Research roundup: Examining readmissions; easing doctor burnout

Feb 14 2014

Each week, KHN compiles a selection of recently released health policy studies and briefs.

Avalere Health: 2014 Industry Outlook
Despite massive early IT problems, exchange enrollment is accelerating rapidly. While enrollment may not reach 7 million by the end of March, we expect at least 5 million to have enrolled by the close of the initial open-enrollment period. If enrollment falls far short, HHS could extend open enrollment for a fixed period to reach its 7 million target. ... We project that 5 million new beneficiaries will be covered by Medicaid and the Children's Health Insurance Program (CHIP) by the end of 2014. Medicaid managed-care enrollment of non-dual beneficiaries will increase by 20 percent from 2013 to 2014 and by 38 percent from 2013 to 2016. We expect that 75 percent of non-dual Medicaid beneficiaries will be covered by Managed Care Organizations (MCOs) starting in 2015, up from 63 percent in 2012 (Feb. 2014).

Health Affairs: Five Features Of Value-Based Insurance Design Plans Were Associated With Higher Rates Of Medication Adherence 
Value-based insurance design (VBID) plans selectively lower cost sharing to increase medication adherence. Existing plans have been structured in a variety of ways, and these variations could influence the effectiveness of VBID plans. We evaluated seventy-six plans introduced by a large pharmacy benefit manager during 2007–10. We found that after we adjusted for the other features and baseline trends, VBID plans that were more generous, targeted high-risk patients, offered wellness programs, did not offer disease management programs, and made the benefit available only for medication ordered by mail had a significantly greater impact on adherence than plans without these features. The effects were as large as 4–5 percentage points. These findings can provide guidance for the structure of future VBID plans (Choudhry et al., 2/12).

JAMA: Thirty-Day Hospital Readmission Following Discharge From Postacute Rehabilitation In Fee-for-Service Medicare Patients
Research examining 30-day readmission has focused on patients discharged from acute care hospitals. Patients discharged to postacute care institutional settings have been excluded from previous research on hospital readmission. ... We examined records for patients from the 6 largest impairment categories receiving postacute inpatient rehabilitation. These include patients with stroke, lower extremity fracture, lower extremity joint replacement, debility, neurologic disorders, and brain dysfunction. ... The 30-day readmission rate among patients discharged to the community for the 6 impairment categories was 11.8%. Readmission varied from 5.8% for patients with lower extremity joint replacement to 18.8% for patients with debility. ... Readmission rates for our sample were higher for men and non-Hispanic blacks, for beneficiaries with dual eligibility, for persons with longer lengths of stay, and for individuals with rehabilitation tier–level comorbidities (Ottenbacher et al., 2/11).

JAMA Surgery: The Relationship Between Timing Of Surgical Complications And Hospital Readmission 
This is a retrospective cohort study of national Veterans Affairs Surgical Quality Improvement Program preoperative risk and outcome data on the Surgical Care Improvement Project cohort for operations performed from January 2005 to August 2009, including colorectal, arthroplasty, vascular, and gynecologic procedures. ... Our study of 59,273 surgical procedures performed at 112 Department of Veterans Affairs (VA) hospitals found an overall complication rate of 22.6% ... Although readmission is associated with complications, almost half of readmissions are not associated with a complication currently assessed by the Veterans Affairs Surgical Quality Improvement Program (Morris et al., 2/11).

JAMA Pediatrics: Effectiveness Of Peer-Based Healthy Living Lesson Plans On Anthropometric Measures And Physical Activity In Elementary School Students
Unfortunately, most teacher-led school-based interventions have been ineffective at reducing body weight in children. In contrast to traditional school-based interventions, peer mentoring is an attractive strategy for eliciting behavior change in children. ... The present study ... [used] a cluster-randomized effectiveness trial to test the hypothesis that a school-based, peer-led healthy living program would reduce adiposity and increase physical activity among children. ... peer-based mentoring led to a reduction in waist circumference in elementary school students compared with students receiving a standard curriculum. Healthy Buddies also improved self-efficacy and knowledge of healthy eating among younger elementary school students who learned about healthy living from their older peers (Santos et al., 2/10).

The Employee Benefit Research Institute: Health Savings Accounts And Health Reimbursement Arrangements: Assets, Account Balances, and Rollovers, 2006–2013
Asset levels growing: In 2013, there was $23.8 billion in health savings accounts (HSAs) and health reimbursement arrangements (HRAs), spread across 11.8 million accounts. ... HSAs growing, but HRAs contracting: For the first time since the survey was launched in 2005, the number of HRAs fell. In 2013, there were 4.7 million HRA accounts, down from 5.1 million in 2012. ... After leveling off, average account balances increased ... Length of time with account has impact ... Total and average rollovers decrease (Fronstin, 2/12).

JAMA Internal Medicine: Patient-Centered Community Health Worker Intervention To Improve Posthospital Outcomes
Socioeconomic and behavioral factors can negatively influence posthospital outcomes among patients of low socioeconomic status (SES). Traditional hospital personnel often lack the time, skills, and community linkages required to address these factors. ... A 2-armed, single-blind, randomized clinical trial was conducted between April 10, 2011, and October 30, 2012, at 2 urban, academically affiliated hospitals. ... 446 patients (65.3%) were enrolled. ... During hospital admission, CHWs [community health workers] worked with patients to create individualized action plans for achieving patients' stated goals for recovery. ... Patient-centered CHW intervention improves access to primary care and quality of discharge while controlling recurrent readmissions in a high-risk population (Kangovi, 2/10).

JAMA Internal Medicine: Intervention To Promote Physician Well-Being, Job Satisfaction, And Professionalism
Burnout affects nearly half of medical students, residents, and practicing physicians in the United States. ... We report the results of a randomized clinical trial testing an intervention with protected time (1 hour of paid time every other week, equal to 0.9% full-time equivalent) provided by the institution to promote well-being and reduce distress in physicians. ... this intervention involved facilitated physician discussion groups organized around a curriculum incorporating elements of mindfulness, reflection, shared experience, and small-group learning intended to promote collegiality and community at work among participants. ... Participants in the facilitated small-group intervention experienced significant improvements in meaning, empowerment, and engagement in work beyond that seen in the physicians receiving only protected time. ... These differences, which became most apparent toward the end of the study period, were sustained for 12 months after the end of the intervention period (West, 2/10).

The Kaiser Family Foundation: The ACA And Recent Section 1115 Medicaid Demonstration Waivers
Under flexibility provided by the [Affordable Care Act's] Medicaid expansion, as well as pre-existing federal Medicaid law, the [ACA's] Medicaid expansion will be implemented differently across states in terms of what specific benefits are provided and how those services are delivered. Moreover, a limited number of states have obtained or are seeking approval through Section 1115 waivers to implement the expansion in ways that extend beyond the flexibility provided by the law. ... For many years, these waivers offered the only way for states to cover otherwise ineligible childless adults; now, the ACA provides new state plan authority for states to offer Medicaid to this population without the need for a waiver. While states use Section 1115 waiver authority for a wide range of purposes, this brief focuses on waivers related to implementation of the ACA Medicaid expansion (eligible for ACA enhanced matching funds) or other coverage (not eligible for ACA enhanced matching funds) (Rudowitz, Artiga and Musumeci, 2/5).

Here is a selection of news coverage of other recent research:

The New York Times: Vast Study Casts Doubts On Value Of Mammograms
One of the largest and most meticulous studies of mammography ever done, involving 90,000 women and lasting a quarter-century, has added powerful new doubts about the value of the screening test for women of any age. It found that the death rates from breast cancer and from all causes were the same in women who got mammograms and those who did not. And the screening had harms: One in five cancers found with mammography and treated was not a threat to the woman's health and did not need treatment such as chemotherapy, surgery or radiation (Kolata, 2/11).

Modern Healthcare: Immunization Rates For Adults Too Low, CDC Says
Immunization rates among adults are too low and risk resurgence in vaccine-preventable diseases that were all but eradicated in the U.S., a federal study warns. Data released this week by the Centers for Disease Control and Prevention showed that only 14% of adults age 19 and older in 2012 reported were vaccinated for tetanus, diphtheria and pertussis, or whooping cough within the past 10 years. The number of adults age 60 and older who reported being vaccinated for shingles was at 20% in 2012, while 35% of women between ages 19 and 26 reported getting vaccinated for human papillomavirus, which protects against cervical cancer (Johnson, 2/7).