Catálogo de publicaciones - revistas

<jats:title>Abstract</jats:title><jats:sec><jats:title>Objective</jats:title><jats:p>To estimate whether those enrolled in the Veterans Health Administration (VHA) were less likely to use VHA‐delivered colorectal cancer screening colonoscopies after the MISSION Act.</jats:p></jats:sec><jats:sec><jats:title>Data Sources and Study Setting</jats:title><jats:p>Secondary data were collected on VHA‐enrolled Veterans from FY2017–FY2021.</jats:p></jats:sec><jats:sec><jats:title>Study Design</jats:title><jats:p>This retrospective cross‐sectional study measured the volume and share of screening colonoscopies that were VHA‐delivered over time and by drive time eligibility—defined as living more than 60 min away from the nearest VHA specialty‐care clinic. We used a multivariable logistic regression to adjust for patient and facility factors.</jats:p></jats:sec><jats:sec><jats:title>Data Extraction</jats:title><jats:p>Data were extracted for VHA enrollees (<jats:italic>n</jats:italic> = 773,766) who underwent a screening colonoscopy either performed or purchased by the VHA from FY2017–FY2021.</jats:p></jats:sec><jats:sec><jats:title>Principal Findings</jats:title><jats:p>In the 9 months after the implementation of the MISSION Act, and before the onset of the Covid‐19 pandemic, the average monthly VHA‐share of screening colonoscopies decreased by 3 percentage points (pp; 95% confidence interval [CI] = [−4 to −2 pp]) for the non‐drive time eligible group and it decreased by 16 pp (95% CI = [−22 to −9 pp]) for the drive time eligible group. The total number of screening colonoscopies did not significantly change in either group during this time period. After adjusting for patient characteristics, a linear time trend, and parent facility fixed effects, implementation of the MISSION Act was associated with a reduction in the probability of a VHA‐delivered screening colonoscopy (average marginal effect [AME]: −2.5 pp; 95% CI = [−5.1 to 0.0 pp]) for the non‐drive time eligible group. The drive time eligible group (AME: −9.4 pp; 95% CI = [−13.2 to −5.5 pp]) experienced a larger change.</jats:p></jats:sec><jats:sec><jats:title>Conclusions</jats:title><jats:p>The VHA‐share of screening colonoscopies among VHA enrollees fell in the 9 months immediately after the passage of the MISSION Act. This decline was larger for VHA enrollees who were targeted for eligibility due to a longer drive time. These results suggest that the MISSION Act led to more VHA‐purchased care among targeted VHA enrollees, though it is unclear whether total utilization increased.</jats:p></jats:sec>

<jats:title>Abstract</jats:title><jats:sec><jats:title>Objective</jats:title><jats:p>Social risks complicate patients' ability to manage their conditions and access healthcare, but their association with health expenditures is not well established. To identify patient‐reported social risk, behavioral, and health factors associated with health expenditures in Veterans Affairs (VA) patients at high risk for hospitalization or death.</jats:p></jats:sec><jats:sec><jats:title>Data Sources, Study Setting, and Study Design</jats:title><jats:p>Prospective cohort study among high‐risk Veterans obtaining VA care. Patient‐reported social risk, function, and other measures derived from a 2018 survey sent to 10,000 VA patients were linked to clinical and demographic characteristics extracted from VA data. Response‐weighted generalized linear and marginalized two‐part models were used to examine VA expenditures (total, outpatient, medication, inpatient) 1 year after survey completion in adjusted models.</jats:p></jats:sec><jats:sec><jats:title>Principal Findings</jats:title><jats:p>Among 4680 survey respondents, the average age was 70.9 years, 6.3% were female, 16.7% were African American, 20% had body mass index ≥35, 42.4% had difficulty with two or more basic or instrumental activities of daily living, 19.3% reported transportation barriers, 12.5% reported medication insecurity and 21.8% reported food insecurity. Medication insecurity was associated with lower outpatient expenditures (−$1859.51 per patient per year, 95% confidence interval [CI]: −3200.77 to −518.25) and lower total expenditures (−$4304.99 per patient per year, 95% CI: −7564.87 to −1045.10). Transportation barriers were negatively associated with medication expenditures (−$558.42, 95% CI: −1087.93 to −31.91). Patients with one functional impairment had higher outpatient expenditures ($2997.59 per patient year, 95% CI: 1185.81–4809.36) than patients without functional impairments. No social risks were associated with inpatient expenditures.</jats:p></jats:sec><jats:sec><jats:title>Conclusions</jats:title><jats:p>In this study of VA patients at high risk for hospitalization and mortality, few social and functional measures were independently associated with the costs of VA care. Individuals with functional limitations and those with barriers to accessing medications and transportation may benefit from targeted interventions to ensure that they are receiving the services that they need.</jats:p></jats:sec>

<jats:title>Abstract</jats:title><jats:sec><jats:title>Objective</jats:title><jats:p>To describe insurance patterns and discontinuity during pregnancy, which may affect the experiences of the pregnant person: their timely access to care, continuity of care, and health outcomes.</jats:p></jats:sec><jats:sec><jats:title>Data Sources and Study Setting</jats:title><jats:p>Data are from the PROMISE study, which utilizes data from community‐based health care organizations (CHCOs) (e.g., federally qualified health centers that serve patients regardless of insurance status or ability to pay) in the United States from 2005 to 2021.</jats:p></jats:sec><jats:sec><jats:title>Study Design</jats:title><jats:p>This descriptive study was a cohort utilizing longitudinal electronic health record data.</jats:p></jats:sec><jats:sec><jats:title>Data Collection/Extraction Methods</jats:title><jats:p>Insurance type at each encounter was recorded in the clinical database and coded as Private, Public, and Uninsured. Pregnant people were categorized into one of several insurance patterns. We analyzed the frequency and timing of insurance changes and care utilization within each group.</jats:p></jats:sec><jats:sec><jats:title>Principal Findings</jats:title><jats:p>Continuous public insurance was the most common insurance pattern (69.2%), followed by uninsured/public discontinuity (11.8%), with 6.4% experiencing uninsurance throughout the entirety of pregnancy. Insurance discontinuity was experienced by 16.6% of pregnant people; a majority of these reflect people transitioning to public insurance. Those with continuous public insurance had the highest frequency of inadequate prenatal care (19.5%), while those with all three types of insurance during pregnancy had the highest percentage of intensive prenatal care (16.5%). The majority (71.7%–81.2%) of those with a discontinuous pattern experienced a single insurance change.</jats:p></jats:sec><jats:sec><jats:title>Conclusions</jats:title><jats:p>Insurance discontinuity and uninsurance are common within our population of pregnant people seeking care at CHCOs. Our findings suggest that insurance status should be regarded as a dynamic rather than a static characteristic during pregnancy and should be measured accordingly. Future research is needed to assess the drivers of perinatal insurance discontinuity and if and how these discontinuities may affect health care access, utilization, and birth outcomes.</jats:p></jats:sec>

<jats:title>Abstract</jats:title><jats:sec><jats:title>Objective</jats:title><jats:p>Test hypotheses that proximity to new transit improves substance use disorder treatment provider cost efficiency (i.e., economies of scale and scope).</jats:p></jats:sec><jats:sec><jats:title>Data Sources and Study Setting</jats:title><jats:p>Connecticut substance uses disorder treatment providers/programs. A 2015 rapid transit line opening with 10 stations, near some providers/programs. Providers' annual operating costs from publicly available federal tax forms (2013–2018). Annual client counts, service‐type (including substance use disorder and/or mental health, among others), and location data, for 50 providers and their programs, from Department of Mental Health and Addiction Services, with an unbalanced panel of 285 provider‐years.</jats:p></jats:sec><jats:sec><jats:title>Study Design</jats:title><jats:p>Economies of scale occur when the percent change in operating costs is less than the percentage change in clients. Economies of scope occur when operating costs fall as providers treat clients with multiple service needs. With our quasi‐experimental, multivariate regressions approach, we test hypotheses that proximity to a new transit line enhances economies of scale and scope (i.e., lowers unit operating costs).</jats:p></jats:sec><jats:sec><jats:title>Data Collection/Extraction Methods</jats:title><jats:p>Annual provider‐level operating costs merged with new transit station locations and Department of Mental Health and Addiction Services program/provider‐level secondary data (locations, client counts/completions/dates, service types, and average demographics).</jats:p></jats:sec><jats:sec><jats:title>Principal Findings</jats:title><jats:p>For providers with programs within 1‐mile of new transit (compared with a “control” sample beyond 1‐mile of new transit), (i) a 10% increase in clients leads to a 0.12% lower operating costs per client; (ii) a 10% increase in clients completing treatment results in a 1.5% decrease in operating costs per client; (iii) a 10% increase in clients receiving treatment for multiple services causes a 0.81% lower operating costs per client; (iv) offering multiple services leads to 6.3% lower operating costs.</jats:p></jats:sec><jats:sec><jats:title>Conclusions</jats:title><jats:p>New transit proximity causes operating cost savings for substance use disorder/mental health treatment providers. System alignment may benefit transit and health care sectors.</jats:p></jats:sec>

<jats:title>Abstract</jats:title><jats:sec><jats:title>Objective</jats:title><jats:p>The study aimed to assess whether individuals with Alzheimer's disease and related dementias (ADRD) experience restricted access to hospitals' high‐volume preferred skilled nursing facility (SNF) partners.</jats:p></jats:sec><jats:sec><jats:title>Data Sources</jats:title><jats:p>The data source includes acute care hospital to SNF transitions identified using 100% Medicare Provider Analysis and Review files, 2017–2019.</jats:p></jats:sec><jats:sec><jats:title>Study Design</jats:title><jats:p>We model and compare the estimated effect of facility “preferredness” on SNF choice for patients with and without ADRD. We use conditional logistic regression with a 1:1 patient sample otherwise matched on demographic and encounter characteristics.</jats:p></jats:sec><jats:sec><jats:title>Data Collection</jats:title><jats:p>Our matched sample included 58,190 patients, selected from a total observed population of 3,019,260 Medicare hospitalizations that resulted in an SNF transfer between 2017 and 2019.</jats:p></jats:sec><jats:sec><jats:title>Principal Findings</jats:title><jats:p>Overall, patients with ADRD have a lower probability of being discharged to a preferred SNF (52.0% vs. 54.4%, <jats:italic>p</jats:italic> &lt; 0.001). Choice model estimation using our matched sample suggests similarly that the marginal effect of preferredness on a patient choosing a proximate SNF is 2.4 percentage points lower for patients with ADRD compared with those without (<jats:italic>p</jats:italic> &lt; 0.001). The differential effect of preferredness based on ADRD status increases when considering (a) the cumulative effect of multiple SNFs in close geographic proximity, (b) the magnitude of the strength of hospital‐SNF relationship, and (c) comparing patients with more versus less advanced ADRD.</jats:p></jats:sec><jats:sec><jats:title>Conclusions</jats:title><jats:p>Preferred relationships are significantly predictive of where a patient receives SNF care, but this effect is weaker for patients with ADRD. To the extent that these high‐volume relationships are indicative of more targeted transitional care improvements from hospitals, ADRD patients may not be fully benefiting from these investments. Hospital leaders can leverage integrated care relationships to reduce SNFs' perceived need to engage in selection behavior (i.e., enhanced resource sharing and transparency in placement practices). Policy intervention may be needed to address selection behavior and to support hospitals in making systemic improvements that can better benefit all SNF partners (i.e., more robust information sharing systems).</jats:p></jats:sec>

<jats:title>Abstract</jats:title><jats:sec><jats:title>Objective</jats:title><jats:p>To test whether the impacts of Medicaid's Home and Community‐Based Services (HCBS) expenditures have been equitable.</jats:p></jats:sec><jats:sec><jats:title>Data Sources and Study Setting</jats:title><jats:p>This is a secondary data analysis. We linked annual data on state‐level Medicaid HCBS expenditures with individual data from U.S. Health and Retirement Study (HRS; 2006–2016).</jats:p></jats:sec><jats:sec><jats:title>Study Design</jats:title><jats:p>We evaluated the association between state‐level HCBS expenditure quartiles and the risk of experiencing challenges in basic or instrumental activities of daily living (I/ADLs) without assistance (unmet needs for care). We fitted generalized estimating equations (GEE) with a Poisson distribution, log link function, and an unstructured covariance matrix. We controlled demographics, time, and place‐based fixed effects and estimated models stratified by race and ethnicity, gender, and urbanicity. We tested the robustness of results with negative controls.</jats:p></jats:sec><jats:sec><jats:title>Data Collection/Extraction Methods</jats:title><jats:p>Our analytic sample included HRS Medicaid beneficiaries, aged 55+, who had difficulty with ≥1 I/ADL (<jats:italic>n</jats:italic> = 2607 unique respondents contributing 4719 person‐wave observations).</jats:p></jats:sec><jats:sec><jats:title>Principal Findings</jats:title><jats:p>Among adults with IADL difficulty, higher quartiles of HCBS expenditure (vs. the lowest quartile) were associated with a lower overall prevalence of unmet needs for care (e.g., Prevalence Ratio [PR], Q4 vs. Q1: 0.91, 95% CI: 0.84–0.98). This protective association was concentrated among non‐Hispanic white respondents (Q4 vs. Q1: 0.82, 95% CI: 0.73–0.93); estimates were imprecise for Hispanic individuals and largely null for non‐Hispanic Black participants. We found no evidence of heterogeneity by gender or urbanicity. Negative control robustness checks indicated that higher quartiles of HCBS expenditure were not associated with (1) the risk of reporting I/ADL difficulty among 55+ Medicaid beneficiaries, and (2) the risk of unmet care needs among non‐Medicaid beneficiaries.</jats:p></jats:sec><jats:sec><jats:title>Conclusion</jats:title><jats:p>The returns to higher state‐level HCBS expenditures under Medicaid for older adults with I/ADL disability do not appear to have been equitable by race and ethnicity.</jats:p></jats:sec>

<jats:title>Abstract</jats:title><jats:sec><jats:title>Objective</jats:title><jats:p>To estimate and contrast the relationships between nurse staffing and health outcomes in nursing homes with low and high dementia census, to understand the association of staffing hours with dementia care quality.</jats:p></jats:sec><jats:sec><jats:title>Data Sources and Study Setting</jats:title><jats:p>A national sample of nursing homes during 2017–2019 (pre‐COVID). Data included the Payroll‐Based Journal, Medicare Claims, Nursing Home Care Compare, and Long‐Term Care Focus.</jats:p></jats:sec><jats:sec><jats:title>Study Design</jats:title><jats:p>Retrospective, regression analyses. We estimated separate linear models predicting six long‐term facility‐level outcomes. Independent variables included staffing hours per resident‐day (HPRD) interacted with the facility percentage of dementia residents, controlling for other resident and facility characteristics.</jats:p></jats:sec><jats:sec><jats:title>Data Collection/Extraction Methods</jats:title><jats:p>Hospital‐based nursing homes, those with fewer than 30% dementia residents, and missing data were excluded.</jats:p></jats:sec><jats:sec><jats:title>Principal Findings</jats:title><jats:p>We found that registered nurses and certified nurse assistants HPRDs were likely to exhibit positive returns in terms of outcomes throughout most of the range of HPRD for both high and low‐census dementia facilities, although, high‐ and low‐dementia facilities differed in most outcome rates at all staffing levels. Average predicted antipsychotics and activities of daily living as functions of HPRD were worse in higher dementia facilities, independent movement, and hospitalizations did not differ significantly, and Emergency Rooms and pressure sores were worse in lower dementia facilities. Average marginal effects were not statistically different [CI included zero] between the high and low dementia facilities for any outcome.</jats:p></jats:sec><jats:sec><jats:title>Conclusions</jats:title><jats:p>These findings suggest that increasing staffing will improve outcomes by similar increments in both low‐ and high‐dementia facilities for all outcomes. However, at any given level of staffing, absolute differences in outcomes between low‐ and high‐dementia facilities remain, suggesting that additional staffing alone will not suffice to close these gaps. Further studies are required to identify opportunities for improvement in performance for both low‐ and high‐dementia census facilities.</jats:p></jats:sec>