Form Approved REPORT DOCUMENTATION PAGE OMB No 0704-0188 Th« put»K reporting burden for th s co'ectwn of information is estrrtateo to average 1 hour per response ncwding the : me fc reviewing rs'ructions, searching exiting data sources, gathering and marta-ning the data neecefl and comp-^hng and rw+wmg the collection of .nfomat on Send comments regarding this burden estimate or any other aspect of this collection of information, rvdudlng suggestions for reducing the burden, to the Department of Defense. Executive Service D-rectorate ;07M-0188). Respondents should be aware that notwithstanding any other provision of law. no person shall be subject to any penaty for failing to comply with a co*eclion of information if it does not display a currently valid OMB confol number. PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ORGANIZATION. REPORT DATE (DD-MM-YYYY) 2. REPORT TYPE 3. DATES COVERED (From • To) 4-1-2008 July 2004-March 2008 Final Report Sa. CONTRACT NUMBER 4. TITLE AND SUBTITLE Continuity of Care for Cancer Patients at Irwin Army Community Hospital 5b GRANT NUMBER 5c. PROGRAM ELEMENT NUMBER 5d. PROJECT NUMBER 6. AUTHOR(S) Hartley, Kay 5e. TASK NUMBER 5(. WORK UNIT NUMBER 8. PERFORMING ORGANIZATION 7. PERFORMING ORGANIZATION NAME(S) AND ADDRESS(ES) REPORT NUMBER Irwin Army Community Hospital 600 Cassion Hill Road 23-06 Fort Riley. Kansas 66544 10. SPONSOR MONITOR'S ACRONYM(S) 9. SPONSORING/MONITORING AGENCY NAME(S) AND ADDRESS(ES) United States Army Medical Department Center and School Building 2841 MCCS-HRA 11. SPONSOR/MONITORS REPORT US Army-Baylor University Graduate Program in Health and Business Administration NUMBER(S) 3151 Scon Road, Suite 1411 23-06 Fort Sam Houston, Texas 7S234-6135 12. DISTRIBUTION/AVAILABILITY STATEMENT Approved for public release: distribution unlimited 13. SUPPLEMENTARY NOTES 14. ABSTRACT This study examined the association between provider continuity and patients with cancer enrolled to Irwin Army Community Hospital. Fort Riley Kansas A set of simple descriptive statistics were performed for all 118 cancer patients and a more rigorous analysis was conducted on a subset of 44 breast cancer patients. The researcher found numerous mathematical models to measure continuity. The Modified Modified Contmuity Index was selected from numerous models as the best measure for continuity The mean score for the 11S patients was 0 59 signifying a moderate level of contmuity. The breast cancer group mean was 0.58 Three predictors, outpatient visits, hospital readmissions and emergency room visits, accounted for 17.1% of the variance in the MMCI scores of the breast cancer patients While the overall study was unable to find statistical significance (p-0.55). the research was able to find statistical differences in Ethnicity (p< 05) and years with cancer (p-01) with MMCI scores The small number of subjects in this study was a limitation. The categorical data optimized manageability but may have sacrificed details in the data. 15. SUBJECT TERMS Continuity of Care. Modified Modified Continuity Index, Cancer, Breast Cancer 17. LIMITATION OF 18. NUMBER 19a. NAME OF RESPONSIBLE PERSON 16. SECURITY CLASSIFICATION OF: ABSTRACT OF Education ^technician b. ABSTRACT a. REPORT c. THIS PAGE PAGES 19b. TELEPHONE NUMBER (incluOe area code) UU UU UU UU 46 (210) 221-6443 Standard Form 298 (Rev. 8/981 Reset ProtnfeM »y ANSt SH Z3» IS Adob* »r3f»;;,; »l 7.0 n Continuity of Care CONTUINITY OF CARE FOR CANCER PATIENTS Continuity of Care for Cancer Patients at Irwin Army Community Hospital Major Kay Hadley U.S. Army-Baylor University Graduate Program in Health and Business Administration 20090210120 Continuity of Care 2 Acknowledgements Numerous individuals have given freely of their time, talents and patience throughout the course of this study. Without them, the completion of this daunting task could never have been possible. This is especially true of Dr. David Mangelsdorff, LTC Rob Goodman and LTC William Dowdy. I would also like to express my appreciation to LTC Wayne Smetana, Dr. Todd Vento and LTC Josh Kimball. And a separate word of thanks goes to Colonel Julie Martin, LTC John Lee and Dr. Hope Ruiz for their encouragement and motivation for ensuring my project's completion. A very special thanks goes out to LTC Sharon Pryor for the time she spent editing paper and to COL Kelly Wolgast who helped organize my thoughts. Continuity of Care 3 Table of Contents Abstract 6 Introduction 7 Conditions Which Prompted Study 8 Statement of the Research Questions 9 Literature Review 10 Purpose (Variables /Hypothesis) 17 Methods and Procedures 18 Study Design 18 Results 20 Ethical Consideration 26 Discussion 26 Conclusions 32 Recommendations 33 List of References 35 Appendices 39 Appendix A Comparisons of Continuity Scores 39 Appendix B Staging and Code Numbers for Cancer 4 0 Tables 41 Table 1 Mean and Standard Deviations All Cancer Patients 41 Table 2 Frequency and Percent of Staging All Cancer Patients 42 Table 3 Minimum, Maximum, Mean and Standard Deviations of the Subgroup with Breast Cancer 4 3 Continuity of Care 4 Table 4 Frequency and Percent of Staging in the Subgroup with Breast Cancer 4 4 Table 5 Regression Results for the Subgroup with Breast Cancer 45 Table 6 Correlation for MMCI scores with the Subgroup with Breast Cancer 4 6 Continuity of Care Form Approved REPORT DOCUMENTATION PAGE OMB No 0704-0188 The pubac repofeng burden lor thra collection 0/ etformatjon eotlmetee to average t hour per response, stcKrdng »>e trie lor rovwwfto rstrucxns searching e-lsung data sources, getnerevg and M meerteeveig eve flaw needed, end compieteig end reviewing the collection of information. Send comments regarding thie burden estmete or any other aspect of Ihie collection ol mrormotiorv rtciudevg suogeetvone (or reducing the burden, to the Deportment of Defense. Executive Service Directorate [O'W-Oioflt Reapoodentt should De ewere ttvat notwlrhetanding any other provejKm of ew no oereon shelf be subject to eny oenelty for feiing to comply with e collection of eiformebon if it does not disoiav a currently vend 0M6 control number PLEASE 00 NOT RETURN YOUR FORM TO THE ABOVE ORGANIZATION. 2. REPORT TYPE 1. REPORT DATE (DD-MM-YYYY) 3. DATES COVERED (From - To) Final Report 4-1-2008 July 2004-Maich 200S 6a. CONTRACT NUMBER 4. TITLE AND SUBTITLE Continuity of Care for Cancer Patients at twin Army Community Hospital 5b. GRANT NUMBER 5c PROGRAM ELEMENT NUMBER Sd. PROJECT NUMBER 6. AUTHOR(S) Hadley. Kay So. TASK NUMBER Sf. WORK UNIT NUMBER J. PERFORMING ORGANIZATION 7. PERFORMING ORGANIZATION NAME(S) AND ADORESS(ES) REPORT NUMBER Invin Army Community Hospital 600 Cassion Hill Road 23-06 Foil Riley. Kansas 66544 10. SPONSOR/MONITOR'S ACRONYM(S| 9. SPONSORING/MONITORING AGENCY NAME(S) AND ADDRESS(ES) United States Army Medical Department Center and School BLDG 2841 MCCS-HRA (Army-Baylor University Graduate Program ui Health and Busmess 11. SPONSOR/MONITOR'S REPORT Administration) NUMBER(S) 3151 Scott Road. Suite 1411 XX-03 Fort Sam Houston, Texas 78254-6135 12. DISTRIBUTION/AVAILABILITY STATEMENT Approved for public release; distribution unlimited 13. SUPPLEMENTARY NOTES 14. ABSTRACT Tins study examined the association between provider continuity and patients with cancer enrolled to Irwm Army Community Hospital. Fort Riley Kansas A set of simple descriptive statistics were performed for all 118 cancer patients and a more rigorous analysis was conducted on a subset of 44 breast cancer patients The researcher found numerous mathematical models to measure continuity The Modified Modified Continuity Index was selected from numerous models as the best measure for continuity The mean scene for the 118 patients was 0.59 signifying a moderate level of continuity The breast cancer group mean was 0.58 Three predictors, outpatient visits, hospital readnussions and emergency room visits, accounted for 17 1% of the variance in the MMCI scores of the breast cancer patients While the overall study was unable to find statistical significance (p=0 55). the research was able to find statistical differences in Ethnicity (p<.05) and years with cancer (p= 01) with MMCI scores The small number of subjects in this study was a limitation The categorical data optimized manageability but may have sacrificed details in the data 15. SUBJECT TERMS Continuity of Care. Modified Modified Continuity Index. Cancer. Breast Cancer 17. LIMITATION OF 1» NUMBER 19a. NAME OF RESPONSIBLE PERSON 16. SECURITY CLASSIFICATION OF: ABSTRACT OF Education Technician a. REPORT b. ABSTRACT c. THIS PAGE PAGES 19b. TELEPHONE NUMBER (Include area codt) UU UU UU UU 46 (210)221-6443 I 1 Standard Form 29« (Rev 8'98 Reset Presented by ANSI Std 239 IS Adobe Profetiiortel 7 C Continuity of Care 6 Abstract The care of cancer patients is often complex and uncoordinated resulting in poor patient handoffs and delays in care (Byers et al., 1999). This study examined the association between provider continuity and patients with cancer enrolled to Irwin Army Community Hospital, Fort Riley, Kansas. Descriptive statistics were performed for all 118 cancer patients and a more in depth analysis was conducted on the subset of 44 breast cancer patients. The Modified Modified Continuity Index (MMCI) was selected to measure continuity of care. The mean score for the 118 patients was 0.59 signifying a moderate level of continuity. The breast cancer group mean was 0.58. Three predictors, outpatient visits, hospital readmissions and emergency room visits, accounted for 17.1 % of the variance in the MMCI scores of Breast Cancer patients. The overall study was not significant (p = .055) but there was statistical differences in Ethnicity (p < .05) and years with cancer (p < .01) in relation to the MMCI scores. The small number of subjects in this study was a limitation and the use of categorical data, may have sacrificed some level of detail in the data. Continuity of Care 7 Continuity of Care for Cancer Patients at Irwin Army Community Hospital Continuity of care is an important part of the health care process. When correctly done, it offers an experience connected and coherent. In theory, it should ensure that the patient's plan of care passes from one visit to the next (Starfield, 1980). This connection depends upon provider consistency, or involvement with a limited number of providers. In addition, these providers must be consistently available and aware of the patient's medical history. This in turn facilitates the goal of continuity to improve the patient's problems and facilitate efficiency in diagnostic workup and management (Haggerty et al., 2003). Continuity of care is an important management tool. Raddish, Horn, and Sharkey (1999) examined the association between provider continuity, utilization and expenditures. They collected data on patients with arthritis, asthma, epigastria pain, peptic ulcer disease, hypertension and otitis media from six health maintenance organizations. They found that as the number of primary or specialty care providers increased, there was an associated increase in costs. Longstanding physician-patient ties result in less intensive medical care that in turn reduces the cost of care Continuity of Care 8 (Weiss & Blustein, 1996). Established continuity of care is also linked with improved patient outcomes and decreased resource utilization and costs (De Maeseneer, De Prins, Gosset, & Heyerick, 2003). Other documented benefits include a reduction in the number of hospitalizations per patient, improved compliance with follow-up appointments, increased patient satisfaction, compliance with recommended care and a reduction in the duplication of tests (Burge, Lawson, & Johnston, 2003). Mainous, Kern, et al. (2004) found evidence this practice helps reduce the likelihood of future hospitalizations and Emergency Department use. For military hospital command groups, continuity is a potential mechanism to contain expenditures while promoting patient care and outcomes. Continuity of care is associated with many of these qualities and measurable. Four of the continuity measures mentioned in the literature are the Usual Provider of Care (UPC), Continuity of Care (COC), Modified Continuity Index (MCI) and the Modified Modified Continuity Index (MMCI). Conditions Which Prompted Study In October 2004, the military health plan transitioned to the Next Generation of the TRICARE contract. Although the basic benefit structure remained unchanged, some of the benefit plan responsibilities transferred from the TRICARE contractor to the Continuity of Care 9 Military Treatment Facility (MTF). The revenue once paid to the contractor began going to the MTF, who in turn paid the contractor for services received by beneficiaries in the network. This change provided incentive for the MTF to develop measurable performance guidelines for best practices, customer service, quality care, and access (TRICARE, 2003). This also allowed the flexibility to offer in-house or network services based on the cost effectiveness. With changes in funding, the question of cost control became more important. From a clinical perspective, it raised a question: could changes in clinical practice have a positive impact for both the patient and the financial bottom line? Would improvements in the continuity of care have a positive impact in a military environment? As the Baylor resident in Health Administration at Irwin Army Community Hospital (IACH), Fort Riley, Kansas, with guidance from my preceptor, LTC Josh Kimball, I developed the following research questions. Statement of the Research Questions Which continuity measure based on a Research Question 1: review of the literature most accurately (conforming to the accepted standard found in the literature review) measures continuity of care (UPC, COC, MCI, and MMCI)?