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The authors announce the creation of a new feature and the call for papers to be included in a future issue of the periodical. The initial theme selected entails the improvement of efficiency and value in health care which is set to improve the quality of American Healthcare System. This theme issue is supported by the Agency for Healthcare Research and Quality (AHRQ).

The article presents an introduction of the articles contained in the 2006 issue of Health Services Research.

Over the past 20 years, much attention has been paid to health care prices and the role they play in driving high health care spending in the US.[1] This is in no small part due to the 2003 paper by Anderson et al. entitled "It's the Prices, Stupid: Why the United States is So Different from Other Countries",[2] and the follow-up paper in 2019 entitled "It's Still The Prices, Stupid: Why The US Spends So Much On Health Care, And A Tribute To Uwe Reinhardt".[3] In this issue, Mehrotra et al.[4] take on the issue of how differences in prices I at the medical group level i may contribute to differences in spending using data for the non-elderly population commercially insured by the United Health Group. With relatively limited cost sharing,[11] patients may be using other criteria to make decisions about whether and where to get inpatient and specialty care. [Extracted from the article]

Discusses the contents of the December 2003 issue special section of "Health Services Research." Appeal for the submission of research focusing on the management of chronic illness in managed care setting; Selection criteria for papers; Funding for the medical care quality research from the Agency for Healthcare Research and Quality.

Objective. To determine whether e/Tablets (wireless tablet computers used in community oncology clinics to collect review of systems information at point of care) are feasible, acceptable, and valid for collecting research-quality data in academic oncology. Data/Setting. Primary/Duke Breast Cancer Clinic. Design. Pilot study enrolling sample of 66 breast cancer patients. Methods. Data were collected using paper- and e/Tablet-based surveys: Functional Assessment of Cancer Therapy General, Functional Assessment of Cancer Therapy-Breast, MD Anderson Symptom Inventory, Functional Assessment of Chronic Illness Therapy (FACIT), Self-Efficacy; and two questionnaires: feasibility, satisfaction. Principal Findings. Patients supported e/Tablets as: easy to read (94 percent), easy to respond to (98 percent), comfortable weight (87 percent). Generally, electronic responses validly reflected responses provided by standard paper data collection on nearly all subscales tested. Conclusions. e/Tablets offer a valid, feasible, acceptable method for collecting research-quality, patient-reported outcomes data in outpatient academic oncology. [ABSTRACT FROM AUTHOR]

AcademyHealth established a Workforce Initiative Task Force in 2016 to conduct an assessment of the state of the health services research workforce and develop recommendations for its future in the context of the changing health care and research ecosystems. This assessment included four components: a series of commissioned papers, an online priority setting process, a multistakeholder summit, and final analysis by the AcademyHealth Education Council. This paper presents this process and the resultant list of prioritized recommendations and planned next steps. [ABSTRACT FROM AUTHOR]

Objective: The design of health insurance, and the role out-of-pocket (OOP) payments play in it, is a key policy issue as rising health costs have encouraged greater cost-sharing measures. This paper compares the percentage of Americans spending large amounts OOP to meet their health needs with percentages in eight other developed countries. By disaggregating by age and income, the paper focuses on the poor and elderly populations within each.Data Source: The study uses nationally representative household survey data made available through the Luxembourg Income Study. It includes nations with high, medium, and low levels of OOP spending.Study Design: Households have high medical spending when their OOP expenditures exceed a threshold share of income. I calculate the share of each nation's population, as well as subpopulations within it, with high OOP expenditures.Principal Findings: The United States is not alone in exposing large numbers of citizens to high OOP expenses. In six of the other eight countries, one-quarter or more of low-income citizens devoted at least 5 percent of their income to OOP expenses, and in all but two countries, more than 1 in 10 elderly citizens had high medical expenses.Conclusions: For some populations in the sample nations, health insurance does not provide adequate financial protection and likely contributes to inequities in health care delivery and outcomes. [ABSTRACT FROM AUTHOR]

In this article the author comments on the paper related to the characteristics of a method of measuring adverse events in hospitalized patients. The author argues that K statistic which is used by researchers to quantify reliability for physician judgments of the quality and safety of health care is not the best measure for the purpose. It informs that the paper also focuses on intraclass correlation and patient safety.

It is important to understand and seek to reduce unwarranted variations in health treatments in order to improve health outcomes, inequalities in access and health system efficiency. Even the definition of the "health system" varies across countries, for example, in the extent to which long-term care is considered a part of the health system. Eur J Health Econ. 2005; 6 (1): 2 - 10. https://doi.org/10.1007/s10198-005-0312-3 12 Figueroa J. A methodology for identifying high-need, high-cost patient personas for international comparisons. There remain few international standards regarding patient-reported outcomes21 or process measures such as waiting times.22 Such metrics are becoming increasingly important indicators of health care quality, and a failure to consider them leads to an incomplete picture of health system performance. [Extracted from the article]

Objective: This paper demonstrates that localized and chronic stop-question-and-frisk (SQF) practices are associated with community members' utilization of emergency department (ED) resources. To explain this relationship, we explore the empirical applicability of a legal epidemiological framework, or the study of legal institutional influences on the distribution of disease and injury.Data and Study Design: Analyses are derived from merging data from the Philadelphia Vehicle and Pedestrians Investigation, the National Historical Geographic Information System, and the Southeastern Philadelphia Community Health database to zip code identifiers common to all datasets. Weighted multilevel negative binomial regressions measure the influence that local SQF practices have on ED use for this population. Analytic methods incorporate patient demographic covariates including household size, health insurance status, and having a doctor as a usual source of care.Principal Findings: Findings reveal that both tract-level frisking and poor health are linked to more frequent use of hospital EDs, per respondent report. Despite their health care needs, however, reporting poor/fair health status is associated with a substantial decrease in the rate of emergency department visits as neighborhood frisk concentration increases (IRR = 0.923; 95% CI: 0.891, 0.957). Moreover, more sickly people in high-frisk neighborhoods live in tracts that have greater racial disparities in frisking-a pattern that accounts for the moderating role of neighborhood frisking in sick people's usage of the emergency room.Conclusions: Findings indicating the robust association reported above interrogate the chronic incompatibility of local health and human service system aims. The study also provides an interdisciplinary theoretical lens through which stakeholders can make sense of these challenges and their implications. [ABSTRACT FROM AUTHOR]

An introduction to the journal is presented which discusses articles on topics including the ways in which the health care workforce is changing due to system transformation, the changing roles for health care occupations, and the staffing arrangements in Community Health Centers who have implemented electronic health records.

An introduction to various papers within the issue which provide an overview of the current state of the research literature around improving the value of the health care system in the U.S. such as payment incentives and the theory and practice of fee-for-service is presented.

The author comments on the study "How Have State Policies to Expand Dependent Coverage Affected the Health Insurance Status of Young Adults?" by Alan C. Monheit and colleagues. He discussed increases in parental coverage among certain subsets of eligibles, the study's measure of dependent coverage and parental and spousal subcategories, and explanation on the Current Population Survey (CPS), which is the main basis for insurance coverage estimates in the U.S.

The article presents author's comments on the Health Services Research exploiting the membership on a committee that advises Medicare on administered pricing system for physician services in Medicare Part B. It mentions that the traditional fee-for-service Medicare program depends on administered prices. It focuses on the Specialty Society Relative Value Scale Update Committee (RUC) and the U.S. Centers for Medicare & Medicaid Services (CMS).

This paper presents longitudinal data representing federal funding for health services research and discusses the observed trends in the larger context of overall funding for research and development in the United States. By putting into context public and private funding trends, the authors examine how these trends effect the supply and demand of the health services research workforce. [ABSTRACT FROM AUTHOR]

Objectives: To explore (1) differences in validity and feasibility ratings for geriatric surgical standards across a diverse stakeholder group (surgeons vs. nonsurgeons, health care providers vs. nonproviders, including patient-family, advocacy, and regulatory agencies); (2) whether three multidisciplinary discussion subgroups would reach similar conclusions.Data Source/study Setting: Primary data (ratings) were reported from 58 stakeholder organizations.Study Design: An adaptation of the RAND-UCLA Appropriateness Methodology (RAM) process was conducted in May 2016.Data Collection/extraction Methods: Stakeholders self-administered ratings on paper, returned via mail (Round 1) and in-person (Round 2).Principal Findings: In Round 1, surgeons rated standards more critically (91.2 percent valid; 64.9 percent feasible) than nonsurgeons (100 percent valid; 87.0 percent feasible) but increased ratings in Round 2 (98.7 percent valid; 90.6 percent feasible), aligning with nonsurgeons (99.7 percent valid; 96.1 percent feasible). Three parallel subgroups rated validity at 96.8 percent (group 1), 100 percent (group 2), and 97.4 percent (group 3). Feasibility ratings were 76.9 percent (group 1), 96.1 percent (group 2), and 92.2 percent (group 3).Conclusions: There are differences in validity and feasibility ratings by health professions, with surgeons rating standards more critically than nonsurgeons. However, three separate discussion subgroups rated a high proportion (96-100 percent) of standards as valid, indicating the RAM can be successfully applied to a large stakeholder group. [ABSTRACT FROM AUTHOR]

Objectives: To examine: (1) what elements of patient-centered medical homes (PCMHs) are typically provided to low-income populations, (2) whether PCMHs improve health behaviors, experiences, and outcomes for low-income groups.Data Sources/study Setting: Existing literature on PCMH utilization among health care organizations serving low-income populations.Study Design: Systematic review and meta-analysis.Data Collection/extraction Methods: We obtained papers through existing systematic and literature reviews and via PubMed, Web of Science, and the TRIP databases, which examined PCMHs serving low-income populations. A total of 434 studies were reviewed. Thirty-three articles met eligibility criteria.Principal Findings: Patient-centered medical home interventions usually were composed of five of the six recommended components. Overall positive effect of PCMH interventions was d = 0.247 (range -0.965 to 1.42). PCMH patients had better clinical outcomes (d = 0.395), higher adherence (0.392), and lower utilization of emergency rooms (d = -0.248), but there were apparent limitations in study quality.Conclusions: Evidence shows that the PCMH model can increase health outcomes among low-income populations. However, limitations to quality include no assessment for confounding variables. Implications are discussed. [ABSTRACT FROM AUTHOR]

Objective: To estimate the impact of the $600 per week Federal Pandemic Unemployment Compensation (FPUC) payments on health care services spending during the Covid pandemic and to investigate if this impact varied by state Medicaid expansion status. Data Sources: This study leverages novel, publicly available data from Opportunity Insights capturing consumer credit and debit card spending on health care services for January 18–August 15, 2020 as well as information on unemployment insurance claims, Covid cases, and state policy changes. Study Design: Using triple‐differences estimation, we leverage two sources of variation—within‐state change in the unemployment insurance claims rate and the introduction of FPUC payments—to estimate the moderating effect of FPUC on health care spending losses as unemployment rises. Results are stratified by state Medicaid expansion status. Extraction Methods: Not applicable. Principal Findings: For each percentage point increase in the unemployment insurance claims rate, health care spending declined by 1.0% (<0.05) in Medicaid expansion states and by 2.0% (<0.01) in nonexpansion states. However, FPUC partially mitigated this association, boosting spending by 0.8% (<0.001) and 1.3% (<0.05) in Medicaid expansion and nonexpansion states, respectively, for every percentage point increase in the unemployment insurance claims rate. Conclusions: We find that FPUC bolstered health care spending during the Covid pandemic, but that both the negative consequences of unemployment and moderating effects of federal income supports were greatest in states that did not adopt Medicaid expansion. These results indicate that emergency federal spending helped to sustain health care spending during a period of rising unemployment. Yet, the effectiveness of this program also suggests possible unmet demand for health care services, particularly in states that did not adopt Medicaid expansion. [ABSTRACT FROM AUTHOR]

Objectives Methodologically sound mixed methods research can improve our understanding of health services by providing a more comprehensive picture of health services than either method can alone. This study describes the frequency of mixed methods in published health services research and compares the presence of methodological components indicative of rigorous approaches across mixed methods, qualitative, and quantitative articles. Data Sources All empirical articles ( n = 1,651) published between 2003 and 2007 from four top-ranked health services journals. Study Design All mixed methods articles ( n = 47) and random samples of qualitative and quantitative articles were evaluated to identify reporting of key components indicating rigor for each method, based on accepted standards for evaluating the quality of research reports (e.g., use of p-values in quantitative reports, description of context in qualitative reports, and integration in mixed method reports). We used chi-square tests to evaluate differences between article types for each component. Principal Findings Mixed methods articles comprised 2.85 percent ( n = 47) of empirical articles, quantitative articles 90.98 percent ( n = 1,502), and qualitative articles 6.18 percent ( n = 102). There was a statistically significant difference (χ2(1) = 12.20, p = .0005, Cramer's V = 0.09, odds ratio = 1.49 [95% confidence interval = 1,27, 1.74]) in the proportion of quantitative methodological components present in mixed methods compared to quantitative papers (21.94 versus 47.07 percent, respectively) but no statistically significant difference (χ2(1) = 0.02, p = .89, Cramer's V = 0.01) in the proportion of qualitative methodological components in mixed methods compared to qualitative papers (21.34 versus 25.47 percent, respectively). Conclusion Few published health services research articles use mixed methods. The frequency of key methodological components is variable. Suggestions are provided to increase the transparency of mixed methods studies and the presence of key methodological components in published reports. [ABSTRACT FROM AUTHOR]

Health services research is a field of study that brings together experts from a wide variety of academic disciplines. It also is a field that places a high priority on empirical analysis. Many of the questions posed by health services researchers involve the effects of treatments, patient and provider characteristics, and policy interventions on outcomes of interest. These are causal questions. Yet many health services researchers have been trained in disciplines that are reluctant to use the language of causality, and the approaches to causal questions are discipline specific, often with little overlap. How did this situation arise? This paper traces the roots of the division and some recent attempts to remedy the situation. Existing literature. Review of the literature. [ABSTRACT FROM AUTHOR]

Objective. To summarize findings from a systematic exploration of existing literature and views regarding interdisciplinarity, to discuss themes and components of such work, and to propose a theoretically based definition of interdisciplinary research. Data Sources/Study Setting. Two major data sources were used: interviews with researchers from various disciplines, and a systematic review of the education, business, and health care literature from January 1980 through January 2005. Study Design. Systematic review of literature, one-on-one interviews, field test (survey). Data Collection/Extraction Methods. We reviewed 14 definitions of interdisciplinarity, the characteristics of 42 interdisciplinary research publications from multiple fields of study, and 14 researcher interviews to arrive at a preliminary definition of interdisciplinary research. That definition was then field tested by 12 individuals with interdisciplinary research experience, and their responses incorporated into the definition of interdisciplinary research proposed in this paper. Principal Findings. Three key definitional characteristics were identified: the qualitative mode of research (and its theoretical underpinnings), existence of a continuum of synthesis among disciplines, and the desired outcome of the interdisciplinary research. Conclusion. Existing literature from several fields did not provide a definition for interdisciplinary research of sufficient specificity to facilitate activities such as identification of the competencies, structure, and resources needed for health care and health policy research. This analysis led to the proposed definition, which is designed to aid decision makers in funding agencies/program committees and researchers to identify and take full advantage the interdisciplinary approach, and to serve as a basis for competency-based formalized training to provide researchers with interdisciplinary skills. [ABSTRACT FROM AUTHOR]

Health care clinicians successfully apply proven medical evidence in common acute, chronic, or preventive care processes less than 80 percent of the time. This low level of reliability at the basic process level means that health care's efforts to improve reliability start from a different baseline from most other industries, and therefore may require a different approach. This paper describes The Institute for Healthcare Improvement's (IHI) current approach to improving health care reliability, including a useful nomenclature for levels of reliability, and a focus on improving reliability of basic health care processes before moving on to more sophisticated high reliability organization concepts. Early IHI work with a community of health care reliability innovators has identified four themes in health care settings that help to explain at least a portion of the gap in process reliability between health care and other industries. These include extreme dependence on hard work and personal vigilance, a focus on mediocre benchmark outcomes rather than process, great tolerance of provider autonomy, and failure to create systems that are specifically designed to reach articulated reliability goals. This paper describes our recommendations for the initial steps health care organizations' might take, based on these four themes, as they begin to move toward higher reliability. [ABSTRACT FROM AUTHOR]

The article introduces several articles on health care reliability published in the August 2006 issue of "Health Services Research."

The article discusses various papers dealing with the issue of racial disparities in health care. The first paper cited is an editorial by Jose Escarce in the February 2005 issue of the journal "Health Services Research" that offers a conceptual bridge between economic and psychosocial understandings of how race matters in the clinical encounter. Also mentioned is the article "Patient and Provider Assessments of Adherence and the Sources of Disparities: Evidence from Diabetes Care," by Karen Lutfey and Jonathan Ketcham.

Objective. To examine potential sources of errors at each step of the described inpatient International Classification of Diseases (ICD) coding process. Data Sources/Study Setting. The use of disease codes from the ICD has expanded from classifying morbidity and mortality information for statistical purposes to diverse sets of applications in research, health care policy, and health care finance. By describing a brief history of ICD coding, detailing the process for assigning codes, identifying where errors can be introduced into the process, and reviewing methods for examining code accuracy, we help code users more systematically evaluate code accuracy for their particular applications. Study Design/Methods. We summarize the inpatient ICD diagnostic coding process from patient admission to diagnostic code assignment. We examine potential sources of errors at each step and offer code users a tool for systematically evaluating code accuracy. Principle Findings. Main error sources along the “patient trajectory” include amount and quality of information at admission, communication among patients and providers, the clinician's knowledge and experience with the illness, and the clinician's attention to detail. Main error sources along the “paper trail” include variance in the electronic and written records, coder training and experience, facility quality-control efforts, and unintentional and intentional coder errors, such as misspecification, unbundling, and upcoding. Conclusions. By clearly specifying the code assignment process and heightening their awareness of potential error sources, code users can better evaluate the applicability and limitations of codes for their particular situations. ICD codes can then be used in the most appropriate ways. [ABSTRACT FROM AUTHOR]

This article focuses on quality improvement in medical care in the U.S. Efforts, particularly in the last decade or so that have been undertaken to improve the quality and efficiency of medical care. Changing the behavior of physicians and other health care workers is at the crux of many of these efforts. Clinical pathways and computerized decision support have been advocated to improve adherence with practice guidelines, and Quality Improvement Organizations have been charged with assisting providers in quality improvement activities. Clinical pathways, structured care plans that note the essential elements of care by hospital day, have been widely used by hospitals in efforts to improve the quality and efficiency of care.

Introduces a series of papers on consumer-driven health care in the U.S. Emergence of consumer-driven health plans; State of the health care industry; Consumer response to the plan; Advantages over other managed care plans.

I Erode physician professionalism and autonomy i Employment by large health systems may erode physician autonomy and weaken the sense of professionalism that is a motive force behind much quality improvement in health care. The AHRQ Comparative Health System Performance (CHSP) initiative was conceived with the goal of generating insights about health system performance, and the conditions under which health system performance improves. TWO POLICY RECOMMENDATIONS Patients will increasingly receive care from physicians, hospitals, and other health care providers that are affiliated with health systems. Racial and ethnic disparities in care for health system-affiliated physician organizations and non-affiliated physician organizations. [Extracted from the article]

Objective: To summarize research relating to health services research translation in the safety net through analysis of the literature and case study of a safety net system.Data Sources/study Setting: Literature review and key informant interviews at an integrated safety net hospital.Study Design: This paper describes the results of a comprehensive literature review of translational science literature as applied to health care paired with qualitative analysis of five key informant interviews conducted with senior-level management at Denver Health and Hospital Authority.Principal Findings: Results from the literature suggest that implementing innovation may be more difficult in the safety net due to multiple factors, including financial and organizational constraints. Results from key informant interviews confirmed the reality of financial barriers to innovation implementation but also implied that factors, including institutional respect for data, organizational attitudes, and leadership support, could compensate for disadvantages.Conclusions: Translating research into practice is of critical importance to safety net providers, which are under increased pressure to improve patient care and satisfaction. Results suggest that translational research done in the safety net can better illuminate the special challenges of this setting; more such research is needed. [ABSTRACT FROM AUTHOR]

Objective Grounded theory ( GT) is an established qualitative research method, but few papers have encapsulated the benefits, limits, and basic tenets of doing GT research on user and provider experiences of health care services. GT can be used to guide the entire study method, or it can be applied at the data analysis stage only. Methods We summarize key components of GT and common GT procedures used by qualitative researchers in health care research. We draw on our experience of conducting a GT study on amyotrophic lateral sclerosis patients' experiences of health care services. Findings We discuss why some approaches in GT research may work better than others, particularly when the focus of study is hard-to-reach population groups. We highlight the flexibility of procedures in GT to build theory about how people engage with health care services. Conclusion GT enables researchers to capture and understand health care experiences. GT methods are particularly valuable when the topic of interest has not previously been studied. GT can be applied to bring structure and rigor to the analysis of qualitative data. [ABSTRACT FROM AUTHOR]

An introduction is presented in which the editor discusses various reports within the issue on topics including the Massachusetts Health Reform Survey, self-reported health measures in predicting individuals with high future health care needs, and the American Community Survey and the Survey of Income Program Participation.

Objective The Patient Protection and Affordable Care Act ( ACA) increases Medicaid physician fees for preventive care up to Medicare rates for 2013 and 2014. The purpose of this paper was to model the relationship between Medicaid preventive care payment rates and the use of U.S. Preventive Services Task Force ( USPSTF)-recommended preventive care use among Medicaid enrollees. Data Sources/Study Session We used data from the 2003 and 2008 Medical Expenditure Panel Survey ( MEPS), a national probability sample of the U.S. civilian, noninstitutionalized population, linked to Kaiser state Medicaid benefits data, including the state Medicaid-to-Medicare physician fee ratio in 2003 and 2008. Study Design Probit models were used to estimate the probability that eligible individuals received one of five USPSF-recommended preventive services. A difference-in-difference model was used to separate out the effect of changes in the Medicaid payment rate and other factors. Data Collection/Extraction Methods Data were linked using state identifiers. Principal Findings Although Medicaid enrollees had a lower rate of use of the five preventive services in univariate analysis, neither Medicaid enrollment nor changes in Medicaid payment rates had statistically significant effects on meeting screening recommendations for the five screenings. The results were robust to a number of different sensitivity tests. Individual and state characteristics were significant. Conclusions Our results suggest that although temporary changes in primary care provider payments for preventive services for Medicaid enrollees may have other desirable effects, they are unlikely to substantially increase the use of these selected USPSTF-recommended preventive care services among Medicaid enrollees. [ABSTRACT FROM AUTHOR]

The long-standing debate over how best to organize services and payment policies for mental health has hinged on how we choose to simplify the multiple complex connections of mental health conditions with other human ailments. Because mental health problems can be legitimately viewed as highly distinct from, or, alternatively, necessarily intertwined with, medical conditions, policies have vacillated between encouraging or discouraging integration of mental health services with other medical services. [Extracted from the article]

Objective To provide a tutorial for using propensity score methods with complex survey data. Data Sources Simulated data and the 2008 Medical Expenditure Panel Survey. Study Design Using simulation, we compared the following methods for estimating the treatment effect: a naïve estimate (ignoring both survey weights and propensity scores), survey weighting, propensity score methods (nearest neighbor matching, weighting, and subclassification), and propensity score methods in combination with survey weighting. Methods are compared in terms of bias and 95 percent confidence interval coverage. In Example 2, we used these methods to estimate the effect on health care spending of having a generalist versus a specialist as a usual source of care. Principal Findings In general, combining a propensity score method and survey weighting is necessary to achieve unbiased treatment effect estimates that are generalizable to the original survey target population. Conclusions Propensity score methods are an essential tool for addressing confounding in observational studies. Ignoring survey weights may lead to results that are not generalizable to the survey target population. This paper clarifies the appropriate inferences for different propensity score methods and suggests guidelines for selecting an appropriate propensity score method based on a researcher's goal. [ABSTRACT FROM AUTHOR]

The maternal and child health workforce needs Black women scholar-activists not only for their professional knowledge but for their deep insights into the barriers faced by those who experience the worst outcomes and the solutions to advance health justice. Maternal mortality is rising in the US, with Non-Hispanic Black (NHB) and Native American (NA) women experiencing rates 2-3 times higher than White women - and 60% of these maternal deaths are preventable.[[1]] Women with chronic conditions such as diabetes, hypertension, and autoimmune disorders are at increased risk.[3] In the US about 60% of adults live with at least one chronic condition, including people of reproductive age.[4] There is an urgent need to improve reproductive and wellness care for people with chronic conditions and ideas for making this happen. Health Serv Res. 2022; 1 - 5. doi: 10.1111/1475-6773.14091 8 Attanasio L, Ranchoff B, Jeung C, Goff S, Geissler K. Preventive care visits with OB/GYNs and generalist physicians among reproductive-age women with chronic conditions. [Extracted from the article]

The article reflects on medical researches prepared on patients participation in health care services. It investigates a patient-centered approach to assess health care expenditures. It highlights how quality information from financial incentives and multiple sources affect consumer choice of physician in Massachusetts. It examines the psychometric properties of Hibbard's Patient Activation Measure (PAM).

Objective. To examine adoption of telehealth in a rural public health district and to explain how the innovation became sustainable. Study Setting. Longitudinal, qualitative study (1988–2008) of the largest public health district in Georgia. Study Design. Case study design provided deep insights into the innovation's social dynamics. Punctuated equilibrium theory helped present and make sense of the process. We identified antecedent conditions and outcomes, and we distinguished between episodes and encounters based on the disruptive effects of events. Data Collection. Twenty-five semistructured interviews with 19 decision makers and professionals, direct observations, published papers, grant proposals, technical specifications, and other written materials. Principal Findings. Strong collaboration within the district, with local community, and with external partners energized the process. Well-functioning outreach clinics made telehealth desirable. Local champions cultivated participation and generative capability, and overcame barriers through opportunistic exploitation of technological and financial options. Telehealth usage fluctuated between medical and administrative operations in response to internal needs and contextual dynamics. External agencies provided initial funding and supported later expansion. Conclusions. Extensive internal and external collaboration, and a combination of technology push and opportunistic exploitation, can enable sustainable rural telehealth innovation. [ABSTRACT FROM AUTHOR]

Objective. To illustrate the impact of moral hazard for estimating relative rates of underinsurance and to present an adjustment method to correct for this source of bias. Data Sources/Study Setting. Secondary data from the 2005 Medical Expenditure Panel Survey (MEPS) are used in this study. We restrict attention to households that report having employer-sponsored insurance (ESI) for all members during the entire 2005 calendar year. Study Design. Individuals or households are often classified as underinsured if out-of-pocket spending on medical care relative to income exceeds some threshold. In this paper, we show that, without adjustment, this common threshold measure of underinsurance will underestimate the number with low levels of insurance coverage due to moral hazard. We propose an adjustment method and apply it to the specific case of estimating the difference in rates of underinsurance among small- versus large-firm workers with full-year ESI. Data Collection/Extraction. Data were abstracted from the MEPS website. All analyses were performed in Stata 9.2. Principal Findings. Applying the adjustment, we find that the underinsurance rate of small-firm households increases by approximately 20 percent with the adjustment for moral hazard and the difference in underinsurance rates between large-firm and small-firm households widens substantially. Conclusions. Adjusting for moral hazard makes a sizeable difference in the estimated prevalence of underinsurance using a threshold measure. [ABSTRACT FROM AUTHOR]

Objective. To summarize the current state of the health services research (HSR) workforce and recommend ways to improve the field's ability to respond to future challenges facing the health system. Data. Summaries of workgroup discussions and recommendations at a stakeholder meeting. Study Design. In late 2007, 50 educators, students, employers, and funders of HSR participated in a meeting to discuss findings of three commissioned papers on the HSR workforce. The group undertook a consultative process to develop recommendations for the field. Principal Findings. Stakeholders developed recommendations in five major areas focused on HSR workforce needs: (1) improving the size and composition of the field; (2) understanding the growth of HSR in the private sector; (3) improving the graduate training of health services researchers, especially at the master's level; (4) expanding postgraduate training and continuing education opportunities; and (5) increasing awareness of the value of HSR. Conclusions. Specific recommendations in the five major areas emphasized developing partnerships between HSR organizations and other professional societies or health organizations, as well as ways to improve training for the future workforce. The need to develop a “client orientation” toward research by improving communication and dissemination skills was discussed, as was the importance of improving diversity in the field. [ABSTRACT FROM AUTHOR]

Research Objective. This paper tests for differences in the effect of State Children's Health Insurance Program (SCHIP) on children's insurance coverage and physician visits across three age groups: pre-elementary school-aged children (pre-ESA), ESA children, and post-ESA children. Data Source. The study uses two cross sections of the Survey of Income and Program Participation (SIPP) from the 1996 and 2001 panels. Study Design. A difference-in-differences approach is used to estimate the effect of SCHIP on coverage and physician visits of newly eligible children of different age groups. Data Collection. Demographic, insurance, and physician visit information for children in families with income below 300 percent of federal poverty line were extracted from the SIPP. Principal Findings. Uninsurance rates for post-ESA children declined due to SCHIP while public coverage and the likelihood of visiting a physician increased. Estimates of cross-age differences show that post-ESA children experienced a larger decline in uninsurance rates compared with pre-ESA and ESA children and a larger increase in physician visits compared with ESA children. Conclusions. The higher rate of physician visits for post-ESA children due to SCHIP demonstrates the importance of extending insurance coverage to teens as well as young children. [ABSTRACT FROM AUTHOR]

Objective. To examine the within-year concentration of family health care and the resulting exposure of families to short periods of high expenditure burdens. Data Source. Household data from the pooled 2003 and 2004 Medical Expenditure Panel Survey (MEPS) yielding nationally representative estimates for the nonelderly civilian noninstitutionalized population. Study Design. The paper examines the within-year concentration of family medical care use and the frequency with which family out-of-pocket expenditures exceeded 20 percent of family income, computed at the annual, quarterly, and monthly levels. Principal Findings. On average among families with medical care, 49 percent of all (charge-weighted) care occurred in a single month, and 63 percent occurred in a single quarter). Nationally, 27 percent of the study population experienced at least 1 month in which out-of-pocket expenditures exceeded 20 percent of income. Monthly 20 percent burden rates were highest among the poor, at 43 percent, and were close to or above 30 percent for all but the highest income group (families above four times the federal poverty line). Conclusions. Within-year spikes in health care utilization can create financial pressures missed by conventional annual burden analyses. Within-year health-related financial pressures may be especially acute among lower-income families due to low asset holdings. [ABSTRACT FROM AUTHOR]

The article discusses various reports published within the issue, including one by John Olson, James Belohlav, Lori Cook and Julie Hays on common quality improvement programs among hospitals, one by Anita Tucker, Sara Singer, Jennifer Hayes and Alyson Falwell on hospital work systems, and one by Vivian Valdmanis, Michael Rosko and Ryan Mutter on inefficiency in hospitals.

Objective. This paper measures agreement between survey and administrative measures of race/ethnicity for Medicaid enrollees. Level of agreement and the demographic and health-related characteristics associated with misclassification on the administrative measure are examined. Data Sources. Minnesota Medicaid enrollee files matched to self-report information from a telephone/mail survey of 4,902 enrollees conducted in 2003. Study Design. Measures of agreement between the two measures of race/ethnicity are computed. Using logistic regression, we also assess whether misclassification of race/ethnicity on administrative files is associated with demographic factors, health status, health care utilization, or ratings of quality of health care. Data Extraction. Race/ethnicity fields from administrative Medicaid files were extracted and merged with self-report data. Principal Findings. The administrative data correctly classified 94 percent of cases on race/ethnicity. Persons who self-identified as Hispanic and those whose home language was English had the greater odds (compared with persons who self-identified as white and those whose home language was not English) of being misclassified in administrative data. Persons classified as unknown/other on administrative data were more likely to self-identify as white. Conclusions. In this case study in Minnesota, researchers can be reasonably confident that the racial designations on Medicaid administrative data comport with how enrollees self-identify. Moreover, misclassification is not associated with common measures of health status, utilization, and ratings of quality of care. Further replication is recommended given variation in how race information is collected and coded by Medicaid agencies in different states. [ABSTRACT FROM AUTHOR]

Objective. To examine how the lives of consumers and their caregivers were affected by making choices and controlling their own resources with the cash option, this paper focuses on six case studies from the Cash and Counseling Demonstration Program. Data Sources. Twenty-one consumers, caregivers, and state consultants were interviewed about their experiences in the program. Study Design. The data come from a larger study of over 200 interviews conducted from June 2000 to August 2004. Interview data were analyzed for themes about caregiving and program satisfaction. Principal Findings. Cash and Counseling benefited consumers and caregivers by allowing consumers increased continuity and reliability of care, increased ability to set hours of care, more satisfaction with how caregiving is offered and more satisfaction with the quality of care. Conclusions. The cash option allowed consumers to create, schedule, and manage their own model of care. Some consumers faced challenges in the program with paperwork, accounting, worries about receiving care, and some ineffective state consultants who could have been more helpful. [ABSTRACT FROM AUTHOR]

Objective. This paper analyzes whether the rise in managed care during the 1990s caused the increase in hospital concentration. Data Sources. We assemble data from the American Hospital Association, InterStudy and government censuses from 1990 to 2000. Study Design. We employ linear regression analyses on long differenced data to estimate the impact of managed care penetration on hospital consolidation. Instrumental variable analogs of these regressions are also analyzed to control for potential endogeneity. Data Collection. All data are from secondary sources merged at the level of the Health Care Services Area. Principle Findings. In 1990, the mean population-weighted hospital Herfindahl–Hirschman index (HHI) in a Health Services Area was .19. By 2000, the HHI had risen to .26. Most of this increase in hospital concentration is due to hospital consolidation. Over the same time frame HMO penetration increased three fold. However, our regression analysis strongly implies that the rise of managed care did not cause the hospital consolidation wave. This finding is robust to a number of different specifications. [ABSTRACT FROM AUTHOR]

Objective. In a recent report, the Institute of Medicine (IOM) defines a health service disparity between population groups to be the difference in treatment or access not justified by the differences in health status or preferences of the groups. This paper proposes an implementation of this definition, and applies it to disparities in outpatient mental health care. Data Sources. Health Care for Communities (HCC) reinterviewed 9,585 respondents from the Community Tracking Study in 1997–1998, oversampling individuals with psychological distress, alcohol abuse, drug abuse, or mental health treatment. The HCC is designed to make national estimates of service use. Study Design. Expenditures are modeled using generalized linear models with a log link for quantity and a probit model for any utilization. We adjust for group differences in health status by transforming the entire distribution of health status for minority populations to approximate the white distribution. We compare disparities according to the IOM definition to other methods commonly used to assess health services disparities. Principal Findings. Our method finds significant service disparities between whites and both blacks and Latinos. Estimated disparities from this method exceed those for competing approaches, because of the inclusion of effects of mediating factors (such as income) in the IOM approach. Conclusions. A rigorous definition of disparities is needed to monitor progress against disparities and to compare their magnitude across studies. With such a definition, disparities can be estimated by adjusting for group differences in models for expenditures and access to mental health services. [ABSTRACT FROM AUTHOR]

Organizational silence refers to a collective-level phenomenon of saying or doing very little in response to significant problems that face an organization. The paper focuses on some of the less obvious factors contributing to organizational silence that can serve as threats to patient safety. Converging areas of research from the cognitive, social, and organizational sciences and the study of sociotechnical systems help to identify some of the underlying factors that serve to shape and sustain organizational silence. These factors have been organized under three levels of analysis: (1) individual factors, including the availability heuristic, self-serving bias, and the status quo trap; (2) social factors, including conformity, diffusion of responsibility, and microclimates of distrust; and (3) organizational factors, including unchallenged beliefs, the good provider fallacy, and neglect of the interdependencies. Finally, a new role for health care leaders and managers is envisioned. It is one that places high value on understanding system complexity and does not take comfort in organizational silence. [ABSTRACT FROM AUTHOR]

Objective. The objective of this paper was to present a comprehensive approach to help health care organizations reliably deliver effective interventions. Context. Reliability in healthcare translates into using valid rate-based measures. Yet high reliability organizations have proven that the context in which care is delivered, called organizational culture, also has important influences on patient safety. Model for Improvement. Our model to improve reliability, which also includes interventions to improve culture, focuses on valid rate-based measures. This model includes (1) identifying evidence-based interventions that improve the outcome, (2) selecting interventions with the most impact on outcomes and converting to behaviors, (3) developing measures to evaluate reliability, (4) measuring baseline performance, and (5) ensuring patients receive the evidence-based interventions. The comprehensive unit-based safety program (CUSP) is used to improve culture and guide organizations in learning from mistakes that are important, but cannot be measured as rates. Conclusions. We present how this model was used in over 100 intensive care units in Michigan to improve culture and eliminate catheter-related blood stream infections—both were accomplished. Our model differs from existing models in that it incorporates efforts to improve a vital component for system redesign—culture, it targets 3 important groups—senior leaders, team leaders, and front line staff, and facilitates change management—engage, educate, execute, and evaluate for planned interventions. [ABSTRACT FROM AUTHOR]

To reduce racial and ethnic disparities in health care, managers, policy makers, and researchers need valid and reliable data on the race and ethnicity of individuals and populations. The federal government is one of the most important sources of such data. In this paper we review the strengths and weaknesses of federal data that pertain to racial and ethnic disparities in health care. We describe recent developments that are likely to influence how these data can be used in the future and discuss how local programs could make use of these data. [ABSTRACT FROM AUTHOR]

The article offers a rejoinder to Roice D. Luke's paper on taxonomy of health networks and systems in the U.S. The authors stress that their primary objective in developing health care system taxonomy was to analyze health networks' structure and strategy as defined by the American Hospital Association. The taxonomy proponents clarified all issues raised by Luke such as the relevance of conceptual framework to health networks and the existence of measurement errors.