BACKGROUND/RATIONALE:
The primary goal of this project is to determine the extent to which the adoption and implementation of clinical practice guidelines leads to changes in the costs of providing care within a healthcare system.
OBJECTIVE(S):
Our project has three aims: (1) Classify VA facilities according to the strategies and intensity of DM guideline implementation; and (2) Determine the extent to which the strategies and intensity of DM guideline implementation at VA facilities is associated with differences in costs and utilization.
METHODS:
The empirical testing of these aims will make use of a unique research tool-a comprehensive VA database created for the purposes of this study that will link together a large national cohort of well-characterized patients in the 1999 Large Health Survey of Veteran Enrollees (LVHS), national guideline, quality improvement and organizational data collected by our study group, and cost data developed by the VA Health Economics Resource Center (HERC). The 1999 LVHS serves as the study cohort. We focus on patients with the primary diagnosis of DM, confirmed by rigorous algorithms that consider clinical and administrative data on utilization, testing and treatment. LVHS respondents are allocated to VAMCs in which they receive most of their care within a given year, and are tracked over the six-year period 1999-2004. We develop a summative scoring scheme based on item response theory (IRT). We estimate fixed and random effects panel data models of (1) the probability of one or more DM-related inpatient admissions and (2) DM-related inpatient treatment costs. Two-stage least squares regression is used to address the potential endogeneity of the hospital-level IRT guideline measure.
FINDINGS/RESULTS:
Fixed-effects model show that hospitals with sicker patients also tend to have higher (i.e., better) guideline adherence. Fixed-effects two-stage lest-squares model show that lagged IRT was associated with significantly lower probability of DM inpatient admission. However, IRT has no statistically significant effects on DM inpatient cost. Higher comorbidity scores were associated with significantly higher inpatient admission probability and higher inpatient costs. The first-stage F values indicate that IVs highly correlate with IRT. Over-identifying restriction tests for both models suggest that IVs do not correlate with unmeasured confounders (p = 0.05). In sensitivity analyses, two-stage least-squares random-effects models show that lagged IRT is associated with significantly lower probability of DM admission and significant lower levels of DM costs. Random-effects IV cost models for IRT were similar to fixed-effects models.
IMPACT:
The results will in turn enable clinicians, managers, and policy makers to gain a better understanding of the resource implications associated with changes in clinical and organizational structures and processes, and provide a business case for improvements in DM guideline adherence.
PUBLICATIONS:
Journal Articles
- Kern EF, Maney M, Miller DR, Tseng CL, Tiwari A, Rajan M, Aron D, Pogach L. Failure of ICD-9-CM codes to identify patients with comorbid chronic kidney disease in diabetes. Health Services Research. 2006; 41(2): 564-80.
- Schneider JE, Peterson NA, Vaughn TE, Mooss EN, Doebbeling BN. Clinical practice guidelines and organizational adaptation: a framework for analyzing economic effects. International Journal of Technology Assessment in Health Care. 2006; 22(1): 58-66.
- Peterson NA, Lowe JB, Schneider JE. Linking social cohesion and gender to intrapersonal and interactional empowerment: support and new implications for theory. Journal of Community Psychology. 2005; 33(2): 233-244.
