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.

Importance: Understanding the results of federal investment in primary care delivery and transformation is essential for informing practitioners, future program developers, and policymakers on how best to improve delivery of primary care.

Objective: To identify outcomes of federal investment in primary care delivery transformation on patient experience, costs and utilization, population health, and practice experience.

Evidence review: Publicly available program evaluation reports and articles published between July 2011 (the start of the earliest identified programs) and December 31, 2024, were identified on PubMed, Scopus, CINAHL, Embase, Web of Science, and the Cochrane Library. The review included independently evaluated federal programs started after January 2011 and completed by December 2021.

Findings: A total of 142 records were included in the analysis from 5 programs that met inclusion criteria: the Federally Qualified Health Center Advanced Primary Care Practice demonstration, the Multi-Payer Advanced Primary Care Practice model, the Comprehensive Primary Care (CPC) initiative, CPC Plus, and EvidenceNOW Advancing Heart Health. Programs supported practice-level changes in care delivery through payment changes, performance requirements, data feedback, and technical assistance. Federal investments were associated with substantial improvements in clinical care delivery, greater patient engagement, modest reductions in utilization, and net increases in expenditures. There was an association between practice efforts and intrinsic practice characteristics, and practices were limited by funding amounts and modality, difficulties in using electronic health records and payer data to support care improvement, staff turnover, and extrinsic factors.

Conclusions and relevance: This systematic review found that investing in primary care was associated with improvements in practice experience and population health, while outcomes regarding patient experience, costs, and utilization were mixed. Access to practice-level data and payment system challenges limited these impacts, and most outcomes were not seen until after at least 2 years. Countervailing payment incentives may have affected outcomes. Future primary care transformation efforts should focus on addressing practice-level barriers, aligning payment, and targeting support for practice-level organizational improvement based on local needs.

Importance: Evidence is limited regarding whether end-of-life care for individuals with dementia varies by race and ethnicity, and whether observed variations can be explained by differences in the physicians providing their care.

Objective: To evaluate end-of-life care among individuals with dementia across racial and ethnic groups, and to investigate whether care variations are explained by differences in treating physicians.

Design, setting, and participants: This cohort study used national, population-based claims data from a 20% random sample of Medicare fee-for-service beneficiaries aged 66 years or older with a diagnosis of dementia who died between 2016 and 2019. Data were analyzed from January 2024 to June 2025.

Main outcomes and measures: Emergency department, hospital, and intensive care unit use, mechanical ventilation or cardiopulmonary resuscitation, and feeding tube placement in last 30 days of life; death in acute care hospital; hospice use and palliative care counseling in last 180 days of life; and any billed advance care planning before death.

Results: Among 259 945 decedents with dementia (mean [SD] age, 85.8 [8.0] years; 60.4% female), 8.3% were non-Hispanic Black, 4.4% were Hispanic, and 87.3% were non-Hispanic White. Compared with non-Hispanic White decedents, non-Hispanic Black decedents were more likely to receive emergency department (difference, 5.7 percentage points [pp]; 95% CI, 5.0-6.4 pp), hospital (difference, 4.0 pp; 95% CI, 3.3-4.7 pp), intensive care unit (difference, 4.3 pp; 95% CI, 3.7-4.9 pp), mechanical ventilation or cardiopulmonary resuscitation (difference, 3.8 pp; 95% CI, 3.3-4.3 pp), and feeding tube placement (difference, 1.8 pp; 95% CI, 1.5-2.1 pp) care, as well as die in a hospital (difference, 3.5 pp; 95% CI, 2.9-4.1 pp). Non-Hispanic Black decedents were less likely to use hospice (difference, -6.1 pp; 95% CI, -6.8 to -5.4 pp) and more likely to receive palliative care counseling (difference, 3.2 pp; 95% CI, 2.6-3.9 pp) and billed advance care planning (difference, 1.8 pp; 95% CI, 1.2-2.3 pp) than non-Hispanic White decedents. Similar patterns were observed among Hispanic decedents. Variations in end-of-life care remained qualitatively unchanged when comparing decedents treated by the same physician.

Conclusions and relevance: Findings from this cohort study suggest that non-Hispanic Black and Hispanic decedents with dementia received more intensive end-of-life care despite higher rates of billed advance care planning and palliative care counseling than non-Hispanic White decedents. Observed racial and ethnic variations were not explained by differences in the physicians treating them.