Medical Care最新文献

Objective: The objective of this study was to compare 2 approaches for representing self-reported race-and-ethnicity, additive modeling (AM), in which every race or ethnicity a person endorses counts toward measurement of that category, and a commonly used mutually exclusive categorization (MEC) approach. The benchmark was a gold-standard, but often impractical approach that analyzes all combinations of race-and-ethnicity as distinct groups.

Methods: Data came from 313,739 respondents to the 2021 Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys who self-reported race-and-ethnicity. We used regression to estimate how accurately AM and MEC approaches predicted racial-and-ethnic differences in 5 CAHPS patient experience measures and 4 patient characteristics that we considered proxies for social determinants of health (SDOH): age, educational attainment, and self-reported general and mental health. We calculated average residual error proportions for AM and MEC estimates relative to all-combination estimates.

Results: In predicting CAHPS scores by race-and-ethnicity, on average 0.9% of the variance across groups in the AM and MEC approaches represented a departure from the gold standard. In predicting proxy SDOH variables, on average 4.7% of the AM variance across groups and 7.1% of the MEC variance across groups represented departures from the gold standard.

Conclusion: Researchers may want to consider AM over MEC when modeling outcomes by race-and-ethnicity given that AM outperforms MEC in predicting racial-and-ethnic differences in proxy SDOH characteristics and is comparably accurate in predicting differences in patient experience. Unlike MEC, AM does not assume that every multiracial person has similar outcomes and that Hispanic persons have similar outcomes irrespective of race.

Objectives: We aimed to identify demographic, acculturation, and health care factors associated with self-reported knowledge of the right to medical interpretation among individuals with non-English language preference (NELP) in California.

Background: NELP is a significant social determinant of health contributing to adverse health outcomes through barriers in communication, limited health literacy, and biases in care delivery. The ability of patients with NELP to self-advocate for interpreter services is crucial yet hindered by various factors, including a lack of knowledge about their rights.

Methods: This cross-sectional study used pooled data from the California Health Interview Survey from 2012 to 2021. Subjects were 12,219 adults with NELP, representing 2,516,157 individuals in California. The primary outcome was self-reported knowledge of the right to medical interpretation. Covariates included demographic, acculturation, and health care factors.

Results: Of the participants, 28.6% were unaware of their rights to interpretation. Married females had higher odds of knowledge, while recent immigrants (≤5 y in the United States), those with mixed language households, no doctor visits in the past year, no insurance, and self-reported poorer health had lower odds. Sociodemographic factors like age, race, ethnicity, education, and geography showed no significant association.

Conclusions: Nearly one-third of individuals with NELP lack awareness of their right to medical interpretation. Factors such as recent immigration, poor health, and limited health care contact are significant barriers. In addition to system and policy level changes, interventions targeting these vulnerable groups are needed to improve health equity and empower patients to use interpreter services.

Objective: We studied patterns in health care access between Latino and non-Latino White adults according to citizenship status before and after the American Rescue Plan Act (ARPA) of 2021 was enacted to determine whether inequities changed.

Methods: This study used 2019-2022 National Health Survey Interview data. Differences in predicted probabilities from logistic regression models were used to estimate changes in health care access outcomes (any insurance coverage, private insurance coverage, delaying care due to cost, and having a usual source of care) among Latino citizens, Latino noncitizens, and non-Latino White citizens in periods before and after ARPA's enactment (2019-2020 vs 2021-2022).

Results: Adjusted models observed that inequities in health care access did not change between Latino and non-Latino White citizens from the 2019-2020 period to the 2021-2022 period. Moreover, the health insurance gap widened by 5.8 percentage points between Latino noncitizens and non-Latino White citizens (P < 0.01) and by 5.2 percentage points between Latino noncitizens and Latino citizens (P < 0.05) from the 2019-2020 period to the 2021-2022 period. The private insurance coverage gap widened by 6.8 percentage points between Latino noncitizens and non-Latino White citizens (P < 0.01) and by 6.9 percentage points between Latino noncitizens and Latino citizens (P < 0.01) from the 2019-2020 period to the 2021-2022 period.

Conclusion: ARPA may have helped increase White citizens' insurance coverage, but this benefit did not extend to Latinos, regardless of citizenship status. Developing more inclusive health policies that do not have restrictions based on citizenship and legal authorization status is an important step toward reducing health care inequities.

Objective: To assess the association of agency nursing staff utilization with nursing home (NH) quality.

Background: Nursing staff are the primary caregivers in NHs, where high-quality care is contingent upon their adequacy and expertise. Long-standing staffing challenges, exacerbated by the COVID-19 pandemic, have led NHs to rely on agency/contract labor to alleviate staffing shortages.

Methods: This study used the following secondary datasets: Payroll-Based Journal, Care Compare: 5-Star Quality Rating System, LTCFocus.org, Area Health Resource Files, and Rural-Urban Commuting Area codes for 2017-2022. Multivariable ordinal logistic regression with 2-way (facility and year-level) fixed effects was employed. The study included all Centers for Medicare and Medicaid Services certified U.S. NHs. Analytic data comprised 80,244 facilities, averaging 13,374 unique NHs per year. The study focused on the quality star rating (1-5 scale) from the 5-Star Quality Rating System as the dependent variable. Independent variables included the proportion of agency nursing staff hours per resident day for registered nurses, licensed practical nurses, and certified nursing assistants while controlling for facility and community characteristics that may affect NH quality.

Results: A 10% increase in agency registered nurses, licensed practical nurses, and certified nursing assistants (logged) was associated with a decrease in the odds of achieving a higher star rating by 4%, 5%, and 4%, respectively (P < 0.001).

Conclusions: The use of agency nursing staff can negatively impact NH quality. Efforts to better integrate agency nursing staff into NHs, combined with strategies to recruit and retain permanent nursing staff, could lead to improved outcomes for residents.

Objective: Given the high prevalence of maternal morbidity and mortality, it is imperative that maternal health interventions are comprehensively evaluated, so they can be scaled with fidelity. Community-based care management models focused on perinatal health care are a priority for health care systems and payers. Alternative care management delivery modalities, such as video visits, are needed to expand program reach amidst growing system-level challenges. This evaluation explores the feasibility, acceptability, and impact of video versus telephonic care in perinatal care management.

Methods: Using a mixed methods approach, we implemented a quality improvement project to learn about the integration and impact of video-enabled care into the UPMC Health Plan "Pregnancy Clinical Support" (PCS) care management delivery model. Focus groups were conducted with PCS care managers (CMs) to explore their perspectives on video-visit integration. Video-only members were propensity scores matched to telephonic-only members; statistical comparisons were conducted to assess between-group differences in engagement.

Results: PCS CMs discussed ways to structure effective video-visit onboarding, strengths, and drawbacks of video-enabled care, workflow integration challenges, and best practices for introducing video visits to members. Video-only members had significantly (P < 0.0001) more clinical sessions (2.56 ± 1.57 vs 2.05 ± 1.52) and longer case duration measured in calendar days (209 ± 80 vs 169 ± 94) during the 17-month project period than telephonic-only members.

Conclusion: Evidence generated provides direct guidance on successfully integrating video visits into workflows of community-based CMs while improving engagement in care across diverse member populations.

Objectives: We identify the association between high- and low-intensity case management services on hospital and emergency department (ED) use among CommunityConnect patients.

Background: Social needs case management services vary in intensity, including the modality, workforce specialization, and maximum caseload. CommunityConnect is a social needs case management program implemented by Contra Costa Health, a county safety-net health system in California's San Francisco Bay Area.

Methods: Due to the endogeneity of high-intensity services assigned to high-risk patients, we instrument for service intensity using the number of specialist case managers hired each month of enrollment. Zero-inflated negative binomial models with 2-stage residual inclusion estimated total and avoidable hospital admissions and ED visits 12 months post-enrollment for adult Medicaid beneficiaries enrolled between August 2017 and December 2018 (n = 19,782).

Results: Compared with low-intensity case management, high-intensity services were associated with a reduction in the incidence rates of inpatient admissions [incidence rate ratio (IRR) = 0.341, 95% CI: 0.106-1.102; P = 0.072], ED visits (IRR = 0.608, 95% CI: 0.188-1.965; P = 0.058), and avoidable ED visits (IRR = 0.579, 95% CI: 0.179-1.872; P = 0.091). No significant association was found between service intensity and the likelihood of an event being an excess zero.

Conclusions: High-intensity social needs case management may be more effective than low-intensity service at reducing health care use for individuals with non-zero use, suggesting that intensive case management may be especially helpful in supporting discharge and transitions of care.

Background: Patient-perpetrated sexual harassment toward health care providers is common and adversely affects provider well-being, workforce outcomes, and patient care. Organizational climate for sexual harassment-shared perceptions about an organization's practices, policies, and procedures-is one of the strongest predictors of harassment prevalence. We conducted a pilot survey assessing provider perceptions of the Veterans Health Administration (VA)'s climate related to patient-perpetrated sexual harassment.

Research design: Responding providers completed a survey assessing: (1) experiences with patient-perpetrated sexual harassment; (2) beliefs about VA's responses to patient-perpetrated sexual harassment of staff; and (3) perceptions of VA's organizational climate related to sexual harassment for each of 4 perpetrator-target pairings (patient-perpetrated harassment of staff, patient-perpetrated harassment of patients, staff-perpetrated harassment of staff, and staff-perpetrated harassment of patients).

Subjects: Respondents included 105 primary care providers (staff physicians, nurse practitioners, and physician assistants) at 15 facilities in the VA Women's Health Practice-Based Research Network.

Results: Seventy-one percent of responding providers reported experiencing patient-perpetrated sexual harassment in the past 6 months. Respondent perceptions of VA's responses to patient-perpetrated harassment of staff were mixed (eg, indicating that VA creates an environment where harassment is safe to discuss but that it fails to offer adequate guidance for responding to harassment). Respondents rated organizational climate related to patient-perpetrated harassment of staff as significantly more negative compared with climate related to other perpetrator-target pairings.

Conclusions: Future work with representative samples is needed to corroborate these findings, which have potential ramifications for VA's ongoing efforts to create a safe, inclusive environment of care.