Medical Care Research and Review最新文献

Recently, the Centers for Medicare & Medicaid Services (CMS) introduced staffing measures related to staffing variability and turnover in the Nursing Home (NH) Care Compare Five-Star Quality Rating System. While the consensus within the literature is that reduced variability and turnover are associated with higher NH quality of care and life, no existing studies have evaluated the relationship between CMS's newly introduced staffing measures and quality. This study uses regression analysis to estimate the relationship between 13 quality measures (used in Care Compare) and CMS's new staffing measures (i.e., weekend nursing staff levels, total nursing and registered nurse staff turnover, and administrator turnover) as well as a measure of daily staffing variation recently introduced in the literature called the coefficient of variation. Regressions analysis finds strong evidence of an association between quality and these staffing measures, though some measures (e.g., nursing staff turnover) are highly correlated and may be duplicative.

Multiple chronic conditions (MCCs) are more common and costly than any individual health condition in the United States. The growing workforce of nurse practitioners (NPs) plays an active role in providing primary care to this patient population. This study identifies the effect of NP primary care models, compared with models without NP involvement, on cost, quality, and service utilization by patients with MCCs. We conducted a literature search of six databases and performed critical appraisal. Fifteen studies met inclusion criteria (years: 2003-2021). Overall, most studies showed reduced or similar costs, equivalent or better quality, and similar or lower rates of emergency department use and hospitalization associated with NP primary care models for patients with MCCs, compared with models without NP involvement. No studies found them associated with worse outcomes. Thus, NP primary care models, compared with models without NP involvement, have similar or positive impacts on MCC patient outcomes.

Emerging technological advances hold potential to assist the long-term care (LTC) workforce in caring for an aging population in the home and LTC settings. Technology may alter workforce needs and mitigate rising workforce demand. This study identified and assessed emerging technologies that may assist, replace, and/or support recruitment and retention of the LTC workforce and identified barriers and facilitators to their implementation. We identified a variety of technologies with applications for LTC, created a taxonomy of technology types and functions across LTC settings, and conducted semi-structured interviews with a sample of company leaders to assess perceived impact of their products and services on the LTC workforce. Thematic analysis of those interviews found that technology is not currently positioned to replace the LTC workforce but may facilitate work and support worker recruitment and retention. More rigorous evaluation of technologies in LTC and financing mechanisms are needed to support widespread adoption.

Health insurance stability among children with adverse childhood experiences (ACEs) is essential for accessing health care services. This cross-sectional study used an extensive, multi-year, nationally representative database of children aged 0 to 17 to examine the association between ACE scores and continuous or intermittent lack of health insurance over a 12-month period. Secondary outcomes were reported reasons for coverage gaps. Compared with children having 0 ACEs, those with 4+ ACEs had a higher likelihood of being part-year uninsured rather than year-round private insured (relative risk ratio [RRR]: 4.20; 95% CI: 3.25, 5.43), year-round public insured (RRR: 1.37; 95% CI: 1.06, 1.76), or year-round uninsured (RRR: 2.28; 95% confidence interval [CI]: 1.63, 3.21). Among children who experienced part-year or year-round uninsurance, a higher ACE score was associated with a greater likelihood of coverage gap due to difficulties with the application or renewal process. Policy changes to reduce administrative burdens may improve health insurance stability and access to health care among children who endure ACEs.

This study assessed whether permanent supportive housing (PSH) participation is associated with health service use among a population of adults with disabilities, including people transitioning into PSH from community and institutional settings. Our primary data sources were 2014 to 2018 secondary data from a PSH program in North Carolina linked to Medicaid claims. We used propensity score weighting to estimate the average treatment effect on the treated of PSH participation. All models were stratified by whether individuals were in institutional or community settings prior to PSH. In weighted analyses, among individuals who were institutionalized prior to PSH, PSH participation was associated with greater hospitalizations and emergency department (ED) visits and fewer primary care visits during the follow-up period, compared with similar individuals who largely remained institutionalized. Individuals who entered PSH from community settings did not have significantly different health service use from similar comparison group members during the 12-month follow-up period.

COVID-19 vaccinations are critical for mitigating outbreaks and reducing mortality for skilled nursing facility (SNF) residents and staff, yet uptake among SNF staff varies widely and remains suboptimal. Understanding which strategies are successful for promoting staff vaccination, and examining the relationship between vaccination policies and staff retention/turnover is key for identifying best practices. We conducted repeated interviews with SNF administrators at 3-month intervals between July 2020 and December 2021 (n = 156 interviews). We found that COVID-19 vaccines were initially met with both enthusiasm and skepticism by SNF staff. Administrators reported strategies to increase staff vaccine acceptance, including incentives, one-on-one education, and less stringent personal protective equipment requirements. Federal and state vaccination mandates further promoted vaccine uptake. This combination of mandates with prioritization of the vaccine by SNFs and their leadership was successful at increasing staff vaccination acceptance, which may be critical to increase staff booster uptake from its current suboptimal levels.

Medicare Advantage (MA) plans increase their risk-adjusted payments through intensive coding in health risk assessments (HRAs) and chart reviews. Whether the additional diagnoses from HRAs and chart reviews are associated with increased resource use is not known. Using national MA encounter data (2016-2019), we examine the relative contributions of three health risk scores to MA resource use: the base risk score that excludes diagnoses from HRAs and chart reviews; the incremental score added to the base score from diagnoses in HRAs; and the incremental score added from diagnoses in chart reviews. We find that the incremental risk scores explain 53.5% to 64.5% of resource use relative to the base risk score effect-that is, 35.5% to 46.5% of the incremental risk scores are not accompanied by increased resource use. While HRAs and chart reviews contribute to more complete coding of diagnoses, they are sources of intensive coding not accompanied by resource use.

Noncitizen immigrants are often excluded from accessing critical safety-net programs, such as Medicaid. Access to health care plays a central role in current policy debates on maternal health. Yet, immigrant exclusions are rarely considered in maternal health policy research. Through open-ended interviews with 31 policymakers, researchers, and program administrators, we examined state variations in approaches to providing care for pregnant, post, and intrapartum immigrant women. We found four themes: (a) a patchwork safety-net exists that provides some access to immigrants ineligible for Medicaid; (b) patchwork coverage leads to patchwork care, which can contribute to maternal health inequities; (c) immigrant Medicaid policy is assembled along a hierarchy of deservingness based on documentation status; (d) Trump-era public charge rules and political climate may have a substantial chilling effect on benefit uptake regardless of eligibility. We discuss implications for efforts to expand Medicaid postpartum and address the maternal health crisis.

Household surveys are an important source of information on medical spending and burden. We examine how recently implemented post-processing improvements to the Current Population Survey Annual Social and Economic Supplement (CPS ASEC) affected estimates of medical expenditures and medical burden. The revised data extraction and imputation procedures mark the second stage of the CPS ASEC redesign and the beginning of a new time series for studying household medical expenditures. Using data for the calendar year 2017, we find that median family medical expenditures are not statistically different from legacy methods; however, updated processing does significantly reduce the percentage of families estimated to have a high medical burden (medical expenses are at least 10% of family income). The updated processing system also changes the characteristics of families with high medical spending and is primarily driven by changes in imputation of health insurance and medical spending.

A high-deductible health plan (HDHP) may incentivize enrollees to limit health care use at the beginning of a plan year, when they are responsible for 100% of costs, or to increase the use of care at the end of the year, when enrollees may have less cost exposure. We investigated both the impact of the deductible reset that occurs at the beginning of a plan year and the option to enroll in an HDHP on the use of substance use disorder (SUD) treatment services over the course of a health plan year. We found decreases in SUD treatment use following the increase in cost exposure related to a deductible reset. There was no variation in this behavior between HDHP offer enrollees and comparison enrollees who were not offered an HDHP. These findings reinforce that cost-sharing poses a barrier to SUD care and continuity of care, which can increase the risk of adverse clinical outcomes.