JAMA Health Forum最新文献

Importance: In the US, a physician can be paid very different amounts for treating different patients, even when providing identical services. Understanding physician practices' financial incentives to serve different racial and ethnic groups may help inform payment policies to reduce health disparities.

Objective: To measure disparities across patient racial and ethnic groups in per-visit payment to physician practices from health insurers and other sources, adjusted for visit content, geographic market, and year, and to quantify the role of health insurance source and other factors in these disparities.

Design, setting, and participants: A unique, nationally representative dataset of outpatient visits containing survey-obtained patient race and ethnicity and payment amounts to physician practices from health insurers and other sources was analyzed. Data were collected from 2014 to 2021.

Main outcomes and measures: Payment disparities were defined as gaps between patient groups defined by race and ethnicity in total payments per visit to physician practices, adjusted for visit content, geographic market, and year. Kitagawa-Oaxaca-Blinder decompositions were used to estimate the magnitude of these disparities and to quantify the roles of factors like health insurance.

Results: The sample included 38 722 patients and 152 336 outpatient visits for evaluation and management services; a total of 8126 (21.0%) were Hispanic, 6150 (15.9%) were non-Hispanic Black, and 24 446 (63.1%) were non-Hispanic White. A total of 152 336 outpatient visits were included for evaluation and management services. In adjusted analyses, outpatient payments were 8.8% (95% CI, 6.7-11.0) less for visits with non-Hispanic Black patients and 9.8% (95% CI, 7.2-12.4) less for visits with Hispanic patients compared with visits with non-Hispanic White patients. Payment gaps were largest for children (13.9% [95% CI, 11.8-16.0] for non-Hispanic Black children; 15.1% [95% CI, 12.8-17.4] for Hispanic children), smaller when adjusted for insurance source (4.9% [95% CI, 2.7-7.1] for non-Hispanic Black patients; 5.6% [95% CI, 3.0-8.3] for Hispanic patients), and absent among patients with fee-for-service Medicare (1.2% [95% CI, -1.5 to 3.9] for non-Hispanic Black patients; -0.6% [95% CI, -4.4 to 3.2] for Hispanic patients).

Conclusions and relevance: In this study, US physician practices were paid more for outpatient visits with non-Hispanic White patients than for outpatient visits with Hispanic or non-Hispanic Black patients. Payment disparities were larger in pediatrics and partly explained by insurance. Differential financial incentives to serve non-Hispanic White patients may worsen disparities in health care access, utilization, and quality.

Importance: Illicitly manufactured fentanyl remains a public health threat and trustworthy measurements in prevalence are crucial to public health approaches. Low prevalence behaviors, such as route of administration of illicitly manufactured fentanyl, may have shifted over time, which changes community risk profiles.

Objective: To assess the impact of bias mitigation methods in an online survey sample and quantify changes in routes of administration in illicitly manufactured fentanyl use over time.

Design, setting, and participants: This repeated cross-sectional survey included US adults 18 years and older in an online, panel-based general population sample fielded twice yearly, in spring and autumn. Corrections for demographic and nondemographic composition bias using calibration weights and removal of misclassification from careless/inattentive responses were applied. Data were collected from April 2022 to October 2024, and data were analyzed in May 2025.

Main outcomes and measures: Self-reported use of illicitly manufactured fentanyl in the past 12 months and routes of administration, which included oral, injection, smoking, or snorting. Weighted frequency and percentages were calculated.

Results: In the full 2022-2024 sample of 175 058 respondents where misclassification removal and calibration was applied, 50.6% (95% uncertainty interval [UI], 50.3-60.0) were female, 48.1% (95% UI, 47.8-48.4) were male, and 1.3% (95% UI, 1.2-1.3) were transgender, nonbinary, or something else, and the median (IQR) age was 47 (32-62) years. The bias-mitigated prevalence estimate of illicitly manufactured fentanyl use in the last 12 months increased from 0.7% (95% UI, 0.7-0.8) in 2022 to 1.1% (95% UI, 1.0-1.2) in 2024. Oral use of illicitly manufactured fentanyl increased from 35.9% (95% UI, 31.1-40.7) in 2022 to 44.4% (95% UI, 40.3-48.5) in 2024, which was the most common route of administration. In 2024, use by smoking was 37.9% (95% UI, 34.1-41.6), use by snorting was 27.1% (95% UI, 23.5-30.7), and use by injection was 24.5% (95% UI, 21.3-27.7). Importantly, bias mitigation cumulatively reduced the national estimate of illicitly manufactured fentanyl by 70.9% in 2024 (from 3.9% [95% UI, 3.8-4.1] when neither was applied to 1.1% [95% UI, 1.0-1.2]), an important factor when considering prevalence and change over time.

Conclusions and relevance: Results of this survey study suggest that fentanyl use has shifted toward oral use, which may contribute to observed lower mortality rates despite an increase in prevalence of use. Methods intended to reduce systematic bias have a strong influence on low prevalence behavior estimates and should be implemented for all survey-based drug use surveillance.