Population-Based Assessments of Health Status and Satisfaction Using ACQUIP
Stephan D. Fihn MD MPH
VA Puget Sound Health Care System, Seattle
Seattle, WA
Funding Period: October 2000 - September 2002

BACKGROUND/RATIONALE:
This project was conducted to advance understanding about how information obtained directly from patients, in conjunction with information from administrative and clinical databases, could be used to better understand and potentially improve the provision of ambulatory care. We used data collected as part of the Ambulatory Care Quality Improvement Project (ACQUIP) including self-reported diagnoses, longitudinal patient assessments of health status and satisfaction, utilization and clinical data for a series of related analyses.

OBJECTIVE(S):
Main objectives were to: 1) construct models for case-mix and severity-of-illness adjustment that incorporate self-reported diagnoses and health status; 2) develop methods for using condition-specific health status in conjunction with data extracted from VistA to determine whether patients are treated in accordance with nationally accepted clinical practice guidelines; and 3) examine characteristics of patients satisfied with their primary care as well as the satisfaction of providers.

METHODS:
Using a Cox proportional hazards model, a case-mix index, the Seattle Index of Comorbidity (SIC), was constructed/validated using information about age, smoking status and 7 of 25 self-reported medical conditions associated with increased mortality. A separate comparison model was constructed using only age and the Physical (PCS) and Mental (MCS) Component Summary Scores of the SF-36 to predict mortality. The performance of several diagnosis-based case-mix measures was compared in predicting hospital admission (from VA and Medicare data), death and cost. Computerized criteria maps were developed to examine characteristics/outcomes of patients treated in accordance with clinical guidelines for CHD and COPD as compared to patients who were not. Health status, comorbidity, symptom burden and continuity of care were correlated to responses to patient satisfaction questionnaires, and predictive models were developed. Self-reported assessments of provider satisfaction were also obtained.

FINDINGS/RESULTS:
The SIC was predictive of mortality/hospitalizations in a validation set of 5478 patients. The PCS/MCS and the SIC had comparable discriminatory ability (Area Under the Curve [AUC] for discrimination of death within 2 years = 0.71 for both models). Combined, the SIC and SF-36 together had improved discrimination for mortality (AUC=0.74, p-value for difference in AUC < 0.005). Many patients with frequent angina appeared to be receiving an inadequate anti-anginal regimen in terms of both number of agents and dosages. Among 7038 veterans with self-reported CHD disease, 70% had angina or took sublingual nitroglycerin preparations two or fewer times per week. Of the 30% with more frequent symptoms, 22% were receiving no anti-anginal medications, and 33% were receiving only one class of anti-anginal medication. Of those with frequent angina who were prescribed medications, 17% had zero and 51% had only one medication class at a recommended therapeutic dose. Of patients with both COPD diagnosis and bronchodilator use, only 55% had a visit to the Pulmonary Function Test (PFT) lab before, during, or 2 years after the study. Factors associated with PFT referral were shorter length of care in the clinic (p<0.004), no non-VA care (p<0.000), and absence of ischemic heart disease (p<0.008). Severely symptomatic patients, as measured by self-reported symptoms, were also more likely to have been referred (OR 1.44, 95% CI 1.10, 1.45). Scores on general and condition-specific patient satisfaction scales were strongly related to perceived continuity of care, ranging from 86.7 to 61.4 (where 100 is best) among veterans who reported “always” seeing the same provider. Satisfaction scores among veterans who reported “rarely or never” seeing the same provider ranged from 69.5 to 41.9 (p<.001). Symptom severity and burden were modestly correlated with satisfaction in patients with heart disease (r=.28 for angina frequency) but not in patients with the other three conditions (r= 04 to .21). Findings persisted after adjustment for age, education, race, income, VA facility, SF-36 scores and length of time receiving VA care. Personal alignment with organizational philosophy of care accounted for most of the variation in provider satisfaction.

IMPACT:
Completed analyses have yielded important findings and products. The SIC is already being used in a variety of studies. Findings regarding compliance with guidelines have formed the basis for ongoing interventional trials. Measures of self-reported health status provide a valuable adjunct to other clinical and administrative data and our experience has informed efforts in the VA Office of Quality and Performance to establish a national system for collecting these data.

PUBLICATIONS:

Journal Articles

1. Bryson CL, Au DH, Young B, McDonell MB, Fihn SD. A refill adherence algorithm for multiple short intervals to estimate refill compliance (ReComp). Medical Care. 2007; 45(6): 497-504.
2. Blough D, Bradley KA, Bryson CL, Au DH, Kivlahan DR. Alcohol screening scores and risk of hospitalizations for GI conditions in men. Alcoholism, Clinical and Experimental Research. 2007; 31(3): 443-51.
3. Davis GE, Bryson CL, Yueh B, McDonell MB, Micek MA, Fihn SD. Treatment delay associated with alternative medicine use among veterans with head and neck cancer. Head and Neck. 2006; 28(10): 926-31.
4. Liu CF, Campbell DG, Chaney EF, Li YF, McDonell M, Fihn SD. Depression diagnosis and antidepressant treatment among depressed VA primary care patients. Administration and Policy in Mental Health. 2006; 33(3): 331-41.
5. DeSalvo KB, Fan VS, McDonell MB, Fihn SD. Predicting mortality and healthcare utilization with a single question. Health Services Research. 2005; 40(4): 1234-46.
6. Keeffe B, Subramanian U, Tierney WM, Udris E, Willems J, McDonell M, Fihn SD. Provider response to computer-based care suggestions for chronic heart failure. Medical Care. 2005; 43(5): 461-5.
7. Au DH, Bryson CL, Fan VS, Udris EM, Curtis JR, McDonell MB, Fihn SD. Beta-blockers as single-agent therapy for hypertension and the risk of mortality among patients with chronic obstructive pulmonary disease. American Journal of Medicine. 2004; 117(12): 925-31.
8. Arterburn DE, McDonell MB, Hedrick SC, Diehr P, Fihn SD. Association of body weight with condition-specific quality of life in male veterans. American Journal of Medicine. 2004; 117(10): 738-46.
9. Bridevaux IP, Bradley KA, Bryson CL, McDonell MB, Fihn SD. Alcohol screening results in elderly male veterans: association with health status and mortality. Journal of The American Geriatrics Society. 2004; 52(9): 1510-7.
10. Burman ML, Kivlahan D, Buchbinder M, Broglio K, Zhou XH, Merrill JO, McDonell MB, Fihn SD, Bradley KA. Alcohol-related advice for Veterans Affairs primary care patients: Who gets it? Who gives it? Journal of Studies On Alcohol. 2004; 65(5): 621-30.
11. Wiest FC, Bryson CL, Burman M, McDonell MB, Henikoff JG, Fihn SD. Suboptimal pharmacotherapeutic management of chronic stable angina in the primary care setting. American Journal of Medicine. 2004; 117(4): 234-41.
12. Ohldin A, Young B, Derleth A, McDonell M, Diehr P, Kiefe C, Fihn S. Ethnic differences in satisfaction and quality of life in veterans with ischemic heart disease. Journal of The National Medical Association. 2004; 96(6): 799-808.
13. Bradley KA, Kivlahan DR, Zhou XH, Sporleder JL, Epler AJ, McCormick KA, Merrill JO, McDonell MB, Fihn SD. Using alcohol screening results and treatment history to assess the severity of at-risk drinking in Veterans Affairs primary care patients. Alcoholism, Clinical and Experimental Research. 2004; 28(3): 448-55.
14. Fan VS, Au DH, McDonell MB, Fihn SD. Intraindividual change in SF-36 in ambulatory clinic primary care patients predicted mortality and hospitalizations. Journal of Clinical Epidemiology. 2004; 57(3): 277-83.
15. Fan VS, Bryson CL, Curtis JR, Fihn SD, Bridevaux PO, McDonell MB, Au DH. Inhaled corticosteroids in chronic obstructive pulmonary disease and risk of death and hospitalization: time-dependent analysis. American Journal of Respiratory and Critical Care Medicine. 2003; 168(12): 1488-94.
16. Diehr P, Patrick DL, McDonell MB, Fihn SD. Accounting for deaths in longitudinal studies using the SF-36: the performance of the Physical Component Scale of the Short Form 36-item health survey and the PCTD. Medical Care. 2003; 41(9): 1065-73.
17. Au D, Curtis J, McDonell M, Anderson S, Fihn S. Assessing internet use by VA patients. Federal Practitioner. 2003; 20: 35-51.
18. Au DH, Udris EM, Fan VS, Curtis JR, McDonell MB, Fihn SD. Risk of mortality and heart failure exacerbations associated with inhaled beta-adrenoceptor agonists among patients with known left ventricular systolic dysfunction. Chest. 2003; 123(6): 1964-9.
19. Au D, Curtis J, Bryson C, Fan V, Udris E, McDonell M, Fihn S. Antihypertensive medications and risk of mortality among patients with COPD and hypertension. American Journal of Respiratory and Critical Care Medicine. 2003; 167: 317.
20. Bridevaux P, Au D, Fan V, McDonell M, Fihn S. Regional variations in health status among COPD patients. American Journal of Respiratory and Critical Care Medicine. 2003; 167: 238.
21. Fan VS, Curtis JR, Tu SP, McDonell MB, Fihn SD. Using quality of life to predict hospitalization and mortality in patients with obstructive lung diseases. Chest. 2002; 122(2): 429-36.
22. Fan VS, Au D, Heagerty P, Deyo RA, McDonell MB, Fihn SD. Validation of case-mix measures derived from self-reports of diagnoses and health. Journal of Clinical Epidemiology. 2002; 55(4): 371-80.
23. Au DH, Curtis JR, Every NR, McDonell MB, Fihn SD. Association between inhaled beta-agonists and the risk of unstable angina and myocardial infarction. Chest. 2002; 121(3): 846-51.
24. Bradley KA, Kivlahan DR, Bush KR, McDonell And, Fihn SD. Variations on the CAGE alcohol screening questionnaire: strengths and limitations in VA general medical patients. Alcoholism, Clinical and Experimental Research. 2001; 25(10): 1472-8.
25. Au DH, McDonell MB, Martin DC, Fihn SD. Regional variations in health status. Medical Care. 2001; 39(8): 879-88.

DRA: Health Services and Systems
DRE: Quality of Care, Treatment
Keywords: Primary care, Quality assessment, Research measure
MeSH Terms: none