Medical Care Research and Review最新文献

Patients increasingly use online rating and review websites to share their clinical experiences, yet few studies have taxonomized how patients perceive their physicians. We developed a theoretical framework identifying the factors comprising patients' perceptions of their physicians' interpersonal manner and technical competence. We conducted a qualitative content analysis of 2,000 online reviews sampled from distinct physicians across the United States, balanced to represent primary care physicians and surgeons, males and females, and low- and high-star rated reviews. Reviews were received between 2015 and 2020 on a large commercial rating and review website. Our theoretical framework identifies 16 interpersonal manner factors and 10 technical competence factors. Interpersonal manner factors were grouped by physicians' attitude and character, behavior, and communication; technical competence factors were grouped by physicians' expertise, treatment approach, and outcomes. This framework may help physicians and health systems seeking to improve care quality, delivery, and patient satisfaction.

To compare the performance of the Chronic Conditions Warehouse (CCW) and the 38-condition Elixhauser Comorbidity Index in predicting all-cause mortality among Medicare beneficiaries with dementia, we used a national sample of 1,566,359 community-dwelling Medicare beneficiaries (age ≥65) with dementia, identified in 2018 claims data. Using elastic net logistic regression, we applied 30 CCW conditions and 38 Elixhauser comorbidities from 2018 to predict mortality at 30, 60, 180 days, and 1 year through December 31, 2019. Mortality rates were 2.42% (30 days), 4.27% (60 days), 10.77% (180 days), and 19.0% (1 year). All models demonstrated good discrimination (C-statistics: 0.696-0.731) and calibration, with no meaningful performance differences between the two measures. Elastic net models produced parsimonious predictors with performance comparable to traditional logistic regression. Both CCW and Elixhauser measures predicted all-cause mortality in dementia with similar accuracy. Elastic net offers a robust approach to claims-based mortality prediction.

Identifying dual-eligible beneficiaries who use Medicaid-funded long-term services and supports (LTSS) is difficult, hindering efforts to monitor use and improve quality. We demonstrate a strategy that uses only Medicare data to identify nursing home (NH) users and Medicaid home-and-community-based-service (HCBS) waiver participants by leveraging the fact that these groups exclusively qualify for zero cost-sharing in Part D. In a multistate cohort of low-income older adults, we identified Part D LTSS beneficiaries (dual-eligible beneficiaries with zero Part D cost-sharing) in Medicare enrollment records and verified LTSS use in NH assessments and Medicaid HCBS data. Over 96% of NH/HCBS waiver users in MDS or Medicaid data were correctly identified as Part D LTSS beneficiaries, and 93% of beneficiaries without NH or HCBS waiver use were accurately identified as not being Part D LTSS beneficiaries. Leveraging Part D data could support more timely evidence on quality and outcomes for dual-eligible LTSS users.

The COVID-19 pandemic disrupted surgical care delivery, yet the extent to which shifts from inpatient to outpatient settings have persisted remains unclear. Using medical claims data from Independence Blue Cross (2018-2022), we examined changes in surgery settings across 102 procedures before the pandemic and during the 2 years following the suspension of elective surgeries. After 2 years, inpatient volumes decreased for 9 of the 20 most common pre-pandemic inpatient procedures, with corresponding increases in outpatient utilization. Hip and knee replacements experienced the most pronounced shifts, with inpatient shares falling by more than 40 percentage points. Patients from lower-income census tracts saw greater declines in overall procedure volumes (-6.0%) compared to those from higher-income areas (+5.2%). Total allowed amounts decreased for procedures with outpatient migration, while out-of-pocket costs remained stable. These findings suggest durable, post-pandemic shifts in surgical care delivery patterns, with potential implications for access, costs, and equity.

Adults age 75+ report worse inpatient experiences than patients 55 to 74. Older adults may have been especially vulnerable to changes such as family access and reduced staffing during the COVID-19 pandemic. We examined 2018-2023 Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys from 14,760,049 respondents discharged from 4,462 hospitals. We examined changes in an HCAHPS summary score (HCAHPS-SS), controlling for pre-pandemic quarterly and linear trends. HCAHPS-SS declined 4.1pp, a medium-to-large drop by Q3/2022, recovering only slightly by Q4/2023 (to -3.5pp). HCAHPS-SS decreased fastest for patients 75+ and least for maternity patients, even controlling for age. Differences by age may reflect older patients' greater need for instrumental support and differential impacts of visitor restrictions. Hospitals' quality improvement efforts should focus on understanding the need for patient support and on restoring prior patient experience gains. The failure to return to pre-pandemic levels points to the need to understand and address the residual factors that continue to alter patient experience.

The number of Catholic hospitals grew by 28% between 2001 and 2020, and today almost one-fifth of U.S. nonprofit hospitals are Catholic. Catholic systems face conflicting institutional pressures to provide mission-oriented services while remaining financially competitive. Using 2009-2022 data from the American Hospital Association (n = 33,552 hospital-years), we applied difference-in-differences methods to compare changes in hospital operations after acquisition by Catholic and non-Catholic systems relative to the control group of never-acquired hospitals. Catholic-acquired hospitals were more likely to offer some mission-oriented services, including chaplaincy and charity care (average treatment effect on the treated, ATT, 10.41 percentage-point [pp] and 3.97 pp, respectively), while non-Catholic-acquired hospitals were less likely to operate an obstetrics unit (ATT -3.45 pp) after acquisition relative to the control group. Hospitals experienced similar cost-cutting measures after acquisition relative to the control group, including reduced operating expenses and employment, regardless of system ownership type. Our findings provide rigorous empirical evidence to inform ongoing policy debates regarding the expansion of Catholic health care.

The COVID-19 pandemic exacerbated staffing shortages in U.S. nursing homes. Staff who are immigrants may have stronger tendencies to remain in their jobs than U.S.-born staff, but evidence is lacking. In this study, we predicted the share of immigrant staff and used a difference-in-differences regression to investigate whether nursing homes with a higher vs. lower proportion of immigrant certified nursing assistants (CNAs) experienced lesser declines in staff hours per resident day (HPRD) during the pandemic. We found that facilities with a larger-than-median predicted share of immigrant staff exhibited a relatively smaller decrease in CNA HPRD by 0.03 HPRD, equivalent to a 1.4% difference of the sample mean. We further found that CNA turnover rates during the pandemic were lower in facilities with relatively higher shares of immigrant staff. Our findings suggest that nursing homes with more immigrant staff may be more resilient in meeting staffing needs during crises.

Provision of medications for opioid use disorder (MOUD) programs in carceral settings is critical to reducing overdose during the high-risk period following release from incarceration. Efforts to expand carceral MOUD programs have increased in recent years. We conducted a narrative review to synthesize evidence on the implementation of MOUD in U.S. carceral facilities. We analyzed 36 studies from 2019 to 2023 using the Exploration, Preparation, Implementation, Sustainment framework. Findings highlight that MOUD in carceral settings requires significant resources, infrastructure, and staffing. MOUD diversion is a common concern, with program responses varying widely. Stigma against MOUD remains a challenge, particularly when treating pregnant people with OUD. Effective coordination between carceral and community stakeholders is critical for MOUD implementation and continuity of treatment postrelease. COVID-19 spurred innovation, increasing telehealth in carceral MOUD programs. Future research should explore MOUD program transition from early adoption to wide-scale implementation, considering external factors, sustainability, and evolving policies.

Improving access to midwifery care has been identified as a strategy to address shortages of reproductive health clinicians and ensure person-centered, equitable care. This article describes findings from a new survey of licensed midwives (LMs) in California, who enter the profession without a nursing background. The data offer new insights into LMs' demographics, training, client population, and practice experiences. LMs predominantly have their own practices, typically working with another midwife and/or an assistant or student, and have relatively small numbers of clients each year. Most of the births they attend occur in homes and birth centers. Many LMs report a lack of understanding of and support for their expertise by physicians and hospitals. Despite these challenges, most LMs are satisfied with their careers. LMs contribute to person-centered care, offering alternatives to hospital birth and expanding access to the midwifery model of care.

Social determinants of health contribute to disparities in cardiovascular outcomes, including hypertension. This study utilized a health equity framework to assess patient-level factors influencing hypertension management across two health systems in North Carolina and Kansas. We interviewed 29 providers and 25 patients with hypertension from 14 clinics, including 13 primary care clinics-6 high-performing, 1 mid-performing, and 6 low-performing-and 1 cardiology clinic. Thematic analysis and open coding methodologies were used during analysis. Five salient patient-level themes emerged: patient resources, health literacy, lifestyle, intentionality, and patient-centered care. All providers identified health literacy as a critical barrier; however, those in low-performing clinics more regularly cited literacy-related challenges, with some associating patients' rurality with decreased understanding and intentionality. Mental health was also linked to hypertension management, as anxiety may exacerbate symptoms, while depression can reduce treatment motivation. Our findings underscore the need for individualized, equity-informed hypertension management strategies.