Medical Care最新文献

Objectives: This study aims to evaluate rates of public insurance participation among the different psychotherapist professions as well as among psychiatrists. In addition, it seeks to assess individual and contextual factors that are associated with public insurance participation.

Background: Historically, Medicaid- and Medicare-insured individuals have faced unique barriers to access to mental health professionals. Because prior literature has focused on psychiatrists, little is currently known of public insurance participation rates among psychotherapists-even though they constitute the bulk of the mental health workforce.

Methods: A retrospective analysis of Medicaid and Medicare participation among a census of all Georgia psychologists, licensed clinical social workers, licensed professional counselors, marriage and family therapists, as well as psychiatrists, using their complete licensing rosters as of November 2023 (N = 21,260).

Results: Findings show that 82.7% of psychotherapists did not accept any public insurance. This rate was 58.8% among psychiatrists. Among Georgia-licensed clinicians located outside of the state, likely to practice through telehealth, insurance acceptance was substantially lower than their in-state peers', suggesting that telehealth may have limited reach among publicly-insured patients. Psychotherapists' different professions, as well as factors such as urbanicity, hospital setting, practice size, and individual tenure length, were strongly associated with the likelihood of insurance participation.

Conclusion: Psychotherapists' low rates of participation in public insurance programs and meaningful variation between professions underscore that policies to better Medicaid and Medicare beneficiaries' access to mental health treatment must consider psychotherapists' unique practice patterns and implement interventions informed by them.

Background: Hearing loss is highly prevalent and associated with increased health care utilization. Recognition of hearing loss may play an important role in self-advocacy in difficult communication situations and prevent negative outcomes.

Objectives: To investigate the associations between self-recognition of hearing loss and hospitalization outcomes.

Research design and subjects: This is a cross-sectional analysis of 1766 participants from the National Health and Aging Trends Study.

Exposures and outcomes: The exposure, recognition of hearing loss, was constructed using participants' self-reported functional hearing difficulty, audiometric hearing loss, and self-reported hearing aid use. Primary outcomes included self-reported hospital stay occurrence and number of hospital stays within the last year. Regression models were adjusted for demographic, socioeconomic, and health characteristics and further stratified by severity of hearing loss.

Results: Among 1766 participants with hearing loss, those with unrecognized hearing loss [60.1% (n=1062)] had higher but statistically insignificant odds of any hospitalization [odds ratio (OR)=1.32; 95% CI: 0.96, 1.81] or higher count of hospitalizations [incident rate ratio (IRR)=1.13; 95% CI: 0.85, 1.51] compared with those with recognized hearing loss (39.9%, n=704). Among participants with mild hearing loss, those with unrecognized hearing loss demonstrated significantly higher odds of any hospitalization occurrence (OR=2.50; 95% CI: 1.26-4.97) and a higher count of hospitalizations (IRR=2.00, 95% CI: 1.00-4.01) than those with recognized hearing loss. There were no significant differences in hospitalization outcomes among participants with moderate or greater hearing loss.

Conclusions: In a nationally representative sample of older adults, individuals with unrecognized hearing loss compared with those with self-recognized hearing loss may be at increased odds of adverse hospitalization outcomes.

Background: Comprehensive health-related quality of life (QOL) assessment under severe respondent burden constraints requires improved single-item scales for frequently surveyed domains. This article documents how new single-item-per-domain (SIPD) QOL General (QGEN-8) measures were constructed for domains common to SF-36 and results from the first psychometric tests comparing scores for the new measure in relation to those for the SF-36 profile and summary components.

Research design: Online NORC surveys of adults, ages 19-93 (mean=52 y) representing the US population in 2020 (N=1648) included QGEN-8 and SF-36 items measuring physical (PF), social (SF), role physical (RP) and role emotional (RE) functioning and feelings of bodily pain (BP), vitality (VT), and mental health (MH). QGEN-8 items were constructed with response categories increasing score ranges for functioning (PF, SF, RP, RE) and directly measuring first-order factors for feelings (BP, VT, and MH). Analyses compared ceiling effects, convergent-discriminant correlations, classic and confirmatory factor analysis (CFA) testing for higher-order physical and mental components, and validity in discriminating across groups differing in comorbid condition severity.

Results: QGEN-8 reduced response times by 75% and lowered ceiling effect percentages (-2.2% to -27.8%, median=-14%) in comparison with SF-36. Their common measurement model was supported by: (1) substantial convergent correlations (r=0.576-0.778, median r=0.721) between methods for all domains; (2) lower discriminant correlations between different domains; (3) patterns of factor loadings equivalent to previous studies and adequate CFA model fit; (4) high correlations between methods for physical (r=0.813) and mental (r=0.761) component scores; and (5) equivalent average declines across groups reporting worse comorbid conditions.

Conclusions: Overall, results support the use of QGEN-8 to reduce respondent burden and ceiling effects while maintaining convergent and discriminant validity sufficient to estimate group-level SF-36 physical (PCS) and mental (MCS) summary scores. To facilitate its use, QGEN-8 has been made available in multiple languages from the non-profit Mapi Research Trust at https://eprovide.mapi-trust.org.

Background: Timely palliative and hospice care, along with advanced care planning, can reduce avoidable high-intensity care and improve quality of life at the end of life (EoL).

Objective: We examined patterns of care at EoL and evaluated predictors of high-intensity care at EoL among adults aged 18-64 with cancer.

Methods: Using data from the Puerto Rico Central Cancer Registry-Health Insurance Linkage Database, we examined 1359 patients diagnosed with cancer in 2010-2019, who died of cancer between 2017 and 2019 at 64 years and younger, and who were enrolled in Medicaid or private health insurance in last 30 days before death. We used composite measures for high-intensity and recommended EoL care using claims-based indicators in the last 30 days before death. Multivariable logistic regression was used to examine predictors associated with high-intensity EoL care.

Results: About 70.3% of young and middle-aged Hispanic cancer patients received high-intensity EoL care, whereas only 20.6% received recommended EoL care. Patients without recommended EoL care were more likely to receive high-intensity EoL care (aOR=4.23; 95% CI=3.18-5.61). High-intensity EoL care was more likely in female patients (aOR=1.43; 95% CI=1.11-1.85) and patients with hematologic cancers (aOR=1.91; 95% CI=1.13-3.20) and less likely in patients who survived >12 months after cancer diagnosis (aOR=0.55; 95% CI=0.43-0.71).

Conclusions: A high proportion of Hispanic adults with cancer in Puerto Rico receive high-intensity EoL care and have unmet needs at EoL. Tailored interventions can reduce high-intensity EoL care and increase recommended EoL care. Recommended EoL care can ease pain, reduce distress, honor personal preferences, and cut unnecessary medical costs.

Background: Historically, access to high-quality care has been a central challenge for Medicaid programs. Prior single-year analyses demonstrated that Medicaid beneficiaries account for disproportionately high patient volumes at low-quality hospitals. Given major Medicaid shifts including expansion and increased managed care, we examined recent trends in low-quality hospital use for Medicaid beneficiaries.

Methods: Using Healthcare Cost and Utilization Project State Inpatient Databases, we compiled adult hospital discharges from 15 states in years 2016-2019 (N=32,788,446). Hospital quality was assessed with the Agency for Healthcare Research and Quality (AHRQ) Composite Inpatient Quality Indicator, reflecting risk-adjusted mortality for prevalent conditions. We constructed a logistic regression modeling odds of discharge from a low-quality hospital (bottom 20th percentile by year), with payer-year interactions and covariates for patient demographics (sex, age, race/ethnicity, income), comorbidities, state, and hospitalization type.

Results: Overall, patients with Medicaid [adjusted odds ratio (aOR)=1.11, P<0.01] or Medicare (aOR=1.03, P<0.01) were more likely to be hospitalized in low-quality hospitals, compared with private insurance (reference). The likelihood of admission to low-quality hospitals over time varied by payer. Patients insured by Medicaid were 2% less likely to be admitted to low-quality hospitals each additional year (aOR=0.98, P<0.01). Medicare-insured patients did not show significant changes longitudinally, and privately insured patients were 3% more likely to be admitted to low-quality hospitals each year (aOR=1.03, P<0.01).

Conclusions: This is one of the first studies examining associations between payer and inpatient care quality over time, critical for our rapidly changing payment environment. Although Medicaid-insured patients remain more likely to be discharged from low-quality hospitals as compared with other payers, we find promising recent trends of improving hospital quality over time for Medicaid beneficiaries.

Background: Obesity is a major contributor to mortality in the United States. Clinical guidelines emphasize the need for multimodal treatment, but novel treatments may be changing care-seeking behavior.

Objective: To characterize obesity treatment access patterns and factors associated with obesity care from 2010 to 2021 in the United States.

Research design: This multiyear cross-sectional study was conducted using Medical Expenditure Panel Survey (MEPS) data, covering respondents from 2010 to 2021.

Subjects: We defined individuals with a BMI ≥30 or those with any health care event linked to a diagnosis of obesity as being clinically eligible for obesity treatment.

Measures: The primary outcome was the proportion of individuals assumed eligible for obesity treatment who accessed obesity treatment or were prescribed medication to treat obesity in each calendar year from 2010 to 2021.

Results: The population of individuals eligible for obesity treatment was 82,729. In total, 1311 (1.6%) reported receiving treatment for obesity. The proportion of participants receiving a prescription for obesity increased from 0.3% (0.2%, 0.6%) in 2010 to 1.8% (1.3%, 2.5%) in 2021. Multivariable logistic regression found that female individuals, older individuals, and those with higher levels of education had higher odds of accessing obesity medication or any obesity treatment.

Conclusions: Utilization of pharmaceutical and nonpharmaceutical obesity treatment has increased from 2010 to 2021 but remains low. The likelihood of receiving treatment was lower for groups with lower socioeconomic status. As more effective obesity therapies become available, efforts should be made to ensure equitable access.

Consolidation of health care providers, and vertical integration of physicians with hospitals and/or payers has accelerated over the past 15 years. Although there is potential for consolidation to improve patient care, efficiencies and reduce overhead costs, participants in our conference identified that almost all research on consolidation has shown increased cost without improvement in outcomes or the experience of care. To provide a framework for considering the impact of consolidation, future research and analysis we offer 4 themes: (1) to move forward, we need to look back at historical drivers, value creation, and unintended consequences; (2) not all consolidation is created equally; (3) real-time, continuous evaluation is critical for improvement; and (4) a policy blueprint is desperately needed. We offer several specific ideas for policy changes.

Background: Home-based primary care (HBPC) is an important care delivery model for high-need older adults. Currently, target patient populations vary across HBPC programs, hindering expansion and large-scale evaluation.

Objectives: Develop and validate criteria that identify appropriate HBPC target populations.

Research design: A modified Delphi process was used to achieve expert consensus on criteria for identifying HBPC target populations. All criteria were defined and validated using linked data from Medicare claims and the National Health and Aging Trends Study (NHATS) (cohort n=21,727). Construct validation involved assessing demographics and health outcomes/expenditures for selected criteria.

Subjects: Delphi panelists (n=29) represented diverse professional perspectives. Criteria were validated on community-dwelling Medicare beneficiaries (age ≥70) enrolled in NHATS.

Measures: Criteria were selected via Delphi questionnaires. For construct validation, sociodemographic characteristics of Medicare beneficiaries were self-reported in NHATS, and annual health care expenditures and mortality were obtained via linked Medicare claims.

Results: Panelists proposed an algorithm of criteria for HBPC target populations that included indicators for serious illness, functional impairment, and social isolation. The algorithm's Delphi-selected criteria applied to 16.8% of Medicare beneficiaries. These HBPC target populations had higher annual health care costs [Med (IQR): $10,851 (3316, 31,556) vs. $2830 (913, 9574)] and higher 12-month mortality [15% (95% CI: 14, 17) vs. 5% (95% CI: 4, 5)] compared with the total validation cohort.

Conclusions: We developed and validated an algorithm to define target populations for HBPC, which suggests a need for increased HBPC availability. By enabling objective identification of unmet demands for HBPC access or resources, this algorithm can foster robust evaluation and equitable expansion of HBPC.

Study design: Retrospective cohort study.

Objective: To characterize variation in dexamethasone and remdesivir use over time among hospitals.

Background: Little is known about hospital-level variation in COVID-19 drug treatments in a large and diverse network in the United States.

Methods: We selected individuals hospitalized with COVID-19 across 163 hospitals between February 23, 2020 and October 31, 2021 from using the HCA CHARGE, an electronic health record repository from a network of community health care facilities in the United States. We quantified receipt of dexamethasone, remdesivir, and combined use of dexamethasone and remdesivir during the hospital stay. We used 2-level logistic regression models to determine the intraclass correlation coefficient (ICC) at the hospital level, adjusting for patient and hospital characteristics. The ICC shows the proportion of total variation in drug use accounted for by hospitals.

Results: Among 161,667 individuals hospitalized with COVID-19, 73.0% were treated with dexamethasone, 49.1% with remdesivir, and 45.0% with both dexamethasone and remdesivir. The proportion of variation in dexamethasone use was 12.7% (adjusted ICC: 0.127), 8.5% for remdesivir, and 11.3% for combined drug use, indicating low interhospital variation. In the fully adjusted models, between-facility variation in dexamethasone use declined from 34.1% in February-March 2020 to 11.3% in January-March 2021 and then increased to 17.3% in July-October 2021. The variation in remdesivir use remained relatively stable during the study period.

Conclusions: During the first 2 years of the pandemic, there was relatively consistent use of dexamethasone and remdesivir across the hospitals examined. Consistent adoption and implementation of treatment guidelines across the hospitals examined may have led to a decrease in variation in drug usage over time.