Medical Care最新文献

Background: Telehealth services can increase access to care by reducing barriers. Telephone-administered care, in particular, requires few resources and may be preferred by communities in areas that are systemically underserved. Understanding the effectiveness of audio-based care is important to combat the current mental health crisis and inform discussions related to reimbursement privileges.

Objectives: We compared the effectiveness of audio-based care to usual care for managing mental health and substance use disorders (MHSUD).

Design: We used systematic review methods to synthesize available evidence.

Studies: We searched for English-language articles reporting randomized controlled trials (RCTs) of adults diagnosed with MHSUD published since 2012.

Outcomes: We abstracted data on clinical outcomes, patient-reported health and quality of life, health care access and utilization, care quality and experience, and patient safety.

Results: We included 31 RCTs of participants diagnosed with depression, post-traumatic stress disorder (PTSD), other serious mental illness (SMI), anxiety, insomnia, or substance use disorder (SUD). Most of the evidence was for interventions targeting depression, PTSD, and SUD. The evidence demonstrates promise for: (1) replacing in-person care with audio care for depression, other SMI, and SUD (very low to moderate certainty of comparable effectiveness); and (2) adding audio care to monitor or treat depression, PTSD, anxiety, insomnia, and SUD (low to moderate certainty of evidence favoring audio care for clinical outcomes).

Conclusions: MHSUD can be managed with audio care in certain situations. However, more evidence is needed across conditions, and specifically for anxiety and other conditions for which no research was identified.

Objective: To examine the characteristics and risk factors associated with 30-day readmissions, including the impact of home health care (HHC), among older sepsis survivors transitioning from hospital to home.

Research design: Retrospective cohort study of the Medical Information Mart for Intensive Care (MIMIC)-IV data (2008-2019), using generalized estimating equations (GEE) models adjusting for patient sociodemographic and clinical characteristics.

Subjects: Sepsis admission episodes with in-hospital stays, aged over 65, and discharged home with or without HHC were included.

Measures: The outcome was all-cause hospital readmission within 30 days following sepsis hospitalization. Covariates, including the primary predictor (HHC vs. Home discharges), were collected during hospital stays.

Results: Among 9115 sepsis admissions involving 6822 patients discharged home (66.8% HHC, 33.2% Home), HHC patients, compared with those discharged without services, were older, had more comorbidities, longer hospital stays, more prior hospitalizations, more intensive care unit admissions, and higher rates of septic shock diagnoses. Despite higher illness severity in the HHC discharges, both groups had high 30-day readmission rates (30.2% HHC, 25.2% Home). GEE analyses revealed 14% higher odds of 30-day readmission for HHC discharges after adjusting for risk factors (aOR: 1.14; 95% CI: 1.02-1.27; P=0.02).

Conclusions: HHC discharges experienced higher 30-day readmission rates than those without, indicating the need for specialized care in HHC settings for sepsis survivors due to their complex health care needs. Attention to sepsis survivors, regardless of HHC receipt, is crucial given the high readmission rates in both groups. Further research is needed to optimize postacute care/interventions for older sepsis survivors.

Background: Medicare Bayesian Improved Surname and Geocoding (MBISG), which augments an imperfect race-and-ethnicity administrative variable to estimate probabilities that people would self-identify as being in each of 6 mutually exclusive racial-and-ethnic groups, performs very well for Asian American and Native Hawaiian/Pacific Islander (AA&NHPI), Black, Hispanic, and White race-and-ethnicity, somewhat less well for American Indian/Alaska Native (AI/AN), and much less well for Multiracial race-and-ethnicity.

Objectives: To assess whether temporal inconsistency of self-reported race-and-ethnicity might limit improvements in approaches like MBISG.

Methods: Using the Medicare Health Outcomes Survey (HOS) baseline (2013-2018) and 2-year follow-up data (2015-2020), we evaluate the consistency of self-reported race-and-ethnicity coded 2 ways: the 6 mutually exclusive MBISG categories and individual endorsements of each racial-and-ethnic group. We compare the consistency of self-reported race-and-ethnicity (HOS) to the accuracy of MBISG (using 2021 Medicare Consumer Assessment of Healthcare Providers and Systems data).

Results: Concordance (C-statistic) of HOS baseline and follow-up self-reported race-and-ethnicity was 0.95-0.97 for AA&NHPI, Black, Hispanic, and White, 0.83 for AI/AN, and 0.72 for Multiracial using mutually exclusive categories (weighted concordance=0.956). Concordance of MBISG with self-report followed a similar pattern and had similar values, with somewhat lower AI/AN and Multiracial values. The concordance of individual endorsements over time was somewhat higher than for classification (weighted concordance=0.975).

Conclusions: The concordance of MBISG with self-reported race-and-ethnicity appears to be limited by the consistency of self-report for some racial-and-ethnic groups when employing the 6-mutually-exclusive category approach. The use of individual endorsements can improve the consistency of self-reported data. Reconfiguring algorithms such as MBISG in this form could improve its overall performance.

Objectives: We compared the effectiveness of audio-based care, as a replacement or a supplement to usual care, for managing diabetes.

Background: Diabetes is a chronic condition afflicting many in the United States. The impact of audio-based care on the health of individuals with diabetes is unclear, particularly for those at risk for disparities-many of whom may only be able to access telehealth services through telephone.

Methods: We used systematic review methods to synthesize available evidence. We systematically searched for English-language articles from 2012 reporting randomized controlled trials of adults diagnosed with diabetes. We abstracted data on clinical outcomes (including A1c), patient-reported health and quality-of-life, health care access and utilization, care quality and experience, and patient safety.

Results: Evidence for replacing in-person care with audio care was limited (n = 2), with low certainty of evidence for greater and comparable effectiveness for A1c and harms, respectively. Supplemental audio care (n = 23) had a positive effect on A1c (pooled mean difference A1c -0.20%; n = 8763; 95% CI: -0.36% to -0.04%), with moderate certainty of evidence. Stratified results indicated that audio interventions supplementing usual care performed more favorably in individuals with A1c ≤ 9%; populations not at risk of disparities; interventions with at least monthly contact; and interventions using remote monitoring tools.

Conclusions: This evidence base reveals some promise for managing diabetes with audio-based care as a supplement to in-person care. Future studies could further investigate the effectiveness of audio-based care as a replacement and modify interventions to better serve individuals with poor glucose control and those at risk for disparities.

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.

Introduction: Adults with type 2 diabetes (T2D) often experience musculoskeletal disorders (MSDs), which complicate health care provision and negatively impact their health and health care utilization and expenditure. The objective of this study was to estimate the incremental health care utilization and expenditure associated with MSD among adult T2D patients in the United States overall and by race/ethnicity.

Methods: A sample (unweighted n=6205) of noninstitutionalized US adults with a T2D diagnosis was obtained from the Medical Expenditure Panel Survey (MEPS), panels 2015-2016 to 2019-2020. Propensity score matching (PSM) was used to reduce selection bias between participants with and without MSD. Differences in health care utilization were estimated using negative binomials, while expenditures were estimated using generalized linear models and 2-part models. Outcomes were estimated overall and by race and ethnicity.

Results: Among the sample of patients with T2D before PSM, 52% had MSD. In the matched sample, increased utilization associated with MSD occurred across all health care service types, with prescription medications (13.31; 95% CI: 11.12, 15.50) having the largest increase. The increased total expenditure associated with MSD among T2D patients was $5712 (95% CI: $4278, $7147), and the major drivers were office and inpatient expenditures. Increased total expenditure associated with MSD was highest among Hispanic patients ($8490; 95% CI: $4744, $12,237).

Conclusions: MSD is associated with increased utilization and expenditure among T2D patients, particularly Hispanics. Efforts targeting earlier recognition and management of MSD may reduce excess utilization and expenditure, and also racial/ethnic disparities.

Background: For nearly a decade, the US Veterans Health Administration (VA) has distributed tablets to Veterans with access barriers who may benefit from video telehealth visits. Older Veterans' lower likelihood of tablet use relative to younger Veterans has prompted interest in factors influencing tablet utilization.

Objectives: We examined whether social support facilitates video telehealth utilization among older Veterans who received VA tablets.

Research design: We performed a cross-sectional analysis of electronic health record-linked survey data. We used multivariable logistic regression to examine the relationship between social support and telehealth use, controlling for predisposing, enabling, and health factors.

Subjects: Veterans aged ≥65 who received a VA-issued tablet and responded to a national survey (September 2021 to January 2022) (n=859).

Measures: The outcome measure was any VA video telehealth use in the 6 months post-tablet receipt. Social support measures included tangible support, living with others, and marital status.

Results: Fewer than two-thirds of respondents (62.4%) had a video visit in the 6 months post-tablet receipt. In all, 32.2% of respondents noted that the absence of family or friends to help with video visits hindered their use of video telehealth. In multivariable analyses, greater tangible social support was associated with 54.1% (95% CI: 10.1%-116.2%) higher odds of having a video visit.

Conclusions: Older adults who receive technological devices to engage in video telehealth benefit from tangible social support from family and friends. Assessing and addressing patients' social and environmental circumstances may help optimize digital divide interventions and ensure that older adults are not excluded from telehealth-related access gains.

Background: Web-first multimode survey protocols increase HCAHPS survey response rates and representativeness but may result in different HCAHPS scores because of survey mode effects and selective email address availability. A variable absent from many patient-mix adjustment models that may result in more positive patient experiences is whether the hospital admission was planned; adjustment for planned stays may better measure hospital performance.

Objectives: Develop adjustments for new Web-first survey protocols and planned admissions to facilitate comparisons across hospitals.

Research design: Using 2021 survey mode experiment data, we estimate survey protocol effects in linear models predicting HCAHPS top-box outcomes from protocol indicators (which incorporate email availability for Web-first protocols), patient-mix adjustors, and hospital intercepts. We evaluate the unique effect on scores of whether a stay was planned.

Results: Phone-only and Web-Phone without email produce more positive responses than Mail-only, requiring negative adjustments. All other survey protocol effects and adjustments are mixed in direction and generally small. Planned stays are associated with more positive experiences for otherwise similar patients and make a unique contribution beyond other current patient-mix adjustment variables.

Conclusions: It is important to adjust HCAHPS scores for survey protocol effects to ensure fair comparisons across hospitals and to enable hospitals to choose the survey protocol that best represents their patients. Incomplete email address availability necessitates that HCAHPS survey protocol adjustment control for email address availability when a Web-first protocol is used. Accounting for differences associated with planned stays may improve patient-mix adjustment.

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.