Most recent papers:

• Health Insurance Type and Lung Cancer Stage Shift Following Coverage of Screening.
  Min Lian, Timothy McBride, Benjamin Kozower, Maria Baggstrom, Ying Liu.
  Health Services Research. 5 days ago
  ["Health Services Research, Volume 61, Issue 4, August 2026. ", "\nABSTRACT\n\nObjective\nTo examine the role of insurance coverage of lung cancer screening in driving shifts in lung cancer stage at diagnosis.\n\n\nStudy Setting and Design\nWe performed difference‐in‐differences (DID) analyses to compare changes in the proportion of early‐stage lung cancer diagnosis between pre‐coverage (2007–2014) and post‐coverage (2015–2019) periods across insurance groups.\n\n\nData Sources and Analytic Sample\nUsing the National Cancer Institute's Surveillance, Epidemiology, and End Results database, we identified patients with non‐small cell lung cancer aged 55–77 years and diagnosed between 2007 and 2019. Health insurance at diagnosis was categorized as private, Medicare (fee‐for‐service [FFS], FFS with supplemental private coverage, FFS with Medicaid, and Medicare Advantage with and without Medicaid), Medicaid (FFS and managed care), military health plans, and uninsured.\n\n\nPrincipal Findings\nAmong 227,112 patients, 63,676 (28.04%) had private insurance, 130,770 (57.58%) Medicare, 14,982 (6.60%) Medicaid, 5941 (2.62%) military health insurance, and 11,743 (5.17%) were uninsured. Compared with uninsured patients, a significantly greater increase in the proportion of early‐stage lung cancer diagnosis between pre‐coverage and post‐coverage periods was observed among Medicaid patients (DID = 2.88 percentage points [ppt], 95% CI 0.73–5.02 ppt), but not patients with private insurance, Medicare, or military health insurance. Among Medicaid beneficiaries, those in managed care showed a significantly greater shift compared with those in FFS during 4–5 years post‐coverage (DID = 8.22 ppt, 95% CI 4.51–11.93 ppt). Among Medicare FFS beneficiaries, dual enrollment in Medicaid was associated with a significantly smaller increase in the proportion of early‐stage diagnosis compared with FFS‐only enrollment during 4–5 years post‐coverage (DID = −4.40 ppt, 95% CI [−6.40]–[−2.40] ppt).\n\n\nConclusions\nThe results suggest that beneficial stage shifts following the recommendation for lung cancer screening varied by health insurance status and type. Addressing patient, provider, and system‐level barriers to lung cancer screening and downstream care is essential to translate lung cancer screening coverage into earlier‐stage diagnosis.\n\n"]

  August 04, 2026   doi: 10.1111/1475-6773.70154   open full text
• Impact of VA‐Purchased Community Care on Polypharmacy and Potentially Inappropriate Medication Use in Older Adult Veterans.
  Catherine S. Hwang, Eric T. Roberts, Florentina E. Sileanu, Yaming Li, Carolyn T. Thorpe, Maria K. Mor, Thomas R. Radomski, John Cashy, Aaron L. Schwartz, Katie J. Suda, Loren J. Schleiden, Timothy S. Anderson, Megan E. Vanneman, Walid F. Gellad.
  Health Services Research. 7 days ago
  ["Health Services Research, Volume 61, Issue 4, August 2026. ", "\nABSTRACT\n\nObjective\nTo investigate whether eligibility for Veterans Health Administration (VA)‐purchased community care, which expanded Veterans' access to care outside VA, was associated with increased polypharmacy or potentially inappropriate medication use among older adult Veterans.\n\n\nStudy Setting and Design\nRegression discontinuity design, leveraging the distance threshold for community care eligibility (residing > 40 miles from the nearest VA facility with ≥ 1 or more full‐time primary care physician), to examine the effects of community care eligibility on polypharmacy and potentially inappropriate medication use among Veterans aged ≥ 65 years.\n\n\nData Sources and Analytic Sample\nVA pharmacy data for all prescriptions filled at VA facilities, VA Program Integrity Tool files for prescriptions paid by VA and filled in community pharmacies, and Medicare Part D data. Analyses included annual cross‐sectional samples of Veterans 36–39 miles or 41–44 miles from their nearest VA facility during FY 2016–2019.\n\n\nPrincipal Findings\nThe sample included 399,250 Veteran‐year observations, of which 226,157 (56.6%) were 36–39 miles and 173,093 (43.4%) were 41–44 miles from the nearest eligible VA facility. Overall, we observed no discontinuities across the 40‐mile threshold in the number of unique medications filled annually (−0.06 medications; 95% confidence interval [CI], −0.15 to 0.03). There were no discontinuities in proportions of Veterans filling ≥ 5 unique medications (−0.25 percentage points [pp]; 95% CI, −0.84 to 0.34), ≥ 10 medications (−0.55 pp.; 95% CI, −1.24 to 0.14), ≥ 1 medication on the Beers list (−0.02 pp.; 95% CI, −0.63 to 0.59), or ≥ 1 high‐risk drug–drug interaction (−0.05 pp.; 95% CI, −0.17 to 0.07). Among Veterans with mental health conditions, exceeding the 40‐mile threshold was associated with a higher likelihood of filling ≥ 10 unique medications annually (2.06 pp.; 95% CI, 0.42 to 3.70). We did not observe clinically or statistically significant discontinuities in other subgroups.\n\n\nConclusions\nOverall, eligibility for VA‐purchased community care was not associated with increased polypharmacy or potentially inappropriate medication use among older adult Veterans.\n\n"]

  August 02, 2026   doi: 10.1111/1475-6773.70152   open full text
• The Economic Toll of Inequitable Dental Care Access: A Welfare Analysis of Racial and Ethnic Disparities.
  Chunxi Guo, John A. Rizzo.
  Health Services Research. 9 days ago
  ["Health Services Research, Volume 61, Issue 4, August 2026. ", "\nABSTRACT\n\nObjective\nTo conduct a formal welfare analysis quantifying the economic costs of racial and ethnic disparities in dental care access among Hispanic and non‐Hispanic Black, Asian, and multiracial adults relative to non‐Hispanic White individuals in the United States.\n\n\nStudy Setting and Design\nCross‐sectional, observational study using pooled nationally representative data from the 2014 to 2023 Medical Expenditure Panel Survey (MEPS). Two‐part models were employed: generalized linear model (GLM) with log link for the probability of any dental visit and generalized linear gamma regression models with log link for modeling visit frequency, total annual expenditures, and expenditure per visit among users.\n\n\nData Sources\nMEPS Full‐Year Consolidated Data Files, 2014–2023. The final pooled cross‐sectional analytic sample included 205,894 respondents aged 18 and older, representing a survey‐weighted annual population of 251,029,718 US adults. Dollar figures are in constant 2023 US dollars.\n\n\nPrincipal Findings\nAll examined minority groups experienced lower dental care access and higher expenditure per visit compared with White individuals. Estimated aggregate annual welfare losses ranged from $8.23 to $12.93 billion for Hispanics, $6.44 to $9.84 billion for non‐Hispanic Blacks, $2.82 to $4.30 billion for Asians, and $1.57 to $2.57 billion for individuals of other or multiple racial identities (total $19.06–$29.64 billion).\n\n\nConclusions\nDental care disparities persist after adjusting for socioeconomic, demographic, and health characteristics, generating large aggregate welfare losses for minority communities. Addressing provider diversity, cultural competency, and structural barriers is essential to reducing these inequities.\n\n"]

  July 31, 2026   doi: 10.1111/1475-6773.70155   open full text
• Quantifying Nurse and Physician Clinical Performance for Mechanically Ventilated Patients.
  Christopher F. Chesley, Yingying Lu, Rachel Kohn, Hayley B. Gershengorn, Kelly C. Vranas, Catherine L. Hough, Olga Yakusheva, Deena Kelly Costa, Deanna J. Marriott, David A. Asch, Aerielle Belk, Stefania Scott, Wei Wang, Meeta Kerlin.
  Health Services Research. 11 days ago
  ["Health Services Research, Volume 61, Issue 4, August 2026. ", "\nABSTRACT\n\nObjective\nExpanding on previous research applying value‐added modeling to clinician performance measurement, we quantified simultaneous nurse and physician performance among mechanically ventilated patients.\n\n\nStudy Setting and Design\nIn a retrospective cohort spanning five academic hospitals, we used multiple linear regression to determine relationships between nurse and physician assignments and changes in patient illness severity (Laboratory‐based Acute Physiology Score) during intensive care unit (ICU) admission. Individual clinician performance was derived from regression coefficients. Collective clinician contribution to disease severity variance was assessed by comparing the coefficient of determination across clinician‐only and joint‐clinician models. Consistency of clinician performance estimates was cross‐validated using random 1:1 partitions of the patient population using Pearson's correlation.\n\n\nData Sources and Analytic Sample\nElectronic health record data were extracted from mechanically ventilated patients at study ICUs between 2018 and 2022.\n\n\nPrincipal Findings\nAmong 17,082 clinical encounters, 215 physicians, and 1719 nurses, nurse and physician assignments improved model fit. Together, they attributed 7% of variability in disease severity trajectory; separately, nurse assignments accounted for greater variance than physician assignments (6% vs. 4%, respectively). Cross‐partition clinician performance was moderately correlated (r = 0.31 [nurses], r = 0.4 [physicians], p < 0.001 for both comparisons).\n\n\nConclusions\nIndividual nurse and physician care independently contribute to disease severity trajectory among mechanically ventilated patients.\n\n"]

  July 29, 2026   doi: 10.1111/1475-6773.70153   open full text
• Modernizing the Front Door to Care: Evaluation of Veterans Administration Health Connect's Impact on Access, Utilization, and Patient Experience.
  Anita A. Vashi, Liam Rose, Tracy Urech, Allison Engstrom Buggaveeti, Linda Diem Tran.
  Health Services Research. July 18, 2026
  ["Health Services Research, Volume 61, Issue 4, August 2026. ", "\nABSTRACT\n\nObjective\nTo evaluate whether centralized appointment scheduling and same‐day virtual clinician evaluation improved appointment timeliness and follow‐up after nurse triage. We also assessed whether these changes were associated with differences in downstream utilization, costs, reach, and Veteran experience.\n\n\nStudy Setting and Design\nRetrospective quasi‐experimental evaluation of Veteran Administration Health Connect (VAHC) modernization across 18 regions between October 1, 2018, and September 30, 2024. Staggered rollout enabled difference‐in‐differences and event‐study analyses comparing outcomes before and after modernization.\n\n\nData Sources and Analytic Sample\nData were drawn from the Veterans Administration Corporate Data Warehouse, Telecare Record Manager, and Customer Relationship Management platforms, and VSignals Veteran experience surveys. The analytic sample comprised 11,118,916 encounters (4,560,677 pre‐modernization; 6,558,239 post‐modernization).\n\n\nPrincipal Findings\nCentralized scheduling was associated with modest and mixed improvements in appointment access. Same‐day scheduling increased by 14.3 percentage points (95% CI, 10.1 to 18.5). Time from call to scheduled appointment decreased by 0.37 days (95% CI, −0.49 to −0.26), while time to completed appointment increased by 2.9 days (95% CI, 0.2 to 5.7). Following modernization, time from nurse triage to any subsequent care decreased by 0.28 days (95% CI, −0.45 to −0.11), and the proportion of callers receiving no follow‐up care within 7 days declined by 2.3 points (95% CI, −4.0 to −0.5). Modernization was not associated with changes in the proportion of all emergency department (ED) visits preceded by a nurse triage call or in total ED visit volume. Seven‐day ED visits, admissions, and total costs did not change meaningfully. Veteran satisfaction was high for post‐modernization virtual encounters.\n\n\nConclusions\nVAHC modernization improved appointment access and follow‐up after nurse triage but was not associated with short‐term changes in ED use or costs, highlighting gains in navigation and experience without immediate shifts in downstream utilization.\n\n"]

  July 18, 2026   doi: 10.1111/1475-6773.70151   open full text
• Are the Best Worth the Wait? Physician Quality Scores and Access Delays.
  Yi‐Jung Shen, Samantha G. Auty, Kevin N. Griffith.
  Health Services Research. July 09, 2026
  ["Health Services Research, Volume 61, Issue 4, August 2026. ", "\nABSTRACT\n\nObjective\nThe Veterans Health Administration's (VHA) Community Care Network generally includes physicians with higher Medicare Merit‐Based Incentive Payment System (MIPS) quality scores than nonparticipants, yet veterans disproportionately receive care from participating physicians with lower scores. Whether physician quality or availability influences veterans' use of community care has not been comprehensively evaluated. Our objective was to assess whether VHA community care specialists with higher MIPS quality scores receive greater referral volume or have longer wait times.\n\n\nStudy Setting and Design\nWe used multivariate regression models to assess the associations between physicians' MIPS quality scores, ranging from 0 to 100, and wait times or referral volumes. We also tested whether wait time moderated the association between physician quality and referral volume.\n\n\nData Sources and Analytic Sample\nWe used administrative data to identify referrals to community‐based specialists during 2021–2022. Referrals were then merged with MIPS quality scores from the Centers for Medicare & Medicaid Services using national provider identifiers.\n\n\nPrincipal Findings\nOur sample included 83,911 specialty care referrals involving 43,736 specialists. The mean MIPS quality score was 81.9 (SD = 20.9), including 77.9% of physicians who scored ≥ 75, the threshold for a positive payment adjustment. The overall mean wait time was 21.8 days (SD = 22.0), and the mean referral volume was 6.6 per year (SD = 10.5). In covariate‐adjusted regression models, MIPS scores were not associated with wait times (+0.12 days per 10‐point increase, 95% CI: −0.02, 0.25) or referral volumes (−0.15 referrals per 10‐point increase, 95% CI: −0.37, 0.06). Wait time did not significantly moderate the relationship between MIPS score and referral volume.\n\n\nConclusion\nPhysician quality appears to play a limited role in shaping referral decisions or access patterns in VHA community care. Although higher‐scoring physicians sometimes have slightly longer wait times, these differences are small and do not translate into higher referral volumes.\n\n"]

  July 09, 2026   doi: 10.1111/1475-6773.70148   open full text
• Who Pays, Who Gains? ACA Medicaid Expansions and Changes in Net Income and Tax Liability by Socioeconomic Status.
  Matthew Hui Liu, Rebecca Anna Schut.
  Health Services Research. July 08, 2026
  ["Health Services Research, Volume 61, Issue 4, August 2026. ", "\nABSTRACT\n\nObjective\nTo evaluate the effects of Affordable Care Act (ACA) Medicaid expansions on changes to net (after‐tax) income and federal tax liability across socioeconomic status (SES).\n\n\nStudy Setting and Design\nEvent study and difference‐in‐difference analyses assessed the effects of state‐level ACA Medicaid expansions post‐2020 on net income and federal tax liability.\n\n\nData Sources and Analytic Sample\nAnalyses were performed on nationally‐representative survey data from the 2010 to 2023 Integrated Public Use Microdata Series Current Population Survey (IPUMS CPS) Annual Social and Economic Supplement (ASEC). We restricted the sample to individuals aged 18–65 with known information on sociodemographic characteristics.\n\n\nPrincipal Findings\nMedicaid expansions contributed to overall net income growth (2.10%, 95% CI 1.31–2.89). By socioeconomic status, postexpansion net incomes were higher among individuals in the lowest income quintile (3.56%, 1.47–5.65), among those employed in low (4.90%, 2.74–7.07), low‐mid (2.05%, 0.57–3.54), and mid‐high (1.97%, 0.61–3.32) skill occupations, and among those with less than a high school degree (3.51%, 0.50–6.51), some college (3.39%, 1.47–5.32), or a bachelor's degree (1.94%, 0.32–3.56). Results further show an increase in overall federal tax liability after deductions (3.84%, 2.43–5.25), namely among individuals in the second (5.20%, 0.72–9.68) and third (4.58%, 2.31–6.86) income quintiles, among those in low (6.99%, 2.78–11.20), low‐mid (6.82%, 4.05–9.60), and mid‐high (2.71%, 0.42–5.01) skill occupations, and among those with a high school degree or GED (4.79%, 1.97–7.60) or a master's degree (7.99%, 3.70–12.28).\n\n\nConclusions\nFindings suggest ACA Medicaid expansions induced downstream net income gains while increasing overall federal tax revenue. Results further suggest that the increased costs of Medicaid expansion are not largely borne by higher SES groups. Broadly, Medicaid expansions may provide substantial economic benefits to the entire U.S. population.\n\n"]

  July 08, 2026   doi: 10.1111/1475-6773.70147   open full text
• Attrition of the Midwifery Workforce: Understanding Factors Associated With Leaving the Profession.
  E. Brie Thumm, Amy H. Goh, Elizabeth G. Phillips, Zachary Giano.
  Health Services Research. July 07, 2026
  ["Health Services Research, Volume 61, Issue 4, August 2026. ", "\nABSTRACT\n\nObjective\nTo understand why advanced practice midwives (certified nurse‐midwives and certified midwives) leave the workforce.\n\n\nStudy Setting and Design\nA multi‐method, multi‐source investigation included secondary analysis of certification data of advanced practice midwives and a cross‐sectional online survey with closed‐ and open‐ended items. Advanced practice midwives' active certification data were used to compare self‐reported demographic characteristics of advanced practice midwives who reported working in the discipline of midwifery to those who did not (n = 9704). A survey was conducted in 2022 with individuals who allowed their certification to lapse between 2017 and 2021 (n = 303) and individuals who maintained certification but reported not working in the discipline of midwifery (n = 1994) to understand why individuals left the workforce and the likelihood of returning. Data were analyzed with ANOVAs, chi‐squares, t‐tests, and thematic analysis.\n\n\nData Sources and Analytic Sample\nAdministrative data from the American Midwifery Certification Board (n = 9704) and an online survey from a national sample of currently and previously certified nurse‐midwives and certified midwives who had left the workforce (n = 646; response rate of 33.8%).\n\n\nPrincipal Findings\nThe most endorsed reasons for leaving were work‐life balance (50.3%, n = 325), unsupportive work environment (34.7%, n = 224), and schedule (32.0%, n = 207). Participants from restrictive regulation states reported lack of opportunities for career advancement, state‐level regulation restricting ability to practice, and lack of employment opportunities at higher rates. Respondents of color more frequently reported inadequate compensation, lack of opportunity for advancement, and workplace discrimination at higher rates. Themes included barriers to re‐entry to practice and compensation.\n\n\nConclusions\nWork‐life balance and work environment drive midwifery workforce attrition. Individuals of color and those living in states with restrictive regulation face unique challenges. Challenges re‐entering the workforce after leaving create barriers to remaining in the workforce, especially with inequitable compensation.\n\n"]

  July 07, 2026   doi: 10.1111/1475-6773.70143   open full text
• Engaging Families in Pediatric Care Management: A Qualitative Study From the North Carolina Integrated Care for Kids Model.
  Hartlee Lidsky, Eleanor Wertman, Hadiya B. Sadiq, Greeshma James, Kimberlin Neblett, Tara Ilsley, Chelsea Swanson, Kori B. Flower, Michael Steiner, Carolyn Avery, Rushina Cholera.
  Health Services Research. July 06, 2026
  ["Health Services Research, Volume 61, Issue 4, August 2026. ", "\nABSTRACT\n\nObjective\nTo describe factors influencing caregiver engagement in pediatric care management.\n\n\nStudy Setting and Design\nThis qualitative descriptive study of family engagement was based in the North Carolina Integrated Care for Kids (NC InCK) care management model. NC InCK proactively offers assistance with healthcare coordination and health‐related social needs to Medicaid‐insured children in five North Carolina counties. Participants were randomly recruited from three cohorts with different levels of engagement (never engaged, briefly engaged, and retained) and participated in semi‐structured virtual interviews to understand barriers and facilitators to both enrollment and retention in care management. Cross‐cohort themes were identified using rapid qualitative analysis.\n\n\nData Sources and Analytic Sample\nInterviews were conducted between May 2024 and January 2025 with 50 NC InCK‐eligible English‐speaking families.\n\n\nPrincipal Findings\nMost participants were mothers (n = 38, 74%) and grandmothers (n = 6, 12%) of non‐Hispanic Black children (n = 32, 64%). Initial enrollment facilitators included clear, genuine explanations of care management tailored to family needs. Enrollment obstacles included high caregiver self‐reliance, confusion around program scope, and negative prior experiences with social service programs. Retention facilitators included flexible scheduling, convenient communication, and strong interpersonal relationships with care managers. Retention obstacles included competing demands, communication challenges, evolution of family needs, and misalignment between caregiver expectations and services. Post‐interview, 32% of briefly engaged and 73% of never engaged participants requested re‐enrollment in the NC InCK model.\n\n\nConclusions\nCare management is a fundamental pediatric population health strategy, but low family engagement limits large‐scale implementation and impact. Strategies to increase participation include clear messaging and simplified eligibility criteria to effectively convey care management benefits. Strong care manager communication skills are needed to build relationships with caregivers from varied backgrounds. Evolving family needs and bandwidth necessitate flexible care management options rather than a one‐size‐fits‐all model.\n\n"]

  July 06, 2026   doi: 10.1111/1475-6773.70129   open full text
• The Effect of Hospital‐Physician Vertical Integration on Utilization‐Driven Changes in Healthcare Spending for an All‐Payer Population With Multiple Chronic Conditions.
  Alexandra Harris, Neil Jordan, Cynthia Barnard, Jeffrey A. Linder, Brady Post.
  Health Services Research. July 06, 2026
  ["Health Services Research, Volume 61, Issue 4, August 2026. ", "\nABSTRACT\n\nObjective\nTo estimate the effect of hospital‐physician vertical integration on utilization‐driven annual healthcare spending for an all‐payer cohort of patients with multiple chronic conditions.\n\n\nStudy Setting and Design\nWe used a quasi‐experimental difference‐in‐differences with staggered adoption approach to estimate the effect of hospital‐physician vertical integration on total annual utilization‐driven spending per patient (primary outcome). We also examined changes in annual inpatient, outpatient, professional, and pharmaceutical utilization‐driven spending (secondary outcomes).\n\n\nData Sources and Analytic Sample\nUsing 2016–2021 Virginia all‐payer administrative claims data, we conducted a retrospective analysis of 77,248 patients aged 45–99, with Medicare, Medicaid, and/or commercial insurance, and at least two qualifying chronic conditions at the beginning of the study period. The treatment group included patients of physicians who began the study period independent and became integrated in 2018, 2019, 2020, or 2021, respectively. The control group included patients of physicians who remained independent during the entire study period.\n\n\nPrincipal Findings\nWhile we found no significant difference in utilization‐driven spending after integration overall ($1063, CI: $‐364 to $2414), meaningful heterogeneity emerged across the staggered integration cohorts. Notably, when excluding the 2021 integration cohort (which exhibited significantly lower total annual utilization‐driven spending), we found evidence of substantially higher annual total ($1750, CI: $207 to $3739) and inpatient ($898, CI: $65 to $2293) spending after integration among the earlier integration cohorts, driven by inpatient utilization. These findings held when limiting our analyses to patients of primary care physicians.\n\n\nConclusions\nThis study provides evidence that the timing of hospital‐physician vertical integration (pre‐pandemic versus pandemic‐era), particularly among primary care physicians, drove heterogeneous treatment effects in utilization‐driven spending for the growing population of adults living with multiple chronic conditions.\n\n"]

  July 06, 2026   doi: 10.1111/1475-6773.70144   open full text
• The Association Between Sepsis Coding and Payment to U.S. Hospitals.
  Andrew M. Ryan, Hallie C. Prescott, Yan Lin, Hayden Rooke‐Ley, Jason D. Buxbaum.
  Health Services Research. June 24, 2026
  ["Health Services Research, Volume 61, Issue 3, June 2026. ", "\nABSTRACT\n\nObjective\nTo assess the prevalence and financial impact of Sepsis‐3 concordant vs. Sepsis‐3 discordant sepsis hospitalizations in Traditional Medicare inpatient claims.\n\n\nStudy Design and Setting\nThis retrospective observational study used a 100% sample of Traditional Medicare inpatient claims from 2016 to 2022. The study population included acute care hospitals reimbursed under the Inpatient Prospective Payment System, excluding those in Maryland and U.S. territories.\n\n\nData Sources and Analytic Sample\nAll Medicare beneficiaries with hospitalizations for sepsis, identified by DRGs 870–872, who were continuously enrolled in Medicare Parts A and B. Hospitalizations were classified as Sepsis‐3 concordant vs. discordant based on the presence of diagnosis codes for acute organ dysfunction.\n\n\nPrincipal Findings\nAmong 4.2 million hospitalizations with a sepsis DRG from 2016–2022, 22.6% (95% CI: 22.3%, 22.9%) lacked a diagnosis code for acute organ dysfunction and were classified as Sepsis‐3 discordant. These hospitalizations were most commonly associated with alternative diagnoses of pneumonia (27.4% (95% CI: 27.2%, 27.7%)), urinary tract infection (27.4% (95% CI: 27.2%, 27.6%)), and skin or subcutaneous tissue infections (9.7% (95% CI: 9.5%, 9.8%)). Thirty‐day mortality was substantially lower among Sepsis‐3 discordant (7.7% (95% CI: 7.6%, 7.8%)) versus concordant (33.4% (95% CI: 33.1%, 33.6%)) sepsis hospitalizations, suggesting meaningful clinical differences among patients with Sepsis‐3 discordant sepsis diagnoses. Hospital payments for Sepsis‐3 discordant sepsis hospitalizations averaged $839 (95% CI: $679, $999) more per hospitalization than alternative simple infections, leading to an estimated $114 (95% CI: $92, $136) million higher annual payments to hospitals.\n\n\nConclusions\nNearly one in four inpatient sepsis hospitalizations in Traditional Medicare may be discordant with Sepsis‐3, leading to substantial increases in spending. CMS could mitigate this by aligning ICD‐10 coding guidelines with clinical definitions.\n\n"]

  June 24, 2026   doi: 10.1111/1475-6773.70135   open full text
• Stagnation in Achieving Recommended Methadone Doses in Opioid Use Disorder Treatment.
  Jemima A. Frimpong, Yinfei Kong, Maya‐Grace T. Archer, Tenie Khachikian, Suojin Wang, Thomas D'Aunno, Daniel L. Howard.
  Health Services Research. June 22, 2026
  ["Health Services Research, Volume 61, Issue 3, June 2026. ", "\nABSTRACT\n\nObjective\nTo assess changes in methadone dosing practices among Opioid Treatment Program (OTP) and evaluate adherence to evidence‐based guidelines recommending doses of at least 80 mg/day.\n\n\nStudy Setting and Design\nThis observational study used a national survey of OTPs to examine longitudinal changes in methadone dosing patterns between 2017 and 2023. Key outcomes included patterns in average dose levels and the relationships between program characteristics and dosing practices.\n\n\nData Sources and Analytic Sample\nSecondary data were analyzed from national OTP surveys conducted in 2017 and 2023. The sample included programs that provided data on dosing practices and program characteristics.\n\n\nPrincipal Findings\nThe proportion of OTPs offering the recommended maintenance dose of at least 80 mg/day remained stagnant, moving from 56% in 2017 to 58% in 2023. Concurrently, private‐for‐profit ownership of programs increased from 36% to 53%. Approximately 42% of patients in 2023 received doses below recommended clinical levels, highlighting a significant misalignment between evidence‐based guidelines and actual practice.\n\n\nConclusions\nNational methadone dosing levels stalled between 2017 and 2023. This pattern leaves a significant gap between evidence‐based guidelines and clinical practice, which may limit the effectiveness of methadone maintenance treatment. Targeted interventions are needed to identify the systematic factors hindering the adoption of evidence‐based care and to maximize treatment success.\n\n"]

  June 22, 2026   doi: 10.1111/1475-6773.70145   open full text
• Understanding Medicaid Estate Recovery: The Experience of North Carolina and Policy Implications for Future Reforms.
  Amanda Spishak‐Thomas, Emma Sandoe, Heather Howard.
  Health Services Research. June 13, 2026
  ["Health Services Research, Volume 61, Issue 3, June 2026. ", "\nABSTRACT\n\nObjective\nTo estimate the prevalence of Medicaid estate recovery in North Carolina.\n\n\nStudy Setting and Design\nWe descriptively analyzed the number of estates, amount recovered, and hardship waiver applications using North Carolina public records data.\n\n\nData Sources and Analytic Sample\nThe data contained information on the number of estates and amount recovered through Medicaid estate recovery between 2017 and 2021 (n = 2975). Additionally, we analyzed hardship waiver application data for residents who applied and had their application processed between 2018 and 2021 (n = 301).\n\n\nPrincipal Findings\nWe found approximately $83 billion was recovered from beneficiaries between 2017 and 2021, or 0.6% of the total cost of North Carolina's annual Medicaid program and just 0.9% of the fee‐for‐service annual long‐term services and supports Medicaid budget. We found that Black homeowners were more likely to have lower value estates recovered, and overall, more money was recovered from white estates.\n\n\nConclusion\nWhile states hope Medicaid estate recovery may balance Medicaid spending through increased revenue, our findings demonstrate that these efforts may be insufficient. Policymakers should opt for strategies outside of the Medicaid program that can more precisely target high‐net‐worth individuals instead of policies like estate recovery that disproportionately impact low‐income families.\n\n"]

  June 13, 2026   doi: 10.1111/1475-6773.70141   open full text
• Racial Disparities and Personal Responsibility Incentives in Medicaid.
  David M. Craig, Elaine M. Hernandez, Elizabeth M. Anderson, Yvette H. Tran, Erik S. Parker, Justin Blackburn, Sumedha Gupta.
  Health Services Research. June 10, 2026
  ["Health Services Research, Volume 61, Issue 3, June 2026. ", "\nABSTRACT\n\nObjective\nTo determine whether personal responsibility incentives in Medicaid differentially affect enrollment and the comprehensiveness of plan benefits among members who are non‐Hispanic Black and non‐Hispanic White.\n\n\nStudy Setting and Design\nWe conducted an interrupted time series analysis to estimate trends in racial disparity ratios of enrollment across more comprehensive Healthy Indiana Plans (HIP) before and during the COVID‐19 Public Health Emergency (PHE) when the state suspended personal responsibility incentives, including monthly premium contributions.\n\n\nData Sources and Analytic Sample\nWe analyzed restricted‐access administrative data from the Indiana Family and Social Services Administration from 2018 through 2023. The analytic cohort comprised 939,667 non‐Hispanic Black and non‐Hispanic White adults (19–64 years) enrolled in one of four HIP tiers, including HIP Plus or HIP Basic, and HIP State Plan Plus or HIP State Plan Basic in which presence of a qualifying health condition is required for eligibility.\n\n\nPrincipal Findings\nBefore the PHE, members who are non‐Hispanic Black were approximately 23 percentage points less likely to be in the more comprehensive HIP Plus plan relative to members who are non‐Hispanic White. An increase in the disparity ratio of 0.076 points toward parity (95% CI, 0.054–0.097 points) for HIP Plus recipients was observed following suspension of personal responsibility incentives during the PHE. After an administrative upgrade of all HIP Basic recipients to HIP Plus plans during July 2021, this disparity ratio increased an additional 0.146 points from the start of the PHE (95% CI, 0.141–0.151 points) to 0.994 (95% CI, 0.993–0.994).\n\n\nConclusions\nPersonal responsibility incentives in Medicaid are associated with substantial and persistent racial disparities in enrollment and plan comprehensiveness. The study indicates that while the temporary removal of these incentives can reduce disparities, proactive policy interventions may be necessary to achieve and maintain equitable access to care.\n\n"]

  June 10, 2026   doi: 10.1111/1475-6773.70139   open full text
• Under‐Documentation of Z‐Codes in Hospitalizations of Homeless Shelter Users in New York City.
  Laila Alsabahi, Anna Zhilkova, Matthew Baker, Duncan Maru, Tsu‐Yu Tsao.
  Health Services Research. June 07, 2026
  ["Health Services Research, Volume 61, Issue 3, June 2026. ", "\nABSTRACT\n\nObjective\nTo assess documentation of social risk International Classification of Diseases, 10th Revision (ICD‐10) Z‐codes among hospitalized homeless shelter users in New York City (NYC).\n\n\nStudy Setting and Design\nCross‐sectional analysis of hospitalizations among individuals experiencing homelessness using 2019 statewide administrative data from New York.\n\n\nData Sources and Analytic Sample\nNew York Statewide Planning and Research Cooperative System (SPARCS) inpatient discharge data linked to NYC homeless shelter addresses. Hospitalizations were identified by matching geocoded discharge addresses to shelter locations (n = 13,105).\n\n\nPrincipal Findings\nAmong 13,105 hospitalizations, 27% had at least one Z‐code documented and 23% included a homelessness Z‐code. In adjusted analyses accounting for hospital‐level clustering, documentation was highest for mental and behavioral health hospitalizations and lowest for maternal health admissions. Documentation was lower among women, younger patients, racial and ethnic minority groups, privately insured patients, and patients treated in private nonacademic hospitals.\n\n\nConclusions\nZ‐code documentation among hospitalized individuals experiencing homelessness is low and varies across clinical, demographic, and institutional groups. Improving documentation completeness is important as reimbursement and equity‐focused policies increasingly rely on accurate Z‐code capture.\n\n"]

  June 07, 2026   doi: 10.1111/1475-6773.70142   open full text
• Health System Integration and Prior Authorization in Medicare Advantage.
  Eunhae Shin.
  Health Services Research. June 02, 2026
  ["Health Services Research, Volume 61, Issue 3, June 2026. ", "\nABSTRACT\n\nObjective\nTo examine whether Medicare Advantage (MA) plans affiliated with health systems adopt less restrictive prior authorization (PA) policies than non‐affiliated plans.\n\n\nStudy Setting and Design\nWe conducted a descriptive analysis comparing PA policies between system‐affiliated and unaffiliated MA plans from 2016 to 2023. Using Plan Benefit Package data, we constructed enrollment‐weighted measures of PA intensity based on the share of service categories requiring PA. We assessed robustness using alternative measures, including service‐specific PA requirements, service mix‐adjusted overall intensity, and measures without enrollment weights, and also examined results by plan type.\n\n\nData Sources and Analytic Sample\nAnalyses included 6480 MA health maintenance organization and preferred provider organization plans operating during the study period.\n\n\nPrincipal Findings\nEnrollees in system‐affiliated MA plans faced fewer PA requirements than those in unaffiliated plans. In 2023, the difference was 31 percentage points (pp): among 23 service categories, enrollees in affiliated plans were enrolled in plans that required PA for 51% of categories, compared with 82% in unaffiliated plans. Differences were especially pronounced for behavioral and mental health services and dialysis (52–59 pp).\n\n\nConclusions\nSystem affiliation is associated with less restrictive PA policies in MA, highlighting organizational structure as an important dimension of utilization management.\n\n"]

  June 02, 2026   doi: 10.1111/1475-6773.70137   open full text
• Medicare Advantage's Provision of Expanded Supplemental Benefits and Acute Care Utilization.
  Jeah Jung, Ge Song, Roger Feldman, Caroline Carlin, Daniel Polsky, Hyunjee Kim.
  Health Services Research. May 29, 2026
  ["Health Services Research, Volume 61, Issue 3, June 2026. ", "\nABSTRACT\n\nObjective\nTo examine whether Medicare Advantage (MA) plans' provision of expanded supplemental benefits reduces enrollees' acute care utilization. Expanded supplemental benefits included non‐medical primarily health‐related (PHR) benefits such as in‐home support services, starting in 2019, and Special Supplemental Benefits for the Chronically Ill (SSBCI) such as food security and housing quality benefits, starting in 2020.\n\n\nStudy Setting and Design\nQuasi‐experimental design using staggered difference‐in‐differences models. We created indicators for offering the following benefits: Any expanded PHR, ≥ 2 expanded PHR, any SSBCI, and ≥ 2 SSBCI. Acute care utilization was measured by three binary indicators of adverse health events: annual emergency department (ED) use, hospitalizations, and re‐admissions.\n\n\nData Sources and Analytic Sample\nWe used 2017–2022 MA encounter data from a random 20% sample of enrollees. We estimated separate models for each benefit indicator, for all non‐dual and all dual‐eligible enrollees, and for highly frail patients within each non‐dual and dual‐eligible group. We used propensity score matching to balance baseline characteristics between treatment and control groups.\n\n\nPrincipal Findings\nOffering expanded supplemental benefits did not generally reduce acute care utilization in all non‐dual or all dual‐eligible enrollees. A few significant effects were relatively small or were not robust to potential differential trends between benefit‐offering and not‐offering plans. However, among highly frail non‐dual enrollees, offering any PHR reduced re‐admissions by −2.82 percentage points (95% CI: −4.78, −0.86), offering ≥ 2 expanded PHR reduced hospitalizations by −1.79 percentage points (95% CI: −2.61, −0.98) and ED use by −1.76 percentage points (95% CI: −2.38, −1.14), and offering ≥ 2 SSBCI reduced ED use by −3.51 percentage points (95% CI: −4.96, −2.05) and hospitalizations by −2.05 percentage points (95% CI: −3.12, −0.099).\n\n\nConclusions\nProvision of expanded supplemental benefits may reduce acute care utilization for certain enrollees. As spending on MA supplemental benefits rises, continued efforts are needed to assess impacts of those benefits.\n\n"]

  May 29, 2026   doi: 10.1111/1475-6773.70136   open full text
• From SMS Text Messaging to Screening Completion: Understanding How SMS Responses Influence Cancer Screening Uptake in Federally Qualified Health Center Clinics.
  Omolola E. Adepoju, Tonghui Xu, Tracy Angelocci.
  Health Services Research. May 28, 2026
  ["Health Services Research, Volume 61, Issue 3, June 2026. ", "\nABSTRACT\n\nObjective\nTo examine how patient engagement with SMS text reminder scan mediate cancer screening completion among patients at Federally Qualified Health Center clinics (FQHCs).\n\n\nStudy Setting and Design\nPatients overdue for cancer screening were randomly assigned to one of two groups: a 3‐week interactive SMS intervention or a 6‐week theory‐informed SMS intervention. The binary outcome was cancer screening completion after 90 days of SMS intervention. A mediation model was used to assess associations between text‐message response rates and cancer screening completion. Exposure variables included sociodemographic characteristics, type of SMS intervention, type of cancer screening needed, and health status variables.\n\n\nData Sources and Analytic Sample\nData were obtained from two large FQHC networks in Texas and California in 2023. We included 4,344 patients who participated in the 3‐week or 6‐week intervention groups, successfully received all interactive messages, had unique phone numbers, and did not opt out of the intervention.\n\n\nPrincipal Findings\nOverall effects were statistically significant, indicating partial mediation. Full mediation was observed for insurance type: compared with Medicaid, private insurance was associated with a 5‐percentage‐point (PP) higher predicted probability of screening completion (Average marginal effect [AME] = 5.0 PP, 95% CI [0.01, 0.09]). Partial mediation was observed for Medicare (AME = 7.0 PP, 95% CI [0.02, 0.13]), uninsurance (AME = 5.0 PP, 95% CI [0.01, 0.09]), patient with diabetes (AME = −4.0 PP, 95% CI [−0.08, −0.01]), non‐primary English language (AME = 8.0 PP, 95% CI [0.05, 0.10], p < 0.001), and large‐city residence (AME = 9.0 PP, 95% CI [0.07, 0.10]), all of which were associated with higher predicted probabilities of screening completion.\n\n\nConclusions\nEngagement with SMS reminders was a significant mediator of cancer screening completion, suggesting that increasing message interactivity may improve cancer screening uptake. Theory‐informed interactive messaging may promote greater patient engagement.\n\n"]

  May 28, 2026   doi: 10.1111/1475-6773.70134   open full text
• Gabapentinoid Polypharmacy Among Medicare Beneficiaries During the Poststroke Recovery Period.
  Julianne D. Brooks, Rebeka Bustamante Rocha, Maria A. Donahue, Joseph P. Newhouse, Sebastien Haneuse, Alexander C. Tsai, Lidia M. V. R. Moura.
  Health Services Research. May 20, 2026
  ["Health Services Research, Volume 61, Issue 3, June 2026. ", "\nABSTRACT\n\nObjective\nTo describe patterns of gabapentinoid (Gabapentin and Pregabalin) use and concurrent use with other central nervous system (CNS) acting pain medications (opioids and benzodiazepines) among US Medicare beneficiaries following acute ischemic stroke (AIS).\n\n\nStudy Setting and Design\nWe analyzed new outpatient gabapentinoid prescriptions in older stroke survivors between 2009 and 2022. We calculated the percent of new gabapentinoid initiators within 6 months of stroke discharge and analyzed concurrent pain medications prescribed within 30 days of gabapentinoid initiation. We presented trends and geographic patterns standardized by age, discharge destination, and modified Rankin Scale (mRS) to control for variations in the sample composition by age and stroke severity over time.\n\n\nData Sources and Analytic Sample\nWe analyzed a 20% sample of US Medicare beneficiaries aged 65 years or older who were hospitalized for AIS. We included those who met Medicare enrollment criteria, had no prior stroke, no prior gabapentinoid use within 6 months, and were discharged home within 30 days of hospitalization.\n\n\nPrincipal Findings\nAmong 153,728 stroke survivors, 4.9% received new gabapentinoid prescriptions within 6 months postdischarge. Of the 7595 gabapentinoid initiators, 1579 (21%) had concurrent opioid and 653 (8.6%) had concurrent benzodiazepine prescriptions. In the sample, the median age was 78 years (Quartile Range: 72–84), 55% were female, and 81% were non‐Hispanic White. The standardized percentage of gabapentinoid initiators increased from 3.8% in 2009 to 5.9% in 2022 (crude: 3.6% in 2009 to 5.8% in 2022). Despite increases in the number of gabapentinoid initiators, the percentage of concurrent opioid users remained low over time, around 1% of the study population. We observed variation in gabapentinoid initiation and concurrent use with opioids by geography.\n\n\nConclusions\nFrom 2009 to 2022, poststroke gabapentinoid use increased in older adults, but concurrent use with opioids remained low over time.\n\n"]

  May 20, 2026   doi: 10.1111/1475-6773.70133   open full text
• Sustained Impacts in the Oncology Care Model: Medicare Payment Impacts in the 18 Months After the Model's End.
  Derek Hoodin, Sean McClellan, Nadine Chami, Caroline Ly, Gabriel A. Brooks, Nancy L. Keating, Colleen M. Kummet, Van Doren Hsu, Stephanie Shao, Matthew J. Trombley.
  Health Services Research. May 15, 2026
  ["Health Services Research, Volume 61, Issue 3, June 2026. ", "\nABSTRACT\n\nObjective\nTo evaluate whether payment reductions achieved during the Oncology Care Model (OCM) continued after the model ended.\n\n\nStudy Setting and Design\nOCM was a voluntary episode‐based alternative payment model designed to improve the value of care for Medicare beneficiaries receiving chemotherapy for cancer. Participating practices received $160 monthly care coordination payments and could receive shared savings (or penalties) according to quality and spending goals during 6‐month episodes. We extended the OCM regression‐adjusted difference‐in‐differences (DID) payment analysis by 18 months after the model's conclusion to assess sustained effects on total episode payments (TEP) and component Parts A, B, and D, and Part B drug payments.\n\n\nData Sources and Analytic Sample\nWe used Medicare administrative data, model program data, and secondary sources describing market and provider characteristics to analyze 6‐month chemotherapy episodes for Medicare fee‐for‐service beneficiaries initiated during January 2014–July 2015 (baseline), July 2016–December 2021 (performance), and January 2022–June 2023 (post‐performance).\n\n\nPrincipal Findings\nIn the 18 months following OCM's end, on average, OCM practices reduced TEP by −$955, driven by significant reductions in Part B payments (−$559). Part B payment reductions were primarily for non‐chemotherapy drugs (−$489). Overall payment reductions totaled $328 million. Sustained payment reductions were predominantly among practices adopting two‐sided risk; these practices reduced TEP by $3379, including significant reductions in Parts A (−$738), B (−$1370), and D (−$1112) payments.\n\n\nConclusion\nOCM savings following the model's end were driven by practices that adopted two‐sided risk. These sustained payment reductions after OCM's conclusion provided substantial additional savings for CMS, reducing estimated model losses from $639 million to $311 million.\n\n"]

  May 15, 2026   doi: 10.1111/1475-6773.70121   open full text
• Do Caregiving Arrangements Influence Hospital Use Among Older Adults With Functional Limitations?
  Erblin Shehu, Kanika Arora.
  Health Services Research. May 15, 2026
  ["Health Services Research, Volume 61, Issue 3, June 2026. ", "\nABSTRACT\n\nObjective\nTo examine whether different caregiving arrangements influence hospitalization risk and frequency among older adults with functional limitations.\n\n\nStudy Setting and Design\nThis longitudinal study used linear probability and Poisson regression models with individual and wave fixed effects, lagged predictors, and household‐clustered standard errors to assess associations between different caregiving arrangements and hospitalization outcomes among community‐dwelling older adults in the United States. Caregiving was categorized as no help, family help, formal help, or combined help. Outcomes included any hospitalization and the number of hospital stays over a two‐year period.\n\n\nData Sources and Analytic Sample\nData came from eight waves of the Health and Retirement Study (2004–2018). The samples included adults aged 65 and older who reported difficulty with at least one activity of daily living and participated in at least two survey waves. The final analytic sample comprised 2926 individuals contributing 5595 person‐wave observations.\n\n\nPrincipal Findings\nWhile the overall hospitalization risk did not differ significantly by caregiving type, receiving combined support was associated with a reduced number of hospital stays among those hospitalized (IRR = 0.712, p < 0.01), compared to receiving no support. Cognitive functioning modified these relationships, with formal help linked to fewer hospitalizations among those with impairment but more among those without. Differences also emerged across racial and ethnic groups, where formal help was linked to lower hospitalization rates for Black individuals, and combined help was associated with increased hospitalizations among Hispanic older adults.\n\n\nConclusions\nPolicies that expand access to both formal and family caregiving support may help reduce hospitalizations among older adults with functional limitations, particularly when tailored to care recipient characteristics.\n\n"]

  May 15, 2026   doi: 10.1111/1475-6773.70130   open full text
• Determinants of Wait Times in the Veterans Health Administration: Implications for Capacity Expansion and Workforce Optimization to Improve Access to Care.
  J. N. Haun, J. Berumen, J. Heuer, C. Byrd, N. Diaz, J. McDaniel, R. S. Bolinski, M. J. Pugh.
  Health Services Research. May 12, 2026
  ["Health Services Research, Volume 61, Issue 3, June 2026. ", "\nABSTRACT\n\nObjective\nEvaluate factors impacting wait times to increase Veterans Health Administration's (VHA) capacity and optimize workforce management to improve veteran access to care.\n\n\nStudy Setting and Design\nQualitative interview guides used the Consolidated Framework for Implementation Research (CFIR) 2.0 and Powell's Implementation Strategies to examine wait time factors at specialty care (SC) clinics. The recruitment strategy yielded 21 participants, comprised of Department of Veteran Affairs (VA) staff members in positions from eight SC clinics. The sample was predominantly White/Caucasian (67%), male (52%), and non‐veteran (90%). Participants were stratified into cohorts by reported wait time.\n\n\nData Sources and Analytic Sample\nPrimary data were collected through individual interviews and small group focused interviews conducted from June 6, 2024, to July 29, 2024. Eligibility requirements included participant position within the SC service and SC service site belonging to a wait time cohort. Notes were taken during interviews and analyzed using rapid iterative content analysis to identify key themes.\n\n\nPrincipal Findings\nFindings demonstrated that wait times may be unsustainably decreased due to staff working above and beyond their allocated work times and levels. Additionally, wait time averages may have resulted from grouping clinics together and, as such, produce inaccurate data. Resources necessary to improve wait times across SC services include: increased staffing levels; clinic space; and assigned medical support assistants.\n\n\nConclusions\nData presented here identified factors that impact wait times at SC clinics and are provided as recommendations to help understand and improve wait times of targeted clinics. As of December 2025, this project was terminated. In lieu of continuing project efforts, we recommend staffing variables be assessed for validity and reliability and we recommend a continuation of developing a community of practice involving all partners and real‐time data sources (e.g., data dashboard), to understand and respond to the staffing needs in the VA.\n\n"]

  May 12, 2026   doi: 10.1111/1475-6773.70128   open full text
• Acute‐Care Utilization and Cost Offsets Associated With Language‐Concordant, Pharmacist‐Integrated Care Management Among High‐Need, High‐Cost Adults.
  Sasha R. Sioni, Lesley Manson, Nicholas Arledge, Janice Yanez, Mohammad Al Mouslmani.
  Health Services Research. May 11, 2026
  ["Health Services Research, Volume 61, Issue 3, June 2026. ", "\nABSTRACT\n\nObjective\nTo estimate utilization and economic effects of a language‐concordant, pharmacist‐integrated care‐management program and examine equity by language and insurance.\n\n\nStudy Setting and Design\nWe conducted a retrospective cohort study emulating a target trial across four Phoenix safety‐net clinics (March 2022–September 2023) using inverse probability weighting and doubly robust Poisson difference‐in‐differences.\n\n\nData Sources and Analytic Sample\nWe linked electronic health records, payer claims, health information exchange admission‐discharge‐transfer alerts, and pharmacist logs for 526 high‐need, high‐cost adults. Enrollees (n = 263) were matched 1:1 to otherwise eligible usual‐care comparators (n = 263) from the same clinics and calendar period.\n\n\nPrincipal Findings\nWithin 60 days, hospital admissions (average marginal effect [AME], −0.44; 95% confidence interval [CI], −0.60 to −0.28; incidence‐rate ratio [IRR], 0.50 [0.29–0.86]) and emergency department visits (AME, −0.16; 95% CI, −0.27 to −0.05; IRR, 0.47 [0.28–0.77]) were lower. Using standardized 2024 national unit costs and a $470 program cost, estimated net savings were $6421 per enrollee (return on investment [ROI], 13.66:1). Spanish‐preferring subgroup estimates were directionally similar, and formal interaction tests were not statistically significant.\n\n\nConclusions\nIn safety‐net clinics, this language‐concordant, pharmacist‐integrated multicomponent program was associated with lower short‐term hospital use and substantial near‐term standardized cost offsets.\n\n"]

  May 11, 2026   doi: 10.1111/1475-6773.70127   open full text
• Examining Staff Perceptions of a Proactive, Telephonic Transition‐of‐Care Program for Pregnant People With Emergency Department Utilization.
  Stephanie M. Garcia, Lanelle Quzack, Erica Hartmann, Natasha Dravid, Michelle Adyniec, Meredith Matone.
  Health Services Research. May 09, 2026
  ["Health Services Research, Volume 61, Issue 3, June 2026. ", "\nABSTRACT\n\nObjective\nTo examine staff perceptions of a proactive, telephonic transition‐of‐care pilot model that connects pregnant people with recent emergency department (ED) utilization to early pregnancy‐related care (e.g., prenatal care, abortion care, miscarriage support) and community resources. Although pregnant individuals disproportionately seek care in the ED, post‐ED discharge models for care navigation remain understudied.\n\n\nStudy Setting and Design\nBetween August 2021 and June 2023, six sites (three health systems, two federally qualified health centers, and one community‐based organization) implemented the transition‐of‐care model with ongoing support from an external organization (‘external facilitator’). We conducted a qualitative descriptive study to explore pilot‐engaged staff and leader perspectives regarding intervention fit and contextual factors influencing implementation and sustainability.\n\n\nData Sources and Analytic Sample\nFrom February to March 2024, we conducted interviews with 13 individuals (six outreach champions; four administrative champions; three senior leaders) representing all six pilot sites. Guided by the integrated Promoting Action on Research Implementation in Health Services (i‐PARIHS) framework, we employed codebook thematic analysis to identify key themes regarding the extent to which intervention characteristics met patients' perceived needs and factors influencing pilot site implementation and sustainability.\n\n\nPrincipal Findings\nPilot site champions and leaders described the transition‐of‐care model as acceptable and feasible. Key strengths included the pilot model's patient‐centered design (e.g., timely, proactive outreach and individualized support), health information exchange (HIE)‐driven ED data infrastructure, and role of the external facilitator. Receipt of coaching and training on sensitive, respectful communication in the early pregnancy period also facilitated program implementation. Adequate outreach staffing acted as a barrier and potential determinant of sustainability.\n\n\nConclusion\nOur findings provide preliminary evidence in support of an outreach model to promote initiation of early pregnancy‐related care following ED utilization and offer a flexible blueprint for adaptation across clinical settings. Our work meaningfully contributes to the limited literature base on early pregnancy care innovation.\n\n"]

  May 09, 2026   doi: 10.1111/1475-6773.70124   open full text
• The Geography of Disconnection: Rural and Urban Gaps in Post‐Pandemic Telehealth Use.
  Sezen O. Onal, Caglar Onal.
  Health Services Research. May 09, 2026
  ["Health Services Research, Volume 61, Issue 3, June 2026. ", "\nABSTRACT\n\nObjective\nTo examine rural–urban disparities in telehealth utilization during the post‐pandemic period and assess whether these disparities persist after adjusting for individual‐level characteristics.\n\n\nStudy Setting and Design\nWe used multivariable logistic regression and propensity score matching to estimate differences in telehealth use by rurality and examined self‐reported reasons for non‐use.\n\n\nData Sources and Analytic Sample\nWe analyzed 2022 and 2024 Health Information National Trends Survey (HINTS) data, a nationally representative survey of noninstitutionalized US adults. The analytic sample included 11,106 respondents after excluding missing observations.\n\n\nPrincipal Findings\nOverall, 38.7% of adults reported telehealth use in the past 12 months. After adjusting for covariates, rural residents were significantly less likely to use telehealth than urban core residents; remote rural residence was associated with a 10–percentage point lower probability (95% CI, −16.2 to −2.8; p < 0.01). Propensity score analyses yielded similar results (−7.7% points; 95% CI, −16.2 to −2.8; p < 0.01). Among non‐users, rural respondents were more likely to report not being offered telehealth.\n\n\nConclusions\nWe observed significant rural–urban disparities in telehealth use in the post‐pandemic period. Rural non‐users were more likely to report not being offered telehealth, indicating delivery‐side barriers.\n\n"]

  May 09, 2026   doi: 10.1111/1475-6773.70126   open full text
• Impact of Prescription Drug Monitoring Programs on Postpartum Opioid Prescribing Practices.
  Sai Vijay Trilochan Reddy Tadi, CeCe Cheng, Alexander Testa, John J. Byrne, Carolina Vivas‐Valencia.
  Health Services Research. May 04, 2026
  ["Health Services Research, Volume 61, Issue 3, June 2026. ", "\nABSTRACT\n\nObjective\nTo evaluate the association between Prescription Drug Monitoring Programs (PDMPs) and postpartum opioid prescribing from 2007 to 2015, prior to the 2016 Centers for Disease Control and Prevention opioid prescribing guidelines, and to assess differences between low‐ and high‐risk populations.\n\n\nStudy Setting and Design\nThis cross‐sectional study captures delivery episodes across the United States, primarily from commercially insured patients. The exposure was the implementation of PDMPs at the state level from 2007 to 2015, with states classified by whether implementation occurred before or after 2016. We used a difference‐in‐difference design for analysis. The primary outcome included: (1) morphine milligram equivalents (MME) per day; (2) pills dispensed; (3) average days' supply, and (4) total number of prescriptions filled during the postpartum period (42 days after delivery).\n\n\nData Sources and Analytic Sample\nWe analyzed secondary data from IQVIA PharMetrics, an administrative claims database from 2006 to 2015. We identified reproductive‐age patients (ages 12–59) with a documented delivery and stratified them into low and high‐risk groups by postpartum prescribing and pre‐delivery opioid exposure.\n\n\nPrincipal Findings\nAmong 361,165 delivery episodes (9.9% cesarean, 90.1% vaginal), PDMP implementation was not associated with changes in postpartum opioid prescribing. In an age‐and comorbidity‐adjusted analysis by risk groups, PDMP implementation was not associated with statistically significant changes in MME per day per delivery in either low‐risk (−0.35; 95% CI, −3.27 to 2.57) or high‐risk groups (1.11; 95% CI, −7.46 to 9.68) in the implementation year, and results for pills dispensed, days' supply, and total prescriptions were similarly null, with confidence intervals spanning zero.\n\n\nConclusion\nState‐level PDMP implementation was not associated with changes in postpartum opioid prescribing. These findings suggest PDMPs alone may be insufficient to influence postpartum prescribing, highlighting the need for alternative strategies to optimize pain management and reduce opioid‐related risks.\n\n"]

  May 04, 2026   doi: 10.1111/1475-6773.70123   open full text
• Effects of National Insurance Reforms and State Medicaid Expansions Under the Affordable Care Act on Insurance Coverage Among American Indian and Alaska Native People.
  Kate W. Strully, Pinka Chatterji, Han Liu.
  Health Services Research. April 28, 2026
  ["Health Services Research, Volume 61, Issue 3, June 2026. ", "\nABSTRACT\n\nObjective\nTo test whether national health insurance reforms under the Affordable Care Act (ACA) and state Medicaid expansions affected insurance coverage among American Indian and Alaska Native (AIAN) people and estimate comparative effects for other racial‐ethnic groups.\n\n\nStudy Setting and Design\nWe use a difference‐in‐differences approach that decomposes effects of national insurance reforms from state Medicaid expansions.\n\n\nData Sources and Analytic Sample\nData are from the 2011 to 2019 American Community Survey. The analytic sample includes respondents aged 19–64 who identify as non‐Hispanic AIAN, non‐Hispanic white (NHW), non‐Hispanic Black (NHB), or Hispanic and live in areas with a minimum of 50 respondents in each racial‐ethnic group for 2009–2013.\n\n\nPrincipal Findings\nMedicaid expansions were associated with a 9.0 pp. reduction in uninsurance (p < 0.001), and a 4.4 pp. increase in Medicaid coverage (p = 0.049) among AIAN respondents, with stronger effects among those who reported having Indian Health Services. However, national insurance reforms were not associated with AIAN respondents' insurance coverage. Similarly, Medicaid expansions rather than national reforms improved Hispanic respondents' insurance coverage. Among NHW and NHB respondents, both Medicaid expansions and national reforms improved insurance coverage.\n\n\nConclusion\nMedicaid expansions were the driving force behind the ACA's positive effects on insurance coverage among AIAN people between 2011 and 2019.\n\n"]

  April 28, 2026   doi: 10.1111/1475-6773.70119   open full text
• State Expansions in Medicaid Financial Assistance for Low‐Income Medicare Beneficiaries: Changes in Enrollment and Use.
  Vicki Fung, David Cheng, Mary Price, Kobi Khong, Zhiyou Yang, Felippe O. Marcondes, J. Wyatt Koma, John Hsu, Margarita Alegria, Joseph P. Newhouse.
  Health Services Research. April 27, 2026
  ["Health Services Research, Volume 61, Issue 3, June 2026. ", "\nABSTRACT\n\nObjective\nTo examine the association between state increases in income or asset eligibility limits for Medicare Savings Programs (MSP), which provide assistance with Medicare cost‐sharing and/or premiums, and MSP enrollment and health care use.\n\n\nStudy Setting and Design\nWe used interrupted time series analysis to evaluate changes in MSP enrollment rates before and after expansion. We estimated associations between post‐expansion enrollment in MSPs with outpatient visits, prescription drug fills, emergency department (ED) visits, and hospitalizations using a matched difference‐in‐differences approach. Matching variables included individual and area‐level sociodemographic characteristics, comorbidity scores, and MSP eligibility group.\n\n\nData Sources and Analytic Sample\nWe used Medicare data from four states that met the inclusion criteria of having at least 24 months of data before and after their expansion between 2006 and 2019: Connecticut (income and assets), Indiana (income), New York (assets), and Oregon (assets).\n\n\nPrincipal Findings\nRelative to predicted enrollment in the absence of MSP expansion, actual enrollment over 24 months increased by varying degrees: 65.3% in Connecticut and 34.1% in Indiana, but only 3.9% and 3.7% in New York and Oregon, respectively. In Connecticut and Indiana, the two states that raised income limits, post‐expansion enrollment in MSPs was associated with increased prescription drug use overall (e.g., 380 fills per 1000 beneficiaries per month in Connecticut, 95% CI: 333, 427) and in three chronic drug classes, and decreased hospitalizations (e.g., −4 hospitalizations per 1000 beneficiaries per month in Indiana, 95% CI: −7, −2).\n\n\nConclusions\nMSP eligibility expansions had positive but variable impacts on enrollment across states, with larger increases in states that expanded eligibility by raising income limits versus those that only eliminated asset tests. In the states that raised income limits, post‐expansion enrollment in MSPs was associated with increased use of chronic drugs, underscoring the potential clinical value of financial assistance for low‐income beneficiaries.\n\n"]

  April 27, 2026   doi: 10.1111/1475-6773.70116   open full text
• Impact of Recent Medicaid Expansions on Office‐Based Primary Care and Specialty Care among the Newly Eligible.
  Adam I. Biener, Samuel H. Zuvekas, Steven C. Hill.
  Health Services Research. October 20, 2017
  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.

  October 20, 2017   doi: 10.1111/1475-6773.12793   open full text
• Providing Family Planning Services at Primary Care Organizations after the Exclusion of Planned Parenthood from Publicly Funded Programs in Texas: Early Qualitative Evidence.
  Kari White, Kristine Hopkins, Daniel Grossman, Joseph E. Potter.
  Health Services Research. October 20, 2017
  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.

  October 20, 2017   doi: 10.1111/1475-6773.12783   open full text
• Rising Drug Costs Drives the Growth of Pharmacy Benefit Managers Exclusion Lists: Are Exclusion Decisions Value‐Based?
  Joshua P. Cohen, Christelle El Khoury, Christopher‐Paul Milne, Sandra M. Peters.
  Health Services Research. October 18, 2017
  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.

  October 18, 2017   doi: 10.1111/1475-6773.12781   open full text
• Modeling Community Discharge of Medicaid Nursing Home Residents: Implications for Money Follows the Person.
  Zachary Hass, Mark Woodhouse, Robert Kane, Greg Arling.
  Health Services Research. October 18, 2017
  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.

  October 18, 2017   doi: 10.1111/1475-6773.12795   open full text
• Effects of Early Dual‐Eligible Special Needs Plans on Health Expenditure.
  Yongkang Zhang, Mark L. Diana.
  Health Services Research. October 18, 2017
  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.

  October 18, 2017   doi: 10.1111/1475-6773.12778   open full text
• Safety Culture and Mortality after Acute Myocardial Infarction: A Study of Medicare Beneficiaries at 171 Hospitals.
  David M. Shahian, Xiu Liu, Laura P. Rossi, Elizabeth A. Mort, Sharon‐Lise T. Normand.
  Health Services Research. October 09, 2017
  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.

  October 09, 2017   doi: 10.1111/1475-6773.12725   open full text
• The Association of Health Reform and Infant Health: Evidence from Massachusetts.
  Michel H. Boudreaux, Rada K. Dagher, Scott A. Lorch.
  Health Services Research. October 02, 2017
  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.

  October 02, 2017   doi: 10.1111/1475-6773.12779   open full text
• Trends in Use of Risk‐Reducing Mastectomy in a Context of Celebrity Decisions and Media Coverage: An Observational Study in the United States and Australia.
  Jialin Mao, Louisa Jorm, Art Sedrakyan.
  Health Services Research. September 25, 2017
  Objective To examine trends in risk‐reducing mastectomy (RRM) and immediate breast reconstruction in New York State and New South Wales, especially before and after Angelina Jolie's announcement of her surgery in 2013. Data Source Hospital discharge data, 2004–2014. Study Design Trends in procedures were assessed using Poisson regression and the Cochrane–Armitage test. Data Extraction Methods Extracted using procedure codes. Principal Findings There was an increase in RRM procedures after May 2013 in both regions, with a peak during late 2013–early 2014. The average bimonthly RRM procedures were significantly higher after Jolie's announcement than before. Conclusions In both countries, we found a substantial increase of RRM after Jolie's announcement, highlighting the impact of celebrity health care coverage on preventive surgical choice and the need for decision aids to assist patients.

  September 25, 2017   doi: 10.1111/1475-6773.12774   open full text
• Using Weighted Hospital Service Area Networks to Explore Variation in Preventable Hospitalization.
  Michael O. Falster, Louisa R. Jorm, Alastair H. Leyland.
  Health Services Research. September 22, 2017
  Objective To demonstrate the use of multiple‐membership multilevel models, which analytically structure patients in a weighted network of hospitals, for exploring between‐hospital variation in preventable hospitalizations. Data Sources Cohort of 267,014 people aged over 45 in NSW, Australia. Study Design Patterns of patient flow were used to create weighted hospital service area networks (weighted‐HSANs) to 79 large public hospitals of admission. Multiple‐membership multilevel models on rates of preventable hospitalization, modeling participants structured within weighted‐HSANs, were contrasted with models clustering on 72 hospital service areas (HSAs) that assigned participants to a discrete geographic region. Data Collection/Extraction Methods Linked survey and hospital admission data. Principal Findings Between‐hospital variation in rates of preventable hospitalization was more than two times greater when modeled using weighted‐HSANs rather than HSAs. Use of weighted‐HSANs permitted identification of small hospitals with particularly high rates of admission and influenced performance ranking of hospitals, particularly those with a broadly distributed patient base. There was no significant association with hospital bed occupancy. Conclusion Multiple‐membership multilevel models can analytically capture information lost on patient attribution when creating discrete health care catchments. Weighted‐HSANs have broad potential application in health services research and can be used across methods for creating patient catchments.

  September 22, 2017   doi: 10.1111/1475-6773.12777   open full text
• Spending per Medicare Beneficiary Is Higher in Hospital‐Owned Small‐ and Medium‐Sized Physician Practices.
  Michael F. Pesko, Andrew M. Ryan, Stephen M. Shortell, Kennon R. Copeland, Patricia P. Ramsay, Xuming Sun, Jayme L. Mendelsohn, Diane R. Rittenhouse, Lawrence P. Casalino.
  Health Services Research. September 21, 2017
  Objective To examine the relationship of physician versus hospital ownership of small‐ and medium‐sized practices with spending and utilization of care. Data Source/Study Setting/Data Collection Survey data for 1,045 primary care‐based practices of 1–19 physicians linked to Medicare claims data for 2008 for 282,372 beneficiaries attributed to the 3,010 physicians in these practices. Study Design We used generalized linear models to estimate the associations between practice characteristics and outcomes (emergency department visits, index admissions, readmissions, and spending). Principal Findings Beneficiaries linked to hospital‐owned practices had 7.3 percent more emergency department visits and 6.4 percent higher total spending compared to beneficiaries linked to physician‐owned practices. Conclusions Physician practices are increasingly being purchased by hospitals. This may result in higher total spending on care.

  September 21, 2017   doi: 10.1111/1475-6773.12765   open full text
• Social Security Disability Insurance Enrollment and Health Care Employment.
  Lawrence C. Pellegrini, Kimberley H. Geissler.
  Health Services Research. September 21, 2017
  Objective To examine the relationship between Social Security Disability Insurance (SSDI) enrollment and health care employment. Data Sources State‐year level data from government and other publicly available sources for all states (2000–2014). Study Design Population‐weighted linear regression analyses model associations between each health care employment measure and each SSDI enrollment measure (i.e., SSDI overall, physical, or mental health enrollment rates), controlling for factors associated with health care employment, state fixed effects, and secular time trends. Data Collection Data are gathered from publicly available sources. Principal Findings A one standard deviation increase in SSDI enrollment per 100,000 population is associated with a statistically significant 2.6 and 4.5 percent increase in the mean employment rate per 100,000 population for health care practitioner and technical occupations and health care support occupations, respectively. The size of this relationship varies by the type of disabling condition for SSDI enrollment (physical versus mental health). Conclusions Social Security Disability Insurance enrollment is significantly associated with health care employment at the state level. Quantifying the magnitude of this relationship is important given high SSDI enrollment rates as well as evolving policy and demographic shifts related to the SSDI program.

  September 21, 2017   doi: 10.1111/1475-6773.12764   open full text
• Understanding the Potential for Patient Engagement in Electronic Consultation and Referral Systems: Lessons From One Safety Net System.
  Jacqueline Nwando Olayiwola, Margae Knox, Kate Dubé, Emily Chen‐Yuan Lu, Tem Woldeyesus, Iguehi E. James, Rachel Willard‐Grace, Delphine Tuot.
  Health Services Research. September 20, 2017
  Objective To understand patient, primary care clinician (PCC), and subspecialist perspectives on potential, unexplored roles for patients in electronic consultation and referral (eCR) systems. Data Sources Primary focus group and survey data collected April–November 2015. Zuckerberg San Francisco General Hospital (ZSFG) is part of an integrated public health delivery system. Its mature eCR system was first implemented in 2005. Study Design This mixed‐methods study synthesizes patient, subspecialist, and PCC perspectives through two patient focus groups in English, Spanish, and Cantonese (n = 6); subspecialist focus groups (n = 2); and an electronic survey of all PCCs (n = 222/634, 35 percent response). Data Collection/Extraction Methods Focus groups were audio‐recorded and transcribed. Two researchers coded the transcripts to identify recurrent themes. Survey data were analyzed using summary and bivariate statistics. Principal Findings Patients expressed minimal desire to directly engage in eCR, instead of emphasizing their PCC's role in advocating, informing, and finding health solutions. Subspecialists requested more consistent communication to patients about the electronic consultation process. Most PCCs (52 percent) supported patient engagement in the eCR process, particularly patient ability to track consult status and securely message with subspecialists. Conclusions Results suggest a continuum of opportunities for patients and their caregivers to engage in eCR systems.

  September 20, 2017   doi: 10.1111/1475-6773.12776   open full text
• Patterns of Collaboration among Health Care and Social Services Providers in Communities with Lower Health Care Utilization and Costs.
  Amanda L. Brewster, Marie A. Brault, Annabel X. Tan, Leslie A. Curry, Elizabeth H. Bradley.
  Health Services Research. September 19, 2017
  Objective To understand how health care providers and social services providers coordinate their work in communities that achieve relatively low health care utilization and costs for older adults. Study Setting Sixteen Hospital Service Areas (HSAs) in the United States. Study Design We conducted a qualitative study of HSAs with performance in the top or bottom quartiles nationally across three key outcomes: ambulatory care sensitive hospitalizations, all‐cause risk‐standardized readmission rates, and average reimbursements per Medicare beneficiary. We selected 10 higher performing HSAs and six lower performing HSAs for inclusion in the study. Data Collection To understand patterns of collaboration in each community, we conducted site visits and in‐depth interviews with a total of 245 representatives of health care organizations, social service agencies, and local government bodies. Principal Findings Organizations in higher performing communities regularly worked together to identify challenges faced by older adults in their areas and responded through collective action—in some cases, through relatively unstructured coalitions, and in other cases, through more hierarchical configurations. Further, hospitals in higher performing communities routinely matched patients with needed social services. Conclusions The collaborative approaches used by higher performing communities, if spread, may be able to improve outcomes elsewhere.

  September 19, 2017   doi: 10.1111/1475-6773.12775   open full text
• Nursing Care Disparities in Neonatal Intensive Care Units.
  Eileen T. Lake, Douglas Staiger, Erika Miles Edwards, Jessica G. Smith, Jeannette A. Rogowski.
  Health Services Research. September 14, 2017
  Objectives To describe the variation across neonatal intensive care units (NICUs) in missed nursing care in disproportionately black and non‐black‐serving hospitals. To analyze the nursing factors associated with missing nursing care. Data Sources/Study Setting Survey of random samples of licensed nurses in four large U.S. states. Study Design This was a retrospective, secondary analysis of 1,037 staff nurses in 134 NICUs classified into three groups based on their percent of infants of black race. Measures included the average patient load, individual nurses’ patient loads, professional nursing characteristics, nurse work environment, and nursing care missed on the last shift. Data Collection Survey data from a Multi‐State Nursing Care and Patient Safety Study were analyzed (39 percent response rate). Principal Findings The patient‐to‐nurse ratio was significantly higher in high‐black hospitals. Nurses in high‐black NICUs missed nearly 50 percent more nursing care than in low‐black NICUs. Lower nurse staffing (an additional patient per nurse) significantly increased the odds of missed care, while better practice environments decreased the odds. Conclusions Nurses in high‐black NICUs face inadequate staffing. They are more likely to miss required nursing care. Improving staffing and workloads may improve the quality of care for the infants born in high‐black hospitals.

  September 14, 2017   doi: 10.1111/1475-6773.12762   open full text
• Do Reduced Hospital Mortality Rates Lead to Increased Utilization of Inpatient Emergency Care? A Population‐Based Cohort Study.
  Mauro Laudicella, Stephen Martin, Paolo Li Donni, Peter C. Smith.
  Health Services Research. September 14, 2017
  Objectives To measure the impact of the improvement in hospital survival rates on patients’ subsequent utilization of unplanned (emergency) admissions. Data Sources/Study Setting Unplanned admissions occurring in all acute hospitals of the National Health Service in England between 2000 and 2009, including 286,027 hip fractures, 375,880 AMI, 387,761 strokes, and 9,966,246 any cause admissions. Study Design Population‐based retrospective cohort study. Unplanned admissions experienced by patients within 28 days, 1 year, and 2 years of discharge from the index admission are modeled as a function of hospital risk‐adjusted survival rates using patient‐level probit and negative binomial models. Identification is also supported by an instrumental variable approach and placebo test. Principal Findings The improvement in hospital survival rates that occurred between 2000 and 2009 explains 37.3 percent of the total increment in unplanned admissions observed over the same period. One extra patient surviving increases the expected number of subsequent admissions occurring within 1 year from discharge by 1.9 admissions for every 100 index admissions (0.019 per admission, 95% CI, 0.016–0.022). Similar results in hip fracture (0.006[0.004–0.007]), AMI (0.006[0.04–0.007]), and stroke (0.004(0.003–0.005)). Conclusions The success of hospitals in improving survival from unplanned admissions can be an important contributory factor to the increase in subsequent admissions.

  September 14, 2017   doi: 10.1111/1475-6773.12755   open full text
• A Randomized Trial of Off‐Site Collaborative Care for Depression in Chronic Hepatitis C Virus.
  Fasiha Kanwal, Jeffrey M. Pyne, Shahriar Tavakoli‐Tabasi, Susan Nicholson, Brian Dieckgraefe, Erma Storay, Matthew Bidwell Goetz, Jennifer R. Kramer, Donna Smith, Shubhada Sansgiry, Aylin Tansel, Allen L. Gifford, Steven M. Asch.
  Health Services Research. September 11, 2017
  Objective To test the effectiveness of a collaborative depression care model in improving depression and hepatitis C virus (HCV) care. Data Sources/Study Setting Hepatitis C virus clinic patients who screened positive for depression at four Veterans Affairs Hospitals. Study Design We compared off‐site depression collaborative care (delivered by depression care manager, pharmacist, and psychiatrist) with usual care in a randomized trial. Primary depression outcomes were treatment response (≥50 percent decrease in 20‐item Hopkins Symptoms Checklist [SCL‐20] score), remission (mean SCL‐20 score, <0.5), and depression‐free days (DFDs). Primary HCV outcome was receipt of HCV treatment. Data Collection Patient data were collected by self‐report telephone surveys at baseline and 12 months, and from electronic medical records. Principal Findings Baseline screening identified 292 HCV‐infected patients with depression, and 242 patients completed 12‐month follow‐up (82.9 percent). Intervention participants were more likely to report depression treatment response, remission, and more DFDs than usual care participants. Intervention participants were more likely to receive antiviral treatment; however, the difference was not statistically significant. Conclusion Off‐site depression collaborative care improved depression outcomes in HCV patients and may serve as a model for collaboration between mental health and specialty physical health providers in other high co‐occurring conditions.

  September 11, 2017   doi: 10.1111/1475-6773.12758   open full text
• The Effect of Medicaid on Dental Care of Poor Adults: Evidence from the Oregon Health Insurance Experiment.
  Katherine Baicker, Heidi L. Allen, Bill J. Wright, Sarah L. Taubman, Amy N. Finkelstein.
  Health Services Research. September 08, 2017
  Objective To evaluate the effect of Medicaid coverage on dental care outcomes, a major health concern for low‐income populations. Data Sources Primary and secondary data on health care use and outcomes for participants in Oregon's 2008 Medicaid lottery. Study Design We used the lottery's random selection to gauge the causal effects of Medicaid on dental care needs, medication, and emergency department visits for dental care. Data Collection Data were collected for lottery participants over 2 years, including mail surveys (N = 23,777) and in‐person questionnaires (N = 12,229). Emergency department (ED) records were matched to lottery participants in Portland (N = 24,646). Principal Findings Medicaid coverage significantly reduced the share of respondents who reported needing dental care (−9.8 percentage points, p < .001) or having unmet dental care needs (−13.5 percentage points, p < 0.001). Medicaid doubled the share visiting the ED for dental care (+2.6 percentage points, p = .003) and the use of anti‐infective medications often prescribed for dental care, but it had no detectable effect on uncovered dental care or out‐of‐pocket spending. Conclusions Expansion of Medicaid covering emergency dental care substantially reduced unmet need for dental care, increasing ED dental visits and medication use, while not changing patient use of uncovered dental services.

  September 08, 2017   doi: 10.1111/1475-6773.12757   open full text
• The Volume–Outcome Relationship Revisited: Practice Indeed Makes Perfect.
  Corinna Hentschker, Roman Mennicken.
  Health Services Research. September 04, 2017
  Objective To examine the causal effect of a hospital's experience with treating hip fractures (volume) on patient treatment outcomes. Data Sources We use a full sample of administrative data from German hospitals for 2007. The data provide detailed information on patients and hospitals. We also reference the hospitals’ addresses and the zip codes of patients’ place of residence. Study Design We apply an instrumental variable approach to address endogeneity concerns due to reverse causality and unobserved patient heterogeneity. As instruments for case volume, we use the number of potential patients and number of other hospitals in the region surrounding each hospital. Principal Findings Our results indicate that after applying an instrumental variables (IV) regression of volume on outcome, volume significantly increases quality. Conclusions We provide evidence for the practice‐makes‐perfect hypothesis by showing that volume is a driving factor for quality.

  September 04, 2017   doi: 10.1111/1475-6773.12696   open full text
• Seasonality and Readmission after Heart Failure, Myocardial Infarction, and Pneumonia.
  Neel M. Butala, Eric A. Secemsky, Jason H. Wasfy, Kevin F. Kennedy, Robert W. Yeh.
  Health Services Research. August 31, 2017
  Objective To investigate whether hospital readmission after admission for heart failure (HF), myocardial infarction (MI), and pneumonia varies by season. Data Sources All patients in 2005–2009 Healthcare Cost and Utilization Project State Inpatient Databases for New York and California hospitalized for HF, MI, or pneumonia. Study Design The relationship between discharge season and unplanned readmission within 30 days was evaluated using multivariate modified Poisson regression. Principal Findings Cohorts included 869,512 patients with HF, 448,945 patients with MI, and 813,593 patients with pneumonia. While admissions varied widely by season, readmission rates only ranged from 25.0 percent (spring) to 25.6 percent (winter) for HF (p > .05), 18.9 percent (summer) to 20.0 percent (winter) for MI (p < .001), and 19.4 percent (spring) to 20.3 percent (summer) for pneumonia (p < .001). In adjusted models, in New York, there was lower readmission in spring and fall (RR: 0.98, 95% CI: 0.96–0.99 for both) after admission for HF and higher readmission in spring (RR: 1.04, 95% CI: 1.01–1.07) after MI. In California, there was lower readmission in spring and winter (RR: 0.95, 95% CI: 0.93–0.96 and RR: 0.96, 95% CI: 0.94–0.98, respectively) after pneumonia. Conclusions Given marked seasonality in incidence and mortality of HF, MI, and pneumonia, the modest seasonality in readmissions suggests that readmissions may be more related to non–seasonally dependent factors than to the seasonal nature of these diseases.

  August 31, 2017   doi: 10.1111/1475-6773.12747   open full text
• Estimating Costs of Care Attributable to Cancer: Does the Choice of Comparison Group Matter?
  Aileen B. Chen, Ling Li, Angel M. Cronin, Gabriel A. Brooks, Brian D. Kavanagh, Deborah Schrag.
  Health Services Research. August 31, 2017
  Objective To compare alternative strategies for specifying cancer‐free control cohorts for estimating cancer‐attributable costs of care. Data Source, Study Design, Data Extraction Secondary data analysis of Surveillance, Epidemiology, and End Results data linked to Medicare claims among patients diagnosed with colorectal, lung, breast, and prostate cancers, 2007–2011. We estimated cancer‐attributable costs using three alternative reference cohorts: (1) noncancer Medicare patients individually matched by demographic characteristics, (2) noncancer patients individually matched on demographic factors and comorbidity score, (3) cancer patients as their own control, using prediagnosis costs. Principal Findings Among 44,266 colorectal, 61,584 lung, 55,921 breast, and 67,733 prostate patients, mean total Medicare spending in the first year of diagnosis was $59,496, $54,261, $31,895, and $26,305, respectively. Estimates of cancer‐attributable costs ranged from 79 percent to 82 percent of spending for colorectal, 76 percent–79 percent for lung, 65 percent–74 percent for breast, and 60 percent–75 percent for prostate cancers, depending on the reference cohort used. For all cancers, estimates were higher when patients were used as their own control, compared to demographic and comorbidity‐matched controls. Conclusions Choice of reference group can have a substantial impact on proportion of total costs attributed to cancer and should be clearly defined in analyses of the costs of cancer care.

  August 31, 2017   doi: 10.1111/1475-6773.12760   open full text
• Trends in the Types of Usual Sources of Care: A Shift from People to Places or Nothing at All.
  Winston Liaw, Anuradha Jetty, Stephen Petterson, Andrew Bazemore, Larry Green.
  Health Services Research. August 31, 2017
  Objective (1) To examine usual source of care (USC) trends across four categories (No USC, Person USC, Person, in Facility USC, and Facility USC), and (2) to determine whether USC types are associated with emergency department (ED) visits and hospital admissions. Data Source 1996–2014 Medical Expenditure Panel Surveys. Study Design We stratified each USC category, by age, region, gender, poverty, insurance, race/ethnicity, and education and used regression to determine the characteristics associated with USC types, ED visits, and hospital admissions. Principal Findings Those with No USC and Facility USCs increased 10 and 18 percent, respectively, while those with Person USCs decreased by 43 percent. Compared to those in the lowest income bracket, those in the highest income bracket were less likely to have a Facility USC. Among those with low incomes, individuals with No USC, Person, in Facility, and Facility USCs were more likely to have ED visits than those with Person USCs. Conclusions A growing number are reporting facilities as their USCs or none at all. The impact of these trends is uncertain, although we found that some USC types are associated with ED visits and hospital admissions. Tracking USCs will be crucial to measuring progress toward enhanced care efficiency.

  August 31, 2017   doi: 10.1111/1475-6773.12753   open full text
• Racial/Ethnic Differences in Receipt of Influenza and Pneumococcal Vaccination among Long‐Stay Nursing Home Residents.
  Jasmine L. Travers, Andrew W. Dick, Patricia W. Stone.
  Health Services Research. August 31, 2017
  Objective/Study Question To examine racial/ethnic differences in influenza and pneumococcal vaccination receipt and nonreceipt among nursing home (NH) residents post implementation of federal vaccination policy. Data Sources/Study Setting/Study Design/Data Collection/Extraction Methods An analysis of a merged national cross‐sectional dataset containing resident assessment, facility, and community data for years 2010–2013 was conducted. Logistic regressions omitting and including facility fixed effects were used to examine the influence of race and ethnicity (black, Hispanic, white) and black concentration on vaccination status across and within NHs. Principle Findings Vaccination receipt of 107,874 residents in 742 NHs was examined. Blacks were less likely than whites to receive influenza and pneumococcal vaccinations (OR = 0.75; OR = 0.81, respectively, p‐values <.001). The likelihood of not being offered the influenza vaccination was greater for blacks (OR=1.25, p = .004) and the likelihood of not being offered the pneumococcal vaccination was greater for Hispanics (OR = 1.65, p = .04) compared to whites. Fixed effects showed that within the same NH, Hispanics were more likely to receive both vaccinations compared to whites (OR=1.22, p = .004 (influenza); OR=1.34, p < .001 (pneumococcal)). Facilities highly concentrated with blacks accounted for large proportions of differences seen in vaccination receipt. Conclusions Racial/ethnic differences remain despite policy changes. Focused strategies aimed at NH personnel and racially segregated NHs are critical to improving vaccination delivery and eliminating disparities in care.

  August 31, 2017   doi: 10.1111/1475-6773.12759   open full text
• Multilevel Comparisons of Hospital Discharge among Older Adults with a Fall‐Related Hospitalization.
  Samuel D. Towne, Kayla Fair, Matthew Lee Smith, Diane M. Dowdy, SangNam Ahn, Obioma Nwaiwu, Marcia G. Ory.
  Health Services Research. August 31, 2017
  Objective We examined multilevel factors associated with hospital discharge status among older adults suffering a fall‐related hospitalization. Data Sources The 2011–2013 (n = 131,978) Texas Inpatient Hospital Discharge Public‐Use File was used. Study Design/Methods Multilevel logistic regression analyses estimated the likelihood of being discharged to institutional settings versus home. Principal Findings Factors associated with a greater likelihood of being discharged to institutional settings versus home/self‐care included being female, white, older, having greater risk of mortality, receiving care in a non‐teaching hospital, having Medicare (versus Private) coverage, and being admitted from a non‐health care facility (versus clinical referral). Conclusions Understanding risk factors for costly discharges to institutional settings enables targeted fall‐prevention interventions with identification of at‐risk groups and allows for identifying policy‐related factors associated with discharge status.

  August 31, 2017   doi: 10.1111/1475-6773.12763   open full text
• Estimation of Population Average Treatment Effects in the FIRST Trial: Application of a Propensity Score‐Based Stratification Approach.
  Jeanette W. Chung, Karl Y. Bilimoria, Jonah J. Stulberg, Christopher M. Quinn, Larry V. Hedges.
  Health Services Research. August 21, 2017
  Objective/Study Question To estimate and compare sample average treatment effects (SATE) and population average treatment effects (PATE) of a resident duty hour policy change on patient and resident outcomes using data from the Flexibility in Duty Hour Requirements for Surgical Trainees Trial (“FIRST Trial”). Data Sources/Study Setting Secondary data from the National Surgical Quality Improvement Program and the FIRST Trial (2014–2015). Study Design The FIRST Trial was a cluster‐randomized pragmatic noninferiority trial designed to evaluate the effects of a resident work hour policy change to permit greater flexibility in scheduling on patient and resident outcomes. We estimated hierarchical logistic regression models to estimate the SATE of a policy change on outcomes within an intent‐to‐treat framework. Propensity score‐based poststratification was used to estimate PATE. Data Collection/Extraction Methods This study was a secondary analysis of previously collected data. Principal Findings Although SATE estimates suggested noninferiority of outcomes under flexible duty hour policy versus standard policy, the noninferiority of a policy change was inconclusively noninferior based on PATE estimates due to imprecision. Conclusions Propensity score‐based poststratification can be valuable tools to address trial generalizability but may yield imprecise estimates of PATE when sparse strata exist.

  August 21, 2017   doi: 10.1111/1475-6773.12752   open full text
• Nurse Staffing Patterns and Patient Experience of Care: An Empirical Analysis of U.S. Hospitals.
  Eva‐Maria Oppel, Gary J. Young.
  Health Services Research. August 14, 2017
  Objective To examine the relationship between nurse staffing patterns and patients’ experience of care in hospitals with a particular focus on staffing flexibility. Data Sources/Study Setting The study sample comprised U.S. general hospitals between 2010 and 2012. Nurse staffing data came from the American Hospital Association Annual Survey, and patient experience data came from the Medicare Hospital Consumer Assessment of Healthcare Providers and Systems. Study Design An observational research design was used entailing a pooled, cross‐sectional data set. Regression models were estimated using generalized estimating equation (GEE) and hospital fixed effects. Nurse staffing patterns were assessed based on both levels (i.e., ratio of full‐time equivalent nurses per 1,000 patient days) and composition (i.e., skill mix—percentage of registered nurses; staffing flexibility—percentage of part‐time nurses). Principal Findings All three staffing variables were significantly associated with patient experience in the GEE analysis, but only staffing flexibility was significant in the fixed‐effects analysis. A higher percentage of part‐time nurses was positively associated with patient experience. Multiplicative and nonlinear effects for the staffing variables were also observed. Conclusions Among three staffing variables, flexibility was found to be the most important relative to patient experience. Unobserved hospital characteristics appear to underlie patient experience as well as certain nurse staffing patterns.

  August 14, 2017   doi: 10.1111/1475-6773.12756   open full text
• Early Impact on Outpatients of Mandatory Adoption of the Diagnosis‐Related Group‐Based Reimbursement System in Korea on Use of Outpatient Care: Differences in Medical Utilization and Presurgery Examination.
  Seung Ju Kim, Kyu‐Tae Han, Woorim Kim, Sun Jung Kim, Eun‐Cheol Park.
  Health Services Research. August 14, 2017
  Objective To explore the impact of mandatory adoption of diagnosis‐related groups (DRGs) on the use of outpatient care in Korea. Data Sources National Health Claim data from 2,022 hospitals and 1,029,101 admission cases during 2011–2014: tonsillectomy/adenoidectomy, inguinal/femoral hernia operation, and hemorrhoidectomy. Study Design Outcome variables included probability of outpatient visit, number of outpatient visits, and outpatient medical expenditures within 30 days. Presurgery examination before hospitalization for surgery, including basic and other examination, was conducted to evaluate a possible shift in health care service. A difference‐in‐difference research design was used to evaluate the impact of the DRG system on the use of outpatient care. Principal Findings Before the introduction of the DRG system, 384,609 (91.1 percent) participants used an outpatient clinic either before or after hospitalization. In our study, the number of outpatient visits and outpatient medical expenditures within 30 days increased after mandatory adoption of the DRG system. After adoption of the DRG system, volume and costs for presurgery examinations increased before hospitalization. Conclusion We observed a spillover effect after mandatory adoption of the DRG system. A future payment system should be designed for spillover effects, and the introduction of a new payment system that expands the DRG‐based reimbursement system should be considered.

  August 14, 2017   doi: 10.1111/1475-6773.12749   open full text
• Development of the Learning Health System Researcher Core Competencies.
  Christopher B. Forrest, Francis D. Chesley, Michelle L. Tregear, Kamila B. Mistry.
  Health Services Research. August 04, 2017
  Objective To develop core competencies for learning health system (LHS) researchers to guide the development of training programs. Data Sources/Study Setting Data were obtained from literature review, expert interviews, a modified Delphi process, and consensus development meetings. Study Design The competencies were developed from August to December 2016 using qualitative methods. Data Collection/Extraction Methods The literature review formed the basis for the initial draft of a competency domain framework. Key informant semi‐structured interviews, a modified Delphi survey, and three expert panel (n = 19 members) consensus development meetings produced the final set of competencies. Principal Findings The iterative development process yielded seven competency domains: (1) systems science; (2) research questions and standards of scientific evidence; (3) research methods; (4) informatics; (5) ethics of research and implementation in health systems; (6) improvement and implementation science; and (7) engagement, leadership, and research management. A total of 33 core competencies were prioritized across these seven domains. The real‐world milieu of LHS research, the embeddedness of the researcher within the health system, and engagement of stakeholders are distinguishing characteristics of this emerging field. Conclusions The LHS researcher core competencies can be used to guide the development of learning objectives, evaluation methods, and curricula for training programs.

  August 04, 2017   doi: 10.1111/1475-6773.12751   open full text
• Medicare Spending for Breast, Prostate, Lung, and Colorectal Cancer Patients in the Year of Diagnosis and Year of Death.
  Christopher T. Chen, Ling Li, Gabriel Brooks, Michael Hassett, Deborah Schrag.
  Health Services Research. July 26, 2017
  Objective To characterize spending patterns for Medicare patients with incident breast, prostate, lung, and colorectal cancer. Data Sources/Study Setting/Study Design 2007–2012 data from the Surveillance, Epidemiology, and End Results Program linked with Medicare fee‐for‐service claims. Data Collection/Extraction Methods We calculate per‐patient monthly and yearly mean and median expenditures, by cancer type, stage at diagnosis, and spending category, over the years of diagnosis and death. Principal Findings Over the year of diagnosis, mean spending was $35,849, $26,295, $55,597, and $63,063 for breast, prostate, lung, and colorectal cancer, respectively. Over the year of death, spending was similar across different cancer types and stage at diagnosis. Conclusions Characterization of Medicare spending according to clinically meaningful categories may assist development of oncology alternative payment models and cost‐effectiveness models.

  July 26, 2017   doi: 10.1111/1475-6773.12745   open full text
• Financial Incentives and Physician Practice Participation in Medicare's Value‐Based Reforms.
  Adam A. Markovitz, Patricia P. Ramsay, Stephen M. Shortell, Andrew M. Ryan.
  Health Services Research. July 26, 2017
  Objectives To evaluate whether greater experience and success with performance incentives among physician practices are related to increased participation in Medicare's voluntary value‐based payment reforms. Data Sources/Study Setting Publicly available data from Medicare's Physician Compare (n = 1,278; January 2012 to November 2013) and nationally representative physician practice data from the National Survey of Physician Organizations 3 (NSPO3; n = 907,538; 2013). Study Design We used regression analysis to examine practice‐level relationships between prior exposure to performance incentives and participation in key Medicare value‐based payment reforms: accountable care organization (ACO) programs, the Physician Quality Reporting System (“Physician Compare”), and the Meaningful Use of Health Information Technology program (“Meaningful Use”). Prior experience and success with financial incentives were measured as (1) the percentage of practices’ revenue from financial incentives for quality or efficiency; and (2) practices’ exposure to public reporting of quality measures. Data Collection/Extraction Methods We linked physician participation data from Medicare's Physician Compare to the NSPO3 survey. Principal Findings There was wide variation in practices’ exposure to performance incentives, with 64 percent exposed to financial incentives, 45 percent exposed to public reporting, and 2.2 percent of practice revenue coming from financial incentives. For each percentage‐point increase in financial incentives, there was a 0.9 percentage‐point increase in the probability of participating in ACOs (standard error [SE], 0.1, p < .001) and a 0.8 percentage‐point increase in the probability of participating in Meaningful Use (SE, 0.1, p < .001), controlling for practice characteristics. Financial incentives were not associated with participation in Physician Compare. Among ACO participants, a 1 percentage‐point increase in incentives was associated with a 0.7 percentage‐point increase in the probability of being “very well” prepared to utilize cost and quality data (SE, 0.1, p < .001). Conclusions Physicians organizations’ prior experience and success with performance incentives were related to participation in Medicare ACO arrangements and participation in the meaningful use criteria but not to participation in Physician Compare. We conclude that Medicare must complement financial incentives with additional efforts to address the needs of practices with less experience with such incentives to promote value‐based payment on a broader scale.

  July 26, 2017   doi: 10.1111/1475-6773.12743   open full text
• An Evaluation of a Clinical Pre‐Exposure Prophylaxis Education Intervention among Men Who Have Sex with Men.
  Julia Raifman, Amy Nunn, Catherine E. Oldenburg, Madeline C. Montgomery, Alexi Almonte, Allison L. Agwu, Renata Arrington‐Sanders, Philip A. Chan.
  Health Services Research. July 25, 2017
  Objective To evaluate the impact of an HIV pre‐exposure prophylaxis (PrEP) education intervention on PrEP awareness and use among men who have sex with men (MSM) attending a sexually transmitted diseases (STD) clinic. Data Sources/Study Setting Men who have sex with men STD clinic patients. Study Design We estimated a difference‐in‐differences linear regression model, comparing MSM whose first visit to the clinic was before (“control”) or after (“treatment”) intervention implementation and controlling for patient. Data Collection/Extraction We used self‐reported data on PrEP awareness and use from STD clinic intake forms. Principal Findings Pre‐exposure prophylaxis awareness between first and second clinic visits increased 27.2 percentage points (pp) in the treatment group, relative to 13.7 pp in the control group. Similarly, PrEP use increased 7.1 pp in the treatment group versus 2.4 pp in the control group. Based on adjusted estimates, the PrEP intervention increased PrEP awareness by 24 pp (p < .01) and PrEP use by 5 pp (p = .01), increases of 63 percent and 159 percent relative to the 6 months prior to the intervention. Conclusion A brief, scalable STD clinic PrEP education intervention led to significantly increased PrEP awareness and use among MSM. Health care providers should consider implementing brief PrEP education interventions in sexual health care settings.

  July 25, 2017   doi: 10.1111/1475-6773.12746   open full text
• Impact of Cost‐Sharing Increases on Continuity of Specialty Drug Use: A Quasi‐Experimental Study.
  Pengxiang Li, Tianyan Hu, Xinyan Yu, Salim Chahin, Nabila Dahodwala, Marissa Blum, Amy R. Pettit, Jalpa A. Doshi.
  Health Services Research. July 24, 2017
  Objective To examine the impact of cost‐sharing increases on continuity of specialty drug use in Medicare beneficiaries with multiple sclerosis (MS) or rheumatoid arthritis (RA). Data Sources/Study Setting Five percent Medicare claims data (2007–2010). Study Design Quasi‐experimental study examining changes in specialty drug use among a group of Medicare Part D beneficiaries without low‐income subsidies (non‐LIS) as they transitioned from a 5 percent cost‐sharing preperiod to a ≥25 percent cost‐sharing postperiod, as compared to changes among a disease‐matched contemporaneous control group of patients eligible for full low‐income subsidies (LIS), who faced minor cost sharing (≤$6.30 copayment) in both the pre‐ and postperiods. Data Collection/Extraction Methods Key variables were extracted from Medicare data. Principal Findings Relative to the LIS group, the non‐LIS group had a greater increase in incidence of 30‐day continuous gaps in any Part D treatment from the lower cost‐sharing period to the higher cost‐sharing period (MS, absolute increase = 10.1 percent, OR = 1.61, 95% CI 1.19–2.17; RA, absolute increase = 21.9 percent, OR = 2.75, 95% CI 2.15–3.51). The increase in Part D treatment gaps was not offset by increased Part B specialty drug use. Conclusions Cost‐sharing increases due to specialty tier‐level cost sharing were associated with interruptions in MS and RA specialty drug treatments.

  July 24, 2017   doi: 10.1111/1475-6773.12744   open full text
• Does Maternity Care Coordination Influence Perinatal Health Care Utilization? Evidence from North Carolina.
  Marianne M. Hillemeier, Marisa E. Domino, Rebecca Wells, Ravi K. Goyal, Hye‐Chung Kum, Dorothy Cilenti, Anirban Basu.
  Health Services Research. July 20, 2017
  Objective To examine effects of maternity care coordination (MCC) on perinatal health care utilization among low‐income women. Data Sources North Carolina Center for Health Statistics Baby Love files that include birth certificates, maternity care coordination records, WIC records, and Medicaid claims. Study Design Causal effects of MCC participation on health care outcomes were estimated in a sample of 7,124 singleton Medicaid‐covered births using multiple linear regressions with inverse probability of treatment weighting (IPTW). Principal Findings Maternity care coordination recipients were more likely to receive first‐trimester prenatal care (p < .01) and averaged three more prenatal visits and two additional primary care visits during pregnancy; they were also more likely to participate in WIC and to receive postpartum family planning services (p < .01). Medicaid expenditures were greater among mothers receiving MCC. Conclusions Maternity care coordination facilitates access to health care and supportive services among Medicaid‐covered women. Increased maternal service utilization may increase expenditures in the short run; however, improved newborn health may reduce the need for costly neonatal care, and by implication the need for early intervention and other supports for at‐risk children.

  July 20, 2017   doi: 10.1111/1475-6773.12742   open full text
• Cross‐Cultural Validation of the Patient Perception of Integrated Care Survey.
  Maike V. Tietschert, Federica Angeli, Arno J. A. Raak, Dirk Ruwaard, Sara J. Singer.
  Health Services Research. July 20, 2017
  Objective To test the cross‐cultural validity of the U.S. Patient Perception of Integrated Care (PPIC) Survey in a Dutch sample using a standardized procedure. Data Sources Primary data collected from patients of five primary care centers in the south of the Netherlands, through survey research from 2014 to 2015. Study Design Cross‐sectional data collected from patients who saw multiple health care providers during 6 months preceding data collection. Data collection The PPIC survey includes 59 questions that measure patient perceived care integration across providers, settings, and time. Data analysis followed a standardized procedure guiding data preparation, psychometric analysis, and included invariance testing with the U.S. dataset. Principal Findings Latent scale structures of the Dutch and U.S. survey were highly comparable. Factor “Integration with specialist” had lower reliability scores and noninvariance. For the remaining factors, internal consistency and invariance estimates were strong. Conclusions The standardized cross‐cultural validation procedure produced strong support for comparable psychometric characteristics of the Dutch and U.S. surveys. Future research should examine the usability of the proposed procedure for contexts with greater cultural differences.

  July 20, 2017   doi: 10.1111/1475-6773.12741   open full text
• Spatial Accessibility of Primary Care in England: A Cross‐Sectional Study Using a Floating Catchment Area Method.
  Jan Bauer, Ruth Müller, Dörthe Brüggmann, David A. Groneberg.
  Health Services Research. July 07, 2017
  Objective To analyze the general practitioners (GPs) with regard to the degree of urbanization, social deprivation, general health, and disability. Data Sources Small area population data and GP practice data in England. Study Design We used a floating catchment area method to measure spatial GP accessibility with regard to the degree of urbanization, social deprivation, general health, and disability. Data Collection Data were collected from the Office for National Statistics and the general practice census and analyzed using a geographic information system. Principal Findings In all, 25.8 percent of the population in England lived in areas with a significant low GP accessibility (mean z‐score: −4.2); 27.6 percent lived in areas with a significant high GP accessibility (mean z‐score: 7.7); 97.8 percent of high GP accessibility areas represented urban areas, and 31.1 percent of low GP accessibility areas represented rural areas (correlation of accessibility and urbanity: r = 0.59; p<.001). Furthermore, a minor negative correlation with social deprivation was present (r = −0.19; p<.001). Results were confirmed by a multivariate analysis. Conclusion This study showed substantially differing GP accessibility throughout England. However, socially deprived areas did not have poorer spatial access to GPs.

  July 07, 2017   doi: 10.1111/1475-6773.12731   open full text
• Identifying Homeless Medicaid Enrollees Using Enrollment Addresses.
  Katherine D. Vickery, Nathan D. Shippee, Peter Bodurtha, Laura M. Guzman‐Corrales, Elyse Reamer, Dana Soderlund, Stephanie Abel, Danielle Robertshaw, Lillian Gelberg.
  Health Services Research. July 03, 2017
  Objective To design and test the validity of a method to identify homelessness among Medicaid enrollees using mailing address data. Data Sources/Study Setting Enrollment and claims data on Medicaid expansion enrollees in Hennepin and Ramsey counties who also provided self‐reported information on their current housing situation in a psychosocial needs assessment. Study Design Construction of address‐based indicators and comparison with self‐report data. Principal Findings Among 1,677 enrollees, 427 (25 percent) self‐reported homelessness, of whom 328 (77 percent) had at least one positive address indicator. Depending on the type of addresses included in the indicator, sensitivity to detect self‐reported homelessness ranged from 30 to 76 percent and specificity from 79 to 97 percent. Conclusions An address‐based indicator can identify a large proportion of Medicaid enrollees who are experiencing homelessness. This approach may be of interest to researchers, states, and health systems attempting to identify homeless populations.

  July 03, 2017   doi: 10.1111/1475-6773.12738   open full text
• Do Patient‐Centered Medical Homes Improve Health Behaviors, Outcomes, and Experiences of Low‐Income Patients? A Systematic Review and Meta‐Analysis.
  Carissa Berk‐Clark, Emily Doucette, Fred Rottnek, William Manard, Mayra Aragon Prada, Rachel Hughes, Tyler Lawrence, F. David Schneider.
  Health Services Research. July 03, 2017
  Objectives To examine: (1) what elements of patient‐centered medical homes (PCMHs) are typically provided to low‐income populations, (2) whether PCMHs improve health behaviors, experiences, and outcomes for low‐income groups. Data Sources/Study Setting Existing literature on PCMH utilization among health care organizations serving low‐income populations. Study Design Systematic review and meta‐analysis. Data Collection/Extraction Methods We obtained papers through existing systematic and literature reviews and via PubMed, Web of Science, and the TRIP databases, which examined PCMHs serving low‐income populations. A total of 434 studies were reviewed. Thirty‐three articles met eligibility criteria. Principal Findings Patient‐centered medical home interventions usually were composed of five of the six recommended components. Overall positive effect of PCMH interventions was d = 0.247 (range −0.965 to 1.42). PCMH patients had better clinical outcomes (d = 0.395), higher adherence (0.392), and lower utilization of emergency rooms (d = −0.248), but there were apparent limitations in study quality. Conclusions Evidence shows that the PCMH model can increase health outcomes among low‐income populations. However, limitations to quality include no assessment for confounding variables. Implications are discussed.

  July 03, 2017   doi: 10.1111/1475-6773.12737   open full text
• Medicaid Expansions and Cervical Cancer Screening for Low‐Income Women.
  Lindsay M. Sabik, Wafa W. Tarazi, Stephanie Hochhalter, Bassam Dahman, Cathy J. Bradley.
  Health Services Research. June 30, 2017
  Objective Medicaid coverage for low‐income women may play an important role in ensuring access to preventive care. This study examines how Medicaid eligibility expansions to nonelderly adults impact cervical cancer screening among low‐income women. Data Sources We use data from the Behavioral Risk Factor Surveillance System from 2000 to 2010. The primary outcome of interest is whether women in the relevant guideline consistent age range reported having a Pap test in the previous year. Study Design We use a difference‐in‐differences approach with matched treatment and comparison states and a simulated eligibility approach based on a continuous measure of Medicaid generosity. Principal Findings Our results indicate that cervical cancer screening increased among low‐income women in expansion states relative to comparison states. Increases in screening rates are largest among low‐income Hispanic women. Conclusions Medicaid expansions during the period from 2000 to 2010 were associated with improved cervical cancer screening rates, which is critical for early cervical cancer detection and prevention of cancer morbidity and mortality in women. The results suggest that more widespread Medicaid expansions may have positive effects on preventive health care for women.

  June 30, 2017   doi: 10.1111/1475-6773.12732   open full text
• Changes in Hospital Inpatient Utilization Following Health Care Reform.
  Gary Pickens, Zeynal Karaca, Eli Cutler, Michael Dworsky, Christine Eibner, Brian Moore, Teresa Gibson, Sharat Iyer, Herbert S. Wong.
  Health Services Research. June 30, 2017
  Objective To estimate the effects of 2014 Medicaid expansions on inpatient outcomes. Data Sources Health Care Cost and Utilization Project State Inpatient Databases, 2011–2014; population and unemployment estimates. Study Design Retrospective study estimating effects of Medicaid expansions using difference‐in‐differences regression. Outcomes included total admissions, referral‐sensitive surgical and preventable admissions, length of stay, cost, and patient illness severity. Findings In 2014 quarter four, compared with nonexpansion states, Medicaid admissions increased (28.5 percent, p = .006), and uninsured and private admissions decreased (–55.1 percent, p = .001, and –6.6 percent, p = .052), whereas all‐payer admissions showed little change. Uninsured expansion effects were negative for preventable admissions (−24.4 percent, p = .068), length of stay (–9.3 percent, p = .039), total cost (−9.2 percent, p = .128), and illness severity (−4.5 percent, p = .397). Significant positive expansion effects were found for Medicaid referral‐sensitive surgeries (11.8 percent, p = .021) and patient illness severity (2.3 percent, p = .015). Private and all‐payer expansion effects for outcomes other than admission volume were small and mainly nonsignificant (p > .05). Conclusion Medicaid expansions did not change all‐payer admission volumes, but they were associated with increased Medicaid and decreased uninsured volumes. Results suggest those previously uninsured with greater needs for inpatient services were most likely to gain coverage. Compositional changes in uninsured and Medicaid admissions may be due to selection.

  June 30, 2017   doi: 10.1111/1475-6773.12734   open full text
• Intra‐Ethnic Coverage Disparities among Latinos and the Effects of Health Reform.
  Sergio Gonzales, Benjamin D. Sommers.
  Health Services Research. June 28, 2017
  Objective To examine the patterns of insurance coverage among nine Latino subgroups and assess heterogeneous effects of the Affordable Care Act (ACA) among these groups. Data Sources American Community Survey (2010–2014). Study Design We examined pre‐ACA disparities in coverage using linear probability models. Then, we used interrupted time series and triple‐difference models to evaluate coverage changes associated with the ACA and Medicaid expansion, respectively. Principal Findings Pre‐ACA coverage disparities between Latino subgroups were nearly 30 percentage points—larger than the gap between whites and Latinos as a whole. Coverage changes associated with the ACA and Medicaid expansion differed significantly between subgroups, with the largest gains among South Americans, Central Americans, and Mexicans. Conclusions Latino subgroups show marked heterogeneity in baseline coverage rates and responses to the ACA.

  June 28, 2017   doi: 10.1111/1475-6773.12733   open full text
• Do Avoidable Hospitalization Rates among Older Adults Differ by Geographic Access to Primary Care Physicians?
  Michael R. Daly, Jennifer M. Mellor, Marco Millones.
  Health Services Research. June 28, 2017
  Objective To investigate the association between older adults’ potentially avoidable hospitalization rates and both a geographic measure of primary care physician (PCP) access and a standard bounded‐area measure of PCP access. Data Sources State physician licensure data from the Virginia Board of Medicine. Patient‐level hospital discharge data from Virginia Health Information. Area‐level data from the American Community Survey and the Area Health Resources Files. Virginia Information Technologies Agency road network data. US Census Bureau TIGER/Line boundary files. Study Design We use enhanced two‐step floating catchment area methods to calculate geographic PCP accessibility for each ZIP Code Tabulation Area in Virginia. We use spatial regression techniques to model potentially avoidable hospitalization rates. Data Collection/Extraction Geographic accessibility was calculated using ArcGIS. Physician locations were geocoded using TAMU GeoServices and ArcGIS. Principal Findings Increased geographic access to PCPs is associated with lower rates of potentially avoidable hospitalization among older adults. This association is robust, allowing for spatial spillovers in spatial lag models. Conclusions Compared to bounded‐area density measures, unbounded geographic accessibility measures provide more robust evidence that avoidable hospitalization rates are lower in areas with more PCPs per person. Results from our spatial lag models reveal the presence of positive spatial spillovers.

  June 28, 2017   doi: 10.1111/1475-6773.12736   open full text
• Feasibility of Collecting Patient‐Reported Outcomes for Inpatient Rehabilitation Quality Reporting.
  Allen Walter Heinemann, Anne Deutsch, David Cella, Karon Frances Cook, Linda Foster, Ana Miskovic, Katharine Davis, Arielle Goldsmith.
  Health Services Research. June 15, 2017
  Objective To evaluate rehabilitation inpatients’ willingness and ability to complete patient‐reported outcomes (PROs) and the burden of completion on patients and staff. Data Sources/Study Setting Two inpatient rehabilitation facilities. Study Design Patients with neurological disorders were assigned randomly to receive a nominal monetary incentive during or 1 month after the stay. Data Collection Patients responded using a tablet computer or paper. Principal Findings Of the 1,055 admissions, 74 percent were eligible, and 51 percent of eligible patients completed the survey. Most answered without assistance. A majority completed the survey 1 month after discharge; incentive timing was unrelated to postdischarge completion. Half of the 285 follow‐up respondents required at least two reminder calls. Conclusions Collection of PROs from rehabilitation patients is feasible. Results inform policy makers regarding feasibility of PRO data in evaluating rehabilitation quality.

  June 15, 2017   doi: 10.1111/1475-6773.12729   open full text
• Quantifying Disparities in Accessibility and Availability of Pediatric Primary Care across Multiple States with Implications for Targeted Interventions.
  Monica Gentili, Pravara Harati, Nicoleta Serban, Jean O'Connor, Julie Swann.
  Health Services Research. June 13, 2017
  Objective To quantify disparities in accessibility and availability of pediatric primary care by modeling interventions across multiple states that compare publicly insured versus privately insured children, and urban versus rural communities. Data Sources Secondary data sources include 2013 National Plan and Provider Enumeration System, 2009 MAX Medicaid claims, 2012 American Community Survey. Study Design The study models accessibility and availability of care for all children in seven states. Methods Optimization modeling with access constraints is used to estimate access. Statistical hypothesis testing is used to quantify systematic disparities. Principal Findings California has the best accessibility for privately insured children and Minnesota for publicly insured children. Mississippi has the lowest availability for both populations. Overall, the disparities in availability for pediatric primary care are not as significant as in accessibility. Both rural and urban communities are in need of improvement in accessibility to primary care for publicly insured children, although at varying levels across states. Conclusions Disparities in availability are not as significant as disparities in accessibility. Opportunities to improve access to pediatric primary care vary by state. Generating specific recommendations for small areas is critical to enabling health policy decision makers to improvement access.

  June 13, 2017   doi: 10.1111/1475-6773.12722   open full text
• Food Insecurity and Health Care Expenditures in the United States, 2011–2013.
  Seth A. Berkowitz, Sanjay Basu, James B. Meigs, Hilary K. Seligman.
  Health Services Research. June 13, 2017
  Objective To determine whether food insecurity, limited or uncertain food access owing to cost, is associated with greater health care expenditures. Data Source/Study Setting Nationally representative sample of the civilian noninstitutionalized population of the United States (2011 National Health Interview Survey [NHIS] linked to 2012–2013 Medication Expenditure Panel Survey [MEPS]). Study Design Longitudinal retrospective cohort. Data Collection/Extraction Methods A total of 16,663 individuals underwent assessment of food insecurity, using the 10‐item adult 30‐day food security module, in the 2011 NHIS. Their total health care expenditures in 2012 and 2013 were recorded in MEPS. Expenditure data were analyzed using zero‐inflated negative binomial regression and adjusted for age, gender, race/ethnicity, education, income, insurance, and residence area. Principal Findings Fourteen percent of individuals reported food insecurity, representing 41,616,255 Americans. Mean annualized total expenditures were $4,113 (standard error $115); 9.2 percent of all individuals had no health care expenditures. In multivariable analyses, those with food insecurity had significantly greater estimated mean annualized health care expenditures ($6,072 vs. $4,208, p < .0001), an extra $1,863 in health care expenditure per year, or $77.5 billion in additional health care expenditure annually. Conclusions Food insecurity was associated with greater subsequent health care expenditures. Future studies should determine whether food insecurity interventions can improve health and reduce health care costs.

  June 13, 2017   doi: 10.1111/1475-6773.12730   open full text
• A Five‐Tier System for Improving the Categorization of Transplant Program Performance.
  Andrew Wey, Nicholas Salkowski, Bertram L. Kasiske, Ajay K. Israni, Jon J. Snyder.
  Health Services Research. June 13, 2017
  Objective To better inform health care consumers by better identifying differences in transplant program performance. Data Source Adult kidney transplants performed in the United States, January 1, 2012–June 30, 2014. Study Design In December 2016, the Scientific Registry of Transplant Recipients instituted a five‐tier system for reporting transplant program performance. We compare the differentiation of program performance and the simulated misclassification rate of the five‐tier system with the previous three‐tier system based on the 95 percent credible interval. Data Collection Scientific Registry of Transplant Recipients database. Principal Findings The five‐tier system improved differentiation and maintained a low misclassification rate of less than 22 percent for programs differing by two tiers. Conclusion The five‐tier system will better inform health care consumers of transplant program performance.

  June 13, 2017   doi: 10.1111/1475-6773.12726   open full text
• Use of Veterans Affairs and Medicaid Services for Dually Enrolled Veterans.
  Jean Yoon, Megan E. Vanneman, Sharon K. Dally, Amal N. Trivedi, Ciaran S. Phibbs.
  Health Services Research. June 13, 2017
  Objectives To examine how dual coverage for nonelderly, low‐income veterans by Veterans Affairs (VA) and Medicaid affects their demand for care. Data Sources Veterans Affairs utilization data and Medicaid Analytic Extract Files. Study Design A retrospective, longitudinal study of VA users prior to and following enrollment in Medicaid 2006–2010. Data Collection/Extraction Methods Veterans Affairs reliance, or proportion of care provided by VA, was estimated with beta‐binomial models, adjusting for patient and state Medicaid program factors. Principal Findings In a cohort of 19,890 nonelderly veterans, VA utilization levels were similar before and after enrolling in Medicaid. VA outpatient reliance was 0.65, and VA inpatient reliance was 0.53 after Medicaid enrollment. Factors significantly associated with greater VA reliance included sociodemographic factors, having a service‐connected disability, comorbidity, and higher state Medicaid reimbursement. Factors significantly associated with less VA reliance included months enrolled in Medicaid, managed care enrollment, Medicaid eligibility type, longer drive time to VA care, greater Medicaid eligibility generosity, and better Medicaid quality. Conclusion Veterans Affairs utilization following new Medicaid enrollment remained relatively unchanged, and the VA continued to provide the large majority of care for dually enrolled veterans. There was variation among patients as Medicaid eligibility and other program factors influenced their use of Medicaid services.

  June 13, 2017   doi: 10.1111/1475-6773.12727   open full text
• Did the Affordable Care Act's Dependent Coverage Expansion Affect Race/Ethnic Disparities in Health Insurance Coverage?
  Joshua Breslau, Bing Han, Bradley D. Stein, Rachel M. Burns, Hao Yu.
  Health Services Research. June 08, 2017
  Objective To test the impact of the dependent coverage expansion (DCE) on insurance disparities across race/ethnic groups. Data Sources/Study Setting Survey data from the National Survey of Drug Use and Health (NSDUH). Study Design Triple‐difference (DDD) models were applied to repeated cross‐sectional surveys of the U.S. adult population. Data Collection/Extraction Methods Data from 6 years (2008–2013) of the NSDUH were combined. Principal Findings Following the DCE, the relative odds of insurance increased 1.5 times (95 percent CI 1.1, 1.9) among whites compared to blacks and 1.4 times (95 percent CI 1.1, 1.8) among whites compared to Hispanics. Conclusions Health reform efforts, such as the DCE, can have negative effects on race/ethnic disparities, despite positive impacts in the general population.

  June 08, 2017   doi: 10.1111/1475-6773.12728   open full text
• Effects of Acute–Postacute Continuity on Community Discharge and 30‐Day Rehospitalization Following Inpatient Rehabilitation.
  James E. Graham, Janet Prvu Bettger, Addie Middleton, Heidi Spratt, Gulshan Sharma, Kenneth J. Ottenbacher.
  Health Services Research. June 05, 2017
  Objective To examine the effects of facility‐level acute–postacute continuity on probability of community discharge and 30‐day rehospitalization following inpatient rehabilitation. Data Sources We used national Medicare enrollment, claims, and assessment data to study 541,097 patients discharged from 1,156 inpatient rehabilitation facilities (IRFs) in 2010–2011. Study Design We calculated facility‐level continuity as the percentages of an IRF's patients admitted from each contributing acute care hospital. Patients were categorized into three groups: low continuity (<26 percent from same hospital that discharged the patient), medium continuity (26–75 percent from same hospital), or high continuity (>75 percent from same hospital). The multivariable models included an interaction term to examine the potential moderating effects of facility type (freestanding facility vs. hospital‐based rehabilitation unit) on the relationships between facility‐level continuity and our two outcomes: community discharge and 30‐day rehospitalization. Principal Findings Medicare beneficiaries in hospital‐based rehabilitation units were more likely to be referred from a high‐contributing hospital compared to those in freestanding facilities. However, the association between higher acute–postacute continuity and desirable outcomes is significantly better in freestanding rehabilitation facilities than in hospital‐based units. Conclusions Improving continuity is a key premise of health care reform. We found that both observed referral patterns and continuity‐related benefits differed markedly by facility type. These findings provide a starting point for health systems establishing or strengthening acute–postacute relationships to improve patient outcomes in this new era of shared accountability and public quality reporting programs.

  June 05, 2017   doi: 10.1111/1475-6773.12678   open full text
• Quality Metrics and Systems Transformation: Are We Advancing Alcohol and Drug Screening in Primary Care?
  Traci Rieckmann, Stephanie Renfro, Dennis McCarty, Robin Baker, K. John McConnell.
  Health Services Research. May 31, 2017
  Objective To examine the influence of Oregon's coordinated care organizations (CCOs) and pay‐for‐performance incentive model on completion of screening and brief intervention (SBI) and utilization of substance use disorder (SUD) treatment services. Data Sources/Study Setting Secondary analysis of Medicaid encounter data from 2012 to 2015 and semiannual qualitative interviews with stakeholders in CCOs. Study Design Longitudinal mixed‐methods design with simultaneous data collection with equal importance. Data Collection/Extraction Methods Qualitative interviews were recorded, transcribed, and coded in ATLAS.ti. Quantitative data included Medicaid encounters 30 months prior to CCO implementation, a 6‐month transition period, and 30 months following CCO implementation. Data were aggregated by half‐year with analyses restricted to Medicaid recipients 18–64 years of age enrolled in a CCO, not eligible for Medicare coverage or Medicaid expansion. Principal Findings Quantitative analysis documented a significant increase in SBI rates coinciding with CCO implementation (0.1 to 4.6 percent). Completed SBI was not associated with increased initiation in treatment for SUD diagnoses. Qualitative analysis highlighted importance of aligning incentives, workflow redesign, and leadership to facilitate statewide SBI. Conclusions Results provide modest support for use of a performance metric to expand SBI in primary care. Future research should examine health reform efforts that increase initiation and engagement in SUD treatment.

  May 31, 2017   doi: 10.1111/1475-6773.12716   open full text
• Two‐Stage Residual Inclusion Estimation in Health Services Research and Health Economics.
  Joseph V. Terza.
  Health Services Research. May 31, 2017
  Objectives Empirical analyses in health services research and health economics often require implementation of nonlinear models whose regressors include one or more endogenous variables—regressors that are correlated with the unobserved random component of the model. In such cases, implementation of conventional regression methods that ignore endogeneity will likely produce results that are biased and not causally interpretable. Terza et al. (2008) discuss a relatively simple estimation method that avoids endogeneity bias and is applicable in a wide variety of nonlinear regression contexts. They call this method two‐stage residual inclusion (2SRI). In the present paper, I offer a 2SRI how‐to guide for practitioners and a step‐by‐step protocol that can be implemented with any of the popular statistical or econometric software packages. Study Design We introduce the protocol and its Stata implementation in the context of a real data example. Implementation of 2SRI for a very broad class of nonlinear models is then discussed. Additional examples are given. Empirical Application We analyze cigarette smoking as a determinant of infant birthweight using data from Mullahy (1997). Conclusion It is hoped that the discussion will serve as a practical guide to implementation of the 2SRI protocol for applied researchers.

  May 31, 2017   doi: 10.1111/1475-6773.12714   open full text
• End‐of‐Life Care Planning in Accountable Care Organizations: Associations with Organizational Characteristics and Capabilities.
  Sangeeta C. Ahluwalia, Benjamin J. Harris, Valerie A. Lewis, Carrie H. Colla.
  Health Services Research. May 30, 2017
  Objective To measure the extent to which accountable care organizations (ACOs) have adopted end‐of‐life (EOL) care planning processes and characterize those ACOs that have established processes related to EOL. Data Sources This study uses data from three waves (2012–2015) of the National Survey of ACOs. Respondents were 397 ACOs participating in Medicare, Medicaid, and commercial ACO contracts. Study Design This is a cross‐sectional survey study using multivariate ordered logit regression models. We measured the extent to which the ACO had adopted EOL care planning processes as well as organizational characteristics, including care management, utilization management, health informatics, and shared decision‐making capabilities, palliative care, and patient‐centered medical home experience. Principal Findings Twenty‐one percent of ACOs had few or no EOL care planning processes, 60 percent had some processes, and 19.6 percent had advanced processes. ACOs with a hospital in their system (OR: 3.07; p = .01), and ACOs with advanced care management (OR: 1.43; p = .02), utilization management (OR: 1.58, p = .00), and shared decision‐making capabilities (OR: 16.3, p = .000) were more likely to have EOL care planning processes than those with no hospital or few to no capabilities. Conclusions There remains considerable room for today's ACOs to increase uptake of EOL care planning, possibly by leveraging existing care management, utilization management, and shared decision‐making processes.

  May 30, 2017   doi: 10.1111/1475-6773.12720   open full text
• Impact of an Individual Mandate and Other Health Reforms on Dependent Coverage for Adolescents and Young Adults.
  Lauren E. Wisk, Jonathan A. Finkelstein, Sara L. Toomey, Gregory S. Sawicki, Mark A. Schuster, Alison A. Galbraith.
  Health Services Research. May 30, 2017
  Objective To determine the effect of state‐level dependent coverage expansion (DCE) with and without other state health reforms on exit from dependent coverage for adolescents and young adults (AYA). Data Sources Administrative longitudinal data for 131,542 privately insured AYA in Massachusetts (DCE with other reforms) versus Maine and New Hampshire (DCE without other reforms) across three periods: prereform (1/00–12/06), poststate reform (1/07–9/10), and postfederal reform (10/10–12/12). Study Design A difference‐in‐differences estimator was used to determine the rate of exit from dependent coverage, age at exit from dependent coverage, and re‐uptake of dependent coverage among AYA in states with comprehensive reforms versus DCE only. Principal Findings Implementation of DCE with other reforms was significantly associated with a 23 percent reduction in exit from dependent coverage among AYA compared to the reduction observed for DCE alone. Additionally, comprehensive reforms were associated with over two additional years of dependent coverage for the average AYA and a 33 percent increase in the odds of regaining dependent coverage after a prior loss. Conclusions Findings suggest that an individual mandate and other reforms may enhance the effect of DCE in preventing loss of coverage among AYA.

  May 30, 2017   doi: 10.1111/1475-6773.12723   open full text
• Patient Experience of Chronic Illness Care and Medical Home Transformation in Safety Net Clinics.
  Elizabeth L. Tung, Yue Gao, Monica E. Peek, Robert S. Nocon, Kathryn E. Gunter, Sang Mee Lee, Marshall H. Chin.
  Health Services Research. May 30, 2017
  Objective To examine the relationship between medical home transformation and patient experience of chronic illness care. Study Setting Thirteen safety net clinics located in five states enrolled in the Safety Net Medical Home Initiative. Study Design Repeated cross‐sectional surveys of randomly selected adult patients were completed at baseline (n = 303) and postintervention (n = 271). Data Collection Methods Questions from the Patient Assessment of Chronic Illness Care (PACIC) (100‐point scale) were used to capture patient experience of chronic illness care. Generalized estimating equation methods were used to (i) estimate how differential improvement in patient‐centered medical home (PCMH) capability affected differences in modified PACIC scores between baseline and postintervention, and (ii) to examine cross‐sectional associations between PCMH capability and modified PACIC scores for patients at completion of the intervention. Principal Findings In adjusted analyses, high PCMH improvement (above median) was only marginally associated with a larger increase in total modified PACIC score (adjusted β = 7.7, 95 percent confidence interval [CI]: −1.1 to 16.5). At completion of the intervention, a 10‐point higher PCMH capability score was associated with an 8.9‐point higher total modified PACIC score (95 percent CI: 3.1–14.7) and higher scores in four of five subdomains (patient activation, delivery system design, contextual care, and follow‐up/coordination). Conclusions We report that sustained, 5‐year medical home transformation may be associated with modest improvement in patient experience of chronic illness care for vulnerable populations in safety net clinics.

  May 30, 2017   doi: 10.1111/1475-6773.12608   open full text
• Payment Reform and Health Disparities: Changes in Dialysis Modality under the New Medicare Dialysis Payment System.
  Marc Turenne, Regina Baker, Jeffrey Pearson, Chad Cogan, Purna Mukhopadhyay, Elizabeth Cope.
  Health Services Research. May 30, 2017
  Objective To evaluate the effect of the Medicare dialysis payment reform on potential disparities in the selection of peritoneal dialysis (PD) for the treatment of end‐stage renal disease (ESRD). Data Sources Centers for Medicare & Medicaid Services (CMS) ESRD Medical Evidence Form, Medicare claims, and other CMS data for 2008–2013. Study Design We examined the association of patient age, race/ethnicity, urban/rural location, pre‐ESRD care, comorbidities, insurance, and other factors with the selection of PD as initial dialysis modality across prereform (2008–2009), interim (2010), and postreform (2011–2013) time periods. Principal Findings Selection of PD increased among diverse patient subgroups following the payment reform. However, the lower PD selection observed with older age, black race, Hispanic ethnicity, less pre‐ESRD care, and Medicaid insurance before the reform largely remained in the initial postreform years. Conclusions Despite recent growth in PD, there may be ongoing disparities in access to PD that have largely not been mitigated by the payment reform. There is potential for modifying provider financial incentives to achieve policy goals related to cost and quality of care. However, even with a substantial shift in financial incentives, separate initiatives to reduce existing disparities in care may be needed.

  May 30, 2017   doi: 10.1111/1475-6773.12713   open full text
• Log Odds and the Interpretation of Logit Models.
  Edward C. Norton, Bryan E. Dowd.
  Health Services Research. May 30, 2017
  Objective We discuss how to interpret coefficients from logit models, focusing on the importance of the standard deviation (σ) of the error term to that interpretation. Study Design We show how odds ratios are computed, how they depend on the standard deviation (σ) of the error term, and their sensitivity to different model specifications. We also discuss alternatives to odds ratios. Principal Findings There is no single odds ratio; instead, any estimated odds ratio is conditional on the data and the model specification. Odds ratios should not be compared across different studies using different samples from different populations. Nor should they be compared across models with different sets of explanatory variables. Conclusions To communicate information regarding the effect of explanatory variables on binary {0,1} dependent variables, average marginal effects are generally preferable to odds ratios, unless the data are from a case–control study.

  May 30, 2017   doi: 10.1111/1475-6773.12712   open full text
• Comparing the Effectiveness of Dynamic Treatment Strategies Using Electronic Health Records: An Application of the Parametric g‐Formula to Anemia Management Strategies.
  Yi Zhang, Jessica G. Young, Mae Thamer, Miguel A. Hernán.
  Health Services Research. May 30, 2017
  Objective To compare the effectiveness of dynamic anemia management strategies by applying the parametric g‐formula to electronic health records. Data Source/Study Setting Patients with end‐stage renal disease from the US Renal Data System who had congestive heart failure or ischemic heart disease and were undergoing hemodialysis in outpatient dialysis facilities between 2006 and 2010. Study Design We explicitly emulated a target trial of three ‎erythropoietin dosing strategies (aimed at achieving a low, middle, or high hematocrit) and estimated the observational analog of the per‐protocol effect. Results Of 156,945 eligible patients, 41,970 died during the 18‐month follow‐up. Compared to the low‐hematocrit strategy, the estimated risk of death was 4.6 (95% CI 4.4–4.9) percentage points higher under the high‐hematocrit strategy and 1.8 (95% CI 1.7–1.9) percentage points higher under the mid‐hematocrit strategy. The corresponding risk differences for a composite outcome of death and myocardial infarction were similar. Conclusion An explicit emulation of a target trial using electronic health records, combined with the parametric g‐formula, allowed comparison of real‐world dynamic strategies that have not been compared in randomized trials.

  May 30, 2017   doi: 10.1111/1475-6773.12718   open full text
• Massachusetts Health Reform's Effect on Hospitalizations with Substance Use Disorder–Related Diagnoses.
  Karen E. Lasser, Amresh D. Hanchate, Danny McCormick, Alexander Y. Walley, Richard Saitz, Meng‐Yun Lin, Nancy R. Kressin.
  Health Services Research. May 19, 2017
  Objective To examine whether Massachusetts (MA) health reform affected substance (alcohol or drug) use disorder (SUD)–related hospitalizations in acute care hospitals. Data/Study Setting 2004–2010 MA inpatient discharge data. Design Difference‐in‐differences analysis to identify pre‐ to postreform changes in age‐ and sex‐standardized population‐based rates of SUD‐related medical and surgical hospitalizations, adjusting for secular trends. Data Extraction Methods We identified 373,751 discharges where a SUD‐related diagnosis was a primary or secondary discharge diagnosis. Findings Adjusted for age and sex, the rates of drug use–related and alcohol use–related hospitalizations prereform were 7.21 and 8.87 (per 1,000 population), respectively, in high‐uninsurance counties, and 8.58 and 9.63, respectively, in low‐uninsurance counties. Both SUD‐related rates increased after health reform in high‐ and low‐uninsurance counties. Adjusting for secular trends in the high‐ and low‐uninsurance counties, health reform was associated with no change in drug‐ or alcohol‐related hospitalizations. Conclusions Massachusetts health reform was not associated with any changes in substance use disorder–related hospitalizations. Further research is needed to determine how to reduce substance use disorder–related hospitalizations, beyond expanding insurance coverage.

  May 19, 2017   doi: 10.1111/1475-6773.12710   open full text
• The Impact of the ACA Medicaid Expansions on Health Insurance Coverage through 2015 and Coverage Disparities by Age, Race/Ethnicity, and Gender.
  George L. Wehby, Wei Lyu.
  Health Services Research. May 18, 2017
  Objective Examine the ACA Medicaid expansion effects on Medicaid take‐up and private coverage through 2015 and coverage disparities by age, race/ethnicity, and gender. Data Sources 2011–2015 American Community Survey for 3,137,989 low‐educated adults aged 19–64 years. Study Design Difference‐in‐differences regressions accounting for national coverage trends and state fixed effects. Principal Findings Expansion effects doubled in 2015 among low‐educated adults, with a nearly 8 percentage‐point increase in Medicaid take‐up and 6 percentage‐point decline in uninsured rate. Significant coverage gains were observed across virtually all examined groups by age, gender, and race/ethnicity. Take‐up and insurance declines were strongest among younger adults and were generally close by gender and race/ethnicity. Despite the increased take‐up however, coverage disparities remained sizeable, especially for young adults and Hispanics who had declining but still high uninsured rates in 2015. There was some evidence of private coverage crowd‐out in certain subgroups, particularly among young adults aged 19–26 years and women, including in both individually purchased and employer‐sponsored coverage. Conclusions The ACA Medicaid expansions have continued to increase coverage in 2015 across the entire population of low‐educated adults and have reduced age disparities in coverage. However, there is still a need for interventions that target eligible young and Hispanic adults.

  May 18, 2017   doi: 10.1111/1475-6773.12711   open full text
• The Impact of Childhood Obesity on Health and Health Service Use.
  Jonas Minet Kinge, Stephen Morris.
  Health Services Research. May 17, 2017
  Objective To test the impact of obesity on health and health care use in children, by the use of various methods to account for reverse causality and omitted variables. Data Sources/Study Setting Fifteen rounds of the Health Survey for England (1998–2013), which is representative of children and adolescents in England. Study Design We use three methods to account for reverse causality and omitted variables in the relationship between BMI and health/health service use: regression with individual, parent, and household control variables; sibling fixed effects; and instrumental variables based on genetic variation in weight. Data Collection/Extraction Methods We include all children and adolescents aged 4–18 years old. Principal Findings We find that obesity has a statistically significant and negative impact on self‐rated health and a positive impact on health service use in girls, boys, younger children (aged 4–12), and adolescents (aged 13–18). The findings are comparable in each model in both boys and girls. Conclusions Using econometric methods, we have mitigated several confounding factors affecting the impact of obesity in childhood on health and health service use. Our findings suggest that obesity has severe consequences for health and health service use even among children.

  May 17, 2017   doi: 10.1111/1475-6773.12708   open full text
• Hospital and Health Insurance Markets Concentration and Inpatient Hospital Transaction Prices in the U.S. Health Care Market.
  Seidu Dauda.
  Health Services Research. May 11, 2017
  Objective To examine the effects of hospital and insurer markets concentration on transaction prices for inpatient hospital services. Data Sources Measures of hospital and insurer markets concentration derived from American Hospital Association and HealthLeaders‐InterStudy data are linked to 2005–2008 inpatient administrative data from Truven Health MarketScan Databases. Study Design Uses a reduced‐form price equation, controlling for cost and demand shifters and accounting for possible endogeneity of market concentration using instrumental variables (IV) technique. Principal Findings The findings suggest that greater hospital concentration raises prices, whereas greater insurer concentration depresses prices. A hypothetical merger between two of five equally sized hospitals is estimated to increase hospital prices by about 9 percent (p < .001). A similar merger of insurers would depress prices by about 15.3 percent (p < .001). Over the 2003–2008 periods, the estimates imply that hospital consolidation likely raised prices by about 2.6 percent, while insurer consolidation depressed prices by about 10.8 percent. Additional analysis using longer panel data and applying hospital fixed effects confirms the impact of hospital concentration on prices. Conclusion The findings provide support for strong antitrust enforcement to curb rising hospital service prices and health care costs.

  May 11, 2017   doi: 10.1111/1475-6773.12706   open full text
• Further Evidence on the System‐Wide Effects of the Hospital Readmissions Reduction Program.
  Berna Demiralp, Fang He, Lane Koenig.
  Health Services Research. May 08, 2017
  Objective To investigate the potential spillover effects of the Hospital Readmissions Reduction Program (HRRP) on readmissions for nontargeted conditions and patient populations. We examine HRRP effects on nontargeted conditions separately and on non‐Medicare populations in Florida and California. Data Sources From 2007–2013, 100 percent Medicare inpatient claims data, 2007–2013 State Inpatient Database (SID) for Florida, and 2007–2011 SID for California. Study Design We conducted an interrupted time series analysis to estimate the change in 30‐day all‐cause unplanned readmission trends after the start of HRRP using logistic regression. Principal Findings Hospitals with the largest reductions in targeted Medicare readmissions experienced higher reductions in nontargeted Medicare readmissions. Among nontargeted conditions, reductions were higher for neurology and surgery conditions than for the cardiovascular and cardiorespiratory conditions, which are clinically similar to the targeted conditions. For non‐Medicare patients, readmission trends for targeted conditions in Florida and California did not change after HRRP. Conclusions Our findings are consistent with positive spillover benefits associated with HRRP. The extent of these benefits, however, varies across condition and patient groups. The observed patterns suggest a complex response, including a role of nonfinancial factors, in driving lower readmissions.

  May 08, 2017   doi: 10.1111/1475-6773.12701   open full text
• The ACA Medicaid Expansion, Disproportionate Share Hospitals, and Uncompensated Care.
  Susan Camilleri.
  Health Services Research. May 08, 2017
  Objective To estimate the effect of the first full year of the ACA Medicaid expansion on hospital provision of uncompensated care, with special attention paid to hospitals that treat a disproportionate share of low‐income patients. Data Sources Data from a balanced panel of short‐term, general, nonfederal, Medicare‐certified hospitals were obtained from Medicare cost reports from 2011 to 2014. Study Design/Study Setting A series of difference‐in‐differences analyses were performed using hospitals in nonexpansion states as the control group. The dependent variable is hospital provision of uncompensated care. Data Collection/Extraction Methods The data were downloaded from the National Bureau of Economic Research website. Principal Findings The Medicaid expansion significantly reduced hospital provision of uncompensated care in 2014. In particular, within expansion states, DSH hospitals saw reductions beyond those experienced by non‐DSH hospitals. Conclusions Evidence from this study indicates that the Medicaid expansion served to widen an already broad gap in provision of uncompensated care between hospitals in expansion and nonexpansion states. In addition, within expansion states, variation in uncompensated care between hospitals that treat a disproportionate share of low‐income patients and those that do not was reduced, with the former experiencing significantly larger reductions. Lawmakers considering expanding Medicaid and those deciding appropriate levels of DSH payments should consider these findings.

  May 08, 2017   doi: 10.1111/1475-6773.12702   open full text
• Racial/Ethnic and Gender Disparities in Health Care Use and Access.
  Jennifer I. Manuel.
  Health Services Research. May 08, 2017
  Objective To document racial/ethnic and gender differences in health service use and access after the Affordable Care Act went into effect. Data Source Secondary data from the 2006–2014 National Health Interview Survey. Study Design Linear probability models were used to estimate changes in health service use and access (i.e., unmet medical need) in two separate analyses using data from 2006 to 2014 and 2012 to 2014. Data Extraction Adult respondents aged 18 years and older (N = 257,560). Principal Findings Results from the 2006–2014 and 2012–2014 analyses show differential patterns in health service use and access by race/ethnicity and gender. Non‐Hispanic whites had the greatest gains in health service use and access across both analyses. While there was significant progress among Hispanic respondents from 2012 to 2014, no significant changes were found pre–post‐health care reform, suggesting access may have worsened before improving for this group. Asian men had the largest increase in office visits between 2006 and 2014, and although not statistically significant, the increase continued 2012–2014. Black women and men fared the worst with respect to changes in health care access. Conclusions Ongoing research is needed to track patterns of health service use and access, especially among vulnerable racial/ethnic and gender groups, to determine whether existing efforts under health care reform reduce long‐standing disparities.

  May 08, 2017   doi: 10.1111/1475-6773.12705   open full text
• Effect of Out‐of‐Pocket Cost on Medication Initiation, Adherence, and Persistence among Patients with Type 2 Diabetes: The Diabetes Study of Northern California (DISTANCE).
  Andrew J. Karter, Melissa M. Parker, Matthew D. Solomon, Courtney R. Lyles, Alyce S. Adams, Howard H. Moffet, Mary E. Reed.
  Health Services Research. May 05, 2017
  Objective To estimate the effect of out‐of‐pocket (OOP) cost on nonadherence to classes of cardiometabolic medications among patients with diabetes. Data Sources/Setting Electronic health records from a large, health care delivery system for 223,730 patients with diabetes prescribed 842,899 new cardiometabolic medications during 2006–2012. Study Design Observational, new prescription cohort study of the effect of OOP cost on medication initiation and adherence. Data Collection Adherence and OOP costs were based on pharmacy dispensing records and benefits. Principal Findings Primary nonadherence (never dispensed) increased monotonically with OOP cost after adjusting for demographics, neighborhood socioeconomic status, Medicare, medical financial assistance, OOP maximum, deductibles, mail order pharmacy incentive and use, drug type, generic or brand, day's supply, and comorbidity index; 7 percent were never dispensed the new medication when OOP cost ≥$11, 5 percent with OOP cost of $1–$10, and 3 percent when the medication was free of charge (p < .0001). Higher OOP cost was also strongly associated with inadequate secondary adherence (≥20 percent of time without adequate medication). There was no clinically significant or consistent relationship between OOP costs and early nonpersistence (dispensed once, never refilled) or later stage nonpersistence (discontinued within 24 months). Conclusions Cost‐sharing may deter clinically vulnerable patients from initiating essential medications, undermining adherence and risk factor control.

  May 05, 2017   doi: 10.1111/1475-6773.12700   open full text
• The HCUP SID Imputation Project: Improving Statistical Inferences for Health Disparities Research by Imputing Missing Race Data.
  Yan Ma, Wei Zhang, Stephen Lyman, Yihe Huang.
  Health Services Research. May 04, 2017
  Objective To identify the most appropriate imputation method for missing data in the HCUP State Inpatient Databases (SID) and assess the impact of different missing data methods on racial disparities research. Data Sources/Study Setting HCUP SID. Study Design A novel simulation study compared four imputation methods (random draw, hot deck, joint multiple imputation [MI], conditional MI) for missing values for multiple variables, including race, gender, admission source, median household income, and total charges. The simulation was built on real data from the SID to retain their hierarchical data structures and missing data patterns. Additional predictive information from the U.S. Census and American Hospital Association (AHA) database was incorporated into the imputation. Principal Findings Conditional MI prediction was equivalent or superior to the best performing alternatives for all missing data structures and substantially outperformed each of the alternatives in various scenarios. Conclusions Conditional MI substantially improved statistical inferences for racial health disparities research with the SID.

  May 04, 2017   doi: 10.1111/1475-6773.12704   open full text
• Repeated, Close Physician Coronary Artery Bypass Grafting Teams Associated with Greater Teamwork.
  Jordan Everson, Russell J. Funk, Samuel R. Kaufman, Jason Owen‐Smith, Brahmajee K. Nallamothu, Francis D. Pagani, John M. Hollingsworth.
  Health Services Research. May 04, 2017
  Objective To determine whether observed patterns of physician interaction around shared patients are associated with higher levels of teamwork as perceived by physicians. Data Sources/Study Setting Michigan Medicare beneficiaries who underwent coronary artery bypass grafting (CABG) procedures at 24 hospitals in the state between 2008 and 2011. Study Design We assessed hospital teamwork using the teamwork climate scale in the Safety Attitudes Questionnaire. After aggregating across CABG discharges at these hospitals, we mapped the physician referral networks (including both surgeons and nonsurgeons) that served them and measured three network properties: (1) reinforcement, (2) clustering, and (3) density. We then used multilevel regression models to identify associations between network properties and teamwork at the hospitals on which the networks were anchored. Principal Findings In hospitals where physicians repeatedly cared for patients with the same colleagues, physicians perceived better teamwork (β‐reinforcement = 3.28, p = .003). When physicians who worked together also had other colleagues in common, the reported teamwork was stronger (β clustering = 1.71, p = .001). Reported teamwork did not change when physicians worked with a higher proportion of other physicians at the hospital (β density = −0.58, p = .64). Conclusion In networks with higher levels of reinforcement and clustering, physicians perceive stronger teamwork, perhaps because the strong ties between them create a shared understanding; however, sharing patients with more physicians overall (i.e., density) did not lead to stronger teamwork. Clinical and organizational leaders may consider designing the structure of clinical teams to increase interactions with known colleagues and repeated interactions between providers.

  May 04, 2017   doi: 10.1111/1475-6773.12703   open full text
• Did Health Care Reform Help Kentucky Address Disparities in Coverage and Access to Care among the Poor?
  Joseph A. Benitez, E. Kathleen Adams, Eric E. Seiber.
  Health Services Research. April 25, 2017
  Objective To evaluate the impact of Kentucky's full rollout of the Affordable Care Act on disparities in access to care due to poverty. Data Source Restricted version of the Behavioral Risk Factor Surveillance System (BRFSS) for Kentucky and years 2011–2015. Study Design We use a difference‐in‐differences framework to compare trends before and after implementation of the Affordable Care Act (ACA) in health insurance coverage, several access measures, and health care utilization for residents in higher versus lower poverty ZIP codes. Principal Findings Much of the reduction in Kentucky's uninsured rate appears driven by large uptakes in coverage from areas with higher concentrations of poverty. Residents in high‐poverty communities experienced larger reductions, 8 percentage points (pp) in uninsured status and 7.5 pp in reporting unmet needs due to costs, than residents of lower poverty areas. These effects helped remove pre‐ACA disparities in uninsured rates across these areas. Conclusion Because we observe positive effects on coverage and reductions in financial barriers to care among those from poorer communities, our findings suggest that expanding Medicaid helps address the health care needs of the impoverished.

  April 25, 2017   doi: 10.1111/1475-6773.12699   open full text
• Do State Continuing Medical Education Requirements for Physicians Improve Clinical Knowledge?
  Jonathan L. Vandergrift, Bradley M. Gray, Weifeng Weng.
  Health Services Research. April 16, 2017
  Objective To evaluate the effect of state continuing medical education (CME) requirements on physician clinical knowledge. Data Sources Secondary data for 19,563 general internists who took the Internal Medicine Maintenance of Certification (MOC) examination between 2006 and 2013. Study Design We took advantage of a natural experiment resulting from variations in CME requirements across states over time and applied a difference‐in‐differences methodology to measure associations between changes in CME requirements and physician clinical knowledge. We measured changes in clinical knowledge by comparing initial and MOC examination performance 10 years apart. We constructed difference‐in‐differences estimates by regressing examination performance changes against physician demographics, county and year fixed effects, trend–state indicators, and state CME change indicators. Data Collection Physician data were compiled by the American Board of Internal Medicine. State CME policies were compiled from American Medical Association reports. Principal Findings More rigorous CME credit‐hour requirements (mostly implementing a new requirement) were associated with an increase in examination performance equivalent to a shift in examination score from the 50th to 54th percentile. Conclusions Among physicians required to engage in a summative assessment of their clinical knowledge, CME requirements were associated with an improvement in physician clinical knowledge.

  April 16, 2017   doi: 10.1111/1475-6773.12697   open full text
• The Effect of Medicaid Physician Fee Increases on Health Care Access, Utilization, and Expenditures.
  Kevin Callison, Binh T. Nguyen.
  Health Services Research. April 16, 2017
  Objective To evaluate the effect of Medicaid fee changes on health care access, utilization, and spending for Medicaid beneficiaries. Data Source We use the 2008 and 2012 waves of the Medical Expenditure Panel Survey linked to state‐level Medicaid‐to‐Medicare primary care reimbursement ratios obtained through surveys conducted by the Urban Institute. We also incorporate data from the Current Population Survey and the Area Resource Files. Study Design Using a control group made up of the low‐income privately insured, we conduct a difference‐in‐differences analysis to assess the relationship between Medicaid fee changes and access to care, utilization of health care services, and out‐of‐pocket medical expenditures for Medicaid enrollees. Principal Findings We find that an increase in the Medicaid‐to‐Medicare payment ratio for primary care services results in an increase in outpatient physician visits, emergency department utilization, and prescription fills, but only minor improvements in access to care. In addition, we report an increase in total annual out‐of‐pocket expenditures and spending on prescription medications. Conclusions Compared to the low‐income privately insured, increased primary care reimbursement for Medicaid beneficiaries leads to higher utilization and out‐of‐pocket spending for Medicaid enrollees.

  April 16, 2017   doi: 10.1111/1475-6773.12698   open full text
• Validity and Reliability of Administrative Coded Data for the Identification of Hospital‐Acquired Infections: An Updated Systematic Review with Meta‐Analysis and Meta‐Regression Analysis.
  Olga Redondo‐González, José María Tenías, Ángel Arias, Alfredo J. Lucendo.
  Health Services Research. April 11, 2017
  Objective To conduct an updated assessment of the validity and reliability of administrative coded data (ACD) in identifying hospital‐acquired infections (HAIs). Methods We systematically searched three libraries for studies on ACD detecting HAIs compared to manual chart review. Meta‐analyses were conducted for prosthetic and nonprosthetic surgical site infections (SSIs), Clostridium difficile infections (CDIs), ventilator‐associated pneumonias/events (VAPs/VAEs) and non‐VAPs/VAEs, catheter‐associated urinary tract infections (CAUTIs), and central venous catheter‐related bloodstream infections (CLABSIs). A random‐effects meta‐regression model was constructed. Results Of 1,906 references found, we retrieved 38 documents, of which 33 provided meta‐analyzable data (N = 567,826 patients). ACD identified HAI incidence with high specificity (≥93 percent), prosthetic SSIs with high sensitivity (95 percent), and both CDIs and nonprosthetic SSIs with moderate sensitivity (65 percent). ACD exhibited substantial agreement with traditional surveillance methods for CDI (κ = 0.70) and provided strong diagnostic odds ratios (DORs) for the identification of CDIs (DOR = 772.07) and SSIs (DOR = 78.20). ACD performance in identifying nosocomial pneumonia depended on the ICD coding system (DORICD‐10/ICD‐9‐CM = 0.05; p = .036). Algorithmic coding improved ACD's sensitivity for SSIs up to 22 percent. Overall, high heterogeneity was observed, without significant publication bias. Conclusions Administrative coded data may not be sufficiently accurate or reliable for the majority of HAIs. Still, subgrouping and algorithmic coding as tools for improving ACD validity deserve further investigation, specifically for prosthetic SSIs. Analyzing a potential lower discriminative ability of ICD‐10 coding system is also a pending issue.

  April 11, 2017   doi: 10.1111/1475-6773.12691   open full text
• The Effect of Access to Electronic Health Records on Throughput Efficiency and Imaging Utilization in the Emergency Department.
  Matthew M. Knepper, Edward M. Castillo, Theodore C. Chan, David A. Guss.
  Health Services Research. April 04, 2017
  Study Objective To evaluate whether the availability of Electronic Health Records (EHRs) reduces throughput time and utilization of advanced imaging for patients in an academic ED. Data Sources All patients arriving at an academic Emergency Department (ED) via ambulance between June 1, 2011, and June 4, 2012, were included in the study. This accounted for 9,970 unique ambulance patient visits. Study Design Retrospective noninterventional analysis of patients in an academic ED. The primary independent variable was whether the patient had a prior EHR at the study hospital. Main outcomes were throughput time, number of advanced diagnostic imaging studies (CT, MRI, ultrasound), and the associated cost of these imaging studies. A set of controls, including age, gender, ICD9 codes, acuity measures, and NYU ED algorithm case severity classifications, was used in an ordinary least‐squares (OLS) regression framework to estimate the association between EHR availability and the outcome measures. Principal Findings A patient with a prior EHR experienced a mean reduction in CT scans of 13.9 percent ([4.9, 23.0]). There was no material change in throughput time for patients with a prior EHR and no difference in utilization of other imaging studies across patients with a prior EHR and those without. Cost savings associated with prior EHRs are $22.52 per patient visit. Conclusion EHR availability for ED patients is associated with a reduction in CT scans and cost savings but had no impact on throughput time or order frequency of other imaging studies.

  April 04, 2017   doi: 10.1111/1475-6773.12695   open full text
• Disparities in Potentially Preventable Hospitalizations: Near‐National Estimates for Hispanics.
  Chen Feng, Michael K. Paasche‐Orlow, Nancy R. Kressin, Jennifer E. Rosen, Lenny López, Eun Ji Kim, Meng‐Yun Lin, Amresh D. Hanchate.
  Health Services Research. April 04, 2017
  Objective To obtain near‐national rates of potentially preventable hospitalization (PPH)—a marker of barriers to outpatient care access—for Hispanics; to examine their differences from other race‐ethnic groups and by Hispanic national origin; and to identify key mediating factors. Data Sources/Study Setting Data from all‐payer inpatient discharge databases for 15 states accounting for 85 percent of Hispanics nationally. Study Design Combining counts of inpatient discharges with census population for adults aged 18 and older, we estimated age‐sex‐adjusted PPH rates. We examined county‐level variation in race‐ethnic disparities in these rates to identify the mediating role of area‐level indicators of chronic condition prevalence, socioeconomic status (SES), health care access, acculturation, and provider availability. Principal Findings Age‐sex‐adjusted PPH rates were 13 percent higher among Hispanics (1,375 per 100,000 adults) and 111 percent higher among blacks (2,578) compared to whites (1,221). Among Hispanics, these rates were relatively higher in areas with predominantly Puerto Rican and Cuban Americans than in areas with Hispanics of other nationalities. Small area variation in chronic condition prevalence and SES fully accounted for the higher rates among Hispanics, but only partially among blacks. Conclusions Hispanics and blacks face higher barriers to outpatient care access; the higher barriers among Hispanics (but not blacks) seem mediated by SES, lack of insurance, cost barriers, and limited provider availability.

  April 04, 2017   doi: 10.1111/1475-6773.12694   open full text
• Development and Validation of the Agency for Healthcare Research and Quality Measures of Potentially Preventable Emergency Department (ED) Visits: The ED Prevention Quality Indicators for General Health Conditions.
  Sheryl Davies, Ellen Schultz, Maria Raven, Nancy Ewen Wang, Carol L. Stocks, Mucio Kit Delgado, Kathryn M. McDonald.
  Health Services Research. March 30, 2017
  Objective To develop and validate rates of potentially preventable emergency department (ED) visits as indicators of community health. Data Sources Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project 2008–2010 State Inpatient Databases and State Emergency Department Databases. Study Design Empirical analyses and structured panel reviews. Methods Panels of 14–17 clinicians and end users evaluated a set of ED Prevention Quality Indicators (PQIs) using a Modified Delphi process. Empirical analyses included assessing variation in ED PQI rates across counties and sensitivity of those rates to county‐level poverty, uninsurance, and density of primary care physicians (PCPs). Principal Findings ED PQI rates varied widely across U.S. communities. Indicator rates were significantly associated with county‐level poverty, median income, Medicaid insurance, and levels of uninsurance. A few indicators were significantly associated with PCP density, with higher rates in areas with greater density. A clinical and an end‐user panel separately rated the indicators as having strong face validity for most uses evaluated. Conclusions The ED PQIs have undergone initial validation as indicators of community health with potential for use in public reporting, population health improvement, and research.

  March 30, 2017   doi: 10.1111/1475-6773.12687   open full text
• Emergency Department Attendance after Telephone Triage: A Population‐Based Data Linkage Study.
  Amy Gibson, Deborah Randall, Duong T. Tran, Mary Byrne, Anthony Lawler, Alys Havard, Maureen Robinson, Louisa R. Jorm.
  Health Services Research. March 29, 2017
  Objective To investigate compliance with telephone helpline advice to attend an emergency department (ED) and the acuity of patients who presented to ED following a call. Data Sources/Collection Methods In New South Wales (NSW), Australia, 2009–2012, all (1.04 million) calls to a telephone triage service, ED presentations, hospital admissions and death registrations, linked using probabilistic data linkage. Study Design Population‐based, observational cohort study measuring ED presentations within 24 hours of a call in patients (1) with dispositions to attend ED (compliance) and (2) low‐urgency dispositions (self‐referral), triage categories on ED presentation. Principal Findings A total of 66.5 percent of patients were compliant with dispositions to attend an ED. A total of 6.2 percent of patients with low‐urgency dispositions self‐referred to the ED within 24 hours. After age adjustment, healthdirect compliant patients were significantly less likely (7.8 percent) to receive the least urgent ED triage category compared to the general NSW ED population (16.9 percent). Conclusions This large population‐based data linkage study provides precise estimates of ED attendance following calls to a telephone triage service and details the predictors of ED attendance. Patients who attend an ED compliant with a healthdirect helpline disposition are significantly less likely than the general ED population to receive the lowest urgency triage category on arrival.

  March 29, 2017   doi: 10.1111/1475-6773.12692   open full text
• Medicare's Acute Care Episode Demonstration: Effects of Bundled Payments on Costs and Quality of Surgical Care.
  Lena M. Chen, Andrew M. Ryan, Terry Shih, Jyothi R. Thumma, Justin B. Dimick.
  Health Services Research. March 28, 2017
  Objective To evaluate whether participation in Medicare's Acute Care Episode (ACE) Demonstration Program—an early, small, voluntary episode‐based payment program—was associated with a change in expenditures or quality of care. Data Sources/Study Setting Medicare claims for patients who underwent cardiac or orthopedic surgery from 2007 to 2012 at ACE or control hospitals. Study Design We used a difference‐in‐differences approach, matching on baseline and pre‐enrollment volume, risk‐adjusted Medicare payments, and clinical outcomes to identify controls. Principal Findings Participation in the ACE Demonstration was not significantly associated with 30‐day Medicare payments (for orthopedic surgery: −$358 with 95 percent CI: −$894, +$178; for cardiac surgery: +$514 with 95 percent CI: −$1,517, +$2,545), or 30‐day mortality (for orthopedic surgery: −0.10 with 95 percent CI: −0.50, 0.31; for cardiac surgery: −0.27 with 95 percent CI: −1.25, 0.72). Program participation was associated with a decrease in total 30‐day post‐acute care payments (for cardiac surgery: −$718; 95 percent CI: −$1,431, −$6; and for orthopedic surgery: −$591; 95 percent CI: $‐$1,161, −$22). Conclusions Participation in Medicare's ACE Demonstration Program was not associated with a change in 30‐day episode‐based Medicare payments or 30‐day mortality for cardiac or orthopedic surgery, but it was associated with lower total 30‐day post‐acute care payments.

  March 28, 2017   doi: 10.1111/1475-6773.12681   open full text
• A Longitudinal Assessment of the Effect of Resident‐Centered Care on Quality in Veterans Health Administration Community Living Centers.
  Jennifer L. Sullivan, Michael Shwartz, Kelly Stolzmann, Melissa K. Afable, James F. Burgess.
  Health Services Research. March 28, 2017
  Objective To examine whether changes in resident‐centered care (RCC) over time were associated with changes in quality. Data Sources/Study Setting Data sources were the Minimum Dataset quality indicators (which consist of measures of both prevalence and incidence of adverse events) and the Artifacts of Culture Change Tool (which measures RCC; FYs 2009–2012) from 130 Veterans Health Administration community living centers. Study Design A retrospective longitudinal study. Data Collection/Extraction Methods Data were from VA secondary data sources. Principal Findings The overall relationship between RCC and quality was not statistically significant (p = .22), although there was a weakly significant negative relationship (i.e., increased RCC was associated with poorer quality) in the seven quarters after implementation of an automated version of the Artifacts Tool (p = .08). In facility‐specific analyses, there were 15 facilities with a weakly significant (p < .10) positive relationship between RCC and quality and 21 with a weakly significant negative relationship. Adjusted cost per patient day was over 50 percent higher in the 21 facilities with a negative relationship than in the 15 facilities with a positive relationship (p < .05). Conclusions The Artifacts score is a formal performance metric in the VA, and thus, facilities were explicitly incentivized to increase RCC. Using qualitative methods to identify characteristics that distinguished those facilities able to increase both RCC and quality from those that suffered declines in quality as RCC was improved is an important follow‐up to this study.

  March 28, 2017   doi: 10.1111/1475-6773.12688   open full text
• Geographic Disparities in Availability of Opioid Use Disorder Treatment for Medicaid Enrollees.
  Amanda J. Abraham, Christina M. Andrews, Marissa E. Yingling, Jerry Shannon.
  Health Services Research. March 27, 2017
  Objective To examine county‐level geographic variation in treatment admissions among opioid treatment programs (OTPs) that accept Medicaid in the continental United States. Data Sources/Study Setting Data come from the 2012 National Survey of Substance Abuse Treatment Services. Study Design/Data Collection We used local measures of spatial autocorrelation (LISA) analysis to identify (1) clusters of counties with higher and lower than average rates of opioid use disorders and (2) clusters of counties with higher and lower than average treatment admissions among OTPs that accept Medicaid, adjusting for county population size. Principal Findings Our results reveal several clusters of counties with higher than average rates of opioid use disorder (OUD) and lower than average treatment admissions among OTPs that accept Medicaid. These clusters are highly concentrated in the Southeast region of the country and include Arkansas, Kentucky, Louisiana, Mississippi, and Tennessee. Conclusions Medicaid enrollees in areas in the Southeast have the largest gaps between county‐level OUD rates and estimated county‐level capacity for treatment, as measured by county‐level total treatment admissions among OTPs that accept Medicaid. Policy makers should consider strategies to increase the availability of OTPs with the capacity to serve Medicaid enrollees.

  March 27, 2017   doi: 10.1111/1475-6773.12686   open full text
• Physician Competition in the Era of Accountable Care Organizations.
  Michael R. Richards, Catherine T. Smith, Amy J. Graves, Melinda B. Buntin, Matthew J. Resnick.
  Health Services Research. March 27, 2017
  Objective To calculate physician concentration levels for all U.S. markets using detailed data on integration and accountable care organization (ACO) participation. Data Source 2015 SK&A office‐based physician survey linked to all commercial and public payer ACOs. Study Design We construct three separate Herfindahl–Hirschman Index (HHI) measures and plot their distributions. We then investigate how prevailing levels of concentration change when incorporating more detailed organizational features into the HHI measure. Principal Findings Horizontal and vertical integration strongly influences measures of physician concentration; however, ACOs have limited impact overall. ACOs are often present in competitive markets, and only in a minority of these markets do ACOs substantively increase physician concentration. Conclusions Monitoring ACO effects on physician competition will likely have to proceed on a case‐by‐case basis.

  March 27, 2017   doi: 10.1111/1475-6773.12690   open full text
• Adapting Evaluations of Alternative Payment Models to a Changing Environment.
  Thomas W. Grannemann, Randall S. Brown.
  Health Services Research. March 27, 2017
  Objective To identify the most robust methods for evaluating alternative payment models (APMs) in the emerging health care delivery system environment. Study Design (Approach) We assess the impact of widespread testing of alternative payment models on the ability to find credible comparison groups. We consider the applicability of factorial research designs for assessing the effects of these models. Principal Findings The widespread adoption of alternative payment models could effectively eliminate the possibility of comparing APM results with a “pure” control or comparison group unaffected by other interventions. In this new environment, factorial experiments have distinct advantages over the single‐model experimental or quasi‐experimental designs that have been the mainstay of recent tests of Medicare payment and delivery models. Conclusions The best prospects for producing definitive evidence of the effects of payment incentives for APMs include fractional factorial experiments that systematically vary requirements and payment provisions within a payment model.

  March 27, 2017   doi: 10.1111/1475-6773.12689   open full text
• Impact of Disease Prevalence Adjustment on Hospitalization Rates for Chronic Ambulatory Care–Sensitive Conditions in Germany.
  Johannes Pollmanns, Patrick S. Romano, Maria Weyermann, Max Geraedts, Saskia E. Drösler.
  Health Services Research. March 22, 2017
  Objectives To explore effects of disease prevalence adjustment on ambulatory care–sensitive hospitalization (ACSH) rates used for quality comparisons. Data Sources/Study Setting County‐level hospital administrative data on adults discharged from German hospitals in 2011 and prevalence estimates based on administrative ambulatory diagnosis data were used. Study Design A retrospective cross‐sectional study using in‐ and outpatient secondary data was performed. Data Collection Hospitalization data for hypertension, diabetes, heart failure, chronic obstructive pulmonary disease, and asthma were obtained from the German Diagnosis Related Groups (DRG) database. Prevalence estimates were obtained from the German Central Research Institute of Ambulatory Health Care. Principal Findings Crude hospitalization rates varied substantially across counties (coefficients of variation [CV] 28–37 percent across conditions); this variation was reduced by prevalence adjustment (CV 21–28 percent). Prevalence explained 40–50 percent of the observed variation (r = 0.65–0.70) in ACSH rates for all conditions except asthma (r = 0.07). Between 30 percent and 38 percent of areas moved into or outside condition‐specific control limits with prevalence adjustment. Conclusions Unadjusted ACSH rates should be used with caution for high‐stakes public reporting as differences in prevalence may have a marked impact. Prevalence adjustment should be considered in models analyzing ACSH.

  March 22, 2017   doi: 10.1111/1475-6773.12680   open full text
• The Longitudinal Association between Psychological Factors and Health Care Use.
  Jens‐Oliver Bock, André Hajek, Hans‐Helmut König.
  Health Services Research. March 15, 2017
  Objective Little attention has been given to psychological factors as correlates of health care use, which could be an important key to manage it. We analyzed the association of psychological factors with health care use. Data Sources Primary data were obtained from three follow‐ups (2002, 2008, and 2011) of a large population‐based study with participants aged 40+. Study Design Using a longitudinal observational study, we analyzed the psychological factors of negative and positive affect (affective well‐being), life satisfaction (cognitive well‐being), self‐efficacy, loneliness, self‐esteem, optimism, and flexible goal adjustment using fixed‐effects regressions. Data Collection The participants provided data on health care use (visits to general practitioners [GPs] and specialists as well as hospitalization) and psychological factors via self‐administered questionnaires and personal interviews (7,116 observations). The sample was drawn using national probability sampling. Principal Findings Controlling for self‐rated health, chronic diseases and sociodemographics, increases in affective well‐being, and optimism decreased health care use of GPs, specialists, and hospital treatment. Increases in cognitive well‐being decreased health care use of GPs and specialists. Increases in self‐efficacy decreased hospitalization. Conclusions The study underlines the influence of psychological factors on health care use. Thus, whenever possible, future studies of health care use should include psychological factors, and efforts to reduce health care use might focus on such factors.

  March 15, 2017   doi: 10.1111/1475-6773.12679   open full text
• Development and Validation of the Modified Patient‐Centered Medical Home Assessment for the Comprehensive Primary Care Initiative.
  Dmitriy Poznyak, Deborah N. Peikes, Breanna A. Wakar, Randall S. Brown, Robert J. Reid.
  Health Services Research. March 13, 2017
  Objective To describe the modified Patient‐Centered Medical Home Assessment (M‐PCMH‐A) survey module developed to track primary care practices’ care delivery approaches over time, assess whether its underlying factor structure is reliable, and produce factor scores that provide a more reliable summary measure of the practice's care delivery than would a simple average of question responses. Data Sources/Study Setting Survey data collected from diverse practices participating in the Comprehensive Primary Care (CPC) initiative in 2012 (n = 497) and 2014 (n = 493) and matched comparison practices in 2014 (n = 423). Study Design Confirmatory factor analysis. Data Collection Thirty‐eight questions organized in six domains: Access and Continuity of Care, Planned Care for Chronic Conditions and Preventive Care, Risk‐Stratified Care Management, Patient and Caregiver Engagement, Coordination of Care across the Medical Neighborhood, and Continuous Data‐Driven Improvement. Principal Findings Confirmatory factor analysis suggested using seven factors (splitting one domain into two), reassigning two questions to different domain factors, and removing one question, resulting in high reliability, construct validity, and stability in all but one factor. The seven factors together formed a single higher‐order factor summary measure. Factor scores guard against potential biases from equal weighting. Conclusions The M‐PCMH‐A can validly and reliably track primary care delivery across practices and over time using factors representing seven key components of care as well as an overall score. Researchers should calculate factor loadings for their specific data if possible, but average scores may be suitable if they cannot use factor analysis due to resource or sample constraints.

  March 13, 2017   doi: 10.1111/1475-6773.12673   open full text
• The Role of Medicare's Inpatient Cost‐Sharing in Medicaid Entry.
  Laura M. Keohane, Amal N. Trivedi, Vincent Mor.
  Health Services Research. March 13, 2017
  Objective To isolate the effect of greater inpatient cost‐sharing on Medicaid entry among Medicare beneficiaries. Data Sources Medicare administrative data (years 2007–2010) were linked to nursing home assessments and area‐level socioeconomic indicators. Study Design Medicare beneficiaries who are readmitted to a hospital must pay an additional deductible ($1,100 in 2010) if their readmission occurs more than 59 days following discharge. In a regression discontinuity analysis, we take advantage of this Medicare benefit feature to test whether beneficiaries with greater cost‐sharing have higher rates of Medicaid enrollment. Data Extraction Methods We identified 221,248 Medicare beneficiaries with an initial hospital stay and a readmission 53–59 days later (no deductible) or 60–66 days later (charged a deductible). Principal Findings Among beneficiaries in low‐socioeconomic areas with two hospitalizations, those readmitted 60–66 days after discharge were 21 percent more likely to join Medicaid compared with those readmitted 53–59 days following their initial hospitalization (absolute difference in adjusted risk of Medicaid entry: 3.7 percent vs. 3.1 percent, p = .01). Conclusions Increasing Medicare cost‐sharing requirements may promote Medicaid enrollment among low‐income beneficiaries. Potential savings from an increased cost‐sharing in the Medicare program may be offset by increased Medicaid participation.

  March 13, 2017   doi: 10.1111/1475-6773.12682   open full text
• Hospital Readmission and Social Risk Factors Identified from Physician Notes.
  Amol S. Navathe, Feiran Zhong, Victor J. Lei, Frank Y. Chang, Margarita Sordo, Maxim Topaz, Shamkant B. Navathe, Roberto A. Rocha, Li Zhou.
  Health Services Research. March 13, 2017
  Objective To evaluate the prevalence of seven social factors using physician notes as compared to claims and structured electronic health records (EHRs) data and the resulting association with 30‐day readmissions. Study Setting A multihospital academic health system in southeastern Massachusetts. Study Design An observational study of 49,319 patients with cardiovascular disease admitted from January 1, 2011, to December 31, 2013, using multivariable logistic regression to adjust for patient characteristics. Data Collection/Extraction Methods All‐payer claims, EHR data, and physician notes extracted from a centralized clinical registry. Principal Findings All seven social characteristics were identified at the highest rates in physician notes. For example, we identified 14,872 patient admissions with poor social support in physician notes, increasing the prevalence from 0.4 percent using ICD‐9 codes and structured EHR data to 16.0 percent. Compared to an 18.6 percent baseline readmission rate, risk‐adjusted analysis showed higher readmission risk for patients with housing instability (readmission rate 24.5 percent; p < .001), depression (20.6 percent; p < .001), drug abuse (20.2 percent; p = .01), and poor social support (20.0 percent; p = .01). Conclusions The seven social risk factors studied are substantially more prevalent than represented in administrative data. Automated methods for analyzing physician notes may enable better identification of patients with social needs.

  March 13, 2017   doi: 10.1111/1475-6773.12670   open full text
• Decrease in Statewide Antipsychotic Prescribing after Implementation of Child and Adolescent Psychiatry Consultation Services.
  Rebecca P. Barclay, Robert B. Penfold, Donna Sullivan, Lauren Boydston, Julia Wignall, Robert J. Hilt.
  Health Services Research. March 12, 2017
  Objective To learn if a quality of care Medicaid child psychiatric consultation service implemented in three different steps was linked to changes in statewide child antipsychotic utilization. Data Sources/Study Setting Washington State child psychiatry consultation program primary data and Medicaid pharmacy division antipsychotic utilization secondary data from July 1, 2006, through December 31, 2013. Study Design Observational study in which consult program data were analyzed with a time series analysis of statewide antipsychotic utilization. Data Collection/Extraction Methods All consultation program database information involving antipsychotics was compared to Medicaid pharmacy division database information involving antipsychotic utilization. Principal Findings Washington State's total child Medicaid antipsychotic utilization fell from 0.51 to 0.25 percent. The monthly prevalence of use fell by a mean of 0.022 per thousand per month following the initiation of elective consults (p = .004), by 0.065 following the initiation of age/dose triggered mandatory reviews (p < .001), then by another 0.022 following the initiation of two or more concurrent antipsychotic mandatory reviews (p = .001). High‐dose antipsychotic use fell by 57.8 percent in children 6‐ to 12‐year old and fell by 52.1 percent in teens. Conclusions Statewide antipsychotic prescribing for Medicaid clients fell significantly at different rates following each implementation step of a multilevel consultation and best‐practice education service.

  March 12, 2017   doi: 10.1111/1475-6773.12539   open full text
• Longitudinal Analysis of Quality of Diabetes Care and Relational Climate in Primary Care.
  Marina Soley‐Bori, Justin K. Benzer, James F. Burgess.
  Health Services Research. March 10, 2017
  Objective To assess the influence of relational climate on quality of diabetes care. Data Sources/Study Setting The study was conducted at the Department of Veterans Affairs (VA). The VA All Employee Survey (AES) was used to measure relational climate. Patient and facility characteristics were gathered from VA administrative datasets. Study Design Multilevel panel data (2008–2012) with patients nested into clinics. Data Collection/Extraction Methods Diabetic patients were identified using ICD‐9 codes and assigned to the clinic with the highest frequency of primary care visits. Multiple quality indicators were used, including an all‐or‐none process measure capturing guideline compliance, the actual number of tests and procedures, and three intermediate continuous outcomes (cholesterol, glycated hemoglobin, and blood pressure). Principal Findings The study sample included 327,805 patients, 212 primary care clinics, and 101 parent facilities in 2010. Across all study years, there were 1,568,180 observations. Clinics with the highest relational climate were 25 percent more likely to provide guideline‐compliant care than those with the lowest relational climate (OR for a 1‐unit increase: 1.02, p‐value <.001). Among insulin‐dependent diabetic veterans, this effect was twice as large. Contrary to that expected, relational climate did not influence intermediate outcomes. Conclusions Relational climate is positively associated with tests and procedures provision, but not with intermediate outcomes of diabetes care.

  March 10, 2017   doi: 10.1111/1475-6773.12675   open full text
• Impact of the Local Public Hospital Reform on the Efficiency of Medium‐Sized Hospitals in Japan: An Improved Slacks‐Based Measure Data Envelopment Analysis Approach.
  Xing Zhang, Kaoru Tone, Yingzhe Lu.
  Health Services Research. March 06, 2017
  Objective To assess the change in efficiency and total factor productivity (TFP) of the local public hospitals in Japan after the local public hospital reform launched in late 2007, which was aimed at improving the financial capability and operational efficiency of hospitals. Data Sources and Data Collection Secondary data were collected from the Ministry of Internal Affairs and Communications on 213 eligible medium‐sized hospitals, each operating 100–400 beds from FY2006 to FY2011. Study Design The improved slacks‐based measure nonoriented data envelopment analysis models (Quasi‐Max SBM nonoriented DEA models) were used to estimate dynamic efficiency score and Malmquist Index. Principal Findings The dynamic efficiency measure indicated an efficiency gain in the first several years of the reform and then was followed by a decrease. Malmquist Index analysis showed a significant decline in the TFP between 2006 and 2011. The financial improvement of medium‐sized hospitals was not associated with enhancement of efficiency. Hospital efficiency was not significantly different among ownership structure and law‐application system groups, but it was significantly affected by hospital location. Conclusions The results indicate a need for region‐tailored health care policies and for a more comprehensive reform to overcome the systemic constraints that might contribute to the decline of the TFP.

  March 06, 2017   doi: 10.1111/1475-6773.12676   open full text
• Meaningful Use and Hospital Performance on Post‐Acute Utilization Indicators.
  Yanick N. Brice, Karen E. Joynt, Christopher P. Tompkins, Grant A. Ritter.
  Health Services Research. March 02, 2017
  Objectives To examine trends in hospital post‐acute utilization indicators and to determine whether improvement in these indicators is associated with attesting to meaningful use (MU). Data Sources Medicare claims‐based, repeated measures on 30‐day hospital‐wide all‐cause readmission and emergency department (ED) utilization rates for 160 short‐stay hospitals (2009–2012); Medicare EHR Incentive Program Payments files (2011–2012); and other hospital and market data. Study Design Interrupted time series with concurrent comparison group. Principal Findings Propensity score‐weighted multilevel models for change demonstrate that 30‐day readmission rates (unadjusted) fell from 13.4 percent in 2009 to 12.1 percent in 2012. Similarly, 30‐day ED utilization declined from 18.9 percent to 17.3 percent during the same period. However, MU and non‐MU hospitals were indistinguishable vis‐à‐vis performance. Controlling for hospital and market characteristics, MU was unrelated to 30‐day readmission. In contrast, 30‐day ED utilization deteriorated. Conclusions Hospitals with MU Stage 1 designation did not show significantly higher improvement on post‐acute utilization compared to their counterparts without. To achieve gains in quality and safety, potentially associated with EHRs, and to advance care coordination and patient engagement, the regulators should strengthen accountability by linking comprehensive, outcomes‐based performance measures to specific MU objectives.

  March 02, 2017   doi: 10.1111/1475-6773.12677   open full text
• The Reduction in ED and Hospital Admissions in Medical Home Practices Is Specific to Primary Care–Sensitive Chronic Conditions.
  Lee A. Green, Hsiu‐Ching Chang, Amanda R. Markovitz, Michael L. Paustian.
  Health Services Research. March 02, 2017
  Objective To determine whether the Patient‐Centered Medical Home (PCMH) transformation reduces hospital and ED utilization, and whether the effect is specific to chronic conditions targeted for management by the PCMH in our setting. Data Sources and Study Setting All patients aged 18 years and older in 2,218 primary care practices participating in a statewide PCMH incentive program sponsored by Blue Cross Blue Shield of Michigan (BCBSM) in 2009–2012. Study Design Quantitative observational study, jointly modeling PCMH‐targeted versus other hospital admissions and ED visits on PCMH score, patient, and practice characteristics in a hierarchical multivariate model using the generalized gamma distribution. Data Collection Claims data and PCMH scores held by BCBSM. Principal Findings Both hospital and ED utilization were reduced proportionately to PCMH score. Hospital utilization was reduced by 13.9 percent for PCMH‐targeted conditions versus only 3.8 percent for other conditions (p = .003), and ED utilization by 11.2 percent versus 3.7 percent (p = .010). Hospital PMPM cost was reduced by 17.2 percent for PCMH‐targeted conditions versus only 3.1 percent for other conditions (p < .001), and ED PMPM cost by 9.4 percent versus 3.6 percent (p < .001). Conclusions PCMH transformation reduces hospital and ED use, and the majority of the effect is specific to PCMH‐targeted conditions.

  March 02, 2017   doi: 10.1111/1475-6773.12674   open full text
• Differences between Proxy and Patient Assessments of Cancer Care Experiences and Quality Ratings.
  Jessica K. Roydhouse, Roee Gutman, Nancy L. Keating, Vincent Mor, Ira B. Wilson.
  Health Services Research. March 02, 2017
  Objective To assess the impact of proxy survey responses on cancer care experience reports and quality ratings. Data Sources/Study Setting Secondary analysis of data from Cancer Care Outcomes Research and Surveillance (CanCORS). Recruitment occurred from 2003 to 2005. Study Design The study was a cross‐sectional observational study. The respondents were patients with incident colorectal or lung cancer or their proxies. Data Collection/Extraction Methods Analyses used linear regression models with an independent variable for proxy versus patient responses as well as study site and clinical covariates. The outcomes were experiences with medical care, nursing care, care coordination, and care quality rating. Multiple imputation was used for missing data. Principal Findings Among 6,471 respondents, 1,011 (16 percent) were proxies. The proportion of proxy respondents varied from 6 percent to 28 percent across study sites. Adjusted proxy scores were modestly higher for medical care experiences (+1.28 points [95 percent CI:+ 0.05 to +2.51]), but lower for nursing care (−2.81 [95 percent CI: −4.11 to −1.50]) and care coordination experiences (−2.98 [95 percent CI: −4.15 to −1.81]). There were no significant differences between adjusted patient and proxy ratings of quality. Conclusions Proxy responses have small but statistically significant differences from patient responses. However, if ratings of care are used for financial incentives, such differences could be exaggerated across practices or areas if proxy use varies.

  March 02, 2017   doi: 10.1111/1475-6773.12672   open full text
• Postponing a General Practitioner Visit: Describing Social Differences in Thirty‐One European Countries.
  Jens Detollenaere, Amelie Van Pottelberge, Lise Hanssens, Lieven Pauwels, Tessa Loenen, Sara Willems.
  Health Services Research. February 19, 2017
  Objective To describe social differences in postponing a general practitioner visit in 31 European countries and to explore whether primary care strength is associated with postponement rates. Data Sources Between October 2011 and December 2013, the multicountry QUALICOPC study collected data on 61,931 patients and 7,183 general practitioners throughout Europe. Study Design Access to primary care was measured by asking the patients whether they postponed a general practitioner visit in the past year. Social differences were described according to patients’ self‐rated household income, education, ethnicity, and gender. Data Collection/Extraction Methods Data were analyzed using multivariable and multilevel binomial logistic regression analyses. Principal Findings According to the variance–decomposition in the multilevel analysis, most of the variance can be explained by patient characteristics. Postponement of general practitioner care is higher for patients with a low self‐rated household income, a low education level, and a migration background. In addition, although the point estimates are consistent with a substantial effect, no statistically significant association between primary care strength and postponement in the 31 countries is determined. Conclusions Despite the universal and egalitarian goals of health care systems, access to general practitioner care in Europe is still determined by patients’ socioeconomic status (self‐rated household income and education) and migration background.

  February 19, 2017   doi: 10.1111/1475-6773.12669   open full text
• Combining Internet‐Based and Postal Survey Methods in a Survey among Gynecologists: Results of a Randomized Trial.
  Sinja Alexandra Ernst, Tilman Brand, Stefan K. Lhachimi, Hajo Zeeb.
  Health Services Research. February 19, 2017
  Objective To assess whether a combination of Internet‐based and postal survey methods (mixed‐mode) compared to postal‐only survey methods (postal‐only) leads to improved response rates in a physician survey, and to compare the cost implications of the different recruitment strategies. Data Sources/Study Setting All primary care gynecologists in Bremen and Lower Saxony, Germany, were invited to participate in a cross‐sectional survey from January to July 2014. Study Design The sample was divided into two strata (A; B) depending on availability of an email address. Within each stratum, potential participants were randomly assigned to mixed‐mode or postal‐only group. Principal Findings In Stratum A, the mixed‐mode group had a lower response rate compared to the postal‐only group (12.5 vs. 20.2 percent; RR = 0.61, 95 percent CI: 0.44–0.87). In stratum B, no significant differences were found (15.6 vs. 16.2 percent; RR = 0.95, 95 percent CI: 0.62–1.44). Total costs (in €) per valid questionnaire returned (Stratum A: 399.72 vs. 248.85; Stratum B: 496.37 vs. 455.15) and per percentage point of response (Stratum A: 1,379.02 vs. 861.02; Stratum B 1,116.82 vs. 1,024.09) were higher, whereas variable costs were lower in mixed‐mode compared to the respective postal‐only groups (Stratum A cost ratio: 0.47, Stratum B cost ratio: 0.71). Conclusions In this study, primary care gynecologists were more likely to participate by traditional postal‐only than by mixed‐mode survey methods that first offered an Internet option. However, the lower response rate for the mixed‐mode method may be partly due to the older age structure of the responding gynecologists. Variable costs per returned questionnaire were substantially lower in mixed‐mode groups and indicate the potential for cost savings if the sample population is sufficiently large.

  February 19, 2017   doi: 10.1111/1475-6773.12664   open full text
• Payer Type and Low‐Value Care: Comparing Choosing Wisely Services across Commercial and Medicare Populations.
  Carrie H. Colla, Nancy E. Morden, Thomas D. Sequist, Alexander J. Mainor, Zhonghe Li, Meredith B. Rosenthal.
  Health Services Research. February 19, 2017
  Objective To compare low‐value health service use among commercially insured and Medicare populations and explore the influence of payer type on the provision of low‐value care. Data Sources 2009–2011 national Medicare and commercial insurance administrative data. Design We created claims‐based algorithms to measure seven Choosing Wisely‐identified low‐value services and examined the correlation between commercial and Medicare overuse overall and at the regional level. Regression models explored associations between overuse and regional characteristics. Methods We created measures of early imaging for back pain, vitamin D screening, cervical cancer screening over age 65, prescription opioid use for migraines, cardiac testing in asymptomatic patients, short‐interval repeat bone densitometry (DXA), preoperative cardiac testing for low‐risk surgery, and a composite of these. Principal Findings Prevalence of four services was similar across the insurance‐defined groups. Regional correlation between Medicare and commercial overuse was high (correlation coefficient = 0.540–0.905) for all measures. In both groups, similar region‐level factors were associated with low‐value care provision, especially total Medicare spending and ratio of specialists to primary care physicians. Conclusions Low‐value care appears driven by factors unrelated to payer type or anticipated reimbursement. These findings suggest the influence of local practice patterns on care without meaningful discrimination by payer type.

  February 19, 2017   doi: 10.1111/1475-6773.12665   open full text
• Identifying Primary Care Pathways from Quality of Care to Outcomes and Satisfaction Using Structural Equation Modeling.
  Ignacio Ricci‐Cabello, Sarah Stevens, Andrew R. H. Dalton, Robert I. Griffiths, John L. Campbell, Jose M. Valderas.
  Health Services Research. February 19, 2017
  Objective To study the relationships between the different domains of quality of primary health care for the evaluation of health system performance and for informing policy decision making. Data Sources A total of 137 quality indicators collected from 7,607 English practices between 2011 and 2012. Study Design Cross‐sectional study at the practice level. Indicators were allocated to subdomains of processes of care (“quality assurance,” “education and training,” “medicine management,” “access,” “clinical management,” and “patient‐centered care”), health outcomes (“intermediate outcomes” and “patient‐reported health status”), and patient satisfaction. The relationships between the subdomains were hypothesized in a conceptual model and subsequently tested using structural equation modeling. Principal Findings The model supported two independent paths. In the first path, “access” was associated with “patient‐centered care” (β = 0.63), which in turn was strongly associated with “patient satisfaction” (β = 0.88). In the second path, “education and training” was associated with “clinical management” (β = 0.32), which in turn was associated with “intermediate outcomes” (β = 0.69). “Patient‐reported health status” was weakly associated with “patient‐centered care” (β = −0.05) and “patient satisfaction” (β = 0.09), and not associated with “clinical management” or “intermediate outcomes.” Conclusions This is the first empirical model to simultaneously provide evidence on the independence of intermediate health care outcomes, patient satisfaction, and health status. The explanatory paths via technical quality clinical management and patient centeredness offer specific opportunities for the development of quality improvement initiatives.

  February 19, 2017   doi: 10.1111/1475-6773.12666   open full text
• Home Health Care: Nurse–Physician Communication, Patient Severity, and Hospital Readmission.
  Michael F. Pesko, Linda M. Gerber, Timothy R. Peng, Matthew J. Press.
  Health Services Research. February 19, 2017
  Objective To evaluate whether communication failures between home health care nurses and physicians during an episode of home care after hospital discharge are associated with hospital readmission, stratified by patients at high and low risk of readmission. Data Source/Study Setting We linked Visiting Nurse Services of New York electronic medical records for patients with congestive heart failure in 2008 and 2009 to hospitalization claims data for Medicare fee‐for‐service beneficiaries. Study Design Linear regression models and a propensity score matching approach were used to assess the relationship between communication failure and 30‐day readmission, separately for patients with high‐risk and low‐risk readmission probabilities. Data Collection/Extraction Methods Natural language processing was applied to free‐text data in electronic medical records to identify failures in communication between home health nurses and physicians. Principal Findings Communication failure was associated with a statistically significant 9.7 percentage point increase in the probability of a patient readmission (32.6 percent of the mean) among high‐risk patients. Conclusions Poor communication between home health nurses and physicians is associated with an increased risk of hospital readmission among high‐risk patients. Efforts to reduce readmissions among this population should consider focusing attention on this factor.

  February 19, 2017   doi: 10.1111/1475-6773.12667   open full text
• Impact of Provider Competition under Global Budgeting on the Use of Cesarean Delivery.
  Bradley Chen, Chin‐Shyan Chen, Tsai‐Ching Liu.
  Health Services Research. February 19, 2017
  Objective To examine the impact of provider competition under global budgeting on the use of cesarean delivery in Taiwan. Data Sources/Study Setting (1) Quarterly inpatient claims data of all clinics and hospitals with birth‐related expenses from 2000 to 2008; (2) file of health facilities’ basic characteristics; and (3) regional quarterly point values (price conversion index) for clinics and hospitals, respectively, from the fourth quarter in 1999 to the third quarter in 2008, from the Statistics of the National Health Insurance Administration. Study Design Panel data of quarterly facility‐level cesarean delivery rates with provider characteristics, birth volumes, and regional point values are analyzed with the fractional response model to examine the effect of external price changes on provider behavior in birth delivery services. Principal Findings The decline in de facto prices of health services as a result of noncooperative competition under global budgeting is associated with an increase in cesarean delivery rates, with a high degree of response heterogeneity across different types of provider facilities. Conclusions While global budgeting is an effective cost containment tool, intensified financial pressures may lead to unintended consequences of compromised quality due to a shift in provider practice in pursuit of financial rewards.

  February 19, 2017   doi: 10.1111/1475-6773.12668   open full text
• Do People with Health Insurance Coverage Who Live in Areas with High Uninsurance Rates Pay More for Emergency Department Visits?
  James B. Kirby, Joel W. Cohen.
  Health Services Research. February 07, 2017
  Objective To investigate the relationship between the percent uninsured in a county and expenditures associated with the typical emergency department visit. Data Sources The Medical Expenditure Panel Survey linked to county‐level data from the American Community Survey, the Healthcare Cost and Utilization Project, and the Area Health Resources Files. Study Design We use a nationally representative sample of emergency department visits that took place between 2009 and 2013 to estimate the association between the percent uninsured in counties and the amount paid for a typical visit. Final estimates come from a diagnosis‐level fixed‐effects model, with additional controls for a wide variety of visit, individual, and county characteristics. Principal Findings Among those with private insurance, we find that an increase of 1 percentage point in the county uninsurance rate is associated with a $20 increase in the mean emergency department payment. No such association is observed among visits covered by other insurance types. Conclusions Results provide tentative evidence that the costs associated with high uninsurance rates spill over to those with insurance, but future research needs to replicate these findings with longitudinal data and methods before drawing causal conclusions. Recent data on changes in area uninsurance rates following the ACA's insurance expansions and subsequent changes in emergency department expenditures afford a valuable opportunity to do this.

  February 07, 2017   doi: 10.1111/1475-6773.12659   open full text
• Telemedical Care and Monitoring for Patients with Chronic Heart Failure Has a Positive Effect on Survival.
  Robert Herold, Neeltje Berg, Marcus Dörr, Wolfgang Hoffmann.
  Health Services Research. January 31, 2017
  Background Telemedical care and monitoring programs for patients with chronic heart failure have shown beneficial effects on survival in several small studies. The utility in routine care remains unclear. Methods We evaluated a large‐sized telemedicine program in a routine care setting, enrolling in total 2,622 patients (54.7 percent male, mean age: 73.7 years) with chronic heart failure. We used reimbursement data from a large statutory health insurance and approached a matched control analysis. In a complex propensity score matching procedure, 3,719 suitable controls (54.2 percent male, mean age: 74.5 years) were matched to 1,943 intervention patients (54.1 percent male, mean age: 74.4 years). The primary endpoint of our analysis was survival after 1 year. Results Analyses revealed a higher survival probability among subjects of the intervention group compared to controls group after 1 year (adjusted OR: 1.47, CI 95 percent: 1.21–1.80, p < .001) and 2 years (adjusted OR: 1.51, CI 95 percent: 1.28–1.77, p < .001), respectively. Conclusions The probabilities to survive after 1 and 2 years were significantly increased in the intervention group. Our findings confirm previous results of controlled trials and importantly indicate that patients with chronic heart failure may benefit from telemonitoring programs in routine care.

  January 31, 2017   doi: 10.1111/1475-6773.12661   open full text
• Malpractice Claim Fears and the Costs of Treating Medicare Patients: A New Approach to Estimating the Costs of Defensive Medicine.
  James D. Reschovsky, Cynthia B. Saiontz‐Martinez.
  Health Services Research. January 26, 2017
  Objective To estimate the cost of defensive medicine among elderly Medicare patients. Data Sources We use a 2008 national physician survey linked to respondents’ elderly Medicare patients’ claims data. Study Design Using a sample of survey respondent/beneficiary dyads stratified by physician specialty, we estimated cross‐sectional regressions of annual costs on patient covariates and a medical malpractice fear index formed from five validated physician survey questions. Defensive medicine costs were calculated as the difference between observed patient costs and those under hypothetical alternative levels of malpractice concern, and then aggregated to estimate average defensive medicine costs per beneficiary. Data Collection Methods The physician survey was conducted by mail. Patient claims were linked to survey respondents and reweighted to approximate the elderly Medicare beneficiary population. Principal Findings Higher levels of the malpractice fear index were associated with higher patient spending. Based on the measured associations, we estimated that defensive medicine accounted for 8 to 20 percent of total costs under alternative scenarios. The highest estimate is associated with a counterfactual of no malpractice concerns, which is unlikely to be socially optimal as some extrinsic incentives to avoid medical errors are desirable. Among specialty groups, primary care physicians contributed the most to defensive medicine spending. Higher costs resulted mostly from more hospital admissions and greater postacute care. Conclusions Although results are based on measured associations between malpractice fears and spending, and may not reflect the true causal effects, they suggest defensive medicine likely contributes substantial additional costs to Medicare.

  January 26, 2017   doi: 10.1111/1475-6773.12660   open full text
• An Ethnographic Study of Health Information Technology Use in Three Intensive Care Units.
  Myles Leslie, Elise Paradis, Michael A. Gropper, Simon Kitto, Scott Reeves, Peter Pronovost.
  Health Services Research. January 25, 2017
  Objectives To identify the impact of a full suite of health information technology (HIT) on the relationships that support safety and quality among intensive care unit (ICU) clinicians. Data Sources A year‐long comparative ethnographic study of three academic ICUs was carried out. A total of 446 hours of observational data was collected in the form of field notes. A subset of these observations—134 hours—was devoted to job‐shadowing individual clinicians and conducting a time study of their HIT usage. Principal Findings Significant variation in HIT implementation rates and usage was noted. Average HIT use on the two “high‐use” ICUs was 49 percent. On the “low‐use” ICU, it was 10 percent. Clinicians on the high‐use ICUs experienced “silo” effects with potential safety and quality implications. HIT work was associated with spatial, data, and social silos that separated ICU clinicians from one another and their patients. Situational awareness, communication, and patient satisfaction were negatively affected by this siloing. Conclusions HIT has the potential to accentuate social and professional divisions as clinical communications shift from being in‐person to electronically mediated. Socio‐technically informed usability testing is recommended for those hospitals that have yet to implement HIT. For those hospitals already implementing HIT, we suggest rapid, locally driven qualitative assessments focused on developing solutions to identified gaps between HIT usage patterns and organizational quality goals.

  January 25, 2017   doi: 10.1111/1475-6773.12466   open full text
• Geography, Not Health System Affiliations, Determines Patients’ Revisits to the Emergency Department.
  Kristin L. Rising, David N. Karp, Rhea E. Powell, Timothy W. Victor, Brendan G. Carr.
  Health Services Research. January 19, 2017
  Objectives To determine how frequently patients revisit the emergency department after an initial encounter, and to describe revisit capture rates for the same hospital, health system, and geographic region. Data Sources/Study Setting Florida state data from January 1, 2010, to June 30, 2011, from the Healthcare Cost and Utilization Project. Study Design This is a retrospective cohort study of emergency department return visits among Florida adults over an 18‐month period. We evaluated pairs of index and 30‐day return emergency department visits and compared capture rates for hospital, health system, and geographic units. Data Collection/Extraction Methods Data were obtained from the Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project and the American Hospital Association Annual Survey Database. Principal Findings Among 9,416,212 emergency department visits, 22.6 percent (2,124,441) were associated with a 30‐day return. Seventy percent (1,477,772) of 30‐day returns occurred to the same hospital. The 30‐day return capture rates were highest within the same geographic area: county‐level capture at 92 percent (IQR=86–96 percent) versus health system capture at 75 percent (IQR = 68–81 percent). Conclusions Acute care utilization patterns are often independent of health system boundaries. Current population‐based health care models that attribute patients to a single provider or health system may be strengthened by considering geographic patterns of acute care utilization.

  January 19, 2017   doi: 10.1111/1475-6773.12658   open full text
• Persistent Variation in Medicare Payment Authorization for Home Hemodialysis Treatments.
  Adam S. Wilk, Richard A. Hirth, Wei Zhang, John R. C. Wheeler, Marc N. Turenne, Tammie A. Nahra, Kathryn K. Sleeman, Joseph M. Messana.
  Health Services Research. January 19, 2017
  Objective To analyze variation in medical care use attributable to Medicare's decentralized claims adjudication process as exemplified in home hemodialysis (HHD) therapy. Data Sources/Study Setting Secondary data analysis using 2009–2012 paid Medicare claims for HHD and in‐center hemodialysis (IHD). Study Design We compared variation across Medicare administrative contractors (MACs) in predicted paid treatments per standardized patient‐month for HHD and IHD patients. We used ordinary least‐squares regression to determine whether higher paid HHD treatment counts expanded HHD programs’ presence among dialysis facilities. Data Collection We identified HHD and IHD treatments using procedure, revenue center, and claim condition codes on type 72x claims. Principal Findings MACs varied persistently in predicted HHD treatments per patient‐month, ranging from 14.3 to 21.9 treatments versus 10.9 to 12.4 IHD treatments. The presence of facilities’ HHD programs was uncorrelated with average HHD payment counts. Conclusions Medicare's claims adjudication process promotes variation in medical care use, as we observe among HHD patients. MACs’ discretionary decision making, while potentially facilitating innovation, may admit inefficiency in care practice as well as inequitable access to health care services. Regulators should weigh the benefits of flexibility in local coverage decisions against those of national standards for medical necessity.

  January 19, 2017   doi: 10.1111/1475-6773.12650   open full text
• Prescription Drug Monitoring Programs Produce a Limited Impact on Painkiller Prescribing in Medicare Part D.
  Courtney R. Yarbrough.
  Health Services Research. January 18, 2017
  Objective To measure the impact of prescription drug monitoring programs (PDMPs) on prescribing of opioid and nonopioid painkillers. Data Source 2010–2013 physician‐level Medicare Part D prescribing data released by the Centers for Medicare and Medicaid Services and Propublica. Study Design Using difference‐in‐differences models with physician‐level fixed effects, the study compares prescribing in states with and without PDMPs for opioid and nonopioid analgesics, oxycodone, hydrocodone, and opioids by controlled substances Schedules II–IV. Principal Findings Prescription drug monitoring programs were associated with a 5.2 percent decrease in days supply prescribed per physician for oxycodone in addition to smaller reductions for hydrocodone and opioids overall (2.8 percent and 2 percent, respectively) and a small increase in prescribing for Schedule IV opioids. PDMPs were not associated with changes for nonopioid analgesics or other opioids in Schedules II and III. The effects of PDMPs were negated in states where statutes explicitly did not require use of the PDMP. Conclusions Prescription drug monitoring programs have a modest effect targeted at the high‐profile drug oxycodone among the Medicare Part D population and an even smaller effect for hydrocodone and opioids in general. The findings suggest some substitution toward lower schedule opioids. Substantially addressing the widespread opioid abuse problem will require enhancing existing PDMPs or implementing new policies.

  January 18, 2017   doi: 10.1111/1475-6773.12652   open full text
• Public Trust in Health Information Sharing: A Measure of System Trust.
  Jodyn E. Platt, Peter D. Jacobson, Sharon L. R. Kardia.
  Health Services Research. January 18, 2017
  Objective To measure public trust in a health information sharing in a broadly defined health system (system trust), inclusive of health care, public health, and research; to identify individual characteristics that predict system trust; and to consider these findings in the context of national health initiatives (e.g., learning health systems and precision medicine) that will expand the scope of data sharing. Data Sources Survey data (n = 1,011) were collected in February 2014. Study Design We constructed a composite index of four dimensions of system trust—competency, fidelity, integrity, and trustworthiness. The index was used in linear regression evaluating demographic and psychosocial predictors of system trust. Data Collection Data were collected by GfK Custom using a nationally representative sample and analyzed in Stata 13.0. Principal Findings Our findings suggest the public's trust may not meet the needs of health systems as they enter an era of expanded data sharing. We found that a majority of the U.S. public does not trust the organizations that have health information and share it (i.e., the health system) in one or more dimensions. Together, demographic and psychosocial factors accounted for ~18 percent of the observed variability in system trust. Future research should consider additional predictors of system trust such as knowledge, attitudes, and beliefs to inform policies and practices for health data sharing.

  January 18, 2017   doi: 10.1111/1475-6773.12654   open full text
• Hospital Variation in Utilization of Life‐Sustaining Treatments among Patients with Do Not Resuscitate Orders.
  Allan J. Walkey, Janice Weinberg, Renda Soylemez Wiener, Colin R. Cooke, Peter K. Lindenauer.
  Health Services Research. January 18, 2017
  Objective To determine between‐hospital variation in interventions provided to patients with do not resuscitate (DNR) orders. Data Sources/Setting United States Agency of Healthcare Research and Quality, Healthcare Cost and Utilization Project, California State Inpatient Database. Study Design Retrospective cohort study including hospitalized patients aged 40 and older with potential indications for invasive treatments: in‐hospital cardiac arrest (indication for CPR), acute respiratory failure (mechanical ventilation), acute renal failure (hemodialysis), septic shock (central venous catheterization), and palliative care. Hierarchical logistic regression to determine associations of hospital “early” DNR rates (DNR order placed within 24 hours of admission) with utilization of invasive interventions. Data Collection/Extraction Methods California State Inpatient Database, year 2011. Principal Findings Patients with DNR orders at high‐DNR‐rate hospitals were less likely to receive invasive mechanical ventilation for acute respiratory failure or hemodialysis for acute renal failure, but more likely to receive palliative care than DNR patients at low‐DNR‐rate hospitals. Patients without DNR orders experienced similar rates of invasive interventions regardless of hospital DNR rates. Conclusions Hospitals vary widely in the scope of invasive or organ‐supporting treatments provided to patients with DNR orders.

  January 18, 2017   doi: 10.1111/1475-6773.12651   open full text
• The Potential of High‐Dimensional Propensity Scores in Health Services Research: An Exemplary Study on the Quality of Care for Elective Percutaneous Coronary Interventions.
  Dirk Enders, Christoph Ohlmeier, Edeltraut Garbe.
  Health Services Research. January 16, 2017
  Objective Evaluating the potential of the high‐dimensional propensity score (HDPS) to control for residual confounding in studies analyzing quality of care based on administrative health insurance data. Data Source Secondary data from 2004 to 2009 from three German statutory health insurance providers. Study Design We conducted a retrospective cohort study in patients with elective percutaneous coronary interventions (PCIs) and compared the mortality risk between the in‐ and outpatient setting using Cox regression. Adjustment for predefined confounders was performed using conventional propensity score (PS) techniques. Further, an HDPS was calculated based on predefined and empirically selected confounders from the database. Principal Findings Conventional PS methods showed a decreased mortality risk for outpatient compared to inpatient PCIs, while trimming of patients with nonoverlap in the HDPS distribution and weighting resulted in a comparable risk. Most comorbidities were less prevalent in the HDPS‐trimmed population compared to the original one. Conclusion The HDPS methodology may reduce residual confounding by rendering the studied cohort more comparable through restriction. However, results cannot be generalized for the entire study population. To provide unbiased results, full assessment of all unmeasured confounders from proxy information in the database would be necessary.

  January 16, 2017   doi: 10.1111/1475-6773.12653   open full text
• Health Services Utilization in Older Adults with Dementia Receiving Care Coordination: The MIND at Home Trial.
  Halima Amjad, Stephanie K. Wong, David L. Roth, Jin Huang, Amber Willink, Betty S. Black, Deirdre Johnston, Peter V. Rabins, Laura N. Gitlin, Constantine G. Lyketsos, Quincy M. Samus.
  Health Services Research. January 12, 2017
  Objective To investigate effects of a novel dementia care coordination program on health services utilization. Data Sources/Study Setting A total of 303 community‐dwelling adults aged ≥70 with a cognitive disorder in Baltimore, Maryland (2008–2011). Study Design Single‐blind RCT evaluating efficacy of an 18‐month care coordination intervention delivered through community‐based nonclinical care coordinators, supported by an interdisciplinary clinical team. Data Collection/Extraction Methods Study partners reported acute care/inpatient, outpatient, and home‐ and community‐based service utilization at baseline, 9, and 18 months. Principal Findings From baseline to 18 months, there were no significant group differences in acute care/inpatient or total outpatient services use, although intervention participants had significantly increased outpatient dementia/mental health visits from 9 to 18 months (p = .04) relative to controls. Home and community‐based support service use significantly increased from baseline to 18 months in the intervention compared to control (p = .005). Conclusions While this dementia care coordination program did not impact acute care/inpatient services utilization, it increased use of dementia‐related outpatient medical care and nonmedical supportive community services, a combination that may have helped participants remain at home longer. Future care model modifications that emphasize delirium, falls prevention, and behavior management may be needed to influence inpatient service use.

  January 12, 2017   doi: 10.1111/1475-6773.12647   open full text
• Does Identification of Previously Undiagnosed Conditions Change Care‐Seeking Behavior?
  Rebecca M. Myerson, Lisandro D. Colantonio, Monika M. Safford, Elbert S. Huang.
  Health Services Research. January 10, 2017
  Objective To determine whether identification of previously undiagnosed high cholesterol, hypertension, and/or diabetes during an in‐home assessment impacts care seeking among Medicare beneficiaries. Data Sources/Study Setting Data from the REasons for Geographic And Racial Differences in Stroke (REGARDS) study, which recruited African American and white participants across the continental United States from 2003–2007, were linked to Medicare claims. Study Design We used panel data models to analyze changes in doctor visits for evaluation and management of conditions after participants were assessed, utilizing the study's rolling recruitment to control for secular trends. Data Extraction Methods We extracted Medicare claims for the 24 months before through 24 months after assessment via REGARDS for 5,884 participants. Principal Findings Semi‐annual doctor visits for previously undiagnosed conditions increased by 22 percentage points (95 percent confidence interval: 16–28) 2 years following assessment. The effect was similar by gender, race, region, and Medicaid, but it may have been lower among participants who lacked a usual health care provider. Conclusions In‐home assessment of cholesterol, blood pressure, and blood glucose can increase doctor visits for individuals with previously undiagnosed conditions. However, biomarker assessment may have more limited impact among individuals with low access to care.

  January 10, 2017   doi: 10.1111/1475-6773.12644   open full text
• The Probability of Hospitalizations for Mild‐to‐Moderate Injuries by Trauma Center Ownership Type.
  Etienne E. Pracht, Barbara Langland‐Orban, Jessica L. Ryan.
  Health Services Research. January 10, 2017
  Objective To corroborate anecdotal evidence with systematic evidence of a lower threshold for admission among for‐profit hospitals. Data Sources The study used Florida emergency department and hospital discharge datasets for 2012 to 2014. The treatment variable of interest was for‐profit‐designated trauma center status. The dependent variable indicated whether a patient with mild‐to‐moderate injuries was admitted after presenting as a trauma alert and then discharged to home. A separate analysis was conducted of discharges that had a 1‐day length of stay. Study Design Generalized estimation equations with logistic distribution models were used to control for the confounding influences and developed for four groups of patients: ICISS = 1 (no probability of mortality), ICISS ≥ 0.99, ICISS ≥ 0.95, and ICISS ≥ 0.85 (zero to 15 percent probability of mortality, which includes all mild and moderate injury patients). Principal Findings For the ICISS = 1 and ICISS ≥ 0.99 models, the centers' for‐profit status was the most important predictor. In the ICISS ≥ 0.95 and ICISS ≥ 0.85 models, injury type played a more important role, but for‐profit status remained important. For patients with a 1‐day stay, for‐profit status was associated with an even higher probability of hospitalization. Conclusions Considerable differences exist between for‐profit and not‐for‐profit trauma centers concerning hospitalization among the study population, which may be explained by supplier‐induced demand.

  January 10, 2017   doi: 10.1111/1475-6773.12646   open full text
• Comparison of Medicaid Payments Relative to Medicare Using Inpatient Acute Care Claims from the Medicaid Program: Fiscal Year 2010–Fiscal Year 2011.
  Devin A. Stone, Bridget A. Dickensheets, John A. Poisal.
  Health Services Research. January 10, 2017
  Objective To compare Medicaid fee‐for‐service (FFS) inpatient hospital payments to expected Medicare payments. Data Sources Medicaid and Medicare claims data, Medicare's MS‐DRG grouper and inpatient prospective payment system pricer (IPPS pricer). Study Design Medicaid FFS inpatient hospital claims were run through Medicare's MS‐DRG grouper and IPPS pricer to compare Medicaid's actual payment against what Medicare would have paid for the same claim. Principal Findings Average inpatient hospital claim payments for Medicaid were 68.8 percent of what Medicare would have paid in fiscal year 2010, and 69.8 percent in fiscal year 2011. Including Medicaid disproportionate share hospital (DSH), graduate medical education (GME), and supplemental payments reduces a substantial proportion of the gap between Medicaid and Medicare payments. Conclusions Medicaid payments relative to expected Medicare payments tend to be lower and vary by state Medicaid program, length of stay, and whether payments made outside of the Medicaid claims process are included.

  January 10, 2017   doi: 10.1111/1475-6773.12645   open full text
• Factors That Distinguish High‐Performing Accountable Care Organizations in the Medicare Shared Savings Program.
  Thomas D'Aunno, Lauren Broffman, Michael Sparer, Sumit R. Kumar.
  Health Services Research. December 26, 2016
  Objective To identify factors that promote the effective performance of accountable care organizations (ACOs) in the Medicare Shared Savings Program. Data Sources/Study Setting Data come from a convenience sample of 16 Medicare Shared Savings ACOs that were organized around large physician groups. We use claims data from the Center for Medicaid and Medicare Services and data from 60 interviews at three high‐performing and three low‐performing ACOs. Study Design Explanatory sequential design, using qualitative data to account for patterns observed in quantitative assessment of ACO performance. Data Collection Methods A total of 16 ACOs were first rank‐ordered on measures of cost and quality of care; we then selected three high and three low performers for site visits; interview data were content‐analyzed. Principal Findings Results identify several factors that distinguish high‐ from low‐performing ACOs: (1) collaboration with hospitals; (2) effective physician group practice prior to ACO engagement; (3) trusted, long‐standing physician leaders focused on improving performance; (4) sophisticated use of information systems; (5) effective feedback to physicians; and (6) embedded care coordinators. Conclusions Shorter interventions can improve ACO performance—use of embedded care coordinators and local, regional health information systems; timely feedback of performance data. However, longer term interventions are needed to promote physician–hospital collaboration and skills of physician leaders. CMS and other stakeholders need realistic timelines for ACO performance.

  December 26, 2016   doi: 10.1111/1475-6773.12642   open full text
• Patient, Physician, and Health‐System Factors Influencing the Quality of Antidepressant and Sedative Prescribing for Older, Community‐Dwelling Adults.
  Rian Marie Extavour, Matthew Perri.
  Health Services Research. December 26, 2016
  Objective To identify determinants of potentially inappropriate (PI) antidepressant and anxiolytic/sedative prescribing for older, community‐dwelling adults. Data Sources/Study Setting Office visits from the 2010 National Ambulatory Medical Care Survey. Study Design A cross‐sectional study measuring associations between various patient and physician factors and prescribing of PI antidepressants, and PI sedatives among elderly, using Beers 2012/2015 criteria, a clinical decision model, and multivariate logistic regressions. Data Collection Visits by older adults (≥65 years) involving medications were extracted to identify visits with antidepressants and sedatives. Principal Findings Black race, asthma, depression, osteoporosis, payment type, consultation time, and computer systems with prescribing support were associated with reduced odds of PI antidepressant prescribing among users. Income, chronic renal failure, diabetes, and obesity were associated with reduced odds of PI sedative prescribing. Female sex, white race, depression, increasing number of medications, and physician specialty were associated with increased odds of PI sedative prescribing. Conclusions Various patient and health‐system factors influence the quality of antidepressant and sedative prescribing for older community‐dwelling adults. Longer consultations and the use of computer systems with prescribing support may minimize potentially inappropriate antidepressant prescribing. As medication numbers increase, exposure to PI sedatives is more likely, requiring medication review and monitoring.

  December 26, 2016   doi: 10.1111/1475-6773.12641   open full text
• Modeling Health Care Spending Growth of Older Adults.
  Laura A. Hatfield, Melissa M. Favreault, Thomas G. McGuire, Michael E. Chernew.
  Health Services Research. December 26, 2016
  Objective To forecast out‐of‐pocket health care spending among older adults. Long‐term forecasts allow policy makers to explore potential impacts of policy scenarios, but existing microsimulations do not incorporate details of supplemental insurance coverage and income effects on health care spending. Data Sources Dynamic microsimulation calibrated to survey and administrative data. Study Design We augment Urban Institute's Dynamic Simulation of Income Model (DYNASIM) with modules that incorporate demand responses and economic equilibria, with dynamics driven by exogenous technological change. A lengthy technical appendix provides details of the microsimulation model and economic assumptions for readers interested in applying these techniques. Principal Findings The model projects total out‐of‐pocket spending (point of care plus premiums) as a share of income for adults aged 65 and older. People with lower incomes and poor health fare worse, despite protections of Medicaid. Spending rises 40 percent from 2012 to 2035 (from 10 to 14 percent of income) for the median beneficiary, but it increases from 5 to 25 percent of income for low‐income beneficiaries and from 23 to 29 percent for the near poor who are in fair/poor health. Conclusions Despite Medicare coverage, near‐poor seniors will face out‐of‐pocket spending that would render them, in practical terms, underinsured.

  December 26, 2016   doi: 10.1111/1475-6773.12640   open full text
• Space–Time Cluster Analysis to Detect Innovative Clinical Practices: A Case Study of Aripiprazole in the Department of Veterans Affairs.
  Robert B. Penfold, James F. Burgess, Austin F. Lee, Mingfei Li, Christopher J. Miller, Marjorie Nealon Seibert, Todd P. Semla, David C. Mohr, Lewis E. Kazis, Mark S. Bauer.
  Health Services Research. December 22, 2016
  Objective To identify space–time clusters of changes in prescribing aripiprazole for bipolar disorder among providers in the VA. Data Sources VA administrative data from 2002 to 2010 were used to identify prescriptions of aripiprazole for bipolar disorder. Prescriber characteristics were obtained using the Personnel and Accounting Integrated Database. Study Design We conducted a retrospective space–time cluster analysis using the space–time permutation statistic. Data Extraction Methods All VA service users with a diagnosis of bipolar disorder were included in the patient population. Individuals with any schizophrenia spectrum diagnoses were excluded. We also identified all clinicians who wrote a prescription for any bipolar disorder medication. Principal Findings The study population included 32,630 prescribers. Of these, 8,643 wrote qualifying prescriptions. We identified three clusters of aripiprazole prescribing centered in Massachusetts, Ohio, and the Pacific Northwest. Clusters were associated with prescribing by VA‐employed (vs. contracted) prescribers. Nurses with prescribing privileges were more likely to make a prescription for aripiprazole in cluster locations compared with psychiatrists. Primary care physicians were less likely. Conclusions Early prescribing of aripiprazole for bipolar disorder clustered geographically and was associated with prescriber subgroups. These methods support prospective surveillance of practice changes and identification of associated health system characteristics.

  December 22, 2016   doi: 10.1111/1475-6773.12639   open full text
• Impact of Health System Affiliation on Hospital Resource Use Intensity and Quality of Care.
  Rachel Mosher Henke, Zeynal Karaca, Brian Moore, Eli Cutler, Hangsheng Liu, William D. Marder, Herbert S. Wong.
  Health Services Research. December 22, 2016
  Objective To assess the impact of hospital affiliation, centralization, and managed care plan ownership on inpatient cost and quality. Data Sources Inpatient discharges from 3,957 community hospitals in 44 states and American Hospital Association Annual Survey data from 2010 to 2012. Study Design We conducted a retrospective longitudinal regression analysis using hierarchical modeling of discharges clustered within hospitals. Data Collection Detailed discharge data including costs, length of stay, and patient characteristics from the Healthcare Cost and Utilization Project State Inpatient Databases were merged with hospital survey data from the American Hospital Association. Principal Findings Hospitals affiliated with health systems had a higher cost per discharge and better quality of care compared with independent hospitals. Centralized systems in particular had the highest cost per discharge and longest stays. Independent hospitals with managed care plans had a higher cost per discharge and better quality of care compared with other independent hospitals. Conclusions Increasing prevalence of health systems and hospital managed care ownership may lead to higher quality but are unlikely to reduce hospital discharge costs. Encouraging participation in innovative payment and delivery reform models, such as accountable care organizations, may be more powerful options.

  December 22, 2016   doi: 10.1111/1475-6773.12631   open full text
• Relationships as Medicine: Quality of the Physician–Patient Relationship Determines Physician Influence on Treatment Recommendation Adherence.
  Heather Orom, Willie Underwood, Zinan Cheng, D. Lynn Homish, I'Yanna Scott.
  Health Services Research. December 15, 2016
  Objective To determine whether quality of physician–patient relationships influences uptake of physician treatment recommendations in men with clinically localized prostate cancer (PCa). Study Setting Data were collected July 2010 to August 2014 at two cancer centers and three community facilities. Study Design Analyses were prospective and cross‐sectional. We modeled associations between quality of the patient–physician relationship and influence of physician recommendations on treatment choice using generalized estimating equations (GEE). Data Collection Data were collected via survey and medical record abstraction. Principal Findings Participants (N = 1166) were 14.7 percent minority; 37.1 percent had low‐, 47.5 percent had intermediate‐, and 15.4 percent had high‐risk PCa. Those reporting a better physician–patient relationship perceived that their physician's treatment recommendation was more influential (RR = 1.05, 95 percent CI = 1.04–1.05, p < .001) and were more likely to choose the recommended treatment (OR = 2.92, 95 percent CI = 2.39, 3.58, p < .001). A pattern of interactions emerged indicating that quality of the physician–patient relationship was more strongly associated with influence of recommendations for more, versus less aggressive treatment in those with low‐risk, but not intermediate‐risk disease. Conclusions Prioritizing quality of the physician–patient relationship through training, practice change, and patient feedback may increase adherence. However, strategies need to align with efforts to reduce physician recommendations for inefficacious treatments to prevent overtreatment.

  December 15, 2016   doi: 10.1111/1475-6773.12629   open full text
• Covariate Balancing through Naturally Occurring Strata.
  Farrokh Alemi, Amr ElRafey, Ivan Avramovic.
  Health Services Research. December 14, 2016
  Objective To provide an alternative to propensity scoring (PS) for the common situation where there are interacting covariates. Setting We used 1.3 million assessments of residents of the United States Veterans Affairs nursing homes, collected from January 1, 2000, through October 9, 2012. Design In stratified covariate balancing (SCB), data are divided into naturally occurring strata, where each stratum is an observed combination of the covariates. Within each stratum, cases with, and controls without, the target event are counted; controls are weighted to be as frequent as cases. This weighting procedure guarantees that covariates, or combination of covariates, are balanced, meaning they occur at the same rate among cases and controls. Finally, impact of the target event is calculated in the weighted data. We compare the performance of SCB, logistic regression (LR), and propensity scoring (PS) in simulated and real data. We examined the calibration of SCB and PS in predicting 6‐month mortality from inability to eat, controlling for age, gender, and nine other disabilities for 296,051 residents in Veterans Affairs nursing homes. We also performed a simulation study, where outcomes were randomly generated from treatment, 10 covariates, and increasing number of covariate interactions. The accuracy of SCB, PS, and LR in recovering the simulated treatment effect was reported. Findings In simulated environment, as the number of interactions among the covariates increased, SCB and properly specified LR remained accurate but pairwise LR and pairwise PS, the most common applications of these tools, performed poorly. In real data, application of SCB was practical. SCB was better calibrated than linear PS, the most common method of PS. Conclusions In environments where covariates interact, SCB is practical and more accurate than common methods of applying LR and PS.

  December 14, 2016   doi: 10.1111/1475-6773.12628   open full text
• The Mental Health Parity and Addiction Equity Act Evaluation Study: Impact on Mental Health Financial Requirements among Commercial “Carve‐In” Plans.
  Sarah A. Friedman, Amber G. Thalmayer, Francisca Azocar, Haiyong Xu, Jessica M. Harwood, Michael K. Ong, Laura Lambert Johnson, Susan L. Ettner.
  Health Services Research. December 12, 2016
  Objective Did mental health cost‐sharing decrease following implementation of the Mental Health Parity and Addiction Equity Act (MHPAEA)? Data Source Specialty mental health copayments, coinsurance, and deductibles, 2008–2013, were obtained from benefits databases for “carve‐in” plans from a national commercial managed behavioral health organization. Study Design Bivariate and regression‐adjusted analyses compare the probability of use and (conditional) level of cost‐sharing pre‐ and postparity. An interaction term is added to compare differential levels of pre‐ and postparity cost‐sharing changes for plans that were and were not already at parity pre‐MHPAEA. Findings Controlling for employer/plan characteristics, MHPAEA is associated with higher intermediate care copayments ($15.9) but lower outpatient ($2.6) copayments among in‐network‐only plans. Among plans with in‐ and out‐of‐network benefits, MHPAEA is associated with lower inpatient ($23.2) and outpatient ($2.5) copayments, but increases in inpatient and intermediate in‐network and out‐of‐network coinsurance (about 1 percentage point). Among the few plans not at parity pre‐MHPAEA, changes in use and level of cost‐sharing associated with MHPAEA were more dramatic. Conclusion Mixed evidence that MHPAEA led to more generous mental health benefits may stem from the finding that many plans were already at parity pre‐MHPAEA. Future policy focus in mental health may shift to slowing growth in cost‐sharing for all health services.

  December 12, 2016   doi: 10.1111/1475-6773.12614   open full text
• Impact of Wisconsin Medicaid Policy Change on Dental Sealant Utilization.
  Christopher Okunseri, Elaye Okunseri, Raul I. Garcia, Cesar Gonzalez, Alexis Visotcky, Aniko Szabo.
  Health Services Research. December 12, 2016
  Background In September 2006, Wisconsin Medicaid changed its policy to allow nondentists to become certified Medicaid providers and to bill for sealants in public health settings. Objective This study examined changes in patterns of dental sealant utilization in first molars of Wisconsin Medicaid enrollees associated with a policy change. Data Source The Electronic Data Systems of Medicaid Evaluation and Decision Support for Wisconsin from 2001 to 2009. Study Design Retrospective claims data analysis of Wisconsin Dental Medicaid for children aged 6‐16 years. Principal Findings A total of 479,847 children followed up for 1,441,300 person‐years with 64,546 visits were analyzed. The rate of visits for sealants by dentists increased significantly from 3 percent per year prepolicy to 11 percent per year postpolicy, and that of nondentists increased from 18 percent per year to 20 percent after the policy change, but this was not significant. Non‐Hispanic blacks had the lowest visit rates for sealant application by dentists and nondentists pre‐ and postpolicy periods. Conclusions The Wisconsin Medicaid policy change was associated with increased rates of visits for dental sealant placement by dentists. The rate of visits with sealant placements by nondentists increased at the same rate pre‐ and postpolicy change.

  December 12, 2016   doi: 10.1111/1475-6773.12627   open full text
• Impact of Enroll America on the Number of Individuals Covered through the Federally Facilitated Marketplace.
  Sean Orzol, Lauren Hula.
  Health Services Research. December 12, 2016
  Objective To assess the impact of Enroll America's field outreach activities on the number of individuals enrolled in Marketplace coverage during the first open enrollment period. Data Sources/Study Setting Marketplace enrollment for the initial open enrollment period linked with data on Enroll America's field activities and baseline local‐area demographic, economic, and health services characteristics. Study Design We used a quasi‐experimental design, comparing Marketplace enrollment during the first open enrollment period in local areas drawn from Enroll America field states to a comparison group of local areas drawn from states that were not served by Enroll America's field effort, but that otherwise match up well with Enroll America states. Principal Findings We find evidence of a large, positive effect of Enroll America's field outreach on Marketplace enrollment in non‐Medicaid expansion states. Across model specifications, the Enroll America effects on Marketplace enrollment ranged between 10 and 15 percent, with most estimates statistically significant at the 5 percent level. Conclusions Enroll America played an important role in the success of individual states' efforts to boost Marketplace enrollment. Enroll American's evidence‐driven, grassroots approach could serve as a model for others interested in conducting similar outreach campaigns for Affordable Care Act–related coverage.

  December 12, 2016   doi: 10.1111/1475-6773.12630   open full text
• Hospital Postacute Care Referral Networks: Is Referral Concentration Associated with Medicare‐Style Bundled Payments?
  Ramandeep Kaur, Jennifer N. Perloff, Christopher Tompkins, Christine E. Bishop.
  Health Services Research. December 05, 2016
  Objective To evaluate whether Medicare‐style bundled payments are lower or higher for beneficiaries discharged from hospitals with postacute care (PAC) referrals concentrated among fewer PAC providers. Data Source Medicare Part A and Part B claim (2008–2012) for all beneficiaries residing in any of 17 market areas: the Provider of Service file, the Healthcare Cost Report Information System, and the Dartmouth Atlas. Study Design An observational study in which hospitals were distinguished according to PAC referral concentration, which is the tendency to utilize fewer rather than more PAC providers. We tested the hypothesis that higher referral concentration would be associated with total Medicare bundled payments. Data Collection/Extraction Methods The data represent a convenience sample of market areas that were defined by the locations of grantees from the ONC Beacon Community Program. Principal Findings The four most‐used PAC providers accounted for an average of 60 percent of patients discharged from hospitals in the sample. Regression analysis suggested that higher referral concentration was associated with lower Medicare costs per bundle. Conclusions Hospitals that tend to use fewer PAC providers may lead to lower costs for payers such as Medicare. The study results reinforce the importance of limited networks for PAC services under bundling arrangements for hospital and PAC payments.

  December 05, 2016   doi: 10.1111/1475-6773.12618   open full text
• Physician Engagement Strategies in Care Coordination: Findings from the Centers for Medicare & Medicaid Services’ Health Care Innovation Awards Program.
  Megan Skillman, Caitlin Cross‐Barnet, Rachel Friedman Singer, Sarah Ruiz, Christina Rotondo, Roy Ahn, Lynne Page Snyder, Erin M. Colligan, Katherine Giuriceo, Adil Moiduddin.
  Health Services Research. December 02, 2016
  Objective To identify roles physicians assumed as part of new health care delivery models and related strategies that facilitated physician engagement across 21 Health Care Innovation Award (HCIA) programs. Data Sources Site‐level in‐depth interviews, conducted from 2014 to 2015 (N = 672) with program staff, leadership, and partners (including 95 physicians) and direct observations. Study Design NORC conducted a mixed‐method evaluation, including two rounds of qualitative data collected via site visits and telephone interviews. Data Collection/Extraction Methods We used qualitative thematic coding for data from 21 programs actively engaging physicians as part of HCIA interventions. Principal Findings Establishing physician champions and ensuring an innovation‐values fit between physicians and programs, including the strategies programs employed, facilitated engagement. Among engagement practices identified in this study, tailoring team working styles to meet physician preferences and conducting physician outreach and education were the most common successful approaches. Conclusions We describe engagement strategies derived from a diverse range of programs. Successful programs considered physicians' values and engagement as components of process and policy, rather than viewing them as exogenous factors affecting innovation adoption. These types of approaches enabled programs to accelerate acceptance of innovations within organizations.

  December 02, 2016   doi: 10.1111/1475-6773.12622   open full text
• The Effect of Certificate of Need Laws on All‐Cause Mortality.
  James Bailey.
  Health Services Research. December 01, 2016
  Objective To test how Certificate of Need laws affect all‐cause mortality in the United States. Data Sources The data of 1992–2011 all‐cause mortality are from the Center for Disease Control's Compressed Mortality File; control variables are from the Current Population Survey, Behavioral Risk Factor Surveillance System, and Area Health Resources File; and data on Certificate of Need laws are from Stratmann and Russ (). Study design Using fixed‐ and random‐effects regressions, I test how the scope of state Certificate of Need laws affects all‐cause mortality within US counties. Principal Findings Certificate of Need laws have no statistically significant effect on all‐cause mortality. Point estimates indicate that if they have any effect, they are more likely to increase mortality than decrease it. Conclusions Proponents of Certificate of Need laws have claimed that they reduce mortality by concentrating more care into fewer, larger facilities that engage in learning‐by‐doing. However, I find no evidence that these laws reduce all‐cause mortality.

  December 01, 2016   doi: 10.1111/1475-6773.12619   open full text
• Using Harm‐Based Weights for the AHRQ Patient Safety for Selected Indicators Composite (PSI‐90): Does It Affect Assessment of Hospital Performance and Financial Penalties in Veterans Health Administration Hospitals?
  Qi Chen, Amy K. Rosen, Ann Borzecki, Michael Shwartz.
  Health Services Research. November 27, 2016
  Objective To assess whether hospital profiles for public reporting and pay‐for‐performance, measured by the Agency for Healthcare Research and Quality (AHRQ) Patient Safety for Selected Indicators (PSI‐90) composite measure, were affected by using the recently developed harm‐based weights. Data Sources/Study Setting Retrospective analysis of 2012–2014 data from the Veterans Health Administration (VA). Study Design The AHRQ PSI software (v5.0) was applied to obtain the original volume‐based PSI‐90 scores for 132 acute‐care hospitals. We constructed a modified PSI‐90 using the harm‐based weights developed by AHRQ. We compared hospital profiles for public reporting and pay‐for‐performance between these two PSI‐90s and assessed patterns in these changes. Principal Findings The volume‐based and the harm‐based PSI‐90s were strongly correlated (r = 0.67, p < .0001). The use of the harm‐based PSI‐90 had a relatively small impact on public reporting (i.e., 5 percent hospitals changed categorization), but it had a much larger impact on pay‐for‐performance (e.g., 15 percent of hospitals would have faced different financial penalties under the Medicare Hospital‐Acquired Condition Reduction Program). Because of changes in weights of specific PSIs, hospital profile changes occurred systematically. Conclusions Use of the harm‐based weights in PSI‐90 has the potential to significantly change payments under pay‐for‐performance programs. Policy makers should carefully develop transition plans for guiding hospitals through changes in any quality metrics used for pay‐for‐performance.

  November 27, 2016   doi: 10.1111/1475-6773.12596   open full text
• Are Two Heads Better Than One or Do Too Many Cooks Spoil the Broth? The Trade‐Off between Physician Division of Labor and Patient Continuity of Care for Older Adults with Complex Chronic Conditions.
  Kenton J. Johnston, Jason M. Hockenberry.
  Health Services Research. November 27, 2016
  Objective To examine the effects of physician division of labor and patient continuity of care (COC) on the care quality and outcomes of older adults with complex chronic conditions. Data Sources/Study Setting Seven years (2006–2012) of panel data from the Medicare Current Beneficiary Survey (MCBS). Study Design Regression models were used to estimate the effect of the specialty‐type of physicians involved in annual patient evaluation and management, as well as patient COC, on simultaneous care processes and following year outcomes. Data Collection/Extraction Methods Multiyear cohorts of Medicare beneficiaries with diabetes and/or heart failure were retrospectively identified to create a panel of 15,389 person‐year observations. Principal Findings Involvement of both primary care physicians and disease‐relevant specialists is associated with better compliance with process‐of‐care guidelines, but patients seeing disease‐relevant specialists also receive more repeat cardiac imaging (p < .05). Patient COC is associated with less repeat cardiac imaging and compliance with some recommended care processes (p < .05), but the effects are small. Receiving care from a disease‐relevant specialist is associated with lower rates of following year functional impairment, institutionalization in long‐term care, and ambulatory care sensitive hospitalization (p < .05). Conclusions Annual involvement of disease‐relevant specialists in the care of beneficiaries with complex chronic conditions leads to more resource use but has a beneficial effect on outcomes.

  November 27, 2016   doi: 10.1111/1475-6773.12600   open full text
• Sampling for Patient Exit Interviews: Assessment of Methods Using Mathematical Derivation and Computer Simulations.
  Pascal Geldsetzer, Günther Fink, Maria Vaikath, Till Bärnighausen.
  Health Services Research. November 24, 2016
  Objective (1) To evaluate the operational efficiency of various sampling methods for patient exit interviews; (2) to discuss under what circumstances each method yields an unbiased sample; and (3) to propose a new, operationally efficient, and unbiased sampling method. Study Design Literature review, mathematical derivation, and Monte Carlo simulations. Principal Findings Our simulations show that in patient exit interviews it is most operationally efficient if the interviewer, after completing an interview, selects the next patient exiting the clinical consultation. We demonstrate mathematically that this method yields a biased sample: patients who spend a longer time with the clinician are overrepresented. This bias can be removed by selecting the next patient who enters, rather than exits, the consultation room. We show that this sampling method is operationally more efficient than alternative methods (systematic and simple random sampling) in most primary health care settings. Conclusion Under the assumption that the order in which patients enter the consultation room is unrelated to the length of time spent with the clinician and the interviewer, selecting the next patient entering the consultation room tends to be the operationally most efficient unbiased sampling method for patient exit interviews.

  November 24, 2016   doi: 10.1111/1475-6773.12611   open full text
• Adjusting Health Expenditures for Inflation: A Review of Measures for Health Services Research in the United States.
  Abe Dunn, Scott D. Grosse, Samuel H. Zuvekas.
  Health Services Research. November 21, 2016
  Objective To provide guidance on selecting the most appropriate price index for adjusting health expenditures or costs for inflation. Data Sources Major price index series produced by federal statistical agencies. Study Design We compare the key characteristics of each index and develop suggestions on specific indexes to use in many common situations and general guidance in others. Data Collection/Extraction Methods Price series and methodological documentation were downloaded from federal websites and supplemented with literature scans. Principal Findings The gross domestic product implicit price deflator or the overall Personal Consumption Expenditures (PCE) index is preferable to the Consumer Price Index (CPI‐U) to adjust for general inflation, in most cases. The Personal Health Care (PHC) index or the PCE health‐by‐function index is generally preferred to adjust total medical expenditures for inflation. The CPI medical care index is preferred for the adjustment of consumer out‐of‐pocket expenditures for inflation. A new, experimental disease‐specific Medical Care Expenditure Index is now available to adjust payments for disease treatment episodes. Conclusions There is no single gold standard for adjusting health expenditures for inflation. Our discussion of best practices can help researchers select the index best suited to their study.

  November 21, 2016   doi: 10.1111/1475-6773.12612   open full text
• Impact of Copayment Changes on Children's Albuterol Inhaler Use and Costs after the Clean Air Act Chlorofluorocarbon Ban.
  Alison A. Galbraith, Vicki Fung, Lingling Li, Melissa G. Butler, James D. Nordin, John Hsu, David Smith, William M. Vollmer, Tracy A. Lieu, Stephen B. Soumerai, Ann Chen Wu.
  Health Services Research. November 20, 2016
  Objective To examine changes in children's albuterol use and out‐of‐pocket (OOP) costs in response to increased copayments after the Food and Drug Administration banned inhalers with chlorofluorocarbon (CFC) propellants. Setting Four health maintenance organizations (HMOs), two that increased copayments for albuterol inhalers that went from generic CFC‐containing to branded CFC‐free versions, and two that retained generic copayments for CFC‐free inhalers (controls). We included children with asthma aged 4–17 years with commercial coverage from 2007 to 2010. Design Interrupted time series with comparison series. Data We obtained enrollee and plan characteristics from enrollment files, and utilization data from pharmacy and medical claims; OOP expenditures were extracted from pharmacy claims for two HMOs with cost data available. Findings There were no significant differences in albuterol use between the group with increased cost‐sharing and controls with respect to changes after the policy change. There was a postpolicy increase of $6.11 OOP per month per child using albuterol among those with increased cost‐sharing versus $0.36 in controls; the difference between groups was significant (p < .01). Conclusions Increased copayments for brand‐name CFC‐free albuterol after the CFC ban did not lead to a decrease in children's albuterol use, but it led to a modest increase in OOP costs.

  November 20, 2016   doi: 10.1111/1475-6773.12615   open full text
• Does Spatial Access to Primary Care Affect Emergency Department Utilization for Nonemergent Conditions?
  Jamie Fishman, Sara McLafferty, William Galanter.
  Health Services Research. November 17, 2016
  Objective To examine the contributions of individual‐ and neighborhood‐level spatial access to care to the utilization of emergency departments (EDs) for preventable conditions through implementation of novel local spatial access measures. Data Sources/Study Setting Emergency department admissions data are from four HealthLNK member hospitals in Chicago from 2007 to 2011. Primary care physician office and clinic locations were obtained from the American Medical Association and the City of Chicago. Study Design Multilevel logit regression was used to model the relationship between individual‐ and neighborhood‐level attributes and preventable ED use. Data Collection/Extraction Methods Emergency department admissions data were classified based on the primary diagnosis for each encounter. Spatial access to care indices were generated in ArcGIS, and values were extracted at each ZIP code centroid to match patients' ZIP codes. Principal Findings Beyond sociodemographic factors such as gender and race, patients living in medically underserved areas (MUAs) and areas with lower spatial access to primary care clinics had higher odds of preventable ED use. Conclusions Preventable ED use can be associated with sociodemographic characteristics, as well as spatial access to primary care services. This study reveals potential for using local measures of spatial accessibility for preventable ED analyses.

  November 17, 2016   doi: 10.1111/1475-6773.12617   open full text
• Mandatory Statewide Medicaid Managed Care in Florida and Hospitalizations for Ambulatory Care Sensitive Conditions.
  Tianyan Hu, Karoline Mortensen.
  Health Services Research. November 17, 2016
  Objective To investigate the impact of implementation of the Statewide Medicaid Managed Care (SMMC) program in Florida on access to and quality of primary care for Medicaid enrollees, measured by hospitalizations for ambulatory care sensitive conditions (ACSCs). Data Sources We examine inpatient data obtained from the Agency for Health Care Administration for 285 hospitals in Florida from January 2010 to June 2015. The analysis includes 3,645,515 discharges for Florida residents between the ages 18 and 64 with a primary payer of Medicaid or private insurance. Study Design We use a difference‐in‐differences approach, comparing the change in the incidence of ACSC‐related inpatient visits among Medicaid patients before and after the implementation of SMMC, relative to the change among the privately insured. Principal Findings After implementation of SMMC, Medicaid patients experienced a 0.35 percentage point slower growth in overall ACSC‐related inpatient visits, and a 0.21 percentage point slower growth in chronic ACSC‐related inpatient visits. The effects were significant in counties with above median Medicaid managed care penetration rates. Conclusions Implementing mandatory managed care in Medicaid in Florida leads to slower growth in inpatient visits for conditions that can potentially be prevented with improved access to outpatient care.

  November 17, 2016   doi: 10.1111/1475-6773.12613   open full text
• Early Impact of the Affordable Care Act's Medicaid Expansion on Dental Care Use.
  Kamyar Nasseh, Marko Vujicic.
  Health Services Research. November 16, 2016
  Objective To examine the impact of the Affordable Care Act on dental care use among poor adults ages 21–64 in 2014. Data 2010–2014 Gallup‐Healthways Wellbeing Index Survey. Study Design Among poor adults with income at or below 138% of the Federal Poverty Level, a differences‐in‐differences analysis was used to compare the changes in dental care use in states with different Medicaid expansion and adult dental policies. Principal Findings Relative to the pre‐reform period and other states, in Medicaid expansion states with adult dental benefits, dental care use increased between 2 and 6 percent points in the second half of 2014, but most of these changes were not statistically significant. Conclusions Early evidence suggests that the Affordable Care Act may either not be having a substantial impact on dental care use or it is too early to assess the impact.

  November 16, 2016   doi: 10.1111/1475-6773.12606   open full text
• Automated Delineation of Hospital Service Areas and Hospital Referral Regions by Modularity Optimization.
  Yujie Hu, Fahui Wang, Imam M. Xierali.
  Health Services Research. November 16, 2016
  Objective To develop an automated, data‐driven, and scale‐flexible method to delineate hospital service areas (HSAs) and hospital referral regions (HRRs) that are up‐to‐date, representative of all patients, and have the optimal localization of hospital visits. Data Sources The 2011 state inpatient database in Florida from the Healthcare Cost and Utilization Project. Study Design A network optimization method was used to redefine HSAs and HRRs by maximizing patient‐to‐hospital flows within each HSA/HRR while minimizing flows between them. We first constructed as many HSAs/HRRs as existing Dartmouth units in Florida, and then compared the two by various metrics. Next, we sought to derive the optimal numbers and configurations of HSAs/HRRs that best reflect the modularity of hospitalization patterns in Florida. Principal Findings The HSAs/HRRs by our method are favored over the Dartmouth units in balance of region size and market structure, shape, and most important, local hospitalization. Conclusions The new method is automated, scale‐flexible, and effective in capturing the natural structure of the health care system. It has great potential for applications in delineating other health care service areas or in larger geographic regions.

  November 16, 2016   doi: 10.1111/1475-6773.12616   open full text
• Organizational Factors Affect Safety‐Net Hospitals’ Breast Cancer Treatment Rates.
  Nina A. Bickell, Alexandra DeNardis Moss, Maria Castaldi, Ajay Shah, Alan Sickles, Peter Pappas, Theophilus Lewis, Margaret Kemeny, Shalini Arora, Lori Schleicher, Kezhen Fei, Rebeca Franco, Ann Scheck McAlearney.
  Health Services Research. November 14, 2016
  Objective To identify key organizational approaches associated with underuse of breast cancer care. Setting Nine New York City area safety‐net hospitals. Study Design Mixed qualitative–quantitative, cross‐sectional cohort. Methods We used qualitative comparative analysis (QCA) of key stakeholder interviews, defined organizational “conditions,” calibrated conditions, and identified solution pathways. We defined underuse as no radiation after lumpectomy in women <75 years or mastectomy in women with ≥4 positive nodes, or no systemic therapy in women with tumors ≥1 cm. We used hierarchical models to assess organizational and patient factors’ impact on underuse. Principal Findings Underuse varied by hospital (8–29 percent). QCA found lower underuse sites designated individuals to track and follow‐up no‐shows; shared clinical information during handoffs; had fully integrated electronic medical records enabling transfer of responsibility across specialties; had strong system support; allocated resources to cancer clinics; had a patient‐centered culture paying close organizational attention to clinic patients. High underuse sites lacked these characteristics. Multivariate modeling found that hospitals with strong approaches to follow‐up had low underuse rates (RR = 0.28; 0.08–0.95); individual patient characteristics were not significant. Conclusions At safety‐net hospitals, underuse of needed cancer therapies is associated with organizational approaches to track and follow‐up treatment. Findings provide varying approaches to safety nets to improve cancer care delivery.

  November 14, 2016   doi: 10.1111/1475-6773.12605   open full text
• Stratifying Patients with Diabetes into Clinically Relevant Groups by Combination of Chronic Conditions to Identify Gaps in Quality of Care.
  Elizabeth M. Magnan, Daniel M. Bolt, Robert T. Greenlee, Jennifer Fink, Maureen A. Smith.
  Health Services Research. November 13, 2016
  Objective To find clinically relevant combinations of chronic conditions among patients with diabetes and to examine their relationships with six diabetes quality metrics. Data Sources/Study Setting Twenty‐nine thousand five hundred and sixty‐two adult patients with diabetes seen at eight Midwestern U.S. health systems during 2010–2011. Study Design We retrospectively evaluated the relationship between six diabetes quality metrics and patients' combinations of chronic conditions. We analyzed 12 conditions that were concordant with diabetes care to define five mutually exclusive combinations of conditions (“classes”) based on condition co‐occurrence. We used logistic regression to quantify the relationship between condition classes and quality metrics, adjusted for patient demographics and utilization. Data Collection We extracted electronic health record data using a standardized algorithm. Principal Findings We found the following condition classes: severe cardiac, cardiac, noncardiac vascular, risk factors, and no concordant comorbidities. Adjusted odds ratios and 95 percent confidence intervals for glycemic control were, respectively, 1.95 (1.7–2.2), 1.6 (1.4–1.9), 1.3 (1.2–1.5), and 1.3 (1.2–1.4) compared to the class with no comorbidities. Results showed similar patterns for other metrics. Conclusions Patients had distinct quality metric achievement by condition class, and those in less severe classes were less likely to achieve diabetes metrics.

  November 13, 2016   doi: 10.1111/1475-6773.12607   open full text
• Out‐of‐Network Emergency Department Use among Managed Medicaid Beneficiaries.
  Maria C. Raven, David Guzman, Alice H. Chen, John Kornak, Margot Kushel.
  Health Services Research. November 11, 2016
  Objective Out‐of‐network emergency department (ED) use, or use that occurs outside the contracted network, may lead to increased care fragmentation and cost. We examined factors associated with out‐of‐network ED use among Medicaid beneficiaries. Data Sources and Study Setting Enrollment, claims, and encounter data for adult Medi‐Cal health plan members with 1+ ED visits and complete Medicaid eligibility during the study period from 2013 to 2014. Study Design We analyzed the data to identify factors associated with out‐of‐network ED use classified by mode of arrival (ambulance vs. nonambulance). Data Extraction Methods We extracted encounter, ambulance, and ED census data and linked them together based on ED visit date. Principal Findings Of 11,143 ED visits, 6,808 (61.1 percent) were out‐of‐network. The number of hours the study ED was on ambulance diversion increased the odds of out‐of‐network visits for the 3,365 (30.2 percent) ED visits arriving by ambulance. For all visit types, assignment to a primary care clinic at the in‐network hospital and having had any primary care visit during the study period decreased the odds of out‐of‐network ED care. Individuals were more likely to go out‐of‐network for ED care if they lived in neighborhoods containing out‐of‐network EDs. Conclusions There are a number of factors related to out‐of‐network ED use, including the proximity and density of out‐of‐network EDs, race and ethnicity, a prior history of out‐of‐network ED use, and individuals’ connection to primary care. EDs that serve Medicaid beneficiaries may need to explore alternative sites and modalities of care as alternatives to the ED, and consider their ability to absorb large numbers of out‐of‐network visits given already limited capacity.

  November 11, 2016   doi: 10.1111/1475-6773.12604   open full text
• Low‐Value Service Use in Provider Organizations.
  Aaron L. Schwartz, Alan M. Zaslavsky, Bruce E. Landon, Michael E. Chernew, J. Michael McWilliams.
  Health Services Research. November 10, 2016
  Objective To assess whether provider organizations exhibit distinct profiles of low‐value service provision. Data Sources 2007–2011 Medicare fee‐for‐service claims and enrollment data. Study Design Use of 31 services that provide minimal clinical benefit was measured for 4,039,733 beneficiaries served by 3,137 provider organizations. Variation across organizations, persistence within organizations over time, and correlations in use of different types of low‐value services within organizations were estimated via multilevel modeling, with adjustment for beneficiary sociodemographic and clinical characteristics. Principal Findings Organizations provided 45.6 low‐value services per 100 beneficiaries on average, with considerable variation across organizations (90th/10th percentile ratio, 1.78; 95 percent CI, 1.72–1.84), including substantial between‐organization variation within hospital referral regions (90th/10th percentile ratio, 1.66; 95 percent CI, 1.60–1.71). Low‐value service use within organizations was highly correlated over time (r, 0.98; 95 percent CI, 0.97–0.99) and positively correlated between 13 of 15 pairs of service categories (average r, 0.26; 95 percent CI, 0.24–0.28), with the greatest correlation between low‐value imaging and low‐value cardiovascular testing and procedures (r, 0.54). Conclusions Use of low‐value services in provider organizations exhibited substantial variation, high persistence, and modest consistency across service types. These findings are consistent with organizations shaping the practice patterns of affiliated physicians.

  November 10, 2016   doi: 10.1111/1475-6773.12597   open full text
• Lactation Support Services and Breastfeeding Initiation: Evidence from the Affordable Care Act.
  Kandice A. Kapinos, Lindsey Bullinger, Tami Gurley‐Calvez.
  Health Services Research. November 10, 2016
  Objective Despite substantial evidence of the benefits of breastfeeding for both mothers and children, rates of sustained breastfeeding in the United States are quite low. This study examined whether mandated coverage of lactation support services under the Affordable Care Act (ACA) affects breastfeeding behavior. Data Source We studied the census of U.S. births included in the National Vital Statistics System from 2009 to 2014. Study Design We used regression‐adjusted difference‐in‐differences (DD) to examine changes in breastfeeding rates for privately insured mothers relative to those covered by Medicaid. We adjusted for several health and sociodemographic measures. We also examined the extent to which the effect varied across vulnerable populations—by race/ethnicity, maternal education, WIC status, and mode of delivery. Principal Findings Results suggest that the ACA mandate increased the probability of breastfeeding initiation by 2.5 percentage points, which translates into about 47,000 more infants for whom breastfeeding was initiated in 2014. We find larger effects for black, less educated, and unmarried mothers. Conclusions The Affordable Care Act–mandated coverage of lactation services increased breastfeeding initiation among privately insured mothers relative to mothers covered by Medicaid. The magnitude of the effect size varied with some evidence of certain groups being more likely to increase breastfeeding rates.

  November 10, 2016   doi: 10.1111/1475-6773.12598   open full text
• Supplemental Insurance and Racial Health Disparities under Medicare Part B.
  Christopher S. Brunt.
  Health Services Research. November 10, 2016
  Objective To assess the impact of preferences, socioeconomic status (SES), and supplemental insurance (SI) on racial/ethnic disparities in the probability and use of services at physicians' offices, hospitals, and emergency departments among Medicare beneficiaries enrolled in Part B. Research Design and Subjects This study includes black and white beneficiaries from the 2009–2011 panel of the Medicare Current Beneficiary Survey who were enrolled in Medicare Part B. Logit and negative binomial multivariate regression analysis were used in conjunction with rank‐and‐replace methods to determine factors influencing utilization and black–white utilization disparities. Principal Findings Among Part B beneficiaries, significant disparities exist for each studied service. Examining contributing factors, 12–19 percent of the black–white health‐adjusted difference in the probability of use is explained by differences in SES, whereas differences in the distribution of SI accounts for 20 percent or more. For volume, SES is found to account for 2–11 percent of differences with SI making up another 9–10 percent. Conclusions A substantial portion of the difference in black–white beneficiary use of outpatient services is due to SI. Policies aimed at increasing coverage are likely to increase the probability of visits with modest increases in volume.

  November 10, 2016   doi: 10.1111/1475-6773.12599   open full text
• Personalizing Nursing Home Compare and the Discharge from Hospitals to Nursing Homes.
  Dana B. Mukamel, Alpesh Amin, David L. Weimer, Heather Ladd, Joseph Sharit, Ran Schwarzkopf, Dara H. Sorkin.
  Health Services Research. October 24, 2016
  Objective To test whether use of a personalized report card, Nursing Home Compare Plus (NHCPlus), embedded in a reengineered discharge process, can lead to better outcomes than the usual discharge process from hospitals to nursing homes. Data Sources/Setting Primary data collected in the Departments of Medicine and Surgery at a University Medical Center between March 2014 and August 2015. Study Design A randomized controlled trial in which patients in the intervention group were given NHCPlus. Participants included 225 patients or their family members/surrogates. Data Collection Key strokes of NHCPlus users were recorded to obtain information about usage. Users were surveyed about usability and satisfaction with NHCPlus. All participants were surveyed at discharge from the hospital. Survey data were merged with medical records. Principal Findings About 85 percent of users indicated satisfaction with NHCPlus. Compared to controls, intervention patients were more satisfied with the choice process (by 40 percent of the standard deviation p < .01), more likely to go to higher ranked five‐star nursing homes (OR = 1.8, p < .05), traveled to further nursing homes (IRR = 1.27, p < .10), and had shorter hospital stays (IRR = 0.84, p < .05). Conclusions Personalizing report cards and reengineering the discharge process may improve quality and may lower costs compared to the usual discharge process.

  October 24, 2016   doi: 10.1111/1475-6773.12588   open full text
• Testing the Replicability of a Successful Care Management Program: Results from a Randomized Trial and Likely Explanations for Why Impacts Did Not Replicate.
  G. Greg Peterson, Jelena Zurovac, Randall S. Brown, Kenneth D. Coburn, Patricia A. Markovich, Sherry A. Marcantonio, William D. Clark, Anne Mutti, Cara Stepanczuk.
  Health Services Research. October 24, 2016
  Objectives To test whether a care management program could replicate its success in an earlier trial and determine likely explanations for why it did not. Data Sources/Setting Medicare claims and nurse contact data for Medicare fee‐for‐service beneficiaries with chronic illnesses enrolled in the trial in eastern Pennsylvania (N = 483). Study Design A randomized trial with half of enrollees receiving intensive care management services and half receiving usual care. We developed and tested hypotheses for why impacts declined. Data Extraction All outcomes and covariates were derived from claims and the nurse contact data. Principal Findings From 2010 to 2014, the program did not reduce hospitalizations or generate Medicare savings to offset program fees that averaged $260 per beneficiary per month. These estimates are statistically different (p < .05) from the large reductions in hospitalizations and spending in the first trial (2002–2010). The treatment–control differences in the second trial disappeared because the control group's risk‐adjusted hospitalization rate improved, not because the treatment group's outcomes worsened. Conclusion Even if demonstrated in a randomized trial, successful results from one test may not replicate in other settings or time periods. Assessing whether gaps in care that the original program filled exist in other settings can help identify where earlier success is likely to replicate.

  October 24, 2016   doi: 10.1111/1475-6773.12595   open full text
• Disparities in Diabetes Care Quality by English Language Preference in Community Health Centers.
  Lucinda B. Leung, Arturo Vargas‐Bustamante, Ana E. Martinez, Xiao Chen, Hector P. Rodriguez.
  Health Services Research. October 21, 2016
  Objective To conduct a parallel analysis of disparities in diabetes care quality among Latino and Asian community health center (CHC) patients by English language preference. Study Setting/Data Collection Clinical outcomes (2011) and patient survey data (2012) for Type 2 diabetes adults from 14 CHCs (n = 1,053). Study Design We estimated separate regression models for Latino and Asian patients by English language preference for Clinician & Group—Consumer Assessment of Healthcare Providers and System, Patient Assessment of Chronic Illness Care, hemoglobin A1c, and self‐reported hypoglycemic events. We used the Blinder–Oaxaca decomposition method to parse out observed and unobserved differences in outcomes between English versus non‐English language groups. Principal Findings After adjusting for socioeconomic and health characteristics, disparities in patient experiences by English language preference were found only among Asian patients. Unobserved factors largely accounted for linguistic disparities for most patient experience measures. There were no significant differences in glycemic control by language for either Latino or Asian patients. Conclusions Given the importance of patient retention in CHCs, our findings indicate opportunities to improve CHC patients' experiences of care and to reduce disparities in patient experience by English preference for Asian diabetes patients.

  October 21, 2016   doi: 10.1111/1475-6773.12590   open full text
• Access to Care for Medicare‐Medicaid Dually Eligible Beneficiaries: The Role of State Medicaid Payment Policies.
  Nan Tracy Zheng, Susan Haber, Sonja Hoover, Zhanlian Feng.
  Health Services Research. October 21, 2016
  Study Objectives Medicaid programs are not required to pay the full Medicare coinsurance and deductibles for Medicare‐Medicaid dually eligible beneficiaries. We examined the association between the percentage of Medicare cost sharing paid by Medicaid and the likelihood that a dually eligible beneficiary used evaluation and management (E&M) services and safety net provider services. Data Sources Medicare and Medicaid Analytic eXtract enrollment and claims data for 2009. Study Design Multivariate analyses used fee‐for‐service dually eligible and Medicare‐only beneficiaries in 20 states. A comparison group of Medicare‐only beneficiaries controlled for state factors that might influence utilization. Principal Findings Paying 100 percent of the Medicare cost sharing compared to 20 percent increased the likelihood (relative to Medicare‐only) that a dually eligible beneficiary had any E&M visit by 6.4 percent. This difference in the percentage of cost sharing paid decreased the likelihood of using safety net providers, by 37.7 percent for federally qualified health centers and rural health centers, and by 19.8 percent for hospital outpatient departments. Conclusions Reimbursing the full Medicare cost‐sharing amount would improve access for dually eligible beneficiaries, although the magnitude of the effect will vary by state and type of service.

  October 21, 2016   doi: 10.1111/1475-6773.12591   open full text
• Longitudinal Patterns of Emergency Department Visits: A Multistate Analysis of Medicaid Beneficiaries.
  Parul Agarwal, Thomas K. Bias, Usha Sambamoorthi.
  Health Services Research. October 21, 2016
  Objective The objective of this study was to examine the longitudinal patterns of emergency department (ED) visits among adult fee‐for‐service Medicaid. Data Sources Data were obtained from the Medicaid analytic eXtract files, Area Health Resource File, and County Health Rankings. Study Design A retrospective longitudinal study design, with four observations for each individual was used. The study population consisted of 33,393 Medicaid beneficiaries who met inclusion criteria. ED visits were time‐lagged and time‐varying patient‐level factors were measured for each year. Time‐invariant characteristics (gender and race/ethnicity) were measured in 2006. Multivariable hurdle models with logistic (ED use versus no ED use) and negative binomial regressions (ED visits among ED users) were used to analyze the ED visits over time. To account for correlation due to repeated observations, mixed effect models with robust standard errors were performed. Principal Findings In both unadjusted and adjusted analysis, the likelihood of ED use did not change from year to year (AOR = 1.00, 95 percent CI: 0.99, 1.01). Among ED users, the estimated number of ED visits increased over time (IRR = 1.01, 95 percent CI: 1.01, 1.03). Conclusions Primary care resources should be a major focus to reduce the increased burden on the EDs.

  October 21, 2016   doi: 10.1111/1475-6773.12584   open full text
• Is a Skilled Nursing Facility's Rehospitalization Rate a Valid Quality Measure?
  Momotazur Rahman, David C. Grabowski, Vincent Mor, Edward C. Norton.
  Health Services Research. October 21, 2016
  Objective To determine whether the observed differences in the risk‐adjusted rehospitalization rates across skilled nursing facilities (SNFs) reflect true differences or merely differences in patient severity. Settings Elderly Medicare beneficiaries newly admitted to an SNF following hospitalization. Study Design We used 2009–2012 Medicare data to calculate SNFs' risk‐adjusted rehospitalization rate. We then estimated the effect of these rehospitalization rates on the rehospitalization of incident patients in 2013, using an instrumental variable (IV) method and controlling for patient's demographic and clinical characteristics and residential zip code fixed effects. We used the number of empty beds in a patient's proximate SNFs during hospital discharge to create the IV. Principal Findings The risk‐adjusted rehospitalization rate varies widely; about one‐quarter of the SNFs have a rehospitalization rate lower than 17 percent, and for one‐quarter, it is higher than 23 percent. All the IV models result in a robust finding that an increase in a SNF's rehospitalization rate of 1 percentage point over the period 2009–2012 leads to an increase in a patient's likelihood of rehospitalization by 0.8 percentage points in 2013. Conclusions Treatment in SNFs with historically low rehospitalization causally reduces a patient's likelihood of rehospitalization. Observed differences in rehospitalization rates reflect true differences and are not an artifact of selection.

  October 21, 2016   doi: 10.1111/1475-6773.12603   open full text
• Physician EHR Adoption and Potentially Preventable Hospital Admissions among Medicare Beneficiaries: Panel Data Evidence, 2010–2013.
  Eric J. Lammers, Catherine G. McLaughlin, Michael Barna.
  Health Services Research. October 21, 2016
  Objective To test for correlation between the growth in adoption of ambulatory electronic health records (EHRs) in the United States during 2010–2013 and hospital admissions and readmissions for elderly Medicare beneficiaries with at least one of four common ambulatory care–sensitive conditions (ACSCs). Data Sources SK&A Information Services Survey of Physicians, American Hospital Association General Survey and Information Technology Supplement; and the Centers for Medicare & Medicaid Services Chronic Conditions Data Warehouse Geographic Variation Database for 2010 through 2013. Study Design Fixed effects model estimated the relationship between hospital referral region (HRR) level measures of physician EHR adoption and ACSC admissions and readmissions. Analyzed rates of admissions and 30‐day readmissions per beneficiary at the HRR level (restricting the denominator to beneficiaries in our sample), adjusted for differences across HRRs in Medicare beneficiary age, gender, and race. Calculated physician EHR adoption rates as the percentage of physicians in each HRR who report using EHR in ambulatory care settings. Principal Findings Each percentage point increase in market‐level EHR adoption by physicians is correlated with a statistically significant decline of 1.06 ACSC admissions per 10,000 beneficiaries over the study period, controlling for the overall time trend as well as market fixed effects and characteristics that changed over time. This finding implies 26,689 fewer ACSC admissions in our study population during 2010 to 2013 that were related to physician ambulatory EHR adoption. This represents 3.2 percent fewer ACSC admissions relative to the total number of such admissions in our study population in 2010. We found no evidence of a correlation between EHR use, by either physicians or hospitals, and hospital readmissions at either the market level or hospital level. Conclusions This study extends knowledge about EHRs' relationship with quality of care and utilization. The results suggest a significant association between EHR use in ambulatory care settings and ACSC admissions that is consistent with policy goals to improve the quality of ambulatory care for patients with chronic conditions. The null findings for readmissions support the need for improved interoperability between ambulatory care EHRs and hospital EHRs to realize improvements in readmissions.

  October 21, 2016   doi: 10.1111/1475-6773.12586   open full text
• Through the Looking Glass: Estimating Effects of Medical Homes for People with Severe Mental Illness.
  Marisa Elena Domino, Mona Kilany, Rebecca Wells, Joseph P. Morrissey.
  Health Services Research. October 21, 2016
  Objective To examine whether medical homes have heterogeneous effects in different subpopulations, leveraging the interpretations from a variety of statistical techniques. Data Sources/Study Setting Secondary claims data from the NC Medicaid program for 2004–2007. The sample included all adults with diagnoses of schizophrenia, bipolar disorder, or major depression who were not dually enrolled in Medicare or in a nursing facility. Study Design We modeled a number of monthly service use, adherence, and expenditure outcomes using fixed effects, generalized estimating equation with and without inverse probability of treatment weights, and instrumental variables analyses. Data Collection Data were received from the Carolina Cost and Quality Initiative. Principal Findings The four estimation techniques consistently revealed generally positive associations between medical homes and access to primary care, specialty mental health care, greater medication adherence, slightly lower emergency room use, and greater expenditures. These findings were consistent across all three major severe mental illness diagnostic groups. Some heterogeneity in effects were noted, especially in preventive screening. Conclusions Expanding access to primary care–based medical homes for people with severe mental illness may not save money for insurance providers, due to greater access for important outpatient services with little cost offset. Health services research examining more of the treatment heterogeneity may contribute to more realistic projections about medical homes outcomes.

  October 21, 2016   doi: 10.1111/1475-6773.12585   open full text
• Reliability of 30‐Day Readmission Measures Used in the Hospital Readmission Reduction Program.
  Michael P. Thompson, Cameron M. Kaplan, Yu Cao, Gloria J. Bazzoli, Teresa M. Waters.
  Health Services Research. October 21, 2016
  Objective To assess the reliability of risk‐standardized readmission rates (RSRRs) for medical conditions and surgical procedures used in the Hospital Readmission Reduction Program (HRRP). Data Sources State Inpatient Databases for six states from 2011 to 2013 were used to identify patient cohorts for the six conditions used in the HRRP, which was augmented with hospital characteristic and HRRP penalty data. Study Design Hierarchical logistic regression models estimated hospital‐level RSRRs for each condition, the reliability of each RSRR, and the extent to which socioeconomic and hospital factors further explain RSRR variation. We used publicly available data to estimate payments for excess readmissions in hospitals with reliable and unreliable RSRRs. Principal Findings Only RSRRs for surgical procedures exceeded the reliability benchmark for most hospitals, whereas RSRRs for medical conditions were typically below the benchmark. Additional adjustment for socioeconomic and hospital factors modestly explained variation in RSRRs. Approximately 25 percent of payments for excess readmissions were tied to unreliable RSRRs. Conclusions Many of the RSRRs employed by the HRRP are unreliable, and one quarter of payments for excess readmissions are associated with unreliable RSRRs. Unreliable measures blur the connection between hospital performance and incentives, and threaten the success of the HRRP.

  October 21, 2016   doi: 10.1111/1475-6773.12587   open full text
• Sustained User Engagement in Health Information Technology: The Long Road from Implementation to System Optimization of Computerized Physician Order Entry and Clinical Decision Support Systems for Prescribing in Hospitals in England.
  Kathrin M. Cresswell, Lisa Lee, Hajar Mozaffar, Robin Williams, Aziz Sheikh,.
  Health Services Research. October 07, 2016
  Objective To explore and understand approaches to user engagement through investigating the range of ways in which health care workers and organizations accommodated the introduction of computerized physician order entry (CPOE) and computerized decision support (CDS) for hospital prescribing. Study Setting Six hospitals in England, United Kingdom. Study Design Qualitative case study. Data Collection We undertook qualitative semi‐structured interviews, non‐participant observations of meetings and system use, and collected organizational documents over three time periods from six hospitals. Thematic analysis was initially undertaken within individual cases, followed by cross‐case comparisons. Findings We conducted 173 interviews, conducted 24 observations, and collected 17 documents between 2011 and 2015. We found that perceived individual and safety benefits among different user groups tended to facilitate engagement in some, while other less engaged groups developed resistance and unsanctioned workarounds if systems were perceived to be inadequate. We identified both the opportunity and need for sustained engagement across user groups around system enhancement (e.g., through customizing software) and the development of user competencies and effective use. Conclusions There is an urgent need to move away from an episodic view of engagement focused on the preimplementation phase, to more continuous holistic attempts to engage with and respond to end‐users.

  October 07, 2016   doi: 10.1111/1475-6773.12581   open full text
• Can a More User‐Friendly Medicare Plan Finder Improve Consumers’ Selection of Medicare Plans?
  Steven C. Martino, David E. Kanouse, David J. Miranda, Marc N. Elliott.
  Health Services Research. October 07, 2016
  Objective To evaluate the efficacy for consumers of two potential enhancements to the Medicare Plan Finder (MPF)—a simplified data display and a “quick links” home page designed to match the specific tasks that users seek to accomplish on the MPF. Data Sources/Study Setting Participants (N = 641) were seniors and adult caregivers of seniors who were recruited from a national online panel. Participants browsed a simulated version of the MPF, made a hypothetical plan choice, and reported on their experience. Study Design Participants were randomly assigned to one of eight conditions in a fully factorial design: 2 home pages (quick links, current MPF home page) × 2 data displays (simplified, current MPF display) × 2 plan types (stand‐alone prescription drug plan [PDP], Medicare Advantage plan with prescription drug coverage [MA‐PD]). Principal Findings The quick links page resulted in more favorable perceptions of the MPF, improved users’ understanding of the information, and increased the probability of choosing the objectively best plan. The simplified data display resulted in a more favorable evaluation of the website, better comprehension of the displayed information, and, among those choosing a PDP only, an increased probability of choosing the best plan. Conclusions Design enhancements could markedly improve average website users’ understanding, ability to use, and experience of using the MPF.

  October 07, 2016   doi: 10.1111/1475-6773.12582   open full text
• Transfer Frequency as a Measure of Hospital Capability and Regionalization.
  Urbano L. França, Michael L. McManus.
  Health Services Research. October 07, 2016
  Objective To provide metrics for quantifying the capability of hospitals and the degree of care regionalization. Data Source Administrative database covering more than 10 million hospital encounters during a 3‐year period (2012–2014) in Massachusetts. Principal Findings We calculated the condition‐specific probabilities of transfer for all acute care hospitals in Massachusetts and devised two new metrics, the Hospital Capability Index (HCI) and the Regionalization Index (RI), for analyzing hospital systems. The HCI had face validity, accurately differentiating academic, teaching, and community hospitals of varying size. Individual hospital capabilities were clearly revealed in “fingerprints” of their condition‐specific transfer behavior. The RI also performed well, with those of specific conditions successfully quantifying the concentration of care arising from regulatory and public health activity. The median RI of all conditions within the Massachusetts health care system was 0.21 (IQR, 0.13–0.36), with a long tail of conditions that were very highly regionalized. Application of the HCI and RI metrics together across the entire state identified the degree of interdependence among its hospitals. Conclusions Condition‐specific transfer activity, as captured in the HCI and RI, provides quantitative measures of hospital capability and regionalization of care.

  October 07, 2016   doi: 10.1111/1475-6773.12583   open full text
• Misclassification Risk of Tier‐Based Physician Quality Performance Systems.
  John L. Adams, Susan M. Paddock.
  Health Services Research. October 07, 2016
  Objective There is increasing interest in identifying high‐quality physicians, such as whether physicians perform above or below a threshold level. To evaluate whether current methods accurately distinguish above‐ versus below‐threshold physicians, we estimate misclassification rates for two‐category identification systems. Data Sources Claims data for Medicare fee‐for‐service beneficiaries residing in Florida or New York in 2010. Study Design Estimate colorectal cancer, glaucoma, and diabetes quality scores for 23,085 physicians. Use a beta‐binomial model to estimate physician score reliabilities. Compute the proportion of physicians whose performance tier would be misclassified under three scoring systems. Principal Findings In the three scoring systems, misclassification ranges were 8.6–25.7 percent, 6.4–22.8 percent, and 4.5–21.7%. True positive rate ranges were 72.9–97.0 percent, 83.4–100.0 percent, and 34.7–88.2 percent. True negative rate ranges were 68.5–91.6 percent, 10.5–92.4 percent, and 81.1–99.9 percent. Positive predictive value ranges were 70.5–91.6 percent, 77.0–97.3 percent, and 55.2–99.1 percent. Conclusions Current methods for profiling physicians on quality may produce misleading results, as the number of eligible events is typically small. Misclassification is a policy‐relevant measure of the potential impact of tiering on providers, payers, and patients. Quantifying misclassification rates should inform the construction of high‐performance networks and quality improvement initiatives.

  October 07, 2016   doi: 10.1111/1475-6773.12561   open full text
• Declining Amenable Mortality: Time Trend (2000–2013) and Geographic Area Analysis.
  Maria Michela Gianino, Jacopo Lenzi, Aida Muça, Maria Pia Fantini, Roberta Siliquini, Walter Ricciardi, Gianfranco Damiani.
  Health Services Research. October 05, 2016
  Objective To update amenable mortality in 32 OECD countries at 2013 (or last available year), to describe the time trends during 2000–2013, and to evaluate the association of these trends with various geographic areas. Data Sources Secondary data from 32 countries during 2000–2013, gathered from the World Health Organization Mortality Database. Study Design Time trend analysis. Data Collection Using Nolte and McKee's list, age‐standardized amenable mortality rates (SDRs) were calculated as the annual number of deaths over the population aged 0–74 years per 100,000 inhabitants. We performed a mixed‐effects polynomial regression analysis on the annual SDRs to determine whether specific geographic areas were associated with different SDR trajectories over time. Principal Findings The OECD average annual decrease was 3.6/100,000 (p < .001), but slowed over time (coefficient for the quadratic term = 0.11, p < .001). Eastern and Atlantic European countries had the steepest decline (−6.1 and −4.7, respectively), while Latin American countries had the lowest slope (−1.7). The OECD average annual decline during the 14‐year period was −0.5 (p < .001) for cancers and −2.5 (p < .001) for cardiovascular diseases, with significant differences among countries. Conclusion Declining trend of amenable SDRs was continuing to 2013 but with steepness change compared with previous periods and with a slowdown.

  October 05, 2016   doi: 10.1111/1475-6773.12563   open full text
• Determinants of Potentially Inappropriate Medication Use among Community‐Dwelling Older Adults.
  G. Edward Miller, Eric M. Sarpong, Amy J. Davidoff, Eunice Y. Yang, Nicole J. Brandt, Donna M. Fick.
  Health Services Research. September 29, 2016
  Objective To examine the determinants of potentially inappropriate medication (PIM) use. Data Sources/Study Setting U.S. nationally representative data on (n = 16,588) noninstitutionalized older adults (age ≥65) with drug use from the 2006–2010 Medical Expenditure Panel Survey. Study Design We operationalized the 2012 Beers Criteria to identify PIM use during the year, and we examined associations with individual‐level characteristics hypothesized to be quality enabling or related to need complexity. Principal Findings Almost one‐third (30.9 percent) of older adults used a PIM. Multivariate results suggest that poor health status and high‐PIM‐risk conditions were associated with increased PIM use, while increasing age and educational attainment were associated with lower PIM use. Contrary to expectations, lack of a usual care source of care or supplemental insurance was associated with lower PIM use. Medication intensity appears to be in the pathway between both quality‐enabling and need‐complexity characteristics and PIM use. Conclusion Our results suggest that physicians attempt to avoid PIM use in the oldest old but have inadequate focus on the high‐PIM‐risk conditions. Educational programs targeted to physician practice regarding high‐PIM‐risk conditions and patient literacy regarding medication use are potential responses.

  September 29, 2016   doi: 10.1111/1475-6773.12562   open full text
• Differences in Hospital Readmission Risk across All Payer Groups in South Carolina.
  Hrishikesh Chakraborty, Robert Neal Axon, Jordan Brittingham, Genevieve Ray Lyons, Laura Cole, Christine B. Turley.
  Health Services Research. September 28, 2016
  Objective To evaluate differences in hospital readmission risk across all payers in South Carolina (SC). Data Sources/Study Setting South Carolina Revenue and Fiscal Affairs Office (SCRFA) statewide all payer claims database including 2,476,431 hospitalizations in SC acute care hospitals between 2008 and 2014. Study Design We compared the odds of unplanned all‐cause 30‐day readmission for private insurance, Medicare, Medicaid, uninsured, and other payers and examined interaction effects between payer and index admission characteristics using generalized estimating equations. Data Collection SCRFA receives claims and administrative health care data from all SC health care facilities in accordance with SC state law. Principal Findings Odds of readmission were lower for females compared to males in private, Medicare, and Medicaid payers. African Americans had higher odds of readmission compared to whites across private insurance, Medicare, and Medicaid, but they had lower odds among the uninsured. Longer length of stay had the strongest association with readmission for private and other payers, whereas an increased number of comorbidities related to the highest readmission odds within Medicaid. Conclusions Associations between index admission characteristics and readmission likelihood varied significantly with payer. Findings should guide the development of payer‐specific quality improvement programs.

  September 28, 2016   doi: 10.1111/1475-6773.12579   open full text
• Does Increased Medication Use among Seniors Increase Risk of Hospitalization and Emergency Department Visits?
  Sara Allin, David Rudoler, Audrey Laporte.
  Health Services Research. September 27, 2016
  Objective To examine the extent of the health risks of consuming multiple medications among the older population. Data Sources/Study Setting Secondary data from the period 2004–2006. The study setting was the province of Ontario, Canada, and the sample consisted of individuals aged 65 years or older who responded to a national health survey. Study Design We estimated a system of equations for inpatient and emergency department (ED) services to test the marginal effect of medication use on hospital services. We controlled for endogeneity in medication use with a two‐stage residual inclusion approach appropriate for nonlinear models. Principal Findings Increased prescription drug use has the effect of increasing the likelihood of both being admitted into hospital and visiting a hospital ED. Each additional medication is associated with a 2–3 percent increase in the likelihood of hospitalization and a 3–4 percent increase in the likelihood of an ED visit, after controlling for past utilization, health status, the endogeneity of medication use, and the unobserved factors that may affect the use of both services. Conclusions Multiple medications appear to increase the risk of hospitalization among seniors covered by a universal prescription drug plan. These results raise questions about the appropriateness of medication use and the need for increased oversight of current prescribing practices.

  September 27, 2016   doi: 10.1111/1475-6773.12560   open full text
• Socioeconomic Differences in Use of Low‐Value Cancer Screenings and Distributional Effects in Medicare.
  Wendy Yi Xu, Jeah Kyoungrae Jung.
  Health Services Research. September 13, 2016
  Objective Consuming low‐value health care not only highlights inefficient resource use but also brings an important concern regarding the economics of disparities. We identify the relation of socioeconomic characteristics to the use of low‐value cancer screenings in Medicare fee‐for‐service (FFS) settings, and quantify the amount subsidized from nonusers and taxpayers to users of these screenings. Data Sources 2007–2013 Medicare Current Beneficiary Survey, Medicare FFS claims, and the Area Health Resource Files. Study Design Our sample included enrollees in FFS Part B for the entire calendar year. We excluded beneficiaries with a claims‐documented or self‐reported history of targeted cancers, or those enrolled in Medicaid or Medicare Advantage plans. We identified use of low‐value Pap smears, mammograms, and prostate‐specific antigen tests based on established algorithms, and estimated a logistic model with year dummies separately for each test. Data Collection/Extraction Methods Secondary data analyses. Principal Findings We found a statistically significant positive association between privileged socioeconomic characteristics and use of low‐value screenings. Having higher income and supplemental private insurance strongly predicted more net subsidies from Medicare. Conclusions FFS enrollees who are better off in terms of sociodemographic characteristics receive greater subsidies from taxpayers for using low‐value cancer screenings.

  September 13, 2016   doi: 10.1111/1475-6773.12559   open full text
• The Role of Program Directors in Treatment Practices: The Case of Methadone Dose Patterns in U.S. Outpatient Opioid Agonist Treatment Programs.
  Jemima A. Frimpong, Karen Shiu‐Yee, Thomas D'Aunno.
  Health Services Research. September 12, 2016
  Objective To describe changes in characteristics of directors of outpatient opioid agonist treatment (OAT) programs, and to examine the association between directors’ characteristics and low methadone dosage. Data Source Repeated cross‐sectional surveys of OAT programs in the United States from 1995 to 2011. Study Design We used generalized linear regression models to examine associations between directors’ characteristics and methadone dose, adjusting for program and patient factors. Data Collection Data were collected through telephone surveys of program directors. Principal Findings The proportion of OAT programs with an African American director declined over time, from 29 percent in 1995 to 16 percent in 2011. The median percentage of patients in each program receiving <60 mg/day declined significantly, from 48.5 percent in 1995 to 29 percent in 2005 and 23 percent in 2011. Programs with an African American director were significantly more likely to provide low methadone doses than other programs. This association was even stronger in programs with an African American director who served populations with higher percentages of African American patients. Conclusions Demographic characteristics of OAT program directors (e.g., their race) may play a key role in explaining variations in methadone dosage across programs and patients. Further research should investigate the causal pathways through which directors’ characteristics affect treatment practices. This may lead to new, multifaceted managerial interventions to improve patient outcomes.

  September 12, 2016   doi: 10.1111/1475-6773.12558   open full text
• Resilience among Employed Physicians and Mid‐Level Practitioners in Upstate New York.
  Anthony C. Waddimba, Melissa Scribani, Melinda A. Hasbrouck, Nicole Krupa, Paul Jenkins, John J. May.
  Health Services Research. September 12, 2016
  Objective To investigate the factors associated with resilience among medical professionals. Data Sources/Study Setting Administrative information from a rural health care network (1 academic medical center, 6 hospitals, 31 clinics, and 20 school health centers) was triangulated with self‐report data from 308 respondents (response rate = 65.1 percent) to a 9/2013–1/2014 survey among practitioners serving a nine‐county 5,600‐square‐mile area. Study Design A cross‐sectional questionnaire survey comprising valid measures of resilience, practice meaningfulness, satisfaction, and risk/uncertainty intolerance, nested within a prospective, community‐based project. Data Collection/Extraction Methods The sampling frame included practitioners on institutional payroll, excluding voluntary/involuntary attritions and advisory board/research team members. In multivariable mixed‐effects models, we regressed full‐range and high‐/low‐resilience scores on demographics, professional satisfaction, workplace needs, risk/uncertainty intolerance, and service unit characteristics. Principal Findings Relational needs, uncertainty intolerance, satisfaction ≥75 percent of the time, number of practitioners on a unit, and workload were significantly associated with resilience. Higher scores were most strongly associated with uncertainty tolerance, satisfaction, and practitioner numbers. Practitioner/unit demographics were mostly nonsignificant. Conclusions More resilient practitioners experienced frequent satisfaction, relational needs gratification, better uncertainty tolerance, lighter workloads, and practiced on units with more colleagues. Further studies should investigate well‐being interventions based on these mutable factors.

  September 12, 2016   doi: 10.1111/1475-6773.12499   open full text
• The Effects of Distance to Dentists and Dentist Supply on Children's Use of Dental Care.
  George L. Wehby, Dan M. Shane, Adweta Joshi, Elizabeth Momany, Donald L. Chi, Raymond A. Kuthy, Peter C. Damiano.
  Health Services Research. September 09, 2016
  Objective To examine the effects of distance to dentists and dentist supply on dental services use among children with Medicaid coverage in Iowa. Data Source Iowa Medicaid claims for enrolled children between 2000 and 2009. Study Design The study sample included 41,554 children (providing 158,942 child‐year observations) who were born in Iowa between 2000 and 2006 and enrolled from birth in the Iowa Medicaid program. Children were followed through 2009. We used logistic regression to simultaneously examine the effects of distance (miles to nearest dentist) and county‐level dentist supply on a broad range of dental services controlling for key confounders. Additional models only used within‐child variation over time to remove unobservable time‐invariant confounders. Principal Findings Distance was related to lower utilization of comprehensive dental exams (2 percent lower odds per 1 mile increase in distance), an effect that also held in models using within‐child variation only. Dentist supply was positively related to comprehensive exams and other preventive services and negatively related to major dental treatments; however, these associations became smaller and insignificant when examining within‐child changes except for other preventive services. Conclusions Longer distance to dentists is a barrier for use of comprehensive dental exams, conditional on dentist supply.

  September 09, 2016   doi: 10.1111/1475-6773.12556   open full text
• Reducing Young Adults’ Health Care Spending through the ACA Expansion of Dependent Coverage.
  Jie Chen, Arturo Vargas‐Bustamante, Priscilla Novak.
  Health Services Research. September 08, 2016
  Objective To estimate health care expenditure trends among young adults ages 19–25 before and after the 2010 implementation of the Affordable Care Act (ACA) provision that extended eligibility for dependent private health insurance coverage. Data Sources Nationally representative Medical Expenditure Panel Survey data from 2008 to 2012. Study Design We conducted repeated cross‐sectional analyses and employed a difference‐in‐differences quantile regression model to estimate health care expenditure trends among young adults ages 19–25 (the treatment group) and ages 27–29 (the control group). Principal Findings Our results show that the treatment group had 14 percent lower overall health care expenditures and 21 percent lower out‐of‐pocket payments compared with the control group in 2011–2012. The overall reduction in health care expenditures among young adults ages 19–25 in years 2011–2012 was more significant at the higher end of the health care expenditure distribution. Young adults ages 19–25 had significantly higher emergency department costs at the 10th percentile in 2011–2012. Differences in the trends of costs of private health insurance and doctor visits are not statistically significant. Conclusions Increased health insurance enrollment as a consequence of the ACA provision for dependent coverage has successfully reduced spending and catastrophic expenditures, providing financial protections for young adults.

  September 08, 2016   doi: 10.1111/1475-6773.12555   open full text
• The Costs of Fall‐Related Injuries among Older Adults: Annual Per‐Faller, Service Component, and Patient Out‐of‐Pocket Costs.
  Geoffrey J. Hoffman, Ron D. Hays, Martin F. Shapiro, Steven P. Wallace, Susan L. Ettner.
  Health Services Research. September 01, 2016
  Objective To estimate expenditures for fall‐related injuries (FRIs) among older Medicare beneficiaries. Data Sources The 2007–2009 Medicare claims and 2008 Health and Retirement Study (HRS) data for 5,497 (228 FRI and 5,269 non‐FRI) beneficiaries. Study Design FRIs were indicated by inpatient/outpatient ICD‐9 diagnostic codes for fractures, trauma, dislocations, and by e‐codes. A pre‐post comparison group design was used to estimate the differential change in pre‐post expenditures for the FRI relative to the non‐FRI cohort (FRI expenditures). Out‐of‐pocket (OOP) costs, service category total annual FRI‐related Medicare expenditures, expenditures related to the type of initial FRI treatment (inpatient, ED, outpatient), and the risk of persistently high expenditures (4th quartile for each post‐FRI quarter) were estimated. Principal Findings Estimated FRI expenditures were $9,389 (95 percent CI: $5,969–$12,808). Inpatient, physician/outpatient, skilled nursing facility, and home health comprised 31, 18, 39, and 12 percent of the total. OOP costs were $1,363.0 (95 percent CI: $889‐$1,837). Expenditures for FRIs initially treated in inpatient/ED/outpatient settings were $21,424/$6,142/$8,622. The FRI cohort had a 64 percent increased risk of persistently high expenditures. Total Medicare expenditures were $13 billion (95 percent CI: $9–$18 billion). Conclusions FRIs are associated with substantial, persistent Medicare expenditures. Cost‐effectiveness of multifactorial falls prevention programs should be assessed using these expenditure estimates.

  September 01, 2016   doi: 10.1111/1475-6773.12554   open full text
• How Does Medicaid Reimbursement Impact Nursing Home Quality? The Effects of Small Anticipatory Changes.
  John R. Bowblis, Robert Applebaum.
  Health Services Research. September 01, 2016
  Objective In 2006, Ohio changed its Medicaid reimbursement methodology for nursing homes (NHs) to promote more efficient staffing levels. This study examines the impacts of this policy change on quality. Research Design and Subjects Ohio NHs were categorized based on their anticipated change in reimbursement under a new reimbursement system initiated in 2006. Linear regressions were utilized to determine how quality changed from 2006 to 2010 relative to a group of NHs that were not anticipated to experience any significant change in reimbursement. We examine resident outcomes constructed from the Minimum Data Set, deficiency citations, staffing levels, and satisfaction scores for residents and families as measures of quality. Principal Findings Nursing homes in the group receiving increased reimbursement showed an increase in nursing and nursing aide staffing levels. NHs in the group receiving a reduction in reimbursement did lower staffing levels. None of the nonstaffing quality outcomes were impacted by changes in Medicaid reimbursement. Conclusion Increased Medicaid reimbursement was found to increase staffing levels, but it had a limited effect, at least in the short run, on an array of nonstaffing quality outcomes.

  September 01, 2016   doi: 10.1111/1475-6773.12553   open full text
• Medication Nonadherence: The Role of Cost, Community, and Individual Factors.
  Ibrahim Abbass, Lee Revere, Jordan Mitchell, Ajit Appari.
  Health Services Research. August 25, 2016
  Objective To explain the association of out‐of‐pocket (OOP) cost, community‐level factors, and individual characteristics on statin therapy nonadherence. Data Sources BlueCross BlueShield of Texas claims data for the period of 2008–2011. Study Design A retrospective cohort of 49,176 insured patients, aged 18–64 years, with at least one statin refill during 2008–2011 was analyzed. Using a weighted proportion of days covered ratio, differences between adherent and nonadherent groups are assessed using chi‐squared tests, t‐tests, and a clustered generalized linear model with logit link function. Principal Findings Statin therapy adherence, measured at 48 percent, is associated with neighborhood‐level socioeconomic factors, including race/ethnicity, educational attainment, and poverty level. Individual characteristics influencing adherence include OOP medication cost, gender, age, comorbid conditions, and total health care utilization. Conclusions This study signifies the importance of OOP costs as a determinant of adherence to medications, but more interestingly, the results suggest that other socioeconomic factors, as measured by neighborhood‐level variables, have a greater association on the likelihood of adherence. The results may be of interest to policy makers, benefit designers, self‐insured employers, and provider organizations.

  August 25, 2016   doi: 10.1111/1475-6773.12547   open full text
• Improving Care Transitions Management: Examining the Role of Accountable Care Organization Participation and Expanded Electronic Health Record Functionality.
  Thomas P. Huber, Stephen M. Shortell, Hector P. Rodriguez.
  Health Services Research. August 22, 2016
  Objective Examine the extent to which physician organization participation in an accountable care organization (ACO) and electronic health record (EHR) functionality are associated with greater adoption of care transition management (CTM) processes. Data Sources/Study Setting A total of 1,398 physician organizations from the third National Study of Physician Organization survey (NSPO3), a nationally representative sample of medical practices in the United States (January 2012—May 2013). Study Design We used data from the third National Study of Physician Organization survey (NSPO3) to assess medical practice characteristics, including CTM processes, ACO participation, EHR functionality, practice type, organization size, ownership, public reporting, and pay‐for‐performance participation. Data Collection/Extraction Methods Multivariate linear regression models estimated the extent to which ACO participation and EHR functionality were associated with greater CTM capabilities, controlling for practice size, ownership, public reporting, and pay‐for‐performance participation. Principal Findings Approximately half (52.4 percent) of medical practices had a formal program for managing care transitions in place. In adjusted analyses, ACO participation (p < .001) and EHR functionality (p < .001) were independently associated with greater use of CTM processes among medical practices. Conclusions The growth of ACOs and similar provider risk‐bearing arrangements across the country may improve the management of care transitions by physician organizations.

  August 22, 2016   doi: 10.1111/1475-6773.12546   open full text
• Hospital Advertising, Competition, and HCAHPS: Does It Pay to Advertise?
  John W. Huppertz, R. Alan Bowman, George Y. Bizer, Mandeep S. Sidhu, Colleen McVeigh.
  Health Services Research. August 22, 2016
  Objective To test whether hospital advertising expenditures predict HCAHPS global ratings. Data Sources/Study Setting We examined media advertising expenditures by 2,142 acute care hospitals in 209 markets in the United States. Data on hospital characteristics, location, and revenue came from CMS reports; system ownership was obtained from the American Hospital Association. Advertising data came from Kantar Media. HCAHPS data were obtained from HospitalCompare. Study Design Regression models examined whether hospitals’ advertising spending predicts HCAHPS global measures and whether market concentration moderated this association. Data Collection/Extraction Methods Hospital advertising spending was calculated by adding each individual hospital's expenditures to the amount spent by its parent health system, proportionally allocated by hospital revenue. Health system market share was used to estimate market concentration. These data were compared to hospitals’ HCAHPS measures. Principal Findings In competitive markets (HHI below 1,000), hospital advertising predicted HCAHPS global measures. A 1‐percent increase in advertising was associated with a 1.173‐percent increase in patients rating the hospital a “9” or “10” on the HCAHPS survey and a 1.540‐percent increase in patients who “definitely” would recommend the hospital. In concentrated markets, this association was not significant. Conclusions In competitive markets, hospitals that spend more on advertising earn higher HCAHPS ratings on global measures.

  August 22, 2016   doi: 10.1111/1475-6773.12549   open full text
• Meaningful Use of Electronic Health Records and Medicare Expenditures: Evidence from a Panel Data Analysis of U.S. Health Care Markets, 2010–2013.
  Eric J. Lammers, Catherine G. McLaughlin.
  Health Services Research. August 22, 2016
  Objective To determine if recent growth in hospital and physician electronic health record (EHR) adoption and use is correlated with decreases in expenditures for elderly Medicare beneficiaries. Data Sources American Hospital Association (AHA) General Survey and Information Technology Supplement, Health Information Management Systems Society (HIMSS) Analytics survey, SK&A Information Services, and the Centers for Medicare & Medicaid Services (CMS) Chronic Conditions Data Warehouse Geographic Variation Database for 2010 through 2013. Study Design Fixed effects model comparing associations between hospital referral region (HRR) level measures of hospital and physician EHR penetration and annual Medicare expenditures for beneficiaries with one of four chronic conditions. Calculated hospital penetration rates as the percentage of Medicare discharges from hospitals that satisfied criteria analogous to Meaningful Use (MU) Stage 1 requirements and physician rates as the percentage of physicians using ambulatory care EHRs. Principal Findings An increase in the hospital penetration rate was associated with a small but statistically significant decrease in total Medicare and Medicare Part A acute care expenditures per beneficiary. An increase in physician EHR penetration was also associated with a significant decrease in total Medicare and Medicare Part A acute care expenditures per beneficiary as well as a decrease in Medicare Part B expenditures per beneficiary. For the study population, we estimate approximately $3.8 billion in savings related to hospital and physician EHR adoption during 2010–2013. We also found that an increase in physician EHR penetration was associated with an increase in lab test expenses. Conclusions Health care markets that had steeper increases in EHR penetration during 2010–2013 also had steeper decreases in total Medicare and acute care expenditures per beneficiary. Markets with greater increases in physician EHR had greater declines in Medicare Part B expenditures per beneficiary.

  August 22, 2016   doi: 10.1111/1475-6773.12550   open full text
• Improving Population Health Management Strategies: Identifying Patients Who Are More Likely to Be Users of Avoidable Costly Care and Those More Likely to Develop a New Chronic Disease.
  Judith H. Hibbard, Jessica Greene, Rebecca M. Sacks, Valerie Overton, Carmen Parrotta.
  Health Services Research. August 22, 2016
  Objective To explore using the Patient Activation Measure (PAM) for identifying patients more likely to have ambulatory care–sensitive (ACS) utilization and future increases in chronic disease. Data Sources Secondary data are extracted from the electronic health record of a large accountable care organization. Study Design This is a retrospective cohort design. The key predictor variable, PAM score, is measured in 2011, and is used to predict outcomes in 2012–2014. Outcomes include ACS utilization and the likelihood of a new chronic disease. Data Our sample of 98,142 adult patients was drawn from primary care clinic users. To be included, patients had to have a PAM score in 2011 and at least one clinic visit in each of the three subsequent years. Principal Findings PAM level is a significant predictor of ACS utilization. Less activated patients had significantly higher odds of ACS utilization compared to those with high PAM scores. Similarly, patients with low PAM scores were more likely to have a new chronic disease diagnosis over each of the years of observation. Conclusions Assessing patient activation may help to identify patients who could benefit from greater support. Such an approach may help ACOs reach population health management goals.

  August 22, 2016   doi: 10.1111/1475-6773.12545   open full text
• Implications of Variation in the Relationships between Beneficiary Characteristics and Medicare Advantage CAHPS Measures.
  Laura A. Hatfield, Alan M. Zaslavsky.
  Health Services Research. August 08, 2016
  Objective To study how differences in quality score adjustments across Medicare Advantage contracts change comparisons for individuals and contracts. Data Sources Responses to the Medicare Advantage implementation of the Consumer Assessments of Healthcare Providers and Systems (CAHPS) survey from 2010 to 2014. Study Design We fit national‐and state‐level hierarchical models to predict CAHPS scores for individuals and contracts, adjusted for self‐reported education, general health, and mental health. We allow the effects of these variables on quality measures to vary across contracts with a hierarchical model. Data Collection/Extraction Methods We perform secondary data analysis. Principal Findings For average consumers, standard adjustment is sufficient to represent variation in contract quality standardized to a common population. For people with characteristics far from average, personalized reporting using their characteristics and contract‐specific coefficients can substantially change the expected quality measures across contracts. This effect is stronger when comparing among contracts within a state than across all contracts. Conclusions Customized reporting may help consumers select the best Medicare Advantage plan, but policies should protect against unintended consequences.

  August 08, 2016   doi: 10.1111/1475-6773.12544   open full text
• Rural–Urban Differences in the Effect of Follow‐Up Care on Postdischarge Outcomes.
  Matthew Toth, Mark Holmes, Courtney Van Houtven, Mark Toles, Morris Weinberger, Pam Silberman.
  Health Services Research. August 08, 2016
  Objective To assess rural–urban differences in quality of postdischarge care among Medicare beneficiaries, controlling for selection bias of postdischarge services. Data Sources The Medicare Current Beneficiary Survey (MCBS), Cost and Use Files from 2000 to 2010, the Area Resource File, Provider of Services File, and the Dartmouth Atlas of Health Care. Study Design Retrospective analysis of 30‐ and 60‐day hospital readmission, emergency department (ED) use, and mortality using two‐stage residual inclusion; receipt of 14‐day follow‐up care was the main independent variable. Data Extraction Method We defined index admission from the MCBS as any admission without a previous admission within 60 days. Principal Findings Noninstrumental variables estimation was the preferred estimation strategy. Fourteen‐day follow‐up care reduced the risk of readmission, ED use, and mortality. There were no rural– urban differences in the effect of 14‐day follow‐up care on readmission and mortality. Rural beneficiaries experienced a greater effect of 14‐day follow‐up care on reducing 30‐day ED use compared to urban beneficiaries. Conclusions Follow‐up care reduces 30‐ and 60‐day readmission, ED use, and mortality. Rural and urban Medicare beneficiaries experience similar beneficial effects of follow‐up care on the outcomes. Policies that improve follow‐up care in rural settings may be beneficial.

  August 08, 2016   doi: 10.1111/1475-6773.12543   open full text
• Impact of Massachusetts Health Reform on Inpatient Care Use: Was the Safety‐Net Experience Different Than in the Non‐Safety‐Net?
  Amresh D. Hanchate, Danny McCormick, Karen E. Lasser, Chen Feng, Meredith G. Manze, Nancy R. Kressin.
  Health Services Research. August 08, 2016
  Objective Most inpatient care for the uninsured and other vulnerable subpopulations occurs in safety‐net hospitals. As insurance expansion increases the choice of hospitals for the previously uninsured, we examined if Massachusetts health reform was associated with shifts in the volume of inpatient care from safety‐net to non‐safety‐net hospitals overall, or among other vulnerable sociodemographic (racial/ethnic minority, low socioeconomic status, high uninsured rate area) and clinical subpopulations (emergent status, diagnosis). Data Sources/Study Setting Discharge records for adults discharged from all nonfederal acute care hospitals in Massachusetts, New Jersey, New York, and Pennsylvania 2004–2010. Study Design Using a difference‐in‐differences design, we compared pre‐/post‐reform changes in safety‐net and non‐safety‐net hospital discharge outcomes in Massachusetts among adults 18–64 with corresponding changes in comparisons states with no reform, overall, and by subpopulations. Principal Findings Reform was not associated with changes in inpatient care use at safety‐net and non‐safety‐net hospitals across all discharges or in most subpopulations examined. Conclusions Demand for inpatient care at safety‐net hospitals may not decrease following insurance expansion. Whether this is due to other access barriers or patient preference needs to be explored.

  August 08, 2016   doi: 10.1111/1475-6773.12542   open full text
• The Impact of Nursing Home Pay‐for‐Performance on Quality and Medicare Spending: Results from the Nursing Home Value‐Based Purchasing Demonstration.
  David C. Grabowski, David G. Stevenson, Daryl J. Caudry, A. James O'Malley, Lisa H. Green, Julia A. Doherty, Richard G. Frank.
  Health Services Research. August 04, 2016
  Objective To evaluate the impact of the Nursing Home Value‐Based Purchasing demonstration on quality of care and Medicare spending. Data Sources/Study Setting Administrative and qualitative data from Arizona, New York, and Wisconsin nursing homes over the base‐year (2008–2009) and 3‐year (2009–2012) demonstration period. Study Design Nursing homes were randomized to the intervention in New York, while the comparison facilities were constructed via propensity score matching in Arizona and Wisconsin. We used a difference‐in‐difference analysis to compare outcomes across the base‐year relative to outcomes in each of the three demonstration years. To provide context and assist with interpretation of results, we also interviewed staff members at participating facilities. Principal Findings Medicare savings were observed in Arizona in the first year only and Wisconsin for the first 2 years; no savings were observed in New York. The demonstration did not systematically impact any of the quality measures. Discussions with nursing home administrators suggested that facilities made few, if any, changes in response to the demonstration, leading us to conclude that the observed savings likely reflected regression to the mean rather than true savings. Conclusion The Federal nursing home pay‐for‐performance demonstration had little impact on quality or Medicare spending.

  August 04, 2016   doi: 10.1111/1475-6773.12538   open full text
• Medicare Part D's Effects on Drug Utilization and Out‐of‐Pocket Costs: A Systematic Review.
  Young Joo Park, Erika G. Martin.
  Health Services Research. August 01, 2016
  Objective To update a past systematic review on whether Medicare Part D changed drug utilization and out‐of‐pocket (OOP) costs overall and within subpopulations, and to identify evidence gaps. Data Sources/Study Setting Published and gray literature from 2010 to 2015 meeting prespecified screening criteria, including having a comparison group, and utilization or OOP cost outcomes. Study Design We conducted a systematic literature review with a quality assessment. Data Collection/Extraction Methods For each study, we extracted information on study design, data sources, analytic methods, outcomes, and limitations. Because outcome measures vary across studies, we did a qualitative synthesis rather than meta‐analysis. Principal Findings Sixty‐five studies met screening criteria. Overall, Medicare Part D enrollees have increased drug utilization and decreased OOP costs, but coverage gaps limit the program's impact. Beneficiaries whose insurance becomes more generous after enrollment had disproportionately increased drug utilization and decreased OOP costs. Outcomes among dual‐eligibles were mixed. Conclusions There is strong evidence on how Medicare Part D and the donut hole coverage gap affect utilization and OOP costs, but weak evidence on how effects vary among dual‐eligibles or across diseases. Findings suggest that the Affordable Care Act's provisions to expand coverage and reduce the donut hole should improve patient outcomes.

  August 01, 2016   doi: 10.1111/1475-6773.12534   open full text
• The Differential Impact of User‐Fee Exemption Compared to Conditional Cash Transfers on Safe Deliveries in Nepal.
  Elina Pradhan, Victoria Y. Fan.
  Health Services Research. August 01, 2016
  Objective To assess the differential impact of a copayment exemption compared to a cash incentive on increasing skilled birth attendance (i.e., birth attended by a skilled health worker) in Nepal. Data Sources/Study Setting This study used data on 8,785 children born between July 2005 and December 2008, obtained from the nationally representative Demographic and Health Surveys, 2006 and 2011. Study Design Twenty‐five districts received both the policy interventions, and the remaining 50 control districts received only the cash incentive. We employed a difference‐in‐differences model to compare children born in districts with both interventions to those in districts with conditional cash transfers only. Average marginal effects of the difference‐in‐difference coefficient on skilled birth attendance measures are estimated. Principal Findings Skilled birth attendance in districts with both interventions was no higher on average than in districts with only the cash incentive. In areas with adequate road networks, however, significantly higher skilled birth attendance was observed in districts with both interventions compared to those with only the cash incentive. Conclusions The added incentive of the user‐fee exemption did not significantly increase skilled birth attendance relative to the presence of the cash incentive. User‐fee exemptions may not be effective in areas with inadequate road infrastructure.

  August 01, 2016   doi: 10.1111/1475-6773.12536   open full text
• Is Anyone Paying Attention to Physician Report Cards? The Impact of Increased Availability on Consumers’ Awareness and Use of Physician Quality Information.
  Yunfeng Shi, Dennis P. Scanlon, Neeraj Bhandari, Jon B. Christianson.
  Health Services Research. July 28, 2016
  Objective 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. Primary Data Sources 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. Study Design 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). Principal Findings 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. Conclusions 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.

  July 28, 2016   doi: 10.1111/1475-6773.12540   open full text
• Trends in Medicare Service Volume for Cataract Surgery and the Impact of the Medicare Physician Fee Schedule.
  Dan Gong, Lin Jun, James C. Tsai.
  Health Services Research. July 28, 2016
  Objective To calculate the associations between Medicare payment and service volume for complex and noncomplex cataract surgeries. Data Sources The 2005–2009 CMS Part B National Summary Data Files, CMS Part B Carrier Summary Data Files, and the Medicare Physician Fee Schedule. Study Design 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. Data Extraction 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. Principal Findings 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]). Conclusions 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.

  July 28, 2016   doi: 10.1111/1475-6773.12535   open full text
• Reducing Readmissions among Heart Failure Patients Discharged to Home Health Care: Effectiveness of Early and Intensive Nursing Services and Early Physician Follow‐Up.
  Christopher M. Murtaugh, Partha Deb, Carolyn Zhu, Timothy R. Peng, Yolanda Barrón, Shivani Shah, Stanley M. Moore, Kathryn H. Bowles, Jill Kalman, Penny H. Feldman, Albert L. Siu.
  Health Services Research. July 28, 2016
  Objective 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. Data Sources National Medicare administrative, claims, and patient assessment data. Study Design 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. Data Extraction Methods All hospitalizations for a HF principal diagnosis with discharge to home health care between July 2009 and June 2010 were identified from source files. Principal Findings 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. Conclusions Our results call for closer coordination between home health and medical providers in the clinical management of HF patients immediately after hospital discharge.

  July 28, 2016   doi: 10.1111/1475-6773.12537   open full text
• Meaningful Use of the Indian Health Service Electronic Health Record.
  Gina R. Kruse, Howard Hays, E. John Orav, Martha Palan, Thomas D. Sequist.
  Health Services Research. July 26, 2016
  Objective To understand the use of electronic health record (EHR) functionalities by physicians practicing in an underserved setting. Data Source/Study Setting A total of 333 Indian Health Service physicians (55 percent response rate) in August 2012. Study Design Cross‐sectional. Data Collection The survey assessed routine use of EHR functionalities, perceived usefulness, and barriers to adoption. Principal Findings 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. Conclusions Significant opportunities exist to increase use of EHR functionalities and preserve physician–patient interactions and productivity in a resource‐limited environment.

  July 26, 2016   doi: 10.1111/1475-6773.12531   open full text
• Impact of Massachusetts Health Reform on Enrollment Length and Health Care Utilization in the Unsubsidized Individual Market.
  Laura F. Garabedian, Dennis Ross‐Degnan, Stephen B. Soumerai, Niteesh K. Choudhry, Jeffrey S. Brown.
  Health Services Research. July 25, 2016
  Objective 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. Data Source Seven years of administrative and claims data from Harvard Pilgrim Health Care. Research Design 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. Principal Findings 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. Conclusions 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.

  July 25, 2016   doi: 10.1111/1475-6773.12532   open full text
• Impact of State Reporting Laws on Central Line–Associated Bloodstream Infection Rates in U.S. Adult Intensive Care Units.
  Hangsheng Liu, Carolyn T. A. Herzig, Andrew W. Dick, E. Yoko Furuya, Elaine Larson, Julie Reagan, Monika Pogorzelska‐Maziarz, Patricia W. Stone.
  Health Services Research. July 24, 2016
  Objective 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). Data Sources 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. Study Design 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. Principal Findings 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. Conclusions 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.

  July 24, 2016   doi: 10.1111/1475-6773.12530   open full text
• Redaction of Substance Abuse Claims in Medicare Research Files Affects Spending Outcomes for Nearly One in Five Beneficiaries with Serious Mental Illness.
  Pamela Roberto, Nicole Brandt, Eberechukwu Onukwugha, Bruce Stuart.
  Health Services Research. July 24, 2016
  Objective To assess the impact of substance abuse claims redaction on Medicare spending estimates for beneficiaries with serious mental illness. Data Sources The 2012 claims and unredacted beneficiary‐level Medicare spending totals from CMS's Chronic Conditions Warehouse. Study Design 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. Principal Findings 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. Conclusions 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.

  July 24, 2016   doi: 10.1111/1475-6773.12528   open full text
• Association between Nurse Staffing and In‐Hospital Bone Fractures: A Retrospective Cohort Study.
  Kojiro Morita, Hiroki Matsui, Kiyohide Fushimi, Hideo Yasunaga.
  Health Services Research. July 24, 2016
  Objective To determine if sufficient nurse staffing reduced in‐hospital fractures in acute care hospitals. Data Sources/Study Setting The Japanese Diagnosis Procedure Combination inpatient (DPC) database from July 2010 to March 2014 linked with the Surveys for Medical Institutions. Study Design 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. Data Collection/Extraction Methods 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.” Principal Findings 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). Conclusions Sufficient nurse staffing may be important to reduce postsurgical in‐hospital fractures in acute care hospitals.

  July 24, 2016   doi: 10.1111/1475-6773.12529   open full text
• Creating Unidimensional Global Measures of Physician Practice Quality Based on Health Insurance Claims Data.
  Grant R. Martsolf, Adam C. Carle, Dennis P. Scanlon.
  Health Services Research. July 24, 2016
  Objective 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. Data Sources Health insurance claims data (October 2007–May 2010) from 134 physician practices in Seattle, WA. Study Design We use confirmatory and exploratory factor analysis to develop theory‐ and empirically driven internally valid composite measures based on 19 quality indicators. Data Collection Methods Health insurance claims data from nine insurance companies and self‐funded employers were collected and aggregated by third‐party organization. Principal Findings 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. Conclusions 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.”

  July 24, 2016   doi: 10.1111/1475-6773.12533   open full text
• Follow Your Heart: Survival Chances and Costs after Heart Attacks—An Instrumental Variable Approach.
  Alice Sanwald, Thomas Schober.
  Health Services Research. July 21, 2016
  Objective To determine the effect of heart attack patients’ access to intensive treatment on mortality and costs. Data Sources 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. Study Design 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. Principal Findings 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. Conclusions 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.

  July 21, 2016   doi: 10.1111/1475-6773.12509   open full text
• The Impact of Social Health Insurance on Diabetes and Hypertension Process Indicators among Older Adults in Mexico.
  Maricruz Rivera‐Hernandez, Momotazur Rahman, Vincent Mor, Omar Galarraga.
  Health Services Research. July 15, 2016
  Objective 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.) Data Sources/Study Setting 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. Study Design Fixed‐effects instrumental variable (FE‐IV) repeated cross‐sectional at the individual level with municipality fixed‐effects estimation was performed. Principal Findings 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. Conclusions Social health insurance for the poor improved some but not all health care process indicators among diabetic and hypertensive older people in Mexico.

  July 15, 2016   doi: 10.1111/1475-6773.12404   open full text
• Community Characteristics and Qualified Health Plan Selection during the First Open Enrollment Period.
  Michel Boudreaux, Lynn A. Blewett, Brett Fried, Katherine Hempstead, Pinar Karaca‐Mandic.
  Health Services Research. June 28, 2016
  Objective To examine state and community factors that contributed to geographic variation in qualified health plan selection during the first open enrollment period. Data Sources/Study Setting Administrative data on qualified health plan selections at the ZIP code area merged with survey estimates from the American Community Survey. Study Design Descriptive and regression analyses. Data Collection/Extraction Methods Data were generated by healthcare.gov and from a household survey. Principal Findings 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. Conclusions Our results suggest community‐level differences in the intensity or receptiveness to outreach and enrollment activities during the first open enrollment period.

  June 28, 2016   doi: 10.1111/1475-6773.12525   open full text
• Duration to Admission and Hospital Transfers Affect Facility Rankings from the Postacute 30‐Day Rehospitalization Quality Measure.
  James E. Graham, Janet Prvu Bettger, Steve R. Fisher, Amol M. Karmarkar, Amit Kumar, Kenneth J. Ottenbacher.
  Health Services Research. June 28, 2016
  Objective To examine changes in facility‐level risk‐standardized rehospitalization rankings for postacute inpatient rehabilitation facilities after modifying two model parameters. Data Sources We used national Medicare enrollment, claims, and assessment data to study 522,260 patients discharged from inpatient rehabilitation in fiscal years 2010–2011. Study Design 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. Principal Findings 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. Conclusions 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.

  June 28, 2016   doi: 10.1111/1475-6773.12526   open full text
• Fighting MRSA Infections in Hospital Care: How Organizational Factors Matter.
  Torsten Oliver Salge, Antonio Vera, David Antons, Jeannie P. Cimiotti.
  Health Services Research. June 22, 2016
  Objective To identify factors associated with methicillin‐resistant Staphylococcus aureus (MRSA) bloodstream infections at the level of the hospital organization. Data Sources Data from all 173 acute trusts in the English National Health Service (NHS). Study Design 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. Data Collection 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. Principal Findings 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). Conclusions 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.

  June 22, 2016   doi: 10.1111/1475-6773.12521   open full text
• Impact of a Pay‐for‐Performance Program on Care for Black Patients with Hypertension: Important Answers in the Era of the Affordable Care Act.
  Laura A. Petersen, Kate Simpson Ramos, Kenneth Pietz, LeChauncy D. Woodard.
  Health Services Research. June 22, 2016
  Objective 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. Data Source/Study Setting Primary data collected between 2007 and 2009 from Veterans Affairs physicians and their primary care panels. Study Design 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 Collection/Extraction Method Data collected electronically and by chart review. Principal Findings 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. Conclusions and Relevance 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.

  June 22, 2016   doi: 10.1111/1475-6773.12517   open full text
• Hospital Quality Reporting in the United States: Does Report Card Design and Incorporation of Patient Narrative Comments Affect Hospital Choice?
  Martin Emmert, Mark Schlesinger.
  Health Services Research. June 20, 2016
  Objective To explore the impact of hospital report card design and incorporation of patient narrative comments on consumers' choices of hospitals. Data Sources Primary data collected from an online survey with 1,350 respondents in February, 2015. Study Design 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. Principal Findings 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. Conclusions 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.

  June 20, 2016   doi: 10.1111/1475-6773.12519   open full text
• How Low‐Income Subsidy Recipients Respond to Medicare Part D Cost Sharing.
  Bruce Stuart, Franklin B. Hendrick, Jing Xu, J. Samantha Dougherty.
  Health Services Research. June 20, 2016
  Objectives 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. Data Sources Medicare data for a 5 percent random sample of beneficiaries with diabetes enrolled in fee‐for‐service Part D drug plans in 2008. Study Design 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. Principal Findings 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. Conclusions 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.

  June 20, 2016   doi: 10.1111/1475-6773.12520   open full text
• A Longitudinal Investigation of Willingness to Pay for Health Insurance in Germany.
  Jens‐Oliver Bock, André Hajek, Hermann Brenner, Kai‐Uwe Saum, Herbert Matschinger, Walter Emil Haefeli, Ben Schöttker, Renate Quinzler, Dirk Heider, Hans‐Helmut König.
  Health Services Research. June 20, 2016
  Objective To investigate factors affecting willingness to pay (WTP) for health insurance of older adults in a longitudinal setting in Germany. Data Sources Survey data from a cohort study in Saarland, Germany, from 2008–2010 and 2011–2014 (n1 = 3,124; n2 = 2,761) were used. Study Design Panel data were taken at two points from an observational, prospective cohort study. Data Collection 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. Principal Findings 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. Conclusions 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.

  June 20, 2016   doi: 10.1111/1475-6773.12522   open full text
• Patient‐Centered Medical Home Recognition and Clinical Performance in U.S. Community Health Centers.
  Leiyu Shi, De‐Chih Lee, Michelle Chung, Hailun Liang, Diana Lock, Alek Sripipatana.
  Health Services Research. June 20, 2016
  Introduction 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. Methods 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. Findings 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. Conclusion 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.

  June 20, 2016   doi: 10.1111/1475-6773.12523   open full text
• The Dynamics of Hospital Use among Older People Evidence for Europe Using SHARE Data.
  Nicolas Sirven, Thomas Rapp.
  Health Services Research. June 20, 2016
  Objective 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. Data source We used data from the Survey on Health, Ageing, and Retirement in Europe (SHARE), in 10 countries between 2004 and 2011. Study Design We estimated a dynamic panel model of hospital admission for respondents aged 50 years or more. Principal Findings 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. Conclusions 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.

  June 20, 2016   doi: 10.1111/1475-6773.12518   open full text
• Management of Hypertension in Primary Care Safety‐Net Clinics in the United States: A Comparison of Community Health Centers and Private Physicians' Offices.
  Valy Fontil, Kirsten Bibbins‐Domingo, Oanh Kieu Nguyen, David Guzman, Lauren Elizabeth Goldman.
  Health Services Research. June 10, 2016
  Objective To examine adherence to guideline‐concordant hypertension treatment practices at community health centers (CHCs) compared with private physicians' offices. Data Sources/Study Setting National Ambulatory Medical Care Survey from 2006 to 2010. Study Design 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. Data Collection/Extraction Methods We identified visits of nonpregnant adults with hypertension at CHCs and private physicians' offices. Principal Findings 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. Conclusions 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.

  June 10, 2016   doi: 10.1111/1475-6773.12516   open full text
• Key Provisions of the Patient Protection and Affordable Care Act (ACA): A Systematic Review and Presentation of Early Research Findings.
  Michael T. French, Jenny Homer, Gulcin Gumus, Lucas Hickling.
  Health Services Research. June 05, 2016
  Objectives 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. Study Design 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. Principal Findings 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. Conclusions 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.

  June 05, 2016   doi: 10.1111/1475-6773.12511   open full text
• Medicaid Disenrollment and Disparities in Access to Care: Evidence from Tennessee.
  Wafa W. Tarazi, Tiffany L. Green, Lindsay M. Sabik.
  Health Services Research. June 03, 2016
  Objective To assess the effects of Tennessee's 2005 Medicaid disenrollment on access to health care among low‐income nonelderly adults. Data Source/Study Setting We use data from the 2003–2008 Behavioral Risk Factor Surveillance System. Study Design 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. Principal Findings 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. Conclusions 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.

  June 03, 2016   doi: 10.1111/1475-6773.12515   open full text
• Methods for Measuring Racial Differences in Hospitals Outcomes Attributable to Disparities in Use of High‐Quality Hospital Care.
  Paul L. Hebert, Elizabeth A. Howell, Edwin S. Wong, Susan E. Hernandez, Seppo T. Rinne, Christine A. Sulc, Emily L. Neely, Chuan‐Fen Liu.
  Health Services Research. June 03, 2016
  Objective To compare two approaches to measuring racial/ethnic disparities in the use of high‐quality hospitals. Data Sources Simulated data. Study Design 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. Principal Findings 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. Conclusions Researchers should consider using the fixed‐effect approach for measuring disparities in use of high‐quality hospital care by vulnerable populations.

  June 03, 2016   doi: 10.1111/1475-6773.12514   open full text
• Association between Temporal Changes in Primary Care Workforce and Patient Outcomes.
  Chiang‐Hua Chang, A. James O'Malley, David C. Goodman.
  Health Services Research. June 03, 2016
  Objective To examine the association between 10‐year temporal changes in the primary care workforce and Medicare beneficiaries' outcomes. Data Sources 2001 and 2011 American Medical Association Masterfiles and fee‐for‐service Medicare claims. Study Design/Methods 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. Principal Findings 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). Conclusions Medicare beneficiaries' outcomes improved as the number of primary care physicians and their clinical effort increased.

  June 03, 2016   doi: 10.1111/1475-6773.12513   open full text
• Evaluating the Impact of Parent‐Reported Medical Home Status on Children's Health Care Utilization, Expenditures, and Quality: A Difference‐in‐Differences Analysis with Causal Inference Methods.
  Bing Han, Hao Yu, Mark W. Friedberg.
  Health Services Research. June 03, 2016
  Objective To evaluate the effects of the parent‐reported medical home status on health care utilization, expenditures, and quality for children. Data Sources 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. Study Design 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. Principal Findings 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. Conclusions Having a medical home may help improve health care quality for children; losing a medical home may lead to higher utilization of emergency care.

  June 03, 2016   doi: 10.1111/1475-6773.12512   open full text
• The Influence of the Degree of Rurality on EMR Adoption, by Physician Specialty.
  Brian E. Whitacre.
  Health Services Research. June 03, 2016
  Objective 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. Data Sources Survey data on over 270,000 office‐based physician practices (representing over 1,250,000 providers) collected by SK&A information services during 2012. Study Design 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. Principal Findings 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). Conclusions 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.

  June 03, 2016   doi: 10.1111/1475-6773.12510   open full text
• Priorities for Patient‐Centered Outcomes Research: The Views of Minority and Underserved Communities.
  Susan Dorr Goold, C. Daniel Myers, Lisa Szymecko, Carla Cunningham Collins, Sal Martinez, Charo Ledón, Terrance R. Campbell, Marion Danis, Stephanie Solomon Cargill, Hyungjin Myra Kim, Zachary Rowe.
  Health Services Research. May 20, 2016
  Objective To learn how minority and underserved communities would set priorities for patient‐centered outcomes research (PCOR). Data Sources 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. Design Academic–community partnerships adapted CHAT for PCOR priority setting using existing research agendas and interviews with community leaders, clinicians, and key informants. Data Collection Tablet‐based CHAT collected demographic information, individual priorities before and after group deliberation, and groups' priorities. Principal Findings 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. Conclusions Members of underserved communities, in informed deliberations, prioritized research on Quality of Life, Patient‐Doctor, Special Needs, Access, and Compare Approaches.

  May 20, 2016   doi: 10.1111/1475-6773.12505   open full text
• The Contribution of Skilled Nursing Facilities to Hospitals’ Readmission Rate.
  Momotazur Rahman, John McHugh, Pedro L. Gozalo, Dana Clay Ackerly, Vincent Mor.
  Health Services Research. May 18, 2016
  Objective To examine the relative influence of hospital and skilled nursing facilities (SNFs) on 30‐day rehospitalization. Data Sources/Settings Elderly Medicare beneficiaries newly admitted to a SNF following hospitalization. Study Design 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. Principal Findings 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. Conclusions 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.

  May 18, 2016   doi: 10.1111/1475-6773.12507   open full text
• Hospital Surgical Volumes and Mortality after Coronary Artery Bypass Grafting: Using International Comparisons to Determine a Safe Threshold.
  Nils Gutacker, Karen Bloor, Richard Cookson, Chris P. Gale, Alan Maynard, Domenico Pagano, José Pomar, Enrique Bernal‐Delgado,.
  Health Services Research. May 16, 2016
  Objective To estimate a safe minimum hospital volume for hospitals performing coronary artery bypass graft (CABG) surgery. Data Source Hospital data on all publicly funded CABG in five European countries, 2007–2009 (106,149 patients). Design Hierarchical logistic regression models to estimate the relationship between hospital volume and mortality, allowing for case mix. Segmented regression analysis to estimate a threshold. Findings 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. Conclusions There is a clear relationship between hospital CABG volume and mortality in Europe, implying a “safe” threshold volume of 415 cases per year.

  May 16, 2016   doi: 10.1111/1475-6773.12508   open full text
• The Effect of Physician and Hospital Market Structure on Medical Technology Diffusion.
  Pinar Karaca‐Mandic, Robert J. Town, Andrew Wilcock.
  Health Services Research. May 16, 2016
  Objective 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. Data Sources/Study Setting Medicare claims linked to physician demographic data from the American Medical Association and to hospital characteristics from the American Hospital Association Survey. Study Design Retrospective claims data analyses. Data Collection/Extraction Methods 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. Principal Findings DESs diffused faster in markets where cardiology practices faced more competition. Conversely, we found no evidence that the structure of the hospital market mattered. Conclusions Competitive pressure to maintain or expand PCI volume shares compelled cardiologists to adopt DESs more quickly.

  May 16, 2016   doi: 10.1111/1475-6773.12506   open full text
• Characteristics Associated with Home Health Care Referrals at Hospital Discharge: Results from the 2012 National Inpatient Sample.
  Christine D. Jones, Heidi L. Wald, Rebecca S. Boxer, Frederick A. Masoudi, Robert E. Burke, Roberta Capp, Eric A. Coleman, Adit A. Ginde.
  Health Services Research. May 16, 2016
  Objective To assess patient‐ and hospital‐level factors associated with home health care (HHC) referrals following nonelective U.S. patient hospitalizations in 2012. Data Source The 2012 National Inpatient Sample (NIS). Study Design Retrospective, cross‐sectional multivariable logistic regression modeling to assess patient‐ and hospital‐level variables in patient discharges with versus without HHC referrals. Data Collection Analysis included 1,109,905 discharges in patients ≥65 years with Medicare. Principal Findings 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). Conclusions 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.

  May 16, 2016   doi: 10.1111/1475-6773.12504   open full text
• Geographic Variation in Quality of Care for Commercially Insured Patients.
  Michael Richard McKellar, Mary Beth Landrum, Teresa B. Gibson, Bruce E. Landon, A. Mark Fendrick, Michael E. Chernew.
  Health Services Research. May 03, 2016
  Background Extensive evidence documents geographic variation in spending, but limited research assesses geographic variation in quality, particularly among commercially insured enrollees. Objective To measure geographic variation in quality measures, correlation among measures, and correlation between measures and spending for commercially insured enrollees. Data Source Administrative claims from the 2007–2009 Truven MarketScan database. Methods 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. Results 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. Conclusion Quality varied across HRRs and there was only a modest geographic “quality footprint.”

  May 03, 2016   doi: 10.1111/1475-6773.12501   open full text
• Industrial Injury Hospitalizations Billed to Payers Other Than Workers' Compensation: Characteristics and Trends by State.
  Jeanne M. Sears, Stephen M. Bowman, Laura Blanar, Sheilah Hogg‐Johnson.
  Health Services Research. May 03, 2016
  Objective 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. Data Sources Hospitalization data for 1998–2009 from State Inpatient Databases, Healthcare Cost and Utilization Project, and Agency for Healthcare Research and Quality. Study Design 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. Principal Findings 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. Conclusions 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.

  May 03, 2016   doi: 10.1111/1475-6773.12500   open full text
• Guidelines for Measuring Disease Episodes: An Analysis of the Effects on the Components of Expenditure Growth.
  Abe Dunn, Eli Liebman, Lindsey Rittmueller, Adam Hale Shapiro.
  Health Services Research. May 03, 2016
  Objective To provide guidelines to researchers measuring health expenditures by disease and compare these methodologies' implied inflation estimates. Data Source 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. Study Design Different methods are used to allocate medical‐care expenditures to distinct condition categories. We compare the estimates of disease‐price inflation by method. Principal Findings 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. Conclusion 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.

  May 03, 2016   doi: 10.1111/1475-6773.12498   open full text
• Wage Growth for the Health Care Workforce: Projecting the Affordable Care Act Impact.
  Stephen T. Parente, Roger Feldman, Joanne Spetz, Bryan Dowd, Emily Egan Baggett.
  Health Services Research. May 03, 2016
  Objective To predict changes in wage growth for health care workers based on projections of insurance enrollment from the Affordable Care Act (ACA). Data Sources 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. Study Design 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. Principal Findings 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. Conclusions Projected wage increases for health care workers may drive substantial growth in insurance premiums and reduce the affordability of health insurance.

  May 03, 2016   doi: 10.1111/1475-6773.12497   open full text
• High‐Cost Users of Prescription Drugs: A Population‐Based Analysis from British Columbia, Canada.
  Deirdre Weymann, Kate Smolina, Emilie J. Gladstone, Steven G. Morgan.
  Health Services Research. April 18, 2016
  Objective To examine variation in pharmaceutical spending and patient characteristics across prescription drug user groups. Data Sources British Columbia's population‐based linked administrative health and sociodemographic databases (N = 3,460,763). Study Design 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. Principal Findings 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. Conclusions 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.

  April 18, 2016   doi: 10.1111/1475-6773.12492   open full text
• Clarifying the Predictive Value of Family‐Centered Care and Shared Decision Making for Pediatric Healthcare Outcomes Using the Medical Expenditure Panel Survey.
  Olivia J. Lindly, Katharine E. Zuckerman, Kamila B. Mistry.
  Health Services Research. April 12, 2016
  Objectives 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. Data Source The Medical Expenditure Panel Survey Household Component (MEPS‐HC), a nationally representative survey of the noninstitutionalized, civilian population. Study Design 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. Data Collection/Extraction Methods We combined four MEPS‐HC longitudinal files from 2007 to 2011. Principal Findings 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. Conclusions 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.

  April 12, 2016   doi: 10.1111/1475-6773.12488   open full text
• Variation in Payment Rates under Medicare's Inpatient Prospective Payment System.
  Sam Krinsky, Andrew M. Ryan, Tod Mijanovich, Jan Blustein.
  Health Services Research. April 08, 2016
  Objective To measure variation in payment rates under Medicare's Inpatient Prospective Payment System (IPPS) and identify the main payment adjustments that drive variation. Data Sources/Study Setting Medicare cost reports for all Medicare‐certified hospitals, 1987–2013, and Dartmouth Atlas geographic files. Study Design 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 Collection/Extraction Methods Data downloaded from the Centers for Medicare and Medicaid Services, the National Bureau of Economic Research, and the Dartmouth Atlas. Principal Findings 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. Conclusions Adjustments are a large and growing share of Medicare hospital payments, and they create significant variation in payment rates.

  April 08, 2016   doi: 10.1111/1475-6773.12490   open full text
• Advice to Quit Smoking and Ratings of Health Care among Medicare Beneficiaries Aged 65+.
  Eleanor Winpenny, Marc N. Elliott, Ann Haas, Amelia M. Haviland, Nate Orr, William G. Shadel, Sai Ma, Mark W. Friedberg, Paul D. Cleary.
  Health Services Research. April 08, 2016
  Objective To examine the relationship between physician advice to quit smoking and patient care experiences. Data Source The 2012 Medicare Consumer Assessment of Healthcare Providers and Systems (MCAHPS) surveys. Study Design 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+. Principal Findings 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. Conclusions Physician‐provided cessation advice was associated with more positive patient assessments of their physicians.

  April 08, 2016   doi: 10.1111/1475-6773.12491   open full text
• Impacts of Geographic Distance on Peritoneal Dialysis Utilization: Refining Models of Treatment Selection.
  Virginia Wang, Matthew L. Maciejewski, Cynthia J. Coffman, Linda L. Sanders, Shoou‐Yih Daniel Lee, Richard Hirth, Joseph Messana.
  Health Services Research. April 07, 2016
  Objective 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. Data Sources U.S. Renal Data System. Study Design 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. Principal Findings 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. Conclusions Analyses of patient choice between alternative treatments should model distance to reflect all relevant dimensions of geographic access to treatment options.

  April 07, 2016   doi: 10.1111/1475-6773.12489   open full text
• Cost Variation in Diabetes Care across Dutch Care Groups?
  Sigrid M. Mohnen, Claudia C. Molema, Wouter Steenbeek, Michael J. Berg, Simone R. Bruin, Caroline A. Baan, Jeroen N. Struijs.
  Health Services Research. March 21, 2016
  Objective 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. Data Source Dutch 2009 nationwide insurance claims data of diabetes type 2 patients (104,544 patients, 50 care groups). Study Design 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. Principal Findings 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. Conclusions 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.

  March 21, 2016   doi: 10.1111/1475-6773.12483   open full text
• Impact of State Public Health Spending on Disease Incidence in the United States from 1980 to 2009.
  Reetu Verma, Samantha Clark, Jonathon Leider, David Bishai.
  Health Services Research. March 21, 2016
  Objective 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. Data Sources 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. Study Design 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. Principal Findings 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. Conclusion 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.

  March 21, 2016   doi: 10.1111/1475-6773.12480   open full text
• Identifying Older Adults with Serious Illness: A Critical Step toward Improving the Value of Health Care.
  Amy S. Kelley, Kenneth E. Covinsky, Rebecca J. Gorges, Karen McKendrick, Evan Bollens‐Lund, R. Sean Morrison, Christine S. Ritchie.
  Health Services Research. March 18, 2016
  Objective To create and test three prospective, increasingly restrictive definitions of serious illness. Data Sources Health and Retirement Study, 2000–2012. Study Design 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. Data Collection Of 11,577 eligible subjects, 5,297 met definition A; 3,151 definition B; and 1,447 definition C. Principal Findings 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. Conclusions 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.

  March 18, 2016   doi: 10.1111/1475-6773.12479   open full text
• Has Interprofessional Education Changed Learning Preferences? A National Perspective.
  T. Michael Kashner, Debbie L. Hettler, Robert A. Zeiss, David C. Aron, David S. Bernett, Judy L. Brannen, John M. Byrne, Grant W. Cannon, Barbara K. Chang, Mary B. Dougherty, Stuart C. Gilman, Gloria J. Holland, Catherine P. Kaminetzky, Annie B. Wicker, Sheri A. Keitz.
  Health Services Research. March 18, 2016
  Objective 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. Primary Data Source 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. Study Design 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). Principal Findings 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. Conclusions Despite changes in medical education, physician trainees continue to lag behind their nonphysician counterparts in valuing experience with interprofessional team and patient‐centered care.

  March 18, 2016   doi: 10.1111/1475-6773.12485   open full text
• Screening Mammography for Free: Impact of Eliminating Cost Sharing on Cancer Screening Rates.
  Anupam B. Jena, Jie Huang, Bruce Fireman, Vicki Fung, Scott Gazelle, Mary Beth Landrum, Michael Chernew, Joseph P. Newhouse, John Hsu.
  Health Services Research. March 17, 2016
  Objectives 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. Study Setting Large MA health maintenance organization offering individual‐subscriber MA insurance and employer‐supplemented group MA insurance. Study Design 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. Principal Findings 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. Conclusions Eliminating cost sharing for screening mammography was associated with modesty lower decline in screening rates among women with previously low screening adherence.

  March 17, 2016   doi: 10.1111/1475-6773.12486   open full text
• Potentially Avoidable Hospitalizations among People at Different Activity of Daily Living Limitation Stages.
  Sophia Miryam Schüssler‐Fiorenza Rose, Margaret G. Stineman, Qiang Pan, Hillary Bogner, Jibby E. Kurichi, Joel E. Streim, Dawei Xie.
  Health Services Research. March 17, 2016
  Objective 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. Data Source Secondary data analysis, including 8,815 beneficiaries from 2005 to 2006 Medicare Current Beneficiary Survey (MCBS). Study Design 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. Data Collection Baseline ADL stage and health conditions were assessed using 2005 MCBS data and count of hospitalization determined using 2006 MCBS data. Principal Findings 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. Conclusions 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.

  March 17, 2016   doi: 10.1111/1475-6773.12484   open full text
• Provider Experience and the Comparative Safety of Laparoscopic and Open Colectomy.
  Kyle H. Sheetz, Edward C. Norton, John D. Birkmeyer, Justin B. Dimick.
  Health Services Research. March 16, 2016
  Objective To evaluate the comparative safety of laparoscopic and open colectomy across surgeons varying in experience with laparoscopy. Data Sources National Medicare data (2008–2010) for beneficiaries undergoing laparoscopic or open colectomy. Study Design 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. Principal Findings 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. Conclusions 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.

  March 16, 2016   doi: 10.1111/1475-6773.12482   open full text
• Physician and Practice‐Level Drivers and Disparities around Meaningful Use Progress.
  Dawn Heisey‐Grove, Jennifer A. King.
  Health Services Research. March 16, 2016
  Objective To identify physician and practice characteristics that are markers of success for meaningful use of electronic health records (EHRs). Data Sources 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. Study Design 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. Principal Findings 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). Conclusions 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.

  March 16, 2016   doi: 10.1111/1475-6773.12481   open full text
• Effects of State Cervical Cancer Insurance Mandates on Pap Test Rates.
  Marianne P. Bitler, Christopher S. Carpenter.
  Health Services Research. March 15, 2016
  Objective 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. Data Sources Individual‐level data on 600,000 women age 19–64 from the CDC's Behavioral Risk Factor Surveillance System. Study Design 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. Principal Findings 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. Conclusions Mandating more generous insurance coverage for even inexpensive, routine services with already high utilization rates such as Pap tests can significantly further increase utilization.

  March 15, 2016   doi: 10.1111/1475-6773.12477   open full text
• Understanding Racial and Ethnic Disparities in Postsurgical Complications Occurring in U.S. Hospitals.
  Whitney P. Witt, Rosanna M. Coffey, Lorena Lopez‐Gonzalez, Marguerite L. Barrett, Brian J. Moore, Roxanne M. Andrews, Raynard E. Washington.
  Health Services Research. March 09, 2016
  Objective To examine the role of patient, hospital, and community characteristics on racial and ethnic disparities in in‐hospital postsurgical complications. Data Sources 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. Methods 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. Principal Findings 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. Conclusions 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.

  March 09, 2016   doi: 10.1111/1475-6773.12475   open full text
• Estimating Surgical Procedure Times Using Anesthesia Billing Data and Operating Room Records.
  Lane F. Burgette, Andrew W. Mulcahy, Ateev Mehrotra, Teague Ruder, Barbara O. Wynn.
  Health Services Research. March 08, 2016
  Objective 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. Data Sources 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. Study Design We estimate surgical times via piecewise linear median regression models. Principal Findings 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. Conclusions Anesthesia and OR times can be used to measure surgical time and thereby improve the payment for surgical procedures in the Medicare fee schedule.

  March 08, 2016   doi: 10.1111/1475-6773.12474   open full text
• Profiling the U.S. Sick Leave Landscape: Presenteeism among Females.
  Philip Susser, Nicolas R. Ziebarth.
  Health Services Research. March 07, 2016
  Objective To profile the sick leave landscape in the United States. Data Sources The 2011 Leave Supplement of the American Time Use Survey. Study Design Bivariate and multivariate analyses to identify (i) employees without sick pay coverage and (ii) employees who attend work sick. Principal Findings 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. Conclusion 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.

  March 07, 2016   doi: 10.1111/1475-6773.12471   open full text
• An Evaluation of Performance Thresholds in Nursing Home Pay‐for‐Performance.
  Rachel M. Werner, Meghan Skira, R. Tamara Konetzka.
  Health Services Research. March 02, 2016
  Objective 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. Data Sources The Minimum Data Set (MDS) and Online Survey, Certification, and Reporting (OSCAR) datasets. Study Setting and Design 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. Principal Findings 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. Conclusions 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.

  March 02, 2016   doi: 10.1111/1475-6773.12467   open full text
• Assessing Differences between Early and Later Adopters of Accountable Care Organizations Using Taxonomic Analysis.
  Frances M. Wu, Stephen M. Shortell, Valerie A. Lewis, Carrie H. Colla, Elliott S. Fisher.
  Health Services Research. February 29, 2016
  Objective 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. Data sources The National Survey of ACOs, Waves 1 and 2. Study design 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. Findings 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. Conclusions 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.

  February 29, 2016   doi: 10.1111/1475-6773.12473   open full text
• Indirect Standardization Matching: Assessing Specific Advantage and Risk Synergy.
  Jeffrey H. Silber, Paul R. Rosenbaum, Richard N. Ross, Justin M. Ludwig, Wei Wang, Bijan A. Niknam, Alexander S. Hill, Orit Even‐Shoshan, Rachel R. Kelz, Lee A. Fleisher.
  Health Services Research. February 29, 2016
  Objective 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. Data Sources/Setting Medicare claims in orthopedics and common general, gynecologic, and urologic surgery from Illinois, New York, and Texas from 2004 to 2006. Study Design Using two example “focal” hospitals, each hospital's patients were matched to 10 very similar patients selected from 619 other hospitals. Data Collection/Extraction Methods 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. Principal Findings 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. Conclusion 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.

  February 29, 2016   doi: 10.1111/1475-6773.12470   open full text
• Preventive Dental Care and Long‐Term Dental Outcomes among ALL Kids Enrollees.
  Bisakha Sen, Justin Blackburn, Meredith L. Kilgore, Michael A. Morrisey, David J. Becker, Cathy Caldwell, Nir Menachemi.
  Health Services Research. February 29, 2016
  Objective To investigate whether early or regular preventive dental visit (PDV) reduces restorative or emergency dental care and costs for low‐income children. Study Setting Enrollees during 1998–2012 in the Alabama CHIP program, ALL Kids. Study Design 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. Data Extraction Claims data were obtained from ALL Kids. Principal Findings Only sealants are associated with a reduced likelihood of using restorative and emergency services and costs. Conclusions Whether PDVs without sealants actually reduce restorative/emergency pediatric dental services is questionable. Further research into benefits of PDV is needed.

  February 29, 2016   doi: 10.1111/1475-6773.12469   open full text
• Predictors of Gaps in Patient Safety and Quality in U.S. Hospitals.
  Lynn Unruh, Richard Hofler.
  Health Services Research. February 29, 2016
  Objective To explore predictors of gaps between observed and best possible Hospital Compare scores in U.S. hospitals. Data Sources American Hospital Association Annual Survey; Area Resource Files; Centers for Medicare and Medicaid Services Medicare Provider and Analysis Review; and Hospital Compare data. Study Design 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 Extraction 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). Principal Findings 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. Conclusions 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.

  February 29, 2016   doi: 10.1111/1475-6773.12468   open full text
• Use of Physical Therapy Following Total Knee Replacement Surgery: Implications of Orthopedic Surgeons’ Ownership of Physical Therapy Services.
  Jean M. Mitchell, James D. Reschovsky, Elizabeth Anne Reicherter.
  Health Services Research. February 23, 2016
  Objective 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. Data Sample of Medicare beneficiaries who underwent TKR surgery during the years 2007–2009. Study Design 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. Principal Findings 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. Conclusions 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.

  February 23, 2016   doi: 10.1111/1475-6773.12465   open full text
• An Examination of Hospital Nurse Staffing and Patient Experience with Care: Differences between Cross‐Sectional and Longitudinal Estimates.
  Grant R. Martsolf, Teresa B. Gibson, Richele Benevent, H. Joanna Jiang, Carol Stocks, Emily D. Ehrlich, Ryan Kandrack, David I. Auerbach.
  Health Services Research. February 21, 2016
  Objective To study the association between hospital nurse staffing and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores. Data Sources State hospital financial and utilization reports, Healthcare Cost and Utilization Project State Inpatient Databases, HCAHPS survey, and American Hospital Association Annual Survey of Hospitals. Study Design Retrospective study using cross‐sectional and longitudinal models to estimate the effect of nurse staffing levels and skill mix on seven HCAHPS measures. Data Collection/Extraction Methods Hospital‐level data measuring nurse staffing, patient experience, and hospital characteristics from 2009 to 2011 for 341 hospitals (977 hospital years) in California, Maryland, and Nevada. Principal Findings Nurse staffing level (i.e., number of licensed practical nurses and registered nurses per 1,000 inpatient days) was significantly and positively associated with all seven HCAHPS measures in cross‐sectional models and three of seven measures in longitudinal models. Nursing skill mix (i.e., percentage of all staff who are registered nurses) was significantly and negatively associated with scores on one measure in cross‐sectional models and none in longitudinal models. Conclusions After controlling for unobserved hospital characteristics, the positive influences of increased nurse staffing levels and skill mix were relatively small in size and limited to a few measures of patients' inpatient experience.

  February 21, 2016   doi: 10.1111/1475-6773.12462   open full text
• Development and Validation of HealthImpact: An Incident Diabetes Prediction Model Based on Administrative Data.
  Rozalina G. McCoy, Vijay S. Nori, Steven A. Smith, Christopher A. Hane.
  Health Services Research. February 21, 2016
  Objective To develop and validate a model of incident type 2 diabetes based solely on administrative data. Data Sources/Study Setting Optum Labs Data Warehouse (OLDW), a national commercial administrative dataset. Study Design HealthImpact model was developed and internally validated using nested case–control study design; n = 473,049 in training cohort and n = 303,025 in internal validation cohort. HealthImpact was externally validated in 2,000,000 adults followed prospectively for 3 years. Only adults ≥18 years were included. Data Collection/Extraction Methods Patients with incident diabetes were identified using HEDIS rules. Control subjects were sampled from patients without diabetes. Medical and pharmacy claims data collected over 3 years prior to index date were used to build the model variables. Principal Findings HealthImpact, scored 0–100, has 48 variables with c‐statistic 0.80815. We identified HealthImpact threshold of 90 as identifying patients at high risk of incident diabetes. HealthImpact had excellent discrimination in external validation cohort (c‐statistic 0.8171). The sensitivity, specificity, positive predictive value, and negative predictive value of HealthImpact >90 for new diagnosis of diabetes within 3 years were 32.35, 94.92, 22.25, and 96.90 percent, respectively. Conclusions HealthImpact is an efficient and effective method of risk stratification for incident diabetes that is not predicated on patient‐provided information or laboratory tests.

  February 21, 2016   doi: 10.1111/1475-6773.12461   open full text
• Using Length of Stay to Control for Unobserved Heterogeneity When Estimating Treatment Effect on Hospital Costs with Observational Data: Issues of Reliability, Robustness, and Usefulness.
  Peter May, Melissa M. Garrido, J. Brian Cassel, R. Sean Morrison, Charles Normand.
  Health Services Research. February 21, 2016
  Objective To evaluate the sensitivity of treatment effect estimates when length of stay (LOS) is used to control for unobserved heterogeneity when estimating treatment effect on cost of hospital admission with observational data. Data Sources/Study Setting We used data from a prospective cohort study on the impact of palliative care consultation teams (PCCTs) on direct cost of hospital care. Adult patients with an advanced cancer diagnosis admitted to five large medical and cancer centers in the United States between 2007 and 2011 were eligible for this study. Study Design Costs were modeled using generalized linear models with a gamma distribution and a log link. We compared variability in estimates of PCCT impact on hospitalization costs when LOS was used as a covariate, as a sample parameter, and as an outcome denominator. We used propensity scores to account for patient characteristics associated with both PCCT use and total direct hospitalization costs. Data Collection/Extraction Methods We analyzed data from hospital cost databases, medical records, and questionnaires. Our propensity score weighted sample included 969 patients who were discharged alive. Principal Findings In analyses of hospitalization costs, treatment effect estimates are highly sensitive to methods that control for LOS, complicating interpretation. Both the magnitude and significance of results varied widely with the method of controlling for LOS. When we incorporated intervention timing into our analyses, results were robust to LOS‐controls. Conclusions Treatment effect estimates using LOS‐controls are not only suboptimal in terms of reliability (given concerns over endogeneity and bias) and usefulness (given the need to validate the cost‐effectiveness of an intervention using overall resource use for a sample defined at baseline) but also in terms of robustness (results depend on the approach taken, and there is little evidence to guide this choice). To derive results that minimize endogeneity concerns and maximize external validity, investigators should match and analyze treatment and comparison arms on baseline factors only. Incorporating intervention timing may deliver results that are more reliable, more robust, and more useful than those derived using LOS‐controls.

  February 21, 2016   doi: 10.1111/1475-6773.12460   open full text
• A Machine Learning Framework for Plan Payment Risk Adjustment.
  Sherri Rose.
  Health Services Research. February 19, 2016
  Objective To introduce cross‐validation and a nonparametric machine learning framework for plan payment risk adjustment and then assess whether they have the potential to improve risk adjustment. Data Sources 2011–2012 Truven MarketScan database. Study Design We compare the performance of multiple statistical approaches within a broad machine learning framework for estimation of risk adjustment formulas. Total annual expenditure was predicted using age, sex, geography, inpatient diagnoses, and hierarchical condition category variables. The methods included regression, penalized regression, decision trees, neural networks, and an ensemble super learner, all in concert with screening algorithms that reduce the set of variables considered. The performance of these methods was compared based on cross‐validated R2. Principal Findings Our results indicate that a simplified risk adjustment formula selected via this nonparametric framework maintains much of the efficiency of a traditional larger formula. The ensemble approach also outperformed classical regression and all other algorithms studied. Conclusions The implementation of cross‐validated machine learning techniques provides novel insight into risk adjustment estimation, possibly allowing for a simplified formula, thereby reducing incentives for increased coding intensity as well as the ability of insurers to “game” the system with aggressive diagnostic upcoding.

  February 19, 2016   doi: 10.1111/1475-6773.12464   open full text
• Treatment Effect Estimation Using Nonlinear Two‐Stage Instrumental Variable Estimators: Another Cautionary Note.
  Cole G. Chapman, John M. Brooks.
  Health Services Research. February 19, 2016
  Objective To examine the settings of simulation evidence supporting use of nonlinear two‐stage residual inclusion (2SRI) instrumental variable (IV) methods for estimating average treatment effects (ATE) using observational data and investigate potential bias of 2SRI across alternative scenarios of essential heterogeneity and uniqueness of marginal patients. Study Design Potential bias of linear and nonlinear IV methods for ATE and local average treatment effects (LATE) is assessed using simulation models with a binary outcome and binary endogenous treatment across settings varying by the relationship between treatment effectiveness and treatment choice. Principal Findings Results show that nonlinear 2SRI models produce estimates of ATE and LATE that are substantially biased when the relationships between treatment and outcome for marginal patients are unique from relationships for the full population. Bias of linear IV estimates for LATE was low across all scenarios. Conclusions Researchers are increasingly opting for nonlinear 2SRI to estimate treatment effects in models with binary and otherwise inherently nonlinear dependent variables, believing that it produces generally unbiased and consistent estimates. This research shows that positive properties of nonlinear 2SRI rely on assumptions about the relationships between treatment effect heterogeneity and choice.

  February 19, 2016   doi: 10.1111/1475-6773.12463   open full text
• Health System Consolidation and Diabetes Care Performance at Ambulatory Clinics.
  Daniel J. Crespin, Jon B. Christianson, Jeffrey S. McCullough, Michael D. Finch.
  Health Services Research. February 07, 2016
  Objective We addressed two questions regarding health system consolidation through the acquisition of ambulatory clinics: (1) Was increasing health system size associated with improved diabetes care performance and (2) Did the diabetes care performance of acquired clinics improve postacquisition? Data Sources/Study Setting Six hundred sixty‐one ambulatory clinics in Minnesota and bordering states that reported performance data from 2007 to 2013. Study Design We employed fixed effects regression to determine if increased health system size and being acquired improved clinics' performance. Using our regression results, we estimated the average effect of consolidation on the performance of clinics that were acquired during our study. Data Collection/Extraction Methods Publicly reported performance data obtained from Minnesota Community Measurement. Principal Findings Acquired clinics experienced performance improvements starting in their third year postacquisition. By their fifth year postacquisition, acquired clinics had 3.6 percentage points (95 percent confidence interval: 2.0, 5.1) higher performance than if they had never been acquired. Increasing health system size was associated with slight performance improvements at the end of the study. Conclusions Health systems modestly improved the diabetes care performance of their acquired clinics; however, we found little evidence that systems experienced large, system‐wide performance gains by increasing their size.

  February 07, 2016   doi: 10.1111/1475-6773.12450   open full text
• The Method for Performance Measurement Matters: Diabetes Care Quality as Measured by Administrative Claims and Institutional Registry.
  Rozalina G. McCoy, Sidna M. Tulledge‐Scheitel, James M. Naessens, Amy E. Glasgow, Robert J. Stroebel, Sarah J. Crane, Kari S. Bunkers, Nilay D. Shah.
  Health Services Research. February 04, 2016
  Objectives Performance measurement is used by health care providers, payers, and patients. Historically accomplished using administrative data, registries are used increasingly to track and improve care. We assess how measured diabetes care quality differs when calculated using claims versus registry. Data Sources/Study Setting Cross‐sectional analysis of administrative claims and electronic health records (EHRs) of patients in a multispecialty integrated health system in 2012 (n = 368,883). Study Design We calculated percent of patients attaining glycohemoglobin <8.0 percent, LDL cholesterol <100 mg/dL, blood pressure <140/90 mmHg, and nonsmoking (D4) in cohorts, identified by Medicare Accountable Care Organization/Minnesota Community Measures (ACO‐MNCM; claims‐based), Healthcare Effectiveness Data and Information Set (HEDIS; claims‐based), and registry (EHR‐based). Data Collection/Extraction Methods Claims were linked to EHR to create a dataset of performance‐eligible patients. Principal Findings ACO‐MNCM, HEDIS, and registry identified 6,475, 6,989, and 6,425 measurement‐eligible patients. Half were common among the methods; discrepancies were due to attribution, age restriction, and encounter requirements. D4 attainment was lower in ACO‐MNCM (36.09 percent) and HEDIS (37.51 percent) compared to registry (43.74 percent) cohorts. Conclusions Registry‐ and claims‐based performance measurement methods identify different patients, resulting in different rates of quality metric attainment with implications for innovative population health management.

  February 04, 2016   doi: 10.1111/1475-6773.12453   open full text
• A Randomized, Controlled Trial of a Shared Panel Management Program for Small Practices.
  Tara F. Bishop, Andrew M. Ryan, Melinda A. Chen, Jayme Mendelsohn, Daniel Gottlieb, Sarah Shih, Priya Desai, Elizabeth A. Wolff, Lawrence P. Casalino.
  Health Services Research. February 04, 2016
  Objectives To determine whether a shared panel management program was effective at improving quality of care for patients with uncontrolled chronic disease. Data Sources Data were extracted from electronic health records. Study Design Randomized controlled trial of a panel management program initiated by New York City Department of Health and Mental Hygiene. Patients from 20 practices with an uncontrolled chronic disease and a lapse in care were assigned to the intervention (a phone call requesting that the patient schedule a physician appointment) or usual care. Outcomes were visits to physician practices, body mass index measurement, blood pressure measurement and control, use of antithrombotics, and low‐density lipoprotein measurement and control. Principal Findings Panel managers were able to successfully speak with 1,676 patients (14.7 percent of the intervention group). There were no significant differences in outcomes between the intervention and usual care groups. Successfully contacted patients were more likely to have an office visit within 1 year of randomization (45.6 percent [95 percent CI: 22.8, 26.9] vs. 38.1 percent [95 percent CI: 36.8, 39.3]) and more likely to be on antithrombotics (24.4 percent [95 percent CI: 17.7, 31.0]) versus those in the usual care group (17.0 percent [95 percent CI: 13.9, 20.0]) but had no other difference in quality. Conclusions A shared, low‐intensity panel management program run by a city health department did not improve quality of care for patients with chronic illnesses and lapses in care.

  February 04, 2016   doi: 10.1111/1475-6773.12455   open full text
• The Comparison of Matching Methods Using Different Measures of Balance: Benefits and Risks Exemplified within a Study to Evaluate the Effects of German Disease Management Programs on Long‐Term Outcomes of Patients with Type 2 Diabetes.
  Birgit Fullerton, Boris Pöhlmann, Robert Krohn, John L. Adams, Ferdinand M. Gerlach, Antje Erler.
  Health Services Research. February 03, 2016
  Objective To present a case study on how to compare various matching methods applying different measures of balance and to point out some pitfalls involved in relying on such measures. Data Sources Administrative claims data from a German statutory health insurance fund covering the years 2004–2008. Study Design We applied three different covariance balance diagnostics to a choice of 12 different matching methods used to evaluate the effectiveness of the German disease management program for type 2 diabetes (DMPDM2). We further compared the effect estimates resulting from applying these different matching techniques in the evaluation of the DMPDM2. Principal Findings The choice of balance measure leads to different results on the performance of the applied matching methods. Exact matching methods performed well across all measures of balance, but resulted in the exclusion of many observations, leading to a change of the baseline characteristics of the study sample and also the effect estimate of the DMPDM2. All PS‐based methods showed similar effect estimates. Applying a higher matching ratio and using a larger variable set generally resulted in better balance. Using a generalized boosted instead of a logistic regression model showed slightly better performance for balance diagnostics taking into account imbalances at higher moments. Conclusion Best practice should include the application of several matching methods and thorough balance diagnostics. Applying matching techniques can provide a useful preprocessing step to reveal areas of the data that lack common support. The use of different balance diagnostics can be helpful for the interpretation of different effect estimates found with different matching methods.

  February 03, 2016   doi: 10.1111/1475-6773.12452   open full text
• Determinants of National Guard Mental Health Service Utilization in VA versus Non‐VA Settings.
  Lisa A. Gorman, Rebecca K. Sripada, Dara Ganoczy, Heather M. Walters, Kipling M. Bohnert, Gregory W. Dalack, Marcia Valenstein.
  Health Services Research. February 03, 2016
  Objective To determine associations between need, enabling, and predisposing factors with mental health service use among National Guard soldiers in the first year following a combat deployment to Iraq or Afghanistan. Data Sources/Study Setting Primary data were collected between 2011 and 2013 from 1,426 Guard soldiers representing 36 units. Study Design Associations between Guard soldier factors and any mental health service use were assessed using multivariable logistic regression models in a cross‐sectional study. Further analysis among service users (N = 405) assessed VA treatment versus treatment in other settings. Principal Findings Fifty‐six percent of Guard soldiers meeting cutoffs on symptom scales received mental health services with 81 percent of those reporting care from the VA. Mental health service use was associated with need (mental health screens and physical health) and residing in micropolitan communities. Among service users, predisposing factors (middle age range and female gender) and enabling factors (employment, income above $50,000, and private insurance) were associated with greater non‐VA services use. Conclusion Overall service use was strongly associated with need, whereas sector of use (non‐VA vs. VA) was insignificantly associated with need but strongly associated with enabling factors. These findings have implications for the recent extension of veteran health coverage to non‐VA providers.

  February 03, 2016   doi: 10.1111/1475-6773.12446   open full text
• The Effect of Clinical Chorioamnionitis on Cesarean Delivery in the United States.
  Kerry M. Bommarito, Gilad A. Gross, Denise M. Willers, Victoria J. Fraser, Margaret A. Olsen.
  Health Services Research. February 03, 2016
  Objective To examine the association of clinical chorioamnionitis on cesarean delivery in a national sample of hospital discharges. Data Source Hospital discharge data from the 1998–2010 Nationwide Inpatient Sample. Study Design We performed a cross‐sectional study and general linear modeling was used to determine the association of clinical chorioamnionitis on risk of cesarean delivery. Principal Findings A total of 10,843,682 deliveries and 51,799,431 nationally weighted deliveries were identified. Clinical chorioamnionitis was present in 2.9 percent of cesarean and 1.3 percent of vaginal deliveries (p < .001). In multivariate analysis, clinical chorioamnionitis was associated with a 1.39‐fold increased risk of cesarean delivery. Compared with women without clinical chorioamnionitis at an urban/teaching hospital, women with clinical chorioamnionitis at an urban/teaching, urban/nonteaching, and rural hospital were 1.4–1.5 times more likely to have cesarean delivery. Compared with women without clinical chorioamnionitis in the Midwest, the relative risk for cesarean in women with clinical chorioamnionitis was 1.54 for women in the South, 1.47 in the Northeast, 1.39 in the Midwest, and 1.34 in the West. Conclusions Women with clinical chorioamnionitis were more likely to have cesarean delivery than those without clinical chorioamnionitis, and the risk of cesarean delivery varied significantly by hospital location, teaching status, and U.S. region.

  February 03, 2016   doi: 10.1111/1475-6773.12447   open full text
• The Relative Importance of Post‐Acute Care and Readmissions for Post‐Discharge Spending.
  Peter J. Huckfeldt, Ateev Mehrotra, Peter S. Hussey.
  Health Services Research. February 03, 2016
  Objective To understand what patterns of health care use are associated with higher post‐hospitalization spending. Data Sources Medicare hospital, skilled nursing, inpatient rehabilitation, and home health agency claims, and Medicare enrollment data from 2007 and 2008. Study Design For 10 common inpatient conditions, we calculated variation across hospitals in price‐standardized and case mix–adjusted Medicare spending in the 30 days following hospital discharge. We estimated the fraction of spending differences between low‐ and high‐spending hospitals attributable to readmissions versus post‐acute care, and within post‐acute care between inpatient rehabilitation facility (IRF) versus skilled nursing facility (SNF) use. For each service, we distinguished between differences in probability of use and spending conditional on use. Data Extraction Methods We identified index hospital claims and examined hospital and post‐acute care occurring within a 30‐day period following hospital discharge. For each Medicare Severity Diagnosis‐Related Group (MS‐DRG) at each hospital, we calculated average price‐standardized Medicare payments for readmissions, SNFs, IRFs, and post‐acute care overall (also including home health agencies and long‐term care hospitals). Principal Findings There was extensive variation across hospitals in Medicare spending in the 30 days following hospital discharge. For example, the interquartile range across hospitals ranged from $1,245 for chronic obstructive pulmonary disease to over $4,000 for myocardial infarction MS‐DRGs. The proportion of differences attributable to readmissions versus post‐acute care differed across conditions. For myocardial infarction, 74 to 93 percent of the variation was due to readmissions. For hip and femur procedures and joint replacement, 72 to 92 percent of the variation was due to differences in post‐acute care spending. There was also variation in the relative importance of the type of post‐acute spending. For hip and femur procedures, joint replacement, and stroke, whether patients received IRF was the key driver of variation in post‐acute care spending In contrast, for pneumonia and heart failure, whether patients received SNF care was the key driver of variation in post‐acute spending. Conclusions Through initiatives such as bundled payment, hospitals are financially responsible for spending in the post‐hospitalization period. The key driver of variation in post‐hospitalization spending varied greatly across conditions. For some conditions, the key driver was having a readmission, for others it was whether patients receive any post‐acute care, and for others the key driver was the type of post‐acute care. These findings may help hospitals implement strategies to reduce post‐discharge spending.

  February 03, 2016   doi: 10.1111/1475-6773.12448   open full text
• Health Insurance Dynamics: Methodological Considerations and a Comparison of Estimates from Two Surveys.
  John A. Graves, Pranita Mishra.
  Health Services Research. February 03, 2016
  Objective To highlight key methodological issues in studying insurance dynamics and to compare estimates across two commonly used surveys. Data Sources/Study Setting Nonelderly uninsured adults and children sampled between 2001 and 2011 in the Medical Expenditure Panel Survey and the Survey of Income and Program Participation. Study Design We utilized nonparametric Kaplan–Meier methods to estimate quantiles (25th, 50th, and 75th percentiles) in the distribution of uninsured spells. We compared estimates obtained across surveys and across different methodological approaches to address issues like attrition, seam bias, censoring and truncation, and survey weighting method. Data Collection/Extraction Methods All data were drawn from publicly available household surveys. Principal Findings Estimated uninsured spell durations in the MEPS were longer than those observed in the SIPP. There were few changes in spell durations between 2001 and 2011, with median durations of 14 months among adults and 5–7 months among children in the MEPS, and 8 months (adults) and 4 months (children) in the SIPP. Conclusions The use of panel survey data to study insurance dynamics presents a unique set of methodological challenges. Researchers should consider key analytic and survey design trade‐offs when choosing which survey can best suit their research goals.

  February 03, 2016   doi: 10.1111/1475-6773.12449   open full text
• Do Smoking Bans Improve Neonatal Health?
  Scott Hankins, Yelena Tarasenko.
  Health Services Research. February 03, 2016
  Research Objective To estimate the effects of smoking bans on neonatal health outcomes and maternal smoking behavior during pregnancy. Data Sources Restricted‐use 1991–2009 Natality Detail Files, a Clean Air Dates Table Report, and the Tax Burden of Tobacco. Study Design A quasi‐experimental study using difference‐in‐differences estimation based on legislative history of smoking restrictions or bans by type/place/county/state level. Dependent variables included average monthly percentage of healthy neonates, of term neonates born with low and very low birth weight, of premature births, of maternal smokers, and average number of cigarettes smoked daily during pregnancy. The analyses were restricted to singleton births and those that occurred in the same county as mother's county of residence. Data Collection/Extraction Methods The data from three data sources were combined using Federal Information Processing Standard codes. Principal Findings Results of the overall and stratified by maternal smoking status, educational level, and age regression analyses suggested no appreciable effect of smoking bans on neonatal health. Smoking bans had also no effect on maternal smoking behavior. Conclusion While there are health benefits to the general population from smoking bans, their effects on neonatal health outcomes and maternal smoking during pregnancy seem to be limited.

  February 03, 2016   doi: 10.1111/1475-6773.12451   open full text
• Risk Adjustment Tools for Learning Health Systems: A Comparison of DxCG and CMS‐HCC V21.
  Todd H. Wagner, Anjali Upadhyay, Elizabeth Cowgill, Theodore Stefos, Eileen Moran, Steven M. Asch, Peter Almenoff.
  Health Services Research. February 03, 2016
  Objective To compare risk scores computed by DxCG (Verisk) and Centers for Medicare and Medicaid Services (CMS) V21. Research Design Analysis of administrative data from the Department of Veterans Affairs (VA) for fiscal years 2010 and 2011. Study Design We regressed total annual VA costs on predicted risk scores. Model fit was judged by R‐squared, root mean squared error, mean absolute error, and Hosmer–Lemeshow goodness‐of‐fit tests. Recalibrated models were tested using split samples with pharmacy data. Data Collection We created six analytical files: a random sample (n = 2 million), high cost users (n = 261,487), users over age 75 (n = 644,524), mental health and substance use users (n = 830,832), multimorbid users (n = 817,951), and low‐risk users (n = 78,032). Principal Findings The DxCG Medicaid with pharmacy risk score yielded substantial gains in fit over the V21 model. Recalibrating the V21 model using VA pharmacy data‐generated risk scores with similar fit statistics to the DxCG risk scores. Conclusions Although the CMS V21 and DxCG prospective risk scores were similar, the DxCG model with pharmacy data offered improved fit over V21. However, health care systems, such as the VA, can recalibrate the V21 model with additional variables to develop a tailored risk score that compares favorably to the DxCG models.

  February 03, 2016   doi: 10.1111/1475-6773.12454   open full text
• High‐Deductible Health Plans: Implications for Substance Use Treatment.
  Sujaya Parthasarathy, Cynthia I. Campbell.
  Health Services Research. February 03, 2016
  Objective To examine whether high‐deductible health plans are related to patient complexity, health services use, and medical care costs among substance use treatment patients. Data Source/Study Setting Electronic health record data from Kaiser Permanente Northern California; 2007–2011. Study Design Retrospective analysis of electronic health record data of substance use treatment patients (N = 31,001). We examined relationship of patient demographics, health comorbidities, and services use and cost to deductible level: none, low ($1–$999), and high (≥$1,000). Methods Demographic, membership, diagnostic, and utilization data were merged with cost data. Utilization and costs were summarized into 6‐month intervals. Generalized estimation methods for repeated measures with logistic, Poisson, and linear regression were used. Principal Findings Substance use patients with deductible plans were younger and had less comorbidity than those without deductibles. Patients with high deductibles had lower emergency room and hospital use 12‐ to 6‐month pretreatment, but rates became similar to other groups in the 6 months immediately prior to treatment; treatment costs were similar. Conclusion Immediately prior to entering treatment, substance use patients with and without high deductibles have similar patterns of health services utilization. We discuss implications for health policy and treatment, particularly in an era of health reform.

  February 03, 2016   doi: 10.1111/1475-6773.12456   open full text
• Why Are Obstetric Units in Rural Hospitals Closing Their Doors?
  Peiyin Hung, Katy B. Kozhimannil, Michelle M. Casey, Ira S. Moscovice.
  Health Services Research. January 25, 2016
  Objectives To understand hospital‐ and county‐level factors for rural obstetric unit closures, using mixed methods. Data Sources 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. Study Design Multivariate logistic regression and qualitative analysis were used to identify factors associated with unit closures between 2010 and 2014. Principal Findings 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. Conclusions 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.

  January 25, 2016   doi: 10.1111/1475-6773.12441   open full text
• The Effect of the 2009 U.S. Preventive Services Task Force Breast Cancer Screening Recommendations on Mammography Rates.
  Natallia Gray, Gabriel Picone.
  Health Services Research. January 22, 2016
  Objective To examine the effect of a change in U.S. Preventive Services Task Force (USPSTF) screening guidelines on mammography rates in the United States. Principal Findings 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. Conclusion 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.

  January 22, 2016   doi: 10.1111/1475-6773.12445   open full text
• High Out‐of‐Pocket Medical Spending among the Poor and Elderly in Nine Developed Countries.
  Katherine Baird.
  Health Services Research. January 22, 2016
  Objective 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. Data Source 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. Study Design 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. Principal Findings 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. Conclusions 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.

  January 22, 2016   doi: 10.1111/1475-6773.12444   open full text
• Location Isn't Everything: Proximity, Hospital Characteristics, Choice of Hospital, and Disparities for Breast Cancer Surgery Patients.
  Nancy L. Keating, Elena M. Kouri, Yulei He, Rachel A. Freedman, Rita Volya, Alan M. Zaslavsky.
  Health Services Research. January 22, 2016
  Objective Assess the relative importance of proximity and other hospital characteristics in the choice of hospital for breast cancer surgery by race/ethnicity. Data SEER‐Medicare data. Study Design 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. Principal Findings 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. Conclusions Residential location alone does not explain concentration of racial/ethnic‐minority breast cancer surgery patients in certain hospitals that are sometimes of lower quality.

  January 22, 2016   doi: 10.1111/1475-6773.12443   open full text
• Accountability across the Continuum: The Participation of Postacute Care Providers in Accountable Care Organizations.
  Carrie H. Colla, Valerie A. Lewis, Savannah L. Bergquist, Stephen M. Shortell.
  Health Services Research. January 22, 2016
  Objective To examine the extent to which accountable care organizations (ACOs) formally incorporate postacute care providers. Data Sources The National Survey of ACOs (N = 269, response rate 66 percent). Study Design We report statistics on ACOs' formal inclusion of postacute care providers and the organizational characteristics and clinical capabilities of ACOs that have postacute care. Principal Findings 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. Conclusions Many ACOs have not formally engaged postacute care, which may leave room to improve service integration and care management.

  January 22, 2016   doi: 10.1111/1475-6773.12442   open full text
• Dartmouth Atlas Area‐Level Estimates of End‐of‐Life Expenditures: How Well Do They Reflect Expenditures for Prospectively Identified Advanced Lung Cancer Patients?
  Nancy L. Keating, Mary Beth Landrum, Haiden A. Huskamp, Elena M. Kouri, Holly G. Prigerson, Deborah Schrag, Paul K. Maciejewski, Mark C. Hornbrook, David A. Haggstrom.
  Health Services Research. January 22, 2016
  Objective 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. Data/Setting/Design 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. Findings 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. Conclusions HRR‐level spending estimates for deceased patient cohorts reflect area‐level care intensity for prospectively identified advanced lung cancer patients.

  January 22, 2016   doi: 10.1111/1475-6773.12440   open full text
• The Impact of Consumer Numeracy on the Purchase of Long‐Term Care Insurance.
  Brian E. McGarry, Helena Temkin‐Greener, Benjamin P. Chapman, David C. Grabowski, Yue Li.
  Health Services Research. January 22, 2016
  Objective To determine the effect of consumers’ numeric abilities on the likelihood of owning private long‐term care insurance. Data Source The 2010 wave of the Health and Retirement Study, a nationally representative survey of Americans age 50 and older, was used (n = 12,796). Study Design Multivariate logistic regression was used to isolate the relationship between numeracy and long‐term care insurance ownership. Principal Findings 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. Conclusions 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.

  January 22, 2016   doi: 10.1111/1475-6773.12439   open full text
• Medicare Payment and Hospital Provision of Outpatient Care to the Uninsured.
  Daifeng He, Jennifer M. Mellor.
  Health Services Research. January 18, 2016
  Objective 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. Data Sources/Study Setting We use hospital outpatient discharge records from Florida from 1997 through 2008. Study Design We estimate multivariate regression models of hospital outpatient care provided to the uninsured in separate samples of nonprofit and for‐profit hospitals. Principal Findings 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. Conclusions 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.

  January 18, 2016   doi: 10.1111/1475-6773.12433   open full text
• Testing the Validity of Primary Care Physicians' Self‐Reported Acceptance of New Patients by Insurance Status.
  Janet M. Coffman, Karin V. Rhodes, Margaret Fix, Andrew B. Bindman.
  Health Services Research. January 14, 2016
  Objective 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. Data Sources/Study Setting Survey administered to California physicians and telephone calls placed to a subsample of respondents. Study Design Cross‐sectional comparison. Data Collection/Extraction Methods 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. Principal Findings 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. Conclusions Physicians overestimate the extent to which their practices are accepting new patients, regardless of insurance status.

  January 14, 2016   doi: 10.1111/1475-6773.12435   open full text
• Impacts on Emergency Department Visits from Personal Responsibility Provisions: Evidence from West Virginia's Medicaid Redesign.
  Tami Gurley‐Calvez, Genevieve M. Kenney, Kosali I. Simon, Douglas Wissoker.
  Health Services Research. January 14, 2016
  Objective 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. Data Sources West Virginia Medicaid enrollment and claims data from 2005 to 2010. Study Design 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 Collection Data were obtained from the West Virginia Bureau for Medical Services. Principal Findings 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.

  January 14, 2016   doi: 10.1111/1475-6773.12434   open full text
• Medicaid Expansions from 1997 to 2009 Increased Coverage and Improved Access and Mental Health Outcomes for Low‐Income Parents.
  Stacey McMorrow, Genevieve M. Kenney, Sharon K. Long, Dana E. Goin.
  Health Services Research. January 14, 2016
  Objective 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. Data Sources 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. Study Design 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. Principal Findings 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. Conclusions 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.

  January 14, 2016   doi: 10.1111/1475-6773.12432   open full text
• Pay for Performance in Medicaid: Evidence from Three Natural Experiments.
  Meredith B. Rosenthal, Mary Beth Landrum, Jacob A. Robbins, Eric C. Schneider.
  Health Services Research. December 27, 2015
  Objective To examine the impact of pay for performance in Medicaid on the quality and utilization of care. Data Sources Medicaid claims and encounter data in three intervention states (Pennsylvania, Minnesota, and Alabama) and three comparison states. Study Design 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. Principal Findings 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. Conclusions 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.

  December 27, 2015   doi: 10.1111/1475-6773.12426   open full text
• Comparing the Cost of Care Provided to Medicare Beneficiaries Assigned to Primary Care Nurse Practitioners and Physicians.
  Jennifer Perloff, Catherine M. DesRoches, Peter Buerhaus.
  Health Services Research. December 27, 2015
  Objective 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). Data Source Medicare Part A (inpatient) and Part B (office visit) claims for 2009–2010. Study Design Retrospective cohort design using propensity score weighted regression. Data Extraction Methods Beneficiaries cared for by a random sample of NPs and primary care physicians. Principal Findings 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. Conclusions 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.

  December 27, 2015   doi: 10.1111/1475-6773.12425   open full text
• Medical Complexity among Children with Special Health Care Needs: A Two‐Dimensional View.
  Ryan J. Coller, Carlos F. Lerner, Jens C. Eickhoff, Thomas S. Klitzner, Daniel J. Sklansky, Mary Ehlenbach, Paul J. Chung.
  Health Services Research. November 30, 2015
  Objective To identify subgroups of U.S. children with special health care needs (CSHCN) and characterize key outcomes. Data Source Secondary analysis of 2009–2010 National Survey of CSHCN. Study Design 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. Principal Findings 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). Conclusions Recognizing distinct impacts of cognitive and mental health impairments and health care delivery needs on CSHCN outcomes may better direct future intervention efforts.

  November 30, 2015   doi: 10.1111/1475-6773.12416   open full text
• Trust and Reflection in Primary Care Practice Redesign.
  Holly Jordan Lanham, Raymond F. Palmer, Luci K. Leykum, Reuben R. McDaniel, Paul A. Nutting, Kurt C. Stange, Benjamin F. Crabtree, William L. Miller, Carlos Roberto Jaén.
  Health Services Research. November 27, 2015
  Objective To test a conceptual model of relationships, reflection, sensemaking, and learning in primary care practices transitioning to patient‐centered medical homes (PCMH). Data Sources/Study Setting Primary data were collected as part of the American Academy of Family Physicians' National Demonstration Project of the PCMH. Study Design 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. Data Collection/Extraction Methods 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. Principal Findings 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. Conclusions Trust and reflection appear to play a key role in moderating relationships, sensemaking, and learning in practices undergoing practice redesign.

  November 27, 2015   doi: 10.1111/1475-6773.12415   open full text
• Effects of Expanded California Health Coverage on Hospitals: Implications for ACA Medicaid Expansions.
  Gloria J. Bazzoli.
  Health Services Research. November 27, 2015
  Objective 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 Sources/Study Setting 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. Study Design 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. Principal Findings 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. Conclusions 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.

  November 27, 2015   doi: 10.1111/1475-6773.12414   open full text
• Potentially Inappropriate Medication and Health Care Outcomes: An Instrumental Variable Approach.
  Chi‐Chen Chen, Shou‐Hsia Cheng.
  Health Services Research. November 25, 2015
  Objective To examine the effects of potentially inappropriate medication (PIM) use on health care outcomes in elderly individuals using an instrumental variable (IV) approach. Data Sources/Study Setting Representative claim data from the universal health insurance program in Taiwan from 2007 to 2010. Study Design 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. Principal Findings 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). Conclusions 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.

  November 25, 2015   doi: 10.1111/1475-6773.12417   open full text
• The Impact of Improved Population Life Expectancy in Survival Trend Analyses of Specific Diseases.
  Carl Walraven.
  Health Services Research. October 20, 2015
  Background 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. Methods 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. Results 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). Conclusions These results highlight the importance of accounting for population life‐expectancy changes in survival trend analyses.

  October 20, 2015   doi: 10.1111/1475-6773.12403   open full text
• Cutting Medicare Hospital Prices Leads to a Spillover Reduction in Hospital Discharges for the Nonelderly.
  Chapin White.
  Health Services Research. May 21, 2014
  Objective To measure spillover effects of Medicare inpatient hospital prices on the nonelderly (under age 65). Primary Data Sources Healthcare Cost and Utilization Project State Inpatient Databases (10 states, 1995–2009) and Medicare Hospital Cost Reports. Study Design Outcomes include nonelderly discharges, length of stay and case mix, staffed hospital bed‐days, and the share of discharges and days provided to the elderly. We use metropolitan statistical areas as our markets. We use descriptive analyses comparing 1995 and 2009 and panel data fixed‐effects regressions. We instrument for Medicare prices using accumulated changes in the Medicare payment formula. Principal Findings Medicare price reductions are strongly associated with reductions in nonelderly discharges and hospital capacity. A 10‐percent reduction in the Medicare price is estimated to reduce discharges among the nonelderly by about 5 percent. Changes in the Medicare price are not associated with changes in the share of inpatient hospital care provided to the elderly versus nonelderly. Conclusions Medicare price reductions appear to broadly constrain hospital operations, with significant reductions in utilization among the nonelderly. The slow Medicare price growth under the Affordable Care Act may result in a spillover slowdown in hospital utilization and spending among the nonelderly.

  May 21, 2014   doi: 10.1111/1475-6773.12183   open full text
• Long‐Term Impact of Medicare Payment Reductions on Patient Outcomes.
  Vivian Y. Wu, Yu‐Chu Shen.
  Health Services Research. May 20, 2014
  Objective To examine the long‐term impact of Medicare payment reductions on patient outcomes for Medicare acute myocardial infarction (AMI) patients. Data Sources Analysis of secondary data compiled from 100 percent Medicare Provider Analysis and Review between 1995 and 2005, Medicare hospital cost reports, Inpatient Prospective Payment System Payment Impact Files, American Hospital Association annual surveys, InterStudy, Area Resource Files, and County Business Patterns. Study Design We used a natural experiment—the Balanced Budget Act (BBA) of 1997—as an instrument to predict cumulative Medicare revenue loss due solely to the BBA, and basing on the predicted loss categorized hospitals into small, moderate, or large payment‐cut groups and followed Medicare AMI patient outcomes in these hospitals over an 11‐year panel between 1995 and 2005. Principal Findings We found that while Medicare AMI mortality trends remained similar across hospitals between pre‐BBA and initial‐BBA periods, hospitals facing large payment cuts saw smaller improvement in mortality rates relative to that of hospitals facing small cuts in the post‐BBA period. Part of the relatively higher AMI mortalities among large‐cut hospitals might be related to reductions in staffing levels and operating costs, and a small part might be due to patient selection. Conclusions We found evidence that hospitals facing large Medicare payment cuts as a result of BBA of 1997 were associated with deteriorating patient outcomes in the long run. Medicare payment reductions may have an unintended consequence of widening the gap in quality across hospitals.

  May 20, 2014   doi: 10.1111/1475-6773.12185   open full text
• Compassion Practices and HCAHPS: Does Rewarding and Supporting Workplace Compassion Influence Patient Perceptions?
  Laura E. McClelland, Timothy J. Vogus.
  Health Services Research. May 19, 2014
  Objective To examine the benefits of compassion practices on two indicators of patient perceptions of care quality—the Hospital Consumer Assessment of Healthcare Providers and systems (HCAHPS) overall hospital rating and likelihood of recommending. Study Setting Two hundred sixty‐nine nonfederal acute care U.S. hospitals. Study Design Cross‐sectional study. Data Collection Surveys collected from top‐level hospital executives. Publicly reported HCAHPS data from October 2012 release. Principal Findings Compassion practices, a measure of the extent to which a hospital rewards compassionate acts and compassionately supports its employees (e.g., compassionate employee awards, pastoral care for employees), is significantly and positively associated with hospital ratings and likelihood of recommending. Conclusions Our findings illustrate the benefits for patients of specific and actionable organizational practices that provide and reinforce compassion.

  May 19, 2014   doi: 10.1111/1475-6773.12186   open full text
• Methods for Assessing Patient–Clinician Communication about Depression in Primary Care: What You See Depends on How You Look.
  Stephen G. Henry, Bo Feng, Peter Franks, Robert A. Bell, Daniel J. Tancredi, Dustin Gottfeld, Richard L. Kravitz.
  Health Services Research. May 19, 2014
  Objective To advance research on depression communication and treatment by comparing assessments of communication about depression from patient report, clinician report, and chart review to assessments from transcripts. Data One hundred sixty‐four primary care visits from seven health care systems (2010–2011). Study Design Presence or absence of discussion about depressive symptoms, treatment recommendations, and follow‐up was measured using patient and clinician postvisit questionnaires, chart review, and coding of audio transcripts. Sensitivity and specificity of indirect measures compared to transcripts were calculated. Principal Findings Patient report was sensitive for mood (83 percent) and sleep (83 percent) but not suicide (55 percent). Patient report was specific for suicide (86 percent) but not for other symptoms (44–75 percent). Clinician report was sensitive for all symptoms (83–98 percent) and specific for sleep, memory, and suicide (80–87 percent), but not for other symptoms (45–48 percent). Chart review was not sensitive for symptoms (50–73 percent), but it was specific for sleep, memory, and suicide (88–96 percent). All indirect measures had low sensitivity for treatment recommendations (patient report: 24–42 percent, clinician report 38–50 percent, chart review 49–67 percent) but high specificity (89–96 percent). For definite follow‐up plans, all three indirect measures were sensitive (82–96 percent) but not specific (40–57 percent). Conclusions Clinician report and chart review generally had the most favorable sensitivity and specificity for measuring discussion of depressive symptoms and treatment recommendations, respectively.

  May 19, 2014   doi: 10.1111/1475-6773.12187   open full text
• Patient Selection and Volume in the Era Surrounding Implementation of Medicare Conditions of Participation for Transplant Programs.
  Sarah L White, Dawn M. Zinsser, Matthew Paul, Gregory N. Levine, Tempie Shearon, Valarie B. Ashby, John C. Magee, Yi Li, Alan B. Leichtman.
  Health Services Research. May 19, 2014
  Objective To evaluate evidence of practice changes affecting kidney transplant program volumes, and donor, recipient and candidate selection in the era surrounding the introduction of Centers for Medicare and Medicaid Services (CMS) conditions of participation (CoPs) for organ transplant programs. Data Scientific Registry of Transplant Recipients; CMS ESRD and Medicare claims databases. Design Retrospective analysis of national registry data. Methods A Cox proportional hazards model of 1‐year graft survival was used to derive risks associated with deceased‐donor kidney transplants performed from 2001 to 2010. Findings Among programs with ongoing noncompliance with the CoPs, kidney transplant volumes declined by 38 percent (n = 766) from 2006 to 2011, including a 55 percent drop in expanded criteria donor transplants. Volume increased by 6 percent (n = 638) among programs remaining in compliance. Aggregate risk of 1‐year graft failure increased over time due to increasing recipient age and obesity, and longer ESRD duration. Conclusions Although trends in aggregate risk of 1‐year kidney graft loss do not indicate that the introduction of the CoPs has systematically reduced opportunities for marginal candidates or that there has been a systematic shift away from utilization of higher risk deceased donor kidneys, total volume and expanded criteria donor utilization decreased overall among programs with ongoing noncompliance.

  May 19, 2014   doi: 10.1111/1475-6773.12188   open full text
• Expanding Coverage to Low‐Income Childless Adults in Massachusetts: Implications for National Health Reform.
  Sharon K. Long, Heather Dahlen.
  Health Services Research. May 19, 2014
  Objective To draw on the experiences under Massachusetts's 2006 reform, the template for the Affordable Care Act (ACA), to provide insights into the potential impacts of the ACA Medicaid expansion for low‐income childless adults in other states. Data Sources/Study Setting The study takes advantage of the natural experiment in Massachusetts and combined data from two surveys—the Massachusetts Health Reform Survey (MHRS) and the National Health Interview Survey (NHIS)—to estimate the impacts of reform on low‐income adults. Study Design Difference‐in‐differences models of the impacts of health reform, using propensity‐score reweighting to improve the match between Massachusetts and the comparison states. Data Collection/Extraction Methods Data for low‐income adults are obtained by combining data from the MHRS and the NHIS, where the MHRS provides a relatively large Massachusetts sample and the NHIS provides data for samples in other states to support the difference‐in‐differences model. Supplemental data on county economic and health care market characteristics are obtained from the Area Health Resource File. Principal Findings There are strong increases in coverage and access to health care for low‐income adults under health reform in Massachusetts, with the greatest gains observed for childless adults, who were not eligible for public coverage prior to reform. Conclusions In the states that implement the Medicaid provisions of the ACA, we would expect to see large increases in coverage rates and commensurate gains in access to care for low‐income childless adults. Linking state and federal surveys offers a strategy for leveraging the value of state‐specific survey data for stronger policy evaluations.

  May 19, 2014   doi: 10.1111/1475-6773.12189   open full text
• An Assessment of Patient Navigator Activities in Breast Cancer Patient Navigation Programs Using a Nine‐Principle Framework.
  Christine M. Gunn, Jack A. Clark, Tracy A. Battaglia, Karen M. Freund, Victoria A. Parker.
  Health Services Research. May 13, 2014
  Objective To determine how closely a published model of navigation reflects the practice of navigation in breast cancer patient navigation programs. Data Source Observational field notes describing patient navigator activities collected from 10 purposefully sampled, foundation‐funded breast cancer navigation programs in 2008–2009. Study Design An exploratory study evaluated a model framework for patient navigation published by Harold Freeman by using an a priori coding scheme based on model domains. Data Collection Field notes were compiled and coded. Inductive codes were added during analysis to characterize activities not included in the original model. Principal Findings Programs were consistent with individual‐level principles representing tasks focused on individual patients. There was variation with respect to program‐level principles that related to program organization and structure. Program characteristics such as the use of volunteer or clinical navigators were identified as contributors to patterns of model concordance. Conclusions This research provides a framework for defining the navigator role as focused on eliminating barriers through the provision of individual‐level interventions. The diversity observed at the program level in these programs was a reflection of implementation according to target population. Further guidance may be required to assist patient navigation programs to define and tailor goals and measurement to community needs.

  May 13, 2014   doi: 10.1111/1475-6773.12184   open full text
• Determinants of Coverage Decisions in Health Insurance Marketplaces: Consumers' Decision‐Making Abilities and the Amount of Information in Their Choice Environment.
  Andrew J. Barnes, Yaniv Hanoch, Thomas Rice.
  Health Services Research. April 30, 2014
  Objective To investigate the determinants and quality of coverage decisions among uninsured choosing plans in a hypothetical health insurance marketplace. Study Setting Two samples of uninsured individuals: one from an Internet‐based sample comprised largely of young, healthy, tech‐savvy individuals (n = 276), and the other from low‐income, rural Virginians (n = 161). Study Design We assessed whether health insurance comprehension, numeracy, choice consistency, and the number of plan choices were associated with participants' ability to choose a cost‐minimizing plan, given their expected health care needs (defined as choosing a plan costing no more than $500 in excess of the total estimated annual costs of the cheapest plan available). Data Collection Primary data were collected using an online questionnaire. Principal Findings Uninsured who were more numerate showed higher health insurance comprehension; those with more health insurance comprehension made choices of health insurance plans more consistent with their stated preferences; and those who made choices more concordant with their stated preferences were less likely to choose a plan that cost more than $500 in excess of the cheapest plan available. Conclusions Increasing health insurance comprehension and designing exchanges to facilitate plan comparison will be critical to ensuring the success of health insurance marketplaces.

  April 30, 2014   doi: 10.1111/1475-6773.12181   open full text
• Impact of States' Nurse Work Hour Regulations on Overtime Practices and Work Hours among Registered Nurses.
  Sung‐Heui Bae, Jangho Yoon.
  Health Services Research. April 30, 2014
  Objectives To examine the degree to which states' work hour regulations for nurses—policies regarding mandatory overtime and consecutive work hours—decrease mandatory overtime practice and hours of work among registered nurses. Methods We analyzed a nationally representative sample of registered nurses from the National Sample Survey of Registered Nurses for years 2004 and 2008. We obtained difference‐in‐differences estimates of the effect of the nurse work hour policies on the likelihood of working mandatory overtime, working more than 40 hours per week, and working more than 60 hours per week for all staff nurses working in hospitals and nursing homes. Principal Findings The mandatory overtime and consecutive work hour regulations were significantly associated with 3.9 percentage‐point decreases in the likelihood of working overtime mandatorily and 11.5 percentage‐point decreases in the likelihood of working more than 40 hours per week, respectively. Conclusions State mandatory overtime and consecutive work hour policies are effective in reducing nurse work hours. The consecutive work hour policy appears to be a better regulatory tool for reducing long work hours for nurses.

  April 30, 2014   doi: 10.1111/1475-6773.12179   open full text
• Using Estimated True Safety Event Rates versus Flagged Safety Event Rates: Does It Change Hospital Profiling and Payment?
  Amy K. Rosen, Qi Chen, Ann M. Borzecki, Marlena Shin, Kamal M. F. Itani, Michael Shwartz.
  Health Services Research. April 30, 2014
  Objective To assess whether use of the AHRQ Patient Safety Indicator (PSI) composite measure versus modified composite measures leads to changes in hospital profiles and payments. Data Sources/Study Setting Retrospective analysis of 2010 Veterans Health Administration discharge data. Study Design We used the AHRQ PSI software (v4.2) to obtain PSI‐flagged events and composite scores for all 151 hospitals in the database (n = 517,814 hospitalizations). We compared the AHRQ PSI composite to two modified composites that estimated “true safety events” from previous chart abstraction findings: one with modified numerators based on the positive predictive value (PPV) of each PSI, and one with similarly modified numerators but whose denominators were based on the expected fraction of PSI‐eligible cases that remained after removing those PSIs that were present‐on‐admission (POA). Principal Findings Although a small percentage (5–6 percent) of hospitals changed outlier status based on modified PSI composites, some of these changes were substantial; 30 and 19 percent of hospitals changed ≥20 ranks after adjustment for PPVs and POA flags, respectively. We estimate that 33 percent of hospitals would see a change of at least 10 percent in performance payments. Conclusions Changes in hospital profiles and payments would be substantial for some hospitals if the PSI composite score used weights reflecting the relative prevalence of true versus flagged events.

  April 30, 2014   doi: 10.1111/1475-6773.12180   open full text
• Health Care Utilization and Receipt of Preventive Care for Patients Seen at Federally Funded Health Centers Compared to Other Sites of Primary Care.
  Neda Laiteerapong, James Kirby, Yue Gao, Tzy‐Chyi Yu, Ravi Sharma, Robert Nocon, Sang Mee Lee, Marshall H. Chin, Aviva G. Nathan, Quyen Ngo‐Metzger, Elbert S. Huang.
  Health Services Research. April 30, 2014
  Objective To compare utilization and preventive care receipt among patients of federal Section 330 health centers (HCs) versus patients of other settings. Data Sources A nationally representative sample of adults from the Medical Expenditure Panel Survey (2004–2008). Study Design HC patients were defined as those with ≥50 percent of outpatient visits at HCs in the first panel year. Outcomes included utilization and preventive care receipt from the second panel year. We used negative binomial and logistic regression models with propensity score adjustment for confounding differences between HC and non‐HC patients. Principal Findings Compared to non‐HC patients, HC patients had fewer office visits (adjusted incidence rate ratio [aIRR], 0.63) and hospitalizations (aIRR, 0.43) (both p < .001). HC patients were more likely to receive breast cancer screening than non‐HC patients (adjusted odds ratio [aOR] 2.78, p < .01). In subgroup analyses, uninsured HC patients had fewer outpatient and emergency room visits and were more likely to receive dietary advice and breast cancer screening compared to non‐HC patients. Conclusions Health centers add value to the health care system by providing socially and medically disadvantaged patients with care that results in lower utilization and maintained or improved preventive care.

  April 30, 2014   doi: 10.1111/1475-6773.12178   open full text
• Community Factors and Hospital Readmission Rates.
  Jeph Herrin, Justin St. Andre, Kevin Kenward, Maulik S. Joshi, Anne‐Marie J. Audet, Stephen C. Hines.
  Health Services Research. April 09, 2014
  Objective To examine the relationship between community factors and hospital readmission rates. Data Sources/Study Setting We examined all hospitals with publicly reported 30‐day readmission rates for patients discharged during July 1, 2007, to June 30, 2010, with acute myocardial infarction (AMI), heart failure (HF), or pneumonia (PN). We linked these to publicly available county data from the Area Resource File, the Census, Nursing Home Compare, and the Neilsen PopFacts datasets. Study Design We used hierarchical linear models to assess the effect of county demographic, access to care, and nursing home quality characteristics on the pooled 30‐day risk‐standardized readmission rate. Data Collection/Extraction Methods Not applicable. Principal Findings The study sample included 4,073 hospitals. Fifty‐eight percent of national variation in hospital readmission rates was explained by the county in which the hospital was located. In multivariable analysis, a number of county characteristics were found to be independently associated with higher readmission rates, the strongest associations being for measures of access to care. These county characteristics explained almost half of the total variation across counties. Conclusions Community factors, as measured by county characteristics, explain a substantial amount of variation in hospital readmission rates.

  April 09, 2014   doi: 10.1111/1475-6773.12177   open full text
• A Randomized, Controlled Pragmatic Trial of Telephonic Medication Therapy Management to Reduce Hospitalization in Home Health Patients.
  Alan J. Zillich, Margie E. Snyder, Caitlin K. Frail, Julie L. Lewis, Donny Deshotels, Patrick Dunham, Heather A. Jaynes, Jason M. Sutherland.
  Health Services Research. April 09, 2014
  Objective To evaluate the effectiveness of a telephonic medication therapy management (MTM) service on reducing hospitalizations among home health patients. Setting Forty randomly selected, geographically diverse home health care centers in the United States. Design Two‐stage, randomized, controlled trial with 60‐day follow‐up. All Medicare‐ insured home health care patients were eligible to participate. Twenty‐eight consecutive patients within each care center were recruited and randomized to usual care or MTM intervention. The MTM intervention consisted of the following: (1) initial phone call by a pharmacy technician to verify active medications; (2) pharmacist‐provided medication regimen review by telephone; and (3) follow‐up pharmacist phone calls at day seven and as needed for 30 days. The primary outcome was 60‐day all‐cause hospitalization. Data Collection Data were collected from in‐home nursing assessments using the OASIS‐C. Multivariate logistic regression modeled the effect of the MTM intervention on the probability of hospitalization while adjusting for patients’ baseline risk of hospitalization, number of medications taken daily, and other OASIS‐C data elements. Principal Findings A total of 895 patients (intervention n = 415, control n = 480) were block‐randomized to the intervention or usual care. There was no significant difference in the 60‐day probability of hospitalization between the MTM intervention and control groups (Adjusted OR: 1.26, 95 percent CI: 0.89–1.77, p = .19). For patients within the lowest baseline risk quartile (n = 232), the intervention group was three times more likely to remain out of the hospital at 60 days (Adjusted OR: 3.79, 95 percent CI: 1.35–10.57, p = .01) compared to the usual care group. Conclusions This MTM intervention may not be effective for all home health patients; however, for those patients with the lowest‐risk profile, the MTM intervention prevented patients from being hospitalized at 60 days.

  April 09, 2014   doi: 10.1111/1475-6773.12176   open full text
• Examining the Association between Utilization Management and Downstream Cardiovascular Imaging.
  Abiy Agiro, Gosia Sylwestrzak, Christiane Shah, Thomas Power, Andrea DeVries.
  Health Services Research. April 09, 2014
  Objectives To examine the association of echocardiography utilization management (EUM) program with downstream cardiac imaging utilization. Data Sources/Study Setting Administrative claims data from commercial health plans in Indiana, Ohio, Kentucky, Wisconsin, and Georgia. Study Design Patients undergoing index cardiovascular imaging with no imaging in the preceding year were identified (N = 112,308). Claims‐derived cardiac risk scores were used for one‐to‐one propensity score matching of patients subject to EUM to patients without EUM (n = 96,906). Downstream cardiac imaging utilization for 12–24 months postindex imaging was analyzed using generalized linear models and Cox proportional hazards model. Principal Findings Downstream cardiac imaging tests were performed for 10,630 (21.9 percent) and 12,012 (24.8 percent) patients in the EUM and non‐EUM groups, respectively. At 12‐month follow‐up, adjusted utilization was 15.2 (95 percent CI, 7.6–22.5) tests per 1,000 initially tested patients lower in the EUM group (p < .001). The likelihood of obtaining downstream cardiac imaging in the EUM group was 7.0 percent lower than the non‐EUM group (hazard ratio: 0.930; 95 percent CI, 0.897–0.964, p < .001). Conclusions Downstream cardiac imaging is relatively common among commercially insured patients. Every 10 initial diagnostic tests yielded two downstream imaging tests in first 24 months. EUM program was associated with lower volumes of downstream imaging.

  April 09, 2014   doi: 10.1111/1475-6773.12175   open full text
• Temporal Changes in Survival after Cardiac Surgery Are Associated with the Thirty‐Day Mortality Benchmark.
  Bryan G. Maxwell, Jim K. Wong, D. Craig Miller, Robert L. Lobato.
  Health Services Research. April 09, 2014
  Objective To assess the hypothesis that postoperative survival exhibits heterogeneity associated with the timing of quality metrics. Data Sources Retrospective observational study using the Nationwide Inpatient Sample from 2005 through 2009. Study Design Survival analysis was performed on all admission records with a procedure code for major cardiac surgery (n = 595,089). The day‐by‐day hazard function for all‐cause in‐hospital mortality at 1‐day intervals was analyzed using joinpoint regression (a data‐driven method of testing for changes in hazard). Data Extraction Methods A comprehensive analysis of a publicly available national administrative database was performed. Principal Findings Statistically significant shifts in the pattern of postoperative mortality occurred at day 6 (95 percent CI = day 5–8) and day 30 (95 percent CI = day 20–35). Conclusions While the shift at day 6 plausibly can be attributed to the separation between routine recovery and a complicated postoperative course, the abrupt increase in mortality at day 30 has no clear organic etiology. This analysis raises the possibility that this observed shift may be related to clinician behavior because of the use of 30‐day mortality as a quality metric, but further studies will be required to establish causality.

  April 09, 2014   doi: 10.1111/1475-6773.12174   open full text
• Hospital and Geographic Variability in Thirty‐Day All‐Cause Mortality Following Colorectal Cancer Surgery.
  Mario Schootman, Min Lian, Sandi L. Pruitt, Anjali D. Deshpande, Samantha Hendren, Matthew Mutch, Donna B. Jeffe, Nicholas Davidson.
  Health Services Research. March 27, 2014
  Objective To assess hospital and geographic variability in 30‐day mortality after surgery for CRC and examine the extent to which sociodemographic, area‐level, clinical, tumor, treatment, and hospital characteristics were associated with increased likelihood of 30‐day mortality in a population‐based sample of older CRC patients. Data Sources/Study Setting Linked Surveillance Epidemiology End Results (SEER) and Medicare data from 47,459 CRC patients aged 66 years or older who underwent surgical resection between 2000 and 2005, resided in 13,182 census tracts, and were treated in 1,447 hospitals. Study Design An observational study using multilevel logistic regression to identify hospital‐ and patient‐level predictors of and variability in 30‐day mortality. Data Collection/Extraction Methods We extracted sociodemographic, clinical, tumor, treatment, hospital, and geographic characteristics from Medicare claims, SEER, and census data. Principal Findings Of 47,459 CRC patients, 6.6 percent died within 30 days following surgery. Adjusted variability in 30‐day mortality existed across residential census tracts (predicted mortality range: 2.7–12.3 percent) and hospitals (predicted mortality range: 2.5–10.5 percent). Higher risk of death within 30 days was observed for CRC patients age 85+ (12.7 percent), census‐tract poverty rate >20 percent (8.0 percent), two or more comorbid conditions (8.8 percent), stage IV at diagnosis (15.1 percent), undifferentiated tumors (11.6 percent), and emergency surgery (12.8 percent). Conclusions Substantial, but similar variability was observed across census tracts and hospitals in 30‐day mortality following surgery for CRC in patients 66 years and older. Risk of 30‐day mortality is driven not only by patient and hospital characteristics but also by larger social and economic factors that characterize geographic areas.

  March 27, 2014   doi: 10.1111/1475-6773.12171a   open full text
• Incident User Cohorts for Assessing Medication Cost‐Offsets.
  Bruce Stuart, F. Ellen Loh, Pamela Roberto, Laura Miller.
  Health Services Research. March 14, 2014
  Objective To develop and test incident drug user designs for assessing cost savings from statin use in diabetics. Data Source Random 5 percent sample of Medicare beneficiaries, 2006–2008. Study Design Seven‐step incident user design to assess impact of statin initiation on subsequent Medicare spending: (1) unadjusted pre/post initiation test; (2) unadjusted difference‐in‐difference (DID) with comparison series; (3) adjusted DID; (4) propensity score (PS)‐matched DID with static and dynamic baseline covariates; (5) PS‐matched DID by drug adherence strata; (6) PS‐matched DID for high adherers controlling for healthy adherer bias; and (7) replication for ACE‐inhibitor/ARB initiators. Data Collection/Extraction Methods Subjects with prevalent diabetes and no statin use (January–June 2006) and statin initiation (July 2006–January 2008) compared to nonusers with a random “potential‐initiation” month. Monthly Medicare spending tracked 24 months pre‐ and post‐initiation. Principal Findings Statistically significant savings in Medicare spending were observed beginning 7 months post‐initiation for statins and 13 months post‐initiation for ACEIs/ARBs. However, these savings were only observed for adherent patients in steps 5 and 6. Conclusions Drug initiator designs are more robust to confounding than prevalent user designs in assessing cost‐offsets from drug use but still require other adjustments and sensitivity analysis to ensure proper inference.

  March 14, 2014   doi: 10.1111/1475-6773.12170   open full text
• Physician Practice Participation in Accountable Care Organizations: The Emergence of the Unicorn.
  Stephen M. Shortell, Sean R. McClellan, Patricia P. Ramsay, Lawrence P. Casalino, Andrew M. Ryan, Kennon R. Copeland.
  Health Services Research. March 14, 2014
  Objective To provide the first nationally based information on physician practice involvement in ACOs. Data Sources/Study Setting Primary data from the third National Survey of Physician Organizations (January 2012–May 2013). Study Design We conducted a 40‐minute phone survey in a sample of physician practices. A nationally representative sample of practices was surveyed in order to provide estimates of organizational characteristics, care management processes, ACO participation, and related variables for four major chronic illnesses. Data Collection/Extraction Methods We evaluated the associations between ACO participation, organizational characteristics, and a 25‐point index of patient‐centered medical home processes. Principal Findings We found that 23.7 percent of physician practices (n = 280) reported joining an ACO; 15.7 percent (n = 186) were planning to become involved within the next 12 months and 60.6 percent (n = 717) reported no involvement and no plans to become involved. Larger practices, those receiving patients from an IPA and/or PHO, those that were physician‐owned versus hospital/health system‐owned, those located in New England, and those with greater patient‐centered medical home (PCMH) care management processes were more likely to have joined an ACO. Conclusions Physician practices that are currently participating in ACOs appear to be relatively large, or to be members of an IPA or PHO, are less likely to be hospital‐owned and are more likely to use more care management processes than nonparticipating practices.

  March 14, 2014   doi: 10.1111/1475-6773.12167   open full text
• Disparities in Quality of Care among Publicly Insured Adults with Schizophrenia in Four Large U.S. States, 2002–2008.
  Marcela Horvitz‐Lennon, Rita Volya, Julie M. Donohue, Judith R. Lave, Bradley D. Stein, Sharon‐Lise T. Normand.
  Health Services Research. March 13, 2014
  Objective To examine racial/ethnic disparities in quality of schizophrenia care and assess the size of observed disparities across states and over time. Data Sources Medicaid claims data from CA, FL, NY, and NC. Study Design Observational repeated cross‐sectional panel cohort study of white, black, and Latino fee‐for‐service adult beneficiaries with schizophrenia. Main outcome was the relationship of race/ethnicity and year with a composite measure of quality of schizophrenia care derived from 14 evidence‐based quality indicators. Principal Findings Quality was assessed for 325,373 twelve‐month person‐episodes between 2002 and 2008, corresponding to 123,496 Medicaid beneficiaries. In 2002, quality was lowest for blacks in all states. With the exception of FL, quality was lower for Latinos than whites. In CA, blacks had about 43 percent of the individual indicators met compared to 58 percent for whites. Quality improved annually for all groups in CA, NY, and NC. While in CA the improvement was slightly larger for Latinos, in FL quality improved for blacks but declined for Latinos and whites. Conclusions Quality of schizophrenia care is poor and racial/ethnic disparities exist among Medicaid beneficiaries from four states. The size of the disparities varied across the states, and most of the initial disparities were unchanged by 2008.

  March 13, 2014   doi: 10.1111/1475-6773.12162   open full text
• The Association between Long‐Term Care Setting and Potentially Preventable Hospitalizations among Older Dual Eligibles.
  Andrea Wysocki, Robert L. Kane, Ezra Golberstein, Bryan Dowd, Terry Lum, Tetyana Shippee.
  Health Services Research. March 13, 2014
  Objective To compare the probability of experiencing a potentially preventable hospitalization (PPH) between older dual eligible Medicaid home and community‐based service (HCBS) users and nursing home residents. Data Sources Three years of Medicaid and Medicare claims data (2003–2005) from seven states, linked to area characteristics from the Area Resource File. Study Design A primary diagnosis of an ambulatory care sensitive condition on the inpatient hospital claim was used to identify PPHs. We used inverse probability of treatment weighting to mitigate the potential selection of HCBS versus nursing home use. Principal Findings The most frequent conditions accounting for PPHs were the same among the HCBS users and nursing home residents and included congestive heart failure, pneumonia, chronic obstructive pulmonary disease, urinary tract infection, and dehydration. Compared to nursing home residents, elderly HCBS users had an increased probability of experiencing both a PPH and a non‐PPH. Conclusions HCBS users’ increased probability for potentially and non‐PPHs suggests a need for more proactive integration of medical and long‐term care.

  March 13, 2014   doi: 10.1111/1475-6773.12168   open full text
• Patient Loyalty in a Mature IDS Market: Is Population Health Management Worth It?
  Caroline S. Carlin.
  Health Services Research. January 24, 2014
  Objective To understand patient loyalty to providers over time, informing effective population health management. Study Setting Patient care‐seeking patterns over a 6‐year timeframe in Minnesota, where care systems have a significant portion of their revenue generated by shared‐saving contracts with public and private payers. Study Design Weibull duration and probit models were used to examine patterns of patient attribution to a care system and the continuity of patient affiliation with a care system. Clustering of errors within family unit was used to account for within‐family correlation in unobserved characteristics that affect patient loyalty. Data Collection The payer provided data from health plan administrative files, matched to U.S. Census‐based characteristics of the patient's neighborhood. Patients were retrospectively attributed to health care systems based on patterns of primary care. Principal Findings I find significant patient loyalty, with past loyalty a very strong predictor of future relationship. Relationships were shorter when the patient's health status was complex and when the patient's care system was smaller. Conclusions Population health management can be beneficial to the care system making this investment, particularly for patients exhibiting prior continuity in care system choice. The results suggest that co‐located primary and specialty services are important in maintaining primary care loyalty.

  January 24, 2014   doi: 10.1111/1475-6773.12147   open full text
• Estimation of Standardized Hospital Costs from Medicare Claims That Reflect Resource Requirements for Care: Impact for Cohort Studies Linked to Medicare Claims.
  John T. Schousboe, Misti L. Paudel, Brent C. Taylor, Lih‐Wen Mau, Beth A. Virnig, Kristine E. Ensrud, Bryan E. Dowd.
  Health Services Research. January 24, 2014
  Objective To compare cost estimates for hospital stays calculated using diagnosis‐related group (DRG) weights to actual Medicare payments. Data Sources/Study Setting Medicare MedPAR files and DRG tables linked to participant data from the Study of Osteoporotic Fractures (SOF) from 1992 through 2010. Participants were women age 65 and older recruited in three metropolitan and one rural area of the United States. Study Design Costs were estimated using DRG payment weights for 1,397 hospital stays for 795 SOF participants for 1 year following a hip fracture. Medicare cost estimates included Medicare and secondary insurer payments, and copay and deductible amounts. Principal Findings The mean (SD) of inpatient DRG‐based cost estimates per person‐year were $16,268 ($10,058) compared with $19,937 ($15,531) for MedPAR payments. The correlation between DRG‐based estimates and MedPAR payments was 0.71, and 51 percent of hospital stays were in different quintiles when costs were calculated based on DRG weights compared with MedPAR payments. Conclusions DRG‐based cost estimates of hospital stays differ significantly from Medicare payments, which are adjusted by Medicare for facility and local geographic characteristics. DRG‐based cost estimates may be preferable for analyses when facility and local geographic variation could bias assessment of associations between patient characteristics and costs.

  January 24, 2014   doi: 10.1111/1475-6773.12151   open full text
• Statistical Benchmarks for Health Care Provider Performance Assessment: A Comparison of Standard Approaches to a Hierarchical Bayesian Histogram‐Based Method.
  Susan M. Paddock.
  Health Services Research. January 24, 2014
  Objective Examine how widely used statistical benchmarks of health care provider performance compare with histogram‐based statistical benchmarks obtained via hierarchical Bayesian modeling. Data Sources Publicly available data from 3,240 hospitals during April 2009–March 2010 on two process‐of‐care measures reported on the Medicare Hospital Compare website. Study Design Secondary data analyses of two process‐of‐care measures comparing statistical benchmark estimates and threshold exceedance determinations under various combinations of hospital performance measure estimates and benchmarking approaches. Principal Findings Statistical benchmarking approaches for determining top 10 percent performance varied with respect to which hospitals exceeded the performance benchmark; such differences were not found at the 50 percent threshold. Benchmarks derived from the histogram of provider performance under hierarchical Bayesian modeling provide a compromise between benchmarks based on direct (raw) estimates, which are overdispersed relative to the true distribution of provider performance and prone to high variance for small providers, and posterior mean provider performance, for which over‐shrinkage and under‐dispersion relative to the true provider performance distribution is a concern. Conclusions Given the rewards and penalties associated with characterizing top performance, the ability of statistical benchmarks to summarize key features of the provider performance distribution should be examined.

  January 24, 2014   doi: 10.1111/1475-6773.12149   open full text
• The Medicare Hospital Readmissions Reduction Program: Potential Unintended Consequences for Hospitals Serving Vulnerable Populations.
  Qian Gu, Lane Koenig, Jennifer Faerberg, Caroline Rossi Steinberg, Christopher Vaz, Mary P. Wheatley.
  Health Services Research. January 13, 2014
  Objective To explore the impact of the Hospital Readmissions Reduction Program (HRRP) on hospitals serving vulnerable populations. Data Sources/Study Setting Medicare inpatient claims to calculate condition‐specific readmission rates. Medicare cost reports and other sources to determine a hospital's share of duals, profit margin, and characteristics. Study Design Regression analyses and projections were used to estimate risk‐adjusted readmission rates and financial penalties under the HRRP. Findings were compared across groups of hospitals, determined based on their share of duals, to assess differential impacts of the HRRP. Principal Findings Both patient dual‐eligible status and a hospital's dual‐eligible share of Medicare discharges have a positive impact on risk‐adjusted hospital readmission rates. Under current Centers for Medicare and Medicaid Service methodology, which does not adjust for socioeconomic status, high‐dual hospitals are more likely to have excess readmissions than low‐dual hospitals. As a result, HRRP penalties will disproportionately fall on high‐dual hospitals, which are more likely to have negative all‐payer margins, raising concerns of unintended consequences of the program for vulnerable populations. Conclusions Policies to reduce hospital readmissions must balance the need to ensure continued access to quality care for vulnerable populations.

  January 13, 2014   doi: 10.1111/1475-6773.12150   open full text
• Characteristics and Performance of Minority‐Serving Dialysis Facilities.
  Yoshio N. Hall, Ping Xu, Glenn M. Chertow, Jonathan Himmelfarb.
  Health Services Research. December 20, 2013
  Objective To examine the structure, processes, and outcomes of American dialysis facilities that predominantly treat racial‐ethnic minority patients. Data Sources/Study Setting Secondary analysis of data from all patients who initiated dialysis during 2005–2008 in the United States. Study Design In this retrospective cohort study, we examined the associations of the racial‐ethnic composition of the dialysis facility with facility‐level survival and achievement of performance targets for anemia and dialysis adequacy. Data Collection/Extraction Methods We obtained dialysis facility‐ and patient‐level data from the national data registry of patients with end‐stage renal disease. We linked these data with clinical performance measures from the Centers for Medicare and Medicaid Services. Principal Findings Overall, minority‐serving facilities were markedly larger, more often community based, and less likely to offer home dialysis than facilities serving predominantly white patients. A significantly higher proportion of minority‐serving dialysis facilities exhibited worse than expected survival as compared with facilities serving predominantly white patients (p < .001 for each). However, clinical performance measures for anemia and dialysis adequacy were similar across minority‐serving status. Conclusions While minority‐serving facilities generally met dialysis performance targets mandated by Medicare, they exhibited worse than expected patient survival.

  December 20, 2013   doi: 10.1111/1475-6773.12144   open full text
• Are Dual Eligibles Admitted to Poorer Quality Skilled Nursing Facilities?
  Momotazur Rahman, David C. Grabowski, Pedro L. Gozalo, Kali S. Thomas, Vincent Mor.
  Health Services Research. December 19, 2013
  Background Dual eligibles, persons who qualify for both Medicare and Medicaid coverage, often receive poorer quality care relative to other Medicare beneficiaries. Objectives To determine whether dual eligibles are discharged to lower quality post‐acute skilled nursing facilities (SNFs) compared with Medicare‐only beneficiaries. Research Design Following the random utility maximization model, we specified a discharge function using a conditional logit model and tested how this discharge rule varied by dual‐eligibility status. Subjects A total of 692,875 Medicare fee‐for‐service patients (22% duals) who were discharged for Medicare paid SNF care between July 2004 and June 2005. Measures Medicare enrollment and the Medicaid Analytic Extract files were used to determine dual eligibility. The proportion of Medicaid patients and nursing staff characteristics provided measures of SNF quality. Results Duals are more likely to be discharged to SNFs with a higher share of Medicaid patients and fewer nurses. These results are robust to estimation with an alternative subsample of patients based on primary diagnoses, propensity of being dual eligible, and likelihood of remaining in the nursing home. Conclusions Disparities exist in access to quality SNF care for duals. Strategies to improve discharge planning processes are required to redirect patients to higher quality providers, regardless of Medicaid eligibility.

  December 19, 2013   doi: 10.1111/1475-6773.12142   open full text
• Nonlinear Pricing in Drug Benefits and Medication Use: The Case of Statin Compliance in Medicare Part D.
  Kyoungrae Jung, Roger Feldman, A. Marshall McBean.
  Health Services Research. December 19, 2013
  Objective To examine how enrollees' statin compliance responds to expected prices in Medicare Part D, which features a nonlinear price schedule due to a coverage gap. Data Sources/Study Setting Prescription Drug Event data for a 5 percent random sample of Medicare Advantage Prescription Drug Plan enrollees in 2008 who did not receive a low‐income subsidy. Study Design We analyze statin compliance prior to the coverage gap, where the “effective price” is higher than the actual copayment for drugs because consumers anticipate that more spending will make them more likely to reach the gap. We construct each enrollee's effective price as her expected price at the end of the year, which is the weighted average between pre‐gap and in‐gap copayments with the weight being the predicted probability of hitting the gap. Compliance is defined as at least 80 percent of days covered. Principal Findings Part D enrollees' pre‐gap statin compliance decreases by 3.7–4.7 percentage points for a $10 increase in the effective price. Conclusion The presence of a coverage gap decreases statin compliance prior to the gap, suggesting that incorporating expected future prices is important to assess the full impact of cost sharing on drug compliance under nonlinear price schedules.

  December 19, 2013   doi: 10.1111/1475-6773.12145   open full text
• Factors Associated with Prolonged Observation Services Stays and the Impact of Long Stays on Patient Cost.
  Jason M. Hockenberry, Ryan Mutter, Marguerite Barrett, Judy Parlato, Michael A. Ross.
  Health Services Research. December 18, 2013
  Background Patients are treated using observation services (OS) when their care needs exceed standard outpatient care (i.e., clinic or emergency department) but do not qualify for admission. Medicare and other private payers seek to limit this care setting to 48 hours. Data Source/Study Setting Healthcare Cost and Utilization Project data from 10 states and data collected from two additional states for 2009. Study Design Bivariate analyses and hierarchical linear modeling were used to examine patient‐ and hospital‐level predictors of OS stays exceeding 48 (and 72) hours (prolonged OS). Hierarchical models were used to examine the additional cost associated with longer OS stays. Principal Findings Of the 696,732 patient OS stays, 8.8 percent were for visits exceeding 48 hours. Having Medicaid or no insurance, a condition associated with no OS treatment protocol, and being discharged to skilled nursing were associated with having a prolonged OS stay. Among Medicare patients, the mean charge for OS stays was $10,373. OS visits of 48–72 hours were associated with a 42 percent increase in costs; visits exceeding 72 hours were associated with a 61 percent increase in costs. Conclusion Patient cost sharing for most OS stays of less than 24 hours is lower than the Medicare inpatient deductible. However, prolonged OS stays potentially increase this cost sharing.

  December 18, 2013   doi: 10.1111/1475-6773.12143   open full text
• Expanding Federal Funding to Community Health Centers Slows Decline in Access for Low‐Income Adults.
  Stacey McMorrow, Stephen Zuckerman.
  Health Services Research. December 18, 2013
  Objective To identify the impact of the Health Center Growth Initiative on access to care for low‐income adults. Data Sources Data on federal funding for health centers are from the Bureau of Primary Health Care's Uniform Data System (2000–2007), and individual‐level measures of access and use are derived from the National Health Interview Survey (2001–2008). Study Design We estimate person‐level models of access and use as a function of individual‐ and market‐level characteristics. By using market‐level fixed effects, we identify the effects of health center funding on access using changes within markets over time. We explore effects on low‐income adults and further examine how those effects vary by insurance coverage. Data Collection We calculate health center funding per poor person in a health care market and attach this information to individual observations on the National Health Interview Survey. Health care markets are defined as hospital referral regions. Principal Findings Low‐income adults in markets with larger funding increases were more likely to have an office visit and to have a general doctor visit. These results were stronger for uninsured and publicly insured adults. Conclusions Expansions in federal health center funding had some mitigating effects on the access declines that were generally experienced by low‐income adults over this time period.

  December 18, 2013   doi: 10.1111/1475-6773.12141   open full text
• Insurer Market Structure and Variation in Commercial Health Care Spending.
  Michael R. McKellar, Sivia Naimer, Mary B. Landrum, Teresa B. Gibson, Amitabh Chandra, Michael Chernew.
  Health Services Research. December 05, 2013
  Objective To examine the relationship between insurance market structure and health care prices, utilization, and spending. Data Sources Claims for 37.6 million privately insured employees and their dependents from the Truven Health Market Scan Database in 2009. Measures of insurer market structure derived from Health Leaders Inter study data. Methods Regression models are used to estimate the association between insurance market concentration and health care spending, utilization, and price, adjusting for differences in patient characteristics and other market‐level traits. Results Insurance market concentration is inversely related to prices and spending, but positively related to utilization. Our results imply that, after adjusting for input price differences, a market with two equal size insurers is associated with 3.9 percent lower medical care spending per capita (p = .002) and 5.0 percent lower prices for health care services relative to one with three equal size insurers (p < .001). Conclusion Greater fragmentation in the insurance market might lead to higher prices and higher spending for care, suggesting some of the gains from insurer competition may be absorbed by higher prices for health care. Greater attention to prices and utilization in the provider market may need to accompany procompetitive insurance market strategies.

  December 05, 2013   doi: 10.1111/1475-6773.12131   open full text
• “Which Box Should I Check?”: Examining Standard Check Box Approaches to Measuring Race and Ethnicity.
  Abbey Eisenhower, Karen Suyemoto, Fernanda Lucchese, Katia Canenguez.
  Health Services Research. December 03, 2013
  Objective This study examined methodological concerns with standard approaches to measuring race and ethnicity using the federally defined race and ethnicity categories, as utilized in National Institutes of Health (NIH) funded research. Data Sources/Study Setting Surveys were administered to 219 economically disadvantaged, racially and ethnically diverse participants at Boston Women Infants and Children (WIC) clinics during 2010. Study Design We examined missingness and misclassification in responses to the closed‐ended NIH measure of race and ethnicity compared with open‐ended measures of self‐identified race and ethnicity. Principal Findings Rates of missingness were 26 and 43 percent for NIH race and ethnicity items, respectively, compared with 11 and 18 percent for open‐ended responses. NIH race responses matched racial self‐identification in only 44 percent of cases. Missingness and misclassification were disproportionately higher for self‐identified Latina(o)s, African‐Americans, and Cape Verdeans. Race, but not ethnicity, was more often missing for immigrant versus mainland U.S.‐born respondents. Results also indicated that ethnicity for Hispanic/Latina(o)s is more complex than captured in this measure. Conclusions The NIH's current race and ethnicity measure demonstrated poor differentiation of race and ethnicity, restricted response options, and lack of an inclusive ethnicity question. Separating race and ethnicity and providing respondents with adequate flexibility to identify themselves both racially and ethnically may improve valid operationalization.

  December 03, 2013   doi: 10.1111/1475-6773.12132   open full text
• Equity in Access to Health Care Services in Italy.
  Valeria Glorioso, S. V. Subramanian.
  Health Services Research. November 19, 2013
  Objective To provide new evidence on whether and how patterns of health care utilization deviate from horizontal equity in a country with a universal and egalitarian public health care system: Italy. Data Sources Secondary analysis of data from the Health Conditions and Health Care Utilization Survey 2005, conducted by the Italian National Institute of Statistics on a probability sample of the noninstitutionalized Italian population. Study Design Using multilevel logistic regression, we investigated how the probability of utilizing five health care services varies among individuals with equal health status but different SES. Data Collection/Extraction Respondents aged 18 or older at the interview time (n = 103,651). Principal Findings Overall, we found that use of primary care is inequitable in favor of the less well‐off, hospitalization is equitable, and use of outpatient specialist care, basic medical tests, and diagnostic services is inequitable in favor of the well‐off. Stratifying the analysis by health status, however, we found that the degree of inequity varies according to health status. Conclusions Despite its universal and egalitarian public health care system, Italy exhibits a significant degree of SES‐related horizontal inequity in health services utilization.

  November 19, 2013   doi: 10.1111/1475-6773.12128   open full text
• Efficiency of U.S. Dialysis Centers: An Updated Examination of Facility Characteristics That Influence Production of Dialysis Treatments.
  Sanatan Shreay, Martin Ma, Jill McCluskey, Ron C. Mittelhammer, Matthew Gitlin, J. Mark Stephens.
  Health Services Research. November 18, 2013
  Objective To explore the relative efficiency of dialysis facilities in the United States and identify factors that are associated with efficiency in the production of dialysis treatments. Data Sources/Study Setting Medicare cost report data from 4,343 free‐standing dialysis facilities in the United States that offered in‐center hemodialysis in 2010. Study Design A cross‐sectional, facility‐level retrospective database analysis, utilizing data envelopment analysis (DEA) to estimate facility efficiency. Data Collection/Extraction Methods Treatment data and cost and labor inputs of dialysis treatments were obtained from 2010 Medicare Renal Cost Reports. Demographic data were obtained from the 2010 U.S. Census. Principal Findings Only 26.6 percent of facilities were technically efficient. Neither the intensity of market competition nor the profit status of the facility had a significant effect on efficiency. Facilities that were members of large chains were less likely to be efficient. Cost and labor savings due to changes in drug protocols had little effect on overall dialysis center efficiency. Conclusions The majority of free‐standing dialysis facilities in the United States were functioning in a technically inefficient manner. As payment systems increasingly employ capitation and bundling provisions, these institutions will need to evaluate their efficiency to remain competitive.

  November 18, 2013   doi: 10.1111/1475-6773.12127   open full text
• Do Provider Service Networks Result in Lower Expenditures Compared with HMOs or Primary Care Case Management in Florida's Medicaid Program?
  Jeffrey S. Harman, Allyson G. Hall, Christy H. Lemak, R. Paul Duncan.
  Health Services Research. November 18, 2013
  Objective To determine the impact of Florida's Medicaid Demonstration 4 years post‐implementation on per member per month (PMPM) Medicaid expenditures and whether receiving care through HMOs versus provider service networks (PSNs) in the Demonstration was associated with PMPM expenditures. Data Florida Medicaid claims from two fiscal years prior to implementation of the Demonstration (FY0405, FY0506) and the first four fiscal years after implementation (FY0607‐FY0910) from two urban Demonstration counties and two urban non‐Demonstration counties. Study Design A difference‐in‐difference approach was used to compare changes in enrollee expenditures before and after implementation of the Demonstration overall and specifically for HMOs and PSNs. Data Extraction Claims data were extracted for enrollees in the Demonstration and non‐Demonstration counties and collapsed into monthly amounts (N = 26,819,987 person‐months). Principal Findings Among SSI enrollees, the Demonstration resulted in lower increases in PMPM expenditures over time ($40) compared with the non‐Demonstration counties ($186), with Demonstration PSNs lowering PMPM expenditures by $7 more than HMOs. Savings were also seen among TANF enrollees but to a lesser extent. Conclusions The Medicaid Demonstration in Florida appears to result in lower PMPM expenditures. Demonstration PSNs generated slightly greater reductions in expenditures compared to Demonstration HMOs. PSNs appear to be a promising model for delivering care to Medicaid enrollees.

  November 18, 2013   doi: 10.1111/1475-6773.12129   open full text
• Does Winning a Pay‐for‐Performance Bonus Improve Subsequent Quality Performance? Evidence from the Hospital Quality Incentive Demonstration.
  Andrew Ryan, Matthew Sutton, Tim Doran.
  Health Services Research. August 01, 2013
  Objective To test whether receiving a financial bonus for quality in the Premier Hospital Quality Incentive Demonstration (HQID) stimulated subsequent quality improvement. Data Hospital‐level data on process‐of‐care quality from Hospital Compare for the treatment of acute myocardial infarction (AMI), heart failure, and pneumonia for 260 hospitals participating in the HQID from 2004 to 2006; receipt of quality bonuses in the first 3 years of HQID from the Premier Inc. website; and hospital characteristics from the 2005 American Hospital Association Annual Survey. Study Design Under the HQID, hospitals received a 1 percent bonus on Medicare payments for scoring between the 80th and 90th percentiles on a composite quality measure, and a 2 percent bonus for scoring at the 90th percentile or above. We used a regression discontinuity design to evaluate whether hospitals with quality scores just above these payment thresholds improved more in the subsequent year than hospitals with quality scores just below the thresholds. In alternative specifications, we examined samples of hospitals scoring within 3, 5, and 10 percentage point “bandwidths” of the thresholds. We used a Generalized Linear Model to estimate whether the relationship between quality and lagged quality was discontinuous at the lagged thresholds required for quality bonuses. Principal Findings There were no statistically significant associations between receipt of a bonus and subsequent quality performance, with the exception of the 2 percent bonus for AMI in 2006 using the 5 percentage point bandwidth (0.8 percentage point increase, p < .01), and the 1 percent bonus for pneumonia in 2005 using all bandwidths (3.7 percentage point increase using the 3 percentage point bandwidth, p < .05). Conclusions We found little evidence that hospitals' receipt of quality bonuses was associated with subsequent improvement in performance. This raises questions about whether winning in pay‐for‐performance programs, such as Hospital Value‐Based Purchasing, will lead to subsequent quality improvement.

  August 01, 2013   doi: 10.1111/1475-6773.12097   open full text
• Health Care Utilization and Costs Associated with Adherence to Clinical Practice Guidelines for Early Magnetic Resonance Imaging among Workers with Acute Occupational Low Back Pain.
  Janessa M. Graves, Deborah Fulton‐Kehoe, Jeffrey G. Jarvik, Gary M. Franklin.
  Health Services Research. August 01, 2013
  Objective To estimate health care utilization and costs associated with adherence to clinical practice guidelines for the use of early magnetic resonance imaging (MRI; within the first 6 weeks of injury) for acute occupational low back pain (LBP). Data Sources Washington State Disability Risk Identification Study Cohort (D‐RISC), consisting of administrative claims and patient interview data from workers’ compensation claimants (2002–2004). Study Design In this prospective, population‐based cohort study, we compared health care utilization and costs among workers whose imaging was adherent to guidelines (no early MRI) to workers whose imaging was not adherent to guidelines (early MRI in the absence of red flags). Data Collection/Extraction Methods We identified workers (age >18) with work‐related LBP using administrative claims. We obtained demographic, injury, health, and employment information through telephone interviews to adjust for baseline differences between groups. We ascertained health care utilization and costs from administrative claims for 1 year following injury. Principal Findings Of 1,770 workers, 336 (19.0 percent) were classified as nonadherent to guidelines. Outpatient and physical/occupational therapy utilization was 52–54 percent higher for workers whose imaging was not adherent to guidelines compared to workers with guideline‐adherent imaging; utilization of chiropractic care was significantly lower (18 percent). Conclusions Nonadherence to guidelines for early MRI was associated with increased likelihood of lumbosacral injections or surgery and higher costs for out‐patient, inpatient, and nonmedical services, and disability compensation.

  August 01, 2013   doi: 10.1111/1475-6773.12098   open full text
• Geographic and Racial Disparities in Breast Cancer–Related Outcomes in Georgia.
  Talar W. Markossian, Robin B. Hines, Rana Bayakly.
  Health Services Research. August 01, 2013
  Objective To measure the effects of race/ethnicity, area measures of socioeconomic status (SES) and geographic residency status, and health care supply (HCS) characteristics on breast cancer (BC)‐related outcomes. Data Sources/Study Setting Female patients in Georgia diagnosed with BC in the years 2000–2009. Study Design Multilevel regression analysis with adjustment for variables at the county, census tract (CT), and individual level. The county represents the spatial unit of analysis for HCS. SES and geographic residency status were grouped at the CT level. Principal Findings Even after controlling for area‐level characteristics, racial and ethnic minority women suffered an unequal BC burden. Despite inferior outcomes for disease stage and receipt of treatment, Hispanics had a marginally significant decreased risk of death compared with non‐Hispanics. Higher CT poverty was associated with worse BC‐related outcomes. Residing in small, isolated rural areas increased the odds of receiving surgery, decreased the odds of receiving radiotherapy, and decreased the risk of death. A higher per‐capita availability of BC care physicians was significantly associated with decreased risk of death. Conclusions Race/ethnicity and area‐level measures of SES, geographic residency status, and HCS contribute to disparities in BC‐related outcomes.

  August 01, 2013   doi: 10.1111/1475-6773.12096   open full text
• Assessing Racial/Ethnic Disparities in Treatment across Episodes of Mental Health Care.
  Benjamin Lê Cook, Samuel H. Zuvekas, Nicholas Carson, Geoffrey Ferris Wayne, Andrew Vesper, Thomas G. McGuire.
  Health Services Research. July 16, 2013
  Objective To investigate disparities in mental health care episodes, aligning our analyses with decisions to start or drop treatment, and choices made during treatment. Study Design We analyzed whites, blacks, and Latinos with probable mental illness from Panels 9–13 of the Medical Expenditure Panel Survey, assessing disparities at the beginning, middle, and end of episodes of care (initiation, adequate care, having an episode with only psychotropic drug fills, intensity of care, the mixture of primary care provider (PCP) and specialist visits, use of acute psychiatric care, and termination). Findings Compared with whites, blacks and Latinos had less initiation and adequacy of care. Black and Latino episodes were shorter and had fewer psychotropic drug fills. Black episodes had a greater proportion of specialist visits and Latino episodes had a greater proportion of PCP visits. Blacks were more likely to have an episode with acute psychiatric care. Conclusions Disparities in adequate care were driven by initiation disparities, reinforcing the need for policies that improve access. Many episodes were characterized only by psychotropic drug fills, suggesting inadequate medication guidance. Blacks' higher rate of specialist use contradicts previous studies and deserves future investigation. Blacks' greater acute mental health care use raises concerns over monitoring of their treatment.

  July 16, 2013   doi: 10.1111/1475-6773.12095   open full text
• Adoption and Diffusion of Evidence‐Based Addiction Medications in Substance Abuse Treatment.
  Carolyn J. Heinrich, Grant R. Cummings.
  Health Services Research. July 16, 2013
  Objective To examine the roles of facility‐ and state‐level factors in treatment facilities' adoption and diffusion of pharmaceutical agents used in addiction treatment. Data Sources Secondary data from the National Survey of Substance Abuse Treatment Services (N‐SSATS), Substance Abuse and Mental Health Services Administration (SAMHSA), Centers for Medicare and Medicaid Services, Alcohol Policy Information System, and Kaiser Family Foundation. Study Design We estimate ordered logit and multinomial logit models to examine the relationship of state and treatment facility characteristics to the adoption and diffusion of three pharmaceutical agents over 4 years when each was at a different stage of adoption or diffusion. Data Collection N‐SSATS data with facility codes, obtained directly from SAMHSA, were linked by state identifiers to the other publicly available, secondary data. Principal Findings The analysis confirms the importance of awareness and exposure to the adoption behavior of others, dissemination of information about the feasibility and effectiveness of innovations, geographical clustering, and licensing and accreditation in legitimizing facilities' adoption and continued use of pharmacotherapies in addiction treatment. Conclusions Policy and administrative levers exist to increase the availability of pharmaceutical technologies and their continued use by substance abuse treatment facilities.

  July 16, 2013   doi: 10.1111/1475-6773.12093   open full text
• Generalizing Observational Study Results: Applying Propensity Score Methods to Complex Surveys.
  Eva H. DuGoff, Megan Schuler, Elizabeth A. Stuart.
  Health Services Research. July 16, 2013
  Objective To provide a tutorial for using propensity score methods with complex survey data. Data Sources Simulated data and the 2008 Medical Expenditure Panel Survey. Study Design Using simulation, we compared the following methods for estimating the treatment effect: a naïve estimate (ignoring both survey weights and propensity scores), survey weighting, propensity score methods (nearest neighbor matching, weighting, and subclassification), and propensity score methods in combination with survey weighting. Methods are compared in terms of bias and 95 percent confidence interval coverage. In Example 2, we used these methods to estimate the effect on health care spending of having a generalist versus a specialist as a usual source of care. Principal Findings In general, combining a propensity score method and survey weighting is necessary to achieve unbiased treatment effect estimates that are generalizable to the original survey target population. Conclusions Propensity score methods are an essential tool for addressing confounding in observational studies. Ignoring survey weights may lead to results that are not generalizable to the survey target population. This paper clarifies the appropriate inferences for different propensity score methods and suggests guidelines for selecting an appropriate propensity score method based on a researcher's goal.

  July 16, 2013   doi: 10.1111/1475-6773.12090   open full text
• State‐Level Unemployment and the Utilization of Preventive Medical Services.
  Nathan Tefft, Andrew Kageleiry.
  Health Services Research. July 16, 2013
  Objective To study the association between macroeconomic conditions and preventive medical service utilization. Data Sources/Study Setting Secondary data collection of a survey of the civilian, non‐institutionalized population of adults (age 18 and older) in the United States between 1987 and 2010. Study Design Regression analyses that adjust for individual‐level demographic and socioeconomic determinants, state and time‐fixed effects, and state‐specific time trends. Data Collection/Extraction Methods State health departments, with technological and methodological assistance from the Centers for Disease Control and Prevention, conducted a cross‐sectional yearly telephone survey using a standardized questionnaire. Principal Findings The use of preventive medical services is procyclical: a 1 percentage point increase in the state‐level unemployment rate is associated with a 1.58 percent decrease in the quantity of distinct preventive care services utilized. Women and economically disadvantaged populations are shown to be especially sensitive to macroeconomic fluctuations. Conclusions Policy makers should be aware of cyclical changes in preventive care use, particularly among disadvantaged populations, when making challenging budgetary decisions during economic downturns. As physician recommendations can have a strong impact on patients' use, health care providers could increase efforts to persuade patients to seek screening exams and necessary vaccinations during periods of high unemployment.

  July 16, 2013   doi: 10.1111/1475-6773.12091   open full text
• HIV Testing in the Nation's Opioid Treatment Programs, 2005–2011: The Role of State Regulations.
  Thomas D'Aunno, Harold A. Pollack, Lan Jiang, Lisa R. Metsch, Peter D. Friedmann.
  Health Services Research. July 16, 2013
  Objective To identify the extent to which clients in a national sample of opioid treatment programs (OTPs) received HIV testing in 2005 and 2011; to examine relationships between state laws for informed consent and pretest counseling and rates of HIV testing among OTP clients. Data Source Data were collected from a nationally representative sample of OTPs in 2005 (n = 171) and 2011 (n = 200). Study Design Random‐effects logit and interval regression analyses were used to examine changes in HIV testing rates and the relationship of state laws to HIV testing among OTPs. Data Collection Data on OTP provision of HIV testing were collected in phone surveys from OTP managers; data also were collected on state laws for HIV testing. Principal Findings The percentage of OTPs offering HIV testing decreased significantly from 93 percent in 2005 to 64 percent in 2011. Similarly, the percentage of clients tested decreased from an average of 41 percent in 2005 to 17 percent in 2011. OTPs located in states whose laws do not require pretest counseling and that use opt‐out consent were more likely to provide HIV testing and to test higher percentages of clients. Conclusions The results show the need to increase HIV testing among OTP clients; the results also underscore the beneficial possibilities of dropping pretest counseling as a requirement for HIV testing and of using the opt‐out approach to informed consent for testing.

  July 16, 2013   doi: 10.1111/1475-6773.12094   open full text
• Validation of Patient and Nurse Short Forms of the Readiness for Hospital Discharge Scale and Their Relationship to Return to the Hospital.
  Marianne E. Weiss, Linda L. Costa, Olga Yakusheva, Kathleen L. Bobay.
  Health Services Research. July 16, 2013
  Objective To validate patient and nurse short forms for discharge readiness assessment and their associations with 30‐day readmissions and emergency department (ED) visits. Data Sources/Study Setting A total of 254 adult medical‐surgical patients and their discharging nurses from an Eastern US tertiary hospital between May and November, 2011. Study Design Prospective longitudinal design, multinomial logistic regression analysis. Data Collection/Extraction Methods Nurses and patients independently completed an eight‐item Readiness for Hospital Discharge Scale on the day of discharge. Patient characteristics, readmissions, and ED visits were electronically abstracted. Principal Findings Nurse assessment of low discharge readiness was associated with a six‐ to nine‐fold increase in readmission risk. Patient self‐assessment was not associated with readmission; neither was associated with ED visits. Conclusions Nurse discharge readiness assessment should be added to existing strategies for identifying readmission risk.

  July 16, 2013   doi: 10.1111/1475-6773.12092   open full text
• Using the Bayesian Improved Surname Geocoding Method (BISG) to Create a Working Classification of Race and Ethnicity in a Diverse Managed Care Population: A Validation Study.
  Dzifa Adjaye‐Gbewonyo, Robert A. Bednarczyk, Robert L. Davis, Saad B. Omer.
  Health Services Research. July 16, 2013
  Objective To validate classification of race/ethnicity based on the Bayesian Improved Surname Geocoding method (BISG) and assess variations in validity by gender and age. Data Sources/Study Setting Secondary data on members of Kaiser Permanente Georgia, an integrated managed care organization, through 2010. Study Design For 191,494 members with self‐reported race/ethnicity, probabilities for belonging to each of six race/ethnicity categories predicted from the BISG algorithm were used to assign individuals to a race/ethnicity category over a range of cutoffs greater than a probability of 0.50. Overall as well as gender‐ and age‐stratified sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated. Receiver operating characteristic (ROC) curves were generated and used to identify optimal cutoffs for race/ethnicity assignment. Principal Findings The overall cutoffs for assignment that optimized sensitivity and specificity ranged from 0.50 to 0.57 for the four main racial/ethnic categories (White, Black, Asian/Pacific Islander, Hispanic). Corresponding sensitivity, specificity, PPV, and NPV ranged from 64.4 to 81.4 percent, 80.8 to 99.7 percent, 75.0 to 91.6 percent, and 79.4 to 98.0 percent, respectively. Accuracy of assignment was better among males and individuals of 65 years or older. Conclusions BISG may be useful for classifying race/ethnicity of health plan members when needed for health care studies.

  July 16, 2013   doi: 10.1111/1475-6773.12089   open full text
• Geographic Disparities in Mammography Capacity in the South: A Longitudinal Assessment of Supply and Demand.
  Jan M. Eberth, Karl Eschbach, Jeffrey S. Morris, Hoang T. Nguyen, Md Monir Hossain, Linda S. Elting.
  Health Services Research. July 05, 2013
  Objective Studies have shown that there is sufficient availability of mammography; however, little is known about geographic variation in capacity. The purpose of this study was to determine the locations and extent of over/undersupply of mammography in 14 southern states from 2002 to 2008. Data Sources Mammography facility data were collected from the U.S. Food and Drug Administration (FDA). Population estimates, used to estimate the potential demand for mammography, were obtained from GeoLytics Inc. Study Design Using the two‐step floating catchment area method, we calculated spatial accessibility at the block group level and categorized the resulting index to represent the extent of under/oversupply relative to the potential demand. Principal Findings Results show decreasing availability of mammography over time. The extent of over/undersupply varied significantly across the South. Reductions in capacity occurred primarily in areas with an oversupply of machines, resulting in a 68 percent decrease in the percent of women living in excess capacity areas from 2002 to 2008. The percent of women living in poor capacity areas rose by 10 percent from 2002 to 2008. Conclusions Our study found decreasing mammography availability and capacity over time, with substantial variation across states. This information can assist providers and policy makers in their business planning and resource allocation decisions.

  July 05, 2013   doi: 10.1111/1475-6773.12081   open full text
• Partial and Incremental PCMH Practice Transformation: Implications for Quality and Costs.
  Michael L. Paustian, Jeffrey A. Alexander, Darline K. El Reda, Chris G. Wise, Lee A. Green, Michael D. Fetters.
  Health Services Research. July 05, 2013
  Objective To examine the associations between partial and incremental implementation of the Patient Centered Medical Home (PCMH) model and measures of cost and quality of care. Data Source We combined validated, self‐reported PCMH capabilities data with administrative claims data for a diverse statewide population of 2,432 primary care practices in Michigan. These data were supplemented with contextual data from the Area Resource File. Study Design We measured medical home capabilities in place as of June 2009 and change in medical home capabilities implemented between July 2009 and June 2010. Generalized estimating equations were used to estimate the mean effect of these PCMH measures on total medical costs and quality of care delivered in physician practices between July 2009 and June 2010, while controlling for potential practice, patient cohort, physician organization, and practice environment confounders. Principal Findings Based on the observed relationships for partial implementation, full implementation of the PCMH model is associated with a 3.5 percent higher quality composite score, a 5.1 percent higher preventive composite score, and $26.37 lower per member per month medical costs for adults. Full PCMH implementation is also associated with a 12.2 percent higher preventive composite score, but no reductions in costs for pediatric populations. Incremental improvements in PCMH model implementation yielded similar positive effects on quality of care for both adult and pediatric populations but were not associated with cost savings for either population. Conclusions Estimated effects of the PCMH model on quality and cost of care appear to improve with the degree of PCMH implementation achieved and with incremental improvements in implementation.

  July 05, 2013   doi: 10.1111/1475-6773.12085   open full text
• Geographic Variations in the Cost of Treating Condition‐Specific Episodes of Care among Medicare Patients.
  James D. Reschovsky, Jack Hadley, A. James O'Malley, Bruce E. Landon.
  Health Services Research. July 05, 2013
  Objectives To measure geographic variations in treatment costs for specific conditions, explore the consistency of these patterns across conditions, and examine how service mix and population health factors are associated with condition‐specific and total area costs. Data Sources Medicare claims for 1.5 million elderly beneficiaries from 60 community tracking study (CTS) sites who received services from 5,500 CTS Physician Survey respondents during 2004–2006. Study Design Episodes of care for 10 costly and common conditions were formed using Episode Treatment Group grouper software. Episode and total annual costs were calculated, adjusted for price, patient demographics, and comorbidities. We correlated episode costs across sites and examined whether episode service mix and patient health were associated with condition‐specific and total per‐beneficiary costs. Principal Findings Adjusted episode costs varied from 34 to 68 percent between the most and least expensive site quintiles. Area mean costs were only weakly correlated across conditions. Hospitalization rates, surgery rates, and specialist involvement were associated with site episode costs, but local population health indicators were most related to site total per‐beneficiary costs. Conclusions Population health appears to drive local per‐beneficiary Medicare costs, whereas local practice patterns likely influence condition‐specific episode costs. Reforms should be flexible to address local conditions and practice patterns.

  July 05, 2013   doi: 10.1111/1475-6773.12087   open full text
• People and Teams Matter in Organizational Change: Professionals' and Managers' Experiences of Changing Governance and Incentives in Primary Care.
  Helen T. Allan, Sally Brearley, Richard Byng, Sara Christian, Julie Clayton, Maureen Mackintosh, Linnie Price, Pam Smith, Fiona Ross.
  Health Services Research. July 05, 2013
  Objectives To explore the experiences of governance and incentives during organizational change for managers and clinical staff. Study Setting Three primary care settings in England in 2006–2008. Study Design Data collection involved three group interviews with 32 service users, individual interviews with 32 managers, and 56 frontline professionals in three sites. The Realistic Evaluation framework was used in analysis to examine the effects of new policies and their implementation. Principal Findings Integrating new interprofessional teams to work effectively is a slow process, especially if structures in place do not acknowledge the painful feelings involved in change and do not support staff during periods of uncertainty. Conclusions Eliciting multiple perspectives, often dependent on individual occupational positioning or place in new team configurations, illuminates the need to incorporate the emotional as well as technocratic and system factors when implementing change. Some suggestions are made for facilitating change in health care systems. These are discussed in the context of similar health care reform initiatives in the United States.

  July 05, 2013   doi: 10.1111/1475-6773.12084   open full text
• Trends in PCI Volume after Negative Results from the COURAGE Trial.
  David H. Howard, Yu‐Chu Shen.
  Health Services Research. July 05, 2013
  Objective To describe trends in the use of percutaneous coronary intervention (PCI) following the COURAGE trial, which found that medical therapy is as effective as PCI for patients with stable angina. Data Sources We used the National Hospital Discharge Survey; inpatient and outpatient discharge data from Florida, Maryland, and New Jersey; and the English Hospital Episode Statistics database. Study Design We report trends in PCI volume by diagnosis (stable angina vs. unstable angina or AMI) before and after publication of the COURAGE trial. Principal Findings The number of PCIs in patients without a diagnosis of AMI or unstable angina in Florida, Maryland, and New Jersey declined from 48,000 in 2006 to 40,000 in 2008 (−17 percent). There was no change in the number of PCIs in patients with a diagnosis of AMI. We observed similar patterns in U.S. community hospitals. PCI volume did not decline in England. Conclusions PCI volume declined after publication of the COURAGE trial. The experience of the COURAGE trial suggests that comparative effectiveness research can lead to cost‐saving changes in medical practice patterns. However, there are many patients with stable coronary disease who continue to receive PCI post‐COURAGE.

  July 05, 2013   doi: 10.1111/1475-6773.12082   open full text
• Blending Group and Practice Site Scores to Increase the Reliability of Physician Quality Information.
  William H. Rogers, Kristy Thornton, Ted Glahn.
  Health Services Research. July 05, 2013
  Objective To use an empirical Bayesian approach, blending practice, and group quality data with physician results to increase the accuracy of quality of care measures. Data Sources Performance data on diabetes glycemic screening for 8,357 physicians collected from multiple payers as part of a statewide physician performance reporting initiative. Study Design A variance components analysis assessed the strength of group, practice, and physician effects compared with random error. We derived formulas to describe reliability and measurement error variances and calculated the optimal blend of physician, practice, and group data. We constructed a simulation to show what various methods can achieve. The value of blending strategies was assessed by simulating a common pay‐for‐performance criterion—performance in the top 25 percent. We estimated the proportion of physicians whose true percentage would place them in the top 20 percent but who would not receive payment based on the observed success rate. Principal Findings Blending reduced the error rate from 29.7 to 22.7 percent. Simpler empirical Bayes estimates using shrinkage alone produced no gains over simple doctor percentages. Conclusions When good structural data about physician groups and practices exist, gains from blending can be substantial.

  July 05, 2013   doi: 10.1111/1475-6773.12086   open full text
• Validity of Infant Race/Ethnicity from Birth Certificates in the Context of U.S. Demographic Change.
  Lisa Reyes Mason, Yunju Nam, Youngmi Kim.
  Health Services Research. July 05, 2013
  Objective To compare infant race/ethnicity based on birth certificates with parent report of infant race/ethnicity in a survey. Data Sources The 2007 Oklahoma birth certificates and SEED for Oklahoma Kids baseline survey. Study Design Using sensitivity scores and positive predictive values, we examined consistency of infant race/ethnicity across two data sources (N = 2,663). Data Collection/Extraction Methods We compared conventional measures of infant race/ethnicity from birth certificate and survey data. We also tested alternative measures that allow biracial classification, determined from parental information on the infant's birth certificate or parental survey report. Principal Findings Sensitivity of conventional measures is highest for whites and African Americans and lowest for Hispanics; positive predictive value is highest for Hispanics and African Americans and lowest for American Indians. Alternative measures improve values among whites but yield mostly low values among minority and biracial groups. Conclusions Health disparities research should consider the source and validity of infant race/ethnicity data when creating sampling frames or designing studies that target infants by race/ethnicity. The common practice of assigning the maternal race/ethnicity as infant race/ethnicity should continue to be challenged.

  July 05, 2013   doi: 10.1111/1475-6773.12083   open full text
• Racial and Ethnic Differences in Childhood Asthma Treatment in the United States.
  Eric M. Sarpong, G. Edward Miller.
  Health Services Research. June 26, 2013
  Objective To examine racial–ethnic differences in asthma controller medication use among insured U.S. children. Data Sources Linked nationally representative data from the Medical Expenditure Panel Survey (2005–2008), the 2000 Decennial Census, and the National Health Interview Survey (2004–2007). Study Design The study quantifies the portion of racial–ethnic differences in children's controller use that are attributable to differences in need, enabling and predisposing characteristics. Principal Findings Non‐Hispanic black and Hispanic children were less likely to use controllers than non‐Hispanic white children. Blinder‐Oaxaca decomposition results indicated that observable characteristics explain less than 40 percent of the overall differential in controller use between non‐Hispanic whites and non‐Hispanic blacks. In contrast, observable characteristics explain more than two‐thirds (71.3 percent) of the overall non‐Hispanic white‐Hispanic differential in controller use. For non‐Hispanic blacks, a majority of the explained differential in controller use were attributed to enabling characteristics. For Hispanics, a significant portion of the explained differential in controller use was attributed to predisposing characteristics. In addition, a larger portion of the differential in controller use was explained by observable characteristics for publicly insured non‐Hispanic black and Hispanic children. Conclusions The large observed differences in controller use highlight the continuing challenges of ensuring that all U.S. children have access to quality asthma care.

  June 26, 2013   doi: 10.1111/1475-6773.12077   open full text
• Incentivizing Primary Care Providers to Innovate: Building Medical Homes in the Post‐Katrina New Orleans Safety Net.
  Diane R. Rittenhouse, Laura A. Schmidt, Kevin J. Wu, James Wiley.
  Health Services Research. June 26, 2013
  Objective To evaluate safety‐net clinics’ responses to a novel community‐wide Patient‐Centered Medical Home (PCMH) financial incentive program in post‐Katrina New Orleans. Data Sources/Study Setting Between June 2008 and June 2010, we studied 50 primary care clinics in New Orleans receiving federal funds to expand services and improve care delivery. Study Design Multiwave, longitudinal, observational study of a local safety‐net primary care system. Data Collection Clinic‐level data from a semiannual survey of clinic leaders (89.3 percent response rate), augmented by administrative records. Principal Findings Overall, 62 percent of the clinics responded to financial incentives by achieving PCMH recognition from the National Committee on Quality Assurance (NCQA). Higher patient volume, higher baseline PCMH scores, and type of ownership were significant predictors of achieving NCQA recognition. The steepest increase in adoption of PCMH processes occurred among clinics achieving the highest, Level 3, NCQA recognition. Following NCQA recognition, 88.9 percent stabilized or increased their use of PCMH processes, although several specific PCMH processes had very low rates of adoption overall. Conclusions Findings demonstrate that widespread PCMH implementation is possible in a safety‐net environment when external financial incentives are aligned with the goal of practice innovation.

  June 26, 2013   doi: 10.1111/1475-6773.12080   open full text
• Nursing Home Quality and Financial Performance: Does the Racial Composition of Residents Matter?
  Latarsha Chisholm, Robert Weech‐Maldonado, Alex Laberge, Feng‐Chang Lin, Kathryn Hyer.
  Health Services Research. June 26, 2013
  Objective To examine the effects of the racial composition of residents on nursing homes’ financial and quality performance. The study examined Medicare and Medicaid‐certified nursing homes across the United States that submitted Medicare cost reports between the years 1999 and 2004 (11,472 average per year). Data Source Data were obtained from the Minimum Data Set, the On‐Line Survey Certification and Reporting, Medicare Cost Reports, and the Area Resource File. Study Design Panel data regression with random intercepts and negative binomial regression were conducted with state and year fixed effects. Principal Findings Financial and quality performance differed between nursing homes with high proportions of black residents and nursing homes with no or medium proportions of black residents. Nursing homes with no black residents had higher revenues and higher operating margins and total profit margins and they exhibited better processes and outcomes than nursing homes with high proportions of black residents. Conclusion Nursing homes’ financial viability and quality of care are influenced by the racial composition of residents. Policy makers should consider initiatives to improve both the financial and quality performance of nursing homes serving predominantly black residents.

  June 26, 2013   doi: 10.1111/1475-6773.12079   open full text
• Geographic Variation in Ambulatory Electronic Health Record Adoption: Implications for Underserved Communities.
  Jennifer King, Michael F. Furukawa, Melinda B. Buntin.
  Health Services Research. June 26, 2013
  Objective To describe small area variation in ambulatory electronic health record (EHR) adoption and assess evidence of a “digital divide” in whether adoption is lagging in traditionally underserved communities. Data Sources Survey data on U.S. ambulatory health care sites (261,973 sites representing 716,160 providers) collected by SK&A Information Services in 2011. Study Design We examined cross‐sectional variation in two measures of local area EHR adoption: share of providers at sites using an EHR with e‐prescribing functionality; and predicted probability of EHR adoption for the average site. Local areas were defined as Public Use Microdata Areas (n = 2,068). Using multivariate regression, we examined the association between adoption and three area characteristics: high concentration of minority population; high concentration of low‐income population; and metropolitan status. Principal Findings EHR adoption varied significantly across local areas, ranging from 8 to 88 percent with a median of 41 percent. Adoption was lower in large metropolitan areas; areas with high concentration of minority population in the Northeast and West; and areas with high concentration of low‐income population in the Midwest. Conclusions Our 2011 estimates suggest there was substantial room for increased EHR adoption across the United States, including some underserved areas with relatively low EHR adoption rates. Further research should monitor policy initiatives in these areas and examine sources of heterogeneity in low‐ and high‐adoption communities.

  June 26, 2013   doi: 10.1111/1475-6773.12078   open full text
• Plan–Provider Integration, Premiums, and Quality in the Medicare Advantage Market.
  Austin B. Frakt, Steven D. Pizer, Roger Feldman.
  Health Services Research. June 26, 2013
  Objective To investigate how integration between Medicare Advantage plans and health care providers is related to plan premiums and quality ratings. Data Source We used public data from the Centers for Medicare and Medicaid Services (CMS) and the Area Resource File and private data from one large insurer. Premiums and quality ratings are from 2009 CMS administrative files and some control variables are historical. Study Design We estimated ordinary least‐squares models for premiums and plan quality ratings, with state fixed effects and firm random effects. The key independent variable was an indicator of plan–provider integration. Data Collection With the exception of Medigap premium data, all data were publicly available. We ascertained plan–provider integration through examination of plans’ websites and governance documents. Principal Findings We found that integrated plan–providers charge higher premiums, controlling for quality. Such plans also have higher quality ratings. We found no evidence that integration is associated with more generous benefits. Conclusions Current policy encourages plan–provider integration, although potential effects on health insurance products and markets are uncertain. Policy makers and regulators may want to closely monitor changes in premiums and quality after integration and consider whether quality improvement (if any) justifies premium increases (if they occur).

  June 26, 2013   doi: 10.1111/1475-6773.12076   open full text
• How Medicare Part D Benefit Phases Affect Adherence with Evidence‐Based Medications Following Acute Myocardial Infarction.
  Bruce Stuart, Amy Davidoff, Mujde Erten, Stephen S. Gottlieb, Mingliang Dai, Thomas Shaffer, Ilene H. Zuckerman, Linda Simoni‐Wastila, Lynda Bryant‐Comstock, Rahul Shenolikar.
  Health Services Research. June 06, 2013
  Objective Assess impact of Medicare Part D benefit phases on adherence with evidence‐based medications after hospitalization for an acute myocardial infarction. Data Source Random 5 percent sample of Medicare beneficiaries. Study Design Difference‐in‐difference analysis of drug adherence by AMI patients stratified by low‐income subsidy (LIS) status and benefit phase. Data Collection/Extraction Methods Subjects were identified with an AMI diagnosis in Medicare Part A files between April 2006 and December 2007 and followed until December 2008 or death (N = 8,900). Adherence was measured as percent of days covered (PDC) per month with four drug classes used in AMI treatment: angiotensin‐converting enzyme (ACE) inhibitors/angiotensin II receptor blockers (ARBs), beta‐blockers, statins, and clopidogrel. Monthly exposure to Part D benefit phases was calculated from flags on each Part D claim. Principal Findings For non‐LIS enrollees, transitioning from the initial coverage phase into the Part D coverage gap was associated with statistically significant reductions in mean PDC for all four drug classes: statins (−7.8 percent), clopidogrel (−7.0 percent), beta‐blockers (−5.9 percent), and ACE inhibitor/ARBs (−5.1 percent). There were no significant changes in adherence associated with transitioning from the gap to the catastrophic coverage phase. Conclusions As the Part D doughnut hole is gradually filled in by 2020, Medicare Part D enrollees with critical diseases such as AMI who rely heavily on brand name drugs are likely to exhibit modest increases in adherence. Those reliant on generic drugs are less likely to be affected.

  June 06, 2013   doi: 10.1111/1475-6773.12073   open full text
• Malpractice Litigation and Nursing Home Quality of Care.
  R. Tamara Konetzka, Jeongyoung Park, Robert Ellis, Elmer Abbo.
  Health Services Research. June 06, 2013
  Objective To assess the potential deterrent effect of nursing home litigation threat on nursing home quality. Data Sources/Study Setting We use a panel dataset of litigation claims and Nursing Home Online Survey Certification and Reporting (OSCAR) data from 1995 to 2005 in six states: Florida, Illinois, Wisconsin, New Jersey, Missouri, and Delaware, for a total of 2,245 facilities. Claims data are from Westlaw's Adverse Filings database, a proprietary legal database, on all malpractice, negligence, and personal injury/wrongful death claims filed against nursing facilities. Study Design A lagged 2‐year moving average of the county‐level number of malpractice claims is used to represent the threat of litigation. We use facility fixed‐effects models to examine the relationship between the threat of litigation and nursing home quality. Principal Findings We find significant increases in registered nurse‐to‐total staffing ratios in response to rising malpractice threat, and a reduction in pressure sores among highly staffed facilities. However, the magnitude of the deterrence effect is small. Conclusions Deterrence in response to the threat of malpractice litigation is unlikely to lead to widespread improvements in nursing home quality. This should be weighed against other benefits and costs of litigation to assess the net benefit of tort reform.

  June 06, 2013   doi: 10.1111/1475-6773.12072   open full text
• Patient Experiences with Involuntary Out‐of‐Network Charges.
  Kelly A. Kyanko, Denise D. Pong, Kathleen Bahan, Leslie A. Curry.
  Health Services Research. June 06, 2013
  Background Approximately 40 percent of individuals using out‐of‐network physicians experience involuntary out‐of‐network care, leading to unexpected and sometimes burdensome financial charges. Despite its prevalence, research on patient experiences with involuntary out‐of‐network care is limited. Greater understanding of patient experiences may inform policy solutions to address this issue. Objective To characterize the experiences of patients who encountered involuntary out‐of‐network physician charges. Methods Qualitative study using 26 in‐depth telephone interviews with a semi‐structured interview guide. Participants were a purposeful sample of privately insured adults from across the United States who experienced involuntary out‐of‐network care. They were diverse with regard to income level, education, and health status. Recurrent themes were generated using the constant comparison method of data analysis by a multidisciplinary team. Results Four themes characterize the perspective of individuals who experienced involuntary out‐of‐network physician charges: (1) responsibilities and mechanisms for determining network participation are not transparent; (2) physician procedures for billing and disclosure of physician out‐of‐network status are inconsistent; (3) serious illness requiring emergency care or hospitalization precludes ability to choose a physician or confirm network participation; and (4) resources for mediation of involuntary charges once they occur are not available. Conclusions Our data reveal that patient education may not be sufficient to reduce the prevalence and financial burden of involuntary out‐of‐network care. Participants described experiencing involuntary out‐of‐network health care charges due to system‐level failures. As policy makers seek solutions, our findings suggest several potential areas of further consideration such as standardization of processes to disclose that a physician is out‐of‐network, holding patients harmless not only for out‐of‐network emergency room care but also for non‐elective hospitalization, and designation of a mediator for involuntary charges.

  June 06, 2013   doi: 10.1111/1475-6773.12071   open full text
• Global Comparators Project: International Comparison of Hospital Outcomes Using Administrative Data.
  Alex Bottle, Steven Middleton, Cor J. Kalkman, Edward H. Livingston, Paul Aylin.
  Health Services Research. June 06, 2013
  Objective To produce comparable risk‐adjusted outcome rates for an international sample of hospitals in a collaborative project to share outcomes and learning. Data Sources Administrative data varying in scope, format, and coding systems were pooled from each participating hospital for the years 2005–2010. Study Design Following reconciliation of the different coding systems in the various countries, in‐hospital mortality, unplanned readmission within 30 days, and “prolonged” hospital stay (>75th percentile) were risk‐adjusted via logistic regression. A web‐based interface was created to facilitate outcomes analysis for individual medical centers and enable peer comparisons. Small groups of clinicians are now exploring the potential reasons for variations in outcomes in their specialty. Principal Findings There were 6,737,211 inpatient records, including 214,622 in‐hospital deaths. Although diagnostic coding depth varied appreciably by country, comorbidity weights were broadly comparable. U.S. hospitals generally had the lowest mortality rates, shortest stays, and highest readmission rates. Conclusions Intercountry differences in outcomes may result from differences in the quality of care or in practice patterns driven by socio‐economic factors. Carefully managed administrative data can be an effective resource for initiating dialog between hospitals within and across countries. Inclusion of important outcomes beyond hospital discharge would increase the value of these analyses.

  June 06, 2013   doi: 10.1111/1475-6773.12074   open full text
• Implications of Metric Choice for Common Applications of Readmission Metrics.
  Sheryl Davies, Olga Saynina, Ellen Schultz, Kathryn M. McDonald, Laurence C. Baker.
  Health Services Research. June 06, 2013
  Objective To quantify the differential impact on hospital performance of three readmission metrics: all‐cause readmission (ACR), 3M Potential Preventable Readmission (PPR), and Centers for Medicare and Medicaid 30‐day readmission (CMS). Data Sources 2000–2009 California Office of Statewide Health Planning and Development Patient Discharge Data Nonpublic file. Study Design We calculated 30‐day readmission rates using three metrics, for three disease groups: heart failure (HF), acute myocardial infarction (AMI), and pneumonia. Using each metric, we calculated the absolute change and correlation between performance; the percent of hospitals remaining in extreme deciles and level of agreement; and differences in longitudinal performance. Principal Findings Average hospital rates for HF patients and the CMS metric were generally higher than for other conditions and metrics. Correlations between the ACR and CMS metrics were highest (r = 0.67–0.84). Rates calculated using the PPR and either ACR or CMS metrics were moderately correlated (r = 0.50–0.67). Between 47 and 75 percent of hospitals in an extreme decile according to one metric remained when using a different metric. Correlations among metrics were modest when measuring hospital longitudinal change. Conclusions Different approaches to computing readmissions can produce different hospital rankings and impact pay‐for‐performance. Careful consideration should be placed on readmission metric choice for these applications.

  June 06, 2013   doi: 10.1111/1475-6773.12075   open full text
• Do Changes in Hospital Outpatient Payments Affect the Setting of Care?
  Daifeng He, Jennifer M. Mellor.
  Health Services Research. May 23, 2013
  Objective To examine whether decreases in Medicare outpatient payment rates under the Outpatient Prospective Payment System (OPPS) caused outpatient care to shift toward the inpatient setting. Data Sources/Study Setting Hospital inpatient and outpatient discharge files from the Florida Agency for Health Care Administration from 1997 through 2008. Study Design This study focuses on inguinal hernia repair surgery, one of the most commonly performed surgical procedures in the United States. We estimate multivariate regressions of inguinal hernia surgery counts in the outpatient setting and in the inpatient setting. The key explanatory variable is the time‐varying Medicare payment rate specific to the procedure and hospital. Control variables include time‐varying hospital and county characteristics and hospital and year‐fixed effects. Principal Findings Outpatient hernia surgeries fell in response to OPPS‐induced rate cuts. The volume of inpatient hernia repair surgeries did not increase in response to reductions in the outpatient reimbursement rate. Conclusions Potential substitution from the outpatient setting to the inpatient setting does not pose a serious threat to Medicare's efforts to contain hospital outpatient costs.

  May 23, 2013   doi: 10.1111/1475-6773.12069   open full text
• An Empirical Comparison of Tree‐Based Methods for Propensity Score Estimation.
  Stephanie Watkins, Michele Jonsson‐Funk, M. Alan Brookhart, Steven A. Rosenberg, T. Michael O'Shea, Julie Daniels.
  Health Services Research. May 23, 2013
  Objective To illustrate the use of ensemble tree‐based methods (random forest classification [RFC] and bagging) for propensity score estimation and to compare these methods with logistic regression, in the context of evaluating the effect of physical and occupational therapy on preschool motor ability among very low birth weight (VLBW) children. Data Source We used secondary data from the Early Childhood Longitudinal Study Birth Cohort (ECLS‐B) between 2001 and 2006. Study Design We estimated the predicted probability of treatment using tree‐based methods and logistic regression (LR). We then modeled the exposure‐outcome relation using weighted LR models while considering covariate balance and precision for each propensity score estimation method. Principal Findings Among approximately 500 VLBW children, therapy receipt was associated with moderately improved preschool motor ability. Overall, ensemble methods produced the best covariate balance (Mean Squared Difference: 0.03–0.07) and the most precise effect estimates compared to LR (Mean Squared Difference: 0.11). The overall magnitude of the effect estimates was similar between RFC and LR estimation methods. Conclusion Propensity score estimation using RFC and bagging produced better covariate balance with increased precision compared to LR. Ensemble methods are a useful alterative to logistic regression to control confounding in observational studies.

  May 23, 2013   doi: 10.1111/1475-6773.12068   open full text
• Estimating Inpatient Hospital Prices from State Administrative Data and Hospital Financial Reports.
  Katharine R. Levit, Bernard Friedman, Herbert S. Wong.
  Health Services Research. May 13, 2013
  Objective To develop a tool for estimating hospital‐specific inpatient prices for major payers. Data Sources AHRQ Healthcare Cost and Utilization Project State Inpatient Databases and complete hospital financial reporting of revenues mandated in 10 states for 2006. Study Design Hospital discharge records and hospital financial information were merged to estimate revenue per stay by payer. Estimated prices were validated against other data sources. Principal Findings Hospital prices can be reasonably estimated for 10 geographically diverse states. All‐payer price‐to‐charge ratios, an intermediate step in estimating prices, compare favorably to cost‐to‐charge ratios. Estimated prices also compare well with Medicare, MarketScan private insurance, and the Medical Expenditure Panel Survey prices for major payers, given limitations of each dataset. Conclusions Public reporting of prices is a consumer resource in making decisions about health care treatment; for self‐pay patients, they can provide leverage in negotiating discounts off of charges. Researchers can also use prices to increase understanding of the level and causes of price differentials among geographic areas. Prices by payer expand investigational tools available to study the interaction of inpatient hospital price setting among public and private payers—an important asset as the payer mix changes with the implementation of the Affordable Care Act.

  May 13, 2013   doi: 10.1111/1475-6773.12065   open full text
• Trends in Racial Disparities for Injured Patients Admitted to Trauma Centers.
  Laurent G. Glance, Turner M. Osler, Dana B. Mukamel, J. Wayne Meredith, Yue Li, Feng Qian, Andrew W. Dick.
  Health Services Research. May 13, 2013
  Objective To determine whether outcome disparities between black and white trauma patients have decreased over the last 10 years. Data Source Pennsylvania Trauma Outcome Study. Study Design We performed an observational cohort study on 191,887 patients admitted to 28 Level 1 and Level II trauma centers. The main outcomes of interest were (1) death, (2) death or major complication, and (3) failure‐to‐rescue. Hospitals were categorized according to the proportion of black patients. Multivariate regression models were used to estimate trends in racial disparities and to assess whether the source of racial disparities was within or between hospitals. Principal Findings Trauma patients admitted to hospitals with high concentrations of blacks (>20 percent) had a 45 percent higher odds of death (adj OR: 1.45, 95 percent CI: 1.09–1.92) and a 73 percent higher odds of death or major complication (adj OR: 1.73, 95 percent CI: 1.42–2.11) compared with patients admitted to hospitals treating low proportions of blacks. Blacks and whites admitted to the same hospitals had no difference in mortality (adj OR: 1.05, 95 percent CI: 0.87, 1.27) or death or major complications (adj OR: 1.01; 95 percent CI: 0.90, 1.13). The odds of overall mortality, and death or major complications have been reduced by 32 percent (adj OR: 0.68; 95 percent CI: 0.54–0.86) and 28 percent (adj OR: 0.72; 95 percent CI: 0.60–0.85) between 2000 and 2009, respectively. Racial disparities did not change over 10 years. Conclusion Despite the overall improvement in outcomes, the gap in quality of care between black and white trauma patients in Pennsylvania has not narrowed over the last 10 years. Racial disparities in trauma are due to the fact that black patients are more likely to be treated in lower quality hospitals compared with whites.

  May 13, 2013   doi: 10.1111/1475-6773.12064   open full text
• Racial/Ethnic Differences in Receipt of Timely Adjuvant Therapy for Older Women with Breast Cancer: Are Delays Influenced by the Hospitals Where Patients Obtain Surgical Care?
  Rachel A. Freedman, Yulei He, Eric P. Winer, Nancy L. Keating.
  Health Services Research. May 13, 2013
  Objective To examine whether hospitals where patients obtain care explain racial/ethnic differences in treatment delay. Data Source Surveillance, Epidemiology, and End Results data linked with Medicare claims. Study Design We examined delays in adjuvant chemotherapy or radiation for women diagnosed with stage I–III breast cancer during 1992–2007. We used multivariable logistic regression to assess the probability of delay by race/ethnicity and included hospital fixed effects to assess whether hospitals explained disparities. Principal Findings Among 54,592 women, black (11.9 percent) and Hispanic (9.9 percent) women had more delays than whites (7.8 percent, p < .0001). After adjustment, black (vs. white) women had higher odds of delay (odds ratio = 1.25, 95 percent confidence interval = 1.10–1.42), attenuated somewhat by including hospital fixed effects (OR = 1.17, 95 percent CI = 1.02–1.33). Conclusions Hospitals are the important contributors to racial disparities in treatment delay.

  May 13, 2013   doi: 10.1111/1475-6773.12063   open full text
• Responses to Medicare Drug Costs among Near‐Poor versus Subsidized Beneficiaries.
  Vicki Fung, Mary Reed, Mary Price, Richard Brand, William H. Dow, Joseph P. Newhouse, John Hsu.
  Health Services Research. May 13, 2013
  Objective There is limited information on the protective value of Medicare Part D low‐income subsidies (LIS). We compared responses to drug costs for LIS recipients with near‐poor (≤200 percent of the Federal Poverty Level) and higher income beneficiaries without the LIS. Data Sources/Study Setting Medicare Advantage beneficiaries in 2008. Study Design We examined three drug cost responses using multivariate logistic regression: cost‐reducing behaviors (e.g., switching to generics), nonadherence (e.g., not refilling prescriptions), and financial stress (e.g., going without necessities). Data Collection Telephone interviews in a stratified random sample (N = 1,201, 70 percent response rate). Principal Findings After adjustment, a comparable percentage of unsubsidized near‐poor (26 percent) and higher income beneficiaries reported cost‐reducing behaviors (23 percent, p = .63); fewer LIS beneficiaries reported cost‐reducing behaviors (15 percent, p = .019 vs near‐poor). Unsubsidized near‐poor beneficiaries were more likely to reduce adherence (8.2 percent) than higher income (3.5 percent, p = .049) and LIS beneficiaries (3.1 percent, p = .027). Near‐poor beneficiaries also more frequently experienced financial stress due to drug costs (20 percent) than higher income beneficiaries (11 percent, p = .050) and LIS beneficiaries (11 percent, p = .015). Conclusions Low‐income subsidies provide protection from drug cost‐related nonadherence and financial stress. Beneficiaries just above the LIS income threshold are most at risk for these potentially adverse behaviors.

  May 13, 2013   doi: 10.1111/1475-6773.12062   open full text
• The Proportion of Work‐Related Emergency Department Visits Not Expected to Be Paid by Workers' Compensation: Implications for Occupational Health Surveillance, Research, Policy, and Health Equity.
  Matthew R. Groenewold, Sherry L. Baron.
  Health Services Research. May 13, 2013
  Objective To examine trends in the proportion of work‐related emergency department visits not expected to be paid by workers' compensation during 2003–2006, and to identify demographic and clinical correlates of such visits. Data Source A total of 3,881 work‐related emergency department visit records drawn from the 2003–2006 National Hospital Ambulatory Medical Care Surveys. Study Design Secondary, cross‐sectional analyses of work‐related emergency department visit data were performed. Odds ratios and 95 percent confidence intervals were modeled using logistic regression. Principal Findings A substantial and increasing proportion of work‐related emergency department visits in the United States were not expected to be paid by workers' compensation. Private insurance, Medicaid, Medicare, and workers themselves were expected to pay for 40 percent of the work‐related emergency department visits with this percentage increasing annually. Work‐related visits by blacks, in the South, to for‐profit hospitals and for work‐related illnesses were all more likely not to be paid by workers' compensation. Conclusions Emergency department‐based surveillance and research that determine work‐relatedness on the basis of expected payment by workers' compensation systematically underestimate the occurrence of occupational illness and injury. This has important methodological and policy implications.

  May 13, 2013   doi: 10.1111/1475-6773.12066   open full text
• The Disparate Impact of the ACA‐Dependent Expansion across Population Subgroups.
  Brett O'Hara, Matthew W. Brault.
  Health Services Research. May 13, 2013
  Objective This study presents evidence on how the dependent provision in the Affordable Care Act (ACA) differentially affected coverage for young adults across states and population subgroups. Study Design/Methods/Data The data derive from the American Community Survey. Using a difference‐in‐difference design, we compare the target population (ages 19–25) with a control group (ages 26–29). Principal Findings Net private health insurance coverage increased by 4.6 percentage points and overall coverage increased by 4.2 percentage points for people aged 19–25; more for Whites than non‐White subgroups. Conclusions and Implications Changes in coverage for states appear driven by demographics rather than the existence of prior dependent expansions by the state. Disparities in health care coverage remain, but the absolute level of coverage is improving.

  May 13, 2013   doi: 10.1111/1475-6773.12067   open full text
• Midwifery Care at a Freestanding Birth Center: A Safe and Effective Alternative to Conventional Maternity Care.
  Sarah Benatar, A. Bowen Garrett, Embry Howell, Ashley Palmer.
  Health Services Research. April 16, 2013
  Objective To estimate the effect of a midwifery model of care delivered in a freestanding birth center on maternal and infant outcomes when compared with conventional care. Data Sources/Study Setting Birth certificate data for women who gave birth in Washington D.C. and D.C. residents who gave birth in other jurisdictions. Study Design Using propensity score modeling and instrumental variable analysis, we compare maternal and infant outcomes among women who receive prenatal care from birth center midwives and women who receive usual care. We match on observable characteristics available on the birth certificate, and we use distance to the birth center as an instrument. Data Collection/Extraction Methods Birth certificate data from 2005 to 2008. Principal Findings Women who receive birth center care are less likely to have a C‐section, more likely to carry to term, and are more likely to deliver on a weekend, suggesting less intervention overall. While less consistent, findings also suggest improved infant outcomes. Conclusions For women without medical complications who are able to be served in either setting, our findings suggest that midwife‐directed prenatal and labor care results in equal or improved maternal and infant outcomes.

  April 16, 2013   doi: 10.1111/1475-6773.12061   open full text
• Medicare Payment Reform and Provider Entry and Exit in the Post‐Acute Care Market.
  Peter J. Huckfeldt, Neeraj Sood, John A. Romley, Alessandro Malchiodi, José J. Escarce.
  Health Services Research. April 05, 2013
  Objective To understand the impacts of Medicare payment reform on the entry and exit of post‐acute providers. Data Sources Medicare Provider of Services data, Cost Reports, and Census data from 1991 through 2010. Study Design We examined market‐level changes in entry and exit after payment reforms relative to a preexisting time trend. We also compared changes in high Medicare share markets relative to lower Medicare share markets and for freestanding relative to hospital‐based facilities. Data Extraction Methods We calculated market‐level entry, exit, and total stock of home health agencies, skilled nursing facilities, and inpatient rehabilitation facilities from Provider of Services files between 1992 and 2010. We linked these measures with demographic information from the Census and American Community Survey, information on Certificate of Need laws, and Medicare share of facilities in each market drawn from Cost Report data. Principal Findings Payment reforms reducing average and marginal payments reduced entries and increased exits from the market. Entry effects were larger and more persistent than exit effects. Entry and exit rates fluctuated more for home health agencies than skilled nursing facilities. Effects on number of providers were consistent with entry and exit effects. Conclusions Payment reform affects market entry and exit, which in turn may affect market structure, access to care, quality and cost of care, and patient outcomes. Policy makers should consider potential impacts of payment reforms on post‐acute care market structure when implementing these reforms.

  April 05, 2013   doi: 10.1111/1475-6773.12059   open full text
• Telephone Care Management's Effectiveness in Coordinating Care for Medicaid Beneficiaries in Managed Care: A Randomized Controlled Study.
  Sue E. Kim, Charles Michalopoulos, Richard M. Kwong, Anne Warren, Michelle S. Manno.
  Health Services Research. April 05, 2013
  Objective To test the effectiveness of a telephone care management intervention to increase the use of primary and preventive care, reduce hospital admissions, and reduce emergency department visits for Medicaid beneficiaries with disabilities in a managed care setting. Data Source Four years (2007–2011) of Medicaid claims data on blind and/or disabled beneficiaries, aged 20–64. Study Design Randomized control trial with an intervention group (n = 3,540) that was enrolled in managed care with telephone care management and a control group (n = 1,524) who remained in fee‐for‐service system without care management services. Multi‐disciplinary care coordination teams provided telephone services to the intervention group to address patients' medical and social needs. Data Collection/Extraction Medicaid claims and encounter data for all participants were obtained from the state and the managed care organization. Principal Findings There was no significant difference in use of primary care, specialist visits, hospital admissions, and emergency department between the intervention and the control group. Care managers experienced challenges in keeping members engaged in the intervention and maintaining contact by telephone. Conclusions The lack of success for Medicaid beneficiaries, along with other recent studies, suggests that more intensive and more targeted interventions may be more effective for the high‐needs population.

  April 05, 2013   doi: 10.1111/1475-6773.12060   open full text
• The Effect of Parity on Expenditures for Individuals with Severe Mental Illness.
  K. John McConnell.
  Health Services Research. April 05, 2013
  Objective To determine whether comprehensive behavioral health parity leads to changes in expenditures for individuals with severe mental illness (SMI), who are likely to be in greatest need for services that could be outside of health plans' traditional limitations on behavioral health care. Data Sources/Study Setting We studied the effects of a comprehensive parity law enacted by Oregon in 2007. Using claims data, we compared expenditures for individuals in four Oregon commercial plans from 2005 through 2008 to a group of commercially insured individuals in Oregon who were exempt from parity. Study Design We used difference‐in‐differences and difference‐in‐difference‐in‐differences analyses to estimate changes in spending, and quantile regression methods to assess changes in the distribution of expenditures associated with parity. Principal Findings Among 2,195 individuals with SMI, parity was associated with increased expenditures for behavioral health services of $333 (95 percent CI $67, $615), without corresponding increases in out‐of‐pocket spending. The increase in expenditures was primarily attributable to shifts in the right tail of the distribution. Conclusions Oregon's parity law led to higher average expenditures for individuals with SMI. Parity may allow individuals with high mental health needs to receive services that may have been limited without parity regulations.

  April 05, 2013   doi: 10.1111/1475-6773.12058   open full text
• Medicaid Bed‐Hold Policies and Hospitalization of Long‐Stay Nursing Home Residents.
  Mark Aaron Unruh, David C. Grabowski, Amal N. Trivedi, Vincent Mor.
  Health Services Research. March 23, 2013
  Objective To evaluate the effect of Medicaid bed‐hold policies on hospitalization of long‐stay nursing home residents. Data Sources A nationwide random sample of long‐stay nursing home residents with data elements from Medicare claims and enrollment files, the Minimum Data Set, the Online Survey Certification and Reporting System, and Area Resource File. The sample consisted of 22,200,089 person‐quarters from 754,592 individuals who became long‐stay residents in 17,149 nursing homes over the period beginning January 1, 2000 through December 31, 2005. Study Design Linear regression models using a pre/post design adjusted for resident, nursing home, market, and state characteristics. Nursing home and year‐quarter fixed effects were included to control for time‐invariant facility influences and temporal trends associated with hospitalization of long‐stay residents. Principal Findings Adoption of a Medicaid bed‐hold policy was associated with an absolute increase of 0.493 percentage points (95% CI: 0.039–0.946) in hospitalizations of long‐stay nursing home residents, representing a 3.883 percent relative increase over the baseline mean. Conclusions Medicaid bed‐hold policies may increase the likelihood of hospitalization of long‐stay nursing home residents and increase costs for the federal Medicare program.

  March 23, 2013   doi: 10.1111/1475-6773.12054   open full text
• Characterizing the Public's Preferential Attitudes Toward End‐of‐Life Care Options: A Role for the Threshold Technique?
  R. Trafford Crump, H. Llewellyn‐Thomas.
  Health Services Research. February 28, 2013
  Objectives To assess the Threshold Technique's (TT) feasibility in community‐wide surveys of U.S. Medicare beneficiaries' preferences for end‐of‐life (EOL) care options. Study Setting Study participants were community‐dwelling Medicare beneficiaries in four different regions in the United States. Study Design During personal interviews, participants considered four EOL scenarios, each presenting a choice between a less intense and more intense care option. Data Collection Participants selected their initially favored option. Depending on that choice, in the subsequent TT the length of life offered by the more intense option was systematically increased or decreased until the participant “switched” to his or her initially rejected option. Principal Findings Participants were able to select an initially favored option (in 3 of the 4 scenarios; this was the less intense option). The majority of participants were able to engage with the subsequent TT. In all scenarios, regardless of the increase/decrease in the length of life offered by the more intense option, the majority of participants were unwilling to “switch” to their initially rejected option. Conclusions In surveys of populations' preferential attitudes toward EOL care options, the TT was a feasible elicitation method, engaging most participants and measuring the strength of their attitudes. Further methodological work is merited, involving (1) populations with various participant characteristics, and (2) different attributes in the TT task itself.

  February 28, 2013   doi: 10.1111/1475-6773.12049   open full text
• Do Clinical Standards for Diabetes Care Address Excess Risk for Hypoglycemia in Vulnerable Patients? A Systematic Review.
  Seth A. Berkowitz, Katherine Aragon, Jonas Hines, Hilary Seligman, Sei Lee, Urmimala Sarkar.
  Health Services Research. February 28, 2013
  Objective To determine whether diabetes clinical standards consider increased hypoglycemia risk in vulnerable patients. Data Sources MEDLINE, the National Guidelines Clearinghouse, the National Quality Measures Clearinghouse, and supplemental sources. Study Design Systematic review of clinical standards (guidelines, quality metrics, or pay‐for‐performance programs) for glycemic control in adult diabetes patients. The primary outcome was discussion of increased risk for hypoglycemia in vulnerable populations. Data Collection/Extraction Methods Manuscripts identified were abstracted by two independent reviewers using prespecified inclusion/exclusion criteria and a standardized abstraction form. Principal Findings We screened 1,166 titles, and reviewed 220 manuscripts in full text. Forty‐four guidelines, 17 quality metrics, and 8 pay‐for‐performance programs were included. Five (11 percent) guidelines and no quality metrics or pay‐for‐performance programs met the primary outcome. Conclusions Clinical standards do not substantively incorporate evidence about increased risk for hypoglycemia in vulnerable populations.

  February 28, 2013   doi: 10.1111/1475-6773.12048   open full text
• Radiation Therapy Resources and Guideline‐Concordant Radiotherapy for Early‐Stage Breast Cancer Patients in an Underserved Region.
  Nengliang Yao, Stephen A. Matthews, Marianne M. Hillemeier, Roger T. Anderson.
  Health Services Research. February 28, 2013
  Objective To examine the relationship between radiation therapy resources and guideline‐concordant radiotherapy after breast‐conserving surgery (BCS) in Kentucky. Data Sources The SEER registry and Area Resource File provided county‐level data describing cancer care resources and socioeconomic conditions of Kentucky residents. Study Design The outcome variable was rate of BCS without radiotherapy in each county for 2000–2007. Eight‐year weighted average rates of radiation therapy providers and hospitals per 100,000 residents were explanatory variables of interest. Exploratory spatial data analyses and spatial econometric models were estimated. Principal Findings Appalachian counties in Kentucky had significantly fewer radiation oncologists, hospitals with radiation therapy facilities, and surgeons per 100,000 residents than non‐Appalachian counties. The likelihood of BCS without radiation was significantly higher among Appalachian compared to non‐Appalachian women (42.5 percent vs. 29.0 percent, p < .001). Higher proportions of women not receiving recommended radiotherapy after BCS were clustered in Eastern Kentucky around Lexington. This geographic disparity was partially explained by significantly fewer radiation therapy facilities in Appalachian Kentucky in adjusted analyses. Conclusions Scarce radiation therapy resources in Appalachian Kentucky are associated with disparities in receipt of guideline‐concordant radiotherapy, suggesting that policy action is needed to improve the cancer treatment infrastructure in disadvantaged mountainous areas.

  February 28, 2013   doi: 10.1111/1475-6773.12047   open full text
• Barriers to Use of Workers' Compensation for Patient Care at Massachusetts Community Health Centers.
  Lenore S. Azaroff, Letitia K. Davis, Robert Naparstek, Dean Hashimoto, James R. Laing, David H. Wegman.
  Health Services Research. February 28, 2013
  Objectives To examine barriers community health centers (CHCs) face in using workers' compensation insurance (WC). Data Sources/Study Setting Leadership of CHCs in Massachusetts. Study Design We used purposeful snowball sampling of CHC leaders for in‐depth exploration of reimbursement policies and practices, experiences with WC, and decisions about using WC. We quantified the prevalence of perceived barriers to using WC through a mail survey of all CHCs in Massachusetts. Data Collection/Extraction Methods Emergent coding was used to elaborate themes and processes related to use of WC. Numbers and percentages of survey responses were calculated. Principal Findings Few CHCs formally discourage use of WC, but underutilization emerged as a major issue: “We see an awful lot of work‐related injury, and I would say that most of it doesn't go through workers' comp.” Barriers include lack of familiarity with WC, uncertainty about work‐relatedness, and reliance on patients to identify work‐relatedness of their conditions. Reimbursement delays and denials lead patients and CHCs to absorb costs of services. Conclusion Follow‐up studies should fully characterize barriers to CHC use of WC and experiences in other states to guide system changes in CHCs and WC agencies. Education should target CHC staff and workers about WC.

  February 28, 2013   doi: 10.1111/1475-6773.12045   open full text
• Nursing Home Staffing Requirements and Input Substitution: Effects on Housekeeping, Food Service, and Activities Staff.
  John R. Bowblis, Kathryn Hyer.
  Health Services Research. February 28, 2013
  Objective To study the effect of minimum nurse staffing requirements on the subsequent employment of nursing home support staff. Data Sources Nursing home data from the Online Survey Certification and Reporting (OSCAR) System merged with state nurse staffing requirements. Study Design Facility‐level housekeeping, food service, and activities staff levels are regressed on nurse staffing requirements and other controls using fixed effect panel regression. Data Extraction Method OSCAR surveys from 1999 to 2004. Principal Findings Increases in state direct care and licensed nurse staffing requirements are associated with decreases in the staffing levels of all types of support staff. Conclusions Increased nursing home nurse staffing requirements lead to input substitution in the form of reduced support staffing levels.

  February 28, 2013   doi: 10.1111/1475-6773.12046   open full text
• Increased Risk of Death among Uninsured Neonates.
  Frank H. Morriss.
  Health Services Research. February 13, 2013
  Objective To estimate the contribution of health insurance status to the risk of death among hospitalized neonates. Data Sources Kids' Inpatient Databases (KID) for 2003, 2006, and 2009. Study Design KID 2006 subpopulation of neonatal discharges was analyzed by weighted frequency distribution and multivariable logistic regression analyses for the outcome of death, adjusted for insurance status and other variables. Multivariable linear regression analyses were conducted for the outcomes mean adjusted length of stay and hospital charges. The death analysis was repeated with KID 2003 and 2009. Principal Findings Of 4,318,121 estimated discharges in 2006, 5.4 percent were uninsured. There were 17,892 deaths; 9.5 percent were uninsured. The largest risks of death were five clinical conditions with adjusted odds ratios (AOR) of 13.7–3.1. Lack of insurance had an AOR of 2.6 (95 percent CI: 2.4, 2.8), greater than many clinical conditions; AOR estimates in alternate models were 2.1–2.7. Compared with insureds, uninsureds were less likely to have been admitted in transfer, more likely to have died in rural hospitals and to have received fewer resources. Similar death outcome results were observed for 2003 and 2009. Conclusions Uninsured neonates had decreased care and increased risk of dying.

  February 13, 2013   doi: 10.1111/1475-6773.12042   open full text
• Potential Bias in Medication Adherence Studies of Prevalent Users.
  Matthew L. Maciejewski, Chris L. Bryson, Virginia Wang, Mark Perkins, Chuan‐Fen Liu.
  Health Services Research. February 13, 2013
  Purpose We examined how the choice of historic medication use criteria for identifying prevalent users may bias estimated adherence changes associated with a medication copayment increase. Methods From pharmacy claims data in a retrospective cohort study, we identified 6,383 prevalent users of oral diabetes medications from four VA Medical Centers. Patients were included in this prevalent cohort if they had one fill both 3 months prior and 4–12 months prior to the index date, defined as the month in which medication copayments increased. To determine whether these historic medication use criteria introduced bias in the estimated response to a $5 medication copayment increase, we compared adherence trends from cohorts defined from different medication use criteria and from different index dates of copayment change. In an attempt to validate the prior observation of an upward trend in adherence prior to the date of the policy change, we replicated time series analyses varying the index dates prior to and following the date of the policy change, hypothesizing that the trend line associated with the policy change would differ from the trend lines that were not. Results Medication adherence trends differed when different medication use criteria were applied. Contrary to our expectations, similar adherence trends were observed when the same medication use criteria were applied at index dates when no copayment changes occurred. Conclusion To avoid introducing bias due to study design in outcomes assessments of medication policy changes, historic medication use inclusion criteria must be chosen carefully when constructing cohorts of prevalent users. Furthermore, while pharmacy data have enormous potential for population research and monitoring, there may be inherent logical flaws that limit cohort identification solely through administrative pharmacy records.

  February 13, 2013   doi: 10.1111/1475-6773.12043   open full text
• Using Common Random Numbers in Health Care Cost‐Effectiveness Simulation Modeling.
  Daniel R. Murphy, Robert W. Klein, Lee J. Smolen, Timothy M. Klein, Stephen D. Roberts.
  Health Services Research. February 13, 2013
  Objectives To identify the problem of separating statistical noise from treatment effects in health outcomes modeling and analysis. To demonstrate the implementation of one technique, common random numbers (CRNs), and to illustrate the value of CRNs to assess costs and outcomes under uncertainty. Methods A microsimulation model was designed to evaluate osteoporosis treatment, estimating cost and utility measures for patient cohorts at high risk of osteoporosis‐related fractures. Incremental cost‐effectiveness ratios (ICERs) were estimated using a full implementation of CRNs, a partial implementation of CRNs, and no CRNs. A modification to traditional probabilistic sensitivity analysis (PSA) was used to determine how variance reduction can impact a decision maker's view of treatment efficacy and costs. Results The full use of CRNs provided a 93.6 percent reduction in variance compared to simulations not using the technique. The use of partial CRNs provided a 5.6 percent reduction. The PSA results using full CRNs demonstrated a substantially tighter range of cost‐benefit outcomes for teriparatide usage than the cost‐benefits generated without the technique. Conclusions CRNs provide substantial variance reduction for cost‐effectiveness studies. By reducing variability not associated with the treatment being evaluated, CRNs provide a better understanding of treatment effects and risks.

  February 13, 2013   doi: 10.1111/1475-6773.12044   open full text
• The Effect of Pay‐for‐Performance in Nursing Homes: Evidence from State Medicaid Programs.
  Rachel M. Werner, R. Tamara Konetzka, Daniel Polsky.
  Health Services Research. February 10, 2013
  Objective Pay‐for‐performance (P4P) is commonly used to improve health care quality in the United States and is expected to be frequently implemented under the Affordable Care Act. However, evidence supporting its use is mixed with few large‐scale, rigorous evaluations of P4P. This study tests the effect of P4P on quality of care in a large‐scale setting—the implementation of P4P for nursing homes by state Medicaid agencies. Data Sources/Study Setting 2001–2009 nursing home Minimum Data Set and Online Survey, Certification, and Reporting (OSCAR) datasets. Study Design Between 2001 and 2009, eight state Medicaid agencies adopted P4P programs in nursing homes. We use a difference‐in‐differences approach to test for changes in nursing home quality under P4P, taking advantage of the variation in timing of implementation across these eight states and using nursing homes in the 42 non‐P4P states plus Washington, DC as contemporaneous controls. Principal Findings Quality improvement under P4P was inconsistent. While three clinical quality measures (the percent of residents being physically restrained, in moderate to severe pain, and developed pressure sores) improved with the implementation of P4P in states with P4P compared with states without P4P, other targeted quality measures either did not change or worsened. Of the two structural measures of quality that were tied to payment (total number of deficiencies and nurse staffing) deficiency rates worsened slightly under P4P while staffing levels did not change. Conclusions Medicaid‐based P4P in nursing homes did not result in consistent improvements in nursing home quality. Expectations for improvement in nursing home care under P4P should be tempered.

  February 10, 2013   doi: 10.1111/1475-6773.12035   open full text
• Disparities in Completion of Substance Abuse Treatment between and within Racial and Ethnic Groups.
  Erick G. Guerrero, Jeanne C. Marsh, Lei Duan, Christine Oh, Brian Perron, Benedict Lee.
  Health Services Research. January 27, 2013
  Objective To evaluate disparities in substance abuse treatment completion between and within racial and ethnic groups in publicly funded treatment in Los Angeles County, California. Data Source The Los Angeles County Participant Reporting System with multicross‐sectional annual data (2006–2009) for adult participants (n = 16,637) who received treatment from publicly funded programs (n = 276) for the first time. Study Design Retrospective analyses of county discharge and admission data. Hierarchical linear regressions models were used to test the hypotheses. Data Collection Client data were collected during personal interviews at admission and discharge for most participants. Principal Findings African Americans and Latinos reported lower odds of completing treatment compared with Whites. Within‐group analysis revealed significant heterogeneity within racial and ethnic groups, highlighting primary drug problem, days of drug use before admission, and homelessness as significant factors affecting treatment completion. Service factors, such as referral by the criminal justice system, enabled completion among Latinos and Whites only. Conclusions These findings have implications for reducing health disparities among members of racial and ethnic minorities by identifying individual and service factors associated with treatment adherence, particularly for first‐time clients.

  January 27, 2013   doi: 10.1111/1475-6773.12031   open full text
• An Examination of Pay‐for‐Performance in General Practice in Australia.
  Jessica Greene.
  Health Services Research. January 27, 2013
  Objective This study examines the impact of Australia's pay‐for‐performance (P4P) program for general practitioners (GPs). The voluntary program pays GPs A$40 and A$100 in addition to fee‐for‐service payment for providing patients recommended diabetes and asthma treatment over a year, and A$35 for screening women for cervical cancer who have not been screened in 4 years. Design Three approaches were used to triangulate the program's impact: (1) analysis of trends in national claims for incentivized services pre‐ and postprogram implementation; (2) fixed effects panel regression models examining the impact of GPs' P4P program participation on provision of incentivized services; and (3) in‐depth interviews to explore GPs' perceptions of their own response to the program. Results There was a short‐term increase in diabetes testing and cervical cancer screens after program implementation. The increase, however, was for all GPs. Neither signing onto the program nor claiming incentive payments was associated with increased diabetes testing or cervical cancer screening. GPs reported that the incentive did not influence their behavior, largely due to the modest payment and the complexity of tracking patients and claiming payment. Implications Monitoring and evaluating P4P programs is essential, as programs may not spark the envisioned impact on quality improvement.

  January 27, 2013   doi: 10.1111/1475-6773.12033   open full text
• Post‐Acute Care and ACOs — Who Will Be Accountable?
  J. Michael McWilliams, Michael E. Chernew, Alan M. Zaslavsky, Bruce E. Landon.
  Health Services Research. January 27, 2013
  Objective To determine how the inclusion of post‐acute evaluation and management (E&M) services as primary care affects assignment of Medicare beneficiaries to accountable care organizations (ACOs). Data Sources Medicare claims for a random 5 percent sample of 2009 Medicare beneficiaries linked to American Medical Association Group Practice data identifying provider groups sufficiently large to be eligible for ACO program participation. Study Design We calculated the fraction of community‐dwelling beneficiaries whose assignment shifted, as a consequence of including post‐acute E&M services, from the group providing their outpatient primary care to a different group providing their inpatient post‐acute care. Principal Findings Assignment shifts occurred for 27.6 percent of 25,992 community‐dwelling beneficiaries with at least one post‐acute skilled nursing facility stay, and they were more common for those incurring higher Medicare spending. Those whose assignment shifted constituted only 1.3 percent of all community‐dwelling beneficiaries cared for by large ACO‐eligible organizations (n = 535,138), but they accounted for 8.4 percent of total Medicare spending for this population. Conclusions Under current Medicare assignment rules, ACOs may not be accountable for an influential group of post‐acute patients, suggesting missed opportunities to improve care coordination and reduce inappropriate readmissions.

  January 27, 2013   doi: 10.1111/1475-6773.12032   open full text
• Association of Medicare Part D Medication Out‐of‐Pocket Costs with Utilization of Statin Medications.
  Pinar Karaca‐Mandic, Tami Swenson, Jean M. Abraham, Robert L. Kane.
  Health Services Research. December 26, 2012
  Objectives To examine the association between statin out‐of‐pocket (OOP) costs and utilization among the Medicare Part D population. Data Sources/Study Setting 2006–2008 administrative claims and enrollment data for the 5 percent Medicare sample. Study Design Sample included 346,583 beneficiary‐year observations of statin users enrolled in stand‐alone prescription drug plans, excluding low‐income subsidy recipients. We estimated the association between a plan's OOP statin costs and statin utilization using an instrumental variable approach to account for potential bias due to plan selection. Adherence was defined as percentage of days covered (PDC) of at least 80 percent. Plan OOP costs were constructed for a representative market basket of statin medications. Analyses controlled for demographic characteristics, cardiovascular disease risk, co‐morbidity presence, and regional characteristics. Principal Findings About 67 percent of the sample had a PDC of at least 80 percent. An increase in annual statin OOP from $200 (50th percentile) to $240 (75th percentile) was associated with a reduction in the rate of adherent beneficiaries from 67 percent to 56 percent (p < .001). Conclusions Greater OOP costs for statins are associated with reductions in statin utilization.

  December 26, 2012   doi: 10.1111/1475-6773.12022   open full text
• Effect of Medicaid Disease Management Programs on Emergency Admissions and Inpatient Costs.
  Matthew S. Conti.
  Health Services Research. December 26, 2012
  Objective To determine the impact of state Medicaid diabetes disease management programs on emergency admissions and inpatient costs. Data National InPatient Sample sponsored by the Agency for Healthcare Research and Quality Project for the years from 2000 to 2008 using 18 states. Study Design A difference‐in‐difference methodology compares costs and number of emergency admissions for Washington, Texas, and Georgia, which implemented disease management programs between 2000 and 2008, to states that did not undergo the transition to managed care (N = 103). Data Extraction Costs and emergency admissions were extracted for diabetic Medicaid enrollees diagnosed in the reform and non‐reform states and collapsed into state and year cells. Principal Findings In the three treatment states, the implementation of disease management programs did not have statistically significant impacts on the outcome variables when compared to the control states. Conclusions States that implemented disease management programs did not achieve improvements in costs or the number of emergency of admissions; thus, these programs do not appear to be an effective way to reduce the burden of this chronic disease.

  December 26, 2012   doi: 10.1111/1475-6773.12024   open full text
• Use of Emergency Departments among Working Age Adults with Disabilities: A Problem of Access and Service Needs.
  Elizabeth K. Rasch, Stephen P. Gulley, Leighton Chan.
  Health Services Research. December 26, 2012
  Objective To examine the relationship between emergency department (ED) use and access to medical care and prescription medications among working age Americans with disabilities. Data Source Pooled data from the 2006–2008 Medical Expenditure Panel Survey (MEPS), a U.S. health survey representative of community‐dwelling civilians. Study Design We compared the health and service utilization of two groups of people with disabilities to a contrast group without disability. We modeled ED visits on the basis of disability status, measures of health and health conditions, access to care, and sociodemographics. Data Extraction These variables were aggregated from the household component, the medical condition, and event files to provide average annual estimates for the period spanning 2006–2008. Principal Findings People with disabilities accounted for almost 40 percent of the annual visits made to U.S. EDs each year. Three key factors affect their ED use: access to regular medical care (including prescription medications), disability status, and the complexity of individuals’ health profiles. Conclusions Given the volume of health conditions among people with disabilities, the ED will always play a role in their care. However, some ED visits could potentially be avoided if ongoing care were optimized.

  December 26, 2012   doi: 10.1111/1475-6773.12025   open full text
• Serious Mental Illness and Nursing Home Quality of Care.
  Momotazur Rahman, David C. Grabowski, Orna Intrator, Shubing Cai, Vincent Mor.
  Health Services Research. December 26, 2012
  Objective To estimate the effect of a nursing home's share of residents with a serious mental illness (SMI) on the quality of care. Data Sources Secondary nursing home level data over the period 2000 through 2008 obtained from the Minimum Data Set, OSCAR, and Medicare claims. Study Design We employ an instrumental variables approach to address the potential endogeneity of the share of SMI residents in nursing homes in a model including nursing home and year fixed effects. Principal Findings An increase in the share of SMI nursing home residents positively affected the hospitalization rate among non‐SMI residents and negatively affected staffing skill mix and level. We did not observe a statistically significant effect on inspection‐based health deficiencies or the hospitalization rate for SMI residents. Conclusions Across the majority of indicators, a greater SMI share resulted in lower nursing home quality. Given the increased prevalence of nursing home residents with SMI, policy makers and providers will need to adjust practices in the context of this new patient population. Reforms may include more stringent preadmission screening, new regulations, reimbursement changes, and increased reporting and oversight.

  December 26, 2012   doi: 10.1111/1475-6773.12023   open full text
• Association between Traditional Nursing Home Quality Measures and Two Sources of Nursing Home Complaints.
  Jennifer L. Troyer, Wendy Sause.
  Health Services Research. December 06, 2012
  Objective To test for an association between traditional nursing home quality measures and two sources of resident‐ and caregiver‐derived nursing home complaints. Data Sources Nursing home complaints to the North Carolina Long‐Term Care Ombudsman Program and state certification agency from October 2002 through September 2006 were matched with Online Survey Certification and Reporting data and Minimum Data Set Quality Indicators (MDS‐QIs). Study Design We examine the association between the number of complaints filed against a facility and measures of inspection violations, staffing levels, and MDS‐QIs. Data Extraction One observation per facility per quarter is constructed by matching quarterly data on complaints to OSCAR data from the same or most recent prior quarter and to MDS‐QIs from the same quarter. One observation per inspection is obtained by matching OSCAR data to complaint totals from both the same and the immediate prior quarter. Principal Findings There is little relationship between MDS‐QIs and complaints. Ombudsman complaints and inspection violations are generally unrelated, but there is a positive relationship between state certification agency complaints and inspection violations. Conclusions Ombudsman and state certification agency complaint data are resident‐ and caregiver‐derived quality measures that are distinctive from and complement traditional quality measures.

  December 06, 2012   doi: 10.1111/1475-6773.12021   open full text
• Squeezing the Balloon: Propensity Scores and Unmeasured Covariate Balance.
  John M. Brooks, Robert L. Ohsfeldt.
  Health Services Research. December 06, 2012
  Objective To assess the covariate balancing properties of propensity score‐based algorithms in which covariates affecting treatment choice are both measured and unmeasured. Data Sources/Study Setting A simulation model of treatment choice and outcome. Study Design Simulation. Data Collection/Extraction Methods Eight simulation scenarios varied with the values placed on measured and unmeasured covariates and the strength of the relationships between the measured and unmeasured covariates. The balance of both measured and unmeasured covariates was compared across patients either grouped or reweighted by propensity scores methods. Principal Findings Propensity score algorithms require unmeasured covariate variation that is unrelated to measured covariates, and they exacerbate the imbalance in this variation between treated and untreated patients relative to the full unweighted sample. Conclusions The balance of measured covariates between treated and untreated patients has opposite implications for unmeasured covariates in randomized and observational studies. Measured covariate balance between treated and untreated patients in randomized studies reinforces the notion that all covariates are balanced. In contrast, forced balance of measured covariates using propensity score methods in observational studies exacerbates the imbalance in the independent portion of the variation in the unmeasured covariates, which can be likened to squeezing a balloon. If the unmeasured covariates affecting treatment choice are confounders, propensity score methods can exacerbate the bias in treatment effect estimates.

  December 06, 2012   doi: 10.1111/1475-6773.12020   open full text