text:
To determine if the release of health care report cards focused on physician practice quality measures leads to changes in consumers' awareness and use of this information.
Data from two rounds of a survey of the chronically ill adult population conducted in 14 regions across the United States, combined with longitudinal information from a public reporting tracking database. Both data were collected as part of the evaluation for Aligning Forces for Quality, a nationwide quality improvement initiative funded by the Robert Wood Johnson Foundation.
Using a longitudinal design and an individual-level fixed effects modeling approach, we estimated the impact of community public reporting efforts, measured by the availability and applicability of physician quality reports, on consumers' awareness and use of physician quality information (PQI).
The baseline level of awareness was 12.6 percent in our study sample, drawn from the general population of chronically ill adults. Among those who were not aware of PQI at the baseline, when PQI became available in their communities for the first time, along with quality measures that are applicable to their specific chronic conditions, the likelihood of PQI awareness increased by 3.8 percentage points. For the same group, we also find similar increases in the uses of PQI linked to newly available physician report cards, although the magnitudes are smaller, between 2 and 3 percentage points.
Specific contents of physician report cards can be an important factor in consumers' awareness and use of PQI. Policies to improve awareness and use of PQI may consider how to customize quality report cards and target specific groups of consumers in dissemination.
To calculate the associations between Medicare payment and service volume for complex and noncomplex cataract surgeries.
The 2005–2009 CMS Part B National Summary Data Files, CMS Part B Carrier Summary Data Files, and the Medicare Physician Fee Schedule.
Conducting a retrospective, longitudinal analysis using a fixed-effects model of Medicare Part B carriers representing all 50 states and the District of Columbia from 2005 to 2009, we calculated the Medicare payment–service volume elasticities for noncomplex (CPT 66984) and complex (CPT 66982) cataract surgeries.
Service volume data were extracted from the CMS Part B National Summary and Carrier Summary Data Files. Payment data were extracted from the Medicare Physician Fee Schedule.
From 2005 to 2009, the proportion of total cataract services billed as complex increased from 3.2 to 6.7 percent. Every 1 percent decrease in Medicare payment was associated with a nonsignificant change in noncomplex cataract service volume (elasticity = 0.15, 95 percent CI [−0.09, 0.38]) but a statistically significant increase in complex cataract service volume (elasticity = −1.12, 95 percent CI [−1.60, −0.63]).
Reduced Medicare payment was associated with a significant increase in complex cataract service volume but not in noncomplex cataract service volume, resulting in a shift toward performing a greater proportion of complex cataract surgeries from 2005 to 2009.
To compare the effectiveness of two "treatments"—early, intensive home health nursing and physician follow-up within a week—versus less intense and later postacute care in reducing readmissions among heart failure (HF) patients discharged to home health care.
National Medicare administrative, claims, and patient assessment data.
Patients with a full week of potential exposure to the treatments were followed for 30 days to determine exposure status, 30-day all-cause hospital readmission, other health care use, and mortality. An extension of instrumental variables methods for nonlinear statistical models corrects for nonrandom selection of patients into treatment categories. Our instruments are the index hospital's rate of early aftercare for non-HF patients and hospital discharge day of the week.
All hospitalizations for a HF principal diagnosis with discharge to home health care between July 2009 and June 2010 were identified from source files.
Neither treatment by itself has a statistically significant effect on hospital readmission. In combination, however, they reduce the probability of readmission by roughly 8 percentage points (p < .001; confidence interval = −12.3, −4.1). Results are robust to changes in implementation of the nonlinear IV estimator, sample, outcome measure, and length of follow-up.
Our results call for closer coordination between home health and medical providers in the clinical management of HF patients immediately after hospital discharge.
To understand the use of electronic health record (EHR) functionalities by physicians practicing in an underserved setting.
A total of 333 Indian Health Service physicians (55 percent response rate) in August 2012.
The survey assessed routine use of EHR functionalities, perceived usefulness, and barriers to adoption.
Physicians routinely used a median 7 of 10 EHR functionalities targeted by the Meaningful Use program, but only 5 percent used all 10. Most (63 percent) felt the EHR improved quality of care. Many (76 percent) reported increased documentation time and poorer quality patient–physician interactions (45 percent). Primary care specialty and time using the EHR were positively associated with use of EHR functionalities, while perceived productivity loss was negatively associated.
Significant opportunities exist to increase use of EHR functionalities and preserve physician–patient interactions and productivity in a resource-limited environment.
To evaluate the impact of the 2006 Massachusetts health reform, the model for the Affordable Care Act, on short-term enrollment and utilization in the unsubsidized individual health insurance market.
Seven years of administrative and claims data from Harvard Pilgrim Health Care.
We employed pre-post survival analysis and an interrupted time series design to examine changes in enrollment length, utilization patterns, and use of elective procedures (discretionary inpatient surgeries and infertility treatment) among nonelderly adult enrollees before (n = 6,912) and after (n = 29,207) the MA reform.
The probability of short-term enrollment dropped immediately after the reform. Rates of inpatient encounters (HR = 0.83, 95 percent CI: 0.74, 0.93), emergency department encounters (HR = 0.85, 95 percent CI: 0.80, 0.91), and discretionary inpatient surgeries (HR = 0.66 95 percent CI: 0.45, 0.97) were lower in the postreform period, whereas the rate of ambulatory visits was somewhat higher (HR = 1.04, 95 percent CI: 1.00, 1.07). The rate of infertility treatment was higher after the reform (HR = 1.61, 95 percent CI: 1.33, 1.97), driven by women in individual (vs. family) plans. The reform was not associated with increased utilization among short-term enrollees.
MA health reform was associated with a decrease in short-term enrollment and changes in utilization patterns indicative of reduced adverse selection in the unsubsidized individual market. Adverse selection may be a problem for specific, high-cost treatments.
To examine the effect of mandated state health care–associated infection (HAI) reporting laws on central line–associated bloodstream infection (CLABSI) rates in adult intensive care units (ICUs).
We analyzed 2006–2012 adult ICU CLABSI and hospital annual survey data from the National Healthcare Safety Network. The final analytic sample included 244 hospitals, 947 hospital years, 475 ICUs, 1,902 ICU years, and 16,996 ICU months.
We used a quasi-experimental study design to identify the effect of state mandatory reporting laws. Several secondary models were conducted to explore potential explanations for the plausible effects of HAI laws.
Controlling for the overall time trend, ICUs in states with laws had lower CLABSI rates beginning approximately 6 months prior to the law's effective date (incidence rate ratio = 0.66; p < .001); this effect persisted for more than 6 1/2 years after the law's effective date. These findings were robust in secondary models and are likely to be attributed to changes in central line usage and/or resources dedicated to infection control.
Our results provide valuable evidence that state reporting requirements for HAIs improved care. Additional studies are needed to further explore why and how mandatory HAI reporting laws decreased CLABSI rates.
To assess the impact of substance abuse claims redaction on Medicare spending estimates for beneficiaries with serious mental illness.
The 2012 claims and unredacted beneficiary-level Medicare spending totals from CMS's Chronic Conditions Warehouse.
We identified beneficiaries with claims affected by the redaction by comparing claims-based spending estimates to unredacted spending totals. Differences in characteristics of beneficiaries with and without redacted claims were examined in bivariate analyses.
Claims-based spending totals differed from unredacted totals for 19.7 percent of the cohort. Part A spending for those with redacted claims was underreported by 57.0 percent. Characteristics of beneficiaries with and without redacted claims differed significantly.
Researchers who rely on Medicare claims to analyze spending outcomes for beneficiaries with serious mental illness should be aware of the potential for bias due to nonrandom redaction of substance abuse data.
To determine if sufficient nurse staffing reduced in-hospital fractures in acute care hospitals.
The Japanese Diagnosis Procedure Combination inpatient (DPC) database from July 2010 to March 2014 linked with the Surveys for Medical Institutions.
We conducted a retrospective cohort study to examine the association of inpatient nurse-to-occupied bed ratio (NBR) with in-hospital fractures. Multivariable logistic regression with generalized estimating equations was performed, adjusting for patient characteristics and hospital characteristics.
We identified 770,373 patients aged 50 years or older who underwent planned major surgery for some forms of cancer or cardiovascular diseases. We used ICD-10 codes and postoperative procedure codes to identify patients with in-hospital fractures. Hospital characteristics were obtained from the "Survey of Medical Institutions and Hospital Report" and "Annual Report for Functions of Medical Institutions."
Overall, 662 (0.09 percent) in-hospital fractures were identified. Logistic regression analysis showed that the proportion of in-hospital fractures in the group with the highest NBR was significantly lower than that in the group with the lowest NBR (adjusted odd ratios, 0.67; 95 percent confidence interval, 0.44–0.99; p = .048).
Sufficient nurse staffing may be important to reduce postsurgical in-hospital fractures in acute care hospitals.
To explore the extent to which commonly used claims-based process quality indicators can be used to create an internally valid global composite measure of physician practice quality.
Health insurance claims data (October 2007–May 2010) from 134 physician practices in Seattle, WA.
We use confirmatory and exploratory factor analysis to develop theory- and empirically driven internally valid composite measures based on 19 quality indicators.
Health insurance claims data from nine insurance companies and self-funded employers were collected and aggregated by third-party organization.
Our results did not support a single global measure using the entire set of quality indicators. We did identify an acceptable multidimensional model (RMSEA = 0.059; CFI = 0.934; TLI = 0.910). The four dimensions in our data were diabetes, depression, preventive care, and generic drug prescribing.
Our study demonstrates that commonly used process indicators can be used to create a small set of useful composite measures. However, the lack of an internally valid single unidimensional global measure has important implications for policy approaches meant to improve quality by rewarding "high-quality physicians."
To determine the effect of heart attack patients' access to intensive treatment on mortality and costs.
Administrative data of 4,920 patients with acute myocardial infarction from the Austrian Social Security Database and the Upper Austrian Sickness Fund for the period 2002–2011.
As treatment intensity in a hospital largely depends on whether it has a catheterization laboratory, we explore the effects of patients' initial admission to such specialized percutaneous coronary intervention (PCI) hospitals. To account for the nonrandom selection of patients into hospitals, we exploit individuals' place of residence as a source of exogenous variation in an instrumental variable framework.
We find that the initial admission to PCI hospitals increases patients' survival chances substantially. The effect on 3-year mortality is −9.5 percentage points. Subgroup analysis shows the strongest effects in relative terms for patients below the age of 65. We do not find significant effects on long-term inpatient costs and only marginal increases in outpatient costs.
Our findings suggest that place of residence affects the access of patients to invasive heart attack treatment and therefore their chance of survival. We conclude that that providing more patients immediate access to PCI hospitals should be beneficial.
To examine changes in facility-level risk-standardized rehospitalization rankings for postacute inpatient rehabilitation facilities after modifying two model parameters.
We used national Medicare enrollment, claims, and assessment data to study 522,260 patients discharged from inpatient rehabilitation in fiscal years 2010–2011.
We calculated risk-standardized 30-day unplanned rehospitalization rates for 1,135 inpatient rehabilitation facilities using four approaches. The first model replicated the current postacute risk-standardization methodology and included patients discharged from acute hospitals up to 30 days prior to postacute admission and excluded patients transferred directly back to acute hospitals following rehabilitation. Our alternative models excluded patients with delayed admissions (>1 day between acute discharge and postacute admission) and counted direct transfers back to acute as rehospitalizations.
Excluding patients with delayed admissions and counting direct transfers back to acute care as rehospitalizations substantially impacted rankings of more than half the postacute providers: 29 percent had better and 27 percent had worse quintile rankings.
Changing the timeframes for duration to admission and rehospitalization will have profound effects on postacute provider quality performance ratings. Reporting rehospitalization rates is an important issue with the explicit goal of improving the quality of postacute care. Research is needed to understand and minimize potential unintended consequences of this quality metric.
To examine state and community factors that contributed to geographic variation in qualified health plan selection during the first open enrollment period.
Administrative data on qualified health plan selections at the ZIP code area merged with survey estimates from the American Community Survey.
Descriptive and regression analyses.
Data were generated by healthcare.gov and from a household survey.
Thirty-one percent of the variation in qualified health plan selection ratios resulted from between-state differences, and the rest was driven by local area differences. Education, language, age, gender, and the ethnic composition of communities contributed to disparate levels of plan selection. Medicaid expansion states had a qualified health plan selection ratio that was 4.4 points lower than non-Medicaid expansion states, controlling for covariates.
Our results suggest community-level differences in the intensity or receptiveness to outreach and enrollment activities during the first open enrollment period.
To provide practical tips for health services researchers considering the use of positive deviance (PD) methods to help explain variations in quality of care or other meaningful parameters.
Published literature and personal experience.
Narrative review.
This review includes a discussion of possible applications of PD to health services research, some methodological choices applicable to PD, and some brief tips regarding publishing the results and incorporating them into future interventions.
It is hoped that this article will help health services researchers to use this valuable research method more effectively, especially those who have not done so before.
Evaluate the effect of a pay-for-performance intervention on the quality of hypertension care provided to black patients and determine whether it produced risk selection.
Primary data collected between 2007 and 2009 from Veterans Affairs physicians and their primary care panels.
Nested study within a cluster randomized controlled trial of three types of financial incentives and no incentives (control). We compared the proportion of physicians' black patients meeting hypertension performance measures for baseline and final performance periods. We measured risk selection by comparing the proportion of patients who switched providers, patient visit frequency, and panel turnover. Due to limited power, we prespecified in the analysis plan combining the three incentive groups and oversampling black patients.
Data collected electronically and by chart review.
The proportion of black patients who achieved blood pressure control or received an appropriate response to uncontrolled blood pressure in the final period was 6.3 percent (95 percent confidence interval, 0.8–11.7 percent) greater for physicians who received an incentive than for controls. There was no difference between intervention and controls in the proportion of patients who switched providers, visit frequency, or panel turnover.
A pay-for-performance intervention improved blood pressure control or appropriate response to uncontrolled blood pressure in black patients and did not produce risk selection.
To identify factors associated with methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infections at the level of the hospital organization.
Data from all 173 acute trusts in the English National Health Service (NHS).
A longitudinal study based on trust-level panel data for the 5-year period from April 2004 to March 2009. Fixed effects negative binominal and system generalized method of moment models were used to examine the effect of (i) patient mix characteristics, (ii) resource endowments, and (iii) infection control practices on yearly MRSA counts.
Archival and staff survey data from multiple sources, including Public Health England, the English Department of Health, and the Healthcare Commission, were merged to form a balanced panel dataset.
MRSA infections decrease with increases in general cleaning (−3.52 MRSA incidents per 1 standard deviation increase; 95 percent confidence interval: −6.61 to −0.44), infection control training (−3.29; −5.22 to −1.36), hand hygiene (−2.72; −4.76 to −0.68), and error reporting climate (−2.06; −4.09 to −0.04).
Intensified general cleaning, improved hand hygiene, additional infection control training, and a climate conducive to error reporting emerged as the factors most closely associated with trust-level reductions in MRSA infections over time.
America's community health centers (HCs) are uniquely poised to implement the patient-centered medical home (PCMH) model, as they are effective in providing comprehensive, accessible, and continuous primary care. This study aims to evaluate the relationship between PCMH recognition in HCs and clinical performance.
Data for this study came from the 2012 Uniform Data System (UDS) as well as a survey of HCs' PCMH recognition achievement. The dependent variables included all 16 measures of clinical performance collected through UDS. Control measures included HC patient, provider, and practice characteristics. Bivariate analyses and multiple logistic regressions were conducted to compare clinical performance between HCs with and without PCMH recognition.
Health centers that receive PCMH recognition generally performed better on clinical measures than HCs without PCMH recognition. After controlling for HC patient, provider, and practice characteristics, HCs with PCMH recognition reported significantly better performance on asthma-related pharmacologic therapy, diabetes control, pap testing, prenatal care, and tobacco cessation intervention.
This study establishes a positive association between PCMH recognition and clinical performance in HCs. If borne out in future longitudinal studies, policy makers and practices should advance the PCMH model as a strategy to further enhance the quality of primary care.
To investigate factors affecting willingness to pay (WTP) for health insurance of older adults in a longitudinal setting in Germany.
Survey data from a cohort study in Saarland, Germany, from 2008–2010 and 2011–2014 (n1 = 3,124; n2 = 2,761) were used.
Panel data were taken at two points from an observational, prospective cohort study.
WTP estimates were derived using a contingent valuation method with a payment card. Participants provided data on sociodemographics, lifestyle factors, morbidity, and health care utilization.
Fixed effects regression models showed higher individual health care costs to increase WTP, which in particular could be found for members of private health insurance. Changes in income and morbidity did not affect WTP among members of social health insurance, whereas these predictors affected WTP among members of private health insurance.
The fact that individual health care costs affected WTP positively might indicate that demanding (expensive) health care services raises the awareness of the benefits of health insurance. Thus, measures to increase WTP in old age should target at improving transparency of the value of health insurances at the moment when individual health care utilization and corresponding costs are still relatively low.
To explore the impact of hospital report card design and incorporation of patient narrative comments on consumers' choices of hospitals.
Primary data collected from an online survey with 1,350 respondents in February, 2015.
A randomized 2 (narrative comments: yes, no) × 3 (design: representation of clinical performance in textual, star, numerical formats) between-subject online-based cross-sectional experiment.
In 51 percent of all cases, respondents selected the hospital with the best clinical results. Report cards with a numerical design induced choices more focused on clinical ratings (56.0 percent chose the highest rated hospital) than those with textual information (48.1 percent) or star ratings (47.3 percent) (p < .001). Report cards without narrative comments (49.7 percent) and with narratives (51.4 percent) were not associated with significant difference in selecting top-rated clinical hospitals (p = .376). But there were significant interactions affecting choice of hospitals among exposure to narratives, formatting of clinical performance, and respondents' education.
Consumers have a difficult time synthesizing quality data in various formats. Hospital report cards continue to pose challenging choices, especially for those with limited education. Narrative comments in their earliest emerging forms do not seem to be altering hospital choice as much as the literature has suggested for other providers, but they may have consequential impact on the choices of certain subsets of consumers.
To determine the magnitude and mechanisms of response to Medicare Part D cost sharing by low-income subsidy (LIS) recipients using oral hypoglycemic agents (OHAs) and statins.
Medicare data for a 5 percent random sample of beneficiaries with diabetes enrolled in fee-for-service Part D drug plans in 2008.
We evaluated the impact of differences between generic and brand cost sharing rates among cohorts of LIS and non-LIS recipients to determine if wider price spreads increased the generic dispensing rate (GDR) and reduced total drug use and cost.
We found little association between cost sharing and aggregate OHA and statin use. In adjusted analyses, non-LIS beneficiaries who paid 46 percent of total OHA costs had 2.5 percent fewer OHA days supply than full benefit dual eligibles who paid just 5 percent of their therapy costs. For statins, the difference in days supply between those facing the lowest and highest cost sharing was 4.6 percent. Higher cost sharing was associated with filling fewer but larger prescriptions for both generics and brands.
Higher generic and brand copays had little association with OHA and statin use among LIS recipients. This implies that modest changes in required cost sharing for these medicines would have very little substantive impact on generic dispensing or utilization patterns among LIS recipients and thus would have little effect on total program spending. At the same time, any increases in out-of-pocket costs would be expected to shift costs and place greater financial burden on low-income beneficiaries, particularly those in poor health.
Hospital services use, which is a major driver of total health expenditures, is expected to rise over the next decades in Europe, especially because of population aging. The purpose of this article is to better understand the dynamics of older people's demand for hospital care over time in a cross-country setting.
We used data from the Survey on Health, Ageing, and Retirement in Europe (SHARE), in 10 countries between 2004 and 2011.
We estimated a dynamic panel model of hospital admission for respondents aged 50 years or more.
Following prior research, we found evidence of state dependence in hospital use over time. We also found that rise in frailty—among other health covariates—is a strong predictor of increased hospital use. Progression by one point on the frailty scale [0;5] is associated with an additional risk of about 2.1 percent on average.
Our results support promotion of early detection of frailty in primary care, and improvement of coordination between actors within the health system, as potential strategies to reduce avoidable or unnecessary hospital use among frail elderly.
To examine adherence to guideline-concordant hypertension treatment practices at community health centers (CHCs) compared with private physicians' offices.
National Ambulatory Medical Care Survey from 2006 to 2010.
We examined four guideline-concordant treatment practices: initiation of a new medication for uncontrolled hypertension, use of fixed-dose combination drugs for patients on multiple antihypertensive medications, use of thiazide diuretics among patients with uncontrolled hypertension on ≥3 antihypertensive medications, and use of aldosterone antagonist for resistant hypertension, comparing use at CHC with private physicians' offices overall and by payer group.
We identified visits of nonpregnant adults with hypertension at CHCs and private physicians' offices.
Medicaid patients at CHCs were as likely as privately insured individuals to receive a new medication for uncontrolled hypertension (AOR 1.0, 95 percent CI: 0.6–1.9), whereas Medicaid patients at private physicians' offices were less likely to receive a new medication (AOR 0.3, 95 percent CI: 0.1–0.6). Use of fixed-dose combination drugs was lower at CHCs (AOR 0.6, 95 percent CI: 0.4–0.9). Thiazide use for patients was similar in both settings (AOR 0.8, 95 percent CI: 0.4–1.7). Use of aldosterone antagonists was too rare (2.1 percent at CHCs and 1.5 percent at private clinics) to allow for statistically reliable comparisons.
Increasing physician use of fixed-dose combination drugs may be particularly helpful in improving hypertension control at CHCs where there are higher rates of uncontrolled hypertension.
To conduct a systematic literature review of selected major provisions of the Affordable Care Act (ACA) pertaining to expanded health insurance coverage. We present and synthesize research findings from the last 5 years regarding both the immediate and long-term effects of the ACA. We conclude with a summary and offer a research agenda for future studies.
We identified relevant articles from peer-reviewed scholarly journals by performing a comprehensive search of major electronic databases. We also identified reports in the "gray literature" disseminated by government agencies and other organizations.
Overall, research shows that the ACA has substantially decreased the number of uninsured individuals through the dependent coverage provision, Medicaid expansion, health insurance exchanges, availability of subsidies, and other policy changes. Affordability of health insurance continues to be a concern for many people and disparities persist by geography, race/ethnicity, and income. Early evidence also indicates improvements in access to and affordability of health care. All of these changes are certain to ultimately impact state and federal budgets.
The ACA will either directly or indirectly affect almost all Americans. As new and comprehensive data become available, more rigorous evaluations will provide further insights as to whether the ACA has been successful in achieving its goals.
To assess the effects of Tennessee's 2005 Medicaid disenrollment on access to health care among low-income nonelderly adults.
We use data from the 2003–2008 Behavioral Risk Factor Surveillance System.
We examined the effects of Medicaid disenrollment on access to care among adults living in Tennessee compared with neighboring states, using difference-in-difference models.
Evidence suggests that Medicaid disenrollment resulted in significant decreases in health insurance and increases in cost-related barriers to care for low-income adults living in Tennessee. Statistically significant changes were not observed for having a personal doctor.
Medicaid disenrollment is associated with reduced access to care. This finding is relevant for states considering expansions or contractions of Medicaid under the Affordable Care Act.
To compare two approaches to measuring racial/ethnic disparities in the use of high-quality hospitals.
Simulated data.
Through simulations, we compared the "minority-serving" approach of assessing differences in risk-adjusted outcomes at minority-serving and non-minority-serving hospitals with a "fixed-effect" approach that estimated the reduction in adverse outcomes if the distribution of minority and white patients across hospitals was the same. We evaluated each method's ability to detect and measure a disparity in outcomes caused by minority patients receiving care at poor-quality hospitals, which we label a "between-hospital" disparity, and to reject it when the disparity in outcomes was caused by factors other than hospital quality.
The minority-serving and fixed-effect approaches correctly identified between-hospital disparities in quality when they existed and rejected them when racial differences in outcomes were caused by other disparities; however, the fixed-effect approach has many advantages. It does not require an ad hoc definition of a minority-serving hospital, and it estimated the magnitude of the disparity accurately, while the minority-serving approach underestimated the disparity by 35–46 percent.
Researchers should consider using the fixed-effect approach for measuring disparities in use of high-quality hospital care by vulnerable populations.
To examine the association between 10-year temporal changes in the primary care workforce and Medicare beneficiaries' outcomes.
2001 and 2011 American Medical Association Masterfiles and fee-for-service Medicare claims.
We calculated two primary care workforce measures within Primary Care Service Areas: the number of primary care physicians per 10,000 population (per capita) and the number of Medicare primary care full-time equivalents (FTEs) per 10,000 Medicare beneficiaries. The three outcomes were mortality, ambulatory care–sensitive condition (ACSC) hospitalizations, and emergency department (ED) visits. We measured the marginal association between changes in primary care workforce and patient outcomes using Poisson regression models.
An increase of one primary care physician per 10,000 population was associated with 15.1 fewer deaths per 100,000 and 39.7 fewer ACSC hospitalizations per 100,000 (both p < .05). An increase of one Medicare primary care FTE per 10,000 beneficiaries was associated with 82.8 fewer deaths per 100,000, 160.8 fewer ACSC hospitalizations per 100,000, and 712.3 fewer ED visits per 100,000 (all p < .05).
Medicare beneficiaries' outcomes improved as the number of primary care physicians and their clinical effort increased.
To evaluate the effects of the parent-reported medical home status on health care utilization, expenditures, and quality for children.
Medical Expenditure Panel Survey (MEPS) during 2004–2012, including a total of 9,153 children who were followed up for 2 years in the survey.
We took a causal difference-in-differences approach using inverse probability weighting and doubly robust estimators to study how changes in medical home status over a 2-year period affected children's health care outcomes. Our analysis adjusted for children's sociodemographic, health, and insurance statuses. We conducted sensitivity analyses using alternative statistical methods, different approaches to outliers and missing data, and accounting for possible common-method biases.
Compared with children whose parents reported having medical homes in both years 1 and 2, those who had medical homes in year 1 but lost them in year 2 had significantly lower parent-reported ratings of health care quality and higher utilization of emergency care. Compared with children whose parents reported having no medical homes in both years, those who did not have medical homes in year 1 but gained them in year 2 had significantly higher ratings of health care quality, but no significant differences in health care expenditures and utilization.
Having a medical home may help improve health care quality for children; losing a medical home may lead to higher utilization of emergency care.
To explore the influence of varying degrees of remoteness on practice-level electronic medical record (EMR) adoption, including whether the effect differs across practice specialty.
Survey data on over 270,000 office-based physician practices (representing over 1,250,000 providers) collected by SK&A information services during 2012.
This study examined differences in EMR adoption by practices located across the nine-category rural–urban continuum. Logistic regressions and associated marginal effects are used to assess how much a move up or down the rural–urban continuum code impacts the likelihood of EMR adoption, after controlling for characteristics likely to affect EMR adoption such as practice size and specialty.
Overall practice-level EMR adoption rates generally increase with the degree of rurality and range from 47 percent in the most urban counties to over 60 percent in the most rural. Moving from the most urban county to the most rural corresponded to a 7 percent increase in the likelihood of EMR adoption (p < .01).
EMR adoption rates do vary significantly across nonmetropolitan counties, and they generally increase as a practice becomes more rural. From a policy perspective, this suggests that urban practices may in fact be the lowest hanging remaining fruit for increasing EMR adoption rates.
To learn how minority and underserved communities would set priorities for patient-centered outcomes research (PCOR).
Sixteen groups (n = 183) from minority and underserved communities in two states deliberated about PCOR priorities using the simulation exercise CHoosing All Together (CHAT). Most participants were minority, one-third reported income <$10,000, and one-fourth reported fair/poor health.
Academic–community partnerships adapted CHAT for PCOR priority setting using existing research agendas and interviews with community leaders, clinicians, and key informants.
Tablet-based CHAT collected demographic information, individual priorities before and after group deliberation, and groups' priorities.
Individuals and groups prioritized research on Quality of Life, Patient-Doctor, Access, Special Needs, and (by total resources spent) Compare Approaches. Those with less than a high school education were less likely to prioritize New Approaches, Patient-Doctor, Quality of Life, and Families/Caregivers. Blacks were less likely to prioritize research on Causes of Disease, New Approaches, and Compare Approaches than whites. Compare Approaches, Special Needs, Access, and Families/Caregivers were significantly more likely to be selected by individuals after compared to before deliberation.
Members of underserved communities, in informed deliberations, prioritized research on Quality of Life, Patient-Doctor, Special Needs, Access, and Compare Approaches.
To examine the relative influence of hospital and skilled nursing facilities (SNFs) on 30-day rehospitalization.
Elderly Medicare beneficiaries newly admitted to a SNF following hospitalization.
We ranked hospitals and SNFs into quartiles based on previous years' adjusted rehospitalization rates (ARRs) and examined how rehospitalizations from a given hospital vary depending upon the admitting SNF ARR quartile. We examined whether the availability of SNFs with low rehospitalization rates influenced hospitals' SNF readmission rates and whether changes in a hospital's ARR over 3 years is associated with changes in the SNFs to which they discharge.
Hospital readmission rates from SNFs varied 5 percentage points between patients discharged to SNFs in the lowest and the highest rehospitalization quartiles. Low rehospitalization rate hospitals sent a larger fraction of their patients to the lowest rehospitalization SNFs available in the area. A 10 percent increase in hospital's share of discharges to the lowest rehospitalization quartile SNFs is associated with a 1 percentage point reduction in hospital's ARR.
The SNF rehospitalization rate has greater influence on patients' risk of rehospitalization than the discharging hospital. Identifying high-performing SNFs may be a powerful strategy for hospitals to reduce rehospitalizations.
To estimate a safe minimum hospital volume for hospitals performing coronary artery bypass graft (CABG) surgery.
Hospital data on all publicly funded CABG in five European countries, 2007–2009 (106,149 patients).
Hierarchical logistic regression models to estimate the relationship between hospital volume and mortality, allowing for case mix. Segmented regression analysis to estimate a threshold.
The 30-day in-hospital mortality rate was 3.0 percent overall, 5.2 percent (95 percent CI: 4.0–6.4) in low-volume hospitals, and 2.1 percent (95 percent CI: 1.8–2.3) in high-volume hospitals. There is a significant curvilinear relationship between volume and mortality, flatter above 415 cases per hospital per year.
There is a clear relationship between hospital CABG volume and mortality in Europe, implying a "safe" threshold volume of 415 cases per year.
To examine the influence of physician and hospital market structures on medical technology diffusion, studying the diffusion of drug-eluting stents (DESs), which became available in April 2003.
Medicare claims linked to physician demographic data from the American Medical Association and to hospital characteristics from the American Hospital Association Survey.
Retrospective claims data analyses.
All fee-for-service Medicare beneficiaries who received a percutaneous coronary intervention (PCI) with a cardiac stent in 2003 or 2004. Each PCI record was joined to characteristics on the patient, the procedure, the cardiologist, and the hospital where the PCI was delivered. We accounted for the endogeneity of physician and hospital market structure using exogenous variation in the distances between patient, physician, and hospital locations. We estimated multivariate linear probability models that related the use of a DES in the PCI on market structure while controlling for patient, physician, and hospital characteristics.
DESs diffused faster in markets where cardiology practices faced more competition. Conversely, we found no evidence that the structure of the hospital market mattered.
Competitive pressure to maintain or expand PCI volume shares compelled cardiologists to adopt DESs more quickly.
To assess patient- and hospital-level factors associated with home health care (HHC) referrals following nonelective U.S. patient hospitalizations in 2012.
The 2012 National Inpatient Sample (NIS).
Retrospective, cross-sectional multivariable logistic regression modeling to assess patient- and hospital-level variables in patient discharges with versus without HHC referrals.
Analysis included 1,109,905 discharges in patients ≥65 years with Medicare.
About 29.2 percent of discharges were referred to HHC, which were more likely with older age, female sex, urban location, low income, longer length of stay, higher severity of illness scores, diagnoses of heart failure or sepsis, and hospital location in New England (referent: Pacific).
As health policy changes influence postacute HHC, defining specific diagnoses and regional patterns associated with HHC is a first step to optimize postacute HHC services.
Extensive evidence documents geographic variation in spending, but limited research assesses geographic variation in quality, particularly among commercially insured enrollees.
To measure geographic variation in quality measures, correlation among measures, and correlation between measures and spending for commercially insured enrollees.
Administrative claims from the 2007–2009 Truven MarketScan database.
We calculated variation in, and correlations among, 10 quality measures across 306 Hospital Referral Regions (HRRs), adjusting for beneficiary traits and sample size differences. Further, we created a quality index and correlated it with spending.
The coefficient of variation of HRR-level performance ranged from 0.04 to 0.38. Correlations among quality measures generally ranged from 0.2 to 0.5. Quality was modestly positively related to spending.
Quality varied across HRRs and there was only a modest geographic "quality footprint."
To describe characteristics of industrial injury hospitalizations, and to test the hypothesis that industrial injuries were increasingly billed to non-workers' compensation (WC) payers over time.
Hospitalization data for 1998–2009 from State Inpatient Databases, Healthcare Cost and Utilization Project, and Agency for Healthcare Research and Quality.
Retrospective secondary analyses described the distribution of payer, age, gender, race/ethnicity, and injury severity for injuries identified using industrial place of occurrence codes. Logistic regression models estimated trends in expected payer.
There was a significant increase over time in the odds of an industrial injury not being billed to WC in California and Colorado, but a significant decrease in New York. These states had markedly different WC policy histories. Industrial injuries among older workers were more often billed to a non-WC payer, primarily Medicare.
Findings suggest potentially dramatic cost shifting from WC to Medicare. This study adds to limited, but mounting evidence that, in at least some states, the burden on non-WC payers to cover health care for industrial injuries is growing, even while WC-related employer costs are decreasing—an area that warrants further research.
To provide guidelines to researchers measuring health expenditures by disease and compare these methodologies' implied inflation estimates.
A convenience sample of commercially insured individuals over the 2003 to 2007 period from Truven Health. Population weights are applied, based on age, sex, and region, to make the sample of over 4 million enrollees representative of the entire commercially insured population.
Different methods are used to allocate medical-care expenditures to distinct condition categories. We compare the estimates of disease-price inflation by method.
Across a variety of methods, the compound annual growth rate stays within the range 3.1 to 3.9 percentage points. Disease-specific inflation measures are more sensitive to the selected methodology.
The selected allocation method impacts aggregate inflation rates, but considering the variety of methods applied, the differences appear small. Future research is necessary to better understand these differences in other population samples and to connect disease expenditures to measures of quality.
To predict changes in wage growth for health care workers based on projections of insurance enrollment from the Affordable Care Act (ACA).
Enrollment data came from three large employers and a sampling of premiums from ehealthinsurance.com. Information on state Medicaid eligibility rules and costs were from the Kaiser Family Foundation. National predictions were based on the MEPS and Medicare Current Beneficiary surveys. Bureau of Labor Statistics data were used to estimate employment.
We projected health insurance enrollment by plan type using a health plan choice model. Using claims data, we measured the services demanded for each plan choice and year. Projections of labor demand were based on current output/input ratios. Changes in wages resulting from changes in labor demand from 2014 to 2021 were based on labor supply and demand elasticities.
Expenditures required to retain and grow the health care workforce will increase substantially. Wages will increase most for professions with the greatest training requirements (physicians and registered nurses). The largest impact will be felt in 2015.
Projected wage increases for health care workers may drive substantial growth in insurance premiums and reduce the affordability of health insurance.
To examine variation in pharmaceutical spending and patient characteristics across prescription drug user groups.
British Columbia's population-based linked administrative health and sociodemographic databases (N = 3,460,763).
We classified individuals into empirically derived prescription drug user groups based on pharmaceutical spending patterns outside hospitals from 2007 to 2011. We examined variation in patient characteristics, mortality, and health services usage and applied hierarchical clustering to determine patterns of concurrent drug use identifying high-cost patients.
Approximately 1 in 20 British Columbians had persistently high prescription costs for 5 consecutive years, accounting for 42 percent of 2011 province-wide pharmaceutical spending. Less than 1 percent of the population experienced discrete episodes of high prescription costs; an additional 2.8 percent transitioned to or from high-cost episodes of unknown duration. Persistent high-cost users were more likely to concurrently use multiple chronic medications; episodic and transitory users spent more on specialized medicines, including outpatient cancer drugs. Cluster analyses revealed heterogeneity in concurrent medicine use within high-cost groups.
Whether low, moderate, or high, costs of prescription drugs for most individuals are persistent over time. Policies controlling high-cost use should focus on reducing polypharmacy and encouraging price competition in drug classes used by ordinary and high-cost users alike.
To estimate (1) family-centered care (FCC) and shared decision-making (SDM) prevalence, and (2) associations of FCC and SDM (FCC/SDM) with health care outcomes among U.S. children.
The Medical Expenditure Panel Survey Household Component (MEPS-HC), a nationally representative survey of the noninstitutionalized, civilian population.
Secondary analyses of prospectively collected data on 15,764 U.S. children were conducted to examine FCC/SDM prevalence in year 1 and associations of FCC/SDM in year 1 with health services utilization, medical expenditures, and unmet health care needs in year 2.
We combined four MEPS-HC longitudinal files from 2007 to 2011.
FCC/SDM prevalence in year 1 varied from 38.6 to 93.7 percent, and it was lower for composites with more stringent scoring approaches. FCC/SDM composites with stringent scoring approaches in year 1 were associated with reduced unmet needs in year 2. FCC/SDM, across all year 1 composites, was not associated with health services utilization or medical expenditures in year 2. FCC/SDM year 1 subcomponents describing consensus building and mutual agreement were consistently associated with unmet health care needs in year 2.
FCC/SDM composites with stringent scoring approaches measuring consensus building and mutual agreement may have the greatest utility for pediatric health care quality improvement efforts.
To examine the relationship between physician advice to quit smoking and patient care experiences.
The 2012 Medicare Consumer Assessment of Healthcare Providers and Systems (MCAHPS) surveys.
Fixed-effects linear regression models were used to analyze cross-sectional survey data, which included a nationally representative sample of 26,432 smokers aged 65+.
Eleven of 12 patient experience measures were significantly more positive among smokers who were always advised to quit smoking than those advised to quit less frequently. There was an attenuated but still significant and positive association of advice to quit smoking with both physician rating and physician communication, after controlling for other measures of care experiences.
Physician-provided cessation advice was associated with more positive patient assessments of their physicians.
To measure variation in payment rates under Medicare's Inpatient Prospective Payment System (IPPS) and identify the main payment adjustments that drive variation.
Medicare cost reports for all Medicare-certified hospitals, 1987–2013, and Dartmouth Atlas geographic files.
We measure the Medicare payment rate as a hospital's total acute inpatient Medicare Part A payment, divided by the standard IPPS payment for its geographic area. We assess variation using several measures, both within local markets and nationally. We perform a factor decomposition to identify the share of variation attributable to specific adjustments. We also describe the characteristics of hospitals receiving different payment rates and evaluate changes in the magnitude of the main adjustments over time.
Data downloaded from the Centers for Medicare and Medicaid Services, the National Bureau of Economic Research, and the Dartmouth Atlas.
In 2013, Medicare paid for acute inpatient discharges at a rate 31 percent above the IPPS base. For the top 10 percent of discharges, the mean rate was double the IPPS base. Variations were driven by adjustments for medical education and care to low-income populations. The magnitude of variation has increased over time.
Adjustments are a large and growing share of Medicare hospital payments, and they create significant variation in payment rates.
To examine the relationship between distance to dialysis provider and patient selection of dialysis modality, informed by the absolute distance from a patient's home and relative distance of alternative modalities.
U.S. Renal Data System.
About 70,131 patients initiating chronic dialysis and 4,795 dialysis facilities in 2006. The primary outcome was patient utilization of peritoneal dialysis (PD). Independent variables included absolute distance between patients' home and the nearest hemodialysis (HD) facility, relative distance between patients' home and nearest PD versus nearest HD facilities, and their interaction. Logistic regression was used to model distance on PD use, controlling for patient and market characteristics.
Nine percent of incident dialysis patients used PD in 2006. There was a positive, nonlinear relationship between absolute distance to HD services and PD use (p < .0001), with the magnitude of the effect increasing at greater distances. In terms of relative distance, odds of PD use increased if a PD facility was closer or the same distance as the nearest HD facility (p = .006). Interaction of distance measures to dialysis facilities was not significant.
Analyses of patient choice between alternative treatments should model distance to reflect all relevant dimensions of geographic access to treatment options.
The introduction of bundled payment for diabetes care in the Netherlands led to the origination of care groups. This study explored to what extent variation in health care costs per patient can be attributed to the performance of care groups. Furthermore, the commonly applied simple mean aggregation was compared with the more advanced generalized linear mixed model (GLMM) to benchmark health care costs per patient between care groups.
Dutch 2009 nationwide insurance claims data of diabetes type 2 patients (104,544 patients, 50 care groups).
Both a simple mean aggregation and a GLMM approach was applied to rank care groups, using two different health care costs variables: total treatment health care costs and diabetes-specific specialist care costs per diabetes patient.
Care groups varied slightly in the first and mainly in the second indicator. Care group variation was not explained by composition. Although the ranking methods were correlated, some care groups' rank positions differed, with consequences on the top-10 and the low-10 positions.
Differences between care groups exist when an appropriate indicator and a sophisticated aggregation technique is used. Currently applied benchmarking may have unfair consequences for some care groups.
To understand the relationship between state-level spending by public health departments and the incidence of three vaccine preventable diseases (VPDs): mumps, pertussis, and rubella in the United States from 1980 to 2009.
This study uses state-level public health spending data from The Census Bureau and annual mumps, pertussis, and rubella incidence counts from the University of Pittsburgh's project Tycho.
Ordinary least squares (OLS), fixed effects, and random effects regression models were tested, with results indicating that a fixed effects model would be most appropriate model for this analysis.
Model output suggests a statistically significant, negative relationship between public health spending and mumps and rubella incidence. Lagging outcome variables indicate that public health spending actually has the greatest impact on VPD incidence in subsequent years, rather than the year in which the spending occurred. Results were robust to models with lagged spending variables, national time trends, and state time trends, as well as models with and without Medicaid and hospital spending.
Our analysis indicates that there is evidence of a significant, negative relationship between a state's public health spending and the incidence of two VPDs, mumps and rubella, in the United States.
To create and test three prospective, increasingly restrictive definitions of serious illness.
Health and Retirement Study, 2000–2012.
We evaluated subjects' 1-year outcomes from the interview date when they first met each definition: (A) one or more severe medical conditions (Condition) and/or receiving assistance with activities of daily living (Functional Limitation); (B) Condition and/or Functional Limitation and hospital admission in the last 12 months and/or residing in a nursing home (Utilization); and (C) Condition and Functional Limitation and Utilization. Definitions are increasingly restrictive, but not mutually exclusive.
Of 11,577 eligible subjects, 5,297 met definition A; 3,151 definition B; and 1,447 definition C.
One-year outcomes were as follows: hospitalization 33 percent (A), 44 percent (B), 47 percent (C); total average Medicare costs $20,566 (A), $26,349 (B), and $30,828 (C); and mortality 13 percent (A), 19 percent (B), 28 percent (C). In comparison, among those meeting no definition, 12 percent had hospitalizations, total Medicare costs averaged $7,789, and 2 percent died.
Prospective identification of older adults with serious illness is feasible using clinically accessible criteria and may be a critical step toward improving health care value. These definitions may aid clinicians and health systems in targeting patients who could benefit from additional services.
To assess how changes in curriculum, accreditation standards, and certification and licensure competencies impacted how medical students and physician residents value interprofessional team and patient-centered care.
The Department of Veterans Affairs Learners' Perceptions Survey (2003–2013). The nationally administered survey asked a representative sample of 56,569 U.S. medical students and physician residents, with a comparison group of 78,038 nonphysician trainees, to rate satisfaction with 28 elements, in two overall domains, describing their clinical learning experiences at VA medical centers.
Value preferences were scored as independent adjusted associations between an element (interprofessional team, patient-centered preceptor) and the respective overall domain (clinical learning environment, faculty, and preceptors) relative to a referent element (quality of clinical care, quality of preceptor).
Physician trainees valued interprofessional (14 percent vs. 37 percent, p < .001) and patient-centered learning (21 percent vs. 36 percent, p < .001) less than their nonphysician counterparts. Physician preferences for interprofessional learning showed modest increases over time (2.5 percent/year, p < .001), driven mostly by internal medicine and surgery residents. Preferences did not increase with trainees' academic progress.
Despite changes in medical education, physician trainees continue to lag behind their nonphysician counterparts in valuing experience with interprofessional team and patient-centered care.
To study the impact of eliminating cost sharing for screening mammography on mammography rates in a large Medicare Advantage (MA) health plan which in 2010 eliminated cost sharing in anticipation of the Affordable Care Act mandate.
Large MA health maintenance organization offering individual-subscriber MA insurance and employer-supplemented group MA insurance.
We investigated the impact on breast cancer screening of a policy that eliminated a $20 copayment for screening mammography in 2010 among 53,188 women continuously enrolled from 2007 to 2012 in an individual-subscriber MA plan, compared with 42,473 women with employer-supplemented group MA insurance in the same health maintenance organization who had full screening coverage during this period. We used differences-in-differences analysis to study the impact of cost-sharing elimination on mammography rates.
Annual screening rates declined over time for both groups, with similar trends pre-2010 and a slower decline after 2010 among women whose copayments were eliminated. Among women aged 65–74 years in the individual-subscriber MA plan, 44.9 percent received screening in 2009 compared with 40.9 percent in 2012, while 49.5 percent of women in the employer-supplemented MA plan received screening in 2009 compared with 44.1 percent in 2012, that is, a difference-in-difference effect of 1.4 percentage points less decline in screening among women experiencing the cost-sharing elimination. Effects were concentrated among women without recent screening. There were no differences by neighborhood socioeconomic status or race/ethnicity.
Eliminating cost sharing for screening mammography was associated with modesty lower decline in screening rates among women with previously low screening adherence.
To determine whether higher activity of daily living (ADL) limitation stages are associated with increased risk of hospitalization, particularly for ambulatory care sensitive (ACS) conditions.
Secondary data analysis, including 8,815 beneficiaries from 2005 to 2006 Medicare Current Beneficiary Survey (MCBS).
ADL limitation stages (0-IV) were determined at the end of 2005. Hospitalization rates were calculated for 2006 and age adjusted using direct standardization. Multivariate negative binomial regression, adjusting for baseline demographic and health characteristics, with the outcome hospitalization count was performed to estimate the adjusted rate ratio of ACS and non-ACS hospitalizations for beneficiaries with ADL stages > 0 compared to beneficiaries without limitations.
Baseline ADL stage and health conditions were assessed using 2005 MCBS data and count of hospitalization determined using 2006 MCBS data.
Referenced to stage 0, the adjusted rate ratios (95 percent confidence interval) for stage I to stage IV ranged from 1.9 (1.4–2.5) to 4.1 (2.2–7.8) for ACS hospitalizations compared with from 1.6 (1.3–1.9) to 1.8 (1.4–2.5) for non-ACS hospitalizations.
Hospitalization rates for ACS conditions increased more dramatically with ADL limitation stage than did rates for non-ACS conditions. Adults with ADL limitations appear particularly vulnerable to potentially preventable hospitalizations for conditions typically manageable in ambulatory settings.
To evaluate the comparative safety of laparoscopic and open colectomy across surgeons varying in experience with laparoscopy.
National Medicare data (2008–2010) for beneficiaries undergoing laparoscopic or open colectomy.
Using instrumental variable methods to address selection bias, we evaluated outcomes of laparoscopic and open colectomy. Our instrument was the regional use of laparoscopy in the year prior to a patient's operation. We then evaluated outcomes stratified by surgeons' annual volume of laparoscopic colectomy.
Laparoscopic colectomy was associated with lower mortality (OR: 0.75, 95 percent CI: 0.70–0.78) and fewer complications than open surgery (OR: 0.82, 95 percent CI: 0.79–0.85). Increasing surgeon volume was associated with better outcomes for both procedures, but the relationship was stronger for laparoscopy. The comparative safety depended on surgeon volume. High-volume surgeons had 40 percent lower mortality (OR: 0.60, 95 percent CI: 0.55–0.65) and 30 percent fewer complications (OR: 0.70, 95 percent CI: 0.67–0.74) with laparoscopy. Conversely, low-volume surgeons had 7 percent higher mortality (OR: 1.07, 95 percent CI: 1.02–1.13) and 18 percent more complications (OR: 1.18, 95 percent CI: 1.12–1.24) with laparoscopy.
This population-based study demonstrates that the comparative safety of laparoscopic and open colectomy is influenced by surgeon volume. Laparoscopic colectomy is only safer for patients whose surgeons have sufficient experience.
To identify physician and practice characteristics that are markers of success for meaningful use of electronic health records (EHRs).
American Medical Association survey, Centers for Medicare & Medicaid Services' (CMS) EHR Incentive, Pioneer Accountable Care Organization, and PECOS Programs, the Office of the National Coordinator for Health IT's Regional Extension Center Program, and National Committee for Quality Assurance Patient-centered Medical Home certification program.
Retrospective analysis of 865,370 physicians' participation in CMS's EHR Incentive Program and progress to stage 1 Meaningful Use between 2011 and 2013. Physician specialty, age, practice size, geographic markers, delivery reform participation, and technical assistance receipt were predictive elements.
Medicaid physicians were progressing more slowly to Meaningful Use than Medicare physicians: by 2013, 8 in 10 physicians registered with Medicare had achieved meaningful use, compared to one-third of Medicaid-registered physicians. The strongest predictors of meaningful use were technical assistance (79 percent more likely) and delivery reform participation (34 percent more likely).
Continued outreach and technical assistance that demonstrates strong interactions between meaningful use of health IT and delivery reform may facilitate further adoption of both initiatives.
To evaluate the effects of state insurance mandates requiring insurance plans to cover Pap tests, the standard screening for cervical cancer that is recommended for nearly all adult women.
Individual-level data on 600,000 women age 19–64 from the CDC's Behavioral Risk Factor Surveillance System.
Twenty-four states adopted state mandates requiring private insurers in the state to cover Pap tests from 1988 to 2000. We performed a difference-in-differences analysis comparing within-state changes in Pap test rates before and after adoption of a mandate, controlling for the associated changes in other states that did not adopt a mandate.
Difference-in-differences estimates indicated that the Pap test mandates significantly increased past 2-year cervical cancer screenings by 1.3 percentage points, with larger effects for Hispanic and non-Hispanic white women. These effects are plausibly concentrated among insured women.
Mandating more generous insurance coverage for even inexpensive, routine services with already high utilization rates such as Pap tests can significantly further increase utilization.
To examine the role of patient, hospital, and community characteristics on racial and ethnic disparities in in-hospital postsurgical complications.
Healthcare Cost and Utilization Project, 2011 State Inpatient Databases; American Hospital Association Annual Survey of Hospitals; Area Health Resources Files; Centers for Medicare & Medicaid Services Hospital Compare database.
Nonlinear hierarchical modeling was conducted to examine the odds of patients experiencing any in-hospital postsurgical complication, as defined by Agency for Healthcare Research and Quality Patient Safety Indicators.
A total of 5,474,067 inpatient surgical discharges were assessed using multivariable logistic regression. Clinical risk, payer coverage, and community-level characteristics (especially income) completely attenuated the effect of race on the odds of postsurgical complications. Patients without private insurance were 30 to 50 percent more likely to have a complication; patients from low-income communities were nearly 12 percent more likely to experience a complication. Private, not-for-profit hospitals in small metropolitan or micropolitan areas and higher nurse-to-patient ratios led to fewer postsurgical complications.
Race does not appear to be an important determinant of in-hospital postsurgical complications, but insurance and community characteristics have an effect. A population-based approach that includes improving the socioeconomic context may help reduce disparities in these outcomes.
The median time required to perform a surgical procedure is important in determining payment under Medicare's physician fee schedule. Prior studies have demonstrated that the current methodology of using physician surveys to determine surgical times results in overstated times. To measure surgical times more accurately, we developed and validated a methodology using available data from anesthesia billing data and operating room (OR) records.
We estimated surgical times using Medicare 2011 anesthesia claims and New York Statewide Planning and Research Cooperative System 2011 OR times. Estimated times were validated using data from the National Surgical Quality Improvement Program. We compared our time estimates to those used by Medicare in the fee schedule.
We estimate surgical times via piecewise linear median regression models.
Using 3.0 million observations of anesthesia and OR times, we estimated surgical time for 921 procedures. Correlation between these time estimates and directly measured surgical time from the validation database was 0.98. Our estimates of surgical time were shorter than the Medicare fee schedule estimates for 78 percent of procedures.
Anesthesia and OR times can be used to measure surgical time and thereby improve the payment for surgical procedures in the Medicare fee schedule.
To profile the sick leave landscape in the United States.
The 2011 Leave Supplement of the American Time Use Survey.
Bivariate and multivariate analyses to identify (i) employees without sick pay coverage and (ii) employees who attend work sick.
Sixty-five percent of full-time employees have sick pay coverage. Coverage rates are below 20 percent for employees with hourly wages below $10, part-time employees, and employees in the hospitality and leisure industry.
Each week, up to 3 million U.S. employees go to work sick. Females, low-income earners, and those aged 25 to 34 years have a significantly elevated risk of presenteeism behavior.
Performance thresholds are commonly used in pay-for-performance (P4P) incentives, where providers receive a bonus payment for achieving a prespecified target threshold but may produce discontinuous incentives, with providers just below the threshold having the strongest incentive to improve and providers either far below or above the threshold having little incentive. We investigate the effect of performance thresholds on provider response in the setting of nursing home P4P.
The Minimum Data Set (MDS) and Online Survey, Certification, and Reporting (OSCAR) datasets.
Difference-in-differences design to test for changes in nursing home performance in three states that implemented threshold-based P4P (Colorado, Georgia, and Oklahoma) versus three comparator states (Arizona, Tennessee, and Arkansas) between 2006 and 2009.
We find that those farthest below the threshold (i.e., the worst-performing nursing homes) had the largest improvements under threshold-based P4P while those farthest above the threshold worsened. This effect did not vary with the percentage of Medicaid residents in a nursing home.
Threshold-based P4P may provide perverse incentives for nursing homes above the performance threshold, but we do not find evidence to support concerns about the effects of performance thresholds on low-performing nursing homes.
To compare early and later adopters of the accountable care organization (ACO) model, using the taxonomy of larger, integrated system; smaller, physician-led; and hybrid ACOs.
The National Survey of ACOs, Waves 1 and 2.
Cluster analysis using the two-step clustering approach, validated using discriminant analysis. Wave 2 data analyzed separately to assess differences from Wave 1 and then data pooled across waves.
Compared to early ACOs, later adopter ACOs included a greater breadth of provider group types and a greater proportion self-reported as integrated delivery systems. When data from the two time periods were combined, a three-cluster solution similar to the original cluster solution emerged. Of the 251 ACOs, 31.1 percent were larger, integrated system ACOs; 45.0 percent were smaller physician-led ACOs; and 23.9 percent were hybrid ACOs—compared to 40.1 percent, 34.0 percent, and 25.9 percent from Wave 1 clusters, respectively.
While there are some differences between ACOs formed prior to August 2012 and those formed in the following year, the three-cluster taxonomy appears to best describe the types of ACOs in existence as of July 2013. The updated taxonomy can be used by researchers, policy makers, and health care organizations to support evaluation and continued development of ACOs.
To develop a method to allow a hospital to compare its performance using its entire patient population to the outcomes of very similar patients treated elsewhere.
Medicare claims in orthopedics and common general, gynecologic, and urologic surgery from Illinois, New York, and Texas from 2004 to 2006.
Using two example "focal" hospitals, each hospital's patients were matched to 10 very similar patients selected from 619 other hospitals.
All patients were used at each focal hospital, and we found the 10 closest matched patients from control hospitals with exactly the same principal procedure as each focal patient.
We achieved exact matches on all procedures and very close matches for other patient characteristics for both hospitals. There were few to no differences between each hospital's patients and their matched control patients on most patient characteristics, yet large and significant differences were observed for mortality, failure-to-rescue, and cost.
Indirect standardization matching can produce fair audits of quality and cost, allowing for a comprehensive, transparent, and relevant assessment of all patients at a focal hospital. With this approach, hospitals will be better able to benchmark their performance and determine where quality improvement is most needed.
To investigate whether early or regular preventive dental visit (PDV) reduces restorative or emergency dental care and costs for low-income children.
Enrollees during 1998–2012 in the Alabama CHIP program, ALL Kids.
Retrospective cohort study using claims data for children continuously enrolled in ALL Kids for at least 4 years. Analyses are conducted separately for children 0–4 years, 4–9 years, and >9 years. For 0–4 years, the intervention of interest is whether they have at least one PDV before age 3. For the other two age groups, interventions of interest are if they have regular PDVs during each of the first 3 years, and if they have claims for a sealant in the first 3 years. Outcomes—namely restorative and emergency dental service and costs—are measured in the fourth year. To account for selection into PDV, a high-dimensional propensity scores approach is utilized.
Claims data were obtained from ALL Kids.
Only sealants are associated with a reduced likelihood of using restorative and emergency services and costs.
Whether PDVs without sealants actually reduce restorative/emergency pediatric dental services is questionable. Further research into benefits of PDV is needed.
To explore predictors of gaps between observed and best possible Hospital Compare scores in U.S. hospitals.
American Hospital Association Annual Survey; Area Resource Files; Centers for Medicare and Medicaid Services Medicare Provider and Analysis Review; and Hospital Compare data.
Using Stochastic Frontier Analysis and secondary cross-sectional data, gaps between the best possible and actual scores of Hospital Compare quality measures were estimated. Poisson regressions were used to ascertain financial, organizational, and market predictors of those gaps.
Data were cleaned and matched based on hospital Medicare IDs. All U.S. hospitals that matched on analysis variables in 2007 were in the study (1,823–2,747, depending upon gap variable).
Most hospitals have a greater than 10 percent gap in quality indicators. Payer mix, registered nurse staffing, size, case mix index, accreditation, being a teaching hospital, market competition, urban location, and region were strong predictors of gaps, although the direction of the association with gaps was not uniform across outcomes.
A significant percentage of hospitals have gaps between their best possible and observed quality scores. It may be better to use gap scores than observed scores in payments systems. More SFA research is needed to know how to lower gaps through changes in hospital and market characteristics.
To examine whether the course of physical therapy treatments received by patients who undergo total knee replacement (TKR) surgery differs depending on whether the orthopedic surgeon has a financial stake in physical therapy services.
Sample of Medicare beneficiaries who underwent TKR surgery during the years 2007–2009.
We used regression analysis to evaluate the effect of physician self-referral on the following outcomes: (1) time from discharge to first physical therapy visit; (2) episode length; (3) number of physical therapy visits per episode; (4) number of physical therapy service units per episode; and (5) number of physical therapy services per episode expressed in relative value units.
TKR patients who underwent physical therapy treatment at a physician-owned clinic received on average twice as many physical therapy visits (8.3 more) than patients whose TKR surgery was performed by a orthopedic surgeon who did not self-refer physical therapy services (p < .001). Regression-adjusted results show that TKR patients treated at physician-owned clinics received almost nine fewer physical therapy service units during an episode compared with patients treated by nonself-referring providers (p < .001). In relative value units, this difference was 4 (p < .001). In contrast, episodes where the orthopedic surgeon owner does not profit from physical therapy services rendered to the patient look virtually identical to episodes where the TKR surgery was performed by a surgeon nonowner.
Physical therapists not involved with physician-owned clinics saw patients for fewer visits, but the composition of physical therapy services rendered during each visit included more individualized therapeutic exercises.
To examine the impact of Seguro Popular (Mexican social health insurance for the poor; SP) on diabetes and hypertension care, intermediate process indicators for older adults (>50 years): pharmacological treatment, blood glucose tests, the use of complementary and alternative medicine (CAM), and adherence to their nutrition and exercise program. (CAM was defined as products or practices that were not part of the medical standard of care.)
Repeated cross-sectional surveys from Encuesta Nacional de Salud y Nutrición (Mexican Health and Nutrition Survey, ENSANUT), a nationally representative health and nutrition survey sampling N = 45,294 older adults in 2000, N = 45,241 older adults in 2005–2006, and N = 46,277 older adults in 2011-2012.
Fixed-effects instrumental variable (FE-IV) repeated cross-sectional at the individual level with municipality fixed-effects estimation was performed.
We found a marginally significant effect of SP on the use of insulin and oral agents (40 percentage points). Contrary to that expected, no other significant differences were found for diabetes or hypertension treatment and care indicators.
Social health insurance for the poor improved some but not all health care process indicators among diabetic and hypertensive older people in Mexico.
To assess the effects of past Medicaid eligibility expansions to parents on coverage, access to care, out-of-pocket (OOP) spending, and mental health outcomes, and consider implications for the Affordable Care Act (ACA) Medicaid expansion.
Person-level data from the National Health Interview Survey (1998–2010) is used to measure insurance coverage and related outcomes for low-income parents. Using state identifiers available at the National Center for Health Statistics Research Data Center, we attach state Medicaid eligibility thresholds for parents collected from a variety of sources to NHIS observations.
We use changes in the Medicaid eligibility threshold for parents within states over time to identify the effects of changes in eligibility on low-income parents.
We find that expanding Medicaid eligibility increases insurance coverage, reduces unmet needs due to cost and OOP spending, and improves mental health status among low-income parents. Moreover, our findings suggest that uninsured populations in states not currently participating in the ACA Medicaid expansion would experience even larger improvements in coverage and related outcomes than those in participating states if they chose to expand eligibility.
The ACA Medicaid expansion has the potential to improve a wide variety of coverage, access, financial, and health outcomes for uninsured parents in states that choose to expand coverage.
To assess the effects on hospitals of early California actions to expand insurance coverage for low-income uninsured adults after passage of the Affordable Care Act.
Data from the California Office of Statewide Health Planning and Development and the California Department of Health were merged with U.S. census data for 294 short-term general hospitals during the period 2009–2012.
A difference-in-difference analysis was conducted with hospitals in counties that did not implement insurance expansions used as a comparison group. Variables examined included payer mix, costs of unreimbursed care, and hospital operating margin. Sensitivity analyses were conducted as well as a triple difference analysis. Effects were estimated for hospitals overall and by ownership type.
California insurance expansions primarily benefited for-profit hospitals, with these facilities experiencing significant decreases in self-pay patients, increases in county-covered patients, and reductions in charity care. Most models yielded no significant change in payer mix and conflicting changes in unreimbursed care for nonprofit hospitals.
California hospitals that treated the most uninsured prior to insurance expansions did not as a group experience substantial benefit in terms of reduced uninsured burden or better financial performance after program expansions occurred.
To describe the amount of hospital outpatient care provided to the uninsured and its association with Medicare payment rate cuts following the implementation of Medicare's Outpatient Prospective Payment System.
We use hospital outpatient discharge records from Florida from 1997 through 2008.
We estimate multivariate regression models of hospital outpatient care provided to the uninsured in separate samples of nonprofit and for-profit hospitals.
Hospital outpatient departments provide significant amounts of care to the uninsured. As Medicare payment rates fall, total charges and the share of charges for outpatient visits by the uninsured decrease at nonprofit hospitals. At for-profit hospitals, the share of outpatient care provided to uninsured patients increases, but there is no significant change in the number of uninsured discharges.
Nonprofit and for-profit hospitals respond differently to reductions in Medicare payments; thus, studies of the impact of legislated Medicare payment cuts on care of the uninsured should account for differences in hospital ownership in communities. Given that outpatient care to the uninsured includes preventive and diagnostic care procedures, reductions in this care following payment cuts may adversely affect long-run health and health care costs in communities dominated by nonprofit hospitals.
This study is designed to assess the cost of services provided to Medicare beneficiaries by nurse practitioners (NPs) billing under their own National Provider Identification number as compared to primary care physicians (PCMDs).
Medicare Part A (inpatient) and Part B (office visit) claims for 2009–2010.
Retrospective cohort design using propensity score weighted regression.
Beneficiaries cared for by a random sample of NPs and primary care physicians.
After adjusting for demographic characteristics, geography, comorbidities, and the propensity to see an NP, Medicare evaluation and management payments for beneficiaries assigned to an NP were $207, or 29 percent, less than PCMD assigned beneficiaries. The same pattern was observed for inpatient and total office visit paid amounts, with 11 and 18 percent less for NP assigned beneficiaries, respectively. Results are similar for the work component of relative value units as well.
This study provides new evidence of the lower cost of care for beneficiaries managed by NPs, as compared to those managed by PCMDs across inpatient and office-based settings. Results suggest that increasing access to NP primary care will not increase costs for the Medicare program and may be cost saving.
To examine the impact of a 2007 redesign of West Virginia's Medicaid program, which included an incentive and "nudging" scheme intended to encourage better health care behaviors and reduce Emergency Department (ED) visits.
West Virginia Medicaid enrollment and claims data from 2005 to 2010.
We utilized a "differences in differences" technique with individual and time fixed effects to assess the impact of redesign on ED visits. Starting in 2007, categorically eligible Medicaid beneficiaries were moved from traditional Medicaid to the new Mountain Health Choices (MHC) Program on a rolling basis, approximating a natural experiment. Members chose between a Basic plan, which was less generous than traditional Medicaid, or an Enhanced plan, which was more generous but required additional enrollment steps.
Data were obtained from the West Virginia Bureau for Medical Services.
We found that contrary to intentions, the MHC program increased ED visits. Those who selected or defaulted into the Basic plan experienced increased overall and preventable ED visits, while those who selected the Enhanced plan experienced a slight reduction in preventable ED visits; the net effect was an increase in ED visits, as most individuals enrolled in the Basic plan.
To examine the impact of pay for performance in Medicaid on the quality and utilization of care.
Medicaid claims and encounter data in three intervention states (Pennsylvania, Minnesota, and Alabama) and three comparison states.
Difference-in-difference analysis with propensity score-matched comparison group. Primary outcomes of interest were Healthcare Effectiveness Data and Information Set (HEDIS)-like process measures of quality, utilization by service category, and ambulatory care–sensitive admissions and emergency department visits.
In Pennsylvania, there was a statistically significant reduction of 88 ambulatory visits per 1,000 enrollee months compared with Florida. In Minnesota, there was a significant decrease of 7.2 hospital admissions per thousand enrollee months compared with Wisconsin. In Alabama, where incentives were not paid out until the end of a 2-year waiver period, there was a decline of 1.6 hospital admissions per thousand member months, and an increase of 59 ambulatory visits per 1,000 enrollees compared with Georgia. No significant quality improvements in intervention relative to control states.
Our findings are mixed, with no measurable quality improvements across the three states, but reductions in hospital admissions in two programs. As states move to value-based payment for patient-centered medical homes and Accountable Care Organizations, lessons learned from these pioneering states should inform program design.
The design of health insurance, and the role out-of-pocket (OOP) payments play in it, is a key policy issue as rising health costs have encouraged greater cost-sharing measures. This paper compares the percentage of Americans spending large amounts OOP to meet their health needs with percentages in eight other developed countries. By disaggregating by age and income, the paper focuses on the poor and elderly populations within each.
The study uses nationally representative household survey data made available through the Luxembourg Income Study. It includes nations with high, medium, and low levels of OOP spending.
Households have high medical spending when their OOP expenditures exceed a threshold share of income. I calculate the share of each nation's population, as well as subpopulations within it, with high OOP expenditures.
The United States is not alone in exposing large numbers of citizens to high OOP expenses. In six of the other eight countries, one-quarter or more of low-income citizens devoted at least 5 percent of their income to OOP expenses, and in all but two countries, more than 1 in 10 elderly citizens had high medical expenses.
For some populations in the sample nations, health insurance does not provide adequate financial protection and likely contributes to inequities in health care delivery and outcomes.
To test a conceptual model of relationships, reflection, sensemaking, and learning in primary care practices transitioning to patient-centered medical homes (PCMH).
Primary data were collected as part of the American Academy of Family Physicians' National Demonstration Project of the PCMH.
We conducted a cross-sectional survey of clinicians and staff from 36 family medicine practices across the United States. Surveys measured seven characteristics of practice relationships (trust, diversity, mindfulness, heedful interrelation, respectful interaction, social/task relatedness, and rich and lean communication) and three organizational attributes (reflection, sensemaking, and learning) of practices.
We surveyed 396 clinicians and practice staff. We performed a multigroup path analysis of the data. Parameter estimates were calculated using a Bayesian estimation method.
Trust and reflection were important in explaining the characteristics of practice relationships and their associations with sensemaking and learning. The strongest associations between relationships, sensemaking, and learning were found under conditions of high trust and reflection. The weakest associations were found under conditions of low trust and reflection.
Trust and reflection appear to play a key role in moderating relationships, sensemaking, and learning in practices undergoing practice redesign.
To compare physicians' self-reported willingness to provide new patient appointments with the experience of research assistants posing as either a Medicaid beneficiary or privately insured person seeking a new patient appointment.
Survey administered to California physicians and telephone calls placed to a subsample of respondents.
Cross-sectional comparison.
All physicians whose California licenses were due for renewal in June or July 2013 were mailed a survey, which included questions about acceptance of new Medicaid and new privately insured patients. Subsequently, research assistants using a script called the practices of a stratified random sample of 209 primary care physician respondents in an attempt to obtain a new patient appointment. By design, half of the physicians selected for the telephone validation reported on the survey that they accepted new Medicaid patients and half indicated that they did not.
The percentage of callers posing as Medicaid patients who could schedule new patient appointments was 18 percentage points lower than the percentage of physicians who self-reported on the survey that they accept new Medicaid patients. Callers were also less likely to obtain appointments when they posed as patients with private insurance.
Physicians overestimate the extent to which their practices are accepting new patients, regardless of insurance status.
To examine the effect of a change in U.S. Preventive Services Task Force (USPSTF) screening guidelines on mammography rates in the United States.
In 2010, the year following the change in guidelines, 12-month mammography prevalence among women aged 40–49 years fell by 2.09 percentage points (95 percent confidence interval [CI]: −2.87 to −1.31) from 54.63 percent in 2008. For women aged 50–74 years, and aged 75 years and older, 12-month screening rates were 2.21 (95 percent CI: −2.65 to −1.77) and 3.60 (95 percent CI: −4.48 to −2.70) percentage points lower than those in 2008. In 2012, for women aged 40–49 years, 12-month prevalence fell to 52.51 percent, a decline of 2.12 percentage points (95 percent CI: −2.79 to −1.32) relative to screening rates prior the USPSTF announcement. For women aged 50–74 years and aged 75 years and older screening rates were 2.45 (95 percent CI: −2.96 to −2.07) and 5.71 (95 percent CI: −6.61 to −4.81) percentage points lower, respectively, in 2012 than in 2008.
This study demonstrates an immediate and lasting reduction in the rates of breast cancer screening among women of all age groups after the 2009 revision of screening guidelines by the USPSTF.
To understand hospital- and county-level factors for rural obstetric unit closures, using mixed methods.
Hospital discharge data from Healthcare Cost and Utilization Project's Statewide Inpatient Databases, American Hospital Association Annual Survey, and Area Resource File for 2010, as well as 2013–2014 telephone interviews of all 306 rural hospitals in nine states with at least 10 births in 2010. Via interview, we ascertained obstetric unit status, reasons for closures, and postclosure community capacity for prenatal care.
Multivariate logistic regression and qualitative analysis were used to identify factors associated with unit closures between 2010 and 2014.
Exactly 7.2 percent of rural hospitals in the study closed their obstetric units. These units were smaller in size, more likely to be privately owned, and located in communities with lower family income, fewer obstetricians, and fewer family physicians. Prenatal care was still available in 17 of 19 communities, but local women would need to travel an average of 29 additional miles to access intrapartum care.
Rural obstetric unit closures are more common in smaller hospitals and communities with a limited obstetric workforce. Concerns about continuity of rural maternity care arise for women with local prenatal care but distant intrapartum care.
Assess the relative importance of proximity and other hospital characteristics in the choice of hospital for breast cancer surgery by race/ethnicity.
SEER-Medicare data.
Observational study of women aged >65 years receiving surgery for stage I/II/III breast cancer diagnosed in 1992–2007 in Detroit (N = 10,746 white/black), Atlanta (N = 4,018 white/black), Los Angeles (N = 9,433 white/black/Asian/Hispanic), and San Francisco (N = 4,856 white/black/Asian). We calculated the distance from each patient's census tract of residence to each area hospital. We estimated discrete choice models for the probability of receiving surgery at each hospital based on distance and assessed whether deviations from these predictions entailed interactions of hospital characteristics with the patient's race/ethnicity. We identified high-quality hospitals by rates of adjuvant radiation therapy and by survey measures of patient experiences, and we assessed how observed surgery rates at high-quality hospitals deviated from those predicted based on distance alone.
Proximity was significantly associated with hospital choice in all areas. Minority more often than white breast cancer patients had surgery at hospitals with more minority patients, those treating more Medicaid patients, and in some areas, lower quality hospitals.
Residential location alone does not explain concentration of racial/ethnic-minority breast cancer surgery patients in certain hospitals that are sometimes of lower quality.
Assess validity of the retrospective Dartmouth hospital referral region (HRR) end-of-life spending measures by comparing with health care expenditures from diagnosis to death for prospectively identified advanced lung cancer patients.
We calculated health care spending from diagnosis (2003–2005) to death or through 2011 for 885 patients aged ≥65 years with advanced lung cancer using Medicare claims. We assessed the association between Dartmouth HRR-level spending in the last 2 years of life and patient-level spending using linear regression with random HRR effects, adjusting for patient characteristics.
For each $1 increase in the Dartmouth metric, spending for our cohort increased by $0.74 (p < .001). The Dartmouth spending variable explained 93.4 percent of the HRR-level variance in observed spending.
HRR-level spending estimates for deceased patient cohorts reflect area-level care intensity for prospectively identified advanced lung cancer patients.
To examine the extent to which accountable care organizations (ACOs) formally incorporate postacute care providers.
The National Survey of ACOs (N = 269, response rate 66 percent).
We report statistics on ACOs' formal inclusion of postacute care providers and the organizational characteristics and clinical capabilities of ACOs that have postacute care.
Half of ACOs formally include at least one postacute service, with inclusion at higher rates in ACOs with commercial (64 percent) and Medicaid contracts (70 percent) compared to ACOs with Medicare contracts only (45 percent). ACOs that have a formal relationship with a postacute provider are more likely to have advanced transition management, end of life planning, readmission prevention, and care management capabilities.
Many ACOs have not formally engaged postacute care, which may leave room to improve service integration and care management.
To determine the effect of consumers' numeric abilities on the likelihood of owning private long-term care insurance.
The 2010 wave of the Health and Retirement Study, a nationally representative survey of Americans age 50 and older, was used (n = 12,796).
Multivariate logistic regression was used to isolate the relationship between numeracy and long-term care insurance ownership.
Each additional question answered correctly on a numeracy scale was associated with a 13 percent increase in the likelihood of holding LTCI, after controlling for predictors of policy demand, education, and cognitive function.
Poor numeracy may create barriers to long-term care insurance purchase. Policy efforts aimed at increasing consumer decision support or restructuring the marketplace for long-term care insurance may be needed to increase older adults' ability to prepare for future long-term care expenses.
Survival trend analyses examine mortality outcomes over time. The impact of conducting survival trend analyses without accounting for improved population survival has not been systematically studied.
The 1-year risk of death in the 100 most common hospital admissions for Ontario adults in 1994, 1999, 2004, and 2009 was determined. Generalized linear models were used to determine if adjusted death risk changed significantly over time with and without accounting for population survival.
The statistical significance of temporal trends in survival changed after accounting for population life expectancy in 16 diagnoses (16 percent) (in 13 of 55 diagnoses, statistically significant decreasing mortality trends became insignificant; in 3 of 15 diagnoses, insignificant trends changed to a significant increase in mortality risk over time).
These results highlight the importance of accounting for population life-expectancy changes in survival trend analyses.
To identify subgroups of U.S. children with special health care needs (CSHCN) and characterize key outcomes.
Secondary analysis of 2009–2010 National Survey of CSHCN.
Latent class analysis grouped individuals into substantively meaningful classes empirically derived from measures of pediatric medical complexity. Outcomes were compared among latent classes with weighted logistic or negative binomial regression.
LCA identified four unique CSHCN subgroups: broad functional impairment (physical, cognitive, and mental health) with extensive health care (Class 1), broad functional impairment alone (Class 2), predominant physical impairment requiring family-delivered care (Class 3), and physical impairment alone (Class 4). CSHCN from Class 1 had the highest ED visit rates (IRR 3.3, p < .001) and hospitalization odds (AOR: 12.0, p < .001) and lowest odds of a medical home (AOR: 0.17, p < .001). CSHCN in Class 3, despite experiencing more shared decision making and medical home attributes, had more ED visits and missed school than CSHCN in Class 2 (p < .001); the latter, however, experienced more cost-related difficulties, care delays, and parents having to stop work (p < .001).
Recognizing distinct impacts of cognitive and mental health impairments and health care delivery needs on CSHCN outcomes may better direct future intervention efforts.
To examine the effects of potentially inappropriate medication (PIM) use on health care outcomes in elderly individuals using an instrumental variable (IV) approach.
Representative claim data from the universal health insurance program in Taiwan from 2007 to 2010.
We employed a panel study design to examine the relationship between PIM and hospitalization. We applied both the naive generalized estimating equation (GEE) model, which controlled for the observed patient and hospital characteristics, and the two-stage residual inclusion (2SRI) GEE model, which further accounted for the unobserved confounding factors. The PIM prescription rate of the physician most frequently visited by each patient was used as the IV.
The naive GEE models indicated that patient PIM use was associated with a higher likelihood of hospitalization (odds ratio [OR], 1.399; 95 percent confidence interval [CI], 1.363–1.435). Using the physician PIM prescribing rate as an IV, we identified a stronger significant association between PIM and hospitalization (OR, 1.990; 95 percent CI, 1.647–2.403).
PIM use is associated with increased hospitalization in elderly individuals. Adjusting for unobserved confounders is needed to obtain unbiased estimates of the relationship between PIM and health care outcomes.