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Prescription Drug Monitoring Program Reminder Emails, Program Use, and Prescribing: A Randomized Clinical Trial. 处方药监测程序提醒电子邮件、程序使用和处方：一项随机临床试验。
IF 11.3 Q1 HEALTH CARE SCIENCES & SERVICES
JAMA Health Forum
Pub Date : 2025-12-05 DOI: 10.1001/jamahealthforum.2025.5623
Adam Sacarny, Tatyana Avilova, Ian Williamson, Weston Merrick, Mireille Jacobson
<p><strong>Importance: </strong>Prescription Drug Monitoring Programs (PDMPs) can contribute to safer prescribing of opioids and other controlled substances but are often underutilized by prescribers. Evidence on the feasibility and effects of email campaigns to increase clinicians' engagement with PDMP is limited.</p><p><strong>Objective: </strong>To investigate whether email communications can increase PDMP use and, in turn, reduce guideline-discordant prescribing among clinicians.</p><p><strong>Design, setting, and participants: </strong>This randomized clinical trial included clinicians who prescribed controlled substances but lacked PDMP accounts, had inactive PDMP accounts, did not search the PDMP, or searched infrequently when prescribing opioids. The study was conducted from January 2024 to November 2025 in the US state of Minnesota.</p><p><strong>Interventions: </strong>Clinicians were randomized (1:1:1 ratio) to 2 intervention groups or a usual care group. Clinicians in the intervention groups were sent up to 2 emails highlighting their lack of PDMP engagement (no account, inactive account, no search, or infrequent search) with hyperlinks to the PDMP website to rectify it. Email content differed by group to focus on either the state's legal requirements to use the PDMP or the clinical benefits of PDMP use.</p><p><strong>Main outcomes and measures: </strong>PDMP engagement, defined as engaging in the activity encouraged in the email (account creation, account reactivation, database searches, or more frequent database searching); and guideline-discordant opioid prescribing, a composite of 5 prescribing measures, both measured within 60 days of the initial email. Secondary outcomes included email communication engagement and components of both primary end points.</p><p><strong>Results: </strong>Among 7872 clinicians, 6574 were physicians (83.5%) and 4385 were men (55.7%). PDMP engagement was 11.8% (309 clinicians) in the usual care group. Legal requirement emails raised the engagement rate by 26.5 (95% CI, 24.3-28.7; P < .001) percentage points, while clinical benefit emails raised engagement 14.2 (95% CI, 12.0-16.3; P < .001) percentage points. Both types of emails raised account holding, database searches, and searches for patients with a history of risky prescribing. Effects endured for at least 7 months. Guideline-discordant prescribing did not differ significantly across groups.</p><p><strong>Conclusions and relevance: </strong>In this randomized clinical trial, email communications increased PDMP engagement, particularly emails emphasizing legal requirements for PDMP use. Such a low-cost, scalable email intervention may be of interest to policymakers and health care organizations seeking to promote PDMP use. Although these emails did not trigger large-scale changes in prescribing, similar interventions may be useful for promoting other best practices.</p><p><strong>Trial registration: </strong>ClinicalTrials.gov Identifier: NCT064433
重要性：处方药监测计划（PDMPs）可以促进阿片类药物和其他受控物质的更安全处方，但通常未被处方者充分利用。关于电子邮件活动提高临床医生参与PDMP的可行性和效果的证据有限。目的：探讨电子邮件沟通是否可以增加临床医生对PDMP的使用，从而减少处方与指南不一致的情况。设计、设置和参与者：该随机临床试验包括处方受控物质但缺乏PDMP帐户、不活跃PDMP帐户、不搜索PDMP或在处方阿片类药物时不经常搜索PDMP的临床医生。这项研究于2024年1月至2025年11月在美国明尼苏达州进行。干预：临床医生按1:1:1的比例随机分为2个干预组或常规护理组。干预组的临床医生被发送了多达2封电子邮件，强调他们缺乏PDMP参与（没有帐户，不活跃帐户，没有搜索或不频繁搜索），并提供了PDMP网站的超链接来纠正它。电子邮件的内容因小组而异，要么关注国家使用PDMP的法律要求，要么关注使用PDMP的临床益处。主要结果和衡量标准：PDMP参与度，定义为参与电子邮件中鼓励的活动（帐户创建、帐户重新激活、数据库搜索或更频繁的数据库搜索）；与指南不一致的阿片类药物处方，由5种处方措施组成，都是在最初的电子邮件发出后60天内测量的。次要结果包括电子邮件沟通参与度和两个主要终点的组成部分。结果：7872名临床医生中，医生6574人（占83.5%），男性4385人（占55.7%）。在常规护理组，PDMP的参与率为11.8%（309名临床医生）。结论和相关性：在这项随机临床试验中，电子邮件交流增加了PDMP的参与度，特别是强调PDMP使用的法律要求的电子邮件。这种低成本、可扩展的电子邮件干预可能会引起寻求促进PDMP使用的政策制定者和卫生保健组织的兴趣。虽然这些电子邮件没有引发处方的大规模变化，但类似的干预措施可能有助于促进其他最佳做法。试验注册：ClinicalTrials.gov标识符：NCT06443385。
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引用次数: 0
Hospital-Medicare Advantage Vertical Integration and Cardiopulmonary Care in Integrated Hospitals. 医院-医疗优势垂直整合与综合医院的心肺护理。
IF 11.3 Q1 HEALTH CARE SCIENCES & SERVICES
JAMA Health Forum
Pub Date : 2025-12-05 DOI: 10.1001/jamahealthforum.2025.5648
Geronimo Bejarano, Meehir N Dixit, Alexander P Philips, Karen E Joynt Maddox, Meredith B Rosenthal, Amal Trivedi, David J Meyers
<p><strong>Importance: </strong>The rate of health care payer and practitioner consolidation is increasing, with limited assessment of hospital-Medicare Advantage (MA) plan vertical integration. Little is known about whether aligned incentives between hospitals and MA contracts may improve care coordination and outcomes.</p><p><strong>Objective: </strong>To investigate the association between hospital-MA contract vertical integration and cardiopulmonary outcomes.</p><p><strong>Design, setting, and participants: </strong>This cross-sectional study included MA enrollees admitted for acute myocardial infarction, heart failure, or pneumonia between January 2015 and December 2022. Admissions that occurred in a hospital that owns an MA plan were matched to comparison admissions based on the propensity score of being enrolled in an integrated MA contract. Analysis was conducted between December 1, 2024, and March 20, 2025.</p><p><strong>Exposure: </strong>Admissions were categorized as nonintegrated (MA contract not owned by a hospital), partially integrated (hospital-owned MA contract but admission at nonaffiliated hospital), or fully integrated (admitted at a hospital that owns MA contract).</p><p><strong>Main outcomes and measures: </strong>Generalized linear models adjusted for demographics, clinical features, and hospital, zip code, year, and diagnosis-related group fixed effects. Care intensity was measured using length of stay and intensive care unit (ICU) use. Clinical outcomes were inpatient mortality, 30-day postdischarge mortality, and 30-day postdischarge readmission.</p><p><strong>Results: </strong>The sample consisted of 1 057 715 admissions, of which 234 587 were partially integrated and 118 017 were fully integrated. After matching, the mean (SD) age was 78.0 (9.9) years for participants in the nonintegrated group, 78.0 (9.9) years for those in the partially integrated group, and 78.0 (9.8) years in the fully integrated group; 48.8% were female in the nonintegrated group, 48.9% in the partially integrated group, and 48.9% in the fully integrated group. Fully integrated admissions had significantly shorter lengths of stay (adjusted difference, -0.24 days; 95% CI, -0.31 to -0.18 days vs nonintegrated; -0.28 days; 95% CI, -0.37 to -0.18 days vs partially integrated) and lower rates of ICU use (-1.17 percentage points; 95% CI, -1.82 to -0.52 percentage points vs nonintegrated; -1.42 percentage points; 95% CI, -2.44 to -0.40 percentage points vs partially integrated), inpatient mortality (-0.61 percentage points; 95% CI, -0.88 to -0.34 percentage points vs nonintegrated), 30-day postdischarge mortality (-0.87 percentage points; 95% CI, -1.30 to -0.44 percentage points vs nonintegrated), and 30-day postdischarge readmission (-0.78 percentage points; 95% CI, -1.30 to -0.26 percentage points vs nonintegrated).</p><p><strong>Conclusions and relevance: </strong>In this study, among patients hospitalized with myocardial infarction, heart failure, o
重要性：医疗保健支付者和执业者合并的比率正在增加，对医院-医疗保险优势（MA）计划垂直整合的评估有限。关于医院和MA合同之间的一致激励是否会改善护理协调和结果，我们知之甚少。目的：探讨医院-医院合同垂直整合与心肺预后的关系。设计、环境和参与者：这项横断面研究包括2015年1月至2022年12月期间因急性心肌梗死、心力衰竭或肺炎入院的MA患者。在拥有MA计划的医院中发生的入院情况与基于纳入综合MA合同的倾向得分的比较入院情况相匹配。分析时间为2024年12月1日至2025年3月20日。暴露：入院分为非整合（非医院拥有的MA合同）、部分整合（医院拥有的MA合同，但在非附属医院入院）或完全整合（在拥有MA合同的医院入院）。主要结果和测量：根据人口统计学、临床特征、医院、邮政编码、年份和诊断相关组固定效应调整的广义线性模型。护理强度通过住院时间和重症监护病房（ICU）使用来衡量。临床结果为住院死亡率、出院后30天死亡率和出院后30天再入院率。结果：共纳入1 057 715份，其中部分纳入234 587份，完全纳入118 017份。匹配后，非整合组参与者的平均（SD）年龄为78.0（9.9）岁，部分整合组参与者的平均（SD）年龄为78.0（9.9）岁，完全整合组参与者的平均（SD）年龄为78.0（9.8）岁；非融合组48.8%为女性，部分融合组48.9%为女性，完全融合组48.9%为女性。完全整合住院患者的住院时间明显缩短（调整后的差异为-0.24天，95% CI为-0.31至-0.18天，95% CI为-0.28天，95% CI为-0.37至-0.18天，部分整合住院患者的住院时间较短），ICU使用率较低（-1.17个百分点，95% CI为-1.82至-0.52个百分点，95% CI为-1.42至-0.40个百分点，部分整合住院患者的住院时间较低），住院患者死亡率(-0.61个百分点；95% CI, -0.88至-0.34个百分点（与非整合），出院后30天死亡率（-0.87个百分点；95% CI, -1.30至-0.44个百分点，与非整合），出院后30天再入院（-0.78个百分点，95% CI, -1.30至-0.26个百分点，与非整合）。结论和相关性：在本研究中，在因心肌梗死、心力衰竭或肺炎住院的患者中，在医院拥有的MA合同中登记并入住附属医院与更短的住院时间、更少的ICU使用、更低的死亡率和再入院率相关。
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引用次数: 0
Using Medical Loss Ratio Data to Examine Advance Premium Tax Credits. 使用医疗损失率数据检查预先保费税收抵免。
IF 11.3 Q1 HEALTH CARE SCIENCES & SERVICES
JAMA Health Forum
Pub Date : 2025-12-05 DOI: 10.1001/jamahealthforum.2025.5896
Elizabeth Plummer, Joshua Brooker, Mark Meiselbach, Ge Bai
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引用次数: 0
Outpatient Emergency Department Use Among Publicly Insured Patients. 门诊急诊科在公共保险患者中的使用。
IF 11.3 Q1 HEALTH CARE SCIENCES & SERVICES
JAMA Health Forum
Pub Date : 2025-12-05 DOI: 10.1001/jamahealthforum.2025.5916
Maya Spencer, Christopher Toretsky, Renee Y Hsia
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引用次数: 0
Different Definitions of Developmental Disability and Implications for Outcomes. 发育障碍的不同定义及其对结果的影响。
IF 11.3 Q1 HEALTH CARE SCIENCES & SERVICES
JAMA Health Forum
Pub Date : 2025-12-05 DOI: 10.1001/jamahealthforum.2025.5642
Ari Ne'eman, Hailey Clark
<p><strong>Importance: </strong>Populations identified under varying definitions of developmental disability (DD) differ in notable dimensions. Understanding these crucial differences is necessary when deciding which definition to utilize for policy analysis or service planning.</p><p><strong>Objective: </strong>To examine the distributive implications of 4 different potential definitions of DD using data from the 2023 Survey of Income and Program Participation (SIPP) and the University of Minnesota's Residential Information Systems Project (RISP).</p><p><strong>Design, setting, and participants: </strong>Cross-sectional study of the 2023 SIPP in the US general population, including institutionalized persons, using supplemental information from 2019 RISP reports. Analyses used person-level weights, and 95% CIs were logit-transformed. The 4 definitions of DD are based on self-reported medical diagnoses of those who answered affirmatively to at least 1 of 18 disability screener questions. The narrowest definition captures cerebral palsy, intellectual disability, and/or autism diagnoses, while the broadest definition also includes epilepsy, learning disability diagnoses, and/or those identified by the SIPP learning and developmental disability screener question.</p><p><strong>Main outcomes and measures: </strong>Outcomes include DD prevalence, utilization of long-term services and supports (LTSS), congregate residential facilities, and income support (Supplemental Security Income/Social Security Disability Insurance), self-reported employment, and impairment characteristics.</p><p><strong>Results: </strong>In the study population of 2535 children and young adults aged 5 to 21 years (1285 [50.7%] males and 1250 [49.3%] females) and 9701 adults aged 22 years or older (4617 [47.6%] males and 5084 [52.4%] females), childhood and young adulthood prevalence of DD ranged from 4.17% (95% CI, 3.41%-5.09%) using the narrowest definition to 15.93% (95% CI, 14.43%-17.55%) using the broadest definition. For adults, DD prevalence varied from 1.24% (95% CI, 1.01%-1.52%) to 8.10% (95% CI, 7.48%-8.77%). Under the narrowest definition, 20.35% (95% CI, 16.67%-24.89%) of children and young adults with DD and 33.05% (95% CI, 26.87%-40.30%) of adults with DD were eligible for LTSS from a state DD agency and 0.98% (95% CI, 0.80%-1.20%) of children and young adults with DD and 9.82% (95% CI, 7.99%-11.98%) of adults with DD were estimated to be residing in a congregate residential setting. As definitions became more comprehensive, employment increased while LTSS eligibility, congregate setting placement, income support receipt (Supplemental Security Income/Social Security Disability Insurance), and functional impairment acuity decreased.</p><p><strong>Conclusions and relevance: </strong>Results of this cross-sectional study of US children and young adults suggest that definition choice substantially affects DD prevalence estimates and the relevance of identified populations
重要性：根据不同的发育性残疾（DD）定义确定的人群在显著方面存在差异。在决定将哪个定义用于策略分析或服务规划时，了解这些关键差异是必要的。目的：利用来自2023年收入和计划参与调查（SIPP）和明尼苏达大学住宅信息系统项目（RISP）的数据，研究4种不同的DD潜在定义的分布含义。设计、设置和参与者：2023年SIPP在美国普通人群中的横断面研究，包括机构人员，使用2019年RISP报告的补充信息。分析使用个人水平权重，95% ci进行对数转换。DD的4种定义是基于那些对18个残疾筛查问题中至少1个回答肯定的人的自我报告的医学诊断。最狭义的定义包括脑瘫、智力残疾和/或自闭症诊断，而最广义的定义还包括癫痫、学习障碍诊断和/或由SIPP学习和发育障碍筛查问题确定的诊断。主要结果和措施：结果包括DD患病率、长期服务和支持（LTSS）的利用、综合居住设施和收入支持（补充安全收入/社会保障残疾保险）、自我报告的就业和损伤特征。结果：在2535名5 - 21岁儿童和青壮年（男性1285名[50.7%]，女性1250名[49.3%]）和9701名22岁及以上成人（男性4617名[47.6%]，女性5084名[52.4%]）的研究人群中，儿童和青壮年的DD患病率从最窄定义4.17% （95% CI, 3.41%-5.09%）到最宽定义15.93% （95% CI, 14.43%-17.55%）不等。成人的DD患病率从1.24% （95% CI, 1.01%-1.52%）到8.10% （95% CI, 7.48%-8.77%）不等。在最狭窄的定义下，20.35% （95% CI, 16.67%-24.89%）的DD儿童和年轻成人和33.05% （95% CI, 26.87%-40.30%）的DD成人符合从国家DD机构获得LTSS的条件，估计0.98% （95% CI, 0.80%-1.20%）的DD儿童和年轻成人和9.82% （95% CI, 7.99%-11.98%）的DD成人居住在一个聚集的居住环境中。随着定义变得更加全面，就业增加，而LTSS资格，聚集环境安置，收入支持收据（补充安全收入/社会保障残疾保险）和功能障碍敏锐度下降。结论和相关性：这项针对美国儿童和年轻人的横断面研究的结果表明，定义的选择在很大程度上影响了DD患病率的估计，以及确定人群在服务提供和社区整合方面的相关性。较窄的方法可能更好地捕获处于最大隔离风险的个体，以及最有可能利用公共资助的DD服务的个体。
{"title":"Different Definitions of Developmental Disability and Implications for Outcomes.","authors":"Ari Ne'eman, Hailey Clark","doi":"10.1001/jamahealthforum.2025.5642","DOIUrl":"10.1001/jamahealthforum.2025.5642","url":null,"abstract":"&lt;p&gt;&lt;strong&gt;Importance: &lt;/strong&gt;Populations identified under varying definitions of developmental disability (DD) differ in notable dimensions. Understanding these crucial differences is necessary when deciding which definition to utilize for policy analysis or service planning.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Objective: &lt;/strong&gt;To examine the distributive implications of 4 different potential definitions of DD using data from the 2023 Survey of Income and Program Participation (SIPP) and the University of Minnesota's Residential Information Systems Project (RISP).&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Design, setting, and participants: &lt;/strong&gt;Cross-sectional study of the 2023 SIPP in the US general population, including institutionalized persons, using supplemental information from 2019 RISP reports. Analyses used person-level weights, and 95% CIs were logit-transformed. The 4 definitions of DD are based on self-reported medical diagnoses of those who answered affirmatively to at least 1 of 18 disability screener questions. The narrowest definition captures cerebral palsy, intellectual disability, and/or autism diagnoses, while the broadest definition also includes epilepsy, learning disability diagnoses, and/or those identified by the SIPP learning and developmental disability screener question.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Main outcomes and measures: &lt;/strong&gt;Outcomes include DD prevalence, utilization of long-term services and supports (LTSS), congregate residential facilities, and income support (Supplemental Security Income/Social Security Disability Insurance), self-reported employment, and impairment characteristics.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Results: &lt;/strong&gt;In the study population of 2535 children and young adults aged 5 to 21 years (1285 [50.7%] males and 1250 [49.3%] females) and 9701 adults aged 22 years or older (4617 [47.6%] males and 5084 [52.4%] females), childhood and young adulthood prevalence of DD ranged from 4.17% (95% CI, 3.41%-5.09%) using the narrowest definition to 15.93% (95% CI, 14.43%-17.55%) using the broadest definition. For adults, DD prevalence varied from 1.24% (95% CI, 1.01%-1.52%) to 8.10% (95% CI, 7.48%-8.77%). Under the narrowest definition, 20.35% (95% CI, 16.67%-24.89%) of children and young adults with DD and 33.05% (95% CI, 26.87%-40.30%) of adults with DD were eligible for LTSS from a state DD agency and 0.98% (95% CI, 0.80%-1.20%) of children and young adults with DD and 9.82% (95% CI, 7.99%-11.98%) of adults with DD were estimated to be residing in a congregate residential setting. As definitions became more comprehensive, employment increased while LTSS eligibility, congregate setting placement, income support receipt (Supplemental Security Income/Social Security Disability Insurance), and functional impairment acuity decreased.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusions and relevance: &lt;/strong&gt;Results of this cross-sectional study of US children and young adults suggest that definition choice substantially affects DD prevalence estimates and the relevance of identified populations","PeriodicalId":53180,"journal":{"name":"JAMA Health Forum","volume":"6 12","pages":"e255642"},"PeriodicalIF":11.3,"publicationDate":"2025-12-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12717609/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"146115000","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
Intensive Care Unit Admissions Purchased or Delivered by Veterans in the VA Health Care System. 退伍军人在VA医疗保健系统中购买或提供的重症监护病房入场券。
IF 11.3 Q1 HEALTH CARE SCIENCES & SERVICES
JAMA Health Forum
Pub Date : 2025-12-05 DOI: 10.1001/jamahealthforum.2025.5605
Zachary Hahn, Hiam Naiditch, Victor Talisa, Brian Tyler, John R Hotchkiss, Bryan J McVerry, Sachin Yende, Florian B Mayr

Importance: The Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act expanded access to community-based health care for veterans enrolled in the Veterans Affairs (VA) Health Care System. At the same time, the COVID-19 pandemic created unprecedented demand for intensive care unit (ICU) care. The combined impact of these changes on critical care delivery, outcomes, and spending remains unclear.

Objective: To describe patterns in ICU admissions, case complexity, 90-day mortality, and VA spending for VA-delivered vs VA-purchased community ICU care from 2019 to 2023.

Design, setting, and participants: Repeated cross-sectional study of 1 151 915 ICU admissions among veterans treated at 99 VA medical centers (VAMCs) and 4288 community hospitals reimbursed through the VA Community Care Network from January 1, 2019, to December 31, 2023. Stratified time series analyses were used to illustrate trends across 4 periods: pre-MISSION, post-MISSION, COVID-19 emergency, and post-COVID-19 stabilization. Interrupted time series analyses were then applied using unified regression models with interaction terms to assess differences across these periods.

Main outcomes and measures: Main outcomes were monthly ICU admission volume, Case Mix Index weight, Charlson Comorbidity Index, 90-day all-cause mortality, and VA expenditures on community ICU care. Models were adjusted for demographic, clinical, and temporal covariates.

Results: Of 1 151 915 ICU admissions among VA-enrolled veterans, including 270 237 at 99 VAMCs and 881 678 at 4288 community hospitals reimbursed through the VA community care network, 881 678 occurred in community hospitals. From 2019 to 2023, ICU admissions decreased by 21.3% in VAMCs and increased by 46.8% in community hospitals. Interrupted time series models showed increased mortality during the COVID-19 period in both settings and decreased mortality in VAMCs following the pandemic. Stratified time series models showed a postpandemic adjusted mortality rate of 18.4% (95% CI, 18.2%-18.7%) at VAMCs compared with 20.0% (95% CI, 19.8%-20.2%) in the community. Community hospitals had higher median Case Mix Indices, and total inflation-adjusted VA spending on community ICU care increased by 50% from $2.70 billion in 2019 to $4.04 billion in 2023, driven by increased admission volume.

Conclusions and relevance: This study found that VA-purchased community ICU care expanded markedly while incurring higher costs and slightly worse outcomes. These shifts underscore growing reliance on external critical care infrastructure and raise policy concerns around VA capacity planning, care integration, and quality oversight for veterans with high-acuity needs.

重要性：维护内部系统和加强整合外部网络（MISSION）法案扩大了在退伍军人事务（VA）医疗保健系统登记的退伍军人获得社区医疗保健的机会。与此同时，COVID-19大流行对重症监护病房（ICU）护理产生了前所未有的需求。这些变化对重症监护服务、结果和支出的综合影响尚不清楚。目的：描述2019年至2023年ICU入院、病例复杂性、90天死亡率和VA提供与VA购买的社区ICU护理的VA支出模式。设计、环境和参与者：从2019年1月1日至2023年12月31日，通过VA社区护理网络，在99个VA医疗中心（VAMCs）和4288个社区医院接受治疗的1 151 915名退伍军人ICU住院患者的重复横断面研究。分层时间序列分析用于说明4个时期的趋势：任务前、任务后、COVID-19紧急情况和COVID-19稳定后。然后使用具有相互作用项的统一回归模型应用中断时间序列分析来评估这些时期之间的差异。主要结局和指标：主要结局包括每月ICU入院人数、病例混合指数权重、Charlson合并症指数、90天全因死亡率和社区ICU护理的VA支出。根据人口统计学、临床和时间协变量对模型进行了调整。结果：1 151 915例退伍军人ICU住院，其中99家VAMCs住院270 237例，4288家社区医院住院881 678例，其中881 678例发生在社区医院。2019 - 2023年，VAMCs的ICU住院率下降了21.3%，社区医院的ICU住院率上升了46.8%。中断时间序列模型显示，在COVID-19期间，这两种情况下的死亡率都有所上升，大流行后VAMCs的死亡率有所下降。分层时间序列模型显示，VAMCs的大流行后调整死亡率为18.4% (95% CI, 18.2%-18.7%)，而社区为20.0% （95% CI, 19.8%-20.2%）。社区医院的病例混合指数中位数较高，在入院人数增加的推动下，经通货膨胀调整后的社区ICU护理VA总支出从2019年的27亿美元增加到2023年的40.4亿美元，增长了50%。结论和相关性：本研究发现，va购买的社区ICU护理显著扩大，但成本较高，结果略差。这些转变强调了对外部重症护理基础设施的日益依赖，并引起了对VA容量规划、护理整合和对有高危需求的退伍军人的质量监督的政策关注。
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引用次数: 0
Potential Changes in US Homelessness by Ending Federal Support for Housing First Programs. 结束联邦政府对住房优先项目的支持，美国无家可归者的潜在变化。
IF 11.3 Q1 HEALTH CARE SCIENCES & SERVICES
JAMA Health Forum
Pub Date : 2025-12-05 DOI: 10.1001/jamahealthforum.2025.5747
Kirk B Fetters, Pranav Padmanabhan, Ashley A Meehan, Margot Kushel, Joshua A Barocas
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引用次数: 0
Obstetric-Related Emergency Medical Treatment and Labor Act Violations and No Health Exception Bans. 与产科有关的紧急医疗和违反《劳动法》和禁止无健康例外。
IF 11.3 Q1 HEALTH CARE SCIENCES & SERVICES
JAMA Health Forum
Pub Date : 2025-12-05 DOI: 10.1001/jamahealthforum.2025.4726
Liana R Woskie, Nora Brower, Jonathan Shaffer, Keren Ladin
<p><strong>Importance: </strong>The Emergency Medical Treatment and Labor Act (EMTALA) guarantees access to emergency care, including for pregnancy-related conditions. Many states have enacted abortion bans that may conflict with the federal mandate under EMTALA to screen and stabilize patients in obstetric emergencies.</p><p><strong>Objective: </strong>To evaluate changes in obstetric-related EMTALA violations following state and federal restrictions on abortion.</p><p><strong>Design and settings: </strong>This study used a staggered difference-in-differences design and Callaway-Sant'Anna estimator, leveraging a 100% sample of EMTALA filings from 2018 through quarter 1 of 2023 that was obtained via the Freedom of Information Act from the US Centers for Medicare & Medicaid Services. Filings were classified by clinical context and associated with stringency of state abortion laws. Additional models incorporated emergency department (ED) utilization data from the Healthcare Cost and Utilization Project and Medicaid expansion status to understand if violation trends were associated with shifting utilization patterns. Data were analyzed from February to July 2025.</p><p><strong>Exposures: </strong>State-level abortion bans that prohibit abortion and lack a clinically meaningful health exception for the pregnant person. Treatment was defined as adoption of a total or near-total abortion ban that (1) were effectively comprehensive across gestation, (2) provided no meaningful health exception, and (3) generated a documented allegation against preemption of federal EMTALA guidance during the study period.</p><p><strong>Main outcomes and measures: </strong>The primary outcome was the count of EMTALA violations involving obstetric emergencies. Secondary analyses examined ED utilization trends and the distribution of violations by infraction type (eg, failure to provide a medical screening examination).</p><p><strong>Results: </strong>States that enacted abortion bans with no health exception experienced a substantial increase in the number of EMTALA violations that were obstetric related, with an additional 1.18 violations per quarter (95% CI, 0.49-1.86; P = .001). Texas, which implemented Senate bill 8 in 2021, showed an average treatment effect on the treated of 0.69 violations per quarter (95% CI, 0.46-0.91; P < .001). The 5 states that triggered no health exception bans had a smaller, imprecise increase (0.49; 95% CI, -0.13 to 1.12; P = .12). A concurrent rise in ED utilization in non-Medicaid expansion states and a growing number of obstetric violations due to failures in medical screening were also observed, suggesting delays in initial triage or assessment.</p><p><strong>Conclusions and relevance: </strong>The results of this difference-in-differences analysis suggest that strict abortion bans, particularly Senate bill 8 in Texas, were followed by a measurable escalation in EMTALA violations involving obstetric emergencies. Uncertainty regarding sta
重要性：《紧急医疗和劳工法》（EMTALA）保证获得紧急护理，包括与怀孕有关的情况。许多州颁布了堕胎禁令，这可能与EMTALA规定的筛查和稳定产科急诊患者的联邦任务相冲突。目的：评估州和联邦限制堕胎后产科相关EMTALA违规行为的变化。设计和设置：本研究使用了交错差中差设计和Callaway-Sant'Anna估计器，利用了从2018年到2023年第一季度的100% EMTALA文件样本，该样本通过《信息自由法》从美国医疗保险和医疗补助服务中心获得。文件按临床情况分类，并与州堕胎法的严格程度有关。其他模型纳入了急诊科（ED）利用数据，这些数据来自医疗成本和利用项目以及医疗补助扩张状态，以了解违规趋势是否与利用模式的转变有关。数据分析时间为2025年2月至7月。暴露：州一级的堕胎禁令禁止堕胎，并且缺乏对孕妇有临床意义的健康例外。治疗被定义为采用完全或近乎完全的堕胎禁令，该禁令(1)在整个妊娠期有效地全面实施，(2)不提供有意义的健康例外，以及(3)在研究期间产生文件指控，反对联邦EMTALA指导的先发制人。主要结果和措施：主要结果是涉及产科急诊的违反《EMTALA》行为的计数。第二次分析审查了急诊的利用趋势和按违规类型（例如，未提供体检）分列的违规分布情况。结果：在没有健康例外的情况下颁布堕胎禁令的国家，与产科有关的EMTALA违规行为数量大幅增加，每季度增加1.18起（95%置信区间，0.49-1.86;P = .001）。德克萨斯州于2021年实施了参议院第8号法案，每季度对0.69例违规行为的平均治疗效果（95% CI, 0.46-0.91； P）结论和相关性：这种差异中差异分析的结果表明，严格的堕胎禁令，特别是德克萨斯州的参议院第8号法案，导致了涉及产科急诊的EMTALA违规行为的可测量升级。州政策的不确定性和对州法律的推迟可能会重塑一线急诊护理，并损害联邦政府保护的产科急诊服务。
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引用次数: 0
Variability in Insurance Adequacy for Children With Special Health Care Needs on Medicaid. 医疗补助中有特殊医疗需求儿童保险充分性的可变性
IF 11.3 Q1 HEALTH CARE SCIENCES & SERVICES
JAMA Health Forum
Pub Date : 2025-12-05 DOI: 10.1001/jamahealthforum.2025.5366
Amy J Houtrow, Matt Hall, James M Perrin, Dennis Z Kuo, Jeffrey D Colvin, Allysa Ware, Jeffery S Schiff, Jay Berry, Ryan J Coller
{"title":"Variability in Insurance Adequacy for Children With Special Health Care Needs on Medicaid.","authors":"Amy J Houtrow, Matt Hall, James M Perrin, Dennis Z Kuo, Jeffrey D Colvin, Allysa Ware, Jeffery S Schiff, Jay Berry, Ryan J Coller","doi":"10.1001/jamahealthforum.2025.5366","DOIUrl":"10.1001/jamahealthforum.2025.5366","url":null,"abstract":"","PeriodicalId":53180,"journal":{"name":"JAMA Health Forum","volume":"6 12","pages":"e255366"},"PeriodicalIF":11.3,"publicationDate":"2025-12-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12681037/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145679364","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
Curbing the Growing Fragmentation of Veterans' Health Care. 遏制退伍军人医疗保健日益分散的局面。
IF 11.3 Q1 HEALTH CARE SCIENCES & SERVICES
JAMA Health Forum
Pub Date : 2025-12-05 DOI: 10.1001/jamahealthforum.2025.4148
Kenneth W Kizer
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引用次数: 0
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