Hospital quality data don't drive healthcare marketplace decisions

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.


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)

Home visits during pregnancy reduce number of subsequent pregnancies and months of welfare use

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.