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--- - |2 Abstract Bayesian methods incorporate model parameter information prior to data collection. Eliciting information from content experts is an option, but has seen little implementation in Bayesian item response theory (IRT) modeling. This study aims to use ethical reasoning content experts to elicit prior information and incorporate this information into Markov Chain Monte Carlo (MCMC) estimation. A six‐step elicitation approach is followed, with relevant details at each stage for two IRT items parameters: difficulty and guessing. Results indicate that using content experts is the preferred approach, rather than noninformative priors, for both parameter types. The use of a noninformative prior for small samples provided dramatically different results when compared to results from content expert–elicited priors. The WAMBS (When to worry and how to Avoid the Misuse of Bayesian Statistics) checklist is used to aid in comparisons. - Journal of Educational Measurement, Volume 55, Issue 3, Page 373-402, Fall 2018.

--- - |2 Abstract This study investigates the effect of multidimensionality on extraction of latent classes in mixture Rasch models. In this study, two‐dimensional data were generated under varying conditions. The two‐dimensional data sets were analyzed with one‐ to five‐class mixture Rasch models. Results of the simulation study indicate the mixture Rasch model tended to extract more latent classes than the number of dimensions simulated, particularly when the multidimensional structure of the data was more complex. In addition, the number of extracted latent classes decreased as the dimensions were more highly correlated regardless of multidimensional structure. An analysis of the empirical multidimensional data also shows that the number of latent classes extracted by the mixture Rasch model is larger than the number of dimensions measured by the test. - Journal of Educational Measurement, Volume 55, Issue 3, Page 403-420, Fall 2018.

--- - |2 Abstract Person reliability parameters (PRPs) model temporary changes in individuals’ attribute level perceptions when responding to self‐report items (higher levels of PRPs represent less fluctuation). PRPs could be useful in measuring careless responding and traitedness. However, it is unclear how well current procedures for estimating PRPs can recover parameter estimates. This study assesses these procedures in terms of mean error (ME), average absolute difference (AAD), and reliability using simulated data with known values. Several prior distributions for PRPs were compared across a number of conditions. Overall, our results revealed little differences between using the χ or lognormal distributions as priors for estimated PRPs. Both distributions produced estimates with reasonable levels of ME; however, the AAD of the estimates was high. AAD did improve slightly as the number of items increased, suggesting that increasing the number of items would ameliorate this problem. Similarly, a larger number of items were necessary to produce reasonable levels of reliability. Based on our results, several conclusions are drawn and implications for future research are discussed. - Journal of Educational Measurement, Volume 55, Issue 3, Page 421-432, Fall 2018.

--- - |2 Abstract This research derived information functions and proposed new scalar information indices to examine the quality of multidimensional forced choice (MFC) items based on the RANK model. We also explored how GGUM‐RANK information, latent trait recovery, and reliability varied across three MFC formats: pairs (two response alternatives), triplets (three alternatives), and tetrads (four alternatives). As expected, tetrad and triplet measures provided substantially more information than pairs, and MFC items composed of statements with high discrimination parameters were most informative. The methods and findings of this study will help practitioners to construct better MFC items, make informed projections about reliability with different MFC formats, and facilitate the development of MFC triplet‐ and tetrad‐based computerized adaptive tests. - Journal of Educational Measurement, Volume 55, Issue 3, Page 357-372, Fall 2018.

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This study reviews the economic viability of the Rashtriya Swasthya Bima Yojana (RSBY), India's landmark health insurance program for below poverty line (BPL) populations in West Bengal state of India. It addresses the issue through in‐depth analysis of literature, national and state level data, and a number of key stakeholder interviews. The study argues that the market failure conditions of this insurance model will continue to perpetuate losses for not only the state, but also for insurance companies, unless they adjust on a continuous basis for profit by raising the premium rate. This will further deplete state budgets for health care affecting the viability of the scheme in the long run.

Objective To quantify the effect of Medicaid expansions on office‐based care among the newly eligible. Data Source 2008–2014 Medical Expenditure Panel Survey. Study Design The main sample is adults age 26–64 with incomes ≤138% of poverty who were not eligible for Medicaid prior to the Affordable Care Act. For this population, difference‐in‐differences linear probability models compare utilization between expansion and nonexpansion states and between 2008–2013 and 2014. Extraction Methods Medicaid eligibility is simulated using data on family relationships, state of residence, and income. Principal Findings Relative to comparable adults in nonexpansion states, newly eligible adults in expansion states were 9.1 percentage points more likely to have any office‐based primary care physician visit in 2014, a 21.4% increase from 2013 (p‐value = .004); 6.9 percentage points more likely to have a specialist visit, a 25.2% increase from 2013 (p‐value = .036); and 5.1 percentage points more likely to have a visit with a nurse practitioner, nurse, or physician assistant, a 34.5% increase from 2013 (p‐value = .016). Conclusions State Medicaid expansions in 2014 were associated with greater likelihoods of visits with a variety of office‐based providers. The estimated effects are larger among newly eligible compared with previous estimates on broader populations of low‐income adults.

Objective To explore organizations’ experiences providing family planning during the first year of an expanded primary care program in Texas. Data Sources Between November 2014 and February 2015, in‐depth interviews were conducted with program administrators at 30 organizations: 7 women's health organizations, 13 established primary care contractors (e.g., community health centers, public health departments), and 10 new primary care contractors. Study Design Interviews addressed organizational capacities to expand family planning and integrate services with primary care. Data Extraction Interview transcripts were analyzed using a theme‐based approach. Themes were compared across the three types of organizations. Principal Findings Established and new primary care contractors identified several challenges expanding family planning services, which were uncommon among women's health organizations. Clinicians often lacked training to provide intrauterine devices and contraceptive implants. Organizations often recruited existing clients into family planning services, rather than expanding their patient base, and new contractors found family planning difficult to integrate because of clients’ other health needs. Primary care contractors frequently described contraceptive provision protocols that were not evidence‐based. Conclusions Many primary care organizations in Texas initially lacked the capacity to provide evidence‐based family planning services that women's health organizations already provided.

The paper examines the value‐generating strategies used in some of New Zealand's primary activities in a rapidly changing trading context in which the countries of East Asia increasingly figure. These strategies range from scaling up volume, with a consequent conspicuous impact on rural landscapes, to innovative value‐enhancing relationships linking producers, processors and consumers in processes which value landscapes for the contribution they make to provenance stories. Our argument is that higher‐value strategies are necessarily more intensely collaborative and involve a pursuit of engaged relationships, especially between onshore producers and manufacturers and consumers at a distance. We term this collaborative form of strategising as ‘the relationships economy’. We illustrate our argument using two case studies, dairying and merino. While there are great differences in scale between them, and dairying focuses significantly on volume‐generating capacity, there are players in dairying who are adopting higher‐value relationships‐based approaches similar to those developed in the merino industry. The common thread connecting the case studies is that of intentional enactment, which echoes earlier periods in New Zealand's trading history when considerable work was undertaken by industry participants to create new markets for primary products.

The 2010 Affordable Care Act extended dependent coverage for adult children up to age 26 in the USA. Since then, considerable studies have assessed its various impacts among young adults. However, little is known about whether there is any change in health care use when young adults age out of dependent coverage. This study examines health care consumption changes among young adults prior to their aging out process. I used data from a large insurance claim database and studied health care utilization of young adults under parents' coverage during a 2‐year period in a difference‐in‐difference framework. I found that young adults had relative reductions in health services use, except ER visits, compared with individuals who stayed under parents' coverage. This pattern was the same for both male and females. Individuals with regular medical needs had greater relative reductions compared with those without regular medical needs. The relative reductions in health care use during the aging out process may have an important impact on young adults' health, especially for those with regular medical needs. More efforts could be made to help them maintain regular medical utilization during the transition.

Objective We examine whether drugs’ excluded versus recommended status on pharmacy benefit manager exclusion lists corresponds to evidence from cost‐effectiveness analyses, lack of evidence, or rebates. Data Sources To find cost‐effectiveness data for drugs on 2016 exclusion lists of CVS Caremark and Express Scripts, we searched the Tufts Cost‐Effectiveness Analysis Registry and the peer‐reviewed literature. Study Design For each excluded and recommended drug, we compared the mean cost‐per‐QALY, and we calculated the difference between the numbers of excluded and recommended drugs for which we could find no cost‐effectiveness evidence. Data Collection As keywords in our searches, we used the brand and generic drug name and “cost‐effectiveness” and “cost‐per‐quality‐adjusted life‐year.” Of 240 retrieved studies, 110 were selected for analysis. Principal Findings The mean cost‐per‐QALY for excluded drugs was higher ($51,611) than the cost‐per‐QALY for recommended drugs ($49,474), but not statistically significant. We could find no cost‐effectiveness evidence in the Registry or peer‐reviewed literature for 23 of the excluded drugs, and no evidence for 5 of the recommended drugs. Conclusions Cost‐effectiveness does not correlate with a drug's excluded or recommended status. Lack of cost‐effectiveness evidence favors a drug's excluded status.

Objective To build and test a model that predicts community discharge probabilities for Medicaid‐eligible nursing home (NH) residents who remain in the nursing home at 90 days after admission and, thus, would be candidates for the Money Follows the Person (MFP) program. Data Source The Minimum Data Set, Medicaid Management Information Systems, and Minnesota Vital Statistics file. Data Cohort of 33, 590 nursing home stays that qualified for Medicaid by the 90th day of their stay from 383 Minnesota nursing homes from July 2011 to June 2013. Study Design Mixed effects logistic regression model to predict community discharge. Principal Findings The scoring system had a high level of accuracy in predicting community discharge for both the fitting and validation cohorts. Subpopulations with severe mental illness or intellectual disability were well represented across the entire score range. Conclusions Findings are being applied in the Minnesota's MFP initiative (Moving Home Minnesota) to target Medicaid‐eligible NH residents for transitioning to the community. This approach could be applied to MFP in other states.

Objective To examine the effects of the penetration of dual‐eligible special needs plans (D‐SNPs) on health care spending. Data Sources/Study Setting Secondary state‐level panel data from Medicare‐Medicaid Linked Enrollee Analytic Data Source (MMLEADS) public use file and Special Needs Plan Comprehensive Reports, Area Health Resource Files, and Medicaid Managed Care Enrollment Report between 2007 and 2011. Study Design A difference‐in‐difference strategy that adjusts for dual‐eligibles’ demographic and socioeconomic characteristics, state health resources, beneficiaries’ health risk factors, Medicare/Medicaid enrollment, and state‐ and year‐fixed effects. Data Collection/Extraction Methods Data from MMLEADS were summarized from Centers for Medicare and Medicaid Services (CMS)'s Chronic Conditions Data Warehouse, which contains 100 percent of Medicare enrollment data, claims for beneficiaries who are enrolled in the fee‐for‐service (FFS) program, and Medicaid Analytic Extract files. The MMLEADS public use file also includes payment information for managed care. Data in Special Needs Plan Comprehensive Reports were from CMS's Health Plan Management System. Principal Findings Results indicate that D‐SNPs penetration was associated with reduced Medicare spending per dual‐eligible beneficiary. Specifically, a 1 percent increase in D‐SNPs penetration was associated with 0.2 percent reduction in Medicare spending per beneficiary. We found no association between D‐SNPs penetration and Medicaid or total spending. Conclusion Involving Medicaid services in D‐SNPs may be crucial to improve coordination between Medicare and Medicaid programs and control Medicaid spending among dual‐eligible beneficiaries. Starting from 2013, D‐SNPs were mandated to have contracts with state Medicaid agencies. This change may introduce new effects of D‐SNPs on health care spending. More research is needed to examine the impact of D‐SNPs on dual‐eligible spending.

This paper presents a copula‐based method for identifying and estimating the coefficient of a binary endogenous regressor in a Poisson regression. The method offers advantages over existing approaches. Most importantly, it relies upon standard maximum likelihood approaches, and it does not require numerical integration. Further, as part of its implementation, the method provides a convenient test for the presence of endogeneity. The empirical application investigates the effect of insurance status (a binary measure) on doctor visits (a count measure).

Despite its high political interest, the impact of removing user charges for health care in low‐income settings remains a debatable issue. We try to clear up this contentious issue by estimating the short‐term effects of a policy change that occurred in 2006 in Zambia, when 54 of 72 districts removed fees. We use a pooled synthetic control method in order to estimate the causal impact of the policy on health care use, the provider chosen, and out‐of‐pocket medical expenses. We find no evidence that user fee removal increased health care utilisation, even among the poorest group. However, we find that the policy is likely to have led to a substitution away from the private sector for those using care and that it virtually eliminated medical expenditures, thereby providing financial protection to service users. We estimate that the policy was equivalent to a transfer of US$3.2 per health visit for the 50% richest but of only US$1.1 for the 50% poorest.

Purpose This study examined the time from breast cancer diagnosis to initiation of treatment among Alaska Native (AN) women. We evaluated the impact of age, cancer stage, and rural/urban residence at diagnosis. Methods We evaluated characteristics of women recorded in the Alaska Native Tumor Registry who received a first diagnosis of breast cancer between 2009 and 2013. Median time from diagnosis to treatment was assessed. Associations of demographic and clinical characteristics with timely initiation of treatment were evaluated using logistic regression and Cox proportional hazards models. Results Two hundred seventy‐eight (278) AN women were diagnosed with invasive breast cancer in years 2009‐2013. Mean age at diagnosis was 56.8 years (SD = 13.0). The median time from diagnosis to initiation of treatment was 23 days (P < .05) with most (94.6%, n = 263) meeting the ≤60‐day guideline target. Time to treatment was not associated with rural/urban residence, age, or stage at cancer diagnosis. Conclusion These findings indicate that most AN women diagnosed with breast cancer within the AN Tribal Health System receive timely treatment after diagnosis.

Background Malaria is a major global health challenge. This study aims to clarify the manner in which contextual factors determine the use and maintenance of bed nets and the extent to which malaria prevention policy is responsive to them in Southern Benin. Methods Semi‐structured interviews and direct observations were undertaken with 30 pregnant women in the municipality of So‐Ava from June to August 2015. Key informants in the Ministry of Health and local community health workers were also interviewed regarding malaria prevention policy formation, and the monitoring and evaluation of bed net interventions, respectively. Data were analyzed through categorical content analysis and grouped into themes. Results The majority of pregnant women participants (80%) declared non‐adherence to instructions for hanging and maintaining insecticide‐treated nets (ITNs). The distributed bed nets were washed like clothes, which affected their bio‐efficacy, and were in poor condition (ie, torn or had holes). Multiple factors contributed to the poor condition of ITNs: Pregnant women's limited understanding of risk including their inability to connect the key environmental factors to personal risk, gendered responsibility for installing bed nets, and lack of public measures that would enable women to re‐treat or access new bed nets as needed. Poverty that determined structural aspects of housing such as the size and quality of homes and access to bed nets exacerbated the challenges. Conclusion Institutionalizing an iterative process of monitoring, review, and responsive adaptation throughout the entire policymaking cycle would better support malaria preventive policy implementation in Benin.

Introduction Administration is vital for health care. Its importance may increase as health care systems become more complex, but academic attention has remained minimal. We investigated trends in administrative expenditure across OECD countries, cross‐country spending differences, spending differences between health care system typologies, and differences in the scale and scope of administrative functions across typologies. Methods We used OECD data, which include health system governance and financing‐related administrative activities by regulators, governance bodies, and insurers (macrolevel), but exclude administrative expenditure by health care providers (mesolevel and microlevel). Results We find that governance and financing‐related administrative spending at the macrolevel has remained stable over the last decade at slightly over 3% of total health spending. Cross‐country differences range from 1.3% of health spending in Iceland to 8.3% in the United States. Voluntary private health insurance bears much higher administrative costs than compulsory schemes in all countries. Among compulsory schemes, multiple payers exhibit significantly higher administrative spending than single payers. Among single‐payer schemes, those where entitlements are based on residency have significantly lower administrative spending than those with single social health insurance, albeit with a small difference. Discussion These differences can partially be explained because multi‐payer and voluntary private health insurance schemes require additional administrative functions and enjoy less economies of scale. Studies in hospitals and primary care indicate similar differences in administrative costs across health system typologies at the mesolevel and microlevel of health care delivery, which warrants more research on total administrative costs at all the levels of health systems.

Background Few studies explore stroke survivor views and motivations towards stem cell therapy (SCT). This qualitative study explores the views and motivations of both stroke survivors and their partners/carers towards a proposed 2‐arm Phase III Randomised Controlled Trial (RCT) comparing intracerebral insertion of stem cells with placebo neurosurgery in stroke survivors with disability. Objective To explore views and motivations towards a proposed 2‐arm stem cell trial and identify factors that may impede and enhance participation. Design This study adopts a naturalistic design to explore the complexity of this field, employing a participatory action‐research approach comprising a specialized Conversation (World) Café form of focus group. Data were collected via 5 Conversation Cafés with stroke survivors (age 40‐75) and partners/carers between June and October 2016. Of 66 participants, 53 (31 male, 22 female) were stroke survivors and 13 (6 female, 7 male) were partners/carers. Qualitative data were analysed using a thematic approach. Discussion and Conclusion Stroke survivor views and motivations reflect anticipation of the personal and future benefits of regenerative medicine. Partners/carers sought to balance the value of stroke survivor hope with carrying the weight of hope as carer, a conflict burden adding to known caregiver burden. All participants expressed the need for during and post‐trial psychological support. This study provides a rare opportunity to explore the prospective views and motivations of stroke survivors and their partners/carers towards a proposed Phase III 2‐arm RCT. This adds weight to qualitative evidence exploring capacity, consent, decision making, perceptions of treatment risk and supports required for clinical trial participation.

Purpose To examine the relationship between area population density and community pharmacy‐based Alzheimer's Disease (AD)‐related services: pharmacists’ medication knowledge and counseling, immunizations, and in‐stock cognitive enhancers in 3 predominantly rural regions of the United States. Methods A standardized interview was administered by telephone to a 100% sample of community pharmacies in 3 areas: Northern California/Southern Oregon (n = 206), North and South Dakota (n = 278), and West Virginia (n = 420). Key study outcomes included: pharmacists’ medication knowledge, availability of immunization services, and cognitive enhancers in stock. Respondents were classified by population density (persons/mi2) by pharmacy location to evaluate the relationship between rurality and AD‐related pharmacy services. Chi‐squared and logistic regression analyses were performed using Stata 10.1. Findings Pharmacies in more rural areas (50.1‐100.0, 25.1‐50.0, and ≤25.0 persons/mi2) were about 50% less likely to offer immunizations (95% CI: 0.32‐0.91; 0.32‐0.76; 0.28‐0.80, respectively) compared to the least rural areas (>100.0 persons/mi2). Compared to the least rural areas, pharmacists in the most rural areas (≤25.0 persons/mi2) were less likely to name ≥2 gastrointestinal adverse effects of donepezil (OR = 0.50, 95% CI: 0.31‐0.82) or have memantine XR 28 mg (OR = 0.61, 95% CI: 0.41‐0.89) and other surveyed medications (OR = 0.57, 95% CI: 0.39‐0.82) in stock. Conclusions We found disparities in AD‐related services in community pharmacies located in more rural counties, wherein individuals with AD and their caregivers may face barriers to obtaining quality pharmaceutical care. There is a need to strengthen pharmacists’ knowledge and improve pharmacy services to reduce disparities.

A growing literature highlights complexity of policy implementation and governance in global health and argues that the processes and outcomes of policies could be improved by explicitly taking this complexity into account. Yet there is a paucity of studies exploring how this can be achieved in everyday practice. This study documents the strategies, tactics, and challenges of boundary‐spanning actors working in 4 Sub‐Saharan Africa countries who supported the implementation of multisectoral nutrition as part of the African Nutrition Security Partnership in Burkina Faso, Mali, Ethiopia, and Uganda. Three action researchers were posted to these countries during the final 2 years of the project to help the government and its partners implement multisectoral nutrition and document the lessons. Prospective data were collected through participant observation, end‐line semistructured interviews, and document analysis. All 4 countries made significant progress despite a wide range of challenges at the individual, organizational, and system levels. The boundary‐spanning actors and their collaborators deployed a wide range of strategies but faced significant challenges in playing these unconventional roles. The study concludes that, under the right conditions, intentional boundary spanning can be a feasible and acceptable practice within a multisectoral, complex adaptive system in low‐ and middle‐income countries.

A trend of the shortening duration of pregnancies carried to term has been observed in several countries and represents a growing public health concern. This paper describes the trend in the Czech Republic and shows its relation to the changing demographic structure of mothers and the organisation of maternity care. Data from the birth register are used and supplemented with information about the capacity of maternity care (number of beds at maternity clinics, number of obstetricians and midwives). Logistic regression is used to estimate the odds of 37 to 39 vs 40+ completed weeks of gestation. The results show that the average gestational age at term decreased by 2.1 days between 2000 and 2013. The odds of 37 to 39 weeks of gestational duration increased, mainly due to the reduction in the number of beds at maternity clinics (adjusted odds ratio of 1.51). The effects of the number of health care staff members were weaker. The number of midwives positively influenced gestational duration, while the number of obstetricians had a negative effect. Maternal demographic structure cannot explain the trend. A likely explanation is the increased use of planned early term caesarean sections.

Background Social network processes impact on the genesis and management of mental health problems. There is currently less understanding of the way people negotiate networked relationships in times of crisis compared to how they manage at other times. Objective This paper explores the patterns and nature of personal network involvement at times of crises and how these may differ from day‐to‐day networks of recovery and maintenance. Method Semi‐structured interviews with 25 participants with a diagnosis of long‐term mental health (MH) problems drawn from recovery settings in the south of England. Interviews centred on personal network mapping of members and resources providing support. The mapping interviews explored the work of network members and changes in times of crisis. Interviews were recorded, transcribed and analysed using a framework analysis. Results Three key themes were identified: the fluidity of network relationality between crisis and recovery; isolation as a means of crises management; leaning towards peer support. Personal network input retreated at times of crisis often as result of “ejection” from the network by participants who used self‐isolation as a personal management strategy in an attempt to deal with crises. Peer support is considered useful during a crisis, whilst the role of services was viewed with some ambiguity. Conclusions Social networks membership, and type and depth of involvement, is subject to change between times of crisis and everyday support. This has implications for managing mental health in terms of engaging with network support differently in times of crises versus recovery and everyday living.

In April 2005, Lucio Gutiérrez was removed from office in the context of a fast‐growing economy. With no economic hardship to fuel social outrage, the failure of Gutiérrez illustrates how political and institutional factors can be the most important forces determining presidential survival. In this article, we qualitatively analyse the path toward confrontation between Gutiérrez and the congressional opposition which led to his political demise. We find that Ecuador's weak democratic tradition working through more proximate causes – radicalism, normative preference for democratic institutions and a negative institutional equilibrium – coupled with other institutional and political variables accelerated Lucio Gutiérrez's fall from power.

Objectives To investigate the association between hospital safety culture and 30‐day risk‐adjusted mortality for Medicare patients with acute myocardial infarction (AMI) in a large, diverse hospital cohort. Subjects The final analytic cohort consisted of 19,357 Medicare AMI discharges (MedPAR data) linked to 257 AHRQ Hospital Survey on Patient Safety Culture surveys from 171 hospitals between 2008 and 2013. Study Design Observational, cross‐sectional study using hierarchical logistic models to estimate the association between hospital safety scores and 30‐day risk‐adjusted patient mortality. Odds ratios of 30‐day, all‐cause mortality, adjusting for patient covariates, hospital characteristics (size and teaching status), and several different types of safety culture scores (composite, average, and overall) were determined. Principal Findings No significant association was found between any measure of hospital safety culture and adjusted AMI mortality. Conclusions In a large cross‐sectional study from a diverse hospital cohort, AHRQ safety culture scores were not associated with AMI mortality. Our study adds to a growing body of investigations that have failed to conclusively demonstrate a safety culture–outcome association in health care, at least with widely used national survey instruments.

Due to its fast economic growth and lifestyle changes, China is experiencing a rapid epidemiological transition from communicable to noncommunicable diseases (NCDs). Mental disorder such as depression is an important yet often neglected NCD and is becoming a growing cause of disability, suicides, and disease burden. This paper provides the first nationally representative estimate of the medical cost attributable to depression and depressive symptoms among the adult population in China. On the basis of the 2012 China Family Panel Studies survey, our results indicate that these mental health conditions have significant impacts on the individual medical expenditure, and they jointly contribute to 14.7% of total personal expected medical spending in China, with depression and depressive symptoms accounting for 6.9% and 7.8%, respectively. Given that patients with mental illness face multiple psychological and institutional barriers in seeking appropriate treatment, the high depression‐induced medical costs may be primarily driven by the cost‐shifting effect from mental health care to general health care, as mental disorders often coexist with other NCDs such as diabetes and hypertension. As an implication, our study calls for an urgent reform of China's mental health and insurance systems to remove the policy‐induced obstacles for the access to mental health care resources.

Aims The aim of the study is to verify the knowledge and practices of health professionals working in prenatal care (PNC) related with syphilis during pregnancy and to identify the main barriers to the implementation of protocols for the control of this disease. Methods A cross‐sectional study in Teresina, Brazil, from January to May 2015, was conducted with 366 physicians and nurses working in PNC, corresponding to 70% of eligible professionals. We evaluated 20 knowledge and practice criteria related to the diagnosis and treatment of syphilis during pregnancy with a 95% compliance standard. We performed descriptive analysis of the data and used χ2 statistical test to verify differences according to professional category. Results Only 2 criteria, “knowledge about mother to child transmission according to gestational age” and “counselling on infection,” reached 95% compliance. Knowledge of the epidemiological profile of congenital syphilis and the goal of elimination of congenital syphilis and knowledge about serological tests had scores below 50%, while practices related with posttest counselling, cure control, and treatment of partners reached 60%. We identified organisational barriers related to the late initiation of PNC, to the delayed return of syphilis test results, to the application of benzathine penicillin in primary care units and to the treatment of partners. Conclusions Strategies for early initiation of PNC, implementation of rapid tests for syphilis, ensuring treatment of pregnant women with penicillin, adequate partner treatment, and continued education of health professionals on clinical management and counselling in sexually transmitted diseases are necessary to eliminate congenital syphilis.

Background Patient engagement in research (PEIR) is promoted to improve the relevance and quality of health research, but has little conceptualization derived from empirical data. Objective To address this issue, we sought to develop an empirically based conceptual framework for meaningful PEIR founded on a patient perspective. Methods We conducted a qualitative secondary analysis of in‐depth interviews with 18 patient research partners from a research centre‐affiliated patient advisory board. Data analysis involved three phases: identifying the themes, developing a framework and confirming the framework. We coded and organized the data, and abstracted, illustrated, described and explored the emergent themes using thematic analysis. Directed content analysis was conducted to derive concepts from 18 publications related to PEIR to supplement, confirm or refute, and extend the emergent conceptual framework. The framework was reviewed by four patient research partners on our research team. Results Participants’ experiences of working with researchers were generally positive. Eight themes emerged: procedural requirements, convenience, contributions, support, team interaction, research environment, feel valued and benefits. These themes were interconnected and formed a conceptual framework to explain the phenomenon of meaningful PEIR from a patient perspective. This framework, the PEIR Framework, was endorsed by the patient research partners on our team. Conclusions The PEIR Framework provides guidance on aspects of PEIR to address for meaningful PEIR. It could be particularly useful when patient‐researcher partnerships are led by researchers with little experience of engaging patients in research.

Little is known about the response of physicians to changes in compensation: Do increases in compensation increase or decrease labour supply? In this paper, we estimate wage elasticities for physicians. We apply both a structural discrete choice approach and a reduced‐form approach to examine how these different approaches affect wage elasticities at the intensive margin. Using uniquely rich data collected from a large sample of general practitioners (GPs) and specialists in Australia, we estimate 3 alternative utility specifications (quadratic, translog, and box‐cox utility functions) in the structural approach, as well as a reduced‐form specification, separately for men and women. Australian data is particularly suited for this analysis due to a lack of regulation of physicians' fees leading to variation in earnings. All models predict small negative wage elasticities for male and female GPs and specialists passing several sensitivity checks. For this high‐income and long‐working‐hours population, the translog and box‐cox utility functions outperform the quadratic utility function. Simulating the effects of 5% and 10% wage increases at the intensive margin slightly reduces the full‐time equivalent supply of male GPs, and to a lesser extent of male specialists and female GPs.

Evidence about cost‐effectiveness is increasingly being used to inform decisions about the funding of new technologies that are usually implemented as guidelines from centralized decision‐making bodies. However, there is also an increasing recognition for the role of patients in determining their preferred treatment option. This paper presents a method to estimate the value of implementing a choice‐based decision process using the cost‐effectiveness analysis toolbox. This value is estimated for 3 alternative scenarios. First, it compares centralized decisions, based on population average cost‐effectiveness, against a decision process based on patient choice. Second, it compares centralized decision based on patients' subgroups versus an individual choice‐based decision process. Third, it compares a centralized process based on average cost‐effectiveness against a choice‐based process where patients choose according to a different measure of outcome to that used by the centralized decision maker. The methods are applied to a case study for the management of acute coronary syndrome. It is concluded that implementing a choice‐based process of treatment allocation may be an option in collectively funded health systems. However, its value will depend on the specific health problem and the social values considered relevant to the health system.

Many high utilizers of the emergency department (ED) have public insurance, especially through Medicaid. We evaluated how participation in Bridges to Care (B2C)—an ED-initiated, multidisciplinary, community-based program—affected subsequent ED use, hospital admissions, and primary care use among publicly insured or Medicaid-eligible high ED utilizers. During the six months after the B2C intervention was completed, participants had significantly fewer ED visits (a reduction of 27.9 percent) and significantly more primary care visits (an increase of 114.0 percent), compared to patients in the control group. In a subanalysis of patients with mental health comorbidities, we found that recipients of B2C services had significantly fewer ED visits (a reduction of 29.7 percent) and hospitalizations (30.0 percent), and significantly more primary care visits (an increase of 123.2 percent), again compared to patients in the control group. The B2C program reduced acute care use and increased the number of primary care visits among high ED utilizers, including those with mental health comorbidities.

Freestanding emergency departments (EDs) are a relatively novel phenomenon, and the epicenter of this movement is in Texas. Limited evidence exists about the communities in which freestanding EDs locate or the possible reasons behind location choice. We estimated logistic regressions to determine whether freestanding EDs in 2016 were more likely to be in areas of high demand or in those that could yield high profits. When we compared Public Use Microdata Areas that contained freestanding EDs and those that did not, we found that areas with such EDs had significantly higher household incomes. This finding was driven by the location choices of independent freestanding emergency centers and not by those of hospital-affiliated satellite emergency centers.

Many frequent emergency department (ED) users do not sustain high use over time, which makes it difficult to create targeted interventions to address their health needs. We performed a retrospective analysis of nonelderly adult frequent ED users in California to measure the persistence of frequent ED use in the period 2005–15, describe characteristics of persistent and nonpersistent frequent users, and identify predictors of persistent frequent use. Of the frequent ED users in 2005, 30.5 percent remained frequent users in 2006. A small but nontrivial population (16.5 percent, 5.7 percent, and 1.9 percent) exhibited persistent frequent use for three, six, and eleven consecutive years, respectively. The strongest predictor of persistent frequent ED use was the intensity of ED use in the baseline study year. The rate at which frequent users stopped using the ED frequently decreased over time, leaving a core group of chronic persistent users. These persistent frequent users differ from nonpersistent frequent users, who engaged in temporary intense use of the ED. Identifying and differentiating persistent frequent users is important, as they may be candidates for distinct interventions.

Firearm-related deaths are the third leading cause of injury-related deaths in the United States. Yet limited data exist on contemporary epidemiological trends and risk factors for firearm-related injuries. Using data from the Nationwide Emergency Department Sample, we report epidemiological trends and quantify the clinical and financial burden associated with emergency department (ED) visits for firearm-related injuries. We identified 150,930 patients—representing a weighted total of 704,916 patients nationally—who presented alive to the ED in the period 2006–14 with firearm-related injuries. Such injuries were approximately nine times more common among male than female patients and highest among males ages 20–24. Of the patients who presented alive to the ED, 37.2 percent were admitted to inpatient care, while 8.3 percent died during their ED visit or inpatient admission. The mean per person ED and inpatient charges were $5,254 and $95,887, respectively, resulting in an annual financial burden of approximately $2.8 billion in ED and inpatient charges. Although future research is warranted to better understand firearm-related injuries, policy makers might consider implementing universal background checks for firearm purchases and limiting access to firearms for people with a history of violence or previous convictions to reduce the clinical and financial burden associated with these injuries.

We examined prevalence, treatment patterns, trends, and correlates of mental health and substance use treatments among adults with co-occurring disorders. Our data were from the 325,800 adults who participated in the National Survey on Drug Use and Health in the period 2008–14. Approximately 3.3 percent of the US adult population, or 7.7 million adults, had co-occurring disorders during the twelve months before the survey interview. Among them, 52.5 percent received neither mental health care nor substance use treatment in the prior year. The 9.1 percent who received both types of care tended to have more serious psychiatric problems and physical comorbidities and to be involved with the criminal justice system. Rates of receiving care only for mental health, receiving treatment only for substance use, and receiving both types of care among adults with co-occurring disorders remained unchanged during the study period. Low perceived need and barriers to care access for both disorders likely contribute to low treatment rates of co-occurring disorders. Future studies are needed to improve treatment rates among this population.

Forty-six states and the District of Columbia have enacted insurance mandates that require commercial insurers to cover treatment for children with autism spectrum disorder (ASD). This study examined whether implementing autism mandates altered service use or spending among commercially insured children with ASD. We compared children age twenty-one or younger who were eligible for mandates to children not subject to mandates using 2008–12 claims data from three national insurers. Increases in service use and spending attributable to state mandates were detected for all outcomes. Mandates were associated with a 3.4-percentage-point increase in monthly use and a $77 increase in monthly spending on ASD-specific services. Effects were larger for younger children and increased with the number of years since mandate implementation. These increases suggest that state mandates are an effective tool for broadening access to autism treatment under commercial insurance.

Enrollment in high-deductible health plans (HDHPs) has greatly increased in recent years. Policy makers and other stakeholders need the best available evidence about how these plans may affect health care cost and utilization, but the literature has not been comprehensively synthesized. We performed a systematic review of methodologically rigorous studies that examined the impact of HDHPs on health care utilization and costs. The plans were associated with a significant reduction in preventive care in seven of twelve studies and a significant reduction in office visits in six of eleven studies—which in turn led to a reduction in both appropriate and inappropriate care. Furthermore, bivariate analyses of data extracted from the included studies suggested that the plans may be associated with a reduction in appropriate preventive care and medication adherence. Current evidence suggests that HDHPs are associated with lower health care costs as a result of a reduction in the use of health services, including appropriate services.

We examined the impact of California’s early Medicaid expansion under the Affordable Care Act on the use of payday loans, a form of high-interest borrowing used by low- and middle-income Americans. Using a data set for the period 2009–13 (roughly twenty-four months before and twenty-four months after the 2011–12 Medicaid expansion) that covered the universe of payday loans from five large payday lenders with locations around the United States, we used a difference-in-differences research design to assess the effect of the expansion on payday borrowing, comparing trends in early-expansion counties in California to those in counties nationwide that did not expand early. The early Medicaid expansion was associated with an 11 percent reduction in the number of loans taken out each month. It also reduced the number of unique borrowers each month and the amount of payday loan debt. We were unable to determine precisely how and for whom the expansion reduced payday borrowing, since to our knowledge, no data exist that directly link payday lending to insurance status. Nonetheless, our results suggest that Medicaid reduced the demand for high-interest loans and improved the financial health of American families.

There are 16.9 million Americans living in poverty in the suburbs—more than in cities or rural communities. Despite recent increases in suburban poverty, the perception of the suburbs as areas of uniform affluence remains, and there has been little research into health care barriers experienced by people living in these areas. The objectives of this study were to compare patterns of insurance coverage and health care access in suburban, urban, and rural areas using national survey data from 2005 to 2015 and to compare outcomes by geography before and after the Affordable Care Act took effect. We found that nearly 40 percent of the uninsured population lived in suburban areas. Though unadjusted rates of health care access were better in suburban areas, compared to urban and rural communities, this advantage was greatly reduced after income and other demographics are accounted for. Overall, a substantial portion of the US population residing in the suburbs lacked health insurance and experienced difficulties accessing care. Increased policy attention is needed to address these challenges for vulnerable populations living in the suburbs.

Previous studies suggest that members of sexual minority groups have poorer access to health services than heterosexuals. However, few studies have examined how sexual orientation interacts with gender and race to affect health care experience. Moreover, little is known about the role in health care disparities played by economic strains such as unemployment and poverty, which may result from prejudice and discrimination based on sexual orientation. Using data for 2013–15 from the National Health Interview Survey, we found that most members of sexual minority groups no longer have higher uninsurance rates than heterosexuals, but many continue to experience poorer access to high-quality care. Gay nonwhite men, bisexual white women, and bisexual and lesbian nonwhite women are disadvantaged in multiple aspects of access, compared to straight white men. Only some of these disparities are attributable to economic factors, which implies that noneconomic barriers to care are substantial. Our results suggest that the intersection of multiple social identities can reveal important gaps in health care experience. Making culturally sensitive services available may be key to closing the gaps.

Through communication-and-resolution programs, hospitals and liability insurers communicate with patients when adverse events occur; investigate and explain what happened; and, where appropriate, apologize and proactively offer compensation. Using data recorded by program staff members and from surveys of involved clinicians, we examined case outcomes of a program used by two academic medical centers and two of their community hospitals in Massachusetts in the period 2013–15. The hospitals demonstrated good adherence to the program protocol. Ninety-one percent of the program events did not meet compensation eligibility criteria, and those events that did were not costly to resolve (the median payment was $75,000). Only 5 percent of events led to malpractice claims or lawsuits. Clinicians were supportive of the program but desired better communication about it from staff members. Our findings suggest that communication-and-resolution programs will not lead to higher liability costs when hospitals adhere to their commitment to offer compensation proactively.

To better understand how clinicians’ job satisfaction relates to work conditions and outcomes for clinicians and patients, we examined data from the Healthy Work Place trial. Data were collected from physicians and advanced practice providers at baseline and approximately one year later. At baseline, 74 percent of respondents indicated job satisfaction. Satisfaction was associated with less chaos, more cohesion, better communication, and closer values alignment at work, but not with higher-quality care or fewer medical errors. At follow-up, the respondents with satisfaction data then and at baseline who indicated increased satisfaction (16 percent of these respondents) were almost three times more likely to report improved burnout scores and over eight times as likely to indicate reduced intention to leave their practices, compared to the clinicians whose satisfaction did not increase. These findings confirm that clinicians’ job satisfaction is related to remediable work conditions and suggest that it may be an important metric for clinical practices and practice organizations.

Achieving an interoperable health care system remains a top US policy priority. Despite substantial efforts to encourage interoperability, the first set of national data in 2014 suggested that hospitals’ engagement levels were low. With 2015 data now available, we examined the first national trends in engagement in four domains of interoperability: finding, sending, receiving, and integrating electronic patient information from outside providers. We found small gains, with 29.7 percent of hospitals engaging in all four domains in 2015 compared to 24.5 percent in 2014. The two domains with the most progress were sending (with an increase of 8.1 percentage points) and receiving (an increase of 8.4 percentage points) information, while there was no change in integrating systems. Hospitals’ use for patient care of data from outside providers was low, with only 18.7 percent of hospitals reporting that they "often" used these data. Our results reveal that hospitals’ progress toward interoperability is slow and that progress is focused on moving information between hospitals, not on ensuring usability of information in clinical decisions.

The effects of health insurance on poverty have been difficult to ascertain because US poverty measures have not taken into account the need for health care and the value of health benefits. We developed the first US poverty measure to include the need for health insurance and to count health insurance benefits as resources available to meet that need—in other words, a health-inclusive poverty measure. We estimated the direct effects of health insurance benefits on health-inclusive poverty for people younger than age sixty-five, comparing the impacts of different health insurance programs and of nonhealth means-tested cash and in-kind benefits, refundable tax credits, and nonhealth social insurance programs. Private health insurance benefits reduced poverty by 3.7 percentage points. Public health insurance benefits (from Medicare, Medicaid, and Affordable Care Act premium subsidies) accounted for nearly one-third of the overall poverty reduction from public benefits. Poor adults with neither children nor a disability experienced little poverty relief from public programs, and what relief they did receive came mostly from premium subsidies and other public health insurance benefits. Medicaid had a larger effect on child poverty than all nonhealth means-tested benefits combined.

The annual Kaiser Family Foundation/Health Research and Educational Trust Employer Health Benefits Survey found that in 2017, average annual premiums (employer and worker contributions combined) rose 4 percent for single coverage, to $6,690, and 3 percent for family coverage, to $18,764. Covered workers contributed 18 percent of the premium for single coverage and 31 percent for family coverage, on average, although there was considerable variation around these averages. For covered workers in small firms, 10 percent did not make a premium contribution for family coverage, while 36 percent made a contribution of more than half of their premium. The average worker contribution for family coverage has increased from $4,316 in 2012 to $5,714 in 2017. The share of firms that offered health benefits (53 percent) and of workers in those firms covered by their employers’ plans (62 percent) remain statistically unchanged from 2016.

Objective To estimate whether the incidence of low birthweight and rates of infant mortality were associated with Massachusetts health reform in the overall population and for subgroups that are at higher risk for poor health outcomes. Data Sources Individual‐level data on birthweight were obtained from the National Center for Health Statistics detailed natality files, and aggregated county‐level mortality rates were generated from linked birth–death files. We used restricted versions of each file that had intact state and substate geographic identifiers. Research Design We employed a quasi‐experimental difference‐in‐differences design. Principal Results We found small and statistically nonsignificant associations between the reform and the incidence of low birthweight and infant mortality rates. Results were consistent across a number of subgroups and were robust to alternative comparison groups and alternative modeling assumptions. Conclusions We found no evidence that the Massachusetts reform was associated with improvements in individual low birthweights or county‐level infant mortality rates, despite increasing health insurance coverage rates for adult women of child‐bearing age. Because our mortality analysis was ecological, we are not able to draw conclusions about how an individual‐level health insurance intervention for uninsured pregnant women would affect the mortality outcomes of their infants.

Background In 2015, 27.5% of births in England and Wales were to mothers born outside of the UK. Compared to their White British peers, minority ethnic and migrant women are at a significantly higher risk of maternal and perinatal mortality, along with lower maternity care satisfaction. Existing literature highlights the importance of midwife–woman relationships in care satisfaction and pregnancy outcomes; however, little research has explored midwife–woman relationships for migrant and minority ethnic women in the UK. Methods A focused ethnography was conducted in South Wales, UK, including semi‐structured interviews with 9 migrant Pakistani participants and 11 practising midwives, fieldwork in the local migrant Pakistani community and local maternity services, observations of antenatal appointments, and reviews of relevant media. Thematic data analysis was undertaken concurrently with data collection. Findings The midwife–woman relationship was important for participants' experiences of care. Numerous social and ecological factors influenced this relationship, including family relationships, culture and religion, differing health‐care systems, authoritative knowledge and communication of information. Marked differences were seen between midwives and women in the perceived importance of these factors. Conclusions Findings provide new theoretical insights into the complex factors contributing to the health‐care expectations of pregnant migrant Pakistani women in the UK. These findings may be used to create meaningful dialogue between women and midwives, encourage women's involvement in decisions about their health care and facilitate future midwifery education and research. Conclusions are relevant to a broad international audience, as achieving better outcomes for migrant and ethnic minority communities is of global concern.

The subsidisation of mosquito nets has been widely used to increase ownership in countries where malaria represents a public health problem. However, an important question that has not been addressed empirically is how far net subsidy programmes increase ownership above the level that would have prevailed in the absence of the subsidy (i.e., incremental ownership). This study addresses that gap by investigating the impact of a large‐scale mosquito net voucher subsidy––the Tanzania National Voucher Scheme (TNVS)––on short‐term demand for unsubsidised commercial nets, estimating a household demand model with nationally representative household survey data. The results suggest that, despite the TNVS using a categorical targeting approach that did not discriminate by wealth, it still led to a large increase in incremental ownership of mosquito nets, with limited evidence of displacement of unsubsidised sales. Although no evidence is found of an additional TNVS voucher decreasing the number of unsubsidised sales in the same period, results indicate that an additional TNVS voucher reduced the probability of purchasing any unsubsidised net in the same period by 14%. The findings also highlight the critical role played by social learning or campaign messaging in increasing mosquito net ownership.

Although healthcare provider payments have been studied extensively in the literature, little is known about the optimal compensation rule when, in addition to unobservable provider effort (moral hazard), the provider's ability type is also private information (adverse selection). We find that when only provider effort is unobservable, to induce the first‐best outcome the optimal compensation rule requires zero fee‐for‐service. When both provider moral hazard and adverse selection exist, the first‐best outcome will be infeasible. The second‐best compensation rule entails combined use of capitation, fee‐for‐service, and pay‐for‐performance.

Background Engagement of the public in defining and shaping the organization and delivery of health care is increasingly viewed as integral to improving quality and promoting transparent decision making. Meaningful engagement of the public in health‐care reform is predicated on shifting entrenched power imbalances between health‐care systems and those it claims to serve. Objectives To describe the expressions, forms and spaces of power from the perspectives of persons who participated as Patient/Family Advisors (PFAs) in Rapid Process Improvement Workshops (RPIWs) within Saskatchewan, Canada. Methods Using a qualitative, interpretive approach, in‐depth interviews were conducted with a purposive sample of 18 PFAs who had participated in at least one RPIW over the past year. Deductive thematic analysis was informed by Gaventa's model of power. Results Motivations for serving as a PFA included a sense of obligation to contribute to the improvement of a public system, recognition of their rights as citizens within a publicly funded system and an opportunity to openly express their concerns where previous encounters had been very negative. The invited spaces of the RPIWs were created by policymakers to accord visible power to PFAs. Participation resulted in PFAs gaining new insights into the structure and operations of the system, affirmation of their right to advocate and recognition of the potential to claim spaces of power as consumers. Advisement on specific health‐care initiatives using the vehicle of PFAs shaped and promoted new forms and spaces of power, representing one step in a very long road to full engagement of consumers in health care.