Health Services Research最新文献

Objective: To develop a novel method for enumerating the oncology specialist workforce triangulating taxonomy codes, board certification data, and clinical diagnosis codes in Medicaid claims, and to describe oncology specialists' Medicaid participation, their patient panels, and ascertain the concentration of types of cancers they treated.

Study setting and design: We identified oncology specialists using multiple data sources and conducted an exploratory analysis of their patient panels using multi-state Medicaid claims data. We used cluster analysis of diagnosis code patterns in claims to accurately determine the concentration of cancers by site in oncologists' panels.

Data sources and analytic sample: We used data from 2016 to 2020 Transformed Medicaid Statistical Information System (T-MSIS) and physician certification data. We included board-certified oncology physicians specialized in medical and radiation oncology, hematology, hematology-oncology, gynecologic oncology, and pediatric hematology-oncology. To identify surgical oncologists, we combined board certification and Medicare Provider Enrollment, Chain, and Ownership System (PECOS) data. We identified Medicaid beneficiaries with malignant neoplasms by cancer site using ICD-10-CM codes.

Principal findings: In 2016, about 89% of oncology specialists participated in Medicaid; this proportion decreased slightly to 86% in 2020. The trends in Medicaid participation and the mean number of beneficiaries differed by oncology specialty. Panels of pediatric hematologist-oncologists had a higher proportion of Hispanic Medicaid beneficiaries with cancer (26%) relative to other specialists. Cluster analysis identified 565 out of 5395 medical oncologists that had high concentration (at least 58%) of breast cancer patients in their panels. Among 6970 hematologist-oncologists, 269 had high concentrations in breast cancer (more than 60%), and 944 in hematological cancer (more than 59%).

Conclusions: Our study offers a pragmatic approach to understand the oncology specialist workforce available to Medicaid beneficiaries. The findings provide baseline estimates to track this workforce and provide policymakers with an opportunity to develop targeted strategies to improve access to cancer care.

Objective: To determine the effectiveness and cost-effectiveness of multi-gene panel sequencing compared to single-gene KRAS testing for metastatic colorectal cancer (mCRC).

Study setting and design: British Columbia, Canada (BC) is a provincial single-payer public healthcare system, and it was the first province to publicly reimburse multi-gene sequencing for mCRC. Panels expand treatment de-escalation by expanding RAS testing for more precise targeting of anti-EGFR therapies. Reimbursement of panels remains unequal across healthcare systems given uncertain clinical and economic impacts. Our quasi-experimental study design followed the target trial emulation approach, emulating random treatment assignment with two different methods to examine the sensitivity of estimates: inverse probability of treatment weighting estimated with super learning (SL-IPTW) and 1:1 genetic algorithm-based matching, a machine learning approach. We then estimated mean three-year survival time and costs (public healthcare payer perspective; 2021CAD) and calculated the incremental net monetary benefit (INMB) for life-years gained (LYG) at $50,000/LYG using weighted linear regression and nonparametric bootstrapping, also accounting for inverse probability of censoring weights. Our sensitivity analysis estimated LYG using targeted minimum-based loss estimation (TMLE), a doubly robust approach that also uses super learning.

Data sources and analytical sample: Patient-level linked administrative health databases capturing cancer and non-cancer care for all BC adults with a metastatic colorectal cancer between 2016 and 2019.

Principal findings: Our study included 892 patients (84.3%) receiving multi-gene panels and 166 (15.7%) receiving single-gene testing. INMB estimates were similar for SL-IPTW ($20,397; 95% CI: $9317, $34,862) and matching ($19,569; 95% CI: $8509, $31,447), with 99.3% and 98.8% probabilities, respectively, of panels being cost-effective. We found statistically significant survival benefits with LYG of 0.31 (SL-IPTW; 95% CI: 0.04, 0.54), 0.25 (matching; 95% CI: 0.03, 0.47) and 0.19 (TMLE; 95% CI: 0.02, 0.37).

Conclusions: Survival impacts were robust to super learning approaches. Real-world evidence demonstrates that reimbursing multi-gene sequencing for more precise targeting of mCRC treatments provides value for healthcare systems and clinically important benefits to patients.

Objective: To explore the satisfaction of limited English proficiency (LEP) Farsi- and Dari-speaking patients with the U.S. healthcare system using a qualitative approach.

Study setting and design: We employed a grounded theory approach to analyze qualitative data collected from five focus groups involving 25 Farsi- and Dari-speaking immigrants with LEP.

Data source and analytical sample: A total of 25 individuals with LEP participated in the focus group sessions, which were transcribed and analyzed using grounded theory methodology.

Principal findings: Two primary categories influencing satisfaction with care emerged: systemic factors and individual factors. Individual factors encompassed cultural beliefs, cross-contextual comparisons, experiences of misdiagnosis, and language barriers. Systemic factors, including discrimination, the high cost of care, the complexity of the U.S. healthcare system, and a pharmaco-centric approach to care, were found to negatively impact satisfaction among immigrants with LEP.

Conclusions: Although many Farsi- and Dari-speaking individuals with LEP expressed satisfaction with the structured aspects of the U.S. healthcare system, dissatisfaction with healthcare providers and interpersonal interactions persisted. Addressing these issues will require targeted interventions to enhance trust, communication, and cultural competency in healthcare delivery.

Objective: To investigate whether the acquisition of physician practices by Optum, a subsidiary of United Health Group (UHG), influences patient volume and service prices, particularly, for patients enrolled in health insurance plans competing with UHG.

Study setting and design: We employed a novel database cataloging health insurer acquisitions of physician practices to identify those acquired by Optum-the nation's largest payvider (vertically integrated payer-provider)-from 2007 to 2023. These data were integrated with non-UHG commercial health insurance claims for practices acquired between 2015 and 2019. Using a stacked difference-in-differences design, we analyzed relative changes in prices and office visits across 12 Optum-acquired practices compared to a control group. Adjustments were made for physician profiles, practice characteristics, and calendar-year fixed effects to ensure robust estimates.

Principal findings: From 2007 to 2023, Optum acquired 44 physician practices, employing 7828 physicians by 2023. Postacquisition, we found no statistically significant average change in prices for most acquired practices relative to controls. However, the single largest acquisition was associated with a relative price increase of 4.5% (95% CI: [1.2%, 7.8%]; p = 0.02) for established patient visits. Preacquisition trends showed prices at acquired practices rising faster than controls. Additionally, Optum acquisitions were linked to suggestive declines in claim volume 1-1.5 years postacquisition, though this shift was predominantly driven by the largest acquired practice, indicating variability in outcomes across the sample.

Conclusions: Optum's acquisition of physician practices did not broadly result in significant price changes for evaluation and management services provided to patients with competing insurance plans, despite higher baseline prices at acquired practices. Suggestive reductions in patient volume emerged postacquisition, but effects were inconsistent. Extended follow-up research is warranted to evaluate whether these acquisitions reshape local healthcare market dynamics over time.

Objective: To evaluate the association between implementation of "Pathways to Success" and quality among beneficiaries cared for in Shared Savings Program accountable care organizations (ACOs).

Study setting and design: Medicare initiated "Pathways to Success" in 2019 that required upside-risk only ACOs in Shared Savings Program to transition to a two-sided risk model and prior two-sided ACOs to assume even greater financial responsibility. We examined the association between Pathways and ACO-targeted (hospitalizations for congestive heart failure [CHF] and all-cause 30-day readmissions) and nontargeted (all-cause emergency department visits without hospitalization for CHF and hospital observation stays) quality measures, using a difference-in-differences framework.

Data sources and analytic sample: Data were extracted from a 20% sample of national Medicare data from 2018 to 2020. This study included 810,070 beneficiary-quarters in 514 ACOs, and 813,855 beneficiary-quarters never attributed to an ACO (i.e., controls).

Principal findings: Implementation of Pathways was not associated with significant relative changes in the quarterly number of CHF admissions (decreasing from 97.98 to 82.04 per 1000 beneficiaries in ACOs; differential change = 3.51 quarterly CHF admissions per 1000 beneficiaries, 95% CI, -4.82 to 11.85) or the quarterly number of emergency department visits for CHF (decreasing from 110.90 to 97.50 per 1000 beneficiaries in ACOs; differential change = 6.47 quarterly CHF emergency department visits per 1000 beneficiaries, 95% CI, -3.71 to 16.64). However, quarterly rates of 30-day all-cause readmissions increased slightly by 0.61% points (95% CI, 0.23 to 0.98; unadjusted readmissions increased from 14.49% to 14.81% in ACOs) after Pathways implementation. Observation stays remained unchanged (differential change = -0.16% points, 95% CI, -0.33 to 0.02; unadjusted observation stays increased from 3.64% to 3.94% in ACOs) after the launch of Pathways.

Conclusions: Medicare's Pathways to Success, which introduced two-sided risk, was not associated with improvement in select quality measures.