Stephanie B Wheeler, Jason Rotter, Lisa P Spees, Caitlin B Biddell, Justin G Trogdon, Catherine M Alfano, Deborah K Mayer, Michaela A Dinan, Larissa Nekhlyudov, Sarah A Birken
Objective: To develop and validate a clinical risk prediction algorithm to identify breast cancer survivors at high risk for adverse outcomes.
Study setting and design: Our national retrospective analysis used cross-validated random forest machine learning models to separately predict the risk of all-cause death, cancer-specific death, claims-derived risk of recurrence, and other adverse health outcomes within 3 and 5 years following treatment completion.
Data sources and analytic sample: Our study used the Surveillance and Epidemiology End Results (SEER) registry-Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey (SEER-CAHPS) linked data for survivors diagnosed between 2003 and 2011, with follow-up claims data to 2017.
Principal findings: Within the 3-year follow-up period, 372/4516 survivors (mean age 75.1; 81.7% white) in the primary cohort (8.2%) died, 111 from cancer (2.5%), 665 (14.7%) experienced cancer recurrence, and 488 (10.8%) were hospitalized for adverse health outcomes. The algorithm's prediction resulted in 91.9% out-of-sample accuracy (the percent of observations classified correctly) and a 37.6% Cohen's Kappa (i.e., improvement over an uninformed model). Out-of-sample accuracy was 97.5% (44% improvement) for predicting cancer-specific death, 85% (26% improvement) for recurrence, and 89% (28% improvement) for other adverse health outcomes. Important predictors across outcomes included geographic region, age, frailty, comorbidity, time since diagnosis, and out-of-pocket cost responsibility.
Conclusions: Machine learning models accurately predicted relevant adverse survivorship outcomes, driven primarily by non-cancer specific factors. Breast cancer survivors at high risk for adverse outcomes may benefit from more intensive care, whereas those at low risk may be more appropriately managed by primary care.
{"title":"Machine Learning Risk Stratification for Older Breast Cancer Survivors: Clinical Care Implications.","authors":"Stephanie B Wheeler, Jason Rotter, Lisa P Spees, Caitlin B Biddell, Justin G Trogdon, Catherine M Alfano, Deborah K Mayer, Michaela A Dinan, Larissa Nekhlyudov, Sarah A Birken","doi":"10.1111/1475-6773.70005","DOIUrl":"https://doi.org/10.1111/1475-6773.70005","url":null,"abstract":"<p><strong>Objective: </strong>To develop and validate a clinical risk prediction algorithm to identify breast cancer survivors at high risk for adverse outcomes.</p><p><strong>Study setting and design: </strong>Our national retrospective analysis used cross-validated random forest machine learning models to separately predict the risk of all-cause death, cancer-specific death, claims-derived risk of recurrence, and other adverse health outcomes within 3 and 5 years following treatment completion.</p><p><strong>Data sources and analytic sample: </strong>Our study used the Surveillance and Epidemiology End Results (SEER) registry-Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey (SEER-CAHPS) linked data for survivors diagnosed between 2003 and 2011, with follow-up claims data to 2017.</p><p><strong>Principal findings: </strong>Within the 3-year follow-up period, 372/4516 survivors (mean age 75.1; 81.7% white) in the primary cohort (8.2%) died, 111 from cancer (2.5%), 665 (14.7%) experienced cancer recurrence, and 488 (10.8%) were hospitalized for adverse health outcomes. The algorithm's prediction resulted in 91.9% out-of-sample accuracy (the percent of observations classified correctly) and a 37.6% Cohen's Kappa (i.e., improvement over an uninformed model). Out-of-sample accuracy was 97.5% (44% improvement) for predicting cancer-specific death, 85% (26% improvement) for recurrence, and 89% (28% improvement) for other adverse health outcomes. Important predictors across outcomes included geographic region, age, frailty, comorbidity, time since diagnosis, and out-of-pocket cost responsibility.</p><p><strong>Conclusions: </strong>Machine learning models accurately predicted relevant adverse survivorship outcomes, driven primarily by non-cancer specific factors. Breast cancer survivors at high risk for adverse outcomes may benefit from more intensive care, whereas those at low risk may be more appropriately managed by primary care.</p>","PeriodicalId":55065,"journal":{"name":"Health Services Research","volume":" ","pages":"e70005"},"PeriodicalIF":3.1,"publicationDate":"2025-07-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144651272","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}
The objective of this study is to update estimates of comprehensive service availability among CCBHCs and compare them to other settings serving individuals with severe mental illness, including community mental health centers (CMHCs) and federally qualified health centers (FQHCs).
Study Design and Setting
This study is a cross-sectional secondary data analysis.
Data Sources and Analytic Sample
Using 2022 National Substance Use and Mental Health Services Survey (N-SUMHSS) data, logistic regression examined associations between service setting (CCBHC, CMHC, FQHC) and the availability of psychiatric, health management, and navigation, and social care services.
Principle Findings
Compared to CCBHCs, FQHC designation was associated with a decreased likelihood of offering psychiatric rehabilitation services, including ACT (marginal effect = −0.26, 95% CI: −0.33 to −0.19) and peer coaching (marginal effect = −0.36, 95% CI: −0.43 to −0.29), and psychiatric crisis intervention (marginal effect = −0.14, 95% CI: −0.22 to −0.07). Rates of health management services were comparable to those at CCBHCs. CMHCs were also less likely to offer health management services (marginal effect = −0.26, 95% CI: −0.32 to −0.21) and a range of psychiatric rehabilitation services relative to CCBHCs.
Conclusions
CCBHC certified clinics were more likely to offer psychiatric and social services than FQHC or CMHC clinics serving individuals with severe mental illness.
{"title":"Enhanced Service Capacity for Severe Mental Illness: A Comparative Analysis of Certified Community Behavioral Health Centers, Community Mental Health Centers, and Federally Qualified Health Centers","authors":"Elizabeth B. Matthews, Victoria Stanhope","doi":"10.1111/1475-6773.70010","DOIUrl":"10.1111/1475-6773.70010","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Objectives</h3>\u0000 \u0000 <p>The objective of this study is to update estimates of comprehensive service availability among CCBHCs and compare them to other settings serving individuals with severe mental illness, including community mental health centers (CMHCs) and federally qualified health centers (FQHCs).</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Study Design and Setting</h3>\u0000 \u0000 <p>This study is a cross-sectional secondary data analysis.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Data Sources and Analytic Sample</h3>\u0000 \u0000 <p>Using 2022 National Substance Use and Mental Health Services Survey (N-SUMHSS) data, logistic regression examined associations between service setting (CCBHC, CMHC, FQHC) and the availability of psychiatric, health management, and navigation, and social care services.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Principle Findings</h3>\u0000 \u0000 <p>Compared to CCBHCs, FQHC designation was associated with a decreased likelihood of offering psychiatric rehabilitation services, including ACT (marginal effect = −0.26, 95% CI: −0.33 to −0.19) and peer coaching (marginal effect = −0.36, 95% CI: −0.43 to −0.29), and psychiatric crisis intervention (marginal effect = −0.14, 95% CI: −0.22 to −0.07). Rates of health management services were comparable to those at CCBHCs. CMHCs were also less likely to offer health management services (marginal effect = −0.26, 95% CI: −0.32 to −0.21) and a range of psychiatric rehabilitation services relative to CCBHCs.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusions</h3>\u0000 \u0000 <p>CCBHC certified clinics were more likely to offer psychiatric and social services than FQHC or CMHC clinics serving individuals with severe mental illness.</p>\u0000 </section>\u0000 </div>","PeriodicalId":55065,"journal":{"name":"Health Services Research","volume":"61 1","pages":""},"PeriodicalIF":3.2,"publicationDate":"2025-07-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"146088096","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}
Alexander C. Egilman, Aaron S. Kesselheim, Benjamin N. Rome
Objective
To examine whether the new Medicare inflation rebate policy was associated with changes in manufacturer pricing behavior.
Study Setting and Design
In this cross-sectional study of 156 top-selling brand-name drugs, we used linear regression to evaluate whether there was an association between drugs' exposure to the policy (i.e., Medicare's share of net US sales) and differences in year-over-year price changes before (2021–2022) versus after (2022–2023, 2023–2024) the policy took effect.
Data Sources and Analytic Sample
The study used Medicare spending data and average sales prices from the Centers for Medicare and Medicaid Services, wholesale acquisition costs from Eversana NAVLIN's Price & Access database, and sales revenue and estimated rebates from SSR Health. Vaccines, biosimilars, drugs approved after 2020, and those with generic or biosimilar competition before 2023 were excluded. Drugs were stratified by whether they derived most sales from Medicare Part B or Part D.
Principal Findings
The median Medicare share of net sales was 28% (IQR: 18%–37%) for 50 Part B drugs and 32% (IQR: 16%–49%) for 106 Part D drugs. Median year-over-year price changes in 2021–2022, 2022–2023, and 2023–2024 were 3.2%, 2.9%, and 3.4% for Part B drugs and 5.0%, 5.9%, and 4.9% for Part D drugs. There was no association between drugs' Medicare share of net sales and differences in price changes pre- vs. post-policy for Part B drugs (2023: p = 0.99; 2024: p = 0.09). For Part D drugs, each 10% increase in drugs' share of Medicare sales was associated with a 0.18% (95% CI, 0.01%–0.35%, p = 0.04) higher price change in the first year after policy implementation; there was no significant association in the second year (p = 0.17).
Conclusions
Medicare inflation rebates were not associated with smaller price increases among the top-selling drugs most affected by the policy. Additional measures are needed to prevent drug manufacturers from raising prices each year, such as extending inflation rebates to commercially insured patients.
{"title":"Share of Sales Subject to Medicare Inflation Rebates and Price Increases of Top-Selling Drugs","authors":"Alexander C. Egilman, Aaron S. Kesselheim, Benjamin N. Rome","doi":"10.1111/1475-6773.70012","DOIUrl":"10.1111/1475-6773.70012","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Objective</h3>\u0000 \u0000 <p>To examine whether the new Medicare inflation rebate policy was associated with changes in manufacturer pricing behavior.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Study Setting and Design</h3>\u0000 \u0000 <p>In this cross-sectional study of 156 top-selling brand-name drugs, we used linear regression to evaluate whether there was an association between drugs' exposure to the policy (i.e., Medicare's share of net US sales) and differences in year-over-year price changes before (2021–2022) versus after (2022–2023, 2023–2024) the policy took effect.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Data Sources and Analytic Sample</h3>\u0000 \u0000 <p>The study used Medicare spending data and average sales prices from the Centers for Medicare and Medicaid Services, wholesale acquisition costs from Eversana NAVLIN's Price & Access database, and sales revenue and estimated rebates from SSR Health. Vaccines, biosimilars, drugs approved after 2020, and those with generic or biosimilar competition before 2023 were excluded. Drugs were stratified by whether they derived most sales from Medicare Part B or Part D.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Principal Findings</h3>\u0000 \u0000 <p>The median Medicare share of net sales was 28% (IQR: 18%–37%) for 50 Part B drugs and 32% (IQR: 16%–49%) for 106 Part D drugs. Median year-over-year price changes in 2021–2022, 2022–2023, and 2023–2024 were 3.2%, 2.9%, and 3.4% for Part B drugs and 5.0%, 5.9%, and 4.9% for Part D drugs. There was no association between drugs' Medicare share of net sales and differences in price changes pre- vs. post-policy for Part B drugs (2023: <i>p</i> = 0.99; 2024: <i>p</i> = 0.09). For Part D drugs, each 10% increase in drugs' share of Medicare sales was associated with a 0.18% (95% CI, 0.01%–0.35%, <i>p</i> = 0.04) higher price change in the first year after policy implementation; there was no significant association in the second year (<i>p</i> = 0.17).</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusions</h3>\u0000 \u0000 <p>Medicare inflation rebates were not associated with smaller price increases among the top-selling drugs most affected by the policy. Additional measures are needed to prevent drug manufacturers from raising prices each year, such as extending inflation rebates to commercially insured patients.</p>\u0000 </section>\u0000 </div>","PeriodicalId":55065,"journal":{"name":"Health Services Research","volume":"61 1","pages":""},"PeriodicalIF":3.2,"publicationDate":"2025-07-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144627795","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}
Kiersten L. Strombotne, Daniel Lipsey, Fernando Mattar, Kathleen Carey, Samantha G. Auty, Brian W. Stanley, Steven D. Pizer
Objective
To examine the relationship between mental health provider productivity, staffing levels, and suicide-related events (SREs) among U.S. Veterans receiving care within the Veterans Health Administration (VHA), focusing on therapy and medication management providers.
Data Sources/Setting
We analyzed administrative data from the Department of Defense and VHA (2014–2018), encompassing 109,376 Veterans who separated from active duty between 2010 and 2017.
Design
A longitudinal design estimated the effects of facility-level provider work rate and staffing on SREs, adjusting for patient and facility characteristics. An instrumental variables (IV) approach addressed potential endogeneity.
Data Collection/Extraction Methods
Data were obtained from the VHA Corporate Data Warehouse and the VHA Survey of Enrollees.
Principal Findings
A 1% increase in therapy provider work rate led to a 12.1% increase in SRE probability, regardless of staffing levels. Conversely, a 1% increase in staffing levels led to a 1.6% reduction in SREs, with the largest effect in low-staffed facilities. For medication management providers, work rate had no overall impact on SREs, except in medium-staffed facilities. A 1% increase in staffing levels for medication management providers led to a 1.7% reduction in SREs.
Conclusions
Increased work rates, particularly in low-staffed VHA facilities, may elevate suicide-related risks. In contrast, staffing increases simultaneously improve access and reduce adverse outcomes. Where possible, policymakers should prioritize staffing growth over productivity gains to improve access to mental health clinics and ensure Veteran safety and care quality.
{"title":"The Impact of Provider Productivity on Suicide-Related Events Among Veterans","authors":"Kiersten L. Strombotne, Daniel Lipsey, Fernando Mattar, Kathleen Carey, Samantha G. Auty, Brian W. Stanley, Steven D. Pizer","doi":"10.1111/1475-6773.70008","DOIUrl":"10.1111/1475-6773.70008","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Objective</h3>\u0000 \u0000 <p>To examine the relationship between mental health provider productivity, staffing levels, and suicide-related events (SREs) among U.S. Veterans receiving care within the Veterans Health Administration (VHA), focusing on therapy and medication management providers.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Data Sources/Setting</h3>\u0000 \u0000 <p>We analyzed administrative data from the Department of Defense and VHA (2014–2018), encompassing 109,376 Veterans who separated from active duty between 2010 and 2017.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Design</h3>\u0000 \u0000 <p>A longitudinal design estimated the effects of facility-level provider work rate and staffing on SREs, adjusting for patient and facility characteristics. An instrumental variables (IV) approach addressed potential endogeneity.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Data Collection/Extraction Methods</h3>\u0000 \u0000 <p>Data were obtained from the VHA Corporate Data Warehouse and the VHA Survey of Enrollees.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Principal Findings</h3>\u0000 \u0000 <p>A 1% increase in therapy provider work rate led to a 12.1% increase in SRE probability, regardless of staffing levels. Conversely, a 1% increase in staffing levels led to a 1.6% reduction in SREs, with the largest effect in low-staffed facilities. For medication management providers, work rate had no overall impact on SREs, except in medium-staffed facilities. A 1% increase in staffing levels for medication management providers led to a 1.7% reduction in SREs.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusions</h3>\u0000 \u0000 <p>Increased work rates, particularly in low-staffed VHA facilities, may elevate suicide-related risks. In contrast, staffing increases simultaneously improve access and reduce adverse outcomes. Where possible, policymakers should prioritize staffing growth over productivity gains to improve access to mental health clinics and ensure Veteran safety and care quality.</p>\u0000 </section>\u0000 </div>","PeriodicalId":55065,"journal":{"name":"Health Services Research","volume":"61 1","pages":""},"PeriodicalIF":3.2,"publicationDate":"2025-07-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144602296","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}
Venice Ng Williams, Michael D. Knudtson, Mandy A. Allison, Gregory J. Tung
Objective
To measure nurse home visiting teams' access to electronic health records (EHR) and determine if access to EHR is associated with increased nurse home visitor collaboration with primary care providers in the United States.
Study Setting and Design
Nurse-Family Partnership (NFP) is an evidence-based home visiting program for first-time parents experiencing adversities. We conducted an observational study using data from 265 local NFP agencies in the United States. We used multivariate regression models to estimate the association between home visitors' EHR access and relational coordination with primary care providers.
Data Sources and Analytic Sample
We linked data from the 2021 NFP Collaboration with Community Providers Survey to 2021 NFP program implementation data and 2010 Rural–Urban Commuting Area Codes. We matched 265 survey respondents to their NFP teams' implementation data, including those with client visits between September 1, 2021, and December 31, 2021.
Principal Findings
Thirty-four percent of NFP teams (91/265) had access to their patients' EHR, with variation by agency type, where more NFP programs implemented by healthcare systems had EHR access (56%) compared to other agency types (X32=19.44, p < 0.01). Most NFP teams with EHR access reported read access (91%), ability to document (64%), and receiving program referrals (53%). EHR access was significantly associated with increased relational coordination with women's care providers (0.36-point difference, 95% CI 0.17 to 0.55, p < 0.01) and pediatric care providers (0.39-point difference, 95% CI 0.18 to 0.61, p < 0.01).
Conclusions
Access to EHRs varies by NFP team and agency type and is associated with greater relational coordination with primary care providers. Increasing home visitors' access to EHRs may help to facilitate collaboration with primary care providers.
{"title":"Association of Electronic Health Records Access and Coordination Between Primary Care Providers and Public Health Nurse Home Visitors in the United States","authors":"Venice Ng Williams, Michael D. Knudtson, Mandy A. Allison, Gregory J. Tung","doi":"10.1111/1475-6773.70006","DOIUrl":"10.1111/1475-6773.70006","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Objective</h3>\u0000 \u0000 <p>To measure nurse home visiting teams' access to electronic health records (EHR) and determine if access to EHR is associated with increased nurse home visitor collaboration with primary care providers in the United States.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Study Setting and Design</h3>\u0000 \u0000 <p>Nurse-Family Partnership (NFP) is an evidence-based home visiting program for first-time parents experiencing adversities. We conducted an observational study using data from 265 local NFP agencies in the United States. We used multivariate regression models to estimate the association between home visitors' EHR access and relational coordination with primary care providers.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Data Sources and Analytic Sample</h3>\u0000 \u0000 <p>We linked data from the 2021 NFP Collaboration with Community Providers Survey to 2021 NFP program implementation data and 2010 Rural–Urban Commuting Area Codes. We matched 265 survey respondents to their NFP teams' implementation data, including those with client visits between September 1, 2021, and December 31, 2021.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Principal Findings</h3>\u0000 \u0000 <p>Thirty-four percent of NFP teams (91/265) had access to their patients' EHR, with variation by agency type, where more NFP programs implemented by healthcare systems had EHR access (56%) compared to other agency types (<i>X</i><sub><i>3</i></sub><sup>2</sup>=19.44, <i>p</i> < 0.01). Most NFP teams with EHR access reported read access (91%), ability to document (64%), and receiving program referrals (53%). EHR access was significantly associated with increased relational coordination with women's care providers (0.36-point difference, 95% CI 0.17 to 0.55, <i>p</i> < 0.01) and pediatric care providers (0.39-point difference, 95% CI 0.18 to 0.61, <i>p</i> < 0.01).</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusions</h3>\u0000 \u0000 <p>Access to EHRs varies by NFP team and agency type and is associated with greater relational coordination with primary care providers. Increasing home visitors' access to EHRs may help to facilitate collaboration with primary care providers.</p>\u0000 </section>\u0000 </div>","PeriodicalId":55065,"journal":{"name":"Health Services Research","volume":"60 6","pages":""},"PeriodicalIF":3.2,"publicationDate":"2025-07-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1111/1475-6773.70006","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144577005","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Eric T. Roberts, Florentina E. Sileanu, Yaming Li, Timothy S. Anderson, Carolyn T. Thorpe, John Cashy, Katie J. Suda, Thomas R. Radomski, Maria K. Mor, Utibe R. Essien, Megan E. Vanneman, Michael J. Fine, Walid F. Gellad
<div> <section> <h3> Objective</h3> <p>To examine whether eligibility for Veterans Health Administration (VA) community care, which expanded Veterans' access to VA-funded care outside VA, increased the likelihood of Veterans concurrently filling prescriptions for opioids and central nervous system (CNS)-active medications.</p> </section> <section> <h3> Study Setting and Design</h3> <p>We used a regression discontinuity design to analyze Veterans across a distance threshold for community care eligibility in the Veterans Choice Program, under which Veterans residing > 40 miles from the closest VA medical facility staffed by ≥ 1 full-time primary care physician qualified for community care. We used local linear regression to test whether exceeding this 40-mile threshold was associated with discontinuities in the probability of receiving overlapping supplies of opioids and another CNS medication (benzodiazepine, muscle relaxant, antiepileptic, or sleep aid) for ≥ 30 days per year.</p> </section> <section> <h3> Data Sources and Analytic Sample</h3> <p>We used VA pharmacy data for prescriptions filled at VA facilities, VA Program Integrity Tool files for prescriptions paid by VA and filled in community pharmacies, and Medicare and Medicaid data for prescriptions covered by those programs. Our analysis included annual cross-sectional samples of Veterans who filled ≥ 1 opioid prescription through VA, community care, Medicare, or Medicaid and lived 36–39 or 41–44 miles from the nearest VA facility during federal FYs 2016–2019 (<i>n</i> = 180,903 Veteran-year observations).</p> </section> <section> <h3> Principal Findings</h3> <p>Among Veterans who filled an opioid prescription, 34.1% concurrently received another CNS medication for ≥ 30 days. Exceeding the threshold for community care eligibility was associated with a 1.14 percentage point (pp) increase (95% CI: 0.08, 2.20) in the probability of concurrently receiving an opioid and another CNS drug during 2016–2019. Discontinuities in overlap were larger among Veterans with a serious mental illness (2.7 pp.; 95% CI: 0.6, 4.9) during 2016–2019. During 2018–2019, discontinuities were larger in the overall sample (1.6 pp.; 0.0, 3.1) and among non-Hispanic Black Veterans (5.4 pp.; 95% CI: 0.5, 10.4).</p> </section> <section> <h3> Conclusions</h3> <p>Overall, VA community care eligibility was associated with a small increase in medication overlap involving opioids and other CNS-active medications. Increases in overlap were larger in certain Veteran subgroups and later study years, underscoring a need for continu
{"title":"VA-Purchased Community Care and Risk of Potentially Unsafe Concurrent Medication Use Among Veterans Receiving Opioids: A Regression Discontinuity Analysis","authors":"Eric T. Roberts, Florentina E. Sileanu, Yaming Li, Timothy S. Anderson, Carolyn T. Thorpe, John Cashy, Katie J. Suda, Thomas R. Radomski, Maria K. Mor, Utibe R. Essien, Megan E. Vanneman, Michael J. Fine, Walid F. Gellad","doi":"10.1111/1475-6773.70001","DOIUrl":"10.1111/1475-6773.70001","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Objective</h3>\u0000 \u0000 <p>To examine whether eligibility for Veterans Health Administration (VA) community care, which expanded Veterans' access to VA-funded care outside VA, increased the likelihood of Veterans concurrently filling prescriptions for opioids and central nervous system (CNS)-active medications.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Study Setting and Design</h3>\u0000 \u0000 <p>We used a regression discontinuity design to analyze Veterans across a distance threshold for community care eligibility in the Veterans Choice Program, under which Veterans residing > 40 miles from the closest VA medical facility staffed by ≥ 1 full-time primary care physician qualified for community care. We used local linear regression to test whether exceeding this 40-mile threshold was associated with discontinuities in the probability of receiving overlapping supplies of opioids and another CNS medication (benzodiazepine, muscle relaxant, antiepileptic, or sleep aid) for ≥ 30 days per year.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Data Sources and Analytic Sample</h3>\u0000 \u0000 <p>We used VA pharmacy data for prescriptions filled at VA facilities, VA Program Integrity Tool files for prescriptions paid by VA and filled in community pharmacies, and Medicare and Medicaid data for prescriptions covered by those programs. Our analysis included annual cross-sectional samples of Veterans who filled ≥ 1 opioid prescription through VA, community care, Medicare, or Medicaid and lived 36–39 or 41–44 miles from the nearest VA facility during federal FYs 2016–2019 (<i>n</i> = 180,903 Veteran-year observations).</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Principal Findings</h3>\u0000 \u0000 <p>Among Veterans who filled an opioid prescription, 34.1% concurrently received another CNS medication for ≥ 30 days. Exceeding the threshold for community care eligibility was associated with a 1.14 percentage point (pp) increase (95% CI: 0.08, 2.20) in the probability of concurrently receiving an opioid and another CNS drug during 2016–2019. Discontinuities in overlap were larger among Veterans with a serious mental illness (2.7 pp.; 95% CI: 0.6, 4.9) during 2016–2019. During 2018–2019, discontinuities were larger in the overall sample (1.6 pp.; 0.0, 3.1) and among non-Hispanic Black Veterans (5.4 pp.; 95% CI: 0.5, 10.4).</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusions</h3>\u0000 \u0000 <p>Overall, VA community care eligibility was associated with a small increase in medication overlap involving opioids and other CNS-active medications. Increases in overlap were larger in certain Veteran subgroups and later study years, underscoring a need for continu","PeriodicalId":55065,"journal":{"name":"Health Services Research","volume":"60 6","pages":""},"PeriodicalIF":3.2,"publicationDate":"2025-07-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144568084","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}
Kenneth A. Michelson, Katherine E. Remick, Emily M. Bucholz, Patrick D. McMullen, Naveen Singamsetty, Andrew D. Skol, Danielle K. Cory, John A. Graves
Objective
To pilot a system for deriving borders of pediatric regions, and to compare these to adult markets based on fit with pediatric utilization data.
Study Setting and Design
In this cross-sectional study, we studied all acute care encounters (emergency department visits and hospitalizations) for children less than 16 years old in Wisconsin 2021–2022.
Data Sources and Analytic Sample
We used the Healthcare Cost and Utilization Project State Emergency Department and Inpatient Databases. We first counted how many patients from each ZIP code visited each hospital and mapped ZIP-hospital connections. Using a network analysis technique called community detection that clustered hospitals by their common connections, we grouped ZIP codes to form pediatric emergency service areas (PESAs). We counted patient referrals within and between PESAs and repeated the community detection procedure, resulting in pediatric emergency referral regions (PERRs). The primary outcome was modularity, a common network fit measure ranging from −1 to 1 (1 represents perfect clustering). We also compared demographics and network quality measures between PERRs, hospital referral regions (HRRs), core-based statistical areas, and Pittsburgh Trauma Atlas regions.
Principal Findings
We analyzed 587,886 encounters, from which ZIP codes grouped into 24 PESAs. Based on referral patterns, there were 4 PERRs. PERRs had modestly higher modularity for interhospital referral patterns than all other systems (0.53, 95% confidence interval [CI] 0.52, 0.54 compared to 0.46, 95% CI 0.46, 0.47 for HRRs). PERRs were larger (median 11,361 mile2 vs. 3957 for HRRs), contained more children (median 265,222 vs. 49,667 for HRRs), and contained more hospitals (median 35 vs. 7 for HRRs) than all other systems.
Conclusions
Using Wisconsin HCUP data, we derived pediatric acute care regions with a strong fit for pediatric utilization data. Future work should test this approach across the whole US, which would allow between-region cost and outcomes comparison.
目的：试点儿科地区边界划分系统，并将其与成人市场进行比较，以符合儿童利用数据。研究设置和设计：在这项横断面研究中，我们研究了威斯康星州2021-2022年16岁以下儿童的所有急性护理遭遇（急诊科就诊和住院）。数据来源和分析样本：我们使用医疗成本和利用项目国家急诊科和住院病人数据库。我们首先统计了每个邮政编码有多少患者访问了每家医院，并绘制了邮政-医院之间的连接图。我们使用一种称为社区检测的网络分析技术，根据医院的共同联系对医院进行分组，将邮政编码分组，形成儿科急诊服务区（pesa）。我们统计了pesa内和pesa之间的患者转诊，并重复了社区检测程序，得出了儿科急诊转诊区域（perr）。主要结果是模块化，这是一种常见的网络拟合度量，范围从-1到1（1代表完美聚类）。我们还比较了perr、医院转诊区域（HRRs）、基于核心的统计区域和匹兹堡创伤地图集区域之间的人口统计学和网络质量测量。主要发现：我们分析了587,886次遭遇，其中邮政编码分为24个PESAs。根据转诊模式，有4个perr。PERRs对医院间转诊模式的模块化程度略高于其他所有系统（hrr为0.53,95%可信区间[CI] 0.52, 0.54，而hrr为0.46,95% CI 0.46, 0.47）。与所有其他系统相比，perr更大（中位数为11,361英里2，HRRs为3957英里2），包含更多儿童（中位数为265,222，HRRs为49,667），包含更多医院（中位数为35，HRRs为7）。结论：使用威斯康辛州HCUP数据，我们得出了与儿科利用数据非常吻合的儿科急症护理区域。未来的工作应该在整个美国测试这种方法，这将允许在地区之间进行成本和结果比较。
{"title":"Network Analysis to Define Pediatric Acute Care Regions in Wisconsin","authors":"Kenneth A. Michelson, Katherine E. Remick, Emily M. Bucholz, Patrick D. McMullen, Naveen Singamsetty, Andrew D. Skol, Danielle K. Cory, John A. Graves","doi":"10.1111/1475-6773.70000","DOIUrl":"10.1111/1475-6773.70000","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Objective</h3>\u0000 \u0000 <p>To pilot a system for deriving borders of pediatric regions, and to compare these to adult markets based on fit with pediatric utilization data.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Study Setting and Design</h3>\u0000 \u0000 <p>In this cross-sectional study, we studied all acute care encounters (emergency department visits and hospitalizations) for children less than 16 years old in Wisconsin 2021–2022.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Data Sources and Analytic Sample</h3>\u0000 \u0000 <p>We used the Healthcare Cost and Utilization Project State Emergency Department and Inpatient Databases. We first counted how many patients from each ZIP code visited each hospital and mapped ZIP-hospital connections. Using a network analysis technique called community detection that clustered hospitals by their common connections, we grouped ZIP codes to form pediatric emergency service areas (PESAs). We counted patient referrals within and between PESAs and repeated the community detection procedure, resulting in pediatric emergency referral regions (PERRs). The primary outcome was modularity, a common network fit measure ranging from −1 to 1 (1 represents perfect clustering). We also compared demographics and network quality measures between PERRs, hospital referral regions (HRRs), core-based statistical areas, and Pittsburgh Trauma Atlas regions.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Principal Findings</h3>\u0000 \u0000 <p>We analyzed 587,886 encounters, from which ZIP codes grouped into 24 PESAs. Based on referral patterns, there were 4 PERRs. PERRs had modestly higher modularity for interhospital referral patterns than all other systems (0.53, 95% confidence interval [CI] 0.52, 0.54 compared to 0.46, 95% CI 0.46, 0.47 for HRRs). PERRs were larger (median 11,361 mile<sup>2</sup> vs. 3957 for HRRs), contained more children (median 265,222 vs. 49,667 for HRRs), and contained more hospitals (median 35 vs. 7 for HRRs) than all other systems.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusions</h3>\u0000 \u0000 <p>Using Wisconsin HCUP data, we derived pediatric acute care regions with a strong fit for pediatric utilization data. Future work should test this approach across the whole US, which would allow between-region cost and outcomes comparison.</p>\u0000 </section>\u0000 </div>","PeriodicalId":55065,"journal":{"name":"Health Services Research","volume":"60 6","pages":""},"PeriodicalIF":3.2,"publicationDate":"2025-07-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144546256","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}
To test whether industry payments to clinicians are clustered at the level of the medical practice.
Study Setting and Design
We performed a cross-sectional study of clinicians who billed Medicare Part B in 2021 to test whether the receipt of an industry payment, log total value of industry payments, or log total number of industry payments to clinicians were clustered at the level of the medical practice. We used mixed effects linear regression to analyze practice-level clustering, controlling for clinician sex, age, urbanicity, state, and specialty, as well as practice size and specialty.
Data Source and Analytic Sample
We used the 2021 Medicare Data on Provider Practice and Specialty file to assign clinicians to medical practices, and the 2021 General Payment Data from the Open Payments Program to calculate the total value and number of industry payments to each clinician.
Principal Findings
We identified 996,982 clinicians who billed Medicare Part B in 2021, of whom 679,577 (68.2%) were physicians and 317,305 (31.8%) were advanced practice clinicians. These clinicians worked across 109,952 medical practices. In total, 474,312 (47.6%) clinicians received an industry payment in 2021. The average total value of industry payments was $1497 (SD $54,823), and the average total number of industry payments was 9.4 (SD 27.5). Regression analysis of each outcome identified significant clustering at the level of the medical practice, including 24.8% of the variation in the receipt of an industry payment, 36.8% in the log total value of industry payments, and 60.5% in the log total number of industry payments.
Conclusions
Industry payments to clinicians are strongly clustered by medical practice. Future research should examine the role of the medical practice in facilitating financial conflicts of interest between industry and clinicians.
{"title":"Practice-Level Clustering of Industry Payments to Clinicians","authors":"Max J. Hyman, Micah T. Prochaska, Parth K. Modi","doi":"10.1111/1475-6773.70004","DOIUrl":"10.1111/1475-6773.70004","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Objective</h3>\u0000 \u0000 <p>To test whether industry payments to clinicians are clustered at the level of the medical practice.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Study Setting and Design</h3>\u0000 \u0000 <p>We performed a cross-sectional study of clinicians who billed Medicare Part B in 2021 to test whether the receipt of an industry payment, log total value of industry payments, or log total number of industry payments to clinicians were clustered at the level of the medical practice. We used mixed effects linear regression to analyze practice-level clustering, controlling for clinician sex, age, urbanicity, state, and specialty, as well as practice size and specialty.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Data Source and Analytic Sample</h3>\u0000 \u0000 <p>We used the 2021 Medicare Data on Provider Practice and Specialty file to assign clinicians to medical practices, and the 2021 General Payment Data from the Open Payments Program to calculate the total value and number of industry payments to each clinician.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Principal Findings</h3>\u0000 \u0000 <p>We identified 996,982 clinicians who billed Medicare Part B in 2021, of whom 679,577 (68.2%) were physicians and 317,305 (31.8%) were advanced practice clinicians. These clinicians worked across 109,952 medical practices. In total, 474,312 (47.6%) clinicians received an industry payment in 2021. The average total value of industry payments was $1497 (SD $54,823), and the average total number of industry payments was 9.4 (SD 27.5). Regression analysis of each outcome identified significant clustering at the level of the medical practice, including 24.8% of the variation in the receipt of an industry payment, 36.8% in the log total value of industry payments, and 60.5% in the log total number of industry payments.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusions</h3>\u0000 \u0000 <p>Industry payments to clinicians are strongly clustered by medical practice. Future research should examine the role of the medical practice in facilitating financial conflicts of interest between industry and clinicians.</p>\u0000 </section>\u0000 </div>","PeriodicalId":55065,"journal":{"name":"Health Services Research","volume":"60 6","pages":""},"PeriodicalIF":3.2,"publicationDate":"2025-06-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1111/1475-6773.70004","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144509517","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Zoe H. Pleasure, Siobhan S. Mahorter, Rachel Hunter-Merrill, Jonathan G. Shaw, Kavita Vinekar, Maria K. Mor, Susan M. Frayne, Lisa S. Callegari
Objective
To examine the provision of long-acting reversible contraceptive (LARC) methods across the Veterans Health Administration's (VA) 140 regional healthcare systems and investigate system-level correlates of low provision as an indicator of potential access barriers.
Study Setting and Design
We conducted a cross-sectional analysis of national VA electronic health record (EHR) data. For each regional healthcare system, we calculated the percentage of pregnancy-capable Veterans who received a LARC method (intrauterine device or contraceptive implant). We categorized healthcare systems in the bottom quartile as low-provision. We examined associations between low-provision and system-level factors, including gynecologist staffing per pregnancy-capable Veteran, Women's Health Medical Director protected time, percent of pregnancy-capable Veterans visiting a women's health clinic, and LARC provision at ≥ 1 community-based outpatient clinic (CBOC).
Data Sources and Analytic Sample
We performed a secondary analysis of EHR data for female pregnancy-capable Veterans ages 18–44 who visited VA primary care or gynecology in 2019. We evaluated associations with chi-squared tests and multivariable logistic regression adjusting for Veteran-level factors.
Principal Findings
The median percentage of Veterans receiving LARC methods across healthcare systems was 4.9%, varying from 0% to 12.0%. In multivariable modeling, each 5% increase in gynecologist half-days per 100 pregnancy-capable Veterans was associated with an average two-percentage point decrease in the probability of being a low-provision system (average marginal effect [AME] = −0.02, 95% CI: −0.02, −0.01). LARC provision at ≥ 1 CBOCs was associated with an average 17-percentage point decrease in the probability of being a low-provision system (AME = −0.17, 95% CI: −0.29, −0.05).
Conclusions
We found significant variation in LARC provision across the VA's 140 regional healthcare systems. Importantly, this EHR analysis is limited as it does not incorporate patient demand for methods. Our findings, however, indicate potential access barriers. Interventions, such as increasing gynecologist staffing and investing in LARC provision in CBOCs, could help ensure access to these methods.
{"title":"System-Level Predictors of Long-Acting Reversible Contraception Provision in the Veterans Health Administration","authors":"Zoe H. Pleasure, Siobhan S. Mahorter, Rachel Hunter-Merrill, Jonathan G. Shaw, Kavita Vinekar, Maria K. Mor, Susan M. Frayne, Lisa S. Callegari","doi":"10.1111/1475-6773.14650","DOIUrl":"10.1111/1475-6773.14650","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Objective</h3>\u0000 \u0000 <p>To examine the provision of long-acting reversible contraceptive (LARC) methods across the Veterans Health Administration's (VA) 140 regional healthcare systems and investigate system-level correlates of low provision as an indicator of potential access barriers.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Study Setting and Design</h3>\u0000 \u0000 <p>We conducted a cross-sectional analysis of national VA electronic health record (EHR) data. For each regional healthcare system, we calculated the percentage of pregnancy-capable Veterans who received a LARC method (intrauterine device or contraceptive implant). We categorized healthcare systems in the bottom quartile as low-provision. We examined associations between low-provision and system-level factors, including gynecologist staffing per pregnancy-capable Veteran, Women's Health Medical Director protected time, percent of pregnancy-capable Veterans visiting a women's health clinic, and LARC provision at ≥ 1 community-based outpatient clinic (CBOC).</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Data Sources and Analytic Sample</h3>\u0000 \u0000 <p>We performed a secondary analysis of EHR data for female pregnancy-capable Veterans ages 18–44 who visited VA primary care or gynecology in 2019. We evaluated associations with chi-squared tests and multivariable logistic regression adjusting for Veteran-level factors.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Principal Findings</h3>\u0000 \u0000 <p>The median percentage of Veterans receiving LARC methods across healthcare systems was 4.9%, varying from 0% to 12.0%. In multivariable modeling, each 5% increase in gynecologist half-days per 100 pregnancy-capable Veterans was associated with an average two-percentage point decrease in the probability of being a low-provision system (average marginal effect [AME] = −0.02, 95% CI: −0.02, −0.01). LARC provision at ≥ 1 CBOCs was associated with an average 17-percentage point decrease in the probability of being a low-provision system (AME = −0.17, 95% CI: −0.29, −0.05).</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusions</h3>\u0000 \u0000 <p>We found significant variation in LARC provision across the VA's 140 regional healthcare systems. Importantly, this EHR analysis is limited as it does not incorporate patient demand for methods. Our findings, however, indicate potential access barriers. Interventions, such as increasing gynecologist staffing and investing in LARC provision in CBOCs, could help ensure access to these methods.</p>\u0000 </section>\u0000 </div>","PeriodicalId":55065,"journal":{"name":"Health Services Research","volume":"60 6","pages":""},"PeriodicalIF":3.2,"publicationDate":"2025-06-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144487195","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}
Pieter Bakx, Carlos Godoy, Saeed Al-Azazi, Amitava Banerjee, Nitzan Burrack, David Ehlig, Christina Fu, Laura A. Hatfield, Asa R. Hartman, Nicole Huang, Dennis T. Ko, Lisa M. Lix, Dominik Moser, Victor Novack, Laura Pasea, Feng Qiu, Kieran L. Quinn, Bheeshma Ravi, Therese A. Stukel, Carin A. Uyl-de Groot, Bruce E. Landon, Peter Cram
Objective
To describe differences in regionalization of hip fracture care and the volume-outcome relationship in five countries.
Study Setting and Design
We conducted a population-based cross-sectional cohort study in Canada, Israel, the Netherlands, Taiwan, and the United States. Within each country, we stratified patients into quintiles based upon the volume of hip fractures in the hospital where they were treated. We measured regionalization by the proportion of acute-care hospitals that treated patients with hip fractures and summarized the hospital volume distribution by the ratio of hip fracture volumes for high-volume hospitals versus low-volume hospitals. We then examined age- and sex-standardized outcomes and treatment for patients treated at high-volume and low-volume hospitals.
Data Sources and Analytic Sample
We used nationally representative administrative data on adults aged ≥ 66 years hospitalized with hip fracture from 2011 to 2019. We followed them until death or 365 days after the discharge date.
Principal Findings
Across countries, the percentage of all acute-care hospitals that treated hip fractures differed widely (from 37.0% in Canada to 82.8% in Israel), with high-volume hospitals treating 4–14 times as many hip fractures as low-volume hospitals. The absolute risk-adjusted difference in 30-day mortality for high-volume compared to low-volume hospitals ranged between (−1.9% [95% CI, −2.2 to −1.7] in Canada and +1.1% [95% CI, 0.4–1.8] in the Netherlands). The proportion of patients receiving non-operative fracture treatment was lower in high-volume hospitals than low-volume hospitals in all countries (−5.4% [95% CI, −6.5 to −4.3] in Israel to −0.1% [95% CI, −0.5 to 0.3] in the Netherlands).
Conclusions
Hip fracture regionalization differed substantially across countries. The direction and the magnitude of association between greater regionalization and improved patient outcomes were inconsistent across countries.
{"title":"Regionalization of Hip Fracture Care in Five High-Income Countries","authors":"Pieter Bakx, Carlos Godoy, Saeed Al-Azazi, Amitava Banerjee, Nitzan Burrack, David Ehlig, Christina Fu, Laura A. Hatfield, Asa R. Hartman, Nicole Huang, Dennis T. Ko, Lisa M. Lix, Dominik Moser, Victor Novack, Laura Pasea, Feng Qiu, Kieran L. Quinn, Bheeshma Ravi, Therese A. Stukel, Carin A. Uyl-de Groot, Bruce E. Landon, Peter Cram","doi":"10.1111/1475-6773.70002","DOIUrl":"10.1111/1475-6773.70002","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Objective</h3>\u0000 \u0000 <p>To describe differences in regionalization of hip fracture care and the volume-outcome relationship in five countries.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Study Setting and Design</h3>\u0000 \u0000 <p>We conducted a population-based cross-sectional cohort study in Canada, Israel, the Netherlands, Taiwan, and the United States. Within each country, we stratified patients into quintiles based upon the volume of hip fractures in the hospital where they were treated. We measured regionalization by the proportion of acute-care hospitals that treated patients with hip fractures and summarized the hospital volume distribution by the ratio of hip fracture volumes for high-volume hospitals versus low-volume hospitals. We then examined age- and sex-standardized outcomes and treatment for patients treated at high-volume and low-volume hospitals.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Data Sources and Analytic Sample</h3>\u0000 \u0000 <p>We used nationally representative administrative data on adults aged ≥ 66 years hospitalized with hip fracture from 2011 to 2019. We followed them until death or 365 days after the discharge date.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Principal Findings</h3>\u0000 \u0000 <p>Across countries, the percentage of all acute-care hospitals that treated hip fractures differed widely (from 37.0% in Canada to 82.8% in Israel), with high-volume hospitals treating 4–14 times as many hip fractures as low-volume hospitals. The absolute risk-adjusted difference in 30-day mortality for high-volume compared to low-volume hospitals ranged between (−1.9% [95% CI, −2.2 to −1.7] in Canada and +1.1% [95% CI, 0.4–1.8] in the Netherlands). The proportion of patients receiving non-operative fracture treatment was lower in high-volume hospitals than low-volume hospitals in all countries (−5.4% [95% CI, −6.5 to −4.3] in Israel to −0.1% [95% CI, −0.5 to 0.3] in the Netherlands).</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusions</h3>\u0000 \u0000 <p>Hip fracture regionalization differed substantially across countries. The direction and the magnitude of association between greater regionalization and improved patient outcomes were inconsistent across countries.</p>\u0000 </section>\u0000 </div>","PeriodicalId":55065,"journal":{"name":"Health Services Research","volume":"60 6","pages":""},"PeriodicalIF":3.2,"publicationDate":"2025-06-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1111/1475-6773.70002","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144477945","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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