The factors driving the rapid increase in US medical spending are a concern for both policymakers... more The factors driving the rapid increase in US medical spending are a concern for both policymakers and payers. This article analyzes variation in spending growth rates for a large sample of persons with workplace injuries. We analyze trends by type and age of injury, and by type of provider. Medical spending growth ranged from 2 percent to 12 percent for different injuries, and 3 percent to 16 percent across different types of providers. We decomposed spending growth into price, volume, and service intensity growth rates. Service intensity accounts for 20 percent of overall expenditure growth, but is a particularly large and variable contributor to spending growth in inpatient services, ranging from 35 percent to 73 percent of total spending growth among the four most prevalent injuries we studied. Efforts to forecast spending, and to design policies that manage spending growth, should account for heterogeneous trends across patients and providers.
Variation in care within and across geographic areas remains poorly understood. The goal of this ... more Variation in care within and across geographic areas remains poorly understood. The goal of this article was to examine whether physician social networks-as defined by shared patients-are associated with rates of complications after radical prostatectomy. In five cities, we constructed networks of physicians on the basis of their shared patients in 2004-2005 Surveillance, Epidemiology and End Results-Medicare data. From these networks, we identified subgroups of urologists who most frequently shared patients with one another. Among men with localized prostate cancer who underwent radical prostatectomy, we used multilevel analysis with generalized linear mixed-effect models to examine whether physician network structure-along with specific characteristics of the network subgroups-was associated with rates of 30-day and late urinary complications, and long-term incontinence after accounting for patient-level sociodemographic, clinical factors, and urologist patient volume. Networks included 2677 men in five cities who underwent radical prostatectomy. The unadjusted rate of 30-day surgical complications varied across network subgroups from an 18.8 percentage-point difference in the rate of complications across network subgroups in city 1 to a 26.9 percentage-point difference in city 5. Large differences in unadjusted rates of late urinary complications and long-term incontinence across subgroups were similarly found. Network subgroup characteristics-average urologist centrality and patient racial composition-were significantly associated with rates of surgical complications. Analysis of physician networks using Surveillance, Epidemiology and End Results-Medicare data provides insight into observed variation in rates of complications for localized prostate cancer. If validated, such approaches may be used to target future quality improvement interventions.
Electronic health data sets, including electronic health records (EHR) and other administrative d... more Electronic health data sets, including electronic health records (EHR) and other administrative databases, are rich data sources that have the potential to help answer important questions about the effects of clinical interventions as well as policy changes. However, analyses using such data are almost always non-experimental, leading to concerns that those who receive a particular intervention are likely different from those who do not, in ways that may confound the effects of interest. This paper outlines the challenges in estimating causal effects using electronic health data, and offers some solutions, with particular attention paid to propensity score methods that help ensure comparisons between similar groups. The methods are illustrated with a case study describing the design of a study using Medicare and Medicaid administrative data to estimate the effect of the Medicare Part D prescription drug program among individuals with serious mental illness.
To examine the association of changing urologists on surgical complications in men with prostate ... more To examine the association of changing urologists on surgical complications in men with prostate cancer. Registry and administrative claims data from the Surveillance, Epidemiology, and End Results-Medicare database from 1995 to 2005. A cross-sectional observational study of men with prostate cancer who underwent radical prostatectomy. Subjects were classified as having "changed urologists" if they had a different urologist who diagnosed their cancer from the one who performed their surgery. "Doubly robust" propensity score weighted multivariable logistic regression models were used to investigate the effect of changing urologists on 30-day surgical complications, late urinary complications, and long-term incontinence. Men who changed urologists between diagnosis and treatment had significantly lower odds of 30-day surgical complications compared with men who did not change urologists (odds ratio: 0.82; 95 percent confidence interval: 0.76-0.89), after adjustment. Changing urologists was associated with lower risks of 30-day complications for both black and white men compared with staying with the same urologist for their diagnosis and surgical treatment. Urologist changing is associated with the observed variation in complications following radical prostatectomy. This may suggest that patients are responding to aspects of surgical quality not captured in surgical volume.
The factors driving the rapid increase in US medical spending are a concern for both policymakers... more The factors driving the rapid increase in US medical spending are a concern for both policymakers and payers. This article analyzes variation in spending growth rates for a large sample of persons with workplace injuries. We analyze trends by type and age of injury, and by type of provider. Medical spending growth ranged from 2 percent to 12 percent for different injuries, and 3 percent to 16 percent across different types of providers. We decomposed spending growth into price, volume, and service intensity growth rates. Service intensity accounts for 20 percent of overall expenditure growth, but is a particularly large and variable contributor to spending growth in inpatient services, ranging from 35 percent to 73 percent of total spending growth among the four most prevalent injuries we studied. Efforts to forecast spending, and to design policies that manage spending growth, should account for heterogeneous trends across patients and providers.
Variation in care within and across geographic areas remains poorly understood. The goal of this ... more Variation in care within and across geographic areas remains poorly understood. The goal of this article was to examine whether physician social networks-as defined by shared patients-are associated with rates of complications after radical prostatectomy. In five cities, we constructed networks of physicians on the basis of their shared patients in 2004-2005 Surveillance, Epidemiology and End Results-Medicare data. From these networks, we identified subgroups of urologists who most frequently shared patients with one another. Among men with localized prostate cancer who underwent radical prostatectomy, we used multilevel analysis with generalized linear mixed-effect models to examine whether physician network structure-along with specific characteristics of the network subgroups-was associated with rates of 30-day and late urinary complications, and long-term incontinence after accounting for patient-level sociodemographic, clinical factors, and urologist patient volume. Networks included 2677 men in five cities who underwent radical prostatectomy. The unadjusted rate of 30-day surgical complications varied across network subgroups from an 18.8 percentage-point difference in the rate of complications across network subgroups in city 1 to a 26.9 percentage-point difference in city 5. Large differences in unadjusted rates of late urinary complications and long-term incontinence across subgroups were similarly found. Network subgroup characteristics-average urologist centrality and patient racial composition-were significantly associated with rates of surgical complications. Analysis of physician networks using Surveillance, Epidemiology and End Results-Medicare data provides insight into observed variation in rates of complications for localized prostate cancer. If validated, such approaches may be used to target future quality improvement interventions.
Electronic health data sets, including electronic health records (EHR) and other administrative d... more Electronic health data sets, including electronic health records (EHR) and other administrative databases, are rich data sources that have the potential to help answer important questions about the effects of clinical interventions as well as policy changes. However, analyses using such data are almost always non-experimental, leading to concerns that those who receive a particular intervention are likely different from those who do not, in ways that may confound the effects of interest. This paper outlines the challenges in estimating causal effects using electronic health data, and offers some solutions, with particular attention paid to propensity score methods that help ensure comparisons between similar groups. The methods are illustrated with a case study describing the design of a study using Medicare and Medicaid administrative data to estimate the effect of the Medicare Part D prescription drug program among individuals with serious mental illness.
To examine the association of changing urologists on surgical complications in men with prostate ... more To examine the association of changing urologists on surgical complications in men with prostate cancer. Registry and administrative claims data from the Surveillance, Epidemiology, and End Results-Medicare database from 1995 to 2005. A cross-sectional observational study of men with prostate cancer who underwent radical prostatectomy. Subjects were classified as having "changed urologists" if they had a different urologist who diagnosed their cancer from the one who performed their surgery. "Doubly robust" propensity score weighted multivariable logistic regression models were used to investigate the effect of changing urologists on 30-day surgical complications, late urinary complications, and long-term incontinence. Men who changed urologists between diagnosis and treatment had significantly lower odds of 30-day surgical complications compared with men who did not change urologists (odds ratio: 0.82; 95 percent confidence interval: 0.76-0.89), after adjustment. Changing urologists was associated with lower risks of 30-day complications for both black and white men compared with staying with the same urologist for their diagnosis and surgical treatment. Urologist changing is associated with the observed variation in complications following radical prostatectomy. This may suggest that patients are responding to aspects of surgical quality not captured in surgical volume.
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Papers by Eva DuGoff