Week of April 19, 2000
American Medical Association Science News Updates are made available to
the public after 3 p.m. Central time (U.S.) on the first four Tuesdays of
each month. We also provide a list of
previous news releases.
THIS WEEK'S CONTENT'S
JAMA REPORTS
CHICAGO — Patients in New York State who undergo coronary artery bypass
graft (CABG) surgery and are covered by either private managed care or
Medicare managed care insurance are significantly less likely to have the
surgery done in hospitals with lower mortality rates, according to an
April 19 study published in The Journal of the American Medical
Association (JAMA).
Lars C. Erickson, M.D., M.P.H., from Children's Hospital in Boston, and
colleagues, conducted a study of 58,902 patients hospitalized for CABG
surgery from 1993 to 1996 using New York Department of Health databases to
determine the use of lower-mortality hospitals by patients with different
types of health insurance. Cardiac surgical centers in New York, of which
14 were classified as lower-mortality hospitals (average mortality rate,
2.1 percent) and 17 were classified as higher-mortality hospitals (average
mortality rate, 3.2 percent), were studied.
"Patients with managed care insurance and, particularly, managed
Medicare insurance were often excluded from many lower-mortality hospitals
entirely, implicating relatively powerful disincentives, such as use
restrictions set by insurance companies, rather than differences in
patient or referring physician preferences," the authors write. "Such
restrictions could include removing a hospital from a plan's preferred
provider list or requiring a significant patient co-payment for the use of
that hospital."
Compared with patients with private fee-for-service insurance, patients
with private managed care insurance were 23 percent less likely to receive
CABG surgery at a lower-mortality hospital; Medicare managed care
insurance patients were 39 percent less likely.
If the managed care plans had guided patients to low-mortality centers
or had considered mortality in selective contracting, the expected outcome
is that managed care patients would be concentrated in low-mortality
centers, according to an editorialist who wrote about this study (see end
of press release). Instead, there was a statistically significant tendency
for managed care plans to use centers with higher mortality rates, even
after researchers adjusted the results for factors that may have
confounded the results.
"Financial risk provides a strong incentive for health plans to select
low-priced hospitals. However, health plans should also consider quality
of care when contracting with hospitals, especially if explicit data on
quality are available," the authors write.
The researchers explain these research findings are opposite previous
California research findings, where managed care patients were more likely
than insured non-managed care patients to use hospitals with lower-than
expected mortality rates for coronary bypass graft surgery. They cite a
commentary written on this study which explains that California has no
certificate-of-need system (some states require hospitals to obtain state
approval before initiating a new medical service, and the approval is
often based partially on the amount of volume that hospital will see when
providing the service to avoid costly duplication of services in a
particular region).
They explain that California has numerous low-volume hospitals with
high mortality rates performing CABG surgery. They say because low volumes
make contracting unattractive, managed care plans in California avoid
sending their patients to the highest mortality hospitals. The authors
Erickson et. al. explain that New York has a certificate-of-need program,
which dictates that all CABG surgery hospitals have high surgical volumes.
In conclusion, the authors write: "... by limiting patient choices,
managed care organizations may prevent patients and their advocates from
taking full advantage of available information about hospital quality.
This could inadvertently stifle incentives for hospitals to compete on the
quality of care. Additional studies on the impact of quality information
on health plans' contracting decisions will be important as price
competition among health plans becomes more intense."
(JAMA.
2000;283:1976-1982)
Note: This study was supported in part by the Kobren Fund, Boston.
EDITORIAL: QUALITY DATA USEFUL, BUT DO NOT SHAPE MARKETPLACE
In an accompanying editorial, Stephen F. Jencks, M.D., from the Health
Care Financing Administration, Baltimore, writes: "A number of studies
indicate that, in general, patients rank quality information far behind
convenience, coverage, access, and cost in choosing health plans, and this
likely holds for choice of provider organizations and practitioners. In
addition, consumers make clear that they value information on health
choices from friends, family, and personal physicians much more than
information from government sources. Such consumer information must
continue to be available and understandable because consumers have a right
to know and because these data can be used for consumer protection, but
should not be expected to reshape the marketplace in the short run."
He concludes: "Although education and technical assistance for
physicians and consumers is clearly needed, help for market forces today
must come largely from health care purchasers, who must deliver the
message both directly and through the health plans with which they deal."
(JAMA.
2000;283:2015-2016)
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CHICAGO — Women who received nurse home visits during pregnancy and up
to two years after the birth of their first child have lower rates of
subsequent pregnancy, longer intervals between first and second child and
fewer months of welfare use, according to an article in the April 19,
2000, issue of The Journal of the American Medical Association
(JAMA).
Harriet Kitzman, R.N., Ph.D., from the University of Rochester in
Rochester, N.Y., and colleagues report on the three-year follow-up of a
trial that randomly assigned pregnant women to either receive prenatal and
infancy home visits by nurses or to a control group, which did not receive
nurse home visits. The majority of the women who participated in the trial
were black (92 percent) and all were from an urban environment (an
obstetrical clinic in Memphis). The women selected to participate were
pregnant for less than 29 weeks at the time they enrolled in the trial,
had no previous live births, and had at least two socioeconomic risk
factors (such as being unmarried, having less than 12 years of education
or being unemployed). The researchers followed the participants for three
years after the two-year program had ended.
The researchers found that women assigned to receive nurse home visits
had on average fewer subsequent pregnancies (14 percent reduction), longer
intervals between the birth of the first and second child, fewer months
using Aid to Families with Dependent Children (AFDC) and fewer months
using food stamps. The women assigned to nurse home visits also had higher
rates of living with a partner (43 percent versus 32 percent) and living
with the father of the child (19 percent versus 13 percent).
The researchers also compared the effects of the program for the time
period when the program was in operation (essentially the first two years
of the infant's life) with the time when it had ended (essentially the
following three years). The researchers found that the effect after the
program was ended was basically the same for AFDC use, a greater effect on
the use of food stamps, greater effect for rates of closely spaced
subsequent pregnancies and smaller for rates of subsequent pregnancy
overall.
The women assigned to home visits received an average of seven visits
during their pregnancy and 26 visits from the child's birth to the child's
second birthday. "The nurses followed detailed visit-by-visit guidelines
to help women improve their health-related behaviors, care of their
children and life-course development (pregnancy planning, educational
achievement, and participation in the workforce)," the authors write. "To
improve maternal life-course outcomes, the nurses helped women clarify
their goals and solve problems that may have interfered with completing
their educations, finding work and planning future pregnancies. The nurses
promoted work, education and family planning, but did so in the context of
helping women envision a future and set goals for themselves at a crucial
stage in their own personal development."
The researchers found smaller effects for this trial compared to an
earlier trial of the same program in a semi-rural setting (Elmira, N.Y.)
with primarily white participants. "The smaller effect of the Memphis
program on maternal fertility outcomes and absence of effect on maternal
employment compared with low-income, unmarried women in the Elmira program
at corresponding periods may be due to the social and economic isolation
experienced by many minority families living in inner-city neighborhoods
in poverty. It may also have to do with the higher rater of staff turnover
in the Memphis program due to a nursing shortage that coincided with the
conduct of the trial." Because of the staff turnover, 37 percent of
families had the relationship with their originally assigned nurse
disrupted.
"Since the effect of the program on the rate of subsequent pregnancies
was reduced after the program ended, it is possible that the long-range
effects of the program on maternal life course will not endure beyond this
three-year period after the end of the program, as it did in Elmira," the
authors write. "The effects of the program on closely spaced subsequent
pregnancies, on partners' duration of employment, and on fathers' presence
in the household, on the other hand, provide an alternative set of
mechanisms through which the program may promote family economic
self-sufficiency for periods beyond the current follow-up."
(JAMA.
2000;283:1983-1989)
Note: The current phase of this research was supported by a grant from
the Administration for Children and Families, Department of Health and
Human Services; a grant from the Carnegie Corporation of New York; a grant
from the Robert Wood Johnson Foundation; and a Senior Research Scientist
Award to co-author David L. Olds, Ph.D.
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