS) to obtain one positive test result was calculated for different guidelines. Sampling weights were applied to construct national estimates. The 2010 Medicare fee schedule was used for cost estimation. Analysis was conducted in January 2014.NNS, under universal screening, drops sharply at age 35 years, from 80 (30-34-year-olds) to 31 (35-39-year-olds). Opportunistic universal screening of eligible people aged ≥35 years would yield an NNS of 15, translating to $66 per positive test. Among people aged 35-44 years (who are not recommended for universal screening by ADA), most (71%) were overweight or obese and all had at least one other ADA risk factor. Only 34% of individuals aged ≥35 years met USPSTF criteria. Strictly enforcing USPSTF guidelines would have resulted in a majority (61%) of potential positive test cases being missed (5,508,164 cases nationwide).Opportunistic universal screening among individuals aged ≥35 years could greatly reduce the national prevalence of undiagnosed pre-diabetes or diabetes at relatively low cost.

    View details for DOI 10.1016/j.amepre.2014.05.012

    View details for Web of Science ID 000342386700003

    View details for PubMedCentralID PMC4171212

  • Relationship Between Self-assessed and Tested Non-English-language Proficiency Among Primary Care Providers MEDICAL CARE Diamond, L., Chung, S., Ferguson, W., Gonzalez, J., Jacobs, E. A., Gany, F. 2014; 52 (5): 435–38


    Individuals with limited English proficiency experience poor patient-clinician communication. Most studies of language concordance have not measured clinician non-English-language proficiency.To evaluate the accuracy of the self-assessment of non-English-language proficiency by clinicians compared with an oral proficiency interview.Primary care providers (PCPs) in California and Massachusetts.PCPs first completed a self-assessment of non-English-language proficiency using a version of the Interagency Language Roundtable (ILR) Scale, followed by the Clinician Cultural and Linguistic Assessment (CCLA), a validated oral proficiency interview. We used nonparametric approaches to analyze CCLA scores at each ILR scale level and the correlation between CCLA and ILR scale scores.Sixteen PCPs in California and 51 in Massachusetts participated (n=67). Participants spoke Spanish (79%), followed by Cantonese, Mandarin, French, Portuguese, and Vietnamese. The respondents self-assessed as having "excellent" proficiency 9% of the time, "very good" proficiency 24% of the time, "good" proficiency 46% of the time, "fair" proficiency 18% of the time, and "poor" proficiency 3% of the time. The average CCLA score was 76/100. There was a positive correlation between self-reported ILR scale and CCLA score (σ=0.49, P<0.001). The variance in CCLA scores was wider in the middle categories than in the low or high ILR categories (P=0.003).Self-assessment of non-English-language proficiency using the ILR correlates to tested language proficiency, particularly on the low and high ends of the scale. Participants who self-assess in the middle of the scale may require additional testing. Further research needs to be conducted to identify the characteristics of PCP whose self-assessments are inaccurate and, thus, require proficiency testing.

    View details for DOI 10.1097/MLR.0000000000000102

    View details for Web of Science ID 000337312800010

    View details for PubMedID 24556893

    View details for PubMedCentralID PMC3981942

  • Leveraging Electronic Health Records to Develop Measurements for Processes of Care HEALTH SERVICES RESEARCH Tai-Seale, M., Wilson, C. J., Panattoni, L., Kohli, N., Stone, A., Hung, D. Y., Chung, S. 2014; 49 (2): 628–44


    To assess the reliability of data in electronic health records (EHRs) for measuring processes of care among primary care physicians (PCPs) and examine the relationship between these measures and clinical outcomes.EHR data from 15,370 patients with diabetes, 49,561 with hypertension, in a group practice serving four Northern California counties.Exploratory factor analysis (EFA) and multilevel analyses of the relationships between processes of care variables and factor scales with control of hemoglobin A1c, blood pressure (BP), and low density lipoprotein (LDL) among patients with diabetes and BP among patients with hypertension.Volume of e-messages, number of days to the third-next-available appointment, and team communication emerged as reliable factors of PCP processes of care in EFA (Cronbach's alpha=0.73, 0.62, and 0.91). Volume of e-messages was associated with higher odds of LDL control (≤100) (OR=1.13, p<.05) among patients with diabetes. Frequent in-person visits were associated with better BP (OR=1.02, p<.01) and LDL control (OR=1.01, p<.01) among patients with diabetes, and better BP control (OR=1.04, p<.01) among patients with hypertension.The EHR offers process of care measures which can augment patient-reported measures of patient-centeredness. Two of them are significantly associated with clinical outcomes. Future research should examine their association with additional outcomes.

    View details for DOI 10.1111/1475-6773.12126

    View details for Web of Science ID 000333413800010

    View details for PubMedID 24236994

    View details for PubMedCentralID PMC3976190

  • Why Do We Observe a Limited Impact of Primary Care Access Measures on Clinical Quality Indicators? JOURNAL OF AMBULATORY CARE MANAGEMENT Chung, S., Panattoni, L., Hung, D., Johns, N., Trujillo, L., Tai-Seale, M. 2014; 37 (2): 155–63


    The study assessed the effects of enhanced primary care access and continuity on clinical quality in a large, multipayer, multispecialty ambulatory care organization with fee-for-service provider incentives. The difference-in-differences estimates indicate that access to own primary care physician is a statistically significant predictor of improved clinical quality, although the effect size is small such that clinical significance may be negligible. Reduced time for own primary care physician appointment and increased enrollment in electronic personal health record are positive predictors of chronic disease management processes and preventive screening but are inconsistently associated with clinical outcomes. Challenges in identifying relationships between access and quality outcomes in a real-world setting are also discussed.

    View details for DOI 10.1097/JAC.0000000000000026

    View details for Web of Science ID 000410161700009

    View details for PubMedID 24594563

  • Standardizing Primary Care Physician Panels: Is Age and Sex Good Enough? AMERICAN JOURNAL OF MANAGED CARE Chung, S., Eaton, L. J., Luft, H. S. 2012; 18 (7): E262–E267


    To determine if patient clinical conditions need to be considered when assessing primary care physician (PCP) workload in the context of standardizing panel sizes.Work resource value units (wRVUs) were used to standardize PCP panel workload. Standardized panels were created using (1) age and sex- and (2) clinical condition-based risk indicators. Billing data were used for all patients, regardless of insurance, for PCPs in a group practice (n = 190). Weighting methods were assessed for subgroups based on PCP specialty (family medicine, internal medicine, and pediatrics) and patient age (adults vs children) and for different levels of aggregation (patient vs PCP).Groupwide weights based on wRVUs of all primary care services delivered during the year were applied to individual patients and then aggregated to PCP panels. For age/sex weighting, only patient age and sex were taken into account. For condition-based weighting, 1275 disease categories, based on a combination of episode treatment groups (ETGs) and age and/or sex, were used.As expected, at the patient level, condition-based weights were far more discriminative than age/sex. At the PCP level, this discrimination was less important; panel weights varied 1.9- (age/sex-based) to 2.6-fold (condition-based) across PCPs. Correlations between the 2 weighting methods were high (r = 0.93) for child panels and moderate (r = 0.71) for adult panels (all P <.001).The heterogeneity of PCP panels should be considered when assessing PCP workload for panel management. Panel variability in workload is well captured by age/sex-based weights for children, but for adults condition-based adjustment may be necessary.

    View details for Web of Science ID 000308443600010

    View details for PubMedID 22823555

  • Underdiagnosis of Hypertension Using Electronic Health Records AMERICAN JOURNAL OF HYPERTENSION Banerjee, D., Chung, S., Wong, E. C., Wang, E. J., Stafford, R. S., Palaniappan, L. P. 2012; 25 (1): 97-102


    Hypertension is highly prevalent and contributes to cardiovascular morbidity and mortality. Appropriate identification of hypertension is fundamental for its management. The rates of appropriate hypertension diagnosis in outpatient settings using an electronic health record (EHR) have not been well studied. We sought to identify prevalent and incident hypertension cases in a large outpatient healthcare system, examine the diagnosis rates of prevalent and incident hypertension, and identify clinical and demographic factors associated with appropriate hypertension diagnosis.We analyzed a 3-year, cross-sectional sample of 251,590 patients aged ≥18 years using patient EHRs. Underlying hypertension was defined as two or more abnormal blood pressure (ABP) readings ≥140/90 mm Hg and/or pharmaceutical treatment. Appropriate hypertension diagnosis was defined by the reporting of ICD-9 codes (401.0-401.9). Factors associated with hypertension diagnosis were assessed through multivariate analyses of patient clinical and demographic characteristics.The prevalence of hypertension was 28.7%, and the diagnosis rate was 62.9%. The incidence of hypertension was 13.3%, with a diagnosis rate of 19.9%. Predictors of diagnosis for prevalent hypertension included older age, Asian, African American, higher body mass index (BMI), and increased number of ABP readings. Predictors for incident hypertension diagnosis were similar. In patients with two or more ABP readings, hypertension diagnosis was associated with significantly higher medication treatment rates (92.6% vs. 15.8%, P < 0.0001).Outpatient EHR diagnosis rates are suboptimal, yet EHR diagnosis of hypertension is strongly associated with treatment. Targeted efforts to improve diagnosis should be a priority.

    View details for DOI 10.1038/ajh.2011.179

    View details for PubMedID 22031453

  • Does the Frequency of Pay-for-Performance Payment Matter?-Experience from a Randomized Trial HEALTH SERVICES RESEARCH Chung, S., Palaniappan, L., Wong, E., Rubin, H., Luft, H. 2010; 45 (2): 553-564


    To examine the effects of incentive payment frequency on quality measures in a physician-specific pay-for-performance (P4P) experiment.A multispecialty physician group practice.In 2007, all primary care physicians (n=179) were randomized into two study arms differing by the frequency of incentive payment, either four quarterly bonus checks or a single year-end bonus (maximum of U.S.$5,000/year for both arms).Data were extracted from electronic health records. Quality measure scores between the two arms over four quarters were compared.There was no difference between the two arms in average quality measure score or in total bonus amount earned.Physicians' responses to a P4P program with a small maximum bonus do not differ by frequency of bonus payment.

    View details for DOI 10.1111/j.1475-6773.2009.01072.x

    View details for Web of Science ID 000275335900012

    View details for PubMedID 20059568

    View details for PubMedCentralID PMC2838160

  • Effect of Physician-Specific Pay-for-Performance Incentives in a Large Group Practice AMERICAN JOURNAL OF MANAGED CARE Chung, S., Palaniappan, L. P., Trujillo, L. M., Rubin, H. R., Luft, H. S. 2010; 16 (2): E35-E42


    To assess the effect of a physician-specific pay-for-performance program on quality-of-care measures in a large group practice.In 2007, Palo Alto Medical Clinic, a multispecialty physician group practice, changed from group-focused to physician-specific pay-for-performance incentives. Primary care physicians received incentive payments based on their quarterly assessed performance.We examined 9 reported and incentivized clinical outcome and process measures. Five reported and nonincentivized measures were used for comparison purposes. The quality score of each physician for each measure was the main dependent variable and was calculated as follows: Quality Score = (Patients Meeting Target / Eligible Patients) x 100. Differences in scores between 2006 and 2007 were compared with differences in scores between 2005 and 2006. We also compared the performance of Palo Alto Medical Clinic with that of 2 other affiliated physician groups implementing group-level incentives.Eight of 9 reported and incentivized measures showed significant improvement in 2007 compared with 2006. Three measures showed an improvement trend significantly better than the previous year's trend. A similar improvement trend was observed in 1 related measure that was reported but was nonincentivized. However, the improvement trend of Palo Alto Medical Clinic was not consistently different from that of the other 2 physician groups.Small financial incentives (maximum, $5000/year) based on individual physicians' performance may have led to continued or enhanced improvement in well-established ambulatory care measures. Compared with other quality improvement programs having alternative foci for incentives (eg, increasing support for staff hours), the effect of physician-specific incentives was not evident.

    View details for Web of Science ID 000274590800009

    View details for PubMedID 20148608

  • Changes in Treatment Content of Services During Trauma-informed Integrated Services for Women with Co-occurring Disorders COMMUNITY MENTAL HEALTH JOURNAL Chung, S., Domino, M., Morrissey, J. P. 2009; 45 (5): 375–84


    The experience of trauma is highly prevalent in the lives of women with mental health and substance abuse problems. We examined how an intervention targeted to provide trauma-informed integrated services in the treatment of co-occurring disorders has changed the content of services reported by clients. We found that the intervention led to an increased provision of integrated services as well as services addressing each content area: trauma, mental health and substance abuse. There was no increase in service quantity from the intervention. Incorporation of trauma-specific element in the treatment of mental health and substance abuse may have been successfully implemented at the service level thereby better serve women with complex behavioral health histories.

    View details for DOI 10.1007/s10597-009-9192-9

    View details for Web of Science ID 000270384200007

    View details for PubMedID 19308729

    View details for PubMedCentralID PMC2758206

  • The Effect of Retirement on Weight JOURNALS OF GERONTOLOGY SERIES B-PSYCHOLOGICAL SCIENCES AND SOCIAL SCIENCES Chung, S., Domino, M. E., Stearns, S. C. 2009; 64 (5): 656–65


    People who are close to retirement age show the highest rates of weight gain and obesity. We investigate the effect of retirement on the change in body mass index (BMI) in diverse groups varying by wealth status and occupation type.Six panels of the Health and Retirement Study (1992-2002) on individuals aged 50-71 were used (N = 37,807). We used fixed-effects regression models with instrumental variables method to estimate the causal effect of retirement on change in the BMI.Retirement leads to modest weight gain, 0.24 BMI on average. Weight gain with retirement was found among people who were already overweight and those with lower wealth retiring from physically demanding occupations. The cumulative effect of aging among people in their 50s, however, outweighs the effect of retirement; the average BMI gain between ages 50 and 60 is 1.30, 5 times the effect of retirement.Given the increasing number of people approaching retirement age, the population level impact of the weight gain ascribed to retirement on health outcomes and health care system might be significant. Future research should evaluate programs targeted to older adults who are most likely to gain weight with retirement.

    View details for DOI 10.1093/geronb/gbn044

    View details for Web of Science ID 000269441100014

    View details for PubMedID 19357073

  • Risk Perception and Preference for Prevention of Alzheimer's Disease VALUE IN HEALTH Chung, S., Mehta, K., Shumway, M., Alvidrez, J., Perez-Stable, E. J. 2009; 12 (4): 450–58


    To understand how older adults perceive their risk of Alzheimer's Disease (AD) and how this may shape their medical care decisions, we examined whether presence of established risk factors of AD is associated with individuals' perceived risk of AD, and with preference for preventing AD.Data came from the US Health and Retirement Study participants who were asked questions on AD risk perception (N = 778).Perceived risk of AD was measured by respondents' estimate of their percent chance (0-100) developing AD in the next 10 years. Preference for AD prevention was measured with questions eliciting willingness to pay for a drug to prevent AD.Multivariate linear regressions were used to estimate correlates of perceived risk and preference for prevention.Better cognitive functioning and physical activity are associated with decreased perceived risk. Neither age nor cardiovascular disease is associated with perceived risk. African Americans have lower perceived risk than non-Latino whites; the difference is wider among people age 65 and above. Only 4% to 7% of the variation in perceived risk was explained by the model. Preference for prevention is stronger with increased perceived risk, but not with the presence of risk factors. Persons with better cognitive functioning, physical functioning, or wealth status have a stronger preference for prevention.Some known risk factors appear to inform, but only modestly, individuals' perceived risk of AD. Furthermore, decisions about AD prevention may not be determined by objective needs alone, suggesting a potential discrepancy between need and demand for AD preventive care.

    View details for DOI 10.1111/j.1524-4733.2008.00482.x

    View details for Web of Science ID 000266467800010

    View details for PubMedID 19900252

    View details for PubMedCentralID PMC4383096

  • Retirement and Physical Activity Analyses by Occupation and Wealth AMERICAN JOURNAL OF PREVENTIVE MEDICINE Chung, S., Domino, M. E., Stearns, S. C., Popkin, B. M. 2009; 36 (5): 422–28


    Older adults close to retirement age show the lowest level of physical activity. Changes in lifestyle with retirement may alter physical activity levels. This study investigated whether retirement changes physical activity and how the effect differs by occupation type and wealth level.This longitudinal study used the Health and Retirement Study (1996-2002), U.S. population-based data. Analyses were conducted in 2007 and 2008. Physical activity was measured by a composite indicator of participation in either work-related or leisure-time physical activity. Fixed-effects regression models were used to account for confounders and unobserved heterogeneity. The dependent variable was a composite indicator of participation in regular physical activity either at work or during nonworking hours.Physical activity decreased with retirement from a physically demanding job but increased with retirement from a sedentary job. Occupation type interacted with wealth level, with the negative impact on physical activity of retirement exacerbated by lack of wealth and the positive effect of retirement on physical activity enhanced by wealth.Substantial differences in the effect of retirement on physical activity occurred across subgroups. As the number of people approaching retirement age rapidly increases, findings suggest that a growing segment of the nation's population may not sustain an adequate level of physical activity.

    View details for DOI 10.1016/j.amepre.2009.01.026

    View details for Web of Science ID 000265315200008

    View details for PubMedID 19269129

  • Reliability of self-reported health service use: Evidence from the women with co-occurring disorders, and violence study Chung, S., Domino, M., Jackson, E. W., Morrissey, J. P. SPRINGER. 2008: 265–78


    In behavioral health services research, self-reporting provides comprehensive information on service use, but may have limited reliability because of recall bias and misclassification. This study examines test-retest reliability of self-reported health service use, factors affecting reliability, and the impact of inconsistent reporting on the robustness of cost estimates using the test-retest data from the Women, Co-occurring Disorders, and Violence Study (n = 186). Reliability varies widely across service types: moderate to substantial (k = 0.65-0.94) for any use; slight to substantial (ICC = 0.12-0.93) for quantity of use; and none to moderate (k = -0.06-0.79) for service content, but is not affected by psychiatric symptom severity. Cost estimates do not differ according to the use of test or retest data. Findings suggest that self-reporting provides reliable data on service quantity and is adequate for economic evaluations. However, self-reporting of treatment content in highly specified service categories (e.g., individual counseling during residential treatment) may not be reliable.

    View details for DOI 10.1007/s11414-007-9105-z

    View details for Web of Science ID 000257496400004

    View details for PubMedID 18236163

  • Effect of retirement on eating out and weight change: An analysis of gender differences OBESITY Chung, S., Popkin, B. M., Domino, M. E., Stearns, S. C. 2007; 15 (4): 1053–60


    The objectives were to understand how the retirement decisions of older Americans influence household food consumption patterns by gender and, in turn, to examine the impact of the change in food consumption on weight.This study used five waves of the Health and Retirement Study (1992 to 2002; n=28,117). Participants were 50 to 71 years old during the study period. We used longitudinal regression analyses controlling for health events, spousal factors, socioeconomic factors, and individual fixed effects over time.Retirement of the individual and of his/her spouse reduced the individual's monthly spending on eating out by $10 and $7 on average, respectively, but did not change household spending on food at home. The wife's, but not the husband's, retirement decreased the spouse's spending on eating out by $13/mo. Spending on eating out was a significant but weak (0.003BMI/$) predictor of weight gain.The decrease in spending on eating out after retirement, particularly women's, suggests that people eat out less when they have more time for food preparation at home. However, increases in other risks of weight gain with retirement, such as physical inactivity, could counteract the effects of eating out less.

    View details for DOI 10.1038/oby.2007.538

    View details for Web of Science ID 000245729300032

    View details for PubMedID 17426342

  • Changes in service use during a trauma-informed intervention for women WOMEN & HEALTH Domino, M., Morrissey, J. P., Chung, S., Nadlicki, T. 2006; 44 (3): 105–22


    We examined the patterns of services used by women with co-occurring mental health and substance abuse problems with histories of interpersonal violence, and examined the change in patterns of use associated with a targeted intervention as part of the Women, Co-Occurring Disorders, and Violence Study. As hypothesized, we observed that intervention women (n=1023) used more of the main service type that the intervention was focused on providing, outpatient group counseling. The intervention did not have strong effects on patterns of service use external to the intervention, such as emergency room, jail, and shelter use in the first six months of follow-up. The reasons for the stability in patterns of services use are likely complex and imply that the observed increased access to group counseling was not being used as a substitute for other types of services, especially individual counseling, since use of these other services did not decrease during the study period.

    View details for DOI 10.1300/J013v44n03_06

    View details for Web of Science ID 000244027400006

    View details for PubMedID 17255068

  • Service use and costs for women with co-occurring mental and substance use disorders and a history of violence PSYCHIATRIC SERVICES Domino, M. E., Morrissey, J. P., Chung, S. Y., Huntington, N., Larson, M. J., Russell, L. A. 2005; 56 (10): 1223–32


    This study examined the 12-month cost of the array of services used by women with co-occurring mental health and substance use disorders and a history of violence and trauma who participated in the Women, Co-occurring Disorders, and Violence Study (WCDVS). The study compared costs of the intervention and external services for women in the WCDVS intervention in outpatient and residential settings-which provided comprehensive, integrated, and trauma-informed services-with the costs for women in the usual-care comparison group. The study also compared costs with recorded clinical outcomes.Costs of service use were examined for 2,026 women who participated in the WCDVS (N=1,018) and in the comparison group (N=1,008). Women were interviewed three, six, nine, and 12 months after baseline about any service use in the past three months. Costs for these services, along with indirect costs (participants' time and transportation) were estimated by using a variety of sources. A number of cost estimates were analyzed by using either ordinary least squares regression or two-part models.The average participant had almost 43,000 dollars in costs related to their service use during the 12 months after baseline. Women in the intervention group had lower service costs and higher overall costs than those in the comparison group, but the null hypotheses of no difference in any cost measure between groups was not rejected. Also, the null hypothesis of no difference in the probability of accessing services external to the study intervention was not rejected.Because no differences were detected in costs but improvements were seen in clinical outcomes, the interventions offered in the WCDVS may be more efficient than usual care.

    View details for DOI 10.1176/

    View details for Web of Science ID 000232470100006

    View details for PubMedID 16215187

  • Does the use of SSRIs reduce medical care utilization and expenditures? JOURNAL OF MENTAL HEALTH POLICY AND ECONOMICS Chung, S. Y. 2005; 8 (3): 119–29


    Although selective serotonin reuptake inhibitors (SSRIs) are more expensive than tricyclic antidepressants (TCAs), SSRIs may reduce overall health costs compared with TCAs through improved compliance and reduced need for other medical care services. Economic evaluation studies using clinical trial or claims data have not accurately estimated the actual costs associated with antidepressants because they did not appropriately address two issues: the heterogeneity of SSRI and TCA users and the use of antidepressants for non-indicated symptoms.This study estimates the relative substitution effect of SSRIs on the overall utilization of outpatient and inpatient care and other prescription drugs compared to TCAs. This study identifies and controls for heterogeneities in diagnosis among SSRI and TCA users and looks for variations in substitution effects across utilization.To estimate the direct effect of SSRIs compared with TCAs on the utilization of other medical care resources in a naturalistic setting, this study uses the Medical Expenditure Panel Survey, national panel survey data, from 1996 to 1998. The main model of analysis is a two-part regression: the first part is a probit model of any use and the second part is a log linear model of expenditures among users. Baseline physical health status, depression severity, and socioeconomic factors that could affect antidepressant choice and medical care utilization are controlled for.A considerable fraction of antidepressant use, especially among TCA users, is for reasons other than depression. After controlling for the heterogeneity in SSRI and TCA users, this study does not find consistent evidence of the substitution of SSRIs for other medical care. Although SSRIs, compared with TCAs, reduce overall outpatient visits and other prescription drugs, they increase the utilization of these services for depression. Antidepressant choice does not influence the utilization or expenditure level for inpatient services which composed the largest part of medical expenditure in this study sample. Results are robust when the analysis is restricted to the SSRI or TCA users with a depression diagnosis.The potential cost-incremental effect of SSRIs over TCAs for the treatment of depression can be compromised by the reduced utilization for symptoms other than depression among SSRI users. This study uses national survey data and takes into account the heterogeneity of SSRI and TCA users so the results can be generalized to real clinical practice.The costs associated with antidepressants are not only for the treatment of depression symptoms. Antidepressants are commonly prescribed for conditions for which the clinical and economic benefits are not established. This practice may lead to significant unnecessary healthcare expenses.Antidepressant prescriptions for non-indicated conditions should be considered in setting policies designed to control costs associated with antidepressants and in developing clinical guidelines for antidepressant prescription.Future research on the economic evaluation of antidepressants should consider the use of antidepressants for health conditions other than depression. The economic incentives for and clinical benefits of the prescription of antidepressants for non-indicated conditions could be explored in future research.

    View details for Web of Science ID 000232211300002

    View details for PubMedID 16278500

  • Service costs for women with co-occurring disorders and trauma JOURNAL OF SUBSTANCE ABUSE TREATMENT Domino, M., Morrissey, J. P., Nadlicki-Patterson, T., Chung, S. 2005; 28 (2): 135–43


    Several aspects of costs related to health care and other service use at 6-month follow-up are presented for women with co-occurring mental health and substance abuse disorders with histories of physical and/or sexual abuse receiving comprehensive, integrated, trauma-informed and consumer/survivor/recovering person-involved interventions (n = 1023) or usual care (n = 983) in a nine-site quasi-experimental study. Results show that, controlling for pre-baseline use, there are no significant differences in total costs between participants in the intervention condition and those in the usual care comparison condition, either from a governmental (avg. US dollars 13,500) or Medicaid reimbursement perspectives (avg. just over US dollars 10,000). When combined with clinical outcomes analyzed in other works in this issue by Cocozza et al. (2005) and Morrissey et al. (2005), which favored the intervention sites, these cost findings indicate that the treatment intervention services are cost-effective as compared with the usual care received by women at the comparison sites.

    View details for DOI 10.1016/j.jsat.2004.08.011

    View details for Web of Science ID 000228143000005

    View details for PubMedID 15780542