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To identify major research topics and exhibit trends in these topics in 15 health services research, health policy, and health economics journals over 2 decades.The study sample of 35,159 abstracts (1999-2020) were collected from PubMed for 15 journals.The study used a 3-phase approach for text analyses: (1) developing the corpus of 40,618 references from PubMed (excluding 5459 of those without abstract or author information); (2) preprocessing and generating the term list using natural language processing to eliminate irrelevant textual data and identify important terms and phrases; (3) analyzing the preprocessed text data using latent semantic analysis, topic analyses, and multiple correspondence analysis.Application of analyses generated 16 major research topics: (1) implementation/intervention science; (2) HIV and women's health; (3) outcomes research and quality; (4) veterans/military studies; (5) provider/primary-care interventions; (6) geriatrics and formal/informal care; (7) policies and health outcomes; (8) medication treatment/therapy; (9) patient interventions; (10) health insurance legislation and policies; (11) public health policies; (12) literature reviews; (13) cost-effectiveness and economic evaluation; (14) cancer care; (15) workforce issues; and (16) socioeconomic status and disparities. The 2-dimensional map revealed that some journals have stronger associations with specific topics. Findings were not consistent with previous studies based on user perceptions.Findings of this study can be used by the stakeholders of health services research, policy, and economics to develop future research agendas, target journal submissions, and generate interdisciplinary solutions by examining overlapping journals for particular topics.

Supplemental Digital Content is available in the text., Background: Rapid approaches to collecting and analyzing qualitative interview data can accelerate discovery timelines and intervention development while maintaining scientific rigor. We describe the application of these methods to a program designed to improve care coordination between the Veterans Health Administration (VHA) and community providers. Methods: Care coordination between VHA and community providers can be challenging in rural areas. The Telehealth-based Coordination of Non-VHA Care (TECNO Care) intervention was designed to improve care coordination among VHA and community providers. To ensure contextually appropriate implementation of TECNO Care, we conducted preimplementation interviews with veterans, VHA administrators, and VHA and community providers involved in community care. Using both a rapid approach and qualitative analysis, an interviewer and 1–2 note-taker(s) conducted interviews. Results: Over 5 months, 18 stakeholders were interviewed and we analyzed these data to identify how best to deliver TECNO Care. Responses relevant to improving care coordination include health system characteristics; target population; metrics and outcomes; challenges with the current system; and core components. Veterans who frequently visit VHA or community providers and are referred for additional services are at risk for poor outcomes and may benefit from additional care coordination. Using these data, we designed TECNO Care to include information on VHA services and processes, assist in the timely completion of referrals, and facilitate record sharing. Conclusion: Rapid qualitative analysis can inform near real-time intervention development and ensure relevant content creation while setting the stage for stakeholder buy-in. Rigorous and timely analyses support the delivery of contextually appropriate, efficient, high-value patient care.

Supplemental Digital Content is available in the text., Background: The Safe Staffing for Quality Care Act under consideration in the New York (NY) state assembly would require hospitals to staff enough nurses to safely care for patients. The impact of regulated minimum patient-to-nurse staffing ratios in acute care hospitals in NY is unknown. Objectives: To examine variation in patient-to-nurse staffing in NY hospitals and its association with adverse outcomes (ie, mortality and avoidable costs). Research Design: Cross-sectional data on nurse staffing in 116 acute care general hospitals in NY are linked with Medicare claims data. Subjects: A total of 417,861 Medicare medical and surgical patients. Measures: Patient-to-nurse staffing is the primary predictor variable. Outcomes include in-hospital mortality, length of stay, 30-day readmission, and estimated costs using Medicare-specific cost-to-charge ratios. Results: Hospital staffing ranged from 4.3 to 10.5 patients per nurse (P/N), and averaged 6.3 P/N. After adjusting for potential confounders each additional patient per nurse, for surgical and medical patients, respectively, was associated with higher odds of in-hospital mortality [odds ratio (OR)=1.13, P=0.0262; OR=1.13, P=0.0019], longer lengths of stay (incidence rate ratio=1.09, P=0.0008; incidence rate ratio=1.05, P=0.0023), and higher odds of 30-day readmission (OR=1.08, P=0.0002; OR=1.06, P=0.0003). Were hospitals staffed at the 4:1 P/N ratio proposed in the legislation, we conservatively estimated 4370 lives saved and $720 million saved over the 2-year study period in shorter lengths of stay and avoided readmissions. Conclusions: Patient-to-nurse staffing varies substantially across NY hospitals and higher ratios adversely affect patients. Our estimates of potential lives and costs saved substantially underestimate potential benefits of improved hospital nurse staffing.

BACKGROUND: Home clinical care (HCC) includes home-based medical care (HBMC –medical visits in the home) and skilled home health care (skilled nursing or therapy visits). Over seven million older adults would benefit from HCC; however, we know surprisingly little about homebound older adults and HCC. OBJECTIVE: To describe HCC received by older adults using claims data within the OptumLabs® Data Warehouse. RESEARCH DESIGN: Using administrative claims data for commercial and Medicare Advantage enrollees, we describe morbidity profiles, health service use, and care coordination (operationalized as care plan oversight [CPO]) for people receiving HCC and the subgroup receiving HBMC. PARTICIPANTS: Three million adults (3,027,247) age ≥ 65 with 12 months of continuous enrollment 2013–2014. MEASURES: CPT or HCPCS codes delineated HCC, HBMC, and CPO recipients and care site, frequency, and provider type. Other measures included demographic characteristics, clinical characteristics, and health care utilization. RESULTS: Overall, 5% of the study population (n=161,801) received 2+ months of HCC visits; of these, 46% also received 2+ HBMC visits (n=73,638) while 54% received only skilled home health (n=88,163 HCC but no HBMC). HBMC-recipients had high comorbidity burden (Charlson score 4.3), dementia (35%), and ambulance trips (58%), but few nursing facility admissions (4.9%). Evidence of care coordination (CPO claims) occurred in 30% of the HCC population, 46% of HBMC, and 17% of the skilled home health care only. CONCLUSIONS: Approximately 1 out of 20 older adults in this study received HCC; 30% or less have a claim for care coordination by their primary care provider.

Supplemental Digital Content is available in the text., Background: Heart failure patients have high rates of repeat acute care use. Current efforts for risk prediction often ignore postdischarge data. Objective: To identify postdischarge patient-reported clinical factors associated with repeat acute care use. Research Design: In a prospective cohort study that followed patients with chronic heart failure for 30 days postdischarge, for 7 days after discharge (or fewer days if patients used acute care within 7 days postdischarge), patients reported health status, heart failure symptoms, medication management, knowledge of follow-up plans, and other issues using a daily interactive automatic phone call. Subjects: A total of 156 patients who had responded to phone surveys. Measures: The outcome variable was dichotomous 30-day acute care use (rehospitalization or emergency department visit). We examined the association between each patient-reported issue and the outcome, using multivariable logistic regression to adjust for confounders. Results: Patients were 63 years old (SD=12.4), with 51% African-American and 53% women. Within 30 days postdischarge, 30 (19%) patients used acute care. After adjustment, poor health status [odds ratio (OR)=3.53; 95% confidence interval (CI), 1.06–11.76], pain (OR=2.44; 95% CI, 1.02–5.84), and poor appetite (OR=3.05; 95% CI, 1.13–8.23) were positively associated with 30-day acute care utilization. Among 58 reports of pain in follow-up nursing notes, 39 (67%) were noncardiac, 2 (3%) were cardiac, and 17 (29%) were indeterminate. Conclusions: Patient-reported poor health status, pain, and poor appetite were positively associated with 30-day acute care utilization. These novel postdischarge markers require further study before incorporation into risk prediction to drive quality improvement efforts.

Background The COMprehensive Post-Acute Stroke Services study was a cluster-randomized pragmatic trial designed to evaluate a comprehensive care transitions model versus usual care. The data collected during this trial were complex and analysis methodology was required that could simultaneously account for the cluster-randomized design, missing patient-level covariates, outcome nonresponse, and substantial nonadherence to the intervention. Objective The objective of this study was to discuss an array of complementary statistical methods to evaluate treatment effectiveness that appropriately addressed the challenges presented by the complex data arising from this pragmatic trial. Methods We utilized multiple imputation combined with inverse probability weighting to account for missing covariate and outcome data in the estimation of intention-to-treat effects (ITT). The ITT estimand reflects the effectiveness of assignment to the COMprehensive Post-Acute Stroke Services intervention compared with usual care (ie, it does not take into account intervention adherence). Per-protocol analyses provide complementary information about the effect of treatment, and therefore are relevant for patients to inform their decision-making. We describe estimation of the complier average causal effect using an instrumental variables approach through 2-stage least squares estimation. For all preplanned analyses, we also discuss additional sensitivity analyses. Discussion Pragmatic trials are well suited to inform clinical practice. Care should be taken to proactively identify the appropriate balance between control and pragmatism in trial design. Valid estimation of ITT and per-protocol effects in the presence of complex data requires application of appropriate statistical methods and concerted efforts to ensure high-quality data are collected.

Supplemental Digital Content is available in the text., Background: Stakeholder involvement in health care research has been shown to improve research development, processes, and dissemination. The literature is developing on stakeholder engagement methods and preliminarily validated tools for evaluating stakeholder level of engagement have been proposed for specific stakeholder groups and settings. Objectives: This paper describes the methodology for engaging a Study Advisory Committee (SAC) in research and reports on the use of a stakeholder engagement survey for measuring level of engagement. Methods: Stakeholders with previous research connections were recruited to the SAC during the planning process for a multicenter randomized control clinical trial, which is ongoing at the time of this writing. All SAC meetings undergo qualitative analysis, while the Stakeholder Engagement Survey instrument developed by the Patient-Centered Outcomes Research Institute (PCORI) is distributed annually for quantitative evaluation. Results: The trial’s SAC is composed of 18 members from 3 stakeholder groups: patients and their caregivers; patient advocacy organizations; and health care payers. After an initial in-person meeting, the SAC meets quarterly by telephone and annually in-person. The SAC monitors research progress and provides feedback on all study processes. The stakeholder engagement survey reveals improved engagement over time as well as continued challenges. Conclusions: Stakeholder engagement in the research process has meaningfully contributed to the study design, patient recruitment, and preliminary analysis of findings.

Background Despite the well-documented risks to patient safety associated with transitions from one care setting to another, health care organizations struggle to identify which interventions to implement. Multiple strategies are often needed, and studying the effectiveness of these complex interventions is challenging. Objective The objective of this study was to present lessons learned in implementing and evaluating complex transitional care interventions in routine clinical care. Research design Nine transitional care study teams share important common lessons in designing complex interventions with stakeholder engagement, implementation, and evaluation under pragmatic conditions (ie, using only existing resources), and disseminating findings in outlets that reach policy makers and the people who could ultimately benefit from the research. Results Lessons learned serve as a guide for future studies in 3 areas: (1) Delineating the function (intended purpose) versus form (prespecified modes of delivery of the intervention); (2) Evaluating both the processes supporting implementation and the impact of adaptations; and (3) Engaging stakeholders in the design and delivery of the intervention and dissemination of study results. Conclusion These lessons can help guide future pragmatic studies of care transitions.

Background: Learning Health Systems strive to continuously integrate innovations and evidence-based practices (EBPs) into routine care settings. Few models provide a specified pathway to accelerate adoption and spread of EBPs across diverse settings. Objective: The US Department of Veterans Affairs Quality Enhancement Research Initiative (QUERI) Implementation Roadmap facilitates uptake of EBPs in routine practice by aligning research and health system priorities. Methods: The Roadmap is based on earlier iterations of the QUERI translational research pipeline, incorporating recent advancements in quality improvement and implementation science. Progressive, dynamic phases were operationalized to form an implementation process that promoted a participatory approach which enables stakeholders (health care consumers, clinicians, administrators, and leaders) to systematically plan, deploy, evaluate, and sustain EBPs using implementation strategies within a Learning Health System framework. Results: The Roadmap consists of Preimplementation, Implementation, and Sustainment phases. Preimplementation identifies a high-priority need, selects EBPs to address the need, engages stakeholders to build implementation capacity, specifies needed EBP adaptions and evaluation goals, and activates leadership support. During Implementation, clinical and research leaders use implementation strategies to promote EBP technical competency and adaptive skills to motivate providers to own and sustain EBPs. Sustainment includes evaluation analyses that establish the EBP business case, and hand-off to system leadership to own EBP implementation maintenance over time. Conclusions: The QUERI Implementation Roadmap systematically guides identification, implementation, and sustainment of EBPs, demystifying implementation science for stakeholders in a Learning Health System to ensure that EBPs are more rapidly implemented into practice to improve overall consumer health.

To develop and assess the reliability of a measure of primary care using items from the Medical Expenditure Panel Survey (MEPS), a US representative survey of community-dwelling persons.On the basis of the domains from the literature on primary care characteristics, we identified relevant items within the 2013-2014 MEPS family of surveys. In a sample of primary survey respondents with at least 1 office-based physician visit in the last 12 months, we conducted exploratory factor analysis, retaining items with a factor loading of 0.30 and factors ≥3 items. Using a hold-out sample, internal consistency, reproducibility, and confirmatory factor analyses were performed.On the basis of 16 care domains, we found 32 candidate items in the MEPS. Factor analyses of data from 4549 persons meeting inclusion criteria (27.6% of the total sample), yielded 3 unique factors involving 24 items. We named these subscales Relationship, Comprehensiveness, and Health Promotion, displaying internal consistency reliability of 0.86, 0.78, and 0.69, respectively. Confirmatory factor analysis corroborated the stability of the exploratory findings in the hold out sample. Sensitivity analyses showed robustness to differences in underlying correlation structure, alternative approach to missing data, and extension to indirect survey respondents.The MEPS Primary Care measure with 3 subscales is reliable and may be useful in conducting primary care health services and outcomes research in the rich MEPS dataset. Further validation is needed, and is described in a companion paper.

Background Integrated behavioral health and primary care can improve the health of persons with complex chronic conditions. The Behavioral Health Integration and Complex Care Initiative (BHICCI) implemented integrated care across a large health system. Whether Behavioral Health Organizations (BHOs) and Federally Qualified Health Centers (FQHCs) implemented the BHICCI differently is unclear. Objectives The objective of this study was to evaluate integration under the BHICCI and to understand implementation differences between BHOs and FQHCs. Methods We used a convergent parallel mixed-method design. Integration was measured quantitatively using the Maine Health Access Site Self-Assessment (SSA), which was completed by clinic teams at baseline and 24 months, and through n=70 qualitative interviews with initiative stakeholders, which were organized using the Consolidated Framework for Implementation Research. Results were compared to understand how qualitative findings explained quantitative results. Results Data were collected in 7 clinics (n=2 FQHC; n=5 BHOs). FQHCs reported greatest improvement in the client centered subscale, with a baseline score of 4.6 (SD=0.64) and 7.8 (SD=0.89) at 24 months. BHOs reported greatest improvement in the organizational supports for integration subscale, with a baseline score of 4.8 (SD=1.07) and 7.9 (SD=1.1) at 24 months. Our Consolidated Framework for Implementation Research analysis illustrates contextual factors, such as insurance plan supports and clinic-level challenges, that explain these scores. Conclusions All clinical settings received support from the health plan, but differences between BHOs and FQHCs affected integration progress. Study results can help identify organizational practices that advance or undermine the delivery of integrated care across multiple clinical settings.

Background Suicide rates for women veterans are increasing faster than for nonveterans. The 2017 suicide rate for women veterans was more than double that for women nonveterans. However, research to inform improved suicide prevention for women veterans is scant. Objectives To accelerate research on women veterans' unique risks and resiliencies for suicide, the Department of Veterans Affairs (VA) Women's Health Research Network launched a Women Veterans Suicide Prevention Research Work Group to target technical support for researchers, promote collaboration with national VA program offices, and ultimately increase dissemination and translation of research into clinical practice, public health strategies, and policies. The objective of this paper is to report on the process and outcomes of the Work Group's strategic planning efforts to identify and fill gaps in suicide prevention research among women veterans. Methods An in-person meeting of 20 researchers and operational leaders was convened to summarize existing research evidence and identify research priorities and challenges. Results Research priorities included civilian reintegration, community connections, psychosocial stressors (eg, social determinants of health) and trauma, risk assessment, clinical interventions, upstream prevention, and health care access. The importance of increasing evidence on gender differences and for women veterans not using VA health care was emphasized. Conclusions Research to inform suicide prevention tailored to meet women veterans' needs is essential; however, many priorities and challenges remain unaddressed. Although Work Group efforts have achieved funding gains, further work to formalize, promote and meet the demands of a suicide prevention research agenda for women veterans requires is ongoing focus.

Background Stakeholders (ie, patients, policymakers, clinicians, advocacy groups, health system leaders, payers, and others) offer critical input at various stages in the research continuum, and their contributions are increasingly recognized as an important component of effective translational research. Natural experiments, in particular, may benefit from stakeholder feedback in addressing real-world issues and providing insight into future policy decisions, though best practices for the engagement of stakeholders in observational studies are limited in the literature. Methods The Natural Experiments for Translation in Diabetes 2.0 (NEXT-D2) network utilizes rigorous methods to evaluate natural experiments in health policy and program delivery with a focus on diabetes-related outcomes. Each of the 8 partnering institutions incorporates stakeholder engagement throughout multiple study phases to enhance the patient-centeredness of results. NEXT-D2 dedicates a committee to Engagement for resource sharing, enhancing engagement approaches, and advancing network-wide engagement activities. Key stakeholder engagement activities include Study Meetings, Proposal Development, Trainings & Educational Opportunities, Data Analysis, and Results Dissemination. Network-wide patient-centered resources and multimedia have also been developed through the broad expertise of each site's stakeholder group. Conclusions This collaboration has created a continuous feedback loop wherein site-level engagement approaches are informed via the network and network-level engagement efforts are shaped by individual sites. Emerging best practices include: incorporating stakeholders in multiple ways throughout the research, building on previous relationships with stakeholders, enhancing capacity through stakeholder and investigator training, involving stakeholders in refining outcome choices and understanding the meaning of variables, and recognizing the power of stakeholders in maximizing dissemination.

Background Acute hospitalization is a frequent reason for live discharge from hospice. Although risk factors for live discharge among hospice patients have been well documented, prior research has not examined the role of neighborhood socioeconomic characteristics, or how these characteristics relate to racial/ethnic disparities in hospice outcomes. Objective To examine associations between neighborhood socioeconomic characteristics and risk for live discharge from hospice because of acute hospitalization. The authors also explore the moderating role of race/ethnicity in any observed relationship. Research design Retrospective cohort study using electronic medical records of hospice patients (N=17,290) linked with neighborhood-level socioeconomic data (N=55 neighborhoods). Multilevel models were used to identify the independent significance of patient and neighborhood-level characteristics for risk of live discharge because of acute hospitalization. Results Compared with the patients in the most well-educated and affluent sections of New York City [quartile (Q)4], the odds of live discharge from hospice because of acute hospitalization were greater among patients who resided in neighborhoods where lower proportions of residents held college degrees [Q1 adjusted odds ratio (AOR), 1.36; 95% confidence interval (CI), 1.06-1.75; Q2 AOR, 1.41; 95% CI, 1.07-1.84] and median household incomes were lower (Q1 AOR, 1.42; 95% CI, 1.10-1.85; Q2 AOR, 1.43; 95% CI, 1.10-1.85; Q3 AOR, 1.39; 95% CI, 1.07-1.80). However, these observed relationships were not equally distributed by patient race/ethnicity; the association of neighborhood socioeconomic disadvantage and risk for live discharge was significantly lower among Hispanic compared with white patients. Conclusions Findings demonstrate neighborhood socioeconomic disadvantage poses a significant risk for live discharge from hospice. Additional research is needed to clarify the social mechanisms underlying this association, including greater attention to the experiences of hospice patients from under-represented racial/ethnic groups.

Background: Health disparities are differences in health or health care between groups based on social, economic, and/or environmental disadvantage. Disparity research often follows 3 steps: detecting (phase 1), understanding (phase 2), and reducing (phase 3), disparities. Although disparities have narrowed over time, many remain. Objectives: We argue that implementation science could enhance disparities research by broadening the scope of phase 2 studies and offering rigorous methods to test disparity-reducing implementation strategies in phase 3 studies. Methods: We briefly review the focus of phase 2 and phase 3 disparities research. We then provide a decision tree and case examples to illustrate how implementation science frameworks and research designs could further enhance disparity research. Results: Most health disparities research emphasizes patient and provider factors as predominant mechanisms underlying disparities. Applying implementation science frameworks like the Consolidated Framework for Implementation Research could help disparities research widen its scope in phase 2 studies and, in turn, develop broader disparities-reducing implementation strategies in phase 3 studies. Many phase 3 studies of disparity-reducing implementation strategies are similar to case studies, whose designs are not able to fully test causality. Implementation science research designs offer rigorous methods that could accelerate the pace at which equity is achieved in real-world practice. Conclusions: Disparities can be considered a “special case” of implementation challenges—when evidence-based clinical interventions are delivered to, and received by, vulnerable populations at lower rates. Bringing together health disparities research and implementation science could advance equity more than either could achieve on their own.

BackgroundOveruse, the provision of health services for which harms outweigh the benefits, results in suboptimal patient care and may contribute to the rising costs of cancer care. We performed a systematic review of the evidence on overuse in oncology.MethodsWe searched Medline, EMBASE, the Cochrane Library, Web of Science, SCOPUS databases, and 2 grey literature sources, for articles published between December 1, 2011 and March 10, 2017. We included publications from December 2011 to evaluate the literature since the inception of the ABIM Foundation's Choosing Wisely initiative in 2012. We included original research articles quantifying overuse of any medical service in patients with a cancer diagnosis when utilizing an acceptable standard to define care appropriateness, excluding studies of cancer screening. One of 4 investigator reviewed titles and abstracts and 2 of 4 reviewed each full-text article and extracted data. Methodology used PRISMA guidelines.ResultsWe identified 59 articles measuring overuse of 154 services related to imaging, procedures, and therapeutics in cancer management. The majority of studies addressed adult or geriatric patients (98%) and focused on US populations (76%); the most studied services were diagnostic imaging in low-risk prostate and breast cancer. Few studies evaluated active cancer therapeutics or interventions aimed at reducing overuse. Rates of overuse varied widely among services and among studies of the same service.ConclusionsDespite recent attention to overuse in cancer, evidence identifying areas of overuse remains limited. Broader investigation, including assessment of active cancer treatment, is critical for identifying improvement targets to optimize value in cancer care.

US federal funding agencies increasingly incentivize stakeholder-engaged research which represents a paradigm shift toward incorporating a range of stakeholders in research design, conduct, and dissemination.We use qualitative methods to capture experience-based recommendations on how to operationalize 4 Patient-Centered Outcomes Research (PCOR) principles in stakeholder-engaged research, specifically: (1) reciprocal relationships; (2) colearning; (3) partnership; and (4) trust, transparency, and honesty.We conducted semistructured interviews with members of a stakeholder panel who participated in a 2-year comparative effectiveness study of cholesterol screening and treatment among young adults.Participants included 8 young adults and parent panelists and 11 professional panelists (clinicians, researchers, policy developers, and disseminators).The interview guide included questions about the 4 PCOR principles and queried preferred strategies to attain them. Interview transcripts were analyzed using an a priori and emergent coding structure.Participants provided strategies to promote the 4 PCOR principles. Although some stakeholder-identified strategies were complementary, others conflicted due to (1) competing ideologies identified among the principles, and (2) distinct stakeholder preferences. Illustrative of competing ideologies, participants simultaneously preferred receiving relevant articles before calls (to facilitate colearning) but also minimal outside reading (to achieve partnership). Illustrative of distinct stakeholder preferences, young adult and parent panelists generally preferred calls to occur on weekends/evenings, whereas professional panelists preferred mid-week work hours.Our exploratory study provides stakeholder-identified strategies to achieve the 4 PCOR principles, and demonstrates the need to identify, acknowledge, and address potentially conflicting strategies due to the potential for competing ideologies or variation in stakeholder preferences.

Background The advancement of primary care research requires reliable and validated measures that capture primary care processes embedded within nationally representative datasets. Objective The objective of this study was to assess the validity of a newly developed measure of primary care processes [Medical Expenditure Panel Survey (MEPS)-PC] with preliminary evidence of moderate to excellent reliability. Study design A retrospective cohort study of community-dwelling adults with history of office-based provider visit/s using the MEPS (2013-2014). Methods The 3 MEPS-PC subscales (Relationship, Comprehensiveness, and Health Promotion) were tested for construct validity against known measures of primary care: Usual Source of Care, Known Provider, and Family-Usual Source of Care. Concurrent and predictive logistic regression analyses were calculated and compared with a priori hypotheses for direction and strength of association. Results For concurrent validity, all odds ratio estimates conformed with hypotheses, with 91% displaying statistical significance. For predictive validity, all estimates were in the direction of hypotheses, with 92% displaying statistically significant results. Although Relationship and Health Promotion subscales conformed uniformly with hypotheses, the Comprehensiveness subscale yielded significant results in 60% of bivariate odds ratio estimates (P Conclusion The MEPS-PC composite measures display modest to strong preliminary evidence of concurrent and predictive validity relative to known indicators of primary care. Implications for policy and practice The MEPS-PC composite measures display preliminary evidence of concurrent and predictive construct validity, and it may be useful to researchers investigating primary care processes and complexities in the health care environment.

Background To promote evidence-based health care, clinical providers and decision makers rely on scientific evidence to inform best practices. Evidence synthesis (ES) is a key component of this process that serves to inform health care decisions by integrating and contextualizing research findings across studies. Objective This paper describes the process of establishing an ES capability in the Military Health System dedicated to psychological health topics. Research designs The goal of establishing the current ES capability was to facilitate evidence-based decision-making among clinicians, clinic managers, research funders, and policymakers, through the production and dissemination of trustworthy ES reports. We describe how we developed this capability, provide an overview of the types of evidence syntheses products we use to respond to different stakeholders, and detail the procedures established for selecting and prioritizing synthesis topics. Results We report on the productivity, acceptability, and impact of our efforts. Our reports were used by a variety of stakeholders and working groups, briefed to major committees, included in official reports and policies, and cited in clinical practice guidelines and the peer-reviewed literature. Conclusions Our experiences thus far suggest that the current ES capability offers a needed service within our health system. Our framework may help inform other agencies interested in developing or sponsoring a similar capability.

BACKGROUND The Healthcare Cost and Utilization Project (HCUP), the nation's most complete source of all-payer hospital care data, supports analyses at the national, regional, state and community levels. However, national HCUP data are often used in inappropriate ways in studies of state-specific issues. OBJECTIVE To describe the opportunities and challenges of using HCUP data to conduct state health policy research and to provide empirical examples of what can go wrong when using the national HCUP data inappropriately. RESEARCH DESIGN Comparison of results from state-level analyses using national HCUP data and the state-specific HCUP data recommended by the Agency for Healthcare Research and Quality (AHRQ). Analyses included trends in state-specific rates of cesarean delivery and a difference-in-differences analysis of Connecticut's Medicaid expansion. SUBJECTS Hospital discharges from the 2004 to 2011 HCUP Nationwide Inpatient Samples (NIS) and State Inpatient Databases (SID). MEASURES Cesarean delivery rates, discharges per capita, and discharges by the payer. RESULTS State-level estimates derived from the NIS are volatile and often provide misleading policy conclusions relative to estimates from the SID. CONCLUSIONS The NIS should not be used for state-level research. AHRQ provides resources to assist analysts with state-specific studies using SID files.

Background A high volume of emergency department (ED) visits in the rural United States may be the result of barriers to accessing primary care. The Affordable Care Act (ACA) increased the number of insured, which may improve patient access to primary care and therefore reduce ED utilization. The objective of this study is to estimate the trends and cost of ED utilization pre-ACA and post-ACA implementation in a rural United States. Data and methods We use 2009-2013 ED utilization data from a rural Georgia hospital to estimate trends and costs by demographic characteristics, referring source, and payor information. T tests and log-linear regression models are used to assess the sociodemographic factors impacting ED inflation-adjusted costs before (2009-2010) and after ACA (2011-2013) implementation. Results During 2009-2013, 39,970 ED encounters were recorded with an average cost (AC) of $2002 per visit. Results indicate that during pre-ACA, on average, 8702 encounters were recorded per year with an AC of $1759. During post-ACA, there were 7521 annual visits, with an annual AC of $2241. Regression model results indicate that AC were significantly higher for men, older adults, nonblack patients, those with private insurance, and during the post-ACA period. Conclusions Results suggest that post-ACA, declining ED visits may be due to more patients with insurance accessing primary care instead of ED. We further hypothesize that increased AC during this period may be due to ED visits being of an emergent nature, which require more resources to treat. Further comprehensive investigation is warranted to study the impact of ACA on ED utilization for nonemergency purposes among rural and nonrural hospitals.