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Stimulant use is an important driver of HIV/STI transmission among men who have sex with men (MSM). Evaluating factors associated with increased stimulant use is critical to inform HIV prevention programming efforts. This study seeks to use machine learning variable selection techniques to determine characteristics associated with increased stimulant use and whether these factors differ by HIV status. Data from a longitudinal cohort of predominantly Black/Latinx MSM in Los Angeles, CA was used. Every 6 months from 8/2014-12/2020, participants underwent STI testing and completed surveys evaluating the following: demographics, substance use, sexual risk behaviors, and last partnership characteristics. Least absolute shrinkage and selection operator (lasso) was used to select variables and create predictive models for an interval increase in self-reported stimulant use across study visits. Mixed-effects logistic regression was then used to describe associations between selected variables and the same outcome. Models were also stratified based on HIV status to evaluate differences in predictors associated with increased stimulant use. Among 2095 study visits from 467 MSM, increased stimulant use was reported at 20.9% (n = 438) visits. Increased stimulant use was positively associated with unstable housing (adjusted [a]OR 1.81; 95% CI 1.27-2.57), STI diagnosis (1.59; 1.14-2.21), transactional sex (2.30; 1.60-3.30), and last partner stimulant use (2.21; 1.62-3.00). Among MSM living with HIV, increased stimulant use was associated with binge drinking, vaping/cigarette use (aOR 1.99; 95% CI 1.36-2.92), and regular use of poppers (2.28; 1.38-3.76). Among HIV-negative MSM, increased stimulant use was associated with participating in group sex while intoxicated (aOR 1.81; 95% CI 1.04-3.18), transactional sex (2.53; 1.40-2.55), and last partner injection drug use (1.96; 1.02-3.74). Our findings demonstrate that lasso can be a useful tool for variable selection and creation of predictive models. These results indicate that risk behaviors associated with increased stimulant use may differ based on HIV status and suggest that co-substance use and partnership contexts should be considered in the development of HIV prevention/treatment interventions.

The model  is designed to estimate the impacts of various elements of the ACA on employer decisions to offer insurance coverage and individual decisions to obtain coverage in California.

BackgroundAsthma disproportionately affects individuals with lower income. High uninsured rates are a potential driver for this disparity. Previous studies have not examined the effect of the Affordable Care Act (ACA) on asthma-related outcomes for individuals with low income.Research questionWhat is the impact of insurance status and the ACA on asthma outcomes for adults 18 to 64 years of age in households with low-income status?Study design and methodsThis study was a pooled cross-sectional observational study using National Health Interview Survey data from 2011 through 2013 and 2016 through 2018. Individuals 18 to 64 years of age with a history of asthma and low income were included. Survey-weighted regression modeling and mediation analysis was used to explore the relationship of insurance status and asthma control. Univariate and multivariate survey-weighted regression modeling then was used to evaluate the correlation of the ACA and asthma outcomes.ResultsWe identified 4,043 individual observations. Having health insurance was correlated with improved asthma outcomes (OR, 1.25). This relationship was completely mediated by cost barriers to medications and physician visits. Although the ACA resulted in significant changes in insurance status (OR, 2.4), no statistically significant change was found in asthma outcomes. Furthermore, cost barriers to both medications and physician visits persisted in the insured population, 20.7% and 30.0%, respectively.InterpretationInsurance coverage is associated with improved asthma control for adults 18 to 64 years from households with low socioeconomic status. The ACA reduced the rates of uninsured, but did not have the same magnitude of effect on reducing cost barriers. The persistence of cost barriers may explain in part the lack of population-level improvement in asthma control.

Substance use during sexual encounters (sexualized substance use) is an important driver of HIV and sexually transmitted infection (STI) disparities that are experienced by men who have sex with men (MSM). This analysis aimed to identify patterns of sexualized substance use and their associations with HIV risk behaviors. We utilized visit-level data from a longitudinal cohort of predominantly Black/Latinx MSM, half with HIV and half with substance use in Los Angeles, California. Every 6 months from 8/2014 to 3/2020, participants underwent STI testing and completed surveys on demographics, sexualized substance use (stimulant and/or alcohol intoxication during oral sex, receptive anal intercourse [RAI] and/or insertive anal intercourse [IAI]), transactional sex, biomedical HIV prevention (pre-/post-exposure prophylaxis use or undetectable viral load), and depressive symptoms. Latent class analysis was used to identify patterns of sexualized substance use. Multinomial logit models evaluated risk behaviors associated with latent classes. Among 2386 study visits from 540 participants, 5 classes were identified: no substance use, sexualized stimulant use, sexualized alcohol use, sexualized stimulant and alcohol use, and stimulant/alcohol use during oral sex and RAI. Compared to the no sexualized substance use class, sexualized stimulant use was associated with transactional sex, current diagnosis of STIs, not using HIV biomedical prevention, and depressive symptoms. Sexualized alcohol use had fewer associations with HIV risk behaviors. Patterns of sexual activities, and the substances that are used during those activities, confer different risk behavior profiles for HIV/STI transmission and demonstrate the potential utility of interventions that combine substance use treatment with HIV prevention.

BackgroundMethamphetamine use, sexual risk behaviors, and depression contribute to ongoing human immunodeficiency virus (HIV) and sexually transmitted infection (STI) disparities among men who have sex with men (MSM). The relative contributions of these effects longitudinally are not well understood.MethodsThis analysis used visit-level data from a longitudinal cohort of MSM, half with HIV, in Los Angeles, CA. From August 2014 to March 2020, participants completed follow-up visits every 6 months and underwent testing for rectal gonorrhea/chlamydia (GC/CT) and completed questionnaires including depressive symptoms, number of receptive anal intercourse (RAI) partners, and methamphetamine use. Path analysis with structural equation modeling using concurrent and lagged covariates was used to identify relative contributions of methamphetamine use and depression on number of RAI partners and rectal GC/CT across time.ResultsFive hundred fifty-seven MSM with up to 6 visits (3 years) were included for a total of 2437 observations. Methamphetamine use and depressive symptoms were positively associated with number of RAI partners (β = 0.28, P < 0.001; β = 0.33, P = 0.018, respectively), which was positively associated with rectal GC/CT (β = 0.02, P < 0.001). When stratified by HIV status, depressive symptoms were positively associated with RAI partners for HIV-negative MSM (β = 0.50, P = 0.007) but were not associated for MSM living with HIV (β = 0.12, P = 0.57). Methamphetamine use was positively associated with RAI partners in both strata.ConclusionsFactors and patterns, which contribute to risk behaviors associated with rectal GC/CT, may differ by HIV status. Our findings demonstrate the importance of combined treatment and prevention efforts that link screening and treatment of stimulant use and depression with STI prevention and treatment.

BackgroundGiven the risks of opioids, clinicians are under growing pressure to treat pain with non-opioid medications. Yet non-opioid analgesics such as non-steroidal anti-inflammatory drugs (NSAIDs) have their own risks: patients with kidney disease or gastrointestinal diseases can experience serious adverse events. We examined the likelihood that patients with back pain diagnoses and contraindications to NSAIDs and opioids received an opioid prescription in primary care.MethodsWe identified office visits for back pain from 2012 to 2017 and sampled the first office visit per patient per year (N = 24,543 visits). We created indicators reflecting contraindications for NSAIDs (kidney, liver, cardiovascular/cerebrovascular, and gastrointestinal diseases; concurrent or chronic use of anticoagulants/antiplatelets, chronic corticosteroid use) and opioids (depression, anxiety, substance use (SUD) and bipolar disorders, and concurrent benzodiazepines) and estimated four logistic regression models, with the one model including all patient visits and models 2-4 stratifying for previous opioid use. We estimated the population attributable risk for each contraindication.ResultsIn our model with all patients-visits, patients received an opioid prescription at 4% of visits. The predicted probability (PP) of receiving an opioid was 4% without kidney disease vs. 7% with kidney disease; marginal effect (ME): 3%; 95%CI: 1-4%). For chronic or concurrent anticoagulant/antiplatelet prescriptions, the PPs were 4% vs. 6% (ME: 2%; 95%CI: 1-3%). For concurrent benzodiazepines, the PPs were 4% vs. 11% (ME: 7%, 95%CI: 5-9%) and for SUD, the PPs were 4% vs. 5% (ME: 1%, 95%CI: 0-3%). For the model including patients with previous long-term opioid use, the PPs for concurrent benzodiazepines were 25% vs. 24% (ME: -1%; 95%CI: - 18-16%). The population attributable risk (PAR) for NSAID and opioid contraindications was small. For kidney disease, the PAR was 0.16% (95%CI: 0.08-0.23%), 0.44% (95%CI: 0.30-0.58%) for anticoagulants and antiplatelets, 0.13% for substance use (95%CI: 0.03-0.22%) and 0.20% for concurrent benzodiazepine use (95%CI: 0.13-0.26%).ConclusionsPatients with diagnoses of kidney disease and concurrent use of anticoagulants/antiplatelet medications had a higher probability of receiving an opioid prescription at a primary care visit for low back pain, but these conditions do not explain a large proportion of the opioid prescriptions.

BackgroundIn response to the opioid crisis, states and health systems are encouraging clinicians to use risk mitigation strategies aimed at assessing a patient's risk for opioid misuse or abuse: opioid agreements, prescription drug monitoring programs (PDMPs), and urine drug tests (UDT). Objective: The objective of this qualitative study was to understand how clinicians perceived and used risk mitigation strategies for opioid abuse/misuse and identify barriers to implementation. Methods: We interviewed clinicians who prescribe opioid medications in the outpatient setting from 2016-2018 and analyzed the data using Constructivist Grounded Theory methodology. Results: We interviewed 21 primary care clinicians and 12 specialists. Nearly all clinicians reported using the PDMP. Some clinicians (adopters) found the opioid agreement and UDTs to be valuable, but most (non-adopters) did not. Adopters found the agreements and UDTs helpful in treating patients equitably, setting limits, and having objective evidence of misuse; protocols and workflows facilitated the use of the strategies. Non-adopters perceived the strategies as awkward, disruptive to the clinician-patient relationship, and introducing a power differential; they also cited lack of time and resources as barriers to use. Conclusions: Our study demonstrates that clinicians in certain settings have found effective ways to implement and use the PDMP, opioid agreements, and UDT but that other clinicians are less comfortable with their use. Administrators and policymakers should ensure that the strategies are designed in a way that strengthens the clinician-patient relationship while maximizing safety for patients and that clinicians are adequately trained and supported when introducing the strategies.

ObjectiveThe California Delivery System Reform Incentive Payment Program (DSRIP) provided incentive payments to Designated Public Hospitals (DPHs) to improve quality of care. We assessed the program's impact on reductions in sepsis mortality, central line-associated bloodstream infections (CLABSIs), venous thromboembolisms (VTEs), and hospital-acquired pressure ulcers (HAPUs).Data sourcesWe used 2009-2014 discharge data from California hospitals.Study designWe used a pre-post study design with a comparison group. We constructed propensity scores and used them to assign inverse probability weights according to their similarity to DPH discharges. Interaction term coefficients of time trends and treatment group provided significance testing.Data extractionWe used Patient Safety Indicators for CLABSI, HAPU, and VTE, and constructed a sepsis mortality measure.Principal findingsDischarges from DPHs and non-DPHs both saw decreases in the four outcomes over the DSRIP period (2010-2014). The difference-in-difference estimator (DD) for sepsis was only significant during two time periods, comparing 2010 with 2012 (DD: -2.90 percent, 95% CI: -5.08, -0.72 percent) and 2010 with 2014 (DD: -5.74, 95% CI: -8.76 percent, -2.72 percent); the DD estimator was not significant comparing 2010 with 2012 (DD: -1.30, 95% CI: -3.18 percent, 0.58 percent) or comparing 2010 with 2013 (DD: -3.05 percent, 95% CI: -6.50 percent, 0.40 percent). For CLABSI, we did not find any meaningful differences between DPHs and non-DPHs across the four time periods. For HAPU and VTE, the only significant DD estimator compared 2014 with 2010.ConclusionsWe did not find that DPHs participating in DSRIP outperformed non-DPHs during the DSRIP program. Our results were robust to multiple sensitivity analyses. Given multiple concurrent inpatient safety initiatives, it was challenging to assign improvements over time periods to DSRIP.

OBJECTIVE: Given the changing political and social climate around opioids, we examined how clinicians in the outpatient setting made decisions about managing opioid prescriptions for new patients already on long-term opioid therapy. METHODS: We conducted in-depth interviews with 32 clinicians in Southern California who prescribed opioid medications in the outpatient setting for chronic pain. The study design, interview guides, and coding for this qualitative study were guided by constructivist grounded theory methodology. RESULTS: We identified three approaches to assuming a new patients opioid prescriptions. Staunch Opposers, mostly clinicians with specialized training in pain medicine, were averse to continuing opioid prescriptions for new patients and often screened outpatients seeking opioids. Cautious and Conflicted Prescribers were wary about prescribing opioids but were willing to refill prescriptions if they perceived the patient as trustworthy and the medication fell within their comfort zone. Clinicians in the first two groups felt resentful about other clinicians dumping patients on opioids on them. Rapport Builders, mostly primary care physicians, were the most willing to assume opioid prescriptions and were strategic in their approach to transitioning patients to safer doses. CONCLUSIONS: Clinicians with the most training in pain management were the least willing to assume responsibility for opioid prescriptions for patients already on long-term opioid therapy. In contrast, primary care clinicians were the most willing to assume this responsibility. However, primary care clinicians face barriers to providing high-quality care for patients with complex pain conditions, such as short visit times and less specialized training.

ObjectiveGiven the changing political and social climate around opioids, we examined how clinicians in the outpatient setting made decisions about managing opioid prescriptions for new patients already on long-term opioid therapy.MethodsWe conducted in-depth interviews with 32 clinicians in Southern California who prescribed opioid medications in the outpatient setting for chronic pain. The study design, interview guides, and coding for this qualitative study were guided by constructivist grounded theory methodology.ResultsWe identified three approaches to assuming a new patient's opioid prescriptions. Staunch Opposers, mostly clinicians with specialized training in pain medicine, were averse to continuing opioid prescriptions for new patients and often screened outpatients seeking opioids. Cautious and Conflicted Prescribers were wary about prescribing opioids but were willing to refill prescriptions if they perceived the patient as trustworthy and the medication fell within their comfort zone. Clinicians in the first two groups felt resentful about other clinicians "dumping" patients on opioids on them. Rapport Builders, mostly primary care physicians, were the most willing to assume opioid prescriptions and were strategic in their approach to transitioning patients to safer doses.ConclusionsClinicians with the most training in pain management were the least willing to assume responsibility for opioid prescriptions for patients already on long-term opioid therapy. In contrast, primary care clinicians were the most willing to assume this responsibility. However, primary care clinicians face barriers to providing high-quality care for patients with complex pain conditions, such as short visit times and less specialized training.

BackgroundSepsis is the leading cause of in-hospital death. The SEP-1 sepsis bundle is a protocol for early sepsis care that requires providers to diagnose and treat sepsis quickly. Limited evidence suggests that adherence to the sepsis bundle is lower in cases of hospital-onset sepsis.ObjectiveTo compare sepsis bundle adherence in hospital-onset vs. community-onset sepsis.DesignRetrospective cohort study using multivariable analysis of clinical data.ParticipantsA total of 4658 inpatients age 18 or older were identified by diagnosis codes consistent with sepsis or disseminated infection.SettingFour university hospitals in California between 2014 and 2016.Main outcomes and measuresThe primary outcome was adherence to key components of the sepsis bundle defined by the Centers for Medicare and Medicaid Services in their core measure, SEP-1. Covariates included clinical characteristics related to the patient, infection, and pathogen.Key resultsCompared with community-onset, cases of hospital-onset sepsis were less likely to receive SEP-1 adherent care (relative risk 0.33, 95% confidence interval 0.29-0.38, p

BackgroundGender sensitivity of providers and staff has assumed increasing importance in closing historical gender disparities in health care quality and outcomes. The Department of Veterans Affairs (VA) has implemented several initiatives intended to improve gender sensitivity of its health care workforce. The current study examines practice- and individual-level characteristics associated with gender sensitivity of primary care providers (PCPs) and staff.MethodsWe surveyed PCPs and staff (nurses, medical assistants, and clerks) at 12 VA medical centers (VAMCs) (n = 256 of 649; response rate, 39%). Gender sensitivity was measured using a 10-item scale adapted from the Gender Awareness Inventory-VA. We used weighted multivariate regression with maximum likelihood estimation to identify individual- and practice-level characteristics associated with gender sensitivity of PCPs and staff.ResultsPCPs and staff had similar gender sensitivity but differed in most characteristics associated with that gender sensitivity. Among PCPs, women's health training and positive communication with others in the clinic were associated with greater gender sensitivity. For staff, prior work experience caring for women, working in Women's Health Patient-Aligned Care Teams, and rural location were associated with greater gender sensitivity, whereas more years of VA service was associated with lower gender sensitivity. Working at VA medical centers with a higher volume of women veteran patients was associated with greater gender sensitivity for both PCPs and staff.ConclusionsWomen's health training and experience in working with other women's health professionals are strongly correlated with greater gender sensitivity in the clinical workforce.

BackgroundAlthough homelessness and opioid overdose are major public health issues in the U.S., evidence is limited as to whether homelessness is associated with an increased risk of opioid overdose.ObjectiveTo compare opioid-related outcomes between homeless versus housed individuals in low-income communities.Design, setting, and participantsCross-sectional analysis of individuals who had at least one ED visit or hospitalization in four states (Florida, Maryland, Massachusetts, and New York) in 2014.MeasurementsRisk of opioid overdose and opioid-related ED visits/hospital admissions were compared between homeless versus low-income housed individuals, adjusting for patient characteristics and hospital-specific fixed effects (effectively comparing homeless versus low-income housed individuals treated at the same hospital). We also examined whether risk of opioid-related outcomes varied by patients' sex and race/ethnicity.ResultsA total of 96,099 homeless and 2,869,230 low-income housed individuals were analyzed. Homeless individuals had significantly higher risk of opioid overdose (adjusted risk, 1.8% for homeless vs. 0.3% for low-income housed individuals; adjusted risk difference [aRD], +1.5%; 95%CI, +1.0% to +2.0%; p

ObjectiveTo examine whether hospitals are more likely to temporarily close their emergency departments (EDs) to ambulances (through ambulance diversions) if neighboring diverting hospitals are public vs private.Data sources/study settingAmbulance diversion logs for California hospitals, discharge data, and hospital characteristics data from California's Office of Statewide Health Planning and Development and the American Hospital Association (2007).Study designWe match public and private (nonprofit or for-profit) hospitals by distance and size. We use random-effects models examining diversion probability and timing of private hospitals following diversions by neighboring public vs matched private hospitals.Data collection/extraction methodsN/A.Principal findingsHospitals are 3.6 percent more likely to declare diversions if neighboring diverting hospitals are public vs private (P

BackgroundInfections due to carbapenem-resistant Gram-negative rods (CR-GNR) are increasing in frequency and result in high morbidity and mortality. Appropriate initial antibiotic therapy is necessary to reduce adverse consequences and shorten length of stay.MethodsTo determine risk factors for recovery on culture of CR-GNR, cases were retrospectively analyzed at a major academic hospital system from 2011 to 2016. Ertapenem resistance (ER-GNR) and antipseudomonal (nonertapenem) carbapenem resistance (ACR-GNR) patterns were analyzed separately. A total of 30951 GNR isolates from 12370 patients were analyzed, 563 of which were ER and 1307 of which were ACR.ResultsIn multivariate analysis, risk factors for ER-GNR were renal disease, admission from another health care facility, ventilation at any point before culture during the index hospitalization, receipt of any carbapenem in the prior 30 days, and receipt of any anti-methicillin-resistant Staphylococcus aureus (anti-MRSA) agent in the prior 30 days (c-statistic, 0.74). Risk factors for ACR-GNR were male sex, admission from another health care facility, ventilation at any point before culture during the index hospitalization, receipt of any carbapenem in the prior 30 days, and receipt of any anti-MRSA agent in the prior 30 days (c-statistic, 0.76).ConclusionsA straightforward scoring system derived from these models can be applied by providers to guide empiric antimicrobial therapy; it outperformed use of a standard hospital antibiogram in predicting infections with ER-GNR and ACR-GNR.

BackgroundHigh-cost patients are a frequent focus of improvement projects based on primary care and other settings. Efforts to characterize high-cost, high-need patients are needed to inform care planning, but such efforts often rely on a priori assumptions, masking underlying complexities of a heterogenous population.ObjectiveTo define recognizable subgroups of patients among high-cost adults based on clinical conditions, and describe their survival and future spending.DesignRetrospective observational cohort study.ParticipantsWithin a large integrated delivery system with 2.7 million adult members, we selected the top 1% of continuously enrolled adults with respect to total healthcare expenditures during 2010.Main measuresWe used latent class analysis to identify clusters of alike patients based on 53 hierarchical condition categories. Prognosis as measured by healthcare spending and survival was assessed through 2014 for the resulting classes of patients.ResultsAmong 21,183 high-cost adults, seven clinically distinctive subgroups of patients emerged. Classes included end-stage renal disease (12% of high-cost population), cardiopulmonary conditions (17%), diabetes with multiple comorbidities (8%), acute illness superimposed on chronic conditions (11%), conditions requiring highly specialized care (14%), neurologic and catastrophic conditions (5%), and patients with few comorbidities (the largest class, 33%). Over 4 years of follow-up, 6566 (31%) patients died, and survival in the classes ranged from 43 to 88%. Spending regressed to the mean in all classes except the ESRD and diabetes with multiple comorbidities groups.ConclusionsData-driven characterization of high-cost adults yielded clinically intuitive classes that were associated with survival and reflected markedly different healthcare needs. Relatively few high-cost patients remain persistently high cost over 4 years. Our results suggest that high-cost patients, while not a monolithic group, can be segmented into few subgroups. These subgroups may be the focus of future work to understand appropriateness of care and design interventions accordingly.

ObjectivesTo evaluate national present-on-admission (POA) reporting for hospital-acquired pressure ulcers (HAPUs) and examine the impact of quality measure exclusion criteria on HAPU rates.Data sources/study settingMedicare inpatient, outpatient, and nursing facility data as well as independent provider claims (2010-2011).Study designRetrospective cross-sectional study.Data collection/extraction methodsWe evaluated acute inpatient hospital admissions among Medicare fee-for-service (FFS) beneficiaries in 2011. Admissions were categorized as follows: (1) no pressure ulcer diagnosis, (2) new pressure ulcer diagnosis, and (3) previously documented pressure ulcer diagnosis. HAPU rates were calculated by varying patient exclusion criteria.Principal findingsAmong admissions with a pressure ulcer diagnosis, we observed a large discrepancy in the proportion of admissions with a HAPU based on hospital-reported POA data (5.2 percent) and the proportion with a new pressure ulcer diagnosis based on patient history in billing claims (49.7 percent). Applying quality measure exclusion criteria resulted in removal of 91.2 percent of admissions with a pressure injury diagnosis from HAPU rate calculations.ConclusionsAs payers and health care organizations expand the use of quality measures, it is important to consider how the measures are implemented, coding revisions to improve measure validity, and the impact of patient exclusion criteria on provider performance evaluation.

BackgroundHospital-acquired pressure injuries (HAPIs) are publicly reported in the USA and used to adjust Medicare payment to acute inpatient facilities. Current methods used to identify HAPIs in administrative claims rely on hospital-reported present-on-admission (POA) data instead of prior patient health information.ObjectiveTo study the reliability of claims data for HAPIs and pressure injury (PI) stage by evaluating diagnostic coding agreement across interfacility transfers.MethodsUsing the 2012 100% Medicare Provider and Analysis Review file, we identified all fee-for-service acute inpatient discharge records with a PI diagnosis among Medicare patients 65 years and older. We then identified additional facility claims (eg, acute inpatient, long-stay inpatient or skilled nursing facility) belonging to the same patient who had either (1) admission within 1day of hospital discharge or (2) discharge within 1day of hospital admission. Multivariable logistic regression and stratified kappa statistics were used to measure coding agreement between transferring and receiving facilities in the presence or absence of a PI diagnosis at the time of patient transfer and PI stage category (early vs advanced).ResultsIn our comparison of claims data between transferring and receiving facilities, we observed poor agreement in the presence or absence of a PI diagnosis at the time of transfer (36.3%, kappa=0.03) and poor agreement in PI stage category (74.3%, kappa=0.17). Among transfers with a POA PI reported by the receiving hospital, only 34.0% had a PI documented at the prior transferring facility.ConclusionsThe observed discordance in PI documentation and staging between transferring and receiving facilities may indicate inaccuracy of HAPI identification in claims data. Future research should evaluate the accuracy of hospital-reported POA data and its impact on PI quality measurement.

The Emergency Medical Treatment and Labor Act (EMTALA), which requires Medicare-participating hospitals to provide emergency care to patients regardless of their ability to pay, plays an important role in protecting the uninsured. Yet many hospitals do not comply. This study examines the reasons for noncompliance and proposes solutions. We conducted 11 semistructured key informant interviews with hospitals, hospital associations, and patient safety organizations in the Centers for Medicare and Medicaid Services region with the highest number of EMTALA complaints filed. Respondents identified 5 main causes of noncompliance: financial incentives to avoid unprofitable patients, ignorance of EMTALA's requirements, high referral burden at hospitals receiving EMTALA transfer patients, reluctance to jeopardize relationships with transfer partners by reporting borderline EMTALA violations, and opposing priorities of hospitals and physicians. Respondents suggested 5 methods to improve compliance, including educating subspecialists about EMTALA, informally educating hospitals about borderline violations, and incorporating EMTALA-compliant processes into hospital operations such as by routing transfer requests through the emergency department. To improve compliance we suggest (1) more closely aligning Medicaid/Medicare payment policies with EMTALA, (2) amending the Act to permit informal mediation between hospitals about borderline violations, (3) increasing the hospital's role in ensuring EMTALA compliance, and (4) expanding the role of hospital associations.

Introduction: About one in six children in the US, about 17% of the population, have one or more intellectual or developmental disabilities. Increases in disability due to neurodevelopmental or mental health conditions have increased by 21% in the last decade. Early intervention based on developmental screening and provider-initiated monitoring can significantly improve long-term health and cognitive outcomes. This paper assesses whether differences in receipt of developmental screening or monitoring are associated with access to a highquality primary care medical home and having a provider who shows sensitivity to a family's customs and values among neurotypical children and children with intellectual and developmental disabilities (IDD). Methods: We used cross-sectional data from the National Survey of Children's Health (NSCH) from 2017 to 2019. The NSCH is a nationally representative, parent-completed annual survey of children under 18. Children between 9 months and 5 years with IDD (n = 2,385) and neurotypical children (n = 20,200) were included in the analysis. Results: Uptake of developmental screening/monitoring in neurotypical children and children with IDD conditions was associated with belonging to minority race/ethnic backgrounds, specifically Black, Asian, and AIAN/NHPI, and single-parent households with lower incomes, being publicly insured or uninsured and not having access to a high-quality medical home. Weighted regression models showed that the odds of neurotypical children receiving developmental monitoring/screening were 53% higher when their healthcare provider always or usually demonstrated cultural sensitivity to the family's values and customs (OR 1.53, 95% CI, 1.08-2.18, p < 0.05). For children with IDD, the odds of receipt of monitoring/screening increased by 2.1 times when the provider always/usually demonstrated an understanding of the family's cultural norms (95% CI, 0.99-4.43, p = 0.053). Being female was significantly associated with a lack of screening/surveillance (OR 0.73, 95% CI, 0.58-0.91, p < 0.05). Discussion: With the rising prevalence of children with IDD conditions, early identification of developmental delays and subsequent access to interventions are crucial steps in supporting children and children with IDD to receive preventive care, services, and reduce disparities in accessing quality care. Implementing culturally sensitive approaches can be a low-cost and effective intervention in improving rates of provider-initiated monitoring and parent-completed screening. [ABSTRACT FROM AUTHOR]

BackgroundThe 'spillover effect' of academic-practice partnerships on hospital nursing staff has received limited attention. In 2007, the Department of Veterans Affairs (VA) created the VA Nursing Academy (VANA) to fund fifteen partnerships between schools of nursing and local VA healthcare facilities. In this paper, we examine the experiences of the VA staff nurses who worked on the units used for VANA clinical training.MethodsWe used survey methods to collect information from staff nurses at all active VANA sites on their characteristics, exposure to the program's clinical training activities, satisfaction with program components, and perspectives of the impact on their work and their own plans for education (N = 314). Our analyses utilized descriptive statistics and bivariate and multivariate regression.ResultsResults show that staff nurses working on VANA units had moderately high levels of exposure to the program's clinical education activities, and most reported positive experiences with those activities. The vast majority (80 %) did not perceive the presence of students as making their work more difficult. Among those who were enrolled or considering enrolling in a higher education program, over a quarter (28 %) said that their VA's participation in VANA had an influence on this decision. The majority of staff nurses were generally satisfied with their experience with the students. Their satisfaction with the program was related to the level or dose of their exposure to it. Those who were more involved were more satisfied. Greater interaction with the students, more information on the program, and a preceptor role were all independently associated with greater program satisfaction.ConclusionsOur study suggests that academic-practice partnerships may have positive spillover effects on staff nurses who work on clinical education units. Further, partnerships may be able to foster positive experiences for their unit nurses by focusing on informing and engaging them in clinical training activities. In particular, our results suggest that academic-practice partnerships should keep unit nurses well informed about program content and learning objectives, encourage frequent interaction with students, involve them in partnership-related unit-based activities, and urge them to become preceptors for the students.

BackgroundUnder bundled payment initiatives, providers will be held financially responsible for patients' acute and post-acute care costs. Certain patients, termed high utilizers, use disproportionate shares of resources during 1 year. The aim of this study was to identify high utilizers, describe their costs, and determine whether preoperative characteristics predict high utilizer status.Study designColectomy patients with 1-year follow-up were identified in a linked clinical (American College of Surgeons NSQIP) and administrative (Medicare inpatient claims) dataset (2005 to 2008). Cost of inpatient care was calculated by multiplying patient Medicare charges in each cost center by cost-to-charge ratios from the Medicare cost reports. A mixed-effects logistic model quantified the association between preoperative characteristics and being a high utilizer after elective and emergent colectomies.ResultsOne thousand and fifty-five of 10,561 colectomy patients accounted for >50% of the inpatient care cost of the entire cohort during 1 year postoperatively. This top decile of patients were labeled high utilizers and had substantially greater costs in the following cost centers: intensive care ($36,322 vs $0), respiratory ($2,875 vs $22), radiology ($649 vs $29), and cardiology ($5,057 vs $166) (all p < 0.001). High utilizers more frequently had emergent index colectomies (43% vs 17%; p < 0.001). Patients with American Society of Anesthesiologists class IV and V had 2-fold increased odds of being high utilizers after both elective (odds ratio = 2.72; 95% CI, 1.89-3.90) and emergent colectomies (odds ratio = 2.09; 95% CI, 1.23-3.55).ConclusionsPatients in the top cost decile account for the majority of costs in the year after colectomy, disproportionately accumulate those costs in particular cost centers, and can be identified preoperatively.

Background and objectivesDespite previous studies demonstrating no difference in mortality or morbidity, the various surgical approaches for necrotizing enterocolitis (NEC) in infants have not been evaluated economically. Our goal was to compare total in-hospital cost and mortality by using propensity score-matched infants treated with peritoneal drainage alone, peritoneal drainage followed by laparotomy, or laparotomy alone for surgical NEC.MethodsUtilizing the California OSHPD Linked Birth File Dataset, 1375 infants with surgical NEC between 1999 and 2007 were retrospectively propensity score matched according to intervention type. Total in-hospital costs were converted from longitudinal patient charges. A multivariate mixed effects model compared adjusted costs and mortality between groups.ResultsSuccessful propensity score matching was performed with 699 infants (peritoneal drainage, n = 101; peritoneal drainage followed by laparotomy, n = 172; and laparotomy, n = 426). Average adjusted cost for peritoneal drainage followed by laparotomy was $398,173 (95% confidence interval [CI]: 287,784-550,907), which was more than for peritoneal drainage ($276,076 [95% CI: 196,238-388,394]; P = .004) and similar to laparotomy ($341,911 [95% CI: 251,304-465,186]; P = .08). Adjusted mortality was highest after peritoneal drainage (56% [95% CI: 34-75]) versus peritoneal drainage followed by laparotomy (35% [95% CI: 19-56]; P = .01) and laparotomy (29% [95% CI: 19-56]; P < .001). Mortality for peritoneal drainage was similar to laparotomy.ConclusionsPropensity score-matched analysis of surgical NEC treatment found that peritoneal drainage followed by laparotomy was associated with decreased mortality compared with peritoneal drainage alone but at significantly increased costs.

BackgroundThis study aims to describe the magnitude of hospital costs among patients undergoing elective colectomy, cholecystectomy, and pancreatectomy, determine whether these costs relate as expected to duration of care, patient case-mix severity and comorbidities, and whether risk-adjusted costs vary significantly by hospital. Correctly estimating the cost of production of surgical care may help decision makers design mechanisms to improve the efficiency of surgical care.Study designPatient data from 202 hospitals in the ACS-NSQIP were linked to Medicare inpatient claims. Patient charges were mapped to cost center cost-to-charge ratios in the Medicare cost reports to estimate costs. The association of patient case-mix severity and comorbidities with cost was analyzed using mixed effects multivariate regression. Cost variation among hospitals was quantified by estimating risk-adjusted hospital cost ratios and 95% confidence intervals from the mixed effects multivariate regression.ResultsThere were 21,923 patients from 202 hospitals who underwent an elective colectomy (n = 13,945), cholecystectomy (n = 5,569), or pancreatectomy (n = 2,409). Median cost was lowest for cholecystectomy ($15,651) and highest for pancreatectomy ($37,745). Room and board costs accounted for the largest proportion (49%) of costs and were correlated with length of stay, R = 0.89, p < 0.001. The patient case-mix severity and comorbidity variables most associated with cost were American Society of Anesthesiologists (ASA) class IV (estimate 1.72, 95% CI 1.57 to 1.87) and fully dependent functional status (estimate 1.63, 95% CI 1.53 to 1.74). After risk-adjustment, 66 hospitals had significantly lower costs than the average hospital and 57 hospitals had significantly higher costs.ConclusionsThe hospital costs estimates appear to be consistent with clinical expectations of hospital resource use and differ significantly among 202 hospitals after risk-adjustment for preoperative patient characteristics and procedure type.

ObjectiveThis study describes the pregnancy and birth outcomes at two hospitals in Lima, Peru. The data collection and analysis is intended to inform patients, providers, and policy makers on Peru's progress toward achieving the Millennium Development Goals and to help set priorities for action and further research.MethodsData were collected retrospectively from a sample of 237 women who delivered between December 2012 and September 2013 at the Instituto Nacional Materno Perinatal or the Hospital Nacional Arzobispo Loayza. The outcomes were recorded by a trained mid-wife through telephone interviews with patients and by review of hospital records. Associations between participant demographic characteristics and pregnancy outcomes were tested with Chi-squared, Fisher's exact, or Student's t-test.ResultsOver 37% of women experienced at least one maternal or perinatal complication, and the most frequent were hypertension/preeclampsia and macrosomia. The women in our sample had a cesarean section rate of 50.2%.ConclusionMaternal and perinatal complications are not uncommon among women in the lower socioeconomic strata of Lima. Also, the high cesarean rate underpins the need for a more comprehensive understanding of the indications for cesarean section deliveries, which could help reduce the number of unnecessary procedures and preventable complications.

BackgroundThe nursing profession is exploring how academic-practice partnerships should be structured to maximize the potential benefits for each partner. As part of an evaluation of the U.S. Department of Veterans Affairs Nursing Academy (VANA) program, we sought to identify indicators of successful partnerships during the crucial first year.MethodsWe conducted a qualitative analysis of 142 individual interviews and 23 focus groups with stakeholders from 15 partnerships across the nation. Interview respondents typically included the nursing school Dean, the VA chief nurse, both VANA Program Directors (VA-based and nursing school-based), and select VANA faculty members. The focus groups included a total of 222 VANA students and the nursing unit managers and staff from units where VANA students were placed. An ethnographic approach was utilized to identify emergent themes from these data that underscored indicators of and influences on Launch Year achievement.ResultsWe emphasize five key themes: the criticality of inter-organizational collaboration; challenges arising from blending different cultures; challenges associated with recruiting nurses to take on faculty roles; the importance of structuring the partnership to promote evidence-based practice and simulation-based learning in the clinical setting; and recognizing that stable relationships must be based on long-term commitments rather than short-term changes in the demand for nursing care.ConclusionsDeveloping an academic-clinical partnership requires identifying how organizations with different leadership and management structures, different responsibilities, goals and priorities, different cultures, and different financial models and accountability systems can bridge these differences to develop joint programs integrating activities across the organizations. The experience of the VANA sites in implementing academic-clinical partnerships provides a broad set of experiences from which to learn about how such partnerships can be effectively implemented, the barriers and challenges that will be encountered, and strategies and factors to overcome challenges and build an effective, sustainable partnership. This framework provides actionable guidelines for structuring and implementing effective academic-practice partnerships that support undergraduate nursing education.

Safety-net hospitals rely on disproportionate-share hospital (DSH) payments to help cover uncompensated care costs and underpayments by Medicaid (known as Medicaid shortfalls). The Affordable Care Act (ACA) anticipates that insurance expansion will increase safety-net hospitals' revenues and will reduce DSH payments accordingly. We examined the impact of the ACA's Medicaid DSH reductions on California public hospitals' financial stability by estimating how total DSH costs (uncompensated care costs and Medicaid shortfalls) will change as a result of insurance expansion and the offsetting DSH reductions. Decreases in uncompensated care costs resulting from the ACA insurance expansion may not match the act's DSH reductions because of the high number of people who will remain uninsured, low Medicaid reimbursement rates, and medical cost inflation. Taking these three factors into account, we estimate that California public hospitals' total DSH costs will increase from $2.044 billion in 2010 to $2.363-$2.503 billion in 2019, with unmet DSH costs of $1.381-$1.537 billion.

The Affordable Care Act (ACA) will significantly expand access to affordable health coverage in California starting in 2014. Californians with the lowest incomes will have access to coverage under the expansion of Medi-Cal, while millions of low- and middle-income families will be eligible for subsidies through the California Health Benefit Exchange (the Exchange). Demand for health insurance in the state will also increase as a result of the minimum coverage requirement.The level of enrollment in the new and expanded programs and the resulting share of Californians who gain coverage under the ACA will depend on a range of factors, including the ease of enrollment and retention, outreach strategies, and language accessibility. We used the California Simulation of Insurance Markets (CalSIM) model, version 1.7, to predict changes in health coverage in California under the ACA using two  scenarios: one based on typical responses by individuals and employers to expanded coverage offerings (the “base” scenario) and another based on a more robust enrollment and retention strategy planned by state coverage programs (the “enhanced” scenario). Based on the results of our CalSIM model, we estimate that in 2019, after the ACA is fully implemented:Between 89 and 92 percent of Californians under the age of 65 will have health coverage, compared to 84 percent without the law.Between 1.8 and 2.1 million Californians will enroll in subsidized coverage in the California Health Benefit Exchange.Between 1.2 and 1.6 million individuals will be newly enrolled in Medi-Cal.Between 3 and just under 4 million Californians will remain uninsured,1 million of whom will not be eligible for coverage due to immigration status.Under our enhanced scenario, we assume that greater enrollment in Medi-Cal and the California Health Benefit Exchange could be achieved through many factors,including:Simplified enrollment and redetermination processes and systems; Robust outreach and education; Culturally competent and linguistically appropriate outreach and enrollment assistance; Pre-enrollment from existing health and human service programs; and Use of institutional connections to reach individuals in life transitions to maximize seamless coverage.

Between 1.2 and 1.6 million more Californians are predicted to be enrolled in Medi-Cal in 2019 than otherwise would have been under current law

The California Simulation of Insurance Markets (CalSIM) model is designed to estimate the impact of various elements of the ACA on employer decisions to offer insurance coverage and individual decisions to obtain coverage in California.

The Affordable Care Act (ACA) will significantly expand access to affordable health coverage in California, increasing the share of insured non-elderly Californians to nearly 90 percent. An estimated 3 to 4 million Californians are predicted to remain uninsured in 2019, depending on the extent of outreach and enrollment activities and ease of enrollment and retention.

As we draw closer to 2014 and the full implementation of the Patient Protection and Affordable Care Act (ACA), we continue to increase our understanding of its full potential and its implications. In California, about 6.7 million nonelderly adults will be eligible for coverage under the law, through either Medi-Cal or tax credits to purchase insurance through California’s new Health Benefit Exchange.This policy brief, developed with support from the California Pan-Ethnic Health Network (CPEHN), highlights findings from the UC Berkeley Center for Labor Research and Education and the UCLA Center for Health Policy Research’s California Simulation of Insurance Markets (CalSIM) model. The CalSIM model estimates the effects of specific provisions of the ACA on family and employer decisions about insurance coverage in California. People of color and those who speak English less than very well (Limited English Proficient, or LEP) could benefit greatly from implementation of the ACA. However, although the LEP population represents a considerable portion of those eligible, without effective multilingual outreach and enrollment efforts, language barriers may result in a difference of 110,000 fewer LEP individuals enrolled in the Exchange. To fully realize the potential of the ACA and California’s Health Benefit Exchange, resources need to be allocated for culturally and linguistically appropriate outreach and education to facilitate enrollment in coverage among all those who are eligible.