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Item The economic burden of untreated mental illness in Indiana(2022-11-28) Taylor, Heather; Blackburn, Justin; Menachemi, NirWe use a prevalence-based approach to estimate annual costs, in a wide-range of categories, associated with untreated mental illness (MI) in Indiana. Economic burden of untreated MI in Indiana is estimated at $4.2 billion annually representing 1.2% of the state’s gross domestic product. Considering average Indiana wages, $4.2 billion is equivalent to approximately 100,000 jobs. Cost of untreated MI includes $3.3 billion for indirect costs such as premature mortality, $708.5 million for direct healthcare costs, and $116.4 million for non-health care costs including incarceration. On average, each individual experiencing untreated MI incurs $18,940 of societal costs; much of which is borne by employers in the form of premature mortality, unemployment, absenteeism and presenteeism.Item Facility and resident characteristics associated with variation in nursing home transfers: evidence from the OPTIMISTIC demonstration project(BMC, 2021-05-24) Blackburn, Justin; Balio, Casey P.; Carnahan, Jennifer L.; Fowler, Nicole R.; Hickman, Susan E.; Sachs, Greg A.; Tu, Wanzhu; Unroe, Kathleen T.; Health Policy and Management, School of Public HealthBackground: Centers for Medicare and Medicaid Services (CMS) funded demonstration project to evaluate financial incentives for nursing facilities providing care for 6 clinical conditions to reduce potentially avoidable hospitalizations (PAHs). The Optimizing Patient Transfers, Impacting Medical Quality, and Improving Symptoms: Transforming Institutional Care (OPTIMISTIC) site tested payment incentives alone and in combination with the successful nurse-led OPTIMISTIC clinical model. Our objective was to identify facility and resident characteristics associated with transfers, including financial incentives with or without the clinical model. Methods: This was a longitudinal analysis from April 2017 to June 2018 of transfers among nursing home residents in 40 nursing facilities, 17 had the full clinical + payment model (1726 residents) and 23 had payment only model (2142 residents). Using CMS claims data, the Minimum Data Set, and Nursing Home Compare, multilevel logit models estimated the likelihood of all-cause transfers and PAHs (based on CMS claims data and ICD-codes) associated with facility and resident characteristics. Results: The clinical + payment model was associated with 4.1 percentage points (pps) lower risk of all-cause transfers (95% confidence interval [CI] - 6.2 to - 2.1). Characteristics associated with lower PAH risk included residents aged 95+ years (- 2.4 pps; 95% CI - 3.8 to - 1.1), Medicare-Medicaid dual-eligibility (- 2.5 pps; 95% CI - 3.3 to - 1.7), advanced and moderate cognitive impairment (- 3.3 pps; 95% CI - 4.4 to - 2.1; - 1.2 pps; 95% CI - 2.2 to - 0.2). Changes in Health, End-stage disease and Symptoms and Signs (CHESS) score above most stable (CHESS score 4) increased the risk of PAH by 7.3 pps (95% CI 1.5 to 13.1). Conclusions: Multiple resident and facility characteristics are associated with transfers. Facilities with the clinical + payment model demonstrated lower risk of all-cause transfers compared to those with payment only, but not for PAHs.Item Organizational characteristics and perceptions of clinical event notification services in healthcare settings: a study of health information exchange(Oxford University Press, 2020-11-29) Wiley, Kevin K.; Hilts, Katy Ellis; Ancker, Jessica S.; Unruh, Mark A.; Jung, Hye-Young; Vest, Joshua R.; Health Policy and Management, School of Public HealthObjective: Event notification systems are an approach to health information exchange (HIE) that notifies end-users of patient interactions with the healthcare system through real-time automated alerts. We examined associations between organizational capabilities and perceptions of event notification system use. Materials and methods: We surveyed representatives (n = 196) from healthcare organizations (n = 96) that subscribed to 1 of 3 Health Information Organizations' event notification services in New York City (response rate = 27%). The survey was conducted in Fall 2017 and Winter 2018. Surveys measured respondent characteristics, perceived organizational capabilities, event notification use, care coordination, and care quality. Exploratory factor analysis was used to identify relevant independent and dependent variables. We examined the relationship between organizational capabilities, care coordination, and care quality using multilevel linear regression models with random effects. Results: Respondents indicated that the majority of their organizations provided follow-up care for emergency department visits (66%) and hospital admissions (73%). Perceptions of care coordination were an estimated 57.5% (β = 0.575; P < 0.001) higher among respondents who reported event notifications fit within their organization's existing workflows. Perceptions of care quality were 46.5% (β = 0.465; P < 0.001) higher among respondents who indicated event notifications fit within existing workflows and 23.8% (β = 0.238; P < 0.01) higher where respondents reported having supportive policies and procedures for timely response and coordination of event notifications. Discussion and conclusion: Healthcare organizations with specific workflow processes and positive perceptions of fit are more likely to use event notification services to improve care coordination and care quality. In addition, event notification capacity and patient consent procedures influence how end-users perceive event notification services.Item Does preventive dental care reduce non-preventive dental visits and expenditures among Medicaid-enrolled adults?(Wiley, 2022) Taylor, Heather L.; Sen, Bisakha; Holmes, Ann M.; Schleyer, Titus; Menachemi, Nir; Blackburn, Justin; Health Policy and Management, School of Public HealthObjective To determine whether preventive dental visits are associated with fewer subsequent non-preventive dental visits and lower dental expenditures. Data Sources Indiana Medicaid enrollment and claims data (2015–2018) and the Area Health Resource File. Study design A repeated measures design with individual and year fixed effects examining the relationship between preventive dental visits (PDVs) and non-preventive dental visits (NPVs) and dental expenditures. Data Collection/Extraction Methods Not applicable. Principal findings Of 28,152 adults (108,349 observation-years) meeting inclusion criteria, 36.0% had any dental visit, 27.8% a PDV, and 22.1% a NPV. Compared to no PDV in the prior year, at least one was associated with fewer NPVs (β = −0.13; 95% CI -0.12, −0.11), lower NPV expenditures (β = −$29.12.53; 95% CI -28.07, −21.05), and lower total dental expenditures (−$70.12; 95% -74.92, −65.31), as well as fewer PDVs (β = −0.24; 95% CI -0.26, −0.23). Conclusions Our findings suggest that prior year PDVs are associated with fewer subsequent NPVs and lower dental expenditures among Medicaid-enrolled adults. Thus, from a public insurance program standpoint, supporting preventive dental care use may translate into improved population oral health outcomes and lower dental costs among certain low-income adult populations, but barriers to consistent utilization of PDV prohibit definitive findings.Item Health systems’ use of enterprise health information exchange vs single electronic health record vendor environments and unplanned readmissions(Oxford University Press, 2019-10-01) Vest, Joshua R.; Unruh, Mark Aaron; Freedman, Seth; Simon, Kosali; Health Policy and Management, School of Public HealthObjective: Enterprise health information exchange (HIE) and a single electronic health record (EHR) vendor solution are 2 information exchange approaches to improve performance and increase the quality of care. This study sought to determine the association between adoption of enterprise HIE vs a single vendor environment and changes in unplanned readmissions. Materials and methods: The association between unplanned 30-day readmissions among adult patients and adoption of enterprise HIE or a single vendor environment was measured in a panel of 211 system-member hospitals from 2010 through 2014 using fixed-effects regression models. Sample hospitals were members of health systems in 7 states. Enterprise HIE was defined as self-reported ability to exchange information with other members of the same health system who used different EHR vendors. A single EHR vendor environment reported exchanging information with other health system members, but all using the same EHR vendor. Results: Enterprise HIE adoption was more common among the study sample than EHR (75% vs 24%). However, adoption of a single EHR vendor environment was associated with a 0.8% reduction in the probability of a readmission within 30 days of discharge. The estimated impact of adopting an enterprise HIE strategy on readmissions was smaller and not statically significant. Conclusion: Reductions in the probability of an unplanned readmission after a hospital adopts a single vendor environment suggests that HIE technologies can better support the aim of higher quality care. Additionally, health systems may benefit more from a single vendor environment approach than attempting to foster exchange across multiple EHR vendors.Item Performance-Shaping Factors Affecting Older Adults' Hospital-to-Home Transition Success: A Systems Approach(Oxford Academic, 2019-04) Werner, Nicole E.; Tong, Michelle; Borkenhagen, Amy; Holden, Richard J.; Health Policy and Management, School of Public HealthBackground and Objectives Facilitating older adults’ successful hospital-to-home transitions remains a persistent challenge. To address this challenge, we applied a systems lens to identify and understand the performance-shaping factors (PSFs) related older adults’ hospital-to-home transition success. Research Design and Methods This study was a secondary analysis of semi-structured interviews from older adults (N = 31) recently discharged from a hospital and their informal caregivers (N = 13). We used a Human Factors Engineering approach to guide qualitative thematic analysis to develop four themes concerning the system conditions shaping hospital-to-home transition success. Results The four themes concerning PSFs were: (a) the hospital-to-home transition was a complex multiphase process—the process unfolded over several months and required substantial, persistent investment/effort; (b) there were unmet needs for specialized tools—information and resources provided at hospital discharge were not aligned with requirements for transition success; (c) alignment of self-care routines with transition needs—pre-hospitalization routines could be supportive/disruptive and could deteriorate/be re-established; and (d) changing levels of work demand and capacity during the transition—demand often exceeded capacity leading to work overload. Discussion and Implications Our findings highlight that the transition is not an episodic event, but rather a longitudinal process extending beyond the days just after hospital discharge. Transition interventions to improve older adults’ hospital-to-home transitions need to account for this complex multiphase process. Future interventions must be developed to support older adults and informal caregivers in navigating the establishment and re-establishment of routines and managing work demands and capacity during the transition process.Item Coordinated Evolution of Ontologies of Informed Consent(ICBO, 2018) Vajda, Jonathan; Otte, J. Neil; Stansbury, Cooper; Manion, Frank J.; Umberfield, Elizabeth; He, Yongqun; Harris, Marcelline; Obeid, Jihad; Brochhausen, Mathias; Duncan, William D.; Tao, Cui; Health Policy and Management, School of Public HealthInformed consent, whether for health or behavioral research or clinical treatment, rests on notions of voluntarism, information disclosure and understanding, and the decisionmaking capacity of the person providing consent. Whether consent is for research or treatment, informed consent serves as a safeguard for trust that permissions given by the research participant or patient are upheld across the informed consent (IC) lifecycle. The IC lifecycle involves not only documentation of the consent when originally obtained, but actions that require clear communication of permissions from the initial acquisition of data and specimens through handoffs to, for example, secondary researchers, allowing them access to data or biospecimens referenced in the terms of the original consent.Item Using Incident Reports to Assess Communication Failures and Patient Outcomes(Elsevier, 2019-06) Umberfield, Elizabeth; Ghaferi, Amir A.; Krein, Sarah L.; Manojlovich, Milisa; Health Policy and Management, School of Public HealthIntroduction Communication failures pose a significant threat to the quality of care and safety of hospitalized patients. Yet little is known about the nature of communication failures. The aims of this study were to identify and describe types of communication failures in which nurses and physicians were involved and determine how different types of communication failures might affect patient outcomes. Methods Incident reports filed during fiscal year 2015–2016 at a Midwestern academic health care system (N = 16,165) were electronically filtered and manually reviewed to identify reports that described communication failures involving nurses and physicians (n = 161). Failures were categorized by type using two classification systems: contextual and conceptual. Thematic analysis was used to identify patient outcomes: actual or potential harm, patient dissatisfaction, delay in care, or no harm. Frequency of failure types and outcomes were assessed using descriptive statistics. Associations between failure type and patient outcomes were evaluated using Fisher's exact test. Results Of the 211 identified contextual communication failures, errors of omission were the most common (27.0%). More than half of conceptual failures were transfer of information failures (58.4%), while 41.6% demonstrated a lack of shared understanding. Of the 179 identified outcomes, 38.0% were delays in care, 20.1% were physical harm, and 8.9% were dissatisfaction. There was no statistically significant association between failure type category and patient outcomes. Conclusion It was found that incident reports could identify specific types of communication failures and patient outcomes. This work provides a basis for future intervention development to prevent communication-related adverse events by tailoring interventions to specific types of failures.Item A Cross-disciplinary Giant at the Crossroads of America(Indiana University, 2019) Silverman, Ross D.; Health Policy and Management, School of Public HealthThe state motto of Indiana is “Crossroads of America.” Like the state in which she spent more than a quarter of a century as a professor, the work of Eleanor Kinney—a brilliant, prescient scholar, generous teacher, and founder and long-time leader of the William S. and Christine S. Hall Center for Law and Health—came to be known for its intersections of law, medicine, health policy, public health, and human rights. My appreciation of Eleanor began as something tribal: like Eleanor, I, too, had a background in law and public health, and I was a graduate of Indiana University. Over more than two decades, while I was faculty at Southern Illinois University and then following my move to Indianapolis, Eleanor became a colleague, mentor, and regular source of inspiration. She left a tremendous impression on me; I can safely say, were it not for Eleanor’s influence on the field of health law, on my alma mater, and on me personally, I would not figuratively and literally, be where I am today. Two areas of Eleanor’s influence I feel most suited to highlighting in this special edition are her early leadership in Empirical Health Law and in discussing her professional contributions after retiring from Indiana University, especially her year as a visiting scholar at Southern Illinois University.Item The complementary nature of query-based and directed health information exchange in primary care practice(Oxford Academic, 2020-01) Vest, Joshua R.; Unruh, Mark A.; Casalino, Lawrence P.; Shapiro, Jason S.; Health Policy and Management, School of Public HealthObjective Many policymakers and advocates assume that directed and query-based health information exchange (HIE) work together to meet organizations’ interoperability needs, but this is not grounded in a substantial evidence base. This study sought to clarify the relationship between the usage of these 2 approaches to HIE. Materials and Methods System user log files from a regional HIE organization and electronic health record system were combined to model the usage of HIE associated with a patient visit at 3 federally qualified health centers in New York. Regression models tested the hypothesis that directed HIE usage was associated with query-based usage and adjusted for factors reflective of the FITT (Fit between Individuals, Task & Technology) framework. Follow-up interviews with 8 key informants helped interpret findings. Results Usage of query-based HIE occurred in 3.1% of encounters and directed HIE in 23.5%. Query-based usage was 0.6 percentage points higher when directed HIE provided imaging information, and 4.8 percentage points higher when directed HIE provided clinical documents. The probability of query-based HIE was lower for specialist visits, higher for postdischarge visits, and higher for encounters with nurse practitioners. Informants used query-based HIE after directed HIE to obtain additional information, support transitions of care, or in cases of abnormal results. Discussion The complementary nature of directed and query-based HIE indicates that both HIE functionalities should be incorporated into EHR Certification Criteria. Conclusions Quantitative and qualitative findings suggest that directed and query-based HIE exist in a complementary manner in ambulatory care settings.