To determine whether biennial eye evaluation or telemedicine screening are cost-effective alternatives to current recommendations for the estimated 10 million people aged 30–84 with diabetes but no or minimal diabetic retinopathy.
United Kingdom Prospective Diabetes Study, National Health and Nutrition Examination Survey, American Academy of Ophthalmology Preferred Practice Patterns, Medicare Payment Schedule.
Cost-effectiveness Monte Carlo simulation.
Data Collection/Extraction Methods
Literature review, analysis of existing surveys.
Biennial eye evaluation was the most cost-effective treatment option when the ability to detect other eye conditions was included in the model. Telemedicine was most cost-effective when other eye conditions were not considered or when telemedicine was assumed to detect refractive error. The current annual eye evaluation recommendation was costly compared with either treatment alternative. Self-referral was most cost-effective up to a willingness to pay (WTP) of U.S.$37,600, with either biennial or annual evaluation most cost-effective at higher WTP levels.
Annual eye evaluations are costly and add little benefit compared with either plausible alternative. More research on the ability of telemedicine to detect other eye conditions is needed to determine whether it is more cost-effective than biennial eye evaluation.
Cost-effectiveness; diabetes care; ophthalmology; telemedicine; simulation modeling
To design a bundled case rate for Collaborative Care for Depression (CCD) that aligns incentives with evidence-based depression care in primary care.
A clinical information system used by all care managers in a randomized controlled trial of CCD for older primary care patients.
We conducted an empirical investigation of factors accounting for variation in CCD resource use over time and across patients. CCD resource use at the patient-episode and patient-month levels was measured by number of care manager contacts and direct patient contact time and analyzed with count data (Poisson or negative binomial) models.
Episode-level resource use varies substantially with patient's time in the program. Monthly use declines sharply in the first 6 months regardless of treatment response or remission status, but it remains stable afterwards. An adjusted episode or monthly case rate design better matches payment with variation in resource use compared with a fixed design.
Our findings lend support to an episode payment adjusted by number of months receiving CCD and a monthly payment adjusted by the ordinal month. Nonpayment tools including program certification and performance evaluation and reward systems are needed to fully align incentives.
Collaborative Care for Depression; payment
To estimate the incidence of adverse drug events (ADEs) associated with health care visits among U.S. adults across all ambulatory settings.
We analyzed data from two nationally representative probability sample surveys: the National Ambulatory Medical Care Survey and the National Hospital and Ambulatory Medical Care Survey. From 2005 to 2007, the presence of an ADE was specifically defined, requested, and recorded in these surveys.
Secondary data analysis.
An estimated 13.5 million ADE-related visits occurred between 2005 and 2007 (0.5 percent of all visits), the large majority (72 percent) occurring in outpatient practice settings, and the remaining in emergency departments. Older patients (age ≥65 years) had the highest age-specific ADE rate, 3.8 ADEs per 10,000 persons per year. In adjusted analyses of outpatient visits, there was an increased odds of an ADE-related visit with increased medication burden (odds ratio [OR] for six to eight medications compared with no medications, OR 3.83 [2.20, 6.65]), and increased odds of ADEs associated with primary care visits compared with specialty visits (OR 2.22 [1.70, 2.89]).
Approximately 4.5 million ambulatory visits related to ADEs occur each year, the majority of these in outpatient office practices. A greater focus on ADE prevention and detection is warranted among patients receiving multiple medications in primary care practices.
Patient safety; adverse drug events; chronic illness
To assess relationships between changes in Medicare Advantage (MA) payment rates and Medicare beneficiary hospitalizations and to simulate the effects of scheduled payment cuts on ambulatory care sensitive (ACS) and elective hospitalization rates.
State Inpatient Database discharge abstracts from Arizona, Florida, and New York merged with administrative Medicare enrollment and MA payment data.
Retrospective, fixed effect regression analysis of the relationship between MA payment rates and rates of ACS and elective hospitalizations among Medicare beneficiaries in counties with at least 10,000 Medicare beneficiaries and 3 percent MA penetration from 1999 to 2005.
MA payment rates were negatively related to rates of ACS admissions. Simulations suggest that payment cuts could be associated with higher rates of ACS admissions. No relationship between MA payments and rates of elective hospitalizations was found.
Reductions in MA payment rates may result in a small increase in ACS admissions. Trends in ACS admissions among chronically ill Medicare beneficiaries should be tracked following MA payment cuts.
Medicare Advantage; payments; hospitalization rates; managed care; quality
To assess whether connections between physicians based on shared patients in administrative data correspond with professional relationships between physicians.
Data Sources/Study Setting
Survey of physicians affiliated with a large academic and community physicians' organization and 2006 Medicare data from a 100 percent sample of patients in the Boston Hospital referral region.
Study Design/Data Collection
We administered a web-based survey to 616 physicians (response rate: 63 percent) about referral and advice relationships with physician colleagues. Relationships measured by this questionnaire were compared with relationships assessed by patient sharing, measured using 2006 Medicare data. Each physician was presented with an individualized roster of physicians' names with whom they did and did not share patients based on the Medicare data.
The probability of two physicians having a recognized professional relationship increased with the number of Medicare patients shared, with up to 82 percent of relationships recognized with nine shared patients, overall representing a diagnostic test with an area under the receiver-operating characteristic curve of 0.73 (95 percent CI: 0.70–0.75). Primary care physicians were more likely to recognize relationships than medical or surgical specialists (p<.001).
Patient sharing identified using administrative data is an informative “diagnostic test” for predicting the existence of relationships between physicians. This finding validates a method that can be used for future research to map networks of physicians.
Physician networks; physician referral; health care systems; network analysis
To assess the value of a novel composite measure for identifying the best hospitals for major procedures.
We used national Medicare data for patients undergoing 5 high risk surgical procedures between 2005 and 2008.
For each procedure, we used empirical Bayes techniques to create a composite measure combining hospital volume, risk-adjusted mortality with the procedure of interest, risk-adjusted mortality with other related procedures, and other variables. Hospitals were ranked based on 2005–06 data and placed in one of 3 groups: 1-star (bottom 20%), 2-star (middle 60%), and 3-star (top 20%). We assessed how well these ratings forecasted risk-adjusted mortality rates in the next two years (2007–08), compared to other measures.
For all 5 procedures, the composite measures based on 2005–06 data performed well in predicting future hospital performance. Compared to 1-star hospitals, risk-adjusted mortality was much lower at 3-star hospitals for esophagectomy (6.7% vs. 14.4%), pancreatectomy (4.7% vs. 9.2%), coronary artery bypass surgery (2.6% vs. 5.0%), aortic valve replacement (4.5% vs. 8.5%), and percutaneous coronary interventions (2.4% vs. 4.1%). Compared to individual surgical quality measures, the composite measures were better at forecasting future risk-adjusted mortality. These measures also outperformed the Center for Medicare and Medicaid Services (CMS) Hospital Compare ratings.
Composite measures of surgical quality are very effective at predicting hospital mortality rates with major procedures. Such measures would be more informative than existing quality indicators in helping patients and payers identify high quality hospitals with specific procedures.
To test the hypothesis that more stringent quality regulations contribute to better quality nursing home care and to assess their cost-effectiveness.
Primary and secondary data from all states and U.S. nursing homes in 2005–2006.
We estimated seven models, regressing quality measures on the Harrington Regulation Stringency Index and control variables. To account for endogeneity between regulation and quality, we used instrumental variables techniques. Quality was measured by staffing hours by type per case-mix adjusted day, hotel expenditures, and risk-adjusted decline in activities of daily living, high-risk pressure sores, and urinary incontinence.
All states' licensing and certification offices were surveyed to obtain data about deficiencies. Secondary data included the Minimum Data Set, Medicare Cost Reports, and the Economic Freedom Index.
Regulatory stringency was significantly associated with better quality for four out of the seven measures studied. The cost-effectiveness for the ADL measure was estimated at about $72,000 in 2011 $/QALY.
Quality regulations lead to better quality in nursing homes along some dimensions, but not all. Our estimates of cost-effectiveness suggest that increased regulatory stringency is in the ballpark of other acceptable cost-effective practices.
nursing homes; quality of care; regulation; cost-effectiveness; comparative effectiveness
To determine the extent to which hospitals vary in the use of intensive care, and the proportion of variation attributable to differences in hospital practice that is independent of known patient and hospital factors.
Hospital discharge data in the State Inpatient Database for Maryland and Washington states in 2006.
Cross sectional analysis of 90 short-term acute, care hospitals with critical care capabilities.
We quantified the proportion of variation in intensive care use attributable to hospitals using intraclass correlation coefficients derived from mixed effects logistic regression models after successive adjustment for known patient and hospital factors.
The proportion of hospitalized patients admitted to an ICU across hospitals ranged from 3% to 55% (median 12%; IQR:9, 17%). After adjustment for patient factors, 19.7% (95%CI: 15.1, 24.4) of total variation in ICU use across hospitals was attributable to hospitals. When observed hospital characteristics were added, the proportion of total variation in intensive care use attributable to unmeasured hospital factors decreased by 26% to 14.6% (95% CI:11, 18.3%).
Wide variability exists in the use of intensive care across hospitals, not attributable to known patient or hospital factors, and may be a target to improve efficiency and quality of critical care.
intensive care; critical illness; variation; hospitals
To characterize patterns of Emergency Medical Technician (EMT) partner familiarity in three Emergency Medical Services (EMS) agencies.
Study Design/Data Sources
We utilized a case study design and retrospective review of administrative data from three EMS agencies and 182 EMTs over 12 months. We used the Kruskal–Wallis test and Bonferroni corrected p-values to compare measures of partner familiarity. Measures included the annual mean number of partners, rate of partners per 10 shifts, mean shifts per EMT, and proportion of shifts worked with same partner. We standardized select measures by size of agency to account for a greater number of possible partnerships in larger agencies.
Across all agencies, the mean number of shifts worked annually by EMTs was (mean [SD]) 77.3 (59.8). The unstandardized mean number of EMT partnerships was 19.3 (12.4) and did not vary across EMS agencies after standardizing by agency size (p = .328). The unstandardized mean rate of EMT partnerships for every 10 shifts worked was 4.0 (2.7) and varied across agencies after standardizing (p<.001). The mean proportion of shifts worked with the same partner was 34.8 percent and varied across agencies (p<.001).
There was wide variation in select measures of EMT partner familiarity.
Emergency Medical Services; partnerships; teamwork
In disparities models, researchers adjust for differences in “clinical need,” including indicators of comorbidities. We reconsider this practice, assessing (1) if and how having a comorbidity changes the likelihood of recognition and treatment of mental illness; and (2) differences in mental health care disparities estimates with and without adjustment for comorbidities.
Longitudinal data from 2000 to 2007 Medical Expenditure Panel Survey (n = 11,083) split into pre and postperiods for white, Latino, and black adults with probable need for mental health care.
First, we tested a crowd-out effect (comorbidities decrease initiation of mental health care after a primary care provider [PCP] visit) using logistic regression models and an exposure effect (comorbidities cause more PCP visits, increasing initiation of mental health care) using instrumental variable methods. Second, we assessed the impact of adjustment for comorbidities on disparity estimates.
We found no evidence of a crowd-out effect but strong evidence for an exposure effect. Number of postperiod visits positively predicted initiation of mental health care. Adjusting for racial/ethnic differences in comorbidities increased black–white disparities and decreased Latino–white disparities.
Positive exposure findings suggest that intensive follow-up programs shown to reduce disparities in chronic-care management may have additional indirect effects on reducing mental health care disparities.
Access/demand/utilization of services; mental health; racial/ethnic differences in health and health care
To measure 3-year medication possession ratios (MPRs) for renin–angiotensin–aldosterone system (RAAS) inhibitors and statins for Medicare beneficiaries with diabetes, and to assess whether better adherence is associated with lower spending on traditional Medicare services controlling for biases common to previous adherence studies.
Medicare Current Beneficiary Survey data from 1997 to 2005.
Longitudinal study of RAAS-inhibitor and statin utilization over 3 years.
The relationship between MPR and Medicare costs was tested in multivariate models with extensive behavioral variables to control for indication bias and healthy adherer bias.
Over 3 years, median MPR values were 0.88 for RAAS-I users and 0.77 for statin users. Higher adherence was strongly associated with lower Medicare spending in the multivariate analysis. A 10 percentage point increase in statin MPR was associated with U.S.$832 lower Medicare spending (SE=219; p<.01). A 10 percentage point increase in MPR for RAAS-Is was associated with U.S.$285 lower Medicare costs (SE=114; p<.05).
Higher adherence with RAAS-Is and statins by Medicare beneficiaries with diabetes results in lower cumulative Medicare spending over 3 years. At the margin, Medicare savings exceed the cost of the drugs.
Diabetes; Medicare; medication adherence; cost offsets
Estimate the lifetime cost of dementia to Medicare and Medicaid.
1997–2005 Medicare Current Beneficiary Survey
A multi-stage analysis was conducted to first predict the probability of developing dementia by age, and then predict the annual Medicare/Medicaid expenditures conditional on dementia status. A cohort-based simulation was conducted to estimate the lifetime cost of dementia.
The average lifetime cost of dementia per patient for Medicare is approximately $12,000 (2005 dollars) and for Medicaid about $11,000. Dementia onset at older age leads to shorter duration and lower lifetime cost. Increased educational level leads to longer longevity, more dementia cases per cohort, but shorter duration, and lower lifetime cost per patient that could offset the cost increase induced by more dementia cases. Increased BMI leads to more dementia cases per cohort, and higher lifetime cost per patient.
Net cost of dementia is lower than the estimates from cross-sectional studies. Promoting healthy lifestyle to reverse the obesity epidemic is short term priority to confront the epidemic of dementia in the near future. Promoting higher education among younger generation is long term priority to mitigate the effect of population aging on dementia epidemic in the distant future.
To assess nonresponse bias in a mixed-mode general population health survey.
Secondary analysis of linked survey sample frame and administrative data including demographic and health-related information.
The survey was administered by mail with telephone follow-up to non-respondents after two mailings. To determine if an additional mail contact or mode switch reduced nonresponse bias, we compared all respondents (N-3437) to respondents from each mailing and telephone respondents to the sample frame (N=6716).
Switching modes did not minimize the under-representation of younger people, non-whites, those with congestive heart failure, high users of office-based services, and low-utilizers of the emergency room but did reduce the over-representation of older adults.
Multiple contact and mixed mode surveys may increase response rates, but do not necessarily reduce nonresponse bias.
Health survey methods; Mixed-mode survey; Mailed survey; Telephone survey; Nonresponse bias
To assess the effects of hospital volume of very low birth weight (VLBW) infants on in-hospital mortality of VLBW and very preterm birth (VPB) infants in South America. Data sources/study setting: Birth registry data for infants born in 1982–2008 at VLBW or very preterm in 66 hospitals in Argentina, Brazil and Chile.
Regression analyses that adjust for several individual-level demographic, socioeconomic and health factors, hospital-level characteristics, and country fixed effects are employed. Data collection/extraction methods: Physicians interviewed mothers before hospital discharge and abstracted hospital medical records using similar methods at all hospitals.
Volume has significant non-linear beneficial effects on VLBW and VPB in-hospital survival. The largest survival benefits – more than 80% decrease in mortality rates – are with volume increases from low to medium or medium-high levels (from ≤ 25 to 72 infants annually) with significantly lower incremental benefits thereafter. The cumulative volume effects are maximized at the 121–144 annual VLBW infant range – about 90% decrease in mortality rates compared to <25 VLBW infants annually.
Increasing the access of pregnancies at-risk of VLBW and VPB to medium or high volume hospitals up to 144 VLBW infants per year may substantially improve in-hospital infant survival in the study countries.
To estimate the impact of deductibles on the initiation and continuation of psychotherapy for depression.
Data sources/study setting
Data from health care encounters and claims from Group Health Cooperative a large integrated health care system in Washington State was merged with information from a centralized behavioral health triage call center to conduct study analyses.
A retrospective observational design using a hierarchical logistic regression model was used to estimate initiation and continuation probabilities for use of psychotherapy adjusting for key socio-demographic/economic factors and prior use of behavioral health services relevant to individual decisions to seek mental health care.
Data collection/extraction methods
Analyses were based on merged data sets on patient enrollment, insurance benefits, use of mental health and general medical services and information collected by a triage specialist at a centralized behavioral health call center
Among individuals with unmet deductibles between $100 and $500, we found a statistically significant lower likelihood of making an initial visit but there was no statistically significant effect on making an initial or subsequent visit among individuals that had met their deductible.
Unmet deductibles appear to influence the likelihood of initiating psychotherapy for treating depression.
Deductibles; Psychotherapy; Depression
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.
Between 2001 and 2009 8 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.
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 to 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.
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.
Quality of care; pay-for-performance; nursing home quality; long-term care
To analyze the relationships between illicit drug use and three types of health services utilization: emergency room utilization, hospitalization, and medical attention required due to injury(s).
Waves 1 and 2 (11,253 males and 13,059 females) from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC).
We derive benchmark estimates by employing standard cross-sectional data models to pooled waves of NESARC data. To control for potential bias due to time-invariant unobserved individual heterogeneity, we reestimate the relationships with fixed-effects models.
The cross-sectional data models suggest that illicit drug use is positively and significantly related to health services utilization in almost all specifications. Conversely, the only significant (p<.05) relationships in the fixed-effects models are the odds of receiving medical attention for an injury and the number of injuries requiring medical attention for men, and the number of times hospitalized for men and women.
Failing to control for time-invariant individual heterogeneity could lead to biased coefficients when estimating the effects of illicit drug use on health services utilization. Moreover, it is important to distinguish between types of drug user (casual versus heavy) and estimate gender-specific models.
Illicit drug use; health services utilization; fixed-effects analysis
To estimate the effect of two separate policy changes in the North Carolina Medicaid program: (1) reduced prescription lengths from 100 to 34 days' supply, and (2) increased copayments for brand name medications.
Data Sources/Study Setting
Medicaid claims data were obtained from the Centers for Medicare and Medicaid Services for January 1, 2000–December 31, 2002.
We used a pre–post controlled partial difference-in-difference-in-differences design to examine the effect of the policy change on adults in North Carolina; adult Medicaid recipients from Georgia served as controls. Outcomes examined include medication adherence and Medicaid expenditures.
Data Collection/Extraction Methods
Data were aggregated to the person-quarter level. Individuals in HMOs, nursing homes, pregnant, or deceased in the quarter were excluded.
Both policies decreased medication adherence. The days' supply policy had a much larger effect on adherence than did the copayment increase. Total Medicaid spending declined from the days' supply policy, but the copayment policy resulted in a net increase in Medicaid expenditures.
Although Medicaid costs decreased with the change in days supply policy, these savings were due to reduced adherence to these chronic medications. Additional research should examine the effect of these policy changes from the perspective of Medicaid enrollees.
Medicaid; prescription drugs; chronic medications; days' supply
To link data from a central cancer registry with Medicaid enrollment and claims files in order to assess cancer care in an economically disadvantaged population.
Over 500,000 cancer patients diagnosed between 2002 and 2006 reported to the New York State Cancer Registry were linked with New York State Medicaid enrollment and claims records.
A probabilistic linkage was performed between the two data sources. The resulting Medicaid and non-Medicaid populations were compared in terms of demographics and stage at diagnosis.
Data Collection Methods
Existing databases were used.
One-quarter of cancer patients were enrolled in Medicaid at or near the time of cancer diagnosis. The Medicaid cohort was younger, more likely to be an ethnic minority, foreign born, never married, live in either an inner-city or remote rural area, and have a higher stage at diagnosis.
The linked dataset will permit detailed analysis of cancer treatment and cancer treatment disparities among historically understudied groups. The linkage has also resulted in improvements in Cancer Registry quality through the identification of errors and missing values. The linkage did present technical challenges in the form of immense file sizes not easily adaptable to desktop computers.
Data linkage; cancer registration; Medicaid; economically disadvantaged populations
To profile hospitals by survival rates of colorectal cancer patients in multiple periods after initial treatment.
California Cancer Registry data from 50,544 patients receiving primary surgery with curative intent for stage I–III colorectal cancer in 1994–1998, supplemented with hospital discharge abstracts.
We estimated a single Bayesian hierarchical model to quantify associations of survival to 30 days, 30 days to 1 year, and 1–5 years by hospital, adjusted for patient age, sex, race, stage, tumor site, and comorbidities. We compared two profiling methods for 30-day survival and four longer-term profiling methods by the fractions of hospitals with demonstrably superior survival profiles and of hospital pairs whose relative standings could be established confidently.
Interperiod correlation coefficients of the random effects are (95 percent credible interval 0.27, 0.85), (0.20, 0.76), and (0.19, 0.82). The three-period model ranks 5.4 percent of pairwise comparisons by 30-day survival with at least 95 percent confidence, versus 3.3 percent of pairs using a single-period model, and 15–20 percent by weighted multiperiod methods.
The quality of care for colorectal cancer provided by a hospital system is somewhat consistent across the immediate postoperative and long-term follow-up periods. Combining mortality profiles across longer periods may improve the statistical reliability of outcome comparisons.
Cancer care; colorectal cancer; provider profiling; quality measurement; Bayesian inference
To examine the association between dialysis facility chain affiliation and patient mortality.
Medicare dialysis population.
Data from the United States Renal Data System (USRDS) were used to identify 3,601 free-standing dialysis facilities and 34,914 Medicare patients' incidence to end-stage renal disease (ESRD) in 2004. Mixed-effect regression models were used to estimate patient mortality by dialysis facility chain and profit status during the 2-year follow-up.
USRDS data were matched with facility, cost, and census data.
Of the five largest dialysis chains, the lowest mortality risk was observed among patients dialyzed at nonprofit (NP) Chain 5 facilities. Compared with Chain 5, hazard ratios were 19 percent higher (95 percent CI 1.06–1.34) and 24 percent higher (95 percent CI 1.10–1.40) for patients dialyzed at for-profit (FP) Chain 1 and Chain 2 facilities, respectively. In addition, patients at FP facilities had a 13 percent higher risk of mortality than those in NP facilities (95 percent CI 1.06–1.22).
Large chain affiliation is an independent risk factor for ESRD mortality in the United States. Given the movement toward further consolidation of large FP chains, reasons behind the increase in mortality require scrutiny.
Dialysis facility; mortality; chain; profit
To assess whether distance to services or diagnosis at a hospital-based medical center compared with a community clinic influences the receipt of psychotherapy versus pharmacotherapy for depression.
Veterans Affairs (VA) administrative data for 132,329 depressed veterans between October 2003 and September 2004.
Multivariable logistic and multinomial regression models were used to examine the relationship between distance to the nearest mental health facility and the facility of initial depression diagnosis on receipt of any and adequate psychotherapy and/or pharmacotherapy, adjusted for patient characteristics.
Compared with those living within 30 miles of the nearest mental health treatment facility, depressed patients living between 30 and 60 miles away had a decreased likelihood of receiving psychotherapy (OR = 0.71; 95 percent CI: 0.66, 0.76) and a greater likelihood of receiving antidepressant treatment (OR = 1.27; 95 percent CI: 1.22, 1.33). Initial diagnosis at a small community clinic compared with a VA medical center was not associated with a difference in receipt of any psychotherapy (OR = 0.95; 95 percent CI: 0.83, 1.09), but it was associated with decreased likelihood of receiving eight or more psychotherapy visits (OR = 0.46; 95 percent CI: 0.35, 0.61) or any antidepressant treatment (OR = 0.69; 95 percent CI: 0.63, 0.75).
The VA and similar health systems should make efforts to insure adequate psychotherapy is provided to patients who initiate treatment at small community clinics and provide psychotherapy alternatives that may be less sensitive to travel barriers for patients living remote distances from mental health treatment. Extending services to small community clinics that support antidepressant treatment should also be considered.
Access; geographic; psychotherapy; antidepressant; services
To determine if racial/ethnic disparities in colonoscopy use vary by physician availability.
We used 100% Texas Medicare claims data for 2003–2007.
We identified beneficiaries aged 66–79 in 2007, examined racial/ethnic differences in colonoscopy use from 2003–2007, and estimated the percentage of white, black, and Hispanic beneficiaries who underwent colonoscopy by level of physician availability and area income.
For the 974,879 beneficiaries, colonoscopy use was higher in whites (40.7%) compared to blacks (35.0%) and Hispanics (28.7%, P<0.001). For whites, increasing availability of colonoscopists and primary care physicians (PCPs) was associated with higher colonoscopy use. For blacks and Hispanics, colonoscopy use was unchanged or decreased with increases in colonoscopist and PCP availability. In multilevel models, the odds of colonoscopy were 20% lower for blacks (OR 0.80, 95% CI 0.79–0.82) and 32% lower for Hispanics (OR 0.68, 95% CI 0.66–0.69) compared to whites; adjusting for availability of colonoscopists or PCPs did not attenuate racial/ethnic disparities. We found greater racial/ethnic disparities in areas with greater colonoscopist and PCP availability.
Greater area availability of colonoscopists and PCPs is associated with increased use of colonoscopy in whites but decreased use in minorities, resulting in larger racial/ethnic disparities.
Colorectal Cancer; Cancer Screening Tests; Health Care Disparities; Primary Care Physicians; Colonoscopy
To examine the association between nursing home (NH) work environment attributes such as teams, consistent assignment and staff cohesion and the risk of pressure ulcers and incontinence.
Minimum Data Set for 46,044 residents in 162 facilities in New York State, for June 2006-July 2007, and survey responses from 7,418 workers in the same facilities.
For each individual and facility primary and secondary data were linked. Random effects logistic models were used to develop/validate outcome measures. GEE models with robust standard errors and probability weights were employed to examine the association between outcomes and work environment attributes. Key independent variables were: staff cohesion, percent staff in daily-care teams, and percent staff with consistent assignment. Other facility factors were also included.
Residents in facilities with worse staff cohesion had significantly greater odds of pressure ulcers and incontinence, compared to residents in facilities with better cohesion scores. Residents in facilities with greater penetration of self-managed teams had lower risk of pressure ulcers, but not of incontinence. Prevalence of consistent assignment was not significantly associated with the outcome measures.
NH environments and management practices influence residents' health outcomes. These findings provide important lessons for administrators and regulators interested in promoting NH quality improvement.
nursing homes; health outcomes; staff cohesion; teams; consistent assignment