Health Services Research最新文献_第4页

The Impact of Community Care on Spine Surgical Complexity and Outcomes in the Veterans Health Administration 退伍军人健康管理局社区护理对脊柱手术复杂性和结果的影响。

IF 3.2 2区医学 Q2 HEALTH CARE SCIENCES & SERVICES

Health Services Research

Pub Date : 2025-10-17 DOI: 10.1111/1475-6773.70057

Allison Dorneo, Yi-Jung Shen, Aigerim Kabdiyeva, Daniel Asfaw, Melissa M. Garrido, Steven D. Pizer, Jacob Rachlin, Hillary J. Mull

Objective

To investigate the relationship between community care (CC) treatment, surgical complexity, and postoperative surgical outcomes in spine surgeries among Veterans.

Data Sources and Study Setting

Veterans Health Administration (VHA) sample with data sourced from the Corporate Data Warehouse and CC claims.

Study Design

To evaluate differences in VHA and CC spine surgical complexity and outcomes, we first characterized VHA patients with lumbar spinal stenosis (LSS) who received spine surgery in the VHA or CC. Then, we estimated adjusted naïve logistic regression models to calculate the effect of CC on the probability of having a complex spine surgery, 30-day readmission, 30-day complication, and 1-year reoperation. Finally, we estimated adjusted 2-stage models using an instrument for primary care provider's historical CC referral rates and imaging rates as a semi-parametric Newey correction for sample selection.

Analytic Sample

LSS-diagnosed patients living ≤ 80 miles from a VHA facility that performed at least one spine surgery between January 1, 2019 and December 31, 2022.

Principal Findings

Of the 41,726 LSS-diagnosed patients, 7496 (18.0%) had spine surgery within 1 year of diagnosis. 2920 (39.0%) were VHA surgeries and 4576 (61.0%) were in CC. In the naïve model, CC surgery was associated with a 26.61 percentage point (pp) increase in the probability of having a complex surgery (95% CI 24.17, 29.05), a 4.31 pp increase in readmission (95% CI 2.76, 5.85), and a 6.80 pp increase in reoperation (95% CI 5.21, 8.40). After accounting for characteristics associated with the likelihood of surgery, CC, and outcomes, only the effect of CC use on the probability of a complex surgery was significant (36.48; 95% CI 22.69, 50.27).

Conclusions

We found no difference in surgical outcomes between VHA and CC patients. Since CC patients were more likely to receive complex spine surgeries, the VHA paid for more costly, resource-intensive procedures with no improvements in quality.

目的：探讨退伍军人脊柱手术中社区护理（CC）治疗、手术复杂性与术后手术效果的关系。数据来源和研究设置：退伍军人健康管理局（VHA）样本，数据来自公司数据仓库和CC索赔。研究设计：为了评估VHA和CC脊柱手术复杂性和结局的差异，我们首先对在VHA或CC中接受脊柱手术的VHA合并腰椎管狭窄（LSS）患者进行了特征分析，然后，我们估计了调整后的naïve逻辑回归模型，以计算CC对复杂脊柱手术、30天再入院、30天并发症和1年再手术概率的影响。最后，我们使用初级保健提供者的历史CC转诊率和成像率作为样本选择的半参数Newey校正的仪器来估计调整后的两阶段模型。分析样本：lss诊断的患者居住在距离2019年1月1日至2022年12月31日期间至少进行过一次脊柱手术的VHA设施≤80英里的地方。主要发现：在41726例lss诊断患者中，7496例（18.0%）在诊断1年内进行了脊柱手术。2920例（39.0%）为VHA手术，4576例（61.0%）为CC手术。在naïve模型中，CC手术与发生复杂手术的概率增加26.61个百分点（95% CI 24.17, 29.05），再入院增加4.31个百分点（95% CI 2.76, 5.85），再手术增加6.80个百分点（95% CI 5.21, 8.40）相关。在考虑了与手术可能性、CC和结局相关的特征后，只有CC使用对复杂手术可能性的影响是显著的（36.48;95% CI 22.69, 50.27）。结论：我们发现VHA和CC患者的手术结果没有差异。由于CC患者更有可能接受复杂的脊柱手术，VHA支付了更昂贵、资源密集的手术，但质量没有提高。

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引用次数: 0

The Expanding Role of Health Services Research in Cancer Prevention and Control. 卫生服务研究在癌症预防和控制中的作用日益扩大。

IF 3.2 2区医学 Q2 HEALTH CARE SCIENCES & SERVICES

Health Services Research

Pub Date : 2025-10-15 DOI: 10.1111/1475-6773.70056

Asal Pilehvari, Xin Hu, Roger Anderson

引用次数: 0

Impact of Scope of Practice Laws for Certified Registered Nurse Anesthetists on the Utilization of Anesthesia Services 《注册麻醉师执业范围法》对麻醉服务使用的影响。

IF 3.2 2区医学 Q2 HEALTH CARE SCIENCES & SERVICES

Health Services Research

Pub Date : 2025-10-15 DOI: 10.1111/1475-6773.70052

Projesh P. Ghosh, Wafa W. Tarazi, Nwanneamaka Ume, Emily E. Ferrara, Paul Hogan, Emily D. Parker

Objective

To assess the impact of pandemic-related changes in state scope of practice law (SOPL) for certified registered nurse anesthetists (CRNAs) on the utilization of anesthesia services during the COVID-19 pandemic, which served as a natural experiment.

Study Setting and Design

We used a difference-in-differences approach to compare changes in the utilization of anesthesia services during the COVID-19 pandemic in areas that expanded SOPL (removed requirements for supervision or direction) to those that did not. Additionally, we examined if the impact of changes in SOPL on patient access differed by underserved status.

Data Sources and Analytic Sample

To understand patient access to anesthesia care, we used a large, national administrative claims database of privately insured and Medicare Advantage enrollees to measure utilization rates per 1000 members from 2018 through 2022. We used the county-level density of anesthesia providers to identify underserved areas. We used data on the changes in SOPL at the state level and assessed changes in utilization prior to and during COVID-19.

Principal Findings

In the areas that changed SOPL, removing requirements for supervision or direction, utilization of anesthesia procedures increased by 18 procedures per 1000 members over the study period (17% increase; p-value 0.066) compared with an increase of 9 procedures per 1000 members (7% increase; p-value 0.031) in areas that maintained SOPL requiring supervision. However, increases in utilization in underserved and not underserved areas were similar across SOPL statuses.

Conclusions

This study provides evidence that the SOPL that allows CRNAs to practice without the requirement of supervision or direction results in greater access to anesthesia services compared with a more restrictive SOPL requiring supervision.

目的：通过自然实验，评估COVID-19大流行期间注册麻醉师（crna）国家执业范围法（SOPL）的流行相关变化对麻醉服务利用的影响。研究设置和设计：我们采用差异中的差异方法来比较COVID-19大流行期间扩大SOPL（取消监督或指导要求）和未扩大SOPL的地区麻醉服务利用的变化。此外，我们检查了SOPL变化对患者访问的影响是否因服务不足状况而异。数据来源和分析样本：为了了解患者获得麻醉护理的情况，我们使用了一个大型的国家行政索赔数据库，其中包括私人保险和医疗保险优势参保者，以衡量2018年至2022年每1000名会员的使用率。我们使用县级麻醉提供者的密度来确定服务不足的地区。我们使用了州一级SOPL变化的数据，并评估了COVID-19之前和期间的利用率变化。主要发现：在改变SOPL，取消监督或指导要求的地区，麻醉程序的使用在研究期间每1000名成员增加了18次（增加17%，p值0.066），而在需要监督的维持SOPL的地区，每1000名成员增加了9次（增加7%，p值0.031）。然而，在服务不足和服务不足的地区，利用率的增加在SOPL状态下是相似的。结论：本研究提供的证据表明，与需要监督的更严格的SOPL相比，允许crna在不需要监督或指导的情况下执业的SOPL可以获得更多的麻醉服务。

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引用次数: 0

Effects of Medicaid Coverage on Work: Evidence From Extending Postpartum Medicaid Coverage 医疗补助覆盖对工作的影响：来自扩大产后医疗补助覆盖的证据。

IF 3.2 2区医学 Q2 HEALTH CARE SCIENCES & SERVICES

Health Services Research

Pub Date : 2025-10-09 DOI: 10.1111/1475-6773.70055

Ufuoma Ejughemre, Wei Lyu, George L. Wehby

Objective

To evaluate the effects of the Family First Coronavirus Response Act (FFCRA) on work outcomes of women for whom the FFCRA effectively expanded income eligibility for Medicaid beyond 60 days postpartum by prohibiting states from redetermining Medicaid eligibility between March 2020 and March 2023.

Study Setting and Design

We use a difference-in-differences design that leverages the differences in income eligibility between pregnancy and non-pregnancy across states, and compares outcome changes pre–post FFCRA over these differences.

Data Sources and Analytic Sample

Data come from the 2016–2022 American Community Survey. The sample includes 205,104 women aged 19–49 years who reported giving birth within the past 12 months in 41 states and Washington D.C.

Principal Findings

On average, the FFCRA increased postpartum Medicaid coverage by 2.8 percentage points (95% CI: 0.7–4.8) or by 9.3% relative to the 2019 Medicaid coverage rate. In contrast, the FFCRA effects on work outcomes were small and not significant: the average effect was 0.10 percentage points for labor force participation (95% CI: −1.0 to 1.2), 0.7 percentage points for employment (95% CI: −0.02 to 1.4), 0.04 h for weekly work hours (95% CI: −0.4 to 0.5), and 0.2 percentage points for full-time employment (95% CI: −1.1 to 1.5). These confidence intervals rule out an employment decline above 0.02 percentage points and full-time employment decline above 1.1 percentage points. The increase in Medicaid coverage is concentrated among states with a larger difference between pregnancy and non-pregnancy eligibility (+5.9 percentage points; 95% CI: 0.9 to 10.9) and estimates in this group also rule out relatively small declines in work outcomes.

Conclusion

There is no evidence of declines in work outcomes following the increase in Medicaid coverage beyond 60 days postpartum that resulted from the FFCRA. The findings suggest that subsequent postpartum Medicaid coverage extensions for 12 months under the American Rescue Plan are unlikely to disincentivize work among beneficiaries.

目的：评估《家庭第一冠状病毒应对法案》（FFCRA）对女性工作成果的影响，FFCRA禁止各州在2020年3月至2023年3月期间重新确定医疗补助资格，从而有效地扩大了产后60天以上的医疗补助收入资格。研究设置和设计：我们采用差异中的差异设计，利用各州怀孕和非怀孕之间收入资格的差异，并比较FFCRA前后的结果变化。数据来源和分析样本：数据来自2016-2022年美国社区调查。该样本包括205,104名年龄在19-49岁之间的妇女，她们报告在过去12个月内在41个州和华盛顿特区分娩。主要发现：相对于2019年的医疗补助覆盖率，FFCRA平均将产后医疗补助覆盖率提高了2.8个百分点（95% CI: 0.7-4.8）或9.3%。相比之下，FFCRA对工作结果的影响较小且不显著：劳动力参与的平均影响为0.10个百分点（95% CI: -1.0至1.2），就业的平均影响为0.7个百分点（95% CI: -0.02至1.4），每周工作时间的平均影响为0.04个小时（95% CI: -0.4至0.5），全职就业的平均影响为0.2个百分点（95% CI: -1.1至1.5）。这些置信区间排除了就业下降超过0.02个百分点和全职就业下降超过1.1个百分点的可能性。医疗补助覆盖范围的增加主要集中在怀孕和非怀孕资格差异较大的州（+5.9个百分点；95% CI: 0.9至10.9），这一组的估计也排除了工作成果相对较小的下降。结论：没有证据表明，在FFCRA导致的产后60天以上医疗补助覆盖率增加后，工作结果会下降。研究结果表明，在美国救援计划下，随后的产后医疗补助覆盖范围延长了12个月，不太可能抑制受益人的工作积极性。

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引用次数: 0

Exploring State-Level Change in Health Care Value Over Three Decades in the United States, 1991–2020 探索三十年来美国州一级医疗保健价值的变化，1991-2020。

IF 3.2 2区医学 Q2 HEALTH CARE SCIENCES & SERVICES

Health Services Research

Pub Date : 2025-10-09 DOI: 10.1111/1475-6773.70054

Haley Lescinsky, Maitreyi Sahu, Meera Beauchamp, Sawyer Crosby, Emily Johnson, Theresa A. McHugh, John W. Scott, Kevin Schulman, Azalea Thomson, Maxwell Weil, Joseph L. Dieleman, Arnold Milstein

Objective

To examine trends in state-level health care value over three decades, defined using statewide health care spending and cause-specific mortality, and to explore its associations with potentially modifiable state attributes.

Study Setting and Design

We use stochastic frontier analysis to identify the “inefficiency” of each state's delivery system in converting health care spending into lower mortality–incidence or mortality–prevalence rates, adjusting for underlying population risk (age, smoking, obesity, etc.). We combine these inefficiency scores to score and compare delivery system value for each state and track change over three decades. Then, we use linear regression to look across states and identify state-level attributes significantly associated with greater health care value.

Data Sources and Analytic Sample

For each US state and year from 1991 to 2020, we extracted mortality–incidence or mortality–prevalence rates for 67 high-mortality health conditions from the Global Burden of Disease 2021 Study and state health care spending from the State Health Expenditure Accounts.

Principal Findings

Across US states, value on average increased from 1991 to 2000, remained relatively constant from 2001 to 2010, and then declined from 2011 to 2020 by 16.7% (95% uncertainty interval [UI]: 14.7–20.1) or 13.6 (95% UI: 11.3–15.9) value points. The percentage of state populations with insurance was positively associated with health delivery system value. In contrast, market consolidation among hospitals and among health insurers of small and large groups, and increased for-profit hospital ownership were each associated with a lower health care value. The net effect of these associations was a reduction in the national value score for the decade ending in 2020.

Conclusions

In contrast to the prior two decades, health care delivery system value scores declined over the last decade. This decline was associated with reduced competition among hospitals and health insurers, increased for-profit hospital ownership, and was partly mitigated by wider insurance coverage.

目的：研究近三十年来州级医疗保健价值的趋势，使用全州医疗保健支出和病因特异性死亡率来定义，并探讨其与潜在可修改的州属性的关联。研究设置和设计：我们使用随机前沿分析来确定每个州在将医疗保健支出转化为较低的死亡率-发病率或死亡率-患病率方面的“低效率”，并根据潜在的人口风险（年龄、吸烟、肥胖等）进行调整。我们将这些低效率分数结合起来，对每个州的交付系统价值进行评分和比较，并跟踪30年来的变化。然后，我们使用线性回归来查看各州，并确定与更大的医疗保健价值显著相关的州级属性。数据来源和分析样本：对于1991年至2020年的美国每个州和年份，我们从2021年全球疾病负担研究中提取了67种高死亡率健康状况的死亡率-发病率或死亡率-患病率，并从州卫生保健支出账户中提取了州卫生保健支出。主要发现：美国各州的平均价值从1991年到2000年增加，从2001年到2010年保持相对稳定，然后从2011年到2020年下降了16.7%（95%不确定性区间[UI]: 14.7-20.1）或13.6 （95% UI: 11.3-15.9）值点。拥有保险的州人口百分比与医疗服务系统价值呈正相关。相比之下，医院之间的市场整合以及小型和大型集团的健康保险公司之间的市场整合，以及营利性医院所有权的增加，都与较低的医疗保健价值相关。这些关联的净影响是，在截至2020年的十年中，国家价值得分有所下降。结论：与前二十年相比，卫生保健服务系统的价值评分在过去十年中有所下降。这一下降与医院和健康保险公司之间的竞争减少、营利性医院所有权增加有关，并在一定程度上因保险覆盖范围的扩大而得到缓解。

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引用次数: 0

How Health Insurance Instability Differentially Impedes Access to Sexual and Reproductive Healthcare, by Race/Ethnicity and Nativity 健康保险不稳定如何因种族/民族和出生而不同地阻碍获得性保健和生殖保健。

IF 3.2 2区医学 Q2 HEALTH CARE SCIENCES & SERVICES

Health Services Research

Pub Date : 2025-10-07 DOI: 10.1111/1475-6773.70049

Hannah Olson, Ayana Douglas-Hall, Madeleine Haas, Megan L. Kavanaugh

<div> <section> <h3> Objective</h3> <p>To document differential risk of insurance instability by race/ethnicity and nativity and investigate the effect of insurance instability on subsequent sexual and reproductive health care utilization and contraceptive access.</p> </section> <section> <h3> Study Setting and Design</h3> <p>We draw on data from the Surveys of Women (SoW), longitudinal household surveys conducted by NORC at the University of Chicago in Arizona, Iowa, New Jersey, and Wisconsin, weighted to reflect the population of women aged 18–44 in each state. SoW respondents included in this analysis were interviewed 2–4 times between 2018 and 2022 about their sexual and reproductive health-related experiences. We use race-stratified population averaged logistic regressions to model the risk of insurance churn and insurance loss for US-born vs. foreign-born people with the capacity for pregnancy, by race/ethnicity. Then, we use within-between (hybrid) logistic regressions to model the effect of insurance instability on subsequent sexual and reproductive health care utilization and contraceptive access outcomes, including receipt of any sexual and reproductive health care, receipt of contraceptive care, experiencing barriers to obtaining contraception, and contraceptive use.</p> </section> <section> <h3> Data Sources and Analytic Sample</h3> <p>Our analytic sample includes 12,208 observations from 4558 respondents between the ages of 18 and 44 who were assumed to have the capacity for pregnancy. Respondents were maintained in the sample if they were neither pregnant nor infertile and had non-missing information on key variables.</p> </section> <section> <h3> Principal Findings</h3> <p>Insurance loss was much more common among foreign-born compared to US-born people, particularly those who were racially or ethnically minoritized, with foreign-born BIPOC and foreign-born Hispanic respondents experiencing insurance loss 2.5 and 3 times as often as their US-born counterparts, respectively. Meanwhile, findings from our hybrid models suggest that losing insurance was associated with a five percentage point reduction in the probability of subsequent utilization of sexual and reproductive health care (∆<i>p</i> = −0.046, <i>p</i> < 0.05, SE = −0.02) and a five percentage point increase in the probability of experiencing subsequent barriers to obtaining preferred contraception (∆<i>p</i> = 0.053, <i>p</i> < 0.001, SE = 0.01).</p> </section> <section> <h3> Conclusion</h3> <p>The disproportionate burden of insurance instability among immigrant people of color may exacerbate barriers to sexual and reproductive health care and contraceptive access for a population that already experiences high bar

目的：记录不同种族/民族和出生的保险不稳定风险差异，并调查保险不稳定对随后的性健康和生殖健康保健利用和避孕药具获取的影响。研究背景和设计：我们利用了妇女调查（SoW）的数据，这是由NORC在亚利桑那州、爱荷华州、新泽西州和威斯康星州的芝加哥大学进行的纵向家庭调查，加权反映了每个州18-44岁的妇女人口。本分析中包括的SoW受访者在2018年至2022年期间接受了2-4次关于其性和生殖健康相关经历的访谈。我们使用种族分层的人口平均逻辑回归来模拟美国出生的和外国出生的有怀孕能力的人的保险流失和保险损失风险，按种族/民族划分。然后，我们使用间内（混合）逻辑回归来模拟保险不稳定性对随后的性和生殖健康保健利用和避孕药具获取结果的影响，包括接受任何性和生殖健康保健、接受避孕药具、获得避孕药具的障碍和避孕药具的使用。数据来源和分析样本：我们的分析样本包括来自4558名年龄在18至44岁之间的受访者的12208次观察结果，这些受访者被认为具有怀孕能力。如果受访者既没有怀孕也没有不孕，并且在关键变量上没有遗漏信息，则保留在样本中。主要发现：与美国出生的人相比，外国出生的人（尤其是那些种族或少数民族）的保险损失更为普遍，外国出生的BIPOC和外国出生的西班牙裔受访者的保险损失分别是美国出生的受访者的2.5倍和3倍。同时，我们的混合模型的结果表明，失去保险与随后利用性和生殖保健的可能性降低5个百分点有关（∆p = -0.046, p）。有色人种移民中不成比例的保险不稳定负担可能会加剧他们在获得性和生殖健康保健和避孕药具方面的障碍，与非西班牙裔白人相比，有色人种移民在获得这些服务方面已经经历了很高的障碍。

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引用次数: 0

The Impact of Private Equity Hospital Acquisitions on Maternal Health for Medicaid Patients 私募股权医院收购对医疗补助患者孕产妇健康的影响。

IF 3.2 2区医学 Q2 HEALTH CARE SCIENCES & SERVICES

Health Services Research

Pub Date : 2025-10-04 DOI: 10.1111/1475-6773.70048

Yang Amy Jiao

Objective

To examine the impact of private equity (PE) hospital acquisitions on maternal health for Medicaid patients.

Study Setting and Design

This quasi-experimental study focuses on 66 PE acquisitions of hospitals between 2014 and 2018, analyzing national Medicaid claims data from 2011 to 2020. Using a difference-in-differences (DiD) framework, the study compares labor and delivery (L&D) outcomes at PE-acquired hospitals with matched control hospitals to evaluate the effects on patient volume, process of care, and quality outcomes for Medicaid patients.

Data Sources and Analytic Sample

The analysis uses data from the Transformed Medicaid Statistical Information System (T-MSIS) and Medicaid Analytic eXtract (MAX), including over 1 million L&D hospitalizations. The analytic sample comprises 66 PE hospitals and 290 matched control hospitals.

Principal Findings

PE acquisition was associated with a significant 12% decrease in Medicaid L&D market share (p < 0.05). The reduction was more pronounced in states with larger Medicaid-to-commercial payment gaps (−15.8% vs. −7.2%). However, no significant changes were observed in low-risk cesarean rates, number of procedures, length of stay, or severe maternal morbidity.

Conclusions

PE acquisitions of hospitals are associated with reduced Medicaid market share, particularly in states with lower Medicaid reimbursement relative to commercial insurance. Policymakers should consider addressing these issues by adjusting Medicaid payment rates to support vulnerable populations in PE-acquired hospitals.

目的：探讨私募股权（PE）医院收购对医疗补助患者孕产妇健康的影响。研究设置和设计：这项准实验研究重点关注2014年至2018年期间66家医院的PE收购，分析2011年至2020年国家医疗补助计划的索赔数据。使用差异中的差异（DiD）框架，该研究比较了pe获得的医院与匹配的对照医院的分娩（L&D）结果，以评估对医疗补助患者的患者数量、护理过程和质量结果的影响。数据来源和分析样本：该分析使用了来自医疗补助统计信息系统（T-MSIS）和医疗补助分析提取（MAX）的数据，包括100多万例L&D住院病例。分析样本包括66家体育医院和290家匹配的对照医院。主要发现：PE收购与医疗补助L&D市场份额显著下降12%有关(p结论：医院PE收购与医疗补助市场份额下降有关，特别是在医疗补助报销相对于商业保险较低的州。决策者应考虑通过调整医疗补助支付率来解决这些问题，以支持pe收购医院的弱势群体。

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引用次数: 0

Correction to “Cross Country Comparisons in Price Growth Over Time” 修正“长期价格增长的跨国比较”。

IF 3.2 2区医学 Q2 HEALTH CARE SCIENCES & SERVICES

Health Services Research

Pub Date : 2025-10-01 DOI: 10.1111/1475-6773.70047

I. Papanicolas, J. Cylus, and L. Lorenzoni, “Cross-Country Comparisons in Health Price Growth Over Time,” Health Services Research 59, no. 6 (2024): e14295, https://doi.org/10.1111/1475-6773.14295.

We apologize for this error.

I. Papanicolas， J. Cylus和L. Lorenzoni，“医疗价格随时间增长的跨国比较”，《卫生服务研究》，第59期。6 (2024): e14295, https://doi.org/10.1111/1475-6773.14295.We为这个错误道歉。

引用次数: 0

The Unreliability of Two Publicly Reported Outcome Quality Measures for Characterizing Health Care Quality Within the Veterans Health Administration 两项公开报告的结果质量措施在退伍军人健康管理局内表征医疗保健质量的不可靠性。

IF 3.2 2区医学 Q2 HEALTH CARE SCIENCES & SERVICES

Health Services Research

Pub Date : 2025-10-01 DOI: 10.1111/1475-6773.70050

Kenneth J. Nieser, Daniel J. Tancredi, Alex H. S. Harris

Objective

To estimate the reliability of two outcome quality measures in Veterans Health Administration (VHA) data using three different methods.

Study Setting and Design

We created two cohorts of VHA patients meeting criteria for two measures: (1) risk-standardized complication rates following elective primary total hip arthroplasty and/or total knee arthroplasty (THA/TKA), and (2) risk-standardized mortality rates following acute myocardial infarction hospitalization (AMI). We fit hierarchical logistic regression models and calculated facility-level risk-standardized rates. We estimated entity-level reliability using three commonly applied methods: (1) delta method approximation; (2) latent scale model; (3) split-sample method.

Data Sources and Analytic Sample

For each measure, we extracted risk adjustment and outcome data from the VHA Corporate Data Warehouse for patients meeting eligibility criteria in fiscal years 2021 and 2022.

Principal Findings

Most facilities had complication rates following total hip and/or knee arthroplasty and mortality rates following hospitalization for acute myocardial infarction that, statistically, were no different from the national average. Reliability estimates based on delta method approximation (0.14 for THA/TKA; 0.12 for AMI) and the split-sample method (0.12 for THA/TKA; 0.19 for AMI) were very low for both measures. As we varied the sample sizes, we found that much higher sample sizes would be needed to reliably differentiate quality of care across facilities. On the other hand, reliability estimates based on the latent scale model were substantially higher than the other two methods (0.64 for THA/TKA; 0.41 for AMI), suggesting that there is substantially more between-facility variation in latent quality than manifests in observed outcomes.

Conclusions

Reliability estimates based on the latent scale approach are not numerically or conceptually interchangeable with estimates based on the other two approaches. Given that health outcomes are generally reported using observed outcomes, reliability estimation based on the latent scale approach should not be used without a strong rationale.

目的：用三种不同的方法评估退伍军人健康管理局（VHA）数据中两种结局质量指标的可靠性。研究背景和设计：我们创建了两个符合两项标准的VHA患者队列：(1)选择性原发性全髋关节置换术和/或全膝关节置换术（THA/TKA）后风险标准化并发症发生率，(2)急性心肌梗死住院（AMI）后风险标准化死亡率。我们拟合了层次逻辑回归模型，并计算了设施级别的风险标准化率。我们使用三种常用的方法估计实体级可靠性：(1)delta法近似；(2)潜标模型；(3)分样法。数据来源和分析样本：对于每项测量，我们从VHA公司数据仓库中提取了2021和2022财政年度符合资格标准的患者的风险调整和结果数据。主要发现：在统计上，大多数设施的全髋关节和/或膝关节置换术后并发症发生率和急性心肌梗死住院后死亡率与全国平均水平没有差异。基于delta法近似的可靠性估计（THA/TKA为0.14，AMI为0.12）和分裂样本法（THA/TKA为0.12，AMI为0.19）对于这两种测量方法都非常低。当我们改变样本量时，我们发现需要更大的样本量来可靠地区分不同设施的护理质量。另一方面，基于潜在尺度模型的信度估计明显高于其他两种方法（THA/TKA为0.64，AMI为0.41），这表明设施之间的潜在质量差异明显大于观察结果。结论：基于潜在量表方法的信度估计与基于其他两种方法的估计在数字或概念上不可互换。鉴于健康结果通常是用观察结果来报告的，因此，在没有充分理由的情况下，不应使用基于潜在量表方法的可靠性估计。

{"title":"The Unreliability of Two Publicly Reported Outcome Quality Measures for Characterizing Health Care Quality Within the Veterans Health Administration","authors":"Kenneth J. Nieser, Daniel J. Tancredi, Alex H. S. Harris","doi":"10.1111/1475-6773.70050","DOIUrl":"10.1111/1475-6773.70050","url":null,"abstract":"<div>\u0000 <section>\u0000 <h3> Objective</h3>\u0000 <p>To estimate the reliability of two outcome quality measures in Veterans Health Administration (VHA) data using three different methods.</p>\u0000 </section>\u0000 <section>\u0000 <h3> Study Setting and Design</h3>\u0000 <p>We created two cohorts of VHA patients meeting criteria for two measures: (1) risk-standardized complication rates following elective primary total hip arthroplasty and/or total knee arthroplasty (THA/TKA), and (2) risk-standardized mortality rates following acute myocardial infarction hospitalization (AMI). We fit hierarchical logistic regression models and calculated facility-level risk-standardized rates. We estimated entity-level reliability using three commonly applied methods: (1) delta method approximation; (2) latent scale model; (3) split-sample method.</p>\u0000 </section>\u0000 <section>\u0000 <h3> Data Sources and Analytic Sample</h3>\u0000 <p>For each measure, we extracted risk adjustment and outcome data from the VHA Corporate Data Warehouse for patients meeting eligibility criteria in fiscal years 2021 and 2022.</p>\u0000 </section>\u0000 <section>\u0000 <h3> Principal Findings</h3>\u0000 <p>Most facilities had complication rates following total hip and/or knee arthroplasty and mortality rates following hospitalization for acute myocardial infarction that, statistically, were no different from the national average. Reliability estimates based on delta method approximation (0.14 for THA/TKA; 0.12 for AMI) and the split-sample method (0.12 for THA/TKA; 0.19 for AMI) were very low for both measures. As we varied the sample sizes, we found that much higher sample sizes would be needed to reliably differentiate quality of care across facilities. On the other hand, reliability estimates based on the latent scale model were substantially higher than the other two methods (0.64 for THA/TKA; 0.41 for AMI), suggesting that there is substantially more between-facility variation in latent quality than manifests in observed outcomes.</p>\u0000 </section>\u0000 <section>\u0000 <h3> Conclusions</h3>\u0000 <p>Reliability estimates based on the latent scale approach are not numerically or conceptually interchangeable with estimates based on the other two approaches. Given that health outcomes are generally reported using observed outcomes, reliability estimation based on the latent scale approach should not be used without a strong rationale.</p>\u0000 </section>\u0000 </div>","PeriodicalId":55065,"journal":{"name":"Health Services Research","volume":"61 1","pages":""},"PeriodicalIF":3.2,"publicationDate":"2025-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145208282","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 0

Addressing Psychiatric Bed Capacity: Evidence From Medicaid's Institutions for Mental Disease Waivers for Serious Mental Illness 解决精神病病床容量：来自医疗补助机构的证据，精神疾病豁免严重精神疾病。

IF 3.2 2区医学 Q2 HEALTH CARE SCIENCES & SERVICES

Health Services Research

Pub Date : 2025-10-01 DOI: 10.1111/1475-6773.70051

K. John McConnell, Jane M. Zhu, Thomas H. A. Meath, Stephan Lindner

Objective

To assess whether the adoption of Section 1115 Serious Mental Illness and Serious Emotional Disturbance (SMI/SED) Medicaid waivers was associated with increased bed capacity among freestanding psychiatric hospitals.

Study Setting and Design

We used a difference-in-differences design to study changes in bed capacity in freestanding psychiatric hospitals across all 50 states and the District of Columbia, comparing states that adopted waivers to those that did not.

Data Sources and Analytic Sample

We used data from the National Mental Health Services Survey, Centers for Medicare and Medicaid Services Provider of Service files, and other state-level datasets from 2014 to 2023.

Principal Findings

Freestanding hospitals were responsible for most of the growth of psychiatric inpatient bed capacity over the last 10 years. We found no correlation between the option to pursue an SMI/SED waiver and bed capacity or other measures of mental health needs, including state-based estimates of SMI prevalence or suicide rates. In our difference-in-differences analyses, we found no association between the adoption of SMI/SED waivers and bed capacity in freestanding psychiatric hospitals. For example, our estimate of the association of SMI/SED waivers with changes in beds in psychiatric hospitals that accepted Medicaid was −24 beds per 100,000 Medicaid-enrolled adults (95% CI: −115, 67). Other specifications and outcome variables yielded similar results.

Conclusion

While SMI/SED waivers offer the potential to address psychiatric bed shortages, these waivers alone may not suffice to increase inpatient capacity. Given the low uptake and absence of significant change in bed capacity, SMI/SED waivers may need to be redesigned to meet the growing mental health needs of the Medicaid population.

目的：评估采用1115节严重精神疾病和严重情绪障碍（SMI/SED）医疗补助豁免是否与独立精神病院床位容量增加有关。研究设置和设计：我们采用差异中的差异设计来研究所有50个州和哥伦比亚特区的独立精神病院床位容量的变化，并比较采用豁免的州和未采用豁免的州。数据来源和分析样本：我们使用的数据来自2014年至2023年的国家精神卫生服务调查、医疗保险和医疗补助服务中心服务提供商文件和其他国家级数据集。主要发现：在过去10年里，精神病住院床位的增长大部分是由独立医院造成的。我们发现，选择放弃重度精神分裂症/SED与床位容量或其他心理健康需求指标（包括基于州的重度精神分裂症患病率或自杀率估计）之间没有相关性。在我们的差异分析中，我们发现在独立精神病院的床位容量与SMI/SED豁免的采用之间没有关联。例如，我们估计，在接受医疗补助的精神病医院中，SMI/SED豁免与床位变化的关系是每10万名参加医疗补助的成年人中有-24张床位（95% CI: - 115,67）。其他规格和结果变量也产生了类似的结果。结论：虽然SMI/SED豁免提供了解决精神科床位短缺问题的潜力，但仅凭这些豁免可能不足以增加住院病人的容量。鉴于使用率低且床位容量没有显著变化，SMI/SED豁免可能需要重新设计，以满足医疗补助人群日益增长的心理健康需求。

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引用次数: 0