Medical Care Research and Review最新文献

Primary care providers (PCPs) in the United States experience burnout more frequently than clinicians in other care settings. Interventions addressing PCP burnout are urgently needed. Organizational-level interventions implemented in the workplace may help address burnout, as poor organizational conditions are primary contributors to burnout. This review synthesized existing evidence on organizational-level interventions' effects on PCP burnout in the United States. A comprehensive search was conducted in four databases and selected journals. Thirteen studies were included, and four overarching categories of interventions emerged. Interventions that addressed the workload, control, and community areas of worklife resulted in notable burnout reduction. Organizations considering using workload interventions to reduce PCP burnout should incorporate both human and time resources. PCP engagement in intervention design and implementation is crucial and may affect burnout. More studies are needed on interventions that target nurse practitioners and physician assistants who increasingly serve as PCPs.

Many regulated health insurance markets use prospective risk adjustment (RA) to mitigate risk selection incentives for insurers. However, prospective RA might underpay insurers for people diagnosed with a new chronic disease. By tracking spending and RA payments over the period t-2 to t+2 for individuals diagnosed with a new chronic disease in year t, we find a substantial payment gap in year t and, to a lesser extent, in prior and/or subsequent years. The extent to which these gaps stimulate selection incentives for insurers depends on the possibilities for insurers to distort consumers' choice of insurance products. Possibilities which-in turn-depend on whether and when consumers respond to the onset of the chronic disease when choosing an insurance product. By analyzing "insurer switching" in the period t-2 to t+2 we find that-on average-people first diagnosed with a chronic disease are more likely to switch insurer than others.

State policies requiring clinicians to review prescription drug monitoring program (PDMP) databases have proliferated. However, patient advocates suggest these policies may adversely affect patients with chronic pain. This study aimed to quantify the effect of must-access PDMP implementation on pain and physical impairment. Using panel data on 34,431 older adults from the Health and Retirement Study (2002-2021), we conducted a heterogeneity-robust difference-in-differences analysis. Must-access PDMPs were associated with a 1.65 (95% CI: 0.43 to 2.87) percentage point increase in frequent pain during the two-year window surrounding policy implementation and a peak 3.52 (95% CI: 0.88 to 6.16) percentage point increase in the second post-policy period, after which the effect dissipated. Effects on impairment outcomes were positive but statistically insignificant. Findings suggest that must-access PDMP policies may increase numbers of older adults reporting frequent pain in the early policy implementation years, though they were not associated with statistically detectable changes in physical impairment.

This 24-month inductive study examined the practices provided by a variety of supporters to six frontline-led innovation teams. Analyzing 86 interviews with 35 team members and 17 supporters, we propose a comprehensive, idealized framework of dynamic and multisource support. These practices offered critical aid as teams dealt with limited innovation experience, limited relationships, and limited contextual awareness. We categorized the practices we identified into six sets-Ensure Foundational Support, Transmit Knowledge and Skills, Nurture Teams and Teamwork, Cultivate Relationships with Decision-Makers, Scaffold Project Work, and Foster a Holistic View of Innovation Work-and discussed their benefits and boundaries of effectiveness. Our framework challenges the notion of "one-size-fits-all" support, emphasizing the value of adaptive support instead. We also highlight the critical role of coaches and identify significant roles unexpectedly played by the funder, insurer, student fellows, and research-observers that provided instruction, resources, and encouragement.

Racial and ethnic disparities in mental health care access are especially consequential for the health outcomes of Medicaid beneficiaries living with serious mental illness (SMI). This descriptive study of Oregon Medicaid claims data assessed for disparities in access to SMI care for Oregon's adult Medicaid beneficiaries from 2010 to 2019, examining changes following the implementation of value-based payment (VBP) in 2012. Multivariable regression analyses compared changes in access to SMI care, pre- and post-VBP implementation, by race and ethnicity. Relative to White beneficiaries, VBP implementation was associated with net increases of 0.28% (95% confidence interval [CI]: [0.01%, 0.55%]) in the rate of access among Black beneficiaries (a complete reduction of the pre-VBP disparity) and 0.34% (95% CI: [0.17%, 0.51%]) among Latinx beneficiaries (narrowing but not closing the pre-VBP disparity). The Oregon policy's focus on access, equity, and beneficiaries with mental illness might have contributed to the observed reductions in disparities.

The 21st Century Cures Act opened Medicare Advantage (MA) enrollment to people with end-stage renal disease (ESRD). Previously, most Medicare beneficiaries with ESRD were only permitted to enroll in traditional Medicare. The purpose of our study was to determine how MA plans responded to this policy change. We conducted 48 interviews with representatives from MA plans, dialysis provider organizations, and chronic kidney disease (CKD) care management companies. One major theme that emerged from our interviews was MA plans partnered with CKD care management companies to manage the care of ESRD patients. Plans partnered because they had little experience with and were wary of the costs of this population, and sought to improve the value and quality of services. MA plans varied in how they contracted with these organizations, and the CKD care management companies employed several methods for managing patients. Participants reported both benefits and challenges related to these partnerships.

Despite playing a pivotal role in rural community health services delivery and in local economies, rural hospitals in the United States have closed or merged with larger health networks at alarming rates. This scoping review examines what is known about the impacts of rural hospital closures and mergers since 2010. Using the literature, we inductively derived a new Health System Ecologies Impact Matrix research tool to assess knowledge related to health system changes. Most of the included studies examined closures, primarily reporting on community impacts. Knowledge gaps remain related to financial-, workforce-, and utilization-related outcomes, and little is known about impacts on neighboring hospitals and communities. Few studies report effects of rural hospital mergers, primarily focusing on financial and utilization outcomes for the merged hospital. No studies examined the impacts of rural hospital mergers on patients or individuals and their social environments.

Contemporary practice guidelines recommend nonpharmacologic therapies instead of prescription opioids as first-line treatment for many pain types, including acute low back pain (aLBP). This serial cross-sectional study describes trends in the annual prevalence of physical therapy (PT), chiropractic care, gabapentinoids, and prescription opioid receipt among Medicare beneficiaries diagnosed with aLBP from 2016 to 2019, overall and within key demographic, clinical, and geographic subgroups. Overall, changes in PT (5.5%-6.7%), chiropractic care (11.0%-11.7%), and gabapentinoid (9.6%-8.9%) receipt were limited, whereas prescription opioid use substantially decreased (26.2%-17.8%). Prescription opioid receipt was higher among individuals under age 65, American Indian/Alaskan Native, non-Hispanic Black/African American, and Hispanic individuals, individuals with opioid use disorder, and in Southern states, while the use of nonpharmacologic pain therapies remained low among these subgroups. It is essential to promote equitable access to multimodal and guideline-recommended approaches for aLBP management including nonpharmacologic therapies.

Empowering beneficiaries to choose a health plan that meets their health needs during the transition to Medicaid managed care is critical to promote informed decision-making. This study uses North Carolina's transition under the 1115 waiver to examine the role of the state, health plans, and providers in informing beneficiaries about the transition. We reviewed policy documents and interviewed 43 individuals representing provider practices and 10 representing the State Department of Health and Human Services and health plans between December 2020 and September 2021. Interviewees from the state described strategies to encourage beneficiaries to select a health plan. Participating practices shared that their patients were unaware or confused about the transition. These concerns led practices to engage beneficiaries and contract with all health plans to ensure continuity of care, contributing to administrative burdens. While the state made significant efforts to engage beneficiaries, the interaction between beneficiaries and providers was still critical.

We sought to understand stakeholder experience with telehealth services, through interviews with patients, providers, and health plans, to inform Medicaid policy after the COVID-19 public health emergency. Our primary aim was to examine whether and how such telehealth policies affect equitable care delivery and to uncover any remaining policy gaps. Applying the Framework for Digital Health Equity our study identified digital determinants that operate at the individual, interpersonal, community and societal levels. Across respondents, telehealth expansion was viewed as overwhelmingly positive and noted as a significant contributor to increased access among marginalized, minoritized, and rural Medicaid participants in this study. Despite these strengths, patients and health care providers identified several challenges and recommendations.