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Objective To develop a prognostic index using Functional Independence Measure grades and stages that would enable clinicians to determine the likelihood of achieving a level of minimum assistance with physical functioning after a stroke. Grades define varying levels of physical function, and stages define varying levels of cognitive functioning. Design Retrospective cohort study. Setting Veterans Affairs Medical Centers throughout the United States. Participants Veterans with a diagnosis of a new stroke discharged between October 1, 2006, and September 30, 2008, who were below physical grade IV (requiring minimal assistance) at initial rehabilitation assessment. Main Outcome Measure Achievement of physical grade IV or above at final rehabilitation assessment. Results Physical grade IV was reached by 25.8% of participants who were initially below this grade. Seven variables remained independently predictive of physical grade IV after adjustment. These variables were assigned the following points: age, ≤69 years=2, 70-79 years=1, ≥80 years=0; initial physical grade, I=0, II=3, III=4; initial cognitive stage, I or II=0, III=2, IV or V=3, VI or VII=4; absence of renal failure=1; no serious nutritional compromise=3; the type of rehabilitation services received, consultative=0, comprehensive=4; and recovery time between admission and discharge physical grade assessment, 1-2 days=0, 3-7 days=4, and ≥8 days=5. The area under the receiver operating characteristic curve was 0.84 and 0.83 for the point system in the derivation and validation cohorts, respectively. The Hosmer-Lemeshow statistic was not significant ( P = .93) in the derivation cohort, indicating that the regression model demonstrated adequate fit. The proportions of patients recovered to physical grade IV in the first (score ≥9), second (score = 10-12), third (score = 13-15), and fourth (score >15) score quartiles were 2.72%, 11.38%, 28.96%, and 60.34%, respectively. Conclusion By using a simple tool, clinicians can forecast the likelihood of recovery to or above the physical grade IV benchmark by the conclusion of rehabilitation services during the acute stroke hospitalization.

Early childhood caries (ECC) is a significant national problem that disproportionately affects low-income children, and its prevalence is increasing (Tomar and Reeves 2009). ECC has significant short- and long-term adverse consequences (Tinanoff and Reisine 2009). ECC is associated with increased risk of future caries (Gray, Marchment, and Anderson 1991; Reisine, Litt, and Tinanoff 1994; O'Sullivan and Tinanoff 1996), missed school days (Gift, Reisine, and Larach 1992; Hollister and Weintraub 1993), hospitalization and emergency room visits (Sheller, Williams, and Lombardi 1997; Griffin et al. 2000), and, in rare cases, death (Casamassimo et al. 2009). These adverse outcomes are avoidable through ECC preventive services (ECCPS). A randomized clinical trial found that fluoride varnish treatment, combined with parent counseling, can reduce caries by up to 50 percent in high-risk children (Weintraub et al. 2006). National guidelines recommend that children have a dental visit by 12 months of age and receive preventive care at regular intervals thereafter (American Academy of Pediatrics Section on Pediatric Dentistry and Oral Health 2008; American Academy of Pediatric Dentistry 2013). The most common recall interval is 6 months. However, the American Academy of Pediatric Dentistry recommends that children at higher caries risk get check-ups, including topical fluoride application, more often (American Academy of Pediatric Dentistry 2013). Medicaid eligibility has been identified as a risk factor for ECC (American Dental Association 2011). Untreated dental caries occurs among 25 percent of children living in poverty compared with 10.5 percent of children living above poverty (Dye, Li, and Thorton-Evans 2012). Comprehensive dental benefits are required in Medicaid and the Children's Health Insurance Program, which cover 35 percent of all U.S. children (DeNavas-Walt, Proctor, and Smith 2012), but only 31 percent of publicly insured children ages 0–5 years receive dental services (Centers for Medicare and Medicaid Services 2012). Although ECC is largely preventable (Savage et al. 2004; Weintraub et al. 2006; Azarpazhooh and Main 2008), it is difficult to reach preschool aged children for caries prevention. Publicly insured, preschool aged children are more likely to receive medical care than dental care (Bouchery 2012a,b). Consequently, 44 state Medicaid programs have implemented policies to reimburse medical primary care providers (M-PCPs), typically including physicians, physician assistants, and advanced registered nurse practitioners, to provide ECCPS. The specific services reimbursed varies across states but may include an examination of the oral cavity, caries risk assessment, anticipatory guidance, topical fluoride application, and referral to a dental home (American Academy of Pediatrics 2013). Despite widespread adoption, there is little scientific evidence on the effects of M-PCP reimbursement on ECCPS receipt, with published studies from only two states. A North Carolina study examined ECCPS receipt subsequent to policy implementation and found steady growth in the number of medical visits that included ECCPS, but it did not use a pre–post study design to evaluate changes in ECCPS receipt (Rozier et al. 2010). Studies of Wisconsin's Medicaid program, which used pre–post designs, found that M-PCP reimbursement was associated with increased claims rates for fluoride varnish treatment with almost one-half of the increase associated with M-PCPs (Okunseri et al. 2009, 2010). This study extends existing research by analyzing the effect of M-PCP reimbursement on ECCPS receipt for Medicaid-enrolled children in Texas and Florida, which are the second and fourth most populous states, respectively, and account for 15 percent of Medicaid-enrolled children nationally (Kaiser Family Foundation 2013; U.S. Census Bureau 2011). These states are among the most diverse with significant representation of African-American and Hispanic populations (Brewer and Suchan 2001), which disproportionately experience low access to dental care (Edelstein and Chinn 2009). In 2008, the Florida and Texas Medicaid programs implemented M-PCP ECCPS reimbursement for children ages 0–4 years. We used secondary data from these programs to test our central hypothesis that M-PCP reimbursement has improved access to ECCPS. Methodologically, we extend existing research by including a control group of children not subject to M-PCP reimbursement and adopting an analytic strategy that allows us to better isolate the treatment effect by controlling for intrinsic differences between the treatment and control groups, secular time trends, and differential time trends between the two groups. In addition to controlling for standard demographic characteristics, we also control for the children's health status and explicitly incorporate enrollment duration into our model.

Objectives To study the degree to which initial physical grades and cognitive stages of independence assessed by physical medicine and rehabilitation (PM&R) staff early after hospitalization for acute stroke relate to the decision to either provide rehabilitation in consultation or admission to a specialized rehabilitation unit (SRU) for comprehensive, high-intensity, multidisciplinary rehabilitation. Design An observational study. Setting Early rehabilitation assessment by PM&R staff during patients' acute hospitalization for stroke in 112 Veterans Affairs facilities. Patients The sample included 8,783 veterans who were assessed by PM&R staff. Methods Shortly after hospital admission, functional status was determined according to 7 physical grades and 7 cognitive stages of increasing independence. Patients' physical grades and cognitive stages ranged at initial PM&R assessment from the lowest and most dependent “I” through intermediate “II, III, IV, V, or VI,” and ended with the highest at total independence “VII.” To assess the statistically independent effects of physical grade and cognitive stage, a multivariable generalized estimating equation was applied to account for within Veterans Affairs facilities correlation and to adjust for demographics, stroke type, comorbidities, clinical events before PM&R assessment, and facility-related factors. Main Outcome Measurements The decision to admit patients to an SRU for comprehensive rehabilitation. Results Only 11.2% of those patients assessed after stroke were admitted to an SRU after the acute management phase. After statistical adjustment, patients at the lowest physical grade (I) of independence had a 9-fold increased odds of admission to an SRU compared with those at the highest combined physical grades VI/VII (adjusted odds ratio 9.15, 95% confidence interval 4.31-19.39). In contrast, patients at intermediate cognitive stages of independence were the most likely to be admitted to an SRU. The presence of an SRU within the treating Veterans Affairs facility was strongly related to admission. Conclusions Patients' physical grades and cognitive stages assessed early after stroke are strong determinants of referral for comprehensive rehabilitation.

State policies and actions are an integral part of our nation's health policy framework. This is particularly obvious in the case of Medicaid, a program for which the states share fiscal obligations and have primary administrative responsibility. Concerns regarding the quality of care provided to enrollees and the financial viability of Medicaid programs in the states are among today's “hot topics” in the health policy arena (The Kaiser Commission on Medicaid and the Uninsured 2006). While the issues are not new, the current conversation may differ from those of previous years because the contemporary political and policy context includes serious consideration of much greater state flexibility in the structuring of Medicaid and the delivery of health care to Medicaid enrollees (Finegold, Wherry, and Schardin 2004; Rowland et al. 2006). At present, a great deal of state interest is focused on moving Medicaid payment systems toward a more intensely managed form of managed care (Bailit, Burgess, and Roddy 2004; Kaye 2005). In considering and pursuing the opportunities deriving from increased flexibility, states frequently begin with overall philosophical preferences and then review past experiences to focus their efforts on Medicaid policy initiatives that are consistent with those preferences and have some demonstrated promise of success. To a significant degree, the observation of prior experience is focused on the outcomes of demonstrations that have been implemented with the authority of a Section 1115 Waiver. While the Deficit Reduction Act of 2005 (DRA) may create new and increased avenues for states to pursue program variation, the historic purpose of waivers has not simply been to change programs, but to test ideas or new approaches to program implementation. Formally, they are “Research and Demonstration Waivers,” explicitly acknowledging the role of observation and research as to the impact of the demonstration. The research part of this function is not always achieved, because that aspect of waiver-based Medicaid program changes typically takes a back seat to program implementation. Furthermore, except for privately funded initiatives such as the State Coverage Initiatives Program (http://www.statecoverage.net) and the State Health Access Data Center (http://www.shadac.umn.edu/), there is no convenient clearinghouse for systematically disseminating demonstration research findings that might prove valuable for subsequent program modifications or to other states as they contemplate policy interventions. Effective July 1, 2006, Florida embarked on a 5-year research and demonstration project that may significantly change its Medicaid program. One element of the Florida reform initiative is the inclusion of provider service networks (PSNs) among the managed care organizations that may be used to organize and deliver care to Medicaid enrollees. The decision to include PSNs in the 2006 reform initiative is explicit in both the enabling legislation (FL Gen. Laws ch. 2005-358 [2005]) and in the state's waiver application. Absent such inclusion, PSNs would not be part of the current reform initiative. The decision to include the PSN option in the current reform initiative derived, in part, from the evaluation research findings from a previous Medicaid demonstration. The purposes of this article are to describe key findings from that prior evaluation and to note the linkages to Florida's current Medicaid Reform initiative.

Health-related quality of life (HRQoL) is increasingly used to measure health status. Health profile and preference-based approaches are two types of methods frequently used to measure HRQoL. Health profiles tap multiple dimensions of health. Preference-based approaches quantify the extent to which an individual prefers specific health states using a single index from 0 (death) to 1 (full health). The MOS-HIV Health Survey (Wu et al. 1997) and EQ-5D (The EuroQol Group 1990) are typical health profile and preference-based instruments, respectively. The availability of preference-based HRQoL data is limited because direct assessment is not always feasible. Therefore, researchers have attempted to predict preference-based scores from health profiles, generally using ordinary least squares (OLS) regression (Fryback et al. 1997; Franks et al. 2004). A common phenomenon observed in both health profile and preference-based measures is that the score distribution tends to be skewed to the left. This is called the “ceiling effect.” When data have pronounced ceiling effects, the use of OLS regression violates the statistical requirement for linearity of conditional expectation, leading to inaccurate predictions of preference-based scores and inaccurate identification of predictor variables (Kennedy 1998). Several methods have been proposed to address ceiling effects, such as Tobit models, the censored least absolute deviation (CLAD) approach, two-part models (TPM), and latent class models (LCM) (Greene 2003). The Tobit and CLAD models are preferable to OLS in the presence of a ceiling effect or censored dependent variable. The Tobit model assumes that there is a true unobservable dependent variable that depends linearly on independent variables. The observable dependent variable is defined to be equal to the unobserved variable whenever the true unobserved variable is greater than or equal to the ceiling value. The Tobit model assumes that the error terms are normally distributed with uniform variance (Greene 2003). Unfortunately, evidence suggests that the distribution of utility scores does not follow those assumptions (Austin 2002a). The CLAD approach is based on an assumption that the median will be more robust to ceiling effects than the mean. The coefficients are estimated so as to minimize the sum of the absolute deviations from the regression line (Arabmazar and Schmidt 1981; Johnston 1997). A TPM approach is a more flexible way to address the fact that the HRQoL scores usually have mixed distributions that contain a disproportionate mass of observation at the ceiling and a left-skewed distribution of observations not at the ceiling. The “two parts” model (1) the probability that the dependent variable (e.g., EQ-5D index) can attain the full score and (2) the distribution if the full score is not attained. Both parts are combined in a joint model to predict the dependent variable using the subject's predictors. The LCM is another approach to address data with ceiling effects. This approach is considered by some to be more flexible than the TPM because LCM can handle situations where there are two (or more) classes, with one class being very healthy (i.e., higher utility index) and another group being less healthy (i.e., lower index), as opposed to a TPM which models perfectly healthy (index=1) versus other than perfectly healthy (index

Oral disadvantage can be defined as the avoidance of certain daily activities because of decrements in oral health. These decrements include oral disease and tissue damage, pain, and functional limitation. The Florida Dental Care Study (FDCS) is a longitudinal study of changes in oral health, which included at baseline 873 subjects who had at least 1 tooth, were 45 years old or older, and who participated for an interview and clinical examination. Three objectives of the FDCS are: (1) to describe selected psychometric properties of the measurement of oral disadvantage; (2) to describe oral disadvantage in a diverse sample of dentate adults; and (3) to describe the relationship between disadvantage and other aspects of oral health, such as disease/tissue damage, pain, and functional limitation. The prevalence of oral disadvantage within the previous 6 months, using eight self-reported measures, ranged from 5% to 25%, depending upon the measure. Factor analysis suggested that oral disadvantage is best described as three factors: disadvantage due to (1) oral disease/tissue damage, (2) oral pain, and (3) oral functional limitation. Irregular dental attenders, poor persons, and blacks had the highest prevalence of oral disadvantage. Clinical measures of oral disease/tissue damage, self-reported measures of oral disease/tissue damage, oral pain, and oral functional limitation were strongly associated with the presence of oral disadvantage. In multivariate analyses that accounted for differences in clinical measures of disease/tissue damage, self-reported disease/tissue damage, oral pain, and oral functional limitation, females were more likely to report disadvantage due to disease/tissue damage, and middle-aged persons and irregular dental attenders were more likely to report oral disadvantage due to pain. In these same regressions, differences in disadvantage due to race, poverty status, socioeconomic status, and rural/urban area of residence were not evident. These results have implications regarding the use of oral disadvantage to assess the long-term effectiveness of dental care.