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Todd WagnerTodd Wagner, Ph.D.
Associate Director
Health Economics Resource Center (HERC)
VA Palo Alto Healthcare System
795 Willow Road (152 MPD)
Menlo Park, CA 94025
P: (650) 493-5000 x22048
F: (650) 617-2639

I'm a health economist with the Palo Alto VA. At the VA, my primary position is with the Health Economics Resource Center, but I am also affiliated with the Center for healthcare Evaluation and the Cooperative Studies Coordinating Center. The Palo Alto VA has a close relationship with Stanford University and I'm affiliated with the Department of Health Research and Policy.

I received my Ph.D. in Health Economics from the Health Services and Policy Analysis Program at the University of California, Berkeley in 1999.

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Todd Wagner's CV
(January 2012) | Download »
Journal Articles

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Coronary artery bypass graft patency: residents versus attending surgeons
Bakaeen, F.G.; Sethi, G.; Wagner, T.; Kelly, R.; Lee, K.; Upadhyay, A.; Thai, H.; Juneman, E.; Goldman, S.; Holman, W.L.
Annals of Thoracic Surgery (2012) | PubMed »
  • BACKGROUND: Data are limited regarding the patency of coronary artery bypass grafts performed by residents versus attending surgeons. METHODS: We analyzed data from a multicenter, randomized Veterans Affairs Cooperative Study in which the left internal mammary artery was used preferentially to graft the left anterior descending coronary artery, and the best remaining coronary vessel received (per random assignment) either a radial artery or a saphenous vein graft. The study vessel's 1-year graft patency was the primary outcome measure. Secondary outcomes included operative times, operative morbidity, mortality, repeat revascularization, cost, angina symptoms, and quality of life. Multivariate analyses were used to compare patient outcomes for residents versus attendings. RESULTS: Residents were designated as primary surgeons in 23% of cases (167 of 725). Among the 531 patients who had a 1-year angiogram, study graft patency rates for resident cases (n = 122) and attending cases (n = 409) were not significantly different (86% versus 90%, p = 0.22). Residents' cases had longer perfusion time (119 versus 105 minutes, p < 0.0001) and cross-clamp time (84 versus 68 minutes, p < 0.0001). After risk adjustment, all outcome measures did not differ between the two groups, and there was no apparent interaction effect between resident/attending designation and radial artery versus saphenous vein use or on-pump versus off-pump approach. CONCLUSIONS: Surgeons in training perform coronary artery bypass surgery without compromising graft patency or patient outcomes. Ongoing evaluation of residents' performance and surgical outcomes is needed, given the major changes that are occurring in residency training.
One-year outcomes of telephone case monitoring for patients with substance use disorders
McKellar, J.; Wagner, T.H.; Harris, A.H.S.; Oehlert, M.; Buckley, S.; Moos, R.
Addictive Behaviors (2012) | PubMed »
  • Background: Many patients treated for substance use disorder (SUD) do not achieve lasting recovery from a single episode of treatment and require continuing care. The current randomized clinical trial investigated whether in-person continuing care as usual (CCAU) following intensive outpatient SUD treatment leads to better SUD outcomes when compared with telephone case monitoring (TCM). Method: This study randomized 667 intensive SUD outpatients to telephone case monitoring versus face-to-face continuing care as usual at two sites. Patients completed data at baseline, 3 and 12 months with telephone interviews. Data of interest include self-report of substance use, psychiatric symptoms, quality of life, and treatment satisfaction. We also evaluated potential interaction effects for distance to VA provider, SUD severity, and presence of co-morbid psychiatric disorder. Results: Participants randomized to the telephone case monitoring condition substantially engaged with face-to-face continuing care resulting in cross-over contamination. We addressed this issue by using randomization as an instrumental variable to evaluate the impact of telephone case monitoring (contamination adjusted, intent to treat analysis). Instrumental variable analyses indicated significant benefit of telephone case monitoring for drug and alcohol percent days abstinent and psychiatric symptom outcomes at 3-months follow-up, but not at 12-month follow-up. No interaction analyses were significant. Discussion: Participants receiving telephone case monitoring achieved better short term outcomes in terms of substance use and psychiatric symptoms. The ôon treatmentö effects suggests the need for future studies to investigate consumer (patient) perspectives on the optimal duration of telephone case monitoring and use of alternative monitoring methods such as text messaging.
A comprehensive care management program to prevent chronic obstructive pulmonary disease hospitalizations: a randomized, controlled trial
Fan, V.S.; Gaziano, J.M.; Lew, R.; Bourbeau, J.; Adams, S.; Leatherman, S.; Thwin, S.S.; Huang, G.D.; Robbins, R.; Sriram, P.S.; Sharafkhaneh, A.; Mador, M.J.; Sarosi, G.; Panos, R.J.; Rastogi, P.; Wagner, T.H.; Mazzuca, S.A.; Shannon, C.; Colling, C.; Liang, M.H.; Stoller, J.K.; Fiore, L.; Niewoehner, D.E.
Ann Intern Med (2012) | PubMed »
  • BACKGROUND: Improving a patient's ability to self-monitor and manage changes in chronic obstructive pulmonary disease (COPD) symptoms may improve outcomes. OBJECTIVE: To determine the efficacy of a comprehensive care management program (CCMP) in reducing the risk for COPD hospitalization. DESIGN: A randomized, controlled trial comparing CCMP with guideline-based usual care. ( registration number: NCT00395083) SETTING: 20 Veterans Affairs hospital-based outpatient clinics. PARTICIPANTS: Patients hospitalized for COPD in the past year. INTERVENTION: The CCMP included COPD education during 4 individual sessions and 1 group session, an action plan for identification and treatment of exacerbations, and scheduled proactive telephone calls for case management. Patients in both the intervention and usual care groups received a COPD informational booklet; their primary care providers received a copy of COPD guidelines and were advised to manage their patients according to these guidelines. Patients were randomly assigned, stratifying by site based on random, permuted blocks of variable size. MEASUREMENTS: The primary outcome was time to first COPD hospitalization. Staff blinded to study group performed telephone-based assessment of COPD exacerbations and hospitalizations, and all hospitalizations were blindly adjudicated. Secondary outcomes included non-COPD health care use, all-cause mortality, health-related quality of life, patient satisfaction, disease knowledge, and self-efficacy. RESULTS: Of the eligible patients, 209 were randomly assigned to the intervention group and 217 to the usual care group. Citing serious safety concerns, the data monitoring committee terminated the intervention before the trial's planned completion after 426 (44%) of the planned total of 960 patients were enrolled. Mean follow-up was 250 days. When the study was stopped, the 1-year cumulative incidence of COPD-related hospitalization was 27% in the intervention group and 24% in the usual care group (hazard ratio, 1.13 [95% CI, 0.70 to 1.80]; P= 0.62). There were 28 deaths from all causes in the intervention group versus 10 in the usual care group (hazard ratio, 3.00 [CI, 1.46 to 6.17]; P= 0.003). Cause could be assigned in 27 (71%) deaths. Deaths due to COPD accounted for the largest difference: 10 in the intervention group versus 3 in the usual care group (hazard ratio, 3.60 [CI, 0.99 to 13.08]; P= 0.053). LIMITATIONS: Available data could not fully explain the excess mortality in the intervention group. Ability to assess the quality of the educational sessions provided by the case managers was limited. Conclusion: A CCMP in patients with severe COPD had not decreased COPD-related hospitalizations when the trial was stopped prematurely. The CCMP was associated with unanticipated excess mortality, results that differ markedly from similar previous trials. A data monitoring committee should be considered in the design of clinical trials involving behavioral interventions.
Vascular surgery patients prescribed preoperative ▀-blockers experienced a decrease in the maximal heart rate observed during induction of general anesthesia
Mudumbai, S.; Wagner, T.H.; Mahajan, S.; King, R.; Heidenreich, P.A.; Hlatky, M.; Wallace, A.; Mariano, E.R.
Journal of Cardiothoracic and Vascular Anesthesia (2012) | PubMed »
  • Objective: To investigate the association of preoperative ▀-blocker usage and maximal heart rates observed during the induction of general anesthesia. Design: Retrospective descriptive, univariate, and multivariate analyses of electronic hospital and anesthesia medical records. Setting: A tertiary-care medical center within the Veterans Health Administration. Participants: Consecutive adult elective and emergent patients presenting for vascular surgery during calendar years 2005 to 2011. Interventions:None. Measurements and Main Results: Of the 430 eligible cases, 218 were prescribed ▀-blockers, and 212 were not taking ▀-blockers. The two groups were comparable across baseline patient factors (ie, demographic, morphometric, surgical duration, and surgical procedures) and induction medication doses. The ▀-blocker group experienced a lower maximal heart rate during the induction of general anesthesia compared with the nonľ▀-blocker group (105 ▒ 41 beats/min v 115 ▒ 45 beats/min, respectively; p < 0.01). Adjusted linear regression found a statistically significant association between lower maximal heart rate and the use of ▀-blockers (▀ = -11.1 beats/min, p < 0.01). There was no difference between groups in total intraoperative ▀-blocker administration. Conclusions: Preoperative ▀-blockade of vascular surgery patients undergoing general anesthesia is associated with a lower maximal heart rate during anesthetic induction. There may be potential benefits in administering ▀-blockers to reduce physiologic stress in this surgical population at risk for perioperative cardiac morbidity. Future research should further explore intraoperative hemodynamic effects in light of existing practice guidelines for optimal medication selection, dosage, and heart rate control.
Identifying Neck and Back Pain in Administrative Data: Defining the right cohort
Sinnott, P.L.; Siroka, A.M.; Shane, A.C.; Trafton, J.A.; Wagner, T.H.
Spine (2012) | PubMed »
  • Study Design. We reviewed existing methods for identifying patients with neck and back pain in administrative data. We compared these methods using data from the Department of Veterans Affairs.Objective. To answer the following questions: 1) what diagnosis codes should be used to identify patients with neck and back pain in administrative data; 2) because the majority of complaints are characterized as non-specific or mechanical, what diagnosis codes should be used to identify patients with non-specific or mechanical problems in administrative data; and 3) what procedure and surgical codes should be used to identify patients who have undergone a surgical procedure on the neck or back.Summary of Background Data. Musculoskeletal neck and back pain are pervasive problems, associated with chronic pain, disability, and high rates of healthcare utilization. Administrative data have been widely used in formative research which has largely relied on the original work of Volinn, Cherkin, Deyo and Einstadter and the Back Pain Patient Outcomes Assessment Team first published in 1992. Significant variation in reports of incidence, prevalence, and morbidity associated with these problems may be due to non standard or conflicting methods to define study cohorts.Methods. A literature review produced seven methods for identifying neck and back pain in administrative data. These code lists were used to search VA data for patients with back and neck problems, and to further categorize each case by spinal segment involved, as non-specific/mechanical and as surgical or not.Results. There is considerable overlap in most algorithms. However, gaps remain. Conclusions. Gaps are evident in existing methods and a new framework to identify patients with neck and back pain in administrative data is proposed.
Patient interest in sharing personal health record information: a web-based survey
Zulman, D.M.; Nazi, K.M.; Turvey, C.L.; Wagner, T.H.; Woods, S.S.; An, L.C.
Annals of Internal Medicine (2011) | PubMed »
  • Background: Electronic personal health record (PHR) systems are proliferating but largely have not realized their potential for enhancing communication among patients and their network of care providers. Objective: To explore preferences about sharing electronic health information among users of the U.S. Department of Veterans Affairs (VA) PHR system, My HealtheVet. Design: Web-based survey of a convenience sample. Setting: My HealtheVet Web site from 7 July through 4 October 2010. Participants: 18 471 users of My HealtheVet. Measurements: Interest in shared PHR access and preferences about who would receive access, the information that would be shared, and the activities that users would delegate.Results: Survey respondents were predominantly men (92%) and aged 50 to 64 years (51%) or 65 years or older (39%); approximately 39% reported poor or fair health status. Almost 4 of 5 respondents (79%) were interested in sharing access to their PHR with someone outside of their health system (62% with a spouse or partner, 23% with a child, 15% with another family member, and 25% with a non-VA health care provider). Among those who selected a family member other than a spouse or partner, 47% lived apart from the specified person. Preferences about degree of access varied on the basis of the type of information being shared, the type of activity being performed, and the respondent's relationship with the selected person.Limitations: The survey completion rate was 40.8%. Results might not be generalizable to all My HealtheVet users.Conclusion: In a large survey of PHR users in the VA system, most respondents were interested in sharing access to their electronic health information with caregivers and non-VA providers. Existing and evolving PHR systems should explore secure mechanisms for shared PHR access to improve information exchange among patients and the multiple persons involved in their health care.
Costs and quality of life associated with radial artery and saphenous vein cardiac bypass surgery: results from a Veterans Affairs multi-site trial
Wagner, T.H.; Sethi, G.; Holman, W.; Lee, K.; Bakaeen, F.G.; Upadhyay, A.; McFalls, E.; Tobler, H.G.; Kelly, R.F.; Crittenden, M.D.; Thai, H.; Goldman, S.
American Journal of Surgery (2011) | PubMed »
  • BACKGROUND: In coronary artery bypass grafting (CABG) surgery, there is uncertainty about whether the radial artery affects quality of life or costs relative to the saphenous vein. This study compared the cost and quality of life for patients randomized to either radial artery or saphenous vein grafts. METHODS: We analyzed the duration and cost of the index surgery and costs and quality of life (Seattle Angina Questionnaire and Health Utility Index) at 1 year for 726 participants. RESULTS: The 2 treatment groups had similar baseline characteristics. Using the radial artery added approximately 31 minutes to the surgery (from skin incision to skin closure; P  .001) compared with a saphenous vein graft. There were no significant differences in terms of costs and quality of life after the index hospitalization or at 1 year. CONCLUSIONS: Coronary artery bypass grafting with the radial artery lasts approximately 31 minutes longer than with the saphenous vein. However, costs and the quality of life were not statistically different.
An economic analysis of robot-assisted therapy for long-term upper-limb impairment after stroke
Wagner, T.H.; Lo, A.C.; Peduzzi, P.; Bravata, D.M.; Huang, G.D.; Krebs, H.I.; Ringer, R.J.; Federman, D.G.; Richards, L.G.; Haselkorn, J.K.; Wittenberg, G.F.; Volpe, B.T.; Bever, C.T.; Duncan, P.W.; Siroka, A.; Guarino, P.D.
Stroke (2011) | PubMed »
  • BACKGROUND AND PURPOSE: Stroke is a leading cause of disability. Rehabilitation robotics have been developed to aid in recovery after a stroke. This study determined the additional cost of robot-assisted therapy and tested its cost-effectiveness. METHODS: We estimated the intervention costs and tracked participants' healthcare costs. We collected quality of life using the Stroke Impact Scale and the Health Utilities Index. We analyzed the cost data at 36 weeks postrandomization using multivariate regression models controlling for site, presence of a prior stroke, and Veterans Affairs costs in the year before randomization. RESULTS: A total of 127 participants were randomized to usual care plus robot therapy (n=49), usual care plus intensive comparison therapy (n=50), or usual care alone (n=28). The average cost of delivering robot therapy and intensive comparison therapy was $5152 and $7382, respectively (P<0.001), and both were significantly more expensive than usual care alone (no additional intervention costs). At 36 weeks postrandomization, the total costs were comparable for the 3 groups ($17 831 for robot therapy, $19 746 for intensive comparison therapy, and $19 098 for usual care). Changes in quality of life were modest and not statistically different. CONCLUSIONS: The added cost of delivering robot or intensive comparison therapy was recuperated by lower healthcare use costs compared with those in the usual care group. However, uncertainty remains about the cost-effectiveness of robotic-assisted rehabilitation compared with traditional rehabilitation.
If substance use disorder treatment more than offsets its costs, why don't more medical centers want to provide it? A budget impact analysis in the Veterans Health Administration
Humphreys, K.; Wagner, T.H.; Gage, M.
J Subst Abuse Treat (2011) | PubMed »
  • Given that many studies have reported that the costs of substance use disorder (SUD) treatment are more than offset by other savings (e.g., in health care, in criminal justice, in foster care), why haven't health care system managers rushed to expand treatment? This article attempts to explain this puzzling discrepancy by analyzing 1998-2006 data from the national Veterans Affairs (VA) health care system. The main outcome measures were annual cost and utilization for VA SUD-diagnosed patients. The key independent variable was the medical centers' annual spending for SUD treatment. There was no evidence that SUD spending was associated with lower medical center costs over time within the medical center that paid for the treatment. Health care system managers may not be influenced by research suggesting that the costs of SUD treatment are more than fully offset because they bear the cost of providing treatment while the savings largely accrue to other systems.
Disparities in Lung Cancer Staging with Positron Emission Tomography in the Cancer Care Outcomes Research and Surveillance (CanCORS) Study
Gould, M.K.; E, M.S.; Wagner, T.H.; Xu, X.; Ghaus, S.J.; Wallace, R.B.; Provenzale, D.; Au, D.H.
J Thorac Oncol (2011) | PubMed »
  • INTRODUCTION:: Disparities in treatment exist for nonwhite and Hispanic patients with non-small cell lung cancer, but little is known about disparities in the use of staging tests or their underlying causes. METHODS:: Prospective, observational cohort study of 3638 patients with newly diagnosed non-small cell lung cancer from 4 large, geographically defined regions, 5 integrated health care systems, and 13 VA health care facilities. RESULTS:: Median age was 69 years, 62% were men, 26% were Hispanic or nonwhite, 68% graduated high school, 50% had private insurance, and 41% received care in the VA or another integrated health care system. After adjustment, positron emission tomography (PET) use was 13% lower among nonwhites and Hispanics than non-Hispanic whites (risk ratio [RR] 0.87, 95% confidence interval [CI] 0.77-0.97), 13% lower among those with Medicare than those with private insurance (RR 0.87, 95% CI 0.76-0.99), and 24% lower among those with an elementary school education than those with a graduate degree (RR 0.76, 95% CI 0.57-0.98). Disparate use of PET was not observed among patients who received care in an integrated health care setting, but the association between race/ethnicity and PET use was similar in magnitude across all other subgroups. Further analysis showed that income, education, insurance, and health care setting do not explain the association between race/ethnicity and PET use. CONCLUSIONS:: Hispanics and nonwhites with non-small cell lung cancer are less likely to receive PET imaging. This finding is consistent across subgroups and not explained by differences in income, education, or insurance coverage.
Mental health and substance use disorder spending in the Department of Veterans Affairs, fiscal years 2000-2007
Wagner, T.H.; Sinnott, P.; Siroka, A.M.
Psychiatr Serv (2011) | PubMed »
  • OBJECTIVE: This study analyzed spending for treatment of mental health and substance use disorders in the Department of Veterans Affairs (VA) in fiscal years (FYs) 2000 through 2007. METHODS: VA spending as reported in the VA Decision Support System was linked to patient utilization data as reported in the Patient Treatment Files, the National Patient Care Database, and the VA Fee Basis files. All care and costs from FY 2000 to FY 2007 were analyzed. RESULTS: Over the study period the number of veterans treated at the VA increased from 3.7 million to over 5.1 million (an average increase of 4.9% per year), and costs increased .7% per person per year. For mental health and substance use disorder treatment, the volume of inpatient care decreased markedly, residential care increased, and spending decreased on average 2% per year (from $668 in FY 2000 to $578 per person in FY 2007). FY 2007 saw large increases in mental health spending, bucking the trend from FY 2000 through FY 2006. CONCLUSIONS: VA's continued emphasis on outpatient and residential care was evident through 2007. This trend in spending might be unimpressive if VA were enrolling healthier Veterans, but the opposite seems to be true: over this time period the prevalence of most chronic conditions, including depression and posttraumatic stress disorder, increased. VA spending on mental health care grew rapidly in 2007, and given current military activities, this trend is likely to increase.
Radial artery grafts vs saphenous vein grafts in coronary artery bypass surgery: a randomized trial
Goldman, S.; Sethi, G.K.; Holman, W.; Thai, H.; McFalls, E.; Ward, H.B.; Kelly, R.F.; Rhenman, B.; Tobler, G.H.; Bakaeen, F.G.; Huh, J.; Soltero, E.; Moursi, M.; Haime, M.; Crittenden, M.; Kasirajan, V.; Ratliff, M.; Pett, S.; Irimpen, A.; Gunnar, W.; Thomas, D.; Fremes, S.; Moritz, T.; Reda, D.; Harrison, L.; Wagner, T.H.; Wang, Y.; Planting, L.; Miller, M.; Rodriguez, Y.; Juneman, E.; Morrison, D.; Pierce, M.K.; Kreamer, S.; Shih, M.C.; Lee, K.
JAMA (2011) | PubMed »
  • CONTEXT: Arterial grafts are thought to be better conduits than saphenous vein grafts for coronary artery bypass grafting (CABG) based on experience with using the left internal mammary artery to bypass the left anterior descending coronary artery. The efficacy of the radial artery graft is less clear. OBJECTIVE: To compare 1-year angiographic patency of radial artery grafts vs saphenous vein grafts in patients undergoing elective CABG. DESIGN, SETTING, AND PARTICIPANTS: Multicenter, randomized controlled trial conducted from February 2003 to February 2009 at 11 Veterans Affairs medical centers among 757 participants (99% men) undergoing first-time elective CABG. INTERVENTIONS: The left internal mammary artery was used to preferentially graft the left anterior descending coronary artery whenever possible; the best remaining recipient vessel was randomized to radial artery vs saphenous vein graft. MAIN OUTCOME MEASURES: The primary end point was angiographic graft patency at 1 year after CABG. Secondary end points included angiographic graft patency at 1 week after CABG, myocardial infarction, stroke, repeat revascularization, and death. RESULTS: Analysis included 733 patients (366 in the radial artery group, 367 in the saphenous vein group). There was no significant difference in study graft patency at 1 year after CABG (radial artery, 238/266; 89%; 95% confidence interval [CI], 86%-93%; saphenous vein, 239/269; 89%; 95% CI, 85%-93%; adjusted OR, 0.99; 95% CI, 0.56-1.74; P = .98). There were no significant differences in the secondary end points. CONCLUSION: Among Veterans Affairs patients undergoing first-time elective CABG, the use of a radial artery graft compared with saphenous vein graft did not result in greater 1-year patency. TRIAL REGISTRATION: Identifier: NCT00054847.
The generalizability of participants in Veterans Affairs Cooperative Studies Program 474, a multi-site randomized cardiac bypass surgery trial
Wagner, T.H.; Holman, W.; Lee, K.; Sethi, G.; Ananth, L.; Thai, H.; Goldman, S.
Contemp Clin Trials (2011) | PubMed »
  • OBJECTIVE: The Department of Veterans Affairs (VA) Cooperative Studies Program (CSP) initiated a multi-site randomized trial (CSP 474) to determine graph patency between radial artery or saphenous vein grafts in coronary artery bypass surgery (CABG). In this paper, we describe the study and compare participants' baseline characteristics to non-participants who received CABG surgery in the VA. METHOD: We identified our participants in the VA administrative databases along with all other CABG patients who did not have a concomitant valve procedure between FY2003 and FY2008. We extracted demographic, clinical information and organizational information at the time of the surgery from the databases. We conducted multiple logistic regression to determine characteristics associated with participation at three levels: between participants and non-participants within participating sites, between participating sites and non-participating sites, between participants and all non-participants. RESULTS: Enrollment ended in early 2008. Participants were similar to non-participants across many parameters. Likewise, participating sites were also quite similar to non-participating sites, although participating sites had a higher volume of CABG surgery, a lower percentage of CABG patients with a prior inpatient mental health admission than non-participating sites. After controlling for site differences, CSP 474 participants were younger and had fewer co-morbid conditions than non-participants. CONCLUSIONS: Participants were significantly younger than non-participants. Participants also had lower rates of some cardiac-related illness including, congestive heart failure, peripheral vascular disease, and cerebrovascular disease than non-participants.
Cost effectiveness analysis of the spinal cord injury vocational integration program (SCI-VIP)
Sinnott, P.L.; Cheng, A.; Wagner, T.H.; Goetz, L.; Ottomanelli, L.
Top Spinal Cord Inj Rehabil (2011) | PubMed »
  • The Spinal Cord Injury Vocational Integration Program (SCI-VIP) is a 5-year multisite randomized clinical trial to test for differences in employment and rehabilitation outcomes in veterans with spinal cord injury, including a cost-effectiveness analysis. This article provides a review of the background on economic analyses in health care and a description of the methods we will follow for the cost-effectiveness analysis of the SCI-VIP intervention.
Returns to physician human capital: evidence from patients randomized to physician teams
Doyle, J.J., Jr.; Ewer, S.M.; Wagner, T.H.
J Health Econ (2010) | PubMed »
  • Physicians play a major role in determining the cost and quality of healthcare, yet estimates of these effects can be confounded by patient sorting. This paper considers a natural experiment where nearly 30,000 patients were randomly assigned to clinical teams from one of two academic institutions. One institution is among the top medical schools in the U.S., while the other institution is ranked lower in the distribution. Patients treated by the two programs have similar observable characteristics and have access to a single set of facilities and ancillary staff. Those treated by physicians from the higher ranked institution have 10-25% less expensive stays than patients assigned to the lower ranked institution. Health outcomes are not related to the physician team assignment. Cost differences are most pronounced for serious conditions, and they largely stem from diagnostic-testing rates: the lower ranked program tends to order more tests and takes longer to order them.
Introduction of a rapid response system at a United States veterans affairs hospital reduced cardiac arrests
Lighthall, G.K.; Parast, L.M.; Rapoport, L.; Wagner, T.H.
Anesth Analg (2010) | PubMed »
  • BACKGROUND: We sought to determine the impact of a rapid response system on cardiac arrest rates and mortality in a United States veteran population. METHODS: We describe a prospective analysis of cardiac arrests in 9 months before and 27 months after institution of a rapid response system, and retrospective analysis of mortality 3.5 years before the intervention and 27 months after the intervention. The study included all inpatients from a university-affiliated United States Veterans Affairs Medical Center, before and after implementation of a rapid response system, including an educational program, patient calling criteria, and a physician-led medical emergency team. Primary end points were hospital-wide cardiac arrests and mortality rates normalized to hospital discharges. Comparisons of event rates between various time points during the implementation process were made by analysis of variance. RESULTS: Three hundred seventy-eight calls were made to the medical emergency team in the time period studied. Compared with preintervention time points, cardiac arrests were reduced by 57%, amounting to a reduction of 5.6 cardiac arrests per 1000 hospital discharges (P < 0.01). Mortality was reduced during the intervention, but this was attributable to a natural decrease occurring over all phases of the study. CONCLUSIONS: A significant reduction in the rate of cardiac arrests was realized with this intervention, as well as a trend toward lower mortality. We estimate that 51 arrests were prevented in the timeframe studied. Our results suggest that further reductions in morbidity can be realized by expansion of rapid response systems throughout the Veterans Affairs network.
Talking about incontinence: the first step toward prevention and treatment
Wagner, T.H.;Subak, L.L.
JAMA (2010) | PubMed »
Disparities in health-related internet use by US veterans: results from a national survey
McInnes, D.K.; Gifford, A.L.; Kazis, L.E.;Wagner, T.H.
Inform Prim Care (2010) | PubMed »
  • BACKGROUND: The internet can contribute to improved access to information and services among underserved populations. Little is known about veterans' use of the internet for health, and how it is affected by socio-demographic characteristics. This knowledge gap is acute given the US Department of Veterans Affairs' (VA's) deployment of a major patient portal/personal health record system. OBJECTIVES: To assess the frequency and correlates of veterans' use of the internet and identify personal characteristics impeding veterans' health-related internet use. METHODS: Survey of 12 878 randomly selected adults from a panel of 60 000 US households. Veterans were oversampled. RESULTS: Of the 3408 veterans responding, 54% had used the internet and 29% had used the internet specifically for health. In multi-variable analyses, general internet use was positively associated with younger age (OR = 0.03, CI = 0.01-0.06, oldest versus youngest group), higher income (OR = 3.12, CI = 2.10-4.63, > or =$75 000 versus <$25 000), more education (OR = 4.2, CI = 2.92-6.02, most versus least educated group), and better health (OR = 0.59, CI = 0.42-83, fair/poor versus very good/excellent). Health-related internet use was positively associated with more education (OR = 2.32, CI = 1.45-3.74, most versus least educated group), urban location (OR = 2.41, CI = 1.66-3.50), and worse health (OR = 1.85, CI = 1.16-2.95, fair/poor versus very good/excellent). CONCLUSIONS: In the first large, systematic survey of veterans' internet use we found that more education and urban location were strongly, and positively, associated with veterans' health-related internet use, even after controlling for multiple socio-demographic characteristics. Interventions may be needed for less educated and rural veterans, e.g. by providers discussing internet use with their patients, or by the VA training veterans in health-related internet use.
Robot-assisted therapy for long-term upper-limb impairment after stroke
Lo, A.C.; Guarino, P.D.; Richards, L.G.; Haselkorn, J.K.; Wittenberg, G.F.; Federman, D.G.; Ringer, R.J.; Wagner, T.H.; Krebs, H.I.; Volpe, B.T.; Bever, C.T., Jr.; Bravata, D.M.; Duncan, P.W.; Corn, B.H.; Maffucci, A.D.; Nadeau, S.E.; Conroy, S.S.; Powell, J.M.; Huang, G.D.;Peduzzi, P.
N Engl J Med (2010) | PubMed »
  • BACKGROUND: Effective rehabilitative therapies are needed for patients with long-term deficits after stroke. METHODS: In this multicenter, randomized, controlled trial involving 127 patients with moderate-to-severe upper-limb impairment 6 months or more after a stroke, we randomly assigned 49 patients to receive intensive robot-assisted therapy, 50 to receive intensive comparison therapy, and 28 to receive usual care. Therapy consisted of 36 1-hour sessions over a period of 12 weeks. The primary outcome was a change in motor function, as measured on the Fugl-Meyer Assessment of Sensorimotor Recovery after Stroke, at 12 weeks. Secondary outcomes were scores on the Wolf Motor Function Test and the Stroke Impact Scale. Secondary analyses assessed the treatment effect at 36 weeks. RESULTS: At 12 weeks, the mean Fugl-Meyer score for patients receiving robot-assisted therapy was better than that for patients receiving usual care (difference, 2.17 points; 95% confidence interval [CI], -0.23 to 4.58) and worse than that for patients receiving intensive comparison therapy (difference, -0.14 points; 95% CI, -2.94 to 2.65), but the differences were not significant. The results on the Stroke Impact Scale were significantly better for patients receiving robot-assisted therapy than for those receiving usual care (difference, 7.64 points; 95% CI, 2.03 to 13.24). No other treatment comparisons were significant at 12 weeks. Secondary analyses showed that at 36 weeks, robot-assisted therapy significantly improved the Fugl-Meyer score (difference, 2.88 points; 95% CI, 0.57 to 5.18) and the time on the Wolf Motor Function Test (difference, -8.10 seconds; 95% CI, -13.61 to -2.60) as compared with usual care but not with intensive therapy. No serious adverse events were reported. CONCLUSIONS: In patients with long-term upper-limb deficits after stroke, robot-assisted therapy did not significantly improve motor function at 12 weeks, as compared with usual care or intensive therapy. In secondary analyses, robot-assisted therapy improved outcomes over 36 weeks as compared with usual care but not with intensive therapy. ( number, NCT00372411.)
Methods of a multisite randomized clinical trial of supported employment among veterans with spinal cord injury
Ottomanelli, L.; Goetz, L.; McGeough, C.; Suris, A.; Sippel, J.; Sinnott, P.; Wagner, T.H.;Cipher, D.J.
J Rehabil Res Dev (2010) | PubMed »
  • This article compares the methods of a randomized multisite clinical trial of evidence-based supported employment with conventional vocational rehabilitation among veterans with spinal cord injury (SCI). The primary hypothesis is that, compared with conventional vocational rehabilitation (i.e., standard care), evidence-based supported employment will significantly improve competitive employment outcomes and general rehabilitation outcomes. The secondary hypothesis is that evidence-based supported employment in SCI will be more cost-effective than standard care. The current article describes the clinical trial and presents baseline data. The present sample includes 301 veterans with SCI, which includes paraplegia (50%), high tetraplegia (32%), and low tetraplegia (18%). Baseline data indicate that 65% of this sample of employment-seeking veterans with SCI had never been employed postinjury, despite the fact that nearly half (41%) had received some type of prior vocational rehabilitation. These rates of unemployment for veterans with SCI are consistent with the rates reported for community samples of persons with SCI. Forthcoming outcome data will provide much needed insights into the best practices for helping these veterans restore vocational goals and improve overall quality of life.
Embracing a health services research perspective on personal health records: lessons learned from the VA My HealtheVet system
Nazi, K.M.; Hogan, T.P.; Wagner, T.H.; McInnes, D.K.; Smith, B.M.; Haggstrom, D.; Chumbler, N.R.; Gifford, A.L.; Charters, K.G.; Saleem, J.J.; Weingardt, K.R.; Fischetti, L.F.;Weaver, F.M.
J Gen Intern Med (2010) | PubMed »
  • BACKGROUND: Personal health records (PHRs) are designed to help people manage information about their health. Over the past decade, there has been a proliferation of PHRs, but research regarding their effects on clinical, behavioral, and financial outcomes remains limited. The potential for PHRs to facilitate patient-centered care and health system transformation underscores the importance of embracing a broader perspective on PHR research. OBJECTIVE: Drawing from the experiences of VA staff to evaluate the My HealtheVet (MHV) PHR, this article advocates for a health services research perspective on the study of PHR systems. METHODS: We describe an organizing framework and research agenda, and offer insights that have emerged from our ongoing efforts regarding the design of PHR-related studies, the need to address PHR data ownership and consent, and the promotion of effective PHR research collaborations. CONCLUSION: These lessons are applicable to other PHR systems and the conduct of PHR research across different organizational contexts.
Description of outpatient utilization and costs in group of veterans with traumatic brain injury
Homaifar, B.Y.; Harwood, J.E.; Wagner, T.H.;Brenner, L.A.
J Rehabil Res Dev (2009) | PubMed »
  • In an attempt to increase understanding regarding the nonacute healthcare needs of veterans with traumatic brain injury (TBI), we examined the outpatient utilization and cost patterns of 72 patients with TBI who were at least 4 years postinjury. We selected participants from a clinical database of veterans receiving care at a western Department of Veterans Affairs (VA) medical center. We extracted data from national utilization databases maintained by the VA and examined data from primary care and internal medicine, psychiatry and substance use, rehabilitation, and other services (e.g., ancillary, diagnostic, prosthetic, dental, nursing home, and home care). We extracted data for fiscal years 2002 to 2007. In addition to descriptive statistics, we modeled visits per year as a function of time since injury. The data show that this sample of patients with TBI consistently used a wide array of outpatient services over time with considerable variation in cost. Further study regarding economic aspects of care for patients with TBI is warranted.
Costs and benefits of the national cancer institute central institutional review board
Wagner, T.H.; Murray, C.; Goldberg, J.; Adler, J.M.;Abrams, J.
J Clin Oncol (2009) | PubMed »
  • PURPOSE: In 2001, the National Cancer Institute (NCI) formed the Central Institutional Review Board (CIRB) to conduct a single human subjects review for its multisite phase III oncology trials. The goal of this study was to assess whether NCI's CIRB was associated with lower effort, time, and cost in processing adult phase III oncology trials. METHODS: We conducted an observational study and compared sites affiliated with the NCI CIRB to unaffiliated sites that used their local IRB for review. Oncology research staff and IRB staff were surveyed to understand effort and timing. Response rates were 60% and 42%, respectively. Analysis of these survey data yielded information on effort, timing, and costs. We combined these data with CIRB operational data to determine the net savings of the CIRB using a societal perspective. RESULTS: CIRB affiliation was associated with faster reviews (33.9 calendar days faster on average), and 6.1 fewer hours of research staff effort. CIRB affiliation was associated with a savings of $717 per initial review. The estimated cost of running the CIRB was $161,000 per month. The CIRB yielded a net cost of approximately $55,000 per month from a societal perspective. Whether the CIRB results in higher or lower quality reviews was not assessed because there is no standard definition of review quality. CONCLUSION: The CIRB was associated with decreases in investigator and IRB staff effort and faster protocol reviews, although savings would be higher if institutions used the CIRB as intended.
New, but Not Improved? Incorporating Comparative-Effectiveness Information into FDA Labeling
Stafford, R.S.; Wagner, T.H.;Lavori, P.W.
N Engl J Med (2009) | PubMed »
Low Back Pain in VA Users
Sinnott, P.;Wagner, T.
Arch Internal Med (2009) | PubMed »
Multicenter Randomized Trial of Robot-Assisted Rehabilitation for Chronic Stroke: Methods and Entry Characteristics for VA ROBOTICS
Lo, A.C.; Guarino, P.; Krebs, H.I.; Volpe, B.T.; Bever, C.T.; Duncan, P.W.; Ringer, R.J.; Wagner, T.H.; Richards, L.G.; Bravata, D.M.; Haselkorn, J.K.; Wittenberg, G.F.; Federman, D.G.; Corn, B.H.; Maffucci, A.D.;Peduzzi, P.
Neurorehabil Neural Repair (2009) | PubMed »
  • BACKGROUND: Chronic upper extremity impairment due to stroke has significant medical, psychosocial, and financial consequences, but few studies have examined the effectiveness of rehabilitation therapy during the chronic stroke period. OBJECTIVE: . To test the safety and efficacy of the MIT-Manus robotic device for chronic upper extremity impairment following stroke. METHODS: . The VA Cooperative Studies Program initiated a multicenter, randomized, controlled trial in November 2006 (VA ROBOTICS). Participants with upper extremity impairment >/=6 months poststroke were randomized to robot-assisted therapy (RT), intensive comparison therapy (ICT), or usual care (UC). RT and ICT consisted of three 1-hour treatment sessions per week for 12 weeks. The primary outcome was change in the Fugl-Meyer Assessment upper extremity motor function score at 12 weeks relative to baseline. Secondary outcomes included the Wolf Motor Function Test and the Stroke Impact Scale. RESULTS: . A total of 127 participants were randomized: 49 to RT, 50 to ICT, and 28 to UC. The majority of participants were male (96%), with a mean age of 65 years. The primary stroke type was ischemic (85%), and 58% of strokes occurred in the anterior circulation. Twenty percent of the participants reported a stroke in addition to their index stroke. The average time from the index stroke to enrollment was 56 months (range, 6 months to 24 years). The mean Fugl-Meyer score at entry was 18.9. CONCLUSIONS: . VA ROBOTICS demonstrates the feasibility of conducting multicenter clinical trials to rigorously test new rehabilitative devices before their introduction to clinical practice. The results are expected in early 2010.
Re: Practice patterns in benign prostatic hyperplasia surgical therapy: the dramatic increase in minimally invasive technologies. X. Yu, S. P. Elliott, T. J. Wilt and A. M. McBean. J Urol 2008; 180: 241-245
Wagner, T.H.
J Urol (2009) | PubMed »
Impact of overactive bladder on work productivity in the United States: results from EpiLUTS
Sexton, C.C.; Coyne, K.S.; Vats, V.; Kopp, Z.S.; Irwin, D.E.;Wagner, T.H.
Am J Manag Care (2009) | PubMed »
  • Little research has focused on the impact of overactive bladder (OAB) on work productivity. Consequently, the impact of OAB and other lower urinary tract symptoms (LUTS) on work productivity was evaluated in employed men and women aged 40 to 65 in the United States. STUDY DESIGN: Data from a population-based, cross-sectional Internet survey were used to examine the impact of OAB symptoms on work productivity. US participants aged 40 to 65 working full- or part-time were included in the analysis. Participants were asked about the incidence of OAB and other LUTS and a series of questions about work productivity. METHODS: Descriptive statistics and linear and logistic regressions were used to evaluate outcome differences for men and women by the OAB groups of no/minimal symptoms, continent OAB, and incontinent OAB. RESULTS: The response rate was 60%, and a total of 2876 men and 2820 women were analyzed. Men and women with incontinent OAB reported the lowest levels of work productivity and highest rates of daily work interference. Storage symptoms associated with OAB were most consistently associated with work productivity outcomes; however, significant associations were also found for other storage, voiding, and postmicturition LUTS. CONCLUSION: In this large US population-based study, OAB was highly prevalent and was associated with lower levels of work productivity. These findings add to the literature documenting the burden of OAB and other LUTS, underscoring the need for increased screening and treatment.
The costs of an outreach intervention for low-income women with abnormal Pap smears
Wagner, T. H.; Engelstad, L. P.; McPhee, S. J.; Pasick, R. J.
Prev Chronic Dis (2007) | PubMed »
  • INTRODUCTION: Follow-up among women who have had an abnormal Papanicolaou (Pap) smear is often poor in public hospitals that serve women at increased risk for cervical cancer. This randomized controlled trial evaluated and compared the total cost and cost per follow-up of a tailored outreach intervention plus usual care with the total cost and cost per follow-up of usual care alone. METHODS: Women with an abnormal Pap smear (n = 348) receiving care at Alameda County Medical Center (Alameda County, California) were randomized to intervention or usual care. The intervention used trained community health advisors to complement the clinic's protocol for usual care. We assessed the costs of the intervention and the cost per follow-up within 6 months of the abnormal Pap smear test result. RESULTS: The intervention increased the rate of 6-month follow-up by 29 percentage points, and the incremental cost per follow-up was 959 dollars (2005 dollars). The cost per follow-up varied by the severity of the abnormality. The cost per follow-up for the most severe abnormality (high-grade squamous intraepithelial lesion) was 681 dollars, while the cost per follow-up for less severe abnormalities was higher. CONCLUSION: In a health care system in which many women fail to get follow-up care for an abnormal Pap smear, outreach workers were more effective than usual care (mail or telephone reminders) at increasing follow-up rates. The results suggest that outreach workers should manage their effort based on the degree of abnormality; most effort should be placed on women with the most severe abnormality (high-grade squamous intraepithelial lesion).
Cost of inpatient rehabilitation care in the Department of Veterans Affairs
Wagner, T. H.; Richardson, S. S.; Vogel, B.; Wing, K.; Smith, M. W.
J Rehabil Res Dev (2006) | Download »
  • We investigated the determinants of inpatient rehabilitation costs in the Department of Veterans Affairs (VA) and examined the relationship between length of stay (LOS) and discharge costs using data from VA and community rehabilitation hospitals. We estimated regression models to identify patient characteristics associated with specialized inpatient rehabilitation costs. VA data included 3,535 patients discharged from 63 facilities in fiscal year 2001. We compared VA costs to community rehabilitation hospitals using a sample from the Uniform Data System for Medical Rehabilitation of 190,112 patients discharged in 1999 from 697 facilities. LOS was a strong predictor of cost for VA and non-VA hospitals. Functional status, measured by Functional Independence Measure (FIM) scores at admission, was statistically significant but added little explanatory value after controlling for LOS. Although FIM scores were associated with LOS, FIM scores accounted for little variance in cost after controlling for LOS. These results are most applicable to researchers conducting cost-effectiveness analyses.
Determinants of cost among people who died in VA nursing homes
Yu, W.; Wagner, T. H.; Barnett, P. G.
Med Care Res Rev (2006) | PubMed »
  • We examined final stays of elderly patients (65 or more years of age) who died in 111 VA nursing homes in fiscal year 2000 (N = 4,897) to evaluate determinants of the cost of final nursing home stays. We analyzed cost and its two main components (length of stay and intensity of care) by primary disease, age, race or ethnicity, gender, and benefit-eligibility type. We found that disease rather than age was the dominant factor influencing the cost of final nursing home stays. After controlling for six common diagnoses, age was not associated with cost. Marital status and race or ethnicity were also significant predictors but accounted for less variation than illnesses. Incorporating illness into models that predict future demand for nursing home use provides greater precision than using age alone, especially as diseases and their treatments change through time.
Medication characteristics beyond cost alone influence decisions to underuse pharmacotherapy in response to financial pressures
Piette, J. D.; Heisler, M.; Wagner, T. H.
J Clin Epidemiol (2006) | PubMed »
  • BACKGROUND AND OBJECTIVE: Little is known about how patients facing medication cost pressures make choices about whether to underuse one or more of their prescription drugs. We calculated the probability that older adults would underuse prescription medications for common chronic illnesses because of cost concerns. We also identified differences in cost-related underuse between symptom-relief medications (e.g., analgesics) and primarily "preventive" medications (e.g., antihypertensives). MATERIALS AND METHODS: Older chronically ill patients using both symptom-relief and preventive medications (N = 2,008) were identified as part of a nationwide survey in the United States and reported information about their cost-related underuse of 16 medication types. We used regression models to estimate the probability of underuse for each medication type, assuming average out-of-pocket costs, no prescription coverage, and the sociodemographic characteristics of a typical American aged 50+. RESULTS: 23% of respondents reported forgoing medication in the prior year due to cost. The likelihood of cost-related underuse was higher for symptom-relief medications (27%) than for primarily preventive medications (20%, P < .001). Among the subset of patients who cut back on adherence due to cost, the likelihood of forgoing symptom-relief medication (69%) was higher than that for preventive drugs (54%, P < .001). CONCLUSIONS: Medication characteristics beyond cost alone influence decisions to underuse treatment in response to financial pressures.
Who searches the internet for health information?
Bundorf, M. K.; Wagner, T. H.; Singer, S. J.; Baker, L. C.
Health Serv Res (2006) | PubMed »
  • Objective. To determine what types of consumers use the Internet as a source of health information. Data Sources. A survey of consumer use of the Internet for health information conducted during December 2001 and January 2002. Study Design. We estimated multivariate regression models to test hypotheses regarding the characteristics of consumers that affect information seeking behavior. Data Collection. Respondents were randomly sampled from an Internet-enabled panel of over 60,000 households. Our survey was sent to 12,878 panel members, and 69.4 percent of surveyed panel members responded. We collected information about respondents' use of the Internet to search for health information and to communicate about health care with others using the Internet or e-mail within the last year. Principal Findings. Individuals with reported chronic conditions were more likely than those without to search for health information on the Internet. The uninsured, particularly those with a reported chronic condition, were more likely than the privately insured to search. Individuals with longer travel times for their usual source of care were more likely to use the Internet for health-related communication than those with shorter travel times. Conclusions. Populations with serious health needs and those facing significant barriers in accessing health care in traditional settings turn to the Internet for health information.
Self-reported utilization of health care services: improving measurement and accuracy
Bhandari, A.; Wagner, T.
Med Care Res Rev (2006) | PubMed »
  • Self-report is often used to estimate health care utilization. However, the accuracy of such data is of paramount concern. The authors conducted a systematic review of 42 studies that evaluated the accuracy of self-report utilization data, where utilization was defined as a visit to a clinical provider or entity. They also present a broad conceptual model that identifies major issues to consider when collecting, analyzing, and reporting such data. The results show that self-report data are of variable accuracy. Factors that affect accuracy include (1) sample population and cognitive abilities, (2) recall time frame, (3) type of utilization, (4) utilization frequency, (5) questionnaire design, (6) mode of data collection, and (7) memory aids and probes.
Health-related consequences of overactive bladder: an economic perspective
Hu, T. W.; Wagner, T. H.
BJU Int (2005) | PubMed »
  • About 34 million people in the USA have an overactive bladder (OAB), a condition characterized by urinary urgency, with or without urinary incontinence, and usually frequency and nocturia. This condition is associated with increased health risks (e.g. urinary tract infection, falls and fall-related injuries, including broken bones), as well as admission to nursing homes and prolonged hospital stays. The annual costs associated with OAB in the community setting are >9 billion dollars, including 2.9 billion dollars for diagnosis and treatment, 1.5 billion dollars for routine care, 3.9 billion dollars for treatment of health-related consequences, and 841 million dollars in lost productivity. These cost patterns raise the possibility that treating OAB at an early stage may both improve patient care and minimize overall use of healthcare resources. However, before a thorough economic analysis of OAB can be undertaken, more data are needed about the long-term costs and the pathogenesis of OAB-related conditions.
Internet use and stigmatized illness
Berger, M.; Wagner, T. H.; Baker, L. C.
Soc Sci Med (2005) | PubMed »
  • People with stigmatized illnesses often avoid seeking health care and education. The internet may be a useful health education and outreach tool for this group. This study examined patterns of internet use for health information among those with and without stigmatized illnesses. A national survey of internet users in the USA was conducted. Respondents who self-reported a stigmatized condition-defined as anxiety, depression, herpes, or urinary incontinence-were compared to respondents who reported having at least one other chronic illness, such as cancer, heart problems, diabetes, and back pain. The analytical sample consisted of 7014 respondents. Cross-sectional associations between stigmatized illness and frequency of internet use for information about health care, use of the internet for communication about health, changes in health care utilization after internet use, and satisfaction with the internet were determined. After controlling for a number of potential confounders, those with stigmatized illnesses were significantly more likely to have used the internet for health information, to have communicated with clinicians about their condition using the internet, and to have increased utilization of health care based on information found on the internet, than those with non-stigmatized conditions. Length of time spent online, frequency of internet use, satisfaction with health information found on the internet, and discussion of internet findings with health care providers did not significantly differ between the two groups. Results from this survey suggest that the internet may be a valuable health communication and education tool for populations who are affected by stigmatized illnesses.
Patient strategies to cope with high prescription medication costs: who is cutting back on necessities, increasing debt, or underusing medications?
Heisler, M.; Wagner, T. H.; Piette, J. D.
J Behav Med (2005) | PubMed »
  • Many chronically ill adults in the United States face high prescription medication costs, yet little is known about the strategies patients adopt to cope with these costs. Through a national survey of 4,055 adults taking prescription medications for one of five chronic diseases, we compared whether respondents cut back on necessities such as food or heat to pay for medications, increased debt, or underused medications because of cost. We also examined the sociodemographic and clinical correlates and differential use by different sub-groups of these three strategies. Overall, 31% of respondents reported pursuing at least one of the strategies over the prior 12 months. Twenty-two percent had cut back on necessities, 16% had increased their debt burden, and 18% had underused prescription drugs. Among patients who underused their medication, 67% also had cut necessities or increased debt. Although we found significant differences in the way patients with varying socio-demographic characteristics responded to medication cost pressures, use of all these strategies was especially common among patients who were low-income, in poor health, and taking multiple medications.
Free Internet access, the digital divide, and health information
Wagner, T. H.; Bundorf, M. K.; Singer, S. J.; Baker, L. C.
Med Care (2005) | PubMed »
  • BACKGROUND:: The Internet has emerged as a valuable tool for health information. Half of the U.S. population lacked Internet access in 2001, creating concerns about those without access. Starting in 1999, a survey firm randomly invited individuals to join their research panel in return for free Internet access. This provides a unique setting to study the ways that people who had not previously obtained Internet access use the Internet when it becomes available to them. METHODS:: In 2001-2002, we surveyed 12,878 individuals 21 years of age and older on the research panel regarding use of the Internet for health; 8935 (69%) responded. We analyzed respondents who had no prior Internet access, and then compared this group to those who had prior Internet access. RESULTS:: Among those newly provided free Internet access, 24% had used the Internet for health information in the past year, and users reported notable benefits, such as improved knowledge and self-care abilities. Not surprisingly, the no-prior-Internet group reported lower rates of using the Internet (24%) than the group that had obtained Internet access prior to joining the research panel (40%), but the 2 groups reported similar perceptions of the Internet and self-reported effects. CONCLUSIONS:: Those who obtained Internet access for the first time by joining the panel used the Internet for health and appeared to benefit from it. Access helps explain the digital divide, although most people given free access do not use the Internet for health information.
An economic evaluation of inpatient residential treatment programs in the department of veterans affairs
Wagner, T. H.; Chen, S.
Med Care Res Rev (2005) | PubMed »
  • The Veterans Health Administration (VA) established psychosocial residential rehabilitation treatment programs (RTPs) to treat eligible veterans who have psychiatric and substance use disorders in a less intensive and more self-reliant inpatient setting. Fortytwo (25 percent) VA medical centers adopted RTPs in 1995. Panel regression models using data from 1993 through 1999 indicated that RTPs were associated with 8.6 and 24.4 percent decreases in the average cost per day for inpatient psychiatry and substance use care, respectively. During this time, VA transitioned much of the inpatient mental health care to ambulatory services. Yet medical centers with RTPs had smaller decreases in the number of inpatient patient days than those without RTPs. Because medical centers with RTPs provided more services, this offset the per diem savings, resulting in no significant differences in total costs between medical centers with and without RPTs.
Use of the internet for health information by the chronically ill
Wagner, T. H.; Baker, L. C.; Bundorf, M. K.; Singer, S.
Prev Chronic Dis (2004) | PubMed » | PDF available on Intranet
  • INTRODUCTION: Chronic conditions are among the leading causes of death and disability in the United States. The Internet is a source of health information and advice for individuals with chronic conditions and shows promise for helping individuals manage their conditions and improve their quality of life. METHODS: We assessed Internet use for health information by people who had one or more of five common chronic conditions. We conducted a national survey of adults aged 21 and older, then analyzed data from 1980 respondents who had Internet access and who reported that they had hypertension, diabetes, cancer, heart problems, and/or depression. RESULTS: Adjusted rates for any Internet use for health information ranged from 33.8% (heart problems only) to 52.0% (diabetes only). A sizable minority of respondents - particularly individuals with diabetes - reported that the Internet helped them to manage their condition themselves, and 7.9% said information on the Internet led them to seek care from a different doctor. CONCLUSION: Use of the Internet for health information by chronically ill patients is moderate. Self-reported effects on choice of treatment or provider are small but noteworthy.
The relationships among age, chronic conditions, and healthcare costs
Yu, W.; Ravelo, A.; Wagner, T. H.; Barnett, P. G.
Am J Manag Care (2004) | PubMed »
  • OBJECTIVE: To learn how age and chronic illness affect costs in the Veterans Affairs healthcare system. STUDY DESIGN: Veterans Affairs patients 65 years or older were identified from administrative data. We noted their healthcare utilization, cost, and diagnosis of any of 29 common chronic conditions (CCs). We examined how those 80 years or older differed from the younger patients. RESULTS: The Department of Veterans Affairs spent dollars 8.5 billion to treat 1.6 million older patients in fiscal year 2000. Age was less important than chronic illness in explaining cost differences. The oldest patients incurred a mean of dollars 1295 greater costs than the younger patients, primarily because they were more likely to have a high-cost CC. The oldest patients incurred higher total costs than the younger patients in only 14 of 29 groups defined by CC. Long-term care accounted for most of the extra cost of the oldest patients. When this cost was excluded, the oldest patients incurred only dollars 266 more cost than the younger patients. CONCLUSIONS: Growth in the population of the oldest patients will increase the number of individuals with CCs requiring long-term care. With its limited long-term care benefit, Medicare will avoid much of this financial consequence. In contrast, the financial risk of acute and long-term care gives the Department of Veterans Affairs an incentive to develop strategies to prevent CCs associated with long-term care.
Behavioral interventions and cost-effectiveness analysis
Wagner, T. H.; Goldstein, M. K.
Prev Med (2004) | PubMed »
  • Behavioral health interventions are often gauged with a dichotomous outcome, "success" or "failure." Hidden by this dichotomy is a series of behavior changes that can be followed with the Transtheoretical Model (stages of change). There has been little consideration, however, about whether this information can and should be used in cost-effectiveness analysis. We review the stages of change model and its applications to behavioral health interventions. We then discuss analytical methods for including stages of change, or similar behavior change models, in cost-effectiveness analysis (CEA). This is typically not done but it may be critical for study design and for interpreting CEA results.
Consumers' use of the Internet for health insurance
Bundorf, M. K.; Singer, S. J.; Wagner, T. H.; Baker, L.
Am J Manag Care (2004) | PubMed »
  • OBJECTIVES: We examined consumers' search for information about health insurance choices and their use of the Internet for that search and to manage health benefits. STUDY DESIGN: We surveyed a random sample of more than 4500 individuals aged 21 years and older who were members of a survey research panel during December 2001 and January 2002. METHODS: The survey included questions about searching for health insurance information in 3 health insurance markets: Medicare, individual or nongroup, and employer-sponsored group. We also asked questions about use of the Internet to manage health benefits. We tabulated means of responses to each question by market and tested for independence across demographic groups using the Pearson chi-square test. RESULTS: We identified important differences across and within markets in the extent to which people look for information about health insurance alternatives and the role of the Internet in their search. Although many individuals were unaware of whether their employer or health plan provided a website to manage health benefits, those who used the sites generally evaluated them favorably. CONCLUSIONS: Our results suggest that the Internet is an important source of health insurance information, particularly for individuals purchasing coverage individually in the nongroup and Medicare markets relative to those obtaining coverage from an employer. In the case of Medicare coverage, studies focusing on beneficiaries' use of Internet resources may underestimate the Internet's importance by neglecting caregivers who use the Internet. Many individuals may be unaware of the valuable resources available through employers or health plans.
Cost-related medication underuse among chronically ill adults: the treatments people forgo, how often, and who is at risk
Piette, J. D.; Heisler, M.; Wagner, T. H.
Am J Public Health (2004) | PubMed »
  • OBJECTIVES: We sought information about the cost-related underuse of medications-which medications are underused, by whom, and how often. METHODS: Chronically ill adults were asked to identify how often they underused prescription medication for 16 health conditions because of the cost. RESULTS: Eighteen percent of respondents cut back on medication use owing to cost in the previous year, and 14% used less medication at least monthly. Although rates of underuse varied substantially across treatments, prescription coverage and out-of-pocket costs were determinants of underuse across medication types. CONCLUSIONS: Many chronically ill adults frequently cut back on medications owing to cost. Patients are selective about the treatments they forgo. Out-of-pocket costs and inadequate prescription coverage may lead to adherence problems for many important medication types.
Cost-related medication underuse: do patients with chronic illnesses tell their doctors?
Piette, J. D.; Heisler, M.; Wagner, T. H.
Arch Intern Med (2004) | PubMed »
  • BACKGROUND: Although many chronically ill patients underuse prescription medications because of cost concerns, we know little about their discussions with clinicians about this issue. METHODS: Nationwide survey of 660 older adults with chronic illnesses who reported underusing medication in the prior year because of cost. We assessed whether patients discussed cost-related medication underuse with clinicians, reasons that some patients did not talk with clinicians about this problem, how clinicians responded when this issue was raised, and how helpful patients perceived clinicians to be. RESULTS: Two thirds of respondents never told a clinician in advance that they planned to underuse medication because of the cost, and 35% never discussed the issue at all. Of those who did not tell a clinician, 66% reported that nobody asked them about their ability to pay for prescriptions and 58% reported that they did not think providers could help them. When patients talked with clinicians about medication costs, 72% found those conversations helpful. However, 31% reported that their medications were never changed to a generic or less expensive alternative, and few patients were given other forms of assistance such as information about programs that help pay drug costs (30%) or where to purchase less expensive medication (28%). Patients were most likely to find clinicians helpful if clinicians provided free samples, asked about problems paying for prescriptions, and offered advice about how to pay for patients' current regimens. CONCLUSIONS: About one third of chronically ill adults who underuse prescription medication because of the cost never talk with clinicians in advance, and many never raise this issue at all. Clinicians should take a more proactive role in identifying and assisting patients who have problems paying for prescription drugs.
Economies of Scale in Institutional Review Boards
Wagner, T. H.; Cruz, A. M.; Chadwick, G. L.
Med Care (2004) | PubMed »
  • BACKGROUND:: Research with human subjects is essential for most clinical and social science research. As such, the ethical treatment of subjects, including the role of Institutional Review Boards (IRBs), is of paramount concern. The prevailing system of IRBs in the United States reflects an integrated approach in which research organizations have their own local IRB. Recent regulatory changes and a few high-profile problems have prompted proposals for greater investments in IRBs. OBJECTIVES:: We conducted regression analyses, looking at how IRB size was associated with IRB costs (economies of scale). RESEARCH DESIGN:: We studied data from a cross-sectional survey. SUBJECTS:: We studied IRBs at Veterans Affairs (VA) and VA-affiliated medical centers (n = 109); 81 (73%) IRB administrators completed the survey. Fourteen of the administrators had missing data and were excluded from final analysis, leaving a sample of 67. MEASURES:: The primary dependent variable was IRB costs in 2001, which we estimated from the survey. Independent variables included IRB size measured as the number of actions (ie, number of initial reviews, amendments, continuing/annual reviews, and harms/adverse event reports) reviewed by the IRB in the last year. RESULTS:: The results indicate that very large economies of scale exist, especially for IRBs that handle fewer than 150 actions per year. CONCLUSIONS:: A discussion of the costs of benefits of having 3000 to 5000 local IRBs in the United States is warranted because other organizational arrangements could be economically and socially advantageous.
Clinician identification of chronically ill patients who have problems paying for prescription medications
Heisler, M.; Wagner, T. H.; Piette, J. D.
Am J Med (2004) | PubMed »
  • PURPOSE: Little is known about whether health care providers are effectively identifying patients who have difficulty covering the costs of out-of-pocket prescription medications. We examined whether and how providers are identifying chronically ill adults who have potential problems paying for prescription medications. METHODS: We conducted a cross-sectional survey of a national sample of 4050 adults aged 50 years or older who use prescription medications for at least one of five chronic health conditions. The primary outcome measure was patient report of being asked by a doctor or nurse in the prior 12 months whether the patient could afford the prescribed medication. The measures of prescription cost burden were cost-related underuse of medications, cutting back on other necessities to pay for medications, and worries about medication costs. We adjusted for patient income, education, race/ethnicity, age, sex, health status, number of prescribed medications, pharmacy benefits, frequency of outpatient visits, having a regular health care provider, and sampling weights. RESULTS: In the weighted analyses, 16% (547/4050) of respondents reported that they had been asked about potential problems paying for a prescribed medication. Only 360 (24%) of the 1499 respondents who reported one or more burdens from out-of-pocket medication costs reported being asked this question. After adjusting for potential confounders, patients who had cut back on medication use or other necessities to cover payments were no more likely than other patients to be asked about the ability to pay for prescription medications. Concerns about medication costs, being a racial/ethnic minority, taking seven or more prescription medications, and having no prescription coverage were independently associated with a greater likelihood of being asked about possible problems with prescription costs. CONCLUSION: Few chronically ill patients who are at risk of or experiencing problems related to prescription medication costs report that their clinicians had asked them about possible medication payment difficulties.
Improving the decision processes of institutional review boards
Wagner, T. H.
JAMA (2004) | PubMed »
Costs of urinary incontinence and overactive bladder in the United States: a comparative study
Hu, T. W.; Wagner, T. H.; Bentkover, J. D.; Leblanc, K.; Zhou, S. Z.; Hunt, T.
Urology (2004) | PubMed »
  • OBJECTIVES: To update the cost of urinary incontinence (UI) for year 2000 and compare it with the cost of overactive bladder (OAB). METHODS: Using the cost-of-illness framework, disease epidemiologic data were combined with treatment rates, consequence probabilities, and average cost estimates. All costs reflect the costs during 2000. RESULTS: The total cost of UI and OAB was 19.5 billion dollars and 12.6 billion dollars, respectively (year 2000 dollars). With UI, 14.2 billion dollars was borne by community residents and 5.3 billion dollars by institutional residents. With OAB, 9.1 and 3.5 billion dollars, respectively, was incurred by community and institutional residents. CONCLUSIONS: OAB affected 34 million individuals compared with 17 million with UI. Despite the differences in epidemiology, the total and per-person costs of UI were higher than the OAB costs because OAB individuals without incontinent episodes incurred fewer costs, on average.
Problems paying out-of-pocket medication costs among older adults with diabetes
Piette, J. D.; Heisler, M.; Wagner, T. H.
Diabetes Care (2004) | PubMed »
  • OBJECTIVE: To identify problems faced by older adults with diabetes due to out-of-pocket medication costs. RESEARCH DESIGN AND METHODS: In this cross-sectional national survey of 875 adults with diabetes treated with hypoglycemic medication, respondents reported whether they had underused prescription medications due to cost pressures or had experienced other financial problems associated with medication costs such as forgoing basic necessities. Respondents also described their interactions with clinicians about medication costs. RESULTS: A total of 19% of respondents reported cutting back on medication use in the prior year due to cost, 11% reported cutting back on their diabetes medications, and 7% reported cutting back on their diabetes medications at least once per month. Moreover, 28% reported forgoing food or other essentials to pay medication costs, 14% increased their credit card debt, and 10% borrowed money from family or friends to pay for their prescriptions. Medication cost problems were especially common among respondents who were younger, had higher monthly out-of-pocket costs, and had no prescription drug coverage. In general, few respondents, including those reporting medication cost problems, reported that their health care providers had given them information or other assistance to address medication cost pressures. CONCLUSIONS: Out-of-pocket medication costs pose a significant burden to many adults with diabetes and contribute to decreased treatment adherence. Clinicians should actively identify patients with diabetes who are facing medication cost pressures and assist them by modifying their medication regimens, helping them understand the importance of each prescribed medication, providing information on sources of low-cost drugs, and linking patients with coverage programs.
Health insurance status, cost-related medication underuse, and outcomes among diabetes patients in three systems of care
Piette, J. D.; Wagner, T. H.; Potter, M. B.; Schillinger, D.
Med Care (2004) | PubMed »
  • BACKGROUND: Chronically ill patients often experience difficulty paying for their medications and, as a result, use less than prescribed. OBJECTIVES: The objectives of this study were to determine the relationship between patients with diabetes' health insurance coverage and cost-related medication underuse, the association between cost-related underuse and health outcomes, and the role of comorbidity in this process. RESEARCH DESIGN: We used a patient survey with linkage to insurance information and hemoglobin A1C (A1C) test results. PATIENTS: We studied 766 adults with diabetes recruited from 3 Veterans Affairs (VA), 1 county, and 1 university healthcare system. MAIN OUTCOMES: Main outcomes consisted of self-reported medication underuse as a result of cost, A1C levels, symptom burden, and Medical Outcomes Study 12-Item Short-Form physical and mental functioning scores. RESULTS: Fewer VA patients reported cost-related medication underuse (9%) than patients with private insurance (18%), Medicare (25%), Medicaid (31%), or no health insurance (40%; P <0.0001). Underuse was substantially more common among patients with multiple comorbid chronic illnesses, except those who used VA care. The risk of cost-related underuse for patients with 3+ comorbidities was 2.8 times as high among privately insured patients as VA patients (95% confidence interval, 1.2-6.5), and 4.3 to 8.3 times as high among patients with Medicare, Medicaid, or no insurance. Individuals reporting cost-related medication underuse had A1C levels that were substantially higher than other patients (P <0.0001), more symptoms, and poorer physical and mental functioning (all P <0.05). CONCLUSIONS: Many patients with diabetes use less of their medication than prescribed because of the cost, and those reporting cost-related adherence problems have poorer health. Cost-related adherence problems are especially common among patients with diabetes with comorbid diseases, although the VA's drug coverage may protect patients from this increased risk.
Cost of Urinary Incontinence
Wagner, TH
Timely Top Med (2004)
Prevalence and costs of chronic conditions in the VA health care system
Yu, W.; Ravelo, A.; Wagner, T. H.; Phibbs, C. S.; Bhandari, A.; Chen, S.; Barnett, P. G.
Med Care Res Rev (2003) | Download »
  • Chronic conditions are among the most common causes of death and disability in the United States. Patients with such conditions receive disproportionate amounts of health care services and therefore cost more per capita than the average patient. This study assesses the prevalence among the Department of Veterans Affairs (VA) health care users and VA expenditures (costs) of 29 common chronic conditions. The authors used regression to identify the marginal impact of these conditions on total, inpatient, outpatient, and pharmacy costs. Excluding costs of contracted medical services at non-VA facilities, total VA health care expenditures in fiscal year 1999 (FY1999) were $14.3 billion. Among the 3.4 million VA patients in FY1999, 72 percent had 1 or more of the 29 chronic conditions, and these patients accounted for 96 percent of the total costs ($13.7 billion). In addition, 35 percent (1.2 million) of VA health care users had 3 or more of the 29 chronic conditions. These individuals accounted for 73 percent of the total cost. Overall, VA health care users have more chronic diseases than the general population.
Average cost of VA rehabilitation, mental health, and long-term hospital stays
Yu, W.; Wagner, T. H.; Chen, S.; Barnett, P. G.
Med Care Res Rev (2003) | Download »
  • This article describes the development of a database for the cost of inpatient rehabilitation, mental health, and long-term care stays in the Department of Veterans Affairs from fiscal year 1998 forward. Using "bedsection," which is analogous to a hospital ward, the authors categorize inpatient services into nine categories: rehabilitation, blind rehabilitation, spinal cord injury, psychiatry, substance abuse, intermediate medicine, domiciliary, psychosocial residential rehabilitation, and nursing home. For each of the nine categories, they estimated a national and a local (i.e., medical center) average per diem cost. The nursing home average per diem costs were adjusted for case mix using patient assessment information. Encounter-level costs were then calculated by multiplying the average per diem cost by the number of days of stay in the fiscal year. The national cost estimates are more reliable than the local cost estimates.
Using average cost methods to estimate encounter-level costs for medical-surgical stays in the VA
Wagner, T. H.; Chen, S.; Barnett, P. G.
Med Care Res Rev (2003) | Download »
  • The U.S. Department of Veterans Affairs (VA) maintains discharge abstracts, but these do not include cost information. This article describes the methods the authors used to estimate the costs of VA medical-surgical hospitalizations in fiscal years 1998 to 2000. They estimated a cost regression with 1996 Medicare data restricted to veterans receiving VA care in an earlier year. The regression accounted for approximately 74 percent of the variance in cost-adjusted charges, and it proved to be robust to outliers and the year of input data. The beta coefficients from the cost regression were used to impute costs of VA medical-surgical hospital discharges. The estimated aggregate costs were reconciled with VA budget allocations. In addition to the direct medical costs, their cost estimates include indirect costs and physician services; both of these were allocated in proportion to direct costs. They discuss the method's limitations and application in other health care systems.
Spending for specialized mental health treatment in The VA: 1995-2001
Chen, S.; Smith, M. W.; Wagner, T. H.; Barnett, P. G.
Health Aff (Millwood) (2003) | PubMed » | PDF available on Intranet
  • The mid-1990s saw dramatic changes in mental health care in the Department of Veterans Affairs (VA), the largest provider of such care in the United States. Spending for specialized inpatient mental health care fell 21 percent from 1995 to 2001, while spending for specialized outpatient care rose 63 percent. The shift from inpatient to outpatient care was accompanied by rapid increases in outpatient medication costs. Overall, the VA reduced the average cost (per VA user) of specialized mental health care by 22 percent while it increased the number of users of these services by 35 percent.
New opportunities for integrated child health systems: results from the multifaceted pre-to-three program
Cuellar, A. E.; Wagner, T. H.; Hu, T. W.; Peifer, K.; Kitzman, H.; Tobin, S. J.; Shih, V.; Morrow, S.
Am J Public Health (2003) | PubMed »
The cost of institutional review board procedures in multicenter observational research
Humphreys, K.; Trafton, J.; Wagner, T. H.
Ann Intern Med (2003) | PubMed »
The effect of age on the use of health and self-care information: confronting the stereotype
Wagner, L. S.; Wagner, T. H.
Gerontologist (2003) | PubMed »
  • PURPOSE: Given stereotypes of older adults, there is the perception that older adults will not use health information technologies. One concern is that practitioners might shy away from providing older patients with health information, and in particular, computerized information. The study's primary objective was to evaluate whether a health information intervention had a differential effect for people of different ages. DESIGN AND METHODS: Quasi-experimental survey data from an assessment of a communitywide informational intervention were used. People were asked about their use of medical reference books, telephone advice nurses, or computers for health information in the past few months. In total, 5,909 surveys were completed. RESULTS: The data show that older adults were no less likely (and were sometimes more likely) to use health information as a result of the intervention than younger adults. For telephone advice nurses and computers, the effect of the intervention was not significantly different for the different age groups. Yet, compared with persons 18-29 years of age, those over the age of 65 had a 17-percentage point increase in using a self-care book. IMPLICATIONS: We find convincing evidence to counter the stereotype that older adults are resistant to trying new health information technologies.
Estimated economic costs of overactive bladder in the United States
Hu, T. W.; Wagner, T. H.; Bentkover, J. D.; LeBlanc, K.; Piancentini, A.; Stewart, W. F.; Corey, R.; Zhou, S. Z.; Hunt, T. L.
Urology (2003) | PubMed »
  • OBJECTIVES: To estimate the economic costs of overactive bladder (OAB), including community and nursing home residents, and to compare the costs in male versus female and older versus younger populations. METHODS: The National Overactive Bladder Evaluation Program included a representative telephone survey of 5204 community-dwelling adults 18 years and older in the United States and a follow-up postal survey of all individuals with OAB identified and age and sex-matched controls. The postal survey asked respondents about bladder symptoms, self-care use, treatment use, work loss, and OAB-related health consequences. Survey data estimates were combined with year 2000 average cost data to calculate the cost of OAB in the community. Institutional costs were estimated from the costs of urinary incontinence in nursing homes, limited to only those with urge incontinence or mixed incontinence (urge and stress). RESULTS: The estimated total economic cost of OAB was 12.02 billion dollars in 2000, with 9.17 and 2.85 billion dollars incurred in the community and institutions, respectively. Community female and male OAB costs totaled 7.37 and 1.79 billion dollars, respectively. The estimated total cost was sensitive to the estimated prevalence of OAB; therefore, we calculated the average cost per community-dwelling person with OAB, which was 267 dollars per year. CONCLUSIONS: By quantifying the total economic costs of OAB, this study-the first obtained from national survey data-provides an important perspective of this condition in society. The conservative estimates of the total cost of OAB were comparable to those of osteoporosis and gynecologic and breast cancer. Although this provides information on the direct and indirect costs of OAB, quality-of-life issues must be taken into account to gain a better understanding of this condition.
The cost of operating institutional review boards (IRBs)
Wagner, T. H.; Bhandari, A.; Chadwick, G. L.; Nelson, D. K.
Acad Med (2003) | PubMed »
  • PURPOSE: Recent reports have claimed that institutional review boards (IRBs) are underfunded, yet little is known about the costs of operating IRBs. This study estimated the costs for operating high-volume and low-volume IRBs. METHOD: IRB costs were calculated from published summary data. Costs were standardized to reflect 2001 dollars. RESULTS: Total estimated costs for operating high-volume and low-volume IRBs were $770,674 and $76,626, respectively. The average cost per action, a measure of economic efficiency, was lower for high-volume IRBs ($277 per action) than it was for low-volume IRBs ($799 per action). CONCLUSIONS: Although high-volume IRBs are more expensive than are low-volume IRBs in absolute terms, they are more economically efficient. Policy debates should consider the potential savings from large IRBs, perhaps by encouraging small IRBs to merge, although this may result in less local review, control, and oversight.
Use of the Internet and E-mail for Health Care Information: Results From a National Survey
Baker, L.; Wagner, T. H.; Singer, S.; Bundorf, M. K.
JAMA (2003) | PubMed »
  • CONTEXT: The Internet has attracted considerable attention as a means to improve health and health care delivery, but it is not clear how prevalent Internet use for health care really is or what impact it has on health care utilization. Available estimates of use and impact vary widely. Without accurate estimates of use and effects, it is difficult to focus policy discussions or design appropriate policy activities. OBJECTIVES: To measure the extent of Internet use for health care among a representative sample of the US population, to examine the prevalence of e-mail use for health care, and to examine the effects that Internet and e-mail use has on users' knowledge about health care matters and their use of the health care system. DESIGN, SETTING, AND PARTICIPANTS: Survey conducted in December 2001 and January 2002 among a sample drawn from a research panel of more than 60 000 US households developed and maintained by Knowledge Networks. Responses were analyzed from 4764 individuals aged 21 years or older who were self-reported Internet users. MAIN OUTCOME MEASURES: Self-reported rates in the past year of Internet and e-mail use to obtain information related to health, contact health care professionals, and obtain prescriptions; perceived effects of Internet and e-mail use on health care use. RESULTS: Approximately 40% of respondents with Internet access reported using the Internet to look for advice or information about health or health care in 2001. Six percent reported using e-mail to contact a physician or other health care professional. About one third of those using the Internet for health reported that using the Internet affected a decision about health or their health care, but very few reported impacts on measurable health care utilization; 94% said that Internet use had no effect on the number of physician visits they had and 93% said it had no effect on the number of telephone contacts. Five percent or less reported use of the Internet to obtain prescriptions or purchase pharmaceutical products. CONCLUSIONS: Although many people use the Internet for health information, use is not as common as is sometimes reported. Effects on actual health care utilization are also less substantial than some have claimed. Discussions of the role of the Internet in health care and the development of policies that might influence this role should not presume that use of the Internet for health information is universal or that the Internet strongly influences health care utilization.
Evaluating an incontinence intervention in nursing home residents
Wagner, T. H.; Subak, L. L.
J Am Geriatr Soc (2003) | PubMed »
Computerized health information and the demand for medical care
Wagner, T. H.; Jimison, H. B.
Value Health (2003) | PubMed »
  • OBJECTIVE: Consumer health information, once the domain of books and booklets, has become increasingly digitized and available on the Internet. This study assessed the effect of using computerized health information on consumers' demand for medical care. METHODS: The dependent variable was self-reported number of visits to the doctor in the past year. The key independent variable was the use of computerized health information, which was treated as endogenous. We tested the effect of using computerized health information on physician visits using ordinary least squares, instrumental variables, fixed effects, and fixed-effects instrumental variables models. The instrumental variables included exposure to the Healthwise Communities Project, a community-wide health information intervention; computer ownership; and Internet access. Random households in three cities were mailed questionnaires before and after the Healthwise Communities Project. In total, 5909 surveys were collected for a response rate of 54%. RESULTS: In both the bivariate and the multivariate analyses, the use of computerized health information was not associated with self-reported entry into care or number of visits. The instrumental variables models also found no differences, with the exception that the probability of entering care was significantly greater with the two-stage conditional logit model (P <.05). CONCLUSIONS: Although providing people with health information is intuitively appealing, we found little evidence of an association between using a computer for health information and self-reported medical visits in the past year. This study used overall self-reported utilizations as the dependent variable, and more research is needed to determine whether health information affects the health production function in other important ways, such as the location of care, the timing of getting care, or the intensity of treatment.
Health-related consequences of overactive bladder
Wagner, T. H.; Hu, T. W.; Bentkover, J.; LeBlanc, K.; Stewart, W.; Corey, R.; Zhou, Z.; Hunt, T.
Am J Manag Care (2002) | PubMed »
  • OBJECTIVE: Overactive bladder (OAB) is a condition of urgency, with or without urge incontinence, usually with frequency and nocturia. This study assesses whether people with OAB are at greater risk for urinary tract infections (UTIs), falls and injuries, and increased number of visits to the doctor compared to age- and gender-matched controls. The study also estimates costs associated with these health-related consequences. PATIENTS & METHODS: A US representative telephone survey under the National Overactive Bladder Evaluation (NOBLE) Program was conducted with 5204 English-speaking adults older than 18 years. The survey asked respondents about bladder symptoms. Based on the telephone survey, 865 symptom-identified OAB cases and 903 age- and gender-matched controls were sent a postal questionnaire. A total of 397 cases and 522 controls returned the questionnaires. Nonrespondent cases and controls did not differ with regard to age, gender, educational status, diabetes, congestive heart failure, and self-rated health status. Regression analyses were conducted to assess the effect of OAB on health-related consequences, controlling for age, gender, race, education, marital status, number of previous births, self-reported health status, diabetes, and congestive heart failure. RESULTS: People with OAB reported 0.84 (20%) more visits to the physician (P < .05) and 0.21 (138%) more UTIs in the last year than people without OAB (P < .001). Overactive bladder cases also had over twice the odds of being injured in a fall than people without OAB (odds ratio = 2.26; 95% confidence interval 1.46, 3.51). Consistent with having more falls, OAB cases had an increased risk of bone fracture (P < .1). This effect, however, was not statistically significant (at alpha level 0.05) due to the limited sample size. The estimated cost of UTIs associated with OAB was approximately $1.37 billion US dollars in year 2000. The cost of falls without bone fracture due to OAB was $55 million. Falls with bone fracture accounted for approximately $386 million; however, further research with a larger sample is needed to accurately estimate these costs. CONCLUSION: People with OAB self-report significantly more UTIs and a greater risk of being injured in a fall. Given the large prevalence of UTIs and concerns of overprescribing antibiotics, these results are important for health plans and policy makers. In addition, people with OAB visit their physicians more often than people without OAB. These consequences entail significant economic costs, of which a large percentage will be incurred by health plans. To the extent that OAB causes these consequences, there may be significant savings from effectively treating OAB.
Who uses self-care books, advice nurses, and computers for health information?
Wagner, T. H.; Hibbard, J. H.
Int J Technol Assess Health Care (2001) | PubMed »
  • OBJECTIVES: While evaluating the effect of a community-wide informational intervention, this study explored access, health, and demographic factors related to the use of medical reference books, telephone advice nurses, and computers for health information. METHODS: A random sample of households in the intervention city (Boise, Idaho) and two control cities were surveyed about their use of health information in 1996. Shortly thereafter, the Healthwise Communities Project (HCP) distributed health information to all Boise residents. A follow-up survey was conducted in 1998. Overall, 5,909 surveys were completed for a 54% response rate. RESULTS: The HCP intervention was associated with statistically significant increases in the use of medical reference books and telephone advice nurses. The increased use of computers for health information was marginally significant. Few access, health, or demographic factors were consistently associated with using the different resources, except that people with depression used more of all three information resources, and income was not a significant predictor. CONCLUSION: Providing free health information led to an increase in use, but access, health, and demographic factors were also important determinants. In particular, poor health status and presence of a chronic illness were associated with health information use. These results suggest that healthy consumers are less interested in health information, and it may take other incentives to motivate them to learn about prevention and healthy behaviors.
The demand for consumer health information
Wagner, T. H.; Hu, T. W.; Hibbard, J. H.
J Health Econ (2001) | PubMed »
  • Using data from an evaluation of a community-wide informational intervention, we modeled the demand for medical reference books, telephone advice nurses, and computers for health information. Data were gathered from random household surveys in Boise, ID (experimental site), Billings, MT, and Eugene, OR (control sites). Conditional difference-in-differences show that the intervention increased the use of medical reference books, advice nurses, and computers for health information by approximately 15, 6, and 4%. respectively. The results also suggest that the intervention was associated with a decreased reliance on health professionals for information.
Does willingness to pay vary by race/ethnicity? An analysis using mammography among low-income women
Wagner, T. H.; Hu, T.; Duenas, G. V.; Kaplan, C. P.; Nguyen, B. H.; Pasick, R. J.
Health Policy (2001) | PubMed »
  • As part of a population-based intervention to improve periodic mammogram screening, we examined WTP for mammography in five ethnic groups. Through random digit dialing, we contacted households in low-income census tracts of Alameda County, California (San Francisco Bay area). Women who met the ethnicity, age and cancer-free eligibility criteria were invited to participate. For the baseline assessment, women were surveyed over the phone in their preferred language. Of the 1465 surveyed women, 499 identified themselves as African-American, 199 were Chinese, 167 were Filipino, 300 were Latina, and 300 were non-Hispanic white. Bivariate and multivariate analysis showed that WTP varied significantly by ethnicity (P<0.05). We also found that when Filipino and Chinese women had a female relative with breast cancer, they were willing to pay less money for a mammogram. African-American, Latino, and non-Hispanic white women, however, were willing to pay more money for a mammogram if a female relative had had breast cancer. This ethnic difference, when there is a familial link to breast cancer, needs further study as it has implication for genetic testing. Nevertheless, WTP studies that do not account for ethnic differences may be overstating net benefits to society.
When parents are given greater access to health information, does it affect pediatric utilization?
Wagner, T. H.; Greenlick, M. R.
Med Care (2001) | PubMed »
  • OBJECTIVE: Most studies assessing the effects of consumer health information on medical utilization have used randomized controlled clinical trials with the chronically ill. In this paper, we analyze the effect of the Healthwise Communities Project, a natural experiment that provided free self-care resources, on reported pediatric utilization. RESEARCH DESIGN: Random household surveys were collected before and after the intervention in Boise, Idaho and in two control communities. SUBJECTS: A total of 5,909 surveys were completed, representing an overall response rate of 54%. Of these, 1,812 respondents were between 18 and 55 years of age and had children under 18 years of age living in the home. All analyses were restricted to these 1,812 persons. MEASURES: Parents were asked how many times their children visited a physician in the last year. Responses were gathered with a categorical response scale, which was then transformed into a continuous variable (number of pediatric visits). RESULTS: The intervention was associated with a decrease in reported pediatric utilization rates. The decrease in visits ranged from -0.72 to -0.66 (P approximately 0.05), depending on the statistical model used. Further analyses of 423 families followed over time found a more modest decrease (-0.19) that was not statistically significant. CONCLUSIONS: This study found that increasing access to self-care books, telephone advice nurses, and Internet-based health information is associated with decreases in reported pediatric utilization. However, the significance of the results was sensitive to the statistical model. More research is needed to understand the average and marginal costs of providing health information to consumers.
Does providing consumer health information affect self-reported medical utilization? Evidence from the Healthwise Communities Project
Wagner, T. H.; Hibbard, J. H.; Greenlick, M. R.; Kunkel, L.
Med Care (2001) | PubMed »
  • OBJECTIVE: To determine whether providing health information to residents of Boise ID had an effect on their self-reported medical utilization. RESEARCH DESIGN: The Healthwise Communities Project (HCP) evaluation followed a quasi-experimental design. SUBJECTS: Random households in metropolitan zip codes were mailed questionnaires before and after the HCP. A total of 5,909 surveys were returned. MEASURES: The dependent variable was self-reported number of visits to the doctor in the past year. A difference-in-differences estimator was used to assess the intervention's community-level effect. We also assessed the intervention's effect on the variance of self-report utilization. RESULTS: Boise residents had a higher adjusted odds of entering care (OR = 1.27, 95% CI 0.88, 1.85) and 0.1 more doctor visits compared with residents in the control cities; however, for both outcomes, the effects were small and not significant. Although the means changed little, the data suggest that the variance of utilization in Boise decreased. CONCLUSIONS: The HCP had a small effect on overall self-reported utilization. Although the findings were not statistically significant, a posthoc power analysis revealed that the study was underpowered to detect effects of this magnitude. It may be possible to achieve larger effects by enrolling motivated people into a clinical trial. However, these data suggest that population-based efforts to provide health information have a small effect on self-reported utilization.
The effect of reforms on spending for veterans' substance abuse treatment, 1993-1999
Chen, S.; Wagner, T. H.; Barnett, P. G.
Health Aff (Millwood) (2001) | PubMed »
Economic considerations in overactive bladder
Hu, T. W.; Wagner, T. H.
Am J Manag Care (2000) | PubMed »
  • Many costs are associated with overactive bladder (OAB). They include direct costs, such as those associated with treatment, diagnosis, routine care, and the consequences of the disease; indirect costs of lost wages and productivity; and intangible costs associated with pain, suffering, and decreased quality of life. Quantification of all these costs is essential for establishing the total economic burden of a disease on society. Currently, the total economic burden of OAB is unknown. However, various studies have determined that the economic burden of urinary incontinence, one of the symptoms of OAB, is substantial. It is also important to establish the economic impact of various interventions for OAB. Cost-minimization, cost-outcome, cost-utility, and cost-benefit models can be used for these analyses. The most difficult aspect of evaluating the economic impact of a treatment is estimating the intangible costs.
Health services utilization among Latinos and white non-Latinos: results from a national survey
Guendelman, S.; Wagner, T. H.
J Health Care Poor Underserved (2000) | PubMed »
  • Utilization patterns may be changing as managed care organizations actively market services to Latinos. This study compares use of any care, emergency services, inpatient hospitalization, nonemergency outpatient care only, and preventive care among 1,001 self-identified Latino and 1,107 white non-Latino adults. Data were from the 1994 Commonwealth Fund Survey of Minority Health. Latinos were less likely than white non-Latinos to have entered the health system for any type of care, to have been admitted to a hospital, or to have used preventive care. Access to a regular source of care along with financial factors reduced the ethnic/racial gap in the use of any care and preventive care, yet cultural and behavioral factors contributed little. Latinos in managed care plans, compared with fee-for-service systems, were twice as likely to receive preventive care. This suggests that managed care has the potential to reduce inequities in preventive care utilization.
Who gets second opinions?
Wagner, T. H.; Wagner, L. S.
Health Aff (Millwood) (1999) | PubMed » | PDF available on Intranet
  • Six states require health plans to provide or authorize second medical opinions (SMOs). The intent of such legislation is to preserve consumer choice, to improve the flow of information, and to improve health outcomes in this era of managed care. However, it is unclear who benefits from these laws. This paper reviews the changing role of second opinions and, using a nationally representative data set from the Commonwealth Fund, examines who gets them. Of persons who had visited a doctor in the previous year, 19 percent received a second opinion, for an estimated cost of $3.2 billion in 1994. Findings suggest that cultural norms and sociocultural factors may partially determine who may benefit from SMO legislation.
Quality of life of women with urinary incontinence: further development of the incontinence quality of life instrument (I-QOL)
Patrick, D. L.; Martin, M. L.; Bushnell, D. M.; Yalcin, I.; Wagner, T. H.; Buesching, D. P.
Urology (1999) | PubMed »
  • OBJECTIVES: To report on the further development of the Incontinence Quality of Life Instrument (I-QOL), a self-report quality of life measure specific to urinary incontinence (UI), including its measurement model, responsiveness, and effect size. METHODS: Incontinent female patients (141 with stress, 147 with mixed UI) completed the I-QOL and comparative measures at screening, pretreatment, and four subsequent follow-up visits during participation in a multicenter, double-blind, placebo-controlled, randomized trial assessing the efficacy of duloxetine. Psychometric testing followed standardized procedures. RESULTS: Factor analysis confirmed an overall score and three subscale scores (avoidance and limiting behaviors, psychosocial impacts, and social embarrassment). All scores were internally consistent (alpha = 0.87 to 0.93) and reproducible (ICC = 0.87 to 0.91). The pattern of previously reported correlations with the Short-Form 36-item Health Survey and Psychological Well-Being Schedule were confirmed. Responsiveness statistics using changes in the independent measures of stress test pad weight, number of incontinent episodes, and patient global impression of improvement ranged from 0.4 to 0.8. Minimally important changes ranged from 2% to 5% in association with these measures and effect sizes. CONCLUSIONS: In a clinical trial, the I-QOL proved to be valid, reproducible, and responsive to treatment for UI in women.