Center Mission

The mission of the Center for Health Care Research and Policy is to:  (1) improve the health of the public by conducting research that examines access to health care, increases the quality of health care services, and informs health policy and practice; and (2) lead educational programs that promote these goals.

Center News [ Recent Publications, 2006 Center Progress Report ]

Fourth Consecutive Year-Center Faculty Named Among Ohio`s Top Doc`s in 2008 This is the fourth consecutive year Center faculty, Irene Katzan MD (Neurology), Patrick K. Murray, MD (Physical Medicine & Rehabilition) and Neal V. Dawson, MD (Internal Medicine) were named in the March 2008 Issue of Cleveland Magazine among Northeast Ohio`s Top Doc`s. Congratulations! Posted 1/2008

Study selected for the Electrode Store Best Paper Presentation at AAP Annual Meeting A study by Richard Wilson, MD, Steven Lewis, MS, and Patrick Murray, MD, MS was selected for the Electrode Store Best Paper Presentation for the annual meeting of the Association of Academic Physiatrists. The study, titled “Trends in Rehabilitation Therapist Workforce in Underserved Areas 1980 – 2000,” examines the supply of physical, occupational, and speech therapists in rural and medically underserved areas in the United States. The key findings are the size of the workforce of physical, occupational, and speech therapists grew at a slower rate in urban and medically underserved areas over the two decades 1980 – 2000 than the size of the workforce in the counterpart areas. This may represent a misallocation of supply given that demand is likely greater in rural areas where there is a greater representation of the elderly. Dr. Wilson will present the findings at the annual meeting of the AAP in Anaheim, California in February of 2008.(posted 1/2008)

Ongoing Work by Center Researchers Covered in Slate A recent study by researchers from Case Western Reserve and Carnegie Mellon University explains that a culprit in inadequate preventive care and effective disease management programs may be the very high rate at which Americans switch among insurance plans. It takes several years for insurers to recoup their investment in early diabetes treatment, for example, and by then odds are that their customer has moved on to another health plan. Alas, says the Slate article, alot of this turnover may be built in to the way Americans get health insurance. And this may be the doing not of individual patients so much as their employers, who are always on the lookout to switch plans for lower-cost coverage. (posted 9/2007)

Visiting Professor Frank Harrell, PhD Held Seminar Frank Harrell , Ph.D., founding Chair of the Department of Biostatistics at Vanderbilt University, visited on Tuesday, May 22 to give a seminar entitled "Presenting Regression Models to Clinicians". Dr. Harrell has devoted his career to the study of patient outcomes. In particular he has worked on accurate prognostic and diagnostic models. Dr. Harrell`s work has been applied to health services and outcomes research, technology evaluation, observational databases, and clinical trials. During his visit to Cleveland, Dr. Harrell gave a full-day short course for the Cleveland Chapter of the American Statistical Association regression modeling strategies.(posted 6/2007)

Center Faculty Again Named Among Northeast Ohio`s Top Docs in 2007 For the third consecutive year, Center faculty Neal V. Dawson, MD (Internal Medicine), Irene L. Katzan, MD (Neurology) and Patrick K. Murray, MD (Physical Medicine and Rehabilitation) were named among Northeast Ohio’s Top Docs in the March 2007 issue of Cleveland Magazine. Congratulations to all! (posted 3/2007)

Center Member Sudano to Present Two Abstracts at IADR in New Orleans Joseph Sudano, PhD, faculty will present two abstracts at the 85th General Session of the International Association for Dental Research to be held in New Orleans March 21-24, 2007. Co-author of both papers, Dr. Sudano will personally present: “Relationship Between Adult Oral Health, Depression, Pain and General Health”. (posted 3/2007)

Graduate of the Clinical Research Scholars Program to Receive Young Investigator Award John Carey, M.D., M.S., a recent graduate of Case`s Clinical Research Scholars Program and Clinical Associate in the Department of Rheumatic and Immunologic Diseases at the Cleveland Clinic, has been selected to receive the International Society for Clinical Densitometry`s Young Investigator Award for his abstract (co-authored by Center faculty Thomas E. Love, Ph.D.) for his work: "The Impact of Subject Demographics on Young Adult DXA Z-Scores." Carey will present the work at the ICSD Annual Meeting in Tampa, Florida on March 15, 2007. (posted 2/2007)

Center Faculty Lead in Region-wide Partnership to Improve Quality of Care The MetroHealth System led a region-wide partnership - of primary care physicians, employers, health plans, and public health agencies – in winning a $600,000 grant from the Robert Wood Johnson Foundation’s “Aligning Forces for Quality” program. Announced February 1st, the Northeast Ohio application was among 68 nationwide, of which 10 communities were awarded grants to measure and improve quality of outpatient care for patients with chronic conditions such as diabetes, heart disease, and asthma. Center Director Randall Cebul will serve as Project Director for the NEO Aligning Forces initiative, although he credits strong partnerships with others in the region – including the leadership of NEO’s primary care practices, the Center for Community Solutions, the Health Action Council, and NEO’s public health agencies – in producing the successful proposal. See coverage by the Plain Dealer and announcements by the RWJF and the Health Action Council. (posted 2/2007)

National Science Foundation Dissertation Improvement Grant Awarded Constance Liu, a student in Case Western Reserve University`s MD/PhD in Health Policy Program, has been awarded a $12,000 Doctoral Dissertation Research Improvement Grant from the National Science Foundation. Her study, which is being carried out in collaboration with the Center for Health Research and Policy, focuses on geographic access to health care for a poor, diabetic population served by the MetroHealth System. The results will clarify the interpretation of studies that use distance as a measure of geographic access, and may additionally guide the selection of geographic measures in future studies carried out in an urban context. CHRP faculty member, Dr. Douglas Einstadter, is serving as a voting member of her dissertation committee. (posted 2/2007)

Henry Glick, PhD Presents Two Seminars on Economic Analysis of Research Trials, January 5th Henry Glick, Ph.D. presented two special seminars concerning "The Economics of Obesity" and "The Economic Analyses in Clinical Trials"at MetroHealth Medical Center, Rammelkamp Research & Education Building. Professor Glick received his M.A. and Ph.D. in Public Policy Analysis from the University of Pennsylvania. He has more than 20 years of experience in conducting economic assessments of medical therapies. He specializes in economic assessments conducted as part of clinical trials. Henry is currently the chair of the Economics Committee for "Studies to Treat or Prevent Pediatric Type 2 Diabetes (STOPP-T2D) Prevention Study" and co-chair of the Economics Committee for the "Action for Health in Diabetes (LookAHEAD) Study", two large, randomized trials sponsored by the National Institute of Diabetes and Digestive and Kidney Disease. (posted 12/2006)

Bridges to Excellence National Coordinator Delivers 2006 Lecture on Health Care Economics and Policy Francois de Brantes, BTE National Coordinator, spoke on: "Improving the Value of Health Care: Lessons Learned from Bridges to Excellence” at Cleveland`s Union Club on Friday November 10th. (posted 11/2006)

Rhoderick Machekano Guest Speaker at November ASA Meeting Center faculty member, Rhoderick Machekano, Ph.D., MPH, spoke at the November 1, 2006 American Statistical Association meeting (held at MetroHealth). The topic of his talk was “Efficacy Studies of Malaria treatments in Africa: Efficient Estimation with Missing Indicators of Failure.” (posted 11/2006)

Center Faculty and Colleagues Well Represented at SMDM Meeting Center faculty, co-investigators, and students were well represented at the annual meeting of the International Society for Medical Decision Making meetings in Boston, October 15-18th. Collectively, Center faculty and colleagues presented 11 abstracts, two short courses, and chaired the plenary symposium that focused on the meeting’s theme: “Real-Time Clinical Decision Support to Improve Quality of Care”. Of special note, the pre-meeting course: “Methods for Cluster Randomized Trials of Clinical Decision Support”, directed by Randall Cebul along with Center colleagues Neal Dawson and Tom Love, won the “Best Short Course” award from among 19 courses offered by SMDM members worldwide.(posted 10/2006)

Dr. Katzan Honored for Work in Stroke Research Irene Katzan, MD, MS, faculty member in the Center for Health Care Research and Policy and Director of the Northeastern Ohio Stroke Outcomes Research Program (SORP), was honored with the 2006 Pacesetter Award for Excellence in Stroke Research and Treatment at the American Heart Association’s annual Gala event in Cleveland on Saturday June 3rd. Others honored with this award were Anthony Furlan MD (Cleveland Clinic), Joseph Hanna MD (MetroHealth Medical Center), and Dennis Landis MD (University Hospitals of Cleveland), all of whom are members of SORP. The award recognizes physicians who have worked to advance the care of stroke patients regionally and nationally. (posted 6/2006)

Time of Day Caesarean Sections Performed does not Impact Complications Concerns that sleep deprivation increases medical errors has led to increased scrutiny of the quality of medical care during night shifts. In a poster presented at the Society for Maternal Fetal Medicine in early February, Jennifer Bailit, MD, MPH from the Center for Health Care Research and Policy presented data from a study that compared complications from Caesarean sections by time of day. Data from over 18,000 Caesarean Sections at 13 medical Centers between 1999 to 2000 was reviewed. Caesarean births that occurred on the night shift did not have higher rates of complications from mother or newborn compared to births that occurred during the day. Data was adjusted for age, race, insurance status, medical conditions in the mother and the presence of preeclampsia. (posted 5/2006)

Donald B. Rubin Gave Special Seminar on May 16th Donald B. Rubin, the John L. Loeb Professor of Statistics at Harvard University, gave a special seminar entitled "The Design (versus analysis) of Observational Studies" on May 16th at the Center for Health Care Research and Policy at MetroHealth Medical Center. He has made enormous contributions to many areas in statistics and related fields, and was the seventh most cited mathematician in the world in 1991-2001. His main research interests include causal inference in experiments and observational studies, inference in sample surveys with nonresponse and in missing data problems, application of Bayesian and empirical Bayesian techniques, and developing and applying statistical models to data in a variety of scientific disciplines. (posted 5/2006)

William C. Knowler, MD, DrPH, Chief of Diabetes Epidemiology and Clinical Research, NIDDK Presented Two Lectures Among his many achievements, Dr. Knowler has served as Principal Investigator of the landmark Diabetes Prevention Program (DPP) trial and the ongoing Family Investigation of Nephropathy and Diabetes (FIND) study. On Thursday April 20th, Dr. Knowler gave Medical Grand Rounds a lecture at MetroHealth, on “Genetic Epidemiology of Type 2 Diabetes Mellitus and Its Vascular Complications”. On Friday April 21st he presented a Health Service Research Seminar entitled: “From Epidemiology to Prevention of Type 2 Diabetes”. (posted 4/2006)

Katzan Receives Pessin Prize for Stroke Research Center faculty member Irene Katzan, MD, MS, Assistant Professor of Neurology, received the 2006 Michael S. Pessin Stroke Leadership Prize for her work in stroke management during the American Academy of Neurology’s 58th Annual Meeting in San Diego, held April 1 – 8. The American Academy of Neurology, an association of more than 19,000 neurologists and neuroscience professionals, is dedicated to improving patient care through education and research. The Pessin Stroke Leadership Prize recognizes emerging neurologists who have demonstrated a passion for learning and expanding the field of stroke research. “My research interests are in evaluating and optimizing care of patients hospitalized for stroke,” said Katzan. “Much of it focuses on stroke management in the community setting, where the majority of stroke patients receive care. Identifying factors that positively or negatively impact the outcomes of stroke patients and ways to optimize care has implications for all stroke victims. “I am grateful to have been nominated and am absolutely thrilled to receive the Pessin Stroke Leadership Prize,” said Katzan. Sponsored by the AAN, this prize is endowed by Dr. Pessin’s family, friends, and colleagues. (posted 3/2006)

"State of Ohio’s Health” Luncheon Series Opened with HPIO President Hayes Furthering its mission to inform health policy through research, the Center will hold several evidence-based policy discussions concerning the State of Ohio’s Health between now and the fall 2006 statewide and national elections. In the first of these, on Friday March 31st, Bill Hayes, President of the Health Policy Institute of Ohio, discussed data and related policy implications from the 2002 and 2004 Ohio Family Health Survey. Sessions will be held at MetroHealth Medical Center. (posted 3/2006)

Congratulations to the Center’s Top Docs In the March issue of Cleveland Magazine, several Center faculty were named among Northeast Ohio’s Top Docs. Congratulations to Neal V. Dawson, MD (Internal Medicine), Irene L. Katzan, MD (Neurology), Patrick K. Murray, MD (Physical Medicine and Rehabilitation) and Allan B. Garland, MD (Pulmonary and Critical Care Medicine). (posted 3/2006)

Dr. Katzan “Lady in Red” in Cleveland Magazine (February 2004 & 2006) Center member Irene L. Katzan, MD, MS was featured for the second time as the "Lady in Red" in the February, 2006 issue of Cleveland Magazine. The magazine also featured American Heart Association funded research led by Dr. Katzan that is evaluating racial differences in stroke severity and management The magazine partnered with the American Heart Association to highlight February’s "Go Red for Women" campaign to make women more conscious of their risks for cardiovascular disease and stroke. Irene leads the citywide Stroke Outcomes Research Program and has been a leader in Northeast Ohio’s Operation Stroke for more than 7 years. (posted 2/2006)

Peter S. Tippett, MD, PhD Gives Special Seminar On Friday, January 27th. Peter S. Tippett, MD, PhD, gave a special Health Services Research Seminar on Friday, January 27, "Flat Earth Thinking in Applied Information Technology." His talk addressed several contemporary issues in the use of health information technology for patient care and research. Dr. Tippett is widely recognized as an information security visionary. He currently serves as a member of the President`s Information Technology Advisory Committee (PITAC) to help guide the Bush administration`s efforts in the development and adoption of health information technologies. Dr. Tippett received both his MD and PhD degrees from Case Western Reserve University and was a resident in Medicine at MetroHealth. Incidentally, not long after leaving MetroHealth, Dr. Tippett sold his cyber-security software – now called Norton Anti-Virus – to Symantec. (posted 2/2006)

The Cleveland Department of Public Health (CDPH) Welcomes Ashwini Sehgal, M.D. New Co-Medical Director Physician to focus on Reducing Health Disparities Ash Sehgal, MD, an experienced physician and researcher in the areas of health disparities and quality improvement, joins the Cleveland Department of Public Health in a shared role as co-medical director. Dr. Sehgal is the Duncan Neuhauser Associate Professor of Community Health Improvement and Director of the Center for Reducing Health Disparities at Case Western Reserve University in Cleveland, Ohio. He is also a practicing nephrologist at MetroHealth Medical Center. "Dr. Sehgal is prepared to enhance the Department’s efforts to reduce health disparities," says Matt Carroll, interim public health director." As a researcher Dr. Sehgal focuses on quality improvement and has worked to identify and overcome barriers for effective care of all patients. We took forward to his expertise as Mayor Jackson and CDPH work to bridge health gaps for all Clevelanders." Dr. Sehgal will serve Cleveland along with his counterpart co-medical director Ann Avery, MD, Infectious Disease physician at MetroHealth Medical Center. Avery`s responsibilities will remain focused on emergency preparedness, communicable and sexually transmitted disease as Dr. Sehgal focuses on health disparities, maternal and child health and chronic disease prevention. Quoted from CDPH Press Release of 1/9/06,   (posted 1/2006)

Hispanic/Latino HIV Patient Program to Improve Medical CareCommunity Education Dr. Ash Sehgal, Director of the Center for Reducing Healthcare Disparities, received a $60,000 grant from the AIDS Taskforce of Greater Cleveland (ATGC) in September to provide better medical access and education to Hispanic/Latino persons with HIV. The goal of this three year commitment is to improve the medical outcomes for Hispanic/Latino persons living with HIV/AIDS in northeast Ohio. Hispanic/Latino people living with HIV, especially those with difficulty speaking and reading English, access HIV care and treatment services at lower rates than their European-American counterparts. Hispanic/Latino people with HIV have comparatively higher levels of HIV morbidity and mortality. These disparities hold true both nationally and locally. The program, entitled Mas Vida (“More Life”) initiative, is a partnership between the AIDS Taskforce of Greater Cleveland (ATGC), and the HIV Unit at MetroHealth Medical Center. The program will provide HIV Hispanic/Latino persons with bilingual services such as social workers in clinics and community programming. It will also facilitate the development of community partnerships including ATGC, MetroHealth Medical Center, and a range of community organizations and groups serving the northeast Ohio Hispanic/Latino communities. (posted 12/2005)

Jennifer Bailit, MD, MPH Awarded a Grant from the Agency for Healthcare Research and Quality (AHRQ) Jennifer Bailit MD, MPH along with Dr. David Aron from the VA hospital and Dr. Thomas Love from the Center for Health Care Research and Policy have been awarded a two year grant from the Agency for Healthcare Research and Quality to investigate the characteristics of hospitals that provide higher quality obstetrical care. Results of this study will help hospitals understand how to improve the quality of inpatient obstetrical care. The study is co-funded by the National Institute for Child Health and Human Development. (posted 12/2005)

The Western Reserve Geriatric Education Center (WRGEC) received full funding for the next 5 year grant cycle, which will carry the WRGEC activities through to 2010. The funding allows the WRGEC to pursue three themes of interest as determined by a needs assessment distributed last fall to past program participants. The three theme areas include geriatric palliative and end-of-life care, geriatric mental health care, and reducing disparities in geriatric care. Included within these themes are activities that will expand curriculum on cancer and aging, determination on capacity in mental health care, and a faculty development program on palliative care. An addition was also made to the consortium which consists of Case Western Reserve University (headquarters), Northeastern Ohio Universities College of Medicine, Ohio University College of Osteopathic Medicine, Miami University, and now Medical University of Ohio (formerly Medical College of Ohio). Congratulations to Dr. Julia Rose and her staff at the WRGEC!

Thomas E. Love, Ph. D. has been selected to receive a 2005 Scholarship in Teaching Award from Case`s School of Medicine. Dr. Love received this award for his work on teaching statistical methods for observational studies, primarily in Case`s Clinical Research Scholars Program, and also in workshops at national and international meetings. The Scholarship in Teaching Award (now in its second year) is designed to encourage the application of scholarship to efforts in education. Dr. Love also received this award (previously called the Best Educational Contribution Award) in 2004.

Institutional Partnerships in Diabetes Research Featured in June 2005 Case Medlines [See pages 4-5 here.]

Faculty Win Case Presidential Research Initiative Award, 2005 For many important medical conditions, providers can improve outcomes by offering services that reduce the future likelihood of costly complications - such as disease management for chronic conditions, treatments for obesity or tobacco use, and certain kinds of primary prevention. Yet these services often are not covered by health insurance plans, and providers frequently don`t provide them. In a partnership between Center faculty in Medicine and Economics, investigators Cebul, Rebitzer, and Votruba seek to examine the economic and health effects of enrollee turnover rates, or insurance "churn", on this impediment to better quality of care. The two-year grant was one of eight awarded by CWRU - with matching funds from the Weatherhead School of Management and MetroHealth Medical Center - to foster interdisciplinary research across schools at CASE.

Irene L. Katzan, M.D., M.S. Awarded AHA Grant to Study Racial Disparities in Stroke Care and Outcomes Dr. Katzan MD and others of the Cleveland Stroke Outcomes Research Program received the $120,000 grant from the American Heart Association`s Ohio Valley Affiliate. The two-year study will collect data at 17 hospitals in Cuyahoga and Geauga Counties to provide information that will address ways to reduce the excess mortality observed in black stroke victims. Currently, stroke mortality is approximately twice as high in blacks as in whites, making it the single most important contributor to excess mortality among blacks.

David Cutler, Professor of Economics at Harvard`s Department of Economics and the Kennedy School of Government, delivered the Center`s Inaugural Lectureship in Health Economics and Policy on Friday, April 15th, at the Cleveland Union Club The talk, entitled: "Prescriptions for Better Health Care: What Greater Cleveland Can Learn From Other Regions", was attended by over 75 representatives of business, provider organizations, government, and academia. Copies of slides are available from his Friday lecture as well as Thursday`s McMyler Lecture: "Your Money or Your Life: Strong Medicine for America`s Health Care System".

Joseph J. Sudano, Jr., PhD, Awarded $1.4 Million to Study Racial/Ethnic Measurement Bias in Health Surveys Center faculty member Joseph J. Sudano, Jr., PhD, Assistant Professor of Medicine and Epidemiology and Biostatistics, has been awarded a 3-year grant from the National Institutes on Aging to investigate racial/ethnic measurement bias in the most commonly used health survey tools. Along with co-Investigators Patrick Murray MD, Thomas Love PhD, and Neal Dawson, MD, 1320 whites, blacks, English-speaking and Spanish-speaking Hispanics will take a standard health survey and then asked to perform a series of tests to measure physical functions related to the concepts in the survey. Comparisons between the subjective assessments of health and the objective tests of physical performance will be made to determine if there are differences in these measures across the 4 groups. Results will help in designing future health surveys and more accurately understand differences in health status across racial/ethnic groups. Joining Dr. Sudano in this study are consortium researchers from Northwestern University`s Feinberg School of Medicine, including David W. Baker, MD and Gail Huber, PT.

Andrew O`Connor, DO, MPH, awarded Pfizer Scholars Grant in Clinical Epidemiology to Study the Role of Chronic Lead Exposure in Diabetic Kidney Disease Center faculty member Andrew O`Connor will undertake a 3-year project to investigate the role of chronic environmental lead toxicity as a factor in the progression of diabetic nephropathy. The research will take advantage of a longitudinal cohort of over 300 diabetic subjects who are being recruited to study genetic factors in diabetic kidney disease. Rather than using blood lead levels, lead exposure will be measured using a novel radiologic technique that allows quantification of long term lead exposure. Decline in kidney function will be assessed annually in the cohort. This will be the first study to examine the role of ambient low level environmental lead toxicity as a factor in chronic diabetic kidney disease. O`Connor`s application ranked first in a nationwide competition for the 3-year career development award, given to two junior medical school faculty each year.

Senior Scholar James R. Rebitzer, Ph.D. Receives Award for Excellence in Health Care Research Dr. Rebtizer, the Frank Tracey Carlton Professor and Chair of Economics at Weatherhead School of Management, received an award for excellence in original and creative health care research from the National Institute for Health Care Management Research and Educational Foundation at its Eleventh Annual Award dinner in Washington, D.C. on November 1st. The award was given to Professor Rebitzer and his co-authors Martin Gaynor and Lowell Taylor of Carnegie Mellon University for their paper "Physician Incentives in Health Maintenance Organizations", which appeared in the August 2004 issue of the Journal of Political Economy. The paper examines how physicians respond to financial incentives to reduce health care costs. The winning paper was selected by a panel of leading health care experts and was accompanied by a $5,000 prize.

Julia Rose, PhD, MA, Awarded $2 Million for a National Center to Support Evaluation in Geriatrics Education Julia Hannum Rose, PhD, MA, Associate Professor of Medicine and Bioethics and Co-Director of the Program for Research on Aging, and her Co-Investigators Diana Gurley, PhD, and Patrick Murray, MD, have been awarded a $2 million, 5-year contract by HRSA to establish a National Technical Assistance Center (NTAC) for geriatric education programs. The central office will be housed at Case in the Center for Health Care Research and Policy, with regional offices at UCLA and the New Jersey College of Osteopathic Medicine. The NTAC will provide support for education evaluation and research to 47 Geriatric Education Centers throughout the country. These centers offer training in geriatric medicine to students, faculty and practitioners across the full range of health professions, including physicians and nurses, social workers, allied health professionals, psychologists, health administrators, and first responders. It will provide online resources and access to individuals throughout the country with expertise in research, policy, health disparities, and education, and will offer two training seminars each year to coincide with national conferences.

Recent Publications

Should Stroke Patients Be Directed to High Stroke Volume Hospitals? In the December issue of Medical Care, Center members Dr. Randall Cebul & Mark E. Votruba, PhD, investigate whether better health outcomes could be expected if stroke patients were directed to hospitals treating higher volumes of stroke patients. Using data from 12,150 Medicare patients admitted for acute stroke to one of 29 hospitals in Greater Cleveland, the authors find that hospital stroke volume is predictive of lower 30-day (risk-adjusted) mortality rates, but that patient distance to nearest hospital is predictive of higher mortality rates. Simulating the effect of hypothetical policies to direct stroke patients exclusively to hospitals meeting a particular volume threshold, they find that potential improvements in mortality are largely offset by the adverse effect of increasing patient-hospital distance. This finding sheds doubt on the value of implementing volume-based referral policies for hospital stroke care. (posted 2/2007)

The Effect of Private Insurance on the Health of Older Working Age Adults Using data from a national survey of adults in late middle age who are nearing entry into Medicare, Drs. Dor, Sudano, and Baker investigated if the presence of private insurance--compared to being uninsured--contributes to better health status over a period of 4 years. They also wanted to determine if past methods of analyzing this problem underestimated the effect of having insurance. The authors of the article published in Health Services Research found that traditional methods of estimating the effect of having insurance were small and statistically significant, but biased downward, i.e., underestimated the effect of having insurance; and using two approaches called “instrumental variables” and “treatment-effects models,” alternative estimates yielded up to a six-fold increase in the insurance effect. They concluded that prior estimates indeed underestimated the effects of having insurance and that extending insurance coverage to working age adults may result in improved health. Additionally, policies aimed at expanding coverage to this population may lead to improved health at retirement and entry to Medicare, potentially leading to savings. (posted 1/2007)

Late Middle Aged Uninsured More Likely to Have Health Decline Than Those With Insurance Uninsured adults in late middle age are more likely to have a health decline than individuals with private insurance. The authors extend their previous investigations in this study by determining how health--and the risk of a future health decline--changes after the uninsured gain Medicare. The uninsured transitioning to Medicare reported a 50% greater risk of having a major decline in health, and also an increased risk for developing functional limitations, when compared to their previously privately insured counterparts. Gaining Medicare did not lead to immediate health benefits for individuals who were uninsured before age 65. However, after two or more years of continuous Medicare coverage, the uninsured no longer had a higher risk of adverse health outcomes. These findings suggest that policy initiatives to expand Medicaid and Medicare coverage by various means would help prevent or attenuate health declines for individuals who otherwise would have been uninsured, thereby reducing health care costs for newly enrolled aged beneficiaries during their first years of Medicare coverage. Center member Joseph Sudano, PhD co-authored this paper in the Journal of General Internal Medicine. (posted 1/2007)

The majority of Older Ohioans with Cancer who Receive Home Health Care Also Have Other Illness or Disability Then needs of patients with cancer vary considerably and are influenced by patients’ overall health at the time of their cancer diagnosis. A paper co-authored by Center faculty member Dr. Patrick Murray examined the rates of co-morbid illness, disability and geriatric syndromes in older Ohio residents with cancer who received home health care. The paper titled “Comorbidity, disability, and geriatric syndromes in elderly cancer patients receiving home health care” was published in the Journal of Clinical Oncology in May, 2006. Authors examined data from Ohioans 65 years of age or older who were receiving home health care and who had been diagnosed with breast, prostate or colon cancer between August 1999 and November 2001. Data from the Outcome and Assessment Information Set, a data base that compiles comprehensive assessment forms for all home healthcare patients was evaluated to determine rates of co-morbidity, disability and geriatric syndromes. The study demonstrated that 26.4% of breast cancer patients, 12% of prostate cancer patients and 14 % of colorectal cancer patients had no comorbid conditions, disability, or geriatric syndromes. At the other end of the spectrum, 11.7%, 24.7% and 15.0% respectively in the three diagnostic groups had all three noted-- comorbid conditions, disability, and a geriatric syndrome. As expected, the proportion of patient with no co-morbidity, disability or geriatric syndrome decreased with increasing age. Tools to assess the presence of co-morbid illness, disability and geriatric syndromes in older patients at the time of a cancer diagnosis may help clinicians better identify older patients more likely to benefit from standard cancer treatment and those more likely to experience adverse outcomes. (posted 10/2006)

Study Finds Heart Failure Patients Who Used Diuretics Regularly Had Higher Hospitalization and Mortality Rates Compared to Patients Not Taking Them A study co-authored by Center faculty member Dr. Thomas E. Love, published in June in the European Heart Journal, found that patients with congestive heart failure who used non-potassium sparing diuretics had an increased risk for death and hospitalization compared to patients not taking diuretics, even after careful adjustment for a wide range of other factors. Non-potassium sparing diuretics are commonly used to treat high blood pressure by reducing the amount of water and sodium in the body. These drugs are often used in the treatment of patients with heart failures. In this study, the authors analyzed data from the Digitalis Investigation Group (DIF)study, an NIH-sponsored randomized trial of 7,788 heart failure patients conducted from 1991-1993. Chronic heart failure patients in this study who were taking diuretics displayed increased risks of death and hospitalization compared to patients not taking diuretics, even after careful adjustment for a wide range of other factors. These findings challenge the wisdom of routine chronic use of diuretics in heart failure patients who have no substantial symptoms of fluid retention. (posted 9/2006)

Hepatitis C Patients Who Are Non-problem Drinkers Continue Intermittent Alcohol Use Despite Recommendations for Abstinence Only 50% of non-problem drinkers with chronic hepatitis C who were interviewed followed the recommendation to abstain from all alcohol consumption, according to the results of a study written by Dr. Eleanor Palo Stoller, Center faculty member Dr. Neal Dawson, and Center researchers Adam Perzynski, Stephanie Kanuch and Noah Webster published in the on-line journal Alcohol and Alcoholism. The study also found that interviewees who did drink often modified their behavior by changing the type of alcohol they consumed, or limiting drinking to particular occasions. Interviewees understood the risks of drinking after HCV infections. Interviewees identified triggers including social pressure and stressful situations in which support was needed to adhere to intentions not to drink. (posted 9/2006)

Risk Adjusted Primary Cesarean Rates May Be Tool to Evaluate Quality of Obstetrical Care No good tools exist to measure the quality of patient care for mothers giving birth in hospitals. In a article titled “Quality of Obstetric Care and Risk Adjusted Primary Cesarean Delivery Rates” by Jennifer Bailit MD, MPH, Thomas E. Love, PhD and Neal V. Dawson MD, data from 2001 California Birth certificates was used to create risk adjusted primary cesarean delivery rates. Primary risk-adjusted cesarean rates were then related to risk for medical complications in both the mother and the baby. Researchers found that hospitals whose actual cesarean rates were lower than expected had higher rates of complications for mothers and the babies. Researchers concluded that risk adjusted primary cesarean rates may be a useful tool to measure health care quality. (posted 7/2006)

People Without Health Insurance Have Higher Death Rates, Worse Overall Health and Eventually Have Higher Costs in Medicare and Medicaid: Public Health Insurance May Cost Taxpayers Less In a study published in the journal Medical Care in March, Drs. David Baker and Joseph Sudano and their colleagues found that uninsured older Americans experienced more rapid declines their health compared to insured Americans of the same age. The uninsured individuals usually enrolled in public insurance programs like Medicare later, after their health was already poorer. The later enrollment resulted in higher health costs than if they had continuous health insurance. Individuals who started out uninsured also had a 35% higher mortality rate. This study analyzed data from the Health and Retirement Survey. The Health Retirement Survey enrolled about 10,000 adults with an average age of 56 at the start of the study. Study participants were surveyed every 2 years since 1992. Individuals with no insurance at each 2 year survey had a 43% higher risk of a serious decline in health compared to insured individuals. Those uninsured had 35% higher mortality rates over the 10 years of the survey compared to insured individuals. The authors findings showed that many of the uninsured transition to public insurance prior to their death and the situation appears to be one of “Pay me now or pay me later” Their study supports the work by researchers Hadley and Waidmann who estimated that Medicare and Medicaid would spend approximately $19 billion less on care for newly enrolled beneficiaries in the first 5 years of coverage if they were insured for the 8 years prior to entering Medicare. Their results suggest that expanding healthcare coverage to those ages 50-65 would lead to improved health in those individuals and lower costs to Medicare. (posted 5/2006)

Poverty is associated with Higher Mortality and Declines in Health among Older Adults A study published in the February 2006 issue of Social Science and Medicine by Center member Joseph Sudano, PhD and Dr. David Baker, a former Center member, showed that declines in the health of older adults were most strongly associated with low SES (socioeconomic status). Higher mortality rates for blacks compared to whites were also observed. The difference in mortality rates between blacks and whites was mostly explained by worse health status in blacks noted at the beginning of the study. These findings suggest that if public health initiatives are to be broadly effective, they must account for SES if poorer patients are to benefit equally with more affluent ones. Data for this study was from the Health Retirement Study conducted between 1992 and 1998. For this study about 6000 non-Hispanic whites, 1300 non-Hispanic blacks and 700 Hispanics were interviewed. (posted 2/2006)

Personal Computer Tablets Use Reduces Cost, Error and Time Spent in Data Collection In the February issue of Journal of Public Health Dentistry Joseph Sudano PhD and colleagues describe how tablet PC computers can be used in data collection. Using PC tablets eliminates intermediate data collection steps and error from data transfer. This technique also reduces study costs. Dr. Joseph Sudano and his colleagues concluded that the use of the PC tablets as direct entry devices may be useful in research and direct patient care in a broad spectrum of disciplines. Sudano, JJ, Kofford B, Wotman, S. Using tablet PC’s in dental practice research: technology, cost savings, and direct data entry “On the Go”. J Publ Health Dentistry 2005;65(4): 244-245. (posted 2/06)

MD-PhD Student Alexander C. Tsai, along with Center Faculty, Publish a Manuscript in the Journal Health Services Research MD-PhD student Alexander C. Tsai, along with Center faculty Mark E. Votruba, PhD and Randall D. Cebul, MD, and former Case faculty member John Bridges, PhD (now of the University of Heidelberg), published a manuscript in the journal Health Services Research in the February 2006 issue. The study, "Overcoming Bias in Estimating the Volume-Outcome Relationship", examines the relationships between volume and outcomes of care for patients with congestive heart failure using a novel instrumental variables strategy based on the geographic distribution of patients and hospitals in Northeast Ohio. (posted 2/2006)

Rehabilitation Services provided to More Patients in Ohio Nursing Homes with Lower Costs After Medicare Payment system changes The amount of rehabilitation services, like physical therapy, given to patients, and the type of patient receiving these services in Ohio nursing homes was examined in an article in the November, 2005 issue of Medical Care by Center members Patrick Murray, MD, Thomas Love, PhD, Neal Dawson, MD, Charles Thomas, and Randall Cebul, MD. “Rehabilitation services following the implementation of the nursing home prospective payment system: Differences related to patient and nursing home characteristics.” In 1998, the Medicare system of payment to nursing homes for patient services changed in an effort to reduce rapidly rising costs. The change in the payment system, called the Prospective Payment System (PPS) resulted in a 15% reduction in costs in the three years subsequent to its initiation. The researchers examined patient billing data and nursing home data for over 50,000 admissions from Ohio nursing homes to see how rehabilitation services changed. They found that despite the overall decrease costs for rehabilitations services, patients who were less likely to get rehabilitation services before PPS was implemented were more likely to receive these services after the payment change. They also found that those most likely to receive the services before the change still received them, but for fewer hours per week. The significance of this shift in services on patient outcomes needs further study. (posted 1/2006)

Reuters cites article on Digoxin recently published in European Heart Journal Reuters Health cited on February 10th, the publication recently published in the European Heart Journal written by Dr. Ali Ahmed and colleagues (including Thomas E. Love, PhD Center faculty member). (posted 2/2006)

Digoxin one of the oldest and least expensive drugs for heart failure was found to improve patient outcomes in an article In the European Heart Journal, Dr. Ali Ahmed and colleagues (including Thomas E. Love, Ph.D., of the Center for Health Care Research and Policy) studied the effectiveness of digoxin for heart failure. The study included a comprehensive re-analysis of data from the Digitalis Investigators Group trial sponsored in the early 1990s by the National Heart, Lung and Blood Institute. In the new article, the investigators found that administering low doses of digoxin to heart failure patients both improved their chances of survival and reduced their average number of future hospitalizations for heart failure. The results suggest that digoxin should play an important role in treating heart failure patients who continue to have symptoms despite the use of more expensive drugs such as ACE inhibitors or beta-blockers. (posted 1/2006)

Increased Physician Visits Did Not Improve Care of Renal Failure Patients Last year Medicare encouraged kidney doctors to see patients receiving hemodialysis treatments more frequently. The average number of doctor-patient visits immediately doubled in the seven months after the policy change. However, little improvement was seen in several routine measures of quality of care. This study is part of an important dialogue between Medicare, who pays for most dialysis care, and doctors, who care for patients face-to-face. Medicare provides policies based on theory and past information, and we provide information on what happens afterward. It lets us know that targeting doctors` time toward certain goals may be more useful than more frequent visits," said author Evelyn Mentari, MD. The study appeared in the October issue of the American Journal of Kidney Diseases, the official journal of the National Kidney Foundation. (posted 12/2005)

Nursing Home Rehabilitation Services Following a Stroke Provide the Greatest Benefit Among Persons Who are Least Likely to Receive Them Nursing home rehabilitation services following a stroke provide the greatest benefit among persons who are least likely to receive them, according to a study published in the May, 2005 issue of Archives of Physical Medicine and Rehabilitation by Center members Patrick Murray, Neal Dawson, Charles Thomas, and Randall Cebul. "Are We Selecting the Right Patients for Stroke Rehabilitation in Nursing Homes?" describes 2013 persons with stroke admitted to nursing homes in Ohio between 1994 and 1996 and their outcomes, including eventual discharge home and improvement in their functional status. Patients were divided into groups according to their propensity to receive rehab services. Patients who were less likely to receive rehabilitation therapy - including Medicaid patients and those with greater cognitive impairment - had relatively higher rates of community discharge when they actually received such therapy. "Developing better guidelines for selecting stroke patients for rehabilitation services may improve patients` community discharge rates and improve their quality of life while simultaneously lowering overall long-term care costs", said Dr. Murray.

Access to the Health Care System Depends Not Only on a Person’s Characteristics and Choices, But Also on the Community in Which the Person Lives Access to the health care system depends not only on a person’s characteristics and choices, but also on the community in which the person lives, according to a study published in the June 2005 issue of Medical Care by David Litaker, M.D., Siran Koroukian, and Center faculty member Thomas E. Love, Ph.D. “Context and Healthcare Access: Looking Beyond the Individual” reports on social, economic and health system characteristics of more than 16,000 adult Ohio residents obtained through a 1998 telephone survey. Persisting disparities in health status increase the need for programs that promote equitable access to health care. Even after accounting for social and economic characteristics of individuals, whether someone will have a usual source of health care (about 18% of Ohio adult residents had no such access) is persistently related to the economic characteristics of their home community. Policy changes may be more effective if they look beyond individual characteristics to address economic factors in communities with poor health care access.

Center Faculty Member Publishes Paper "Health Insurance Coverage During the Years Preceding Medicare Eligibility" in the Archives of Internal Medicine Center faculty Joseph Sudano, PhD co-authored a paper with former Center member David Baker, MD, MPH in the April 11th, 2005, issue of the Archives of Internal Medicine. "Health Insurance Coverage During the Years Preceding Medicare Eligibility" describes the prevalence of uninsurance in a longitudinal cohort of over 6000 US adults 51-57 years old in 1992. Baker and Sudano used data from the Health and Retirement Study that enabled follow-up from 1992 through 2000. They found that the proportion of late-middle aged adults at risk of being uninsured over the follow-up period was 2-3 times higher than current estimates of uninsurance that are based on cross-sectional data. At least one quarter of older adults will be uninsured at some point during the years preceding Medicare eligibility.

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