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Background The extent to which a surgeon's risk aversion influences their clinical decisions remains unknown. We assessed whether a surgeon's attitude toward risk (“risk aversion”) influences their surgical decisions and whether the relationship can be explained by differences in surgeons’ perception of treatment risks and benefits. Materials and methods We presented a series of detailed clinical vignettes to a national sample of surgeons (n = 1,769; 13.4% adjusted response rate) and asked them to complete an instrument that measured how risk averse they are within their clinical practice (scale 6-36; higher number indicates greater risk aversion). For each vignette, participants rated their likelihood of recommending an operation and judged the likelihood of complications or full recovery. We examined whether differences in perceived likelihood of complications versus recovery could explain why risk-averse surgeons may be less likely to recommend an operation. Results Surgeons varied in their self-reported risk aversion score (median = 25, interquartile range[22,28]). Scores did not differ by level of surgeon experience or gender. Risk-averse surgeons were significantly less likely to recommend an operation for patients with exactly the same condition (65.5% for surgeons in highest quartile of risk aversion versus 62.3% for lowest quartile; P = 0.02). However, after controlling for surgeons’ perception of the likelihood of complications versus recovery, there was no longer a significant association between surgeons’ risk aversion and the decision to recommend an operation (64.7% versus 64.8%; P = 0.96). Conclusions Surgeons vary widely in their self-reported risk aversion. Risk-averse surgeons were significantly less likely to recommend an operation, a finding that was explained by a higher perceived probability of post-operative complications than their colleagues.

Purpose: The 2016 U.S. election significantly changed the political landscape for sexual and gender minority (SGM) individuals. The current study assessed the consequences of the election and transition to a new overtly discriminatory administration on the health-related quality of life of SGM adults compared with their cisgender and heterosexual counterparts. Methods: The study used repeated cross-sectional data from the 17 states that administered the sexual orientation and gender identity module in the 2015 and 2018 Behavioral Risk Factor Surveillance System surveys. The sample included 268,851 adult respondents: 12,006 SGM adults (5.35%) and 256,845 cisgender and heterosexual adults (94.65%). Outcomes were frequent (≥14 days in the last month) physical distress, mental distress, limited activity, and/or fair/poor general health. Difference-in-differences estimates were calculated from logistic regression models, controlling for sociodemographic, health care coverage, and chronic medical condition confounders. Results: Compared with the cisgender and heterosexual population, frequent mental distress among SGM adults increased by 5% points, corresponding to a relative increase of 32.5% (p

This study explores possible associations of the Mental Health Parity and Addiction Equity Act (MHPAEA) with child access to behavioral health (BH) services (preimplementation = 2008-2009, transition = 2010, and post = 2011-2013). The study sample included children aged 4-17 years in self-insured "carve-in" plans from large employers. In "carve-ins," BH and medical care are covered through the same insurance plan. The unit of analysis is the person-month (N = 61,823,533). This study employs an interrupted time series model allowing for intercept and slope changes for the transition and postparity periods. Outcomes included total, plan and patient out-of-pocket (OOP) expenditures, and several categories of service utilization. Generalized estimating equations were used to account for clustering. There were significant increases in total and plan expenditures postparity. To illustrate, in July 2012, mean per-member-per-month total expenditures were predicted to be $5.65 without parity but $8.72 with parity. Patient OOP costs did not change significantly. Significant overall increases were seen for utilization of most outpatient services but not intermediate or inpatient services. Our findings suggest that the introduction of MHPAEA was associated with an increase in specialty BH service access for children without a commensurate increase in financial burden for families.

We used 2010-16 Medicare Cost Reports for 10,737 freestanding home health agencies (HHAs) to examine the impact of home health (HH) and nursing home (NH) certificate-of-need (CON) laws on HHA caseload, total and per-patient variable costs. After adjusting for other HHA characteristics, total costs were higher in states with only HH CON laws ($2,975,698), only NH CON laws ($1,768,097), and both types of laws ($3,511,277), compared with no CON laws ($1,538,536). Higher costs were driven by caseloads, as CON reduced per-patient costs. Additional research is needed to distinguish whether this is due to skimping on quality vs. economies of scale.

The aim of this study was to determine whether exposure to data from a risk calculator influences surgeons' assessments of risk and in turn, their decisions to operate.Little is known about how risk calculators inform clinical judgment and decision-making.We asked a national sample of surgeons to assess the risks (probability of serious complications or death) and benefits (recovery) of operative and nonoperative management and to rate their likelihood of recommending an operation (5-point scale) for 4 detailed clinical vignettes wherein the best treatment strategy was uncertain. Surgeons were randomized to the clinical vignettes alone (control group; n = 384) or supplemented by data from a risk calculator (risk calculator group; n = 395). We compared surgeons' judgments and decisions between the groups.Surgeons exposed to the risk calculator judged levels of operative risk that more closely approximated the risk calculator value (RCV) compared with surgeons in the control group [mesenteric ischemia: 43.7% vs 64.6%, P0.001 (RCV = 25%); gastrointestinal bleed: 47.7% vs 53.4%, P0.001 (RCV = 38%); small bowel obstruction: 13.6% vs 17.5%, P0.001 (RCV = 14%); appendicitis: 13.4% vs 24.4%, P0.001 (RCV = 5%)]. Surgeons exposed to the risk calculator also varied less in their assessment of operative risk (standard deviations: mesenteric ischemia 20.2% vs 23.2%, P = 0.01; gastrointestinal bleed 17.4% vs 24.1%, P0.001; small bowel obstruction 10.6% vs 14.9%, P0.001; appendicitis 15.2% vs 21.8%, P0.001). However, averaged across the 4 vignettes, the 2 groups did not differ in their reported likelihood of recommending an operation (mean 3.7 vs 3.7, P = 0.76).Exposure to risk calculator data leads to less varied and more accurate judgments of operative risk among surgeons, and thus may help inform discussions of treatment options between surgeons and patients. Interestingly, it did not alter their reported likelihood of recommending an operation.

© 2015, American Psychiatric Association. All rights reserved. Objective: The study assessed racial-ethnic differences in receipt of mental health services among children enrolled in systems of care under the Children's Mental Health Initiative (CMHI). Methods: Survey data for 3,920 CMHI enrollees were used to estimate the association between race-ethnicity and the number of days in the 12 months postenrollment during which the child received individual psychotherapy, family and group psychotherapy, medication monitoring, assessment and evaluation, case management, residential treatment, and inpatient care. Two-part regressionswith fixedsiteeffectswereestimated to adjust for geography and baseline population differences, including child and caregiver characteristics. Results: Compared with white non-Latino children, African Americans had lower odds of using any individual psychotherapy (odds ratio [OR]=.73, p=.019), family and group psychotherapy (OR=.79, p=.043), and medication monitoring (OR=.51, p

Objectives To compare the strength of the association between depression and mortality between elderly and younger individuals with diabetes mellitus. Design A survival analysis conducted in a longitudinal cohort study of persons with diabetes mellitus to test the association between depression and mortality in older (≥65) and younger (18-65) adults. Setting Managed care. Participants Persons aged 18 and older with diabetes mellitus who participated in the Wave 2 survey of the Translating Research Into Action for Diabetes (TRIAD) Study (N = 3,341). Measurements The primary outcome was mortality risk, which was measured as days until death using linked data from the National Death Index. Depression was measured using the Patient Health Questionnaire. Results After controlling for age, sex, race and ethnicity, income, and other comorbidities, mortality risk in persons with diabetes mellitus was 49% higher in those with depression than in those without, although results varied according to age. After controlling for the same variables, mortality risk in persons aged 65 and older with depression was 78% greater than in those without. For those younger than 65, the effect of depression on mortality was smaller and not statistically significant. Conclusion This analysis suggests that the effect of depression on mortality in persons with diabetes mellitus is most significant for older adults. Because there is evidence in the literature that treatment of depression in elderly adults can lead to lower mortality, these results may suggest that older adults with diabetes mellitus should be considered a high-priority population for depression screening and treatment. © 2014, Copyright the Authors Journal compilation © 2014, The American Geriatrics Society.

Objectives: To compare 12-month outpatient healthcare expenditures of at-risk and not-at-risk drinkers aged 60 and older. Design: Secondary analysis of data from Project Senior Health and Alcohol Risk Education, a cluster, randomized trial to test the efficacy of an intervention to reduce at-risk drinking. Setting: Seven primary care clinics in or near Santa Barbara, California. Participants: Current drinkers aged 60 and older who completed a baseline survey (N = 2,779) and did not receive the study intervention, including 628 at-risk drinkers and 2,151 not-at-risk drinkers. Measurements: Comparisons of at-risk and not-at-risk drinkers for baseline demographic characteristics, health indicators, alcohol consumption, and adjusted and unadjusted outpatient healthcare expenditures incurred over 12 months after baseline. Results: At-risk drinkers were younger, more often male, and more likely to be married and had higher education and incomes than not-at-risk drinkers. Unadjusted 12-month mean outpatient healthcare expenditures were $1,333 ± 2,973 for at-risk drinkers and $1,417 ± 2,952 for the not-at-risk drinkers. There were no statistically significant differences in expenditures between groups before and after controlling for sociodemographic and health characteristics. Conclusion: In this short-term study, no adjusted differences in healthcare expenditures were observed between at-risk and not-at-risk older drinkers. Future study is warranted to determine the role of at-risk drinking in long-term healthcare expenditures in older adults.

Hospital use near the end of life is often undesirable to patients, represents considerable Medicare cost, and varies widely across regions.To concurrently examine regional and patient factors, including disability and functional decline, associated with end-of-life hospital use.We sampled decedents aged 65 and older (n = 2,493) from the Health and Retirement Study (2000-2006), and linked data from individual Medicare claims and the Dartmouth Atlas of Health Care. Two-part regression models estimated the relationship between total hospital days in the last 6 months and patient characteristics including physical function, while adjusting for regional resources and hospital care intensity (HCI).Median hospital days was 7 (range = 0-183). 53% of respondents had functional decline. Compared with decedents without functional decline, those with severe disability or decline had more regression-adjusted hospital days (range 3.47-9.05, depending on category). Dementia was associated with fewer days (-3.02); while chronic kidney disease (2.37), diabetes (2.40), stroke or transient ischemic attack (2.11), and congestive heart failure (1.74) were associated with more days. African Americans and Hispanics had more days (5.91 and 4.61, respectively). Those with family nearby had 1.62 fewer days and hospice enrollees had 1.88 fewer days. Additional hospital days were associated with urban residence (1.74) and residence in a region with more specialists (1.97) and higher HCI (2.27).Functional decline is significantly associated with end-of-life hospital use among older adults. To improve care and reduce costs, health care programs and policies should address specific needs of patients with functional decline and disability.

Collaborative Care for Depression (CCD) in primary care redesigns care processes to incorporate evidence-based depression treatment guidelines and components of the Chronic Care Model (Wagner 2000; Wagner, Austin, and Von Korff 1996). A central element of the model is a care manager in the clinic who serves as a physician extender and conducts patient assessment, education, follow-ups, and care coordination, largely outside a patient’s visits to his/her primary care physician (PCP) (Schulberg et al. 2001). More than 30 randomized controlled trials have shown that CCD improves depression outcomes, patient adherence to treatment, and satisfaction with care (Gilbody et al. 2006; Neumeyer-Gromen et al. 2004; Williams et al. 2007). The prevailing visit-based fee-for-service physician payment system, however, constitutes a serious disincentive for providing this service (Bachman et al. 2006; Berenson, and Horvath 2003; Unutzer et al. 2006; Wolff, and Boult 2005). Recognizing the importance of a payment mechanism, several recent large-scale implementation initiatives adopted case-rate based payment models to cover the cost of delivering evidence-based CCD. The Depression Improvement Across Minnesota, Offering a New Direction (DIAMOND) initiative adopted a flat monthly case rate (Institute for Clinical Systems Improvement 2008). This monthly rate was determined based on the average monthly cost of a 12-month CCD intervention tested in a randomized controlled trial (RCT) known as IMPACT (Improving Mood-Promoting Access to Collaborative Treatment) (Unutzer et al. 2002b). A more recent implementation of the IMPACT model to treat a broader set of behavioral health disorders among community health centers in Washington state adopted a lump sum payment to each clinic covering the cost of the yearlong program, with minimum caseload expectations and 25% of the payment retained to reward providers achieving pre-specified depression treatment and outcome targets. The CCD payment in both initiatives is intended to cover CCD program cost to the clinic that is not covered by the visit-based physician payment. The underlying goals of these pioneering efforts to pay for CCD are twofold: 1) to adequately cover the cost of providing CCD, and 2) to align incentives with the delivery of CCD in a way that leads to better outcomes. The design of such a payment should reflect meaningful variation in resource requirement for evidence-based practice of CCD. In addition, it requires a consideration of incentives associated with a given design, and ways to address or ameliorate related issues. In this paper, we used data from a large randomized controlled trial, the IMPACT study (Unutzer et al. 2002b; Unutzer et al. 2001) to investigate salient and feasible properties of a bundled case rate payment design for CCD. In IMPACT, with close monitoring and guidance from the research team, the CCD intervention protocol was implemented with high fidelity. Meanwhile, participating practices came from diverse community and organizational settings (Unutzer et al. 2001). Delivery of CCD as seen in IMPACT thus represents probably the closest to evidence-based practice in “real-world” implementation where provider adoption of financial strategies is likely to be minimal. This unique feature of the data enables us to identify factors accounting for practically significant variation in resource use of CCD, which then guided our recommendation of two case rate based payment models. We further compared implications for health care organizations in the IMPACT study of alternative payment models..

Background— Stroke is the leading cause of adult disability. Inpatient programs optimize secondary stroke prevention care at the time of hospital discharge, but such care may not be continued after hospital discharge. Methods— To improve the delivery of secondary stroke preventive services after hospital discharge, we have designed a chronic care model–based program called SUSTAIN (Systemic Use of STroke Averting INterventions). This care intervention includes group clinics, self-management support, report cards, decision support through care guides and protocols, and coordination of ongoing care. The first specific aim is to test, in a randomized, controlled trial, whether SUSTAIN improves blood pressure control among an analytic sample of 268 patients with a recent stroke or transient ischemic attack discharged from 4 Los Angeles County public hospitals. Secondary outcomes consist of control of other stroke risk factors, lifestyle habits, medication adherence, patient perceptions of care quality, functional status, and quality of life. A second specific aim is to conduct a cost analysis of SUSTAIN from the perspective of the Los Angeles County Department of Health Services by using direct costs of the intervention, cost equivalents of associated utilization of county system resources, and cost equivalents of the observed and predicted averted vascular events. Conclusions— If SUSTAIN is effective, we will have the expertise and findings to advocate for its continued support at Los Angeles County hospitals and to disseminate the SUSTAIN program to other settings serving indigent, minority populations. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT00861081.

Aim The broad objective of this study was to examine multiple dimensions of depression in a large, diverse population of adults with diabetes. Specific aims were to measure the association of depression with: (1) patient characteristics; (2) outcomes; and (3) diabetes-related quality of care. Methods Cross-sectional analyses were performed using survey and chart data from the Translating Research Into Action for Diabetes (TRIAD) study, including 8790 adults with diabetes, enrolled in 10 managed care health plans in 7 states. Depression was measured using the Patient Health Questionnaire (PHQ-8). Patient characteristics, outcomes and quality of care were measured using validated survey items and chart data. Results Nearly 18% of patients had major depression, with prevalence 2–3 times higher among patients with low socioeconomic status. Pain and limited mobility were strongly associated with depression, controlling for other patient characteristics. Depression was associated with slightly worse glycemic control, but not other intermediate clinical outcomes. Depressed patients received slightly fewer recommended diabetes-related processes of care. Conclusions In a large, diverse cohort of patients with diabetes, depression was most prevalent among patients with low socioeconomic status and those with pain, and was associated with slightly worse glycemic control and quality of care.

OBJECTIVES: To identify predictors of alcohol-related patient-physician discussions. DESIGN: Cross-sectional study using baseline data from a randomized controlled trial. SETTING: Community-based group practice. PARTICIPANTS: Thirty-one physicians in Project Senior Health and Alcohol Risk Education and 3,305 of their patients aged 60 and older who use alcohol and completed a survey that included the Comorbidity Alcohol Risk Evaluation Tool (CARET). MEASUREMENTS: At study baseline, older adults were asked whether alcohol-related discussions with a physician had occurred in the prior year. This outcome was modeled using logistic regression models with physician random effects. Predictor variables included patient-level variables such as demographics and seven CARET-defined risk factors, specifically a medical or psychiatric comorbidity that alcohol might worsen, a potentially alcohol-related symptom, use of a medication that may interact negatively with alcohol, excessive quantity or frequency of alcohol use, binge drinking, concern from others about drinking, and drinking and driving. Physician-level predictors (age, sex, years since graduation, specialty) were also included. RESULTS: The probability of reporting alcohol-related discussions declined with patient age (e.g., odds ratio (OR)=0.40 for patients aged ≥80) and was significantly lower for Latinos (OR=0.38). Drinking and driving (OR=1.69) or concern from others (OR=6.04) were significantly associated with alcohol-related discussions; having comorbidities or using medications that may interact with alcohol were not. CONCLUSION: Although patient demographics, including age and ethnicity, are associated with the occurrence of alcohol-related discussions, clinical factors that may negatively interact with alcohol to increase risk are not. This suggests that physicians may not be attuned to the entire spectrum of alcohol-related risks for older adults. Language: en

Empirical evidence suggests that individuals who consume relatively large amounts of alcohol are more likely to use expensive acute medical care and less likely to use preventive or ambulatory services than other individuals. The few studies that investigated the associations between heavy drinking and health promotion activities did not try to address omitted-variable biases that may confound the relationships. To fill this void in the literature, we examined the effects of heavy alcohol use on three health promotion activities (routine physical exam, flu shot, regular seatbelt use) using the US 2006 Behavioral Risk Factor Surveillance Survey. Although specification tests indicated that omitted variable bias was not present in the majority of the single-equation probit models, we cautiously interpret our findings as evidence of strong associations rather than causal effects. Among both men and women, heavy alcohol use is negatively and significantly associated with each of our three outcomes. These findings suggest that heavy drinkers may be investing less in health promotion activities relative to abstainers and other drinkers. Policy options to address the associated externalities may be warranted.

Research during the past few decades has greatly advanced our understanding of the cost, quality, and variability of medical care at the end of life. The current health-care policy debate has focused considerable attention on the unsustainable rate of spending and wide regional variation associated with medical treatments in the last year of life. New initiatives aim to standardize quality and reduce over-utilization at the end of life. We argue, however, that focusing exclusively on medical treatment at the end of life is not likely to lead to effective health-care policy reform or reduce costs. Specifically, end-of-life policy initiatives face the challenges of political feasibility, inaccurate prognostication, and gaps in the existing literature.With the ultimate aim of improving the quality and efficiency of care, we propose a research and policy agenda guided by a new conceptual framework of factors associated with treatment intensity for patients with serious and complicated medical illness. This model not only expands the population of interest to include all adults with serious illness, but also provides a blueprint for the thorough investigation of the diverse and interconnected determinants of treatment intensity.The new conceptual framework presented in this paper can be used to develop future research and policy initiatives designed to improve the quality and efficiency of care for adults with serious illness.

Background Medicare Part D beneficiaries with diabetes are at risk of medication non-adherence and forgoing necessities due to cost pressures. Generic drug coverage during the Part D gap may attenuate these potentially adverse behaviors.

Objectives. We sought to examine the extent to which children in the child welfare system receive mental health care consistent with national standards. Methods. We used data from 4 waves (3 years of follow-up) of the National Survey of Child and Adolescent Well-Being, the nation's first longitudinal study of children in the child welfare system, and the Area Resource File to examine rates of screening, assessment, and referral to mental health services among 3802 youths presenting to child welfare agencies. Weighted population-averaged logistic regression models were used to identify variables associated with standards-consistent care. Results. Only half of all children in the sample received care consistent with any 1 national standard, and less than one tenth received care consistent with all of them. Older children, those exhibiting externalizing behaviors, and those placed in foster care had, on average, higher odds of receiving care consistent with national standards. Conclusions. Adverse consequences of childhood disadvantage cannot be reduced unless greater collaboration occurs between child welfare and mental health agencies. Current changes to Medicaid regulations that weaken entitlements to screening and assessment may also worsen mental health disparities among these vulnerable children.

To determine healthcare access and costs for triply diagnosed adults, we examined baseline data from the HIV/AIDS Treatment Adherence, Health Outcomes and Cost Study, a multi-site cohort study of HIV+ adults with co-occurring mental and substance abuse disorders conducted between 2000 and 2004. Baseline interviews were conducted with 1138 triply diagnosed adults in eight predominantly urban sites nationwide. A modified version of Structured Interview for DSM-IV Axis I Disorders (SCID) was used to assign Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) diagnoses for the preceding year. Utilization of a broad range of inpatient and outpatient services and medications over the preceding three months was patient-reported in face-to-face interviews. We then applied nationally representative unit costs to impute average monthly expenditures. We measured (poor) access to care during the three-month period by whether the patient had: (a) no outpatient medical visits; (b) at least one emergency room visit without an associated hospitalization; and (c) at least one hospitalization. At baseline, mean expenditures were $3880 per patient per month. This is nearly twice as high as expenditures for HIV/AIDS patients in general. Inpatient care (36%), medications (33%), and outpatient services (31%) each accounted for roughly one-third of expenditures. Expenditures varied by a factor of 2:1 among subgroups of patients, with those on Medicare or Medicaid, not in stable residences, or with poor physical health or high viral loads exhibiting the highest costs. Access to care was worse for women and those with low incomes, unstable residences, same-sex exposure, poor physical or mental health, and high viral loads. We conclude that HIV triply diagnosed adults account for roughly one-fifth of medical spending on HIV patients and that there are large variations in utilization/costs across patient subgroups. Realized access is good for many triply diagnosed patients, but remains suboptimal overall. Deficiencies in HIV care are unevenly distributed, tending to concentrate on already disadvantaged populations.

Between 1986 and 1996, there was dramatic growth in Medicare home health (HH) utilization, increasing from $2.6 billion per year (3 percent of Medicare Part A expenditures) to $17.5 billion per year (13 percent of Part A expenditures). This resulted from growth in both the annual number of beneficiaries served (increasing from 1.6 to 3.6 million) and the average number of annual visits per beneficiary (increasing from 23 to 79 visits per beneficiary) (105th Congress United States of America 1998). At the same time it was noted that there was significant regional variation in utilization of HH services (Kenney and Dubay 1992; Welch, Wennberg, and Welch 1996; McCall et al. 2001;). Welch, Wennberg, and Welch (1996) reported greater variation in utilization of HH services than either skilled nursing days, hospital days, physician services, or hospital admissions, leading the authors to conclude that there was no “national consensus on whether and, if so, how often to use HH care.” The significant regional variation raised concern within Congress and at the Office of Inspector General (OIG) that much of this regional variation could be attributable to either inefficient or fraudulent practices. Beginning July 1995, the OIG working with other agencies initiated Operation Restore Trust, a five-state (California, Florida, Illinois, New York, and Texas) audit that documented examples of fraud and abuse (Health Care Financing Administration 1995). The program was expanded nationwide in 1997. In addition to these regulatory efforts, Congress passed the Balanced Budget Act of 1997, and the Centers for Medicare and Medicaid Services (CMS) implemented the HH Interim Payment System (IPS) on October 1, 1997 (with refinements starting October 1, 1998), and the HH Prospective Payment System (PPS) on October 1, 2000 (105th Congress United States of America 1997). The IPS reduced the aggregate per-visit limit on payments from 112 percent of national mean historical costs to 105 percent of the national median costs. As per-visit limits do little to control the growth in number of visits per beneficiary, per-beneficiary limits were also implemented. These per-beneficiary limits were partly designed to also reduce regional variation (105th Congress United States of America 1998). This was accomplished by blending agencies' historical mean per-beneficiary cost with standardized regional per-beneficiary costs, thereby driving limits toward regional means. (See Table S1 in the appendix for details.) These policies were phased-in based on each agency's fiscal year end. Under the PPS, implemented on October 1, 2000, HH care was organized into 60-day episodes of care for HH resource groups (HHRGs) (Health Care Financing Administration 2000). The Congressional Medicare Payment Advisory Commission (MEDPAC) and several independent groups have described reductions in HH care after implementation of the IPS and PPS policies (MEDPAC 1999; McCall et al. 2001, 2003a, 2003b; Komisar 2002; Schwartz et al. 2002; Liu, Long, and Dowling 2003; Murkofsky et al. 2003; Murtaugh et al. 2003; Spector, Cohen, and Pesis-Katz 2004). In our prior analyses focusing on postacute care HH patients, we reported the reduction in HH utilization for patients undergoing major orthopedic surgery (FitzGerald et al. 2006). We expand upon these prior analyses to examine how these changes in reimbursement policy affected regional variation over time, as well as how the reimbursement changes affected the mix of skilled HH services delivered.

Author(s): Ettner, Susan L; Cadwell, Betsy L; Russell, Louise B; Brown, Arleen; Karter, Andrew J; Safford, Monika; Mangione, Carol; Beckles, Gloria; Herman, William H; Thompson, Theodore J; TRIAD Study Group | Abstract: BackgroundResearch on self-care for chronic disease has not examined time requirements. Translating Research into Action for Diabetes (TRIAD), a multi-site study of managed care patients with diabetes, is among the first to assess self-care time.ObjectiveTo examine associations between socioeconomic position and extra time patients spend on foot care, shopping/cooking, and exercise due to diabetes.DataEleven thousand nine hundred and twenty-seven patient surveys from 2000 to 2001.MethodsBayesian two-part models were used to estimate associations of self-reported extra time spent on self-care with race/ethnicity, education, and income, controlling for demographic and clinical characteristics.ResultsProportions of patients spending no extra time on foot care, shopping/cooking, and exercise were, respectively, 37, 52, and 31%. Extra time spent on foot care and shopping/cooking was greater among racial/ethnic minorities, less-educated and lower-income patients. For example, African-Americans were about 10 percentage points more likely to report spending extra time on foot care than whites and extra time spent was about 3 min more per day.DiscussionExtra time spent on self-care was greater for socioeconomically disadvantaged patients than for advantaged patients, perhaps because their perceived opportunity cost of time is lower or they cannot afford substitutes. Our findings suggest that poorly controlled diabetes risk factors among disadvantaged populations may not be attributable to self-care practices.

This study examined mental health service utilization and costs associated with the California Assembly Bill 2034 housing-first program for homeless persons in San Diego County: Reaching Out and Engaging to Achieve Consumer Health (REACH).Encounter data were used to identify REACH clients and a control group that was matched by propensity score. Mental health services costs for case management, outpatient services, inpatient and emergency services, criminal justice system services, and total services were summarized for two-year periods before and after clients initiated REACH. Incremental costs of the program were calculated as the difference in cost among clients in the REACH group, from pre- to postintervention, less the difference in cost among those in the control group from pre- to postintervention.A total of 177 REACH clients and 161 clients in a control group matched by propensity score were identified. Among REACH participants, case management costs increased by $6,403 (p.001) from pre- to postintervention, inpatient plus emergency services costs declined by $6,103 (p=.034), and costs for mental health services provided by the criminal justice system declined by $570 (p=.020) compared with the control group. The standardized difference-in-difference estimate of the total costs between REACH clients and the control group was not significant.Participation in REACH was associated with substantial increases in outpatient services as well as cost offsets in inpatient and emergency services and criminal justice system services. The net cost of services, $417 over two years, was substantially lower than the total cost of services ($20,241).

Concerns have been voiced about financial pressures faced by rural hospices, because of possible implications for hospice access in rural areas. To assess whether financial performance differs between existing urban and rural hospices, we used the 2003 California Office of Statewide Health Planning and Development survey to compare revenues, costs, and profitability (with and without charitable donations). We adjusted for factors related to financial performance, including agency size, years in operation, profit status, whether hospices were freestanding or chain-, home-health-, or hospital-based, and the proportion of patients by insurance type and referral source, race/ethnicity, and diagnosis. One hundred forty-four (91%) hospices were urban, and 14 (9%) were rural. Mean values per patient for total revenue, total cost, and post-tax profit were $7203, $7440 and −$256, respectively, for urban hospices and $6726, $6274 and $452, respectively, for rural hospices. Compared with urban hospices, rural hospices were at least as profitable per patient-day (+$33, P = 0.15). They were significantly more profitable (+$47, P = 0.05) when charitable donations were excluded. In summary, we found that in California, rural hospices fared no worse financially than urban hospices. These counterintuitive findings underscore the need to examine urban-rural hospice financial differences using a national sample.

Flexible work arrangements, or organizational practises that permit employees to adjust their work schedule or location to better manage demands outside of work, are a popular family-friendly benefit. There is relatively little research examining the health outcomes associated with flexibility and no published studies examining associations with health care utilization. We analyzed responses to self-administered Health Risk Appraisals (HRAs) completed by employees of a large multinational pharmaceutical company in the USA (N = 2976). The HRA included measures of perceived flexibility and self-appraised health. Health care utilization records from the year following completion of the HRA were merged with the self-reported data. Greater levels of flexibility were associated with better health: that is, with less self-reported stress and strain, and better physical health. Flexibility was not related to either acute visits to a health care provider or number of prescriptions. However, after controll...

Objective: To evaluate factors that affect the financial performance of hospice. Methods: Using the California Office of Statewide Health Planning and Development 2003 survey, we evaluated the organizational attributes, clinical care, and financial performance of 185 operational hospices. As outcomes, we evaluated revenues, costs, and profits per patient and per patient–day, the intensity and skill mix of care, and the provision of charitable and special palliative services. We evaluated regression-adjusted differences by profit status controlling for other organizational features and aggregate patient characteristics. Results: Hospices reported median revenue of $6865 per patient and $138 per patient–day (for-profit-not-for profit [FP-NFP] difference −$20, p = 0.045), median cost of $6737 per patient, and $135 per patient–day (FP-NFP difference −$55, p = 0.002), and median pretax profit of $334 per patient and $6 per patient–day (FP-NFP difference $34, p = 0.026). Patients received a median of 2...

Non-VA services may provide an important alternative to veterans affairs (VA) services for VA patients who are eligible for Medicare coverage, especially in areas with poor geographic access to the VA. As Medicare and the VA are legally prohibited from billing each other for services provided to dually eligible veterans, cost-shifting may occur, especially as the population ages and increasingly more veterans become Medicare eligible. It is of strong interest to understand which VA patients are also obtaining services outside of the VA and how their outside utilization responds to the allocation of VA resources. That is, where access to VA services becomes more limited, do dually eligible veterans increasingly turn to the Medicare sector for their care (substitution), or do they actually receive fewer Medicare services, e.g., due to fewer VA referrals (complementarity)? Veterans 65 and older use Medicare for their medical care (Borowsky and Cowper 1999; Wright et al. 1999; Weeks et al. 2005, 2006), but only one previous study, limited to elderly veterans in northern New England (Weeks et al. 2005), has examined use of Medicare for behavioral health care among dually eligible veterans. The question of cost-shifting and substitution is particularly interesting for veterans with mental health and substance abuse (MH/SA) disorders. The prevalence of mental disorders is generally higher in the VA than in other health care systems, with approximately 29 percent of veterans having at least one MH/SA disorder (Hankin et al. 1999; Piette, Baisden, and Moos 1999). Psychiatric comorbidities are common as well. Although the VA is sometimes viewed as a “provider of last resort” for medical care, due to its limited choice of providers and lack of resources, the limitations of Medicare coverage on behavioral health care (Ettner 1997), in conjunction with the wide array of services provided by VA in this area, makes the VA an indispensable source of care for many veterans with behavioral health problems. The VA operates the largest mental health service delivery system in the nation, servicing over 900,000 veterans annually at a cost of more than $2.5 billion. Special emphasis programs target populations including the severely mentally ill, the homeless, and those with posttraumatic stress disorder (PTSD) and SA problems. Furthermore, the VA provides more comprehensive prescription drug coverage than Medicare, so patients have a strong financial incentive to receive pharmacotherapy from VA providers. Yet, the greater relative distance to VA versus Medicare providers may impede some veterans from taking advantage of VA's unique MH/SA services. Proximity to care has been shown to influence medical utilization in the general population (Nemet and Bailey 2000; Shahain et al. 2000; Arcury et al. 2005) as well as in the VA (Mooney et al. 2000; Fortney et al. 2005). For mental health care, earlier studies found that VA patients living further from VA facilities used fewer VA resources (Fortney et al. 1995, 1998; Rosenheck and Stolar 1998; Druss and Rosenheck 2000), but were unable to determine whether the reduction in the use of VA services was offset by increased Medicare utilization. Another paper found that rural veterans experience changes in policy that restrict access to SA services more dramatically than urban veterans, without substituting private-sector care (Wallace et al. 2007). Similarly, studies have identified a role of distance to provider in determining treatment patterns of Medicare patients with psychiatric conditions (Ettner and Hermann 1997; Ettner 1999; Ettner, Hermann, and Tang 1999), but did not look at crossover between the VA and Medicare among patients who had a choice between the two. A recent study showed that dual eligibles who lived farther from VA hospitals were less likely to rely on VA health care, particularly inpatient care (Hynes et al. 2007). However, this study focused on patient characteristics and did not examine behavioral health care. This research uses a national linked VA-Medicare database to examine health care sector choices among VA patients diagnosed with MH/SA disorders who are dually eligible for Medicare. We focus on the effects of geographic proximity to care on utilization of services in each sector. Our goal is to establish whether veterans with more limited geographic access to VA behavioral health services reduce their utilization of these services and whether their use of Medicare behavioral health services increases or decreases concomitantly. This issue has important policy implications regarding allocation of MH/SA resources within the VA system. If Medicare behavioral health care serves as a substitute for VA care, then an understanding of the nature of the cost-shifting involved is important information for VA managers in their budget allocation decisions. If Medicare services are complementary to VA services, then the VA may need to increase its outreach efforts to identify veterans who are in need of behavioral care but not receiving it.

OBJECTIVE—Recent data suggest that residential environment may influence health behaviors and outcomes. We assessed whether perception of neighborhood problems was associated with diabetes behaviors and outcomes. RESEARCH DESIGN AND METHODS—This cross-sectional analysis included 7,830 diabetic adults enrolled in Translating Research Into Action for Diabetes, a study of diabetes care and outcomes in managed care settings. Perception of neighborhood problems was measured using a summary score of participants’ ratings of crime, trash, litter, lighting at night, and access to exercise facilities, transportation, and supermarkets. Outcomes included health behaviors and clinical outcomes. Hierarchical regression models were used to account for clustering of patients within neighborhoods and to adjust for objective neighborhood socioeconomic status (percentage living in poverty) and potential individual-level confounders (age, sex, race/ethnicity, education, income, comorbidity index, and duration of diabetes). RESULTS—After adjustment, residents of neighborhoods in the lowest tertile (most perceived problems) reported higher rates of current smoking (15 vs. 11%) than those in the highest tertile and had slightly lower participation in any weekly physical activity (95 vs. 96%). In addition, their blood pressure control was worse (25 vs. 31% CONCLUSIONS—Neighborhood problems were most strongly associated with more smoking and higher blood pressure, both of which have significant implications for cardiovascular risk. Potential mechanisms that explain these associations should be further explored in longitudinal studies.

OBJECTIVE—The purpose of this study was to analyze the economic outcomes of a clinical program implemented to achieve strict glycemic control with intensive insulin therapy in patients admitted to the intensive care unit (ICU). RESEARCH DESIGN AND METHODS—A difference-in-differences (quasi-experimental) study design was used to examine the associations of an intensive insulin therapy intervention with changes in hospital length of stay (ICU and total), costs (ICU and total), and mortality. Hospital administrative data were obtained for 6,719 adult patients admitted between 2003 and 2005 to one of five intervention or four comparison ICUs in a large academic medical center. Linear regression models with log transformations and appropriate retransformations were used to estimate length of stay (LOS) and costs; logistic regressions were used to estimate mortality. RESULTS—After adjustment for observable patient characteristics and secular time trends, the intervention was consistently associated with lower average glucose levels and a trend toward shorter LOS, lower costs, and lower mortality. However, associations with resource use and outcomes were statistically significant in only ICU LOS, with an average reduction of 1.19 days of ICU care per admission. Other associations, although large in magnitude and in the hypothesized directions, were not estimated with sufficient precision to rule out other net effects. The associations with ICU days and costs were larger in magnitude than total days and costs. CONCLUSIONS—A clinical team focused on hyperglycemia management for ICU patients can be a valuable investment with significant economic benefits for hospitals.

Standard inference procedures for regression analysis make assumptions that are rarely satisfied in practice. Adjustments must be made to insure the validity of statistical inference. These adjustments, known for many years, are used routinely by some health researchers but not by others. We review some of these methods and give an example of their use in a health services study for a continuous and a count outcome. For the continuous outcome, we describe retransformation using the smear factor, accounting for missing cases via multiple imputation and attrition weights and improving results with bootstrap methods. For the count outcome, we describe zero inflated Poisson and negative binomial models and the two-part model to account for overabundance of zero values. Recent advances in computing and software development have produced user-friendly computer programs that enable the data analyst to improve prediction and inference based on regression analysis.

Since the implementation in 1983 of the acute care prospective payment system, hospitals have had a strong financial pressure to reduce costs. These cost reductions have been achieved primarily through reduced length of stay (LOS) (Meyers et al. 1996; Metz and Freiberg 1998; Healy et al. 2002) and a greater reliance on postacute care (PAC) (Kenney and Holahan 1991; Manton et al. 1993; Prospective Payment Assessment Commission 1996; Forrest, Roque, and Dawodu 1999; Huusko et al. 1999). The initial substitution of PAC for longer LOS was first seen as an efficient transfer of care from the more expensive inpatient care setting to less expensive PAC settings. However, as the growth in PAC outpaced reductions in LOS, Congress became concerned that PAC was no longer cost saving (MEDPAC: Medicare Payment Advisory Commission 2000). Therefore, to reduce the financial incentive to discharge patients “early” and thus reduce the utilization of potentially unnecessary PAC, in 1998 the Centers for Medicare and Medicaid Services (CMS) targeted 10 diagnosis-related groupings (DRGs) with the highest rate of PAC utilization for modifications to the DRG reimbursement system (Prospective Payment Assessment Commission 1997). At that time, these 10 DRGs represented 8.8 percent of all hospital discharges (Medicare Payment Advisory Commission 1999). By defining the relative odds of PAC use among short versus long hospitalizations, Cromwell, Donoghue, and Gilman (2002) demonstrated that these 10 DRGs were well chosen. On October 1, 1998, Congress implemented the Short Stay Transfer Policy (SSTP) as part of the Balanced Budget Act of 1997 (One-hundred-fifth Congress of the United States of America 1997). Under this policy, hospital payments for these 10 DRGs were discounted for patients discharged “early” to a PAC setting. “Early” discharge was defined as any patient transferred to a PAC facility before the national geometric mean LOS for the related DRG. Qualifying PAC stays include transfer to skilled nursing facility or rehabilitation hospital or discharge to home with home health care beginning within 3 days of discharge. Despite well-documented regional variation in LOS (Chassin et al. 1986; Chassin et al. 1987) CMS purposefully selected a national geometric LOS rather than regional means as “national standardized [DRG payment] amounts … reflect costs across all regions” and “one of the reasons for this variation [in LOS] is the greater reliance on postacute care earlier in the stay in those areas with lower average lengths of stay” (Health Care Financing Administration 1998). In October 2003, CMS expanded this policy to include a total of 29 DRGs, bringing the proportion of all discharges subject to the transfer policy to 34 percent (Centers for Medicare and Medicaid Statistics 2004). By discouraging “early” discharge to PAC with discounted payments, CMS had hoped to realize further cost savings through an increase in “late” discharge without PAC (substituting inpatient for postacute care; Health Care Financing Administration 1998; see Figure 1 for conceptual discharge decision model). Figure 1 Conceptual Model for Nested Logistic Statistical Design A preferential increase in patients discharged “early” without PAC would suggest that hospitals were discouraging access to PAC. As authors have suggested beneficial effects of PAC and the rehabilitative care (Kane et al. 1996; Intrator and Berg 1998; Munin et al. 1998), reduction in PAC could have a potential harmful impact on patient care. Alternatively, hospitals could simply keep patients in hospital longer without change in PAC utilization. Slowing the trend in shorter LOS could potentially improve patient care as some researchers have raised the concern that patients may be discharged too early after joint replacement (Mauerhan et al. 1998). MEDPAC reported to Congress that the crude mean LOS for the 10 SSTP DRGs continued to fall between 1997 and 1999, but at a slower rate than non-SSTP DRGS (MEDPAC: Medicare Payment Advisory Commission 2000). However, during this same timeframe, Medicare implemented policy changes that affected skilled nursing and home health care markets potentially restricting access to PAC (One-hundred-fifth Congress of the United States of America 1997), which in turn could affect hospital LOS and use of early PAC. To examine the impact of the SSTP and discern its effects from other concurrent policies, we selected a 100 percent sample of select Medicare fee-for-service claims between January 1, 1996 and December 31, 2000 for an interrupted time-series analysis so that month-to-month change in practice patterns could be correlated with the date of SSTP implementation. We hypothesized that implementation of the SSTP would attenuate or perhaps even reverse the historical trend for shorter hospital LOS, resulting in a smaller proportion of patients discharged “early” to PAC. We also tested for differential effects of the policy by patient, hospital, and regional characteristics.

To compare nurse practitioner/physician management of hospital care, multidisciplinary team-based planning, expedited discharge, and assessment after discharge to usual management.In the context of managed care, the goal of academic medical centers is to provide quality care at the lowest cost and minimize length of stay (LOS) while not compromising quality.Comparative, 2-group, quasiexperimental design was used; 1,207 general medicine patients (n=581 in the experimental group and n=626 in the control group) were enrolled. The control unit provided usual care. The care management in the experimental unit had 3 different components: an advanced practice nurse who followed the patients during hospitalization and 30 days after discharge, a hospitalist medical director and another hospitalist, and daily multidisciplinary rounds. LOS, hospital costs, mortality, and readmission 4 months after discharge were measured.Average LOS was significantly lower for patients in the experimental group than the control group (5 vs. 6 days, P.0001). The "backfill profit" to the hospital was US$1591 per patient in the experimental group (SE, US$639). There were no significant group differences in mortality or readmissions.Collaborative physician/nurse practitioner multidisciplinary care management of hospitalized medical patients reduced LOS and improved hospital profit without altering readmissions or mortality.

BACKGROUND:: Understanding differences in cause-specific mortality between Latinos and whites is important for targeting future public health interventions and research aimed at eliminating health disparities. OBJECTIVES:: We sought to determine the contribution of specific causes of death to Latino-white differences in mortality. RESEARCH DESIGN:: Using nationally representative data, we estimated cause-specific mortality risks, which were then used in a simulation model to estimate mortality events for a cohort of persons starting at age 25 and followed until death or age 75. SUBJECTS:: Subjects were 507,820 Latino and white adults, age 25 or older, who participated in the 1986-1994 National Health Interview Surveys. MEASURES:: Outcomes were years of potential life lost before age 75 from specific causes of death and age-specific mortality rate ratios for Latinos compared with whites. RESULTS:: Latinos had higher mortality rates than whites before age 45 and similar mortality rates at older ages. Latino women lost 315 (95% confidence interval [CI], 229-2423) more years of potential life (per 1000 persons before the age of 75) than white women and Latino men lost 595 (95% CI, 513-1675) more years than white men. For both men and women, whites lost substantially more years of potential life than Latinos from lung cancer. Homicide, diabetes, HIV, and liver disease contributed most to the excess years of potential life lost among Latino men, and diabetes and HIV contributed most to the excess years of potential life lost among Latino women. CONCLUSIONS:: To eliminate health disparities between Latinos and whites, future health policy and public health efforts should target diabetes, homicide, HIV, and liver disease among Latinos and lung cancer among whites.

Objectives: To evaluate selected hospice admission practices that could represent barriers to hospice use and the association between these admission practices and organizational characteristics. Design: From December 1999 to March 2000, hospices were surveyed about selected admission practices, and their responses were linked to the 1999 California Office of Statewide Health Planning and Development's Home and Hospice Care Survey that describes organizational characteristics of California hospices. Setting: California statewide. Participants: One hundred of 149 (67%) operational licensed hospices. Measurements: Whether hospices admit patients who lack a caregiver; would not forgo hospital admissions; or are receiving total parenteral nutrition (TPN), tube feedings, radiotherapy, chemotherapy, or transfusions. Results: Sixty-three percent of hospices restricted admission on at least one criterion. A significant minority of hospices would not admit patients lacking a caregiver (26%). Patients unwilling to forgo hospitalization could not be admitted to 29% of hospices. Receipt of complex medical care, including TPN (38%), tube feedings (3%), transfusions (25%), radiotherapy (36%), and chemotherapy (48%), precluded admission. Larger program size was significantly associated with a lower likelihood of all admission practices except restricting the admission of patients receiving TPN or tube feedings. Hospice programs that were part of a hospice chain were less likely to restrict the admission of patients using TPN, radiotherapy, or chemotherapy than were freestanding programs. Conclusion: Patients who are receiving complex palliative treatments could face barriers to hospice enrollment. Policy makers should consider the clinical capacity of hospice providers in efforts to improve access to palliative care and more closely incorporate palliation with other healthcare services.

Background and Objective The aim of this study was to develop and apply an automated linkage algorithm to 10 years of California hospitalization discharge abstracts and death records (1990 to 1999), evaluate linkage accuracy, and identify sources of bias. Methods Among the 1,858,458 acute hospital discharge records with unique social security numbers (SSNs) from 1 representative year of discharge data (1997), which had at least 2 years of follow-up, 66,410 of 69,757 deaths occurring in the hospital (95%) and 66,998 of 1,788,701 of individuals discharged alive (3.7%) linked to death records. Linkage sensitivity and specificity were estimated as 0.9524 and 0.9998 and positive and negative predictive values as 0.994 and 0.998 (corresponding to 400 incorrect death linkages among out-of-hospital death record linkages and 3,300 unidentified record pairs among unlinked live discharges). Results Based upon gold standard linkage rates, discharge records for those of age 1 year and older without SSNs may have 2,520 additional uncounted posthospitalization deaths at 1 year after admission. Gold standard comparison for those with SSNs showed women, the elderly, and Hispanics and non-Hispanic Blacks had more unlinked hospital death records, although absolute differences were small. The concentration of unidentified linkages among discharge records of traditionally vulnerable populations may result in understating mortality rates and other estimates (i.e., events with competing hazard of death) for these populations if SSN is differentially related to a patient's disease severity and comorbidities. Conclusion Because identification of cases of out-of-hospital deaths has improved over the past decade, observed improvements in patient survival over this time are likely to be conservative.

OBJECTIVE—Despite the increased shifting of health care costs to consumers, little is known about the impact of financial barriers on health care utilization. This study investigated the effect of out-of-pocket expenditures on the utilization of recommended diabetes preventive services. RESEARCH DESIGN AND METHODS—This was a survey-based observational study (2000–2001) in 10 managed care health plans and 68 provider groups across the U.S. serving ∼180,000 patients with diabetes. From 11,922 diabetic survey respondents, we studied the occurrence of self-reported annual dilated eye exams and diabetes health education and among insulin users, daily self-monitoring of blood glucose (SMBG). Conditional probabilities were estimated for outcomes at each level of self-reported out-of-pocket expenditure by using hierarchical logistic regression models with random intercepts. RESULTS—Conditional probabilities of utilization (95% CI) varied by expenditure for dilated eye exam [no cost 78% (75–82), copay 79% (75–82), and full price 70% (64–75); P < 0.0001]; diabetes health education [no cost 29% (23–36), copay 29% (23–36), and full price 19% (14–25); P < 0.0001]; and daily SMBG [no cost 75% (68–81), copay 68% (60–75), and full price 59% (49–68); P < 0.0001]. Extensive adjustment for patient factors had no discernible effect on the estimates or their significance, and cost-utilization relationships were similar across income levels and other patient characteristics. CONCLUSIONS—Benefit packages structured to derive greater fiscal contribution from the health plan membership result in suboptimal use of diabetes preventive services and may thus lead to poorer clinical outcomes, greater future costs, and lower health plan quality ratings.

OBJECTIVE To determine whether competing demands for time affect diabetes self-care behaviors, processes of care, and intermediate outcomes. RESEARCH DESIGN AND METHODS We used survey and medical record data from 5,478 participants in Translating Research Into Action for Diabetes (TRIAD) and hierarchical regression models to examine the cross-sectional associations between competing demands for time and diabetes outcomes, including self-management, processes of care, and intermediate health outcomes. RESULTS Fifty-two percent of participants reported no competing demands, 7% reported caregiving responsibilities only, 36% reported employment responsibilities only, and 6% reported both caregiving and employment responsibilities. For both women and men, employment responsibilities (with or without caregiving responsibilities) were associated with lower rates of diabetes self-care behaviors, worse processes of care, and, in men, worse HbA1c. CONCLUSIONS Accommodations for competing demands for time may promote self-management and improve the processes and outcomes of care for employed adults with diabetes.

A national sample of 2,048 workers was asked to rate the impact of their job on their physical and mental health. Ordered logistic regression analyses based on social ecology theory showed that the workers' responses were significantly correlated with objective and subjective features of their jobs, in addition to personality characteristics. Workers who had higher levels of perceived constraints and neuroticism, worked nights or overtime, or reported serious ongoing stress at work or higher job pressure reported more negative effects. Respondents who had a higher level of extraversion, were self-employed, or worked part time or reported greater decision latitude or use of skills on the job reported more positive effects. These findings suggest that malleable features of the work environment are associated with perceived effects of work on health, even after controlling for personality traits and other sources of reporting bias. Work and health are intimately connected, yet the complex association between multiple features of employment arrangements and workers' health is not well understood. Given the dramatic labor supply and demand changes in the past decade, better identification of the employment characteristics that underlie the health of workers is of profound practical importance. As outlined by the National Occupational Research Agenda (National Institute of Occupational Safety and Health [NIOSH], 1996), the changing nature of jobs (e.g., shift from manufacturing to services) as well as the aging and growing diversity of the workforce suggests that the threats to worker

Medicare claims for elderly admitted for psychiatric care were used to estimate the impact of hospital profit status on costs, length of stay (LOS), and rehospitalizations. No evidence was found that not-for-profits (NFPs) treated sicker patients or had fewer rehospitalizations. For-profits (FPs) actually treated poorer patients. Longer LOS and lower daily costs of NFPs were attributable to their other characteristics, e.g. medical school affiliation. Instrumental variables (IV) estimates suggested that NFP general hospitals actually have lower adjusted costs. These findings fail to support concerns that FP growth leads to declining access and quality or contentions that NFPs are less efficient.

Purpose: Compare Medicare beneficiaries admitted to public, private not-for-profit, and for-profit psychiatric hospitals. Methods: Administrative data on all beneficiaries admitted to psychiatric hospitals in 1990 were used to estimate multinomial logit models of treatment in for-profit or private not-for-profit (vs. public) hospitals, controlling for patient characteristics. Results: Women and beneficiaries with worse geographic access to public hospitals, better access to private hospitals, or comorbidities were more likely to be treated in private hospitals. Blacks, rural residents, and beneficiaries who were disabled, had previous psychiatric hospitalizations, or a primary diagnosis of schizophrenia were less likely to be treated in private hospitals. Residents of lower-income areas were less likely to be treated in private not-for-profits. Conclusions: In addition to being essential providers for the uninsured, public hospitals also play an important role in ensuring access to care for Medicare beneficiaries. Public psychiatric hospitals treat a disproportionate share of the sickest, lowest-income, and minority patients. Geographic proximity and bed supply also play an important role in provider choices. Plans to privatize state psychiatric facilities should take these considerations into account.

METHODS: Criteria were elicited from an institution’s surgical faculty when making discharge decisions, using a survey instrument. Patient data from these surgical services were then analyzed using a time-to-event model to identify criteria that explain the timing of discharges. The data were then used to develop a timevarying prediction model of unplanned readmissions. The readmissions model was validated via a series of inand out-of-sample tests using bootstrapped, partitioned patients. All 3 sources of discharge practices were then compared.

The National Survey of Mid-life Developments in the United States (MIDUS) is one of several studies that demonstrate socioeconomic gradients in mortality during midlife. When MIDUS findings on self-reported health, waist to hip ratio, and psychological well-being were analyzed for their possible roles in generating socioeconomic differences in health, they revealed clear educational gradients for women and men (i.e., higher education predicted better health). Certain potential mediating variables, like household income, parents’ education, smoking behavior, and social relations, contributed to an explanation of the socioeconomic gradient. In addition, two census-based measures, combined into an area poverty index, independently predicted ill health. The results suggest that a set of both early and current life circumstances cumulatively contribute toward explaining why people of lower soeioeconomic status have worse health and lower psychological well-being.

OBJECTIVES: The purpose of this study was to determine the effects of poverty, program generosity, and health on state variations in enrollment of children and adolescents in the Supplemental Security Income (SSI) program during recent program expansions. METHODS: The relationship of state SSI rates for 1989 and 1992 to child poverty, health, and program generosity were determined by multiple regression. RESULTS: The mean percentage of children enrolled grew from 0.36% (1989) to 0.75% (1992). Poverty rates accounted for 78% of the variance among states in 1989 and 53% in 1992. Other indicators accounted for little variance. CONCLUSIONS: Differences in state poverty levels explained almost all variation in SSI enrollment.

This paper evaluates the ability of Ambulatory Care Groups (ACGs) to prospectively predict mental health and substance abuse expenditures and total health care expenditures of persons enrolled in the New Hampshire Medicaid Program during fiscal years 1993 and 1994. A series of multi-part models is estimated separately for adults and children and a synthetic R-squared and the mean absolute predictive error are calculated. The results show that with the exception of predicting total expenditures for children, ACGs do not perform as well as simple models containing various demographic and prior mental health/substance abuse utilization measures.

This study uses data from the Survey of Income and Program Participation to address three issues: (1) what were the 1987 rates of Medicaid participation and private insurance coverage among elderly predicted to be categorically eligible and medically needy?; (2) how did these rates change between 1987 and 1992?; and (3) which factors influence insurance choices among persons who are categorically eligible for Medicaid? The 1987 Medicaid participation rates were 64 percent for the categorically eligible, but only 11 percent among the medically needy. Participation among the categorically eligible declined to 59 percent by 1992, but the difference was insignificant. In both years, about 23 percent of all categorically eligible persons had private insurance, but among those who do not participate in Medicaid, the rate rises to 48 percent.

OBJECTIVES: This study investigated the causal effect of having a usual source of medical care on the timing of preventive services by women and children. METHODS: Data on 17,110 children and 23,488 women from the 1988 and 1990 National Health Interview Surveys were used to estimate ordered probit models of the effect of having a usual source of medical care on the time since the last receipt of each preventive service (routine checkups for children; blood pressure checks, Pap smears, and breast exams for adult women; mammograms for older women). Two-stage instrumental variables methods were used to eliminate simultaneity bias. RESULTS: The existence of a usual source of medical care was strongly correlated with the earlier receipt of preventive services, and the relationship appears to be causal for Pap smears, breast exams, and mammograms. However, there was little evidence that having a regular provider caused an increased rate of routine checkups for children or blood pressure checks for adult women. CONCLUSIONS: Delivery systems that encourage the development of long-term relationships with medical providers may increase cancer screening rates among women.

Using data from the National Survey of Families and Households, the Survey of Income and Program Participation, and the National Health Interview Survey, I estimate the structural impact of income on the following measures of health: self-assessed health status, work and functional limitations, bed days, average daily consumption of alcohol, and scales of depressive symptoms and alcoholic behavior. Both ordinary and IV estimates indicate that increases in income significantly improve mental and physical health but increase the prevalence of alcohol consumption. Cost-benefit analyses of government policies that may reduce disposable income should take into account potential effects on morbidity.