The Association of High-Quality Hospital Use on Health Care Outcomes for Pediatric Congenital Heart Defects in a Universal Health Care System.

INTRODUCTION: Congenital heart disease (CHD) has an incidence of 0.8% to 1.2% worldwide, making it the most common birth defect. Researchers have compared high-volume to low-volume hospitals and found significant hospital-level variation in major complications, health resource utilization, and mortality after CHD surgery. In addition, researchers found critical CHD patients at low-volume/non-teaching facilities to be associated with higher odds of inpatient mortality when compared to CHD patients at high-volume/teaching hospitals (odds ratio 1.76). We examined the effects of high-quality hospital (HQH) use on health care outcomes and health care costs in pediatric CHD care using an instrumental variable (IV) approach. MATERIALS AND METHODS: Using nationwide representative claim data from the United States Military Health System from 2016 to 2020, TRICARE beneficiaries with a diagnosis of CHD were tabulated based on relevant ICD-10 (International Classification of Diseases, 10th revision) codes. We examined the relationships between annual readmissions, annual emergency room (ER) use, and mortality and HQH use. We applied both the naive linear probability model (LPM), controlling for the observed patient and hospital characteristics, and the two-stage least squares (2SLS) model, accounting for the unobserved confounding factors. The differential distance between the patient and the closest HQH at the index date and the patient and nearest non-HQH was used as the IV. This protocol was approved by the Institutional Review Board at the University of Maryland, College Park (Approval Number: 1576246-2). RESULTS: The naive LPM indicated that HQH use was associated with a higher probability of annual readmissions (marginal effect, 18%; 95% CI, 0.12 to 0.23). The naive LPM indicated that HQH use was associated with a higher probability of mortality (marginal effect, 2.2%; 95% CI, 0.01 to 0.03). Using the differential distance of closest HQH and non-HQH, we identified a significant association between HQH use and annual ER use (marginal effect, -14%; 95% CI, -0.24 to -0.03). CONCLUSIONS: After controlling for patient-level and facility-level covariates and adjusting for endogeneity, (1) HQH use did not increase the probability of more than one admission post 1-year CHD diagnosis, (2) HQH use lowered the probability of annual ER use post 1-year CHD diagnosis, and (3) HQH use did not increase the probability of mortality post 1-year CHD diagnosis. Patients who may have benefited from utilizing HQH for CHD care did not, alluding to potential barriers to access, such as health insurance restrictions or lack of patient awareness. Although we used hospital quality rating for congenital cardiac surgery as reported by the Society of Thoracic Surgeons, the contributing data span a 4-year period and may not reflect real-time changes in center performance. Since this study focused on inpatient care within the first-year post-initial CHD diagnosis, it may not reflect the full range of health system utilization. It is necessary for clinicians and patient advocacy groups to collaborate with policymakers to promote the development of an overarching HQH designation authority for CHD care. Such establishment will facilitate access to HQH for military beneficiary populations suffering from CHD.

Does universal insurance influence disparities in high-quality hospital use for inpatient pediatric congenital heart defect care within the first year of diagnosis?

BACKGROUND: Healthcare disparities are an issue in the management of Congenital Heart Defects (CHD) in children. Although universal insurance may mitigate racial or socioeconomic status (SES) disparities in CHD care, prior studies have not examined these effects in the use of High-Quality Hospitals (HQH) for inpatient pediatric CHD care in the Military Healthcare System (MHS). To assess for racial and SES disparities in inpatient pediatric CHD care that may persist despite universal insurance coverage, we performed a cross-sectional study of the HQH use for children treated for CHD in the TRICARE system, a universal healthcare system for the U.S. Department of Defense. In the present work we evaluated for the presence of disparities, like those seen in the civilian U.S. healthcare system, among military ranks (SES surrogate) and races and ethnicities in HQH use for pediatric inpatient admissions for CHD care within a universal healthcare system (MHS). METHODS: We conducted a cross-sectional study using claims data from the U.S. MHS Data Repository from 2016 to 2020. We identified 11,748 beneficiaries aged 0 to 17 years who had an inpatient admission for CHD care from 2016 to 2020. The outcome variable was a dichotomous indicator for HQH utilization. In the sample, 42 hospitals were designated as HQH. Of the population, 82.9% did not use an HQH at any point for CHD care and 17.1% used an HQH at some point for CHD care. The primary predictor variables were race and sponsor rank. Military rank has been used as an indicator of SES status. Patient demographic information at the time of index admission post initial CHD diagnosis (age, gender, sponsor marital status, insurance type, sponsor service branch, proximity to HQH based on patient zip code centroid, and provider region) and clinical information (complexity of CHD, common comorbid conditions, genetic syndromes, and prematurity) were used as covariates in multivariable logistic regression analysis. RESULTS: After controlling for demographic and clinical factors including age, gender, sponsor marital status, insurance type, sponsor service branch, proximity to HQH based on patient zip code centroid, provider region, complexity of CHD, common comorbid conditions, genetic syndromes, and prematurity, we did not find disparities in HQH use for inpatient pediatric CHD care based upon military rank. After controlling for demographic and clinical factors, lower SES (Other rank) was less likely to use an HQH for inpatient pediatric CHD care; OR of 0.47 (95% CI of 0.31 to 0.73). CONCLUSIONS: We found that for inpatient pediatric CHD care in the universally insured TRICARE system, historically reported racial disparities in care were mitigated, suggesting that this population benefitted from expanded access to care. Despite universal coverage, SES disparities persisted in the civilian care setting, suggesting that universal insurance alone cannot sufficiently address differences in SES disparities in CHD care. Future studies are needed to address the pervasiveness of SES disparities and potential interventions to mitigate these disparities such as a more comprehensive patient travel program.

Geographic Variations and the Associated Factors in Adherence to and Persistence with Adjuvant Hormonal Therapy for the Privately Insured women Aged 18-64 with Breast Cancer in Texas.

The purpose of this study is to examine the geographical patterns of adjuvant hormonal therapy adherence and persistence and the associated factors in insured Texan women aged 18-64 with early breast cancer. A retrospective cohort study was conducted using 5-year claims data for the population insured by the Blue Cross Blue Shield of Texas (BCBSTX). Women diagnosed with early breast cancer who were taking tamoxifen or aromatase inhibitors (AIs) for adjuvant hormonal therapy with at least one prescription claim were identified. Adherence to adjuvant hormonal therapy and persistence with adjuvant hormonal therapy were calculated as outcome measures. Women without a gap between two consecutively dispensed prescriptions of at least 90 days were considered to be persistently taking the medications. Patient-level multivariate logistic regression models with repeated regional-level adjustments and a Cox proportional hazards model with mixed effects were used to determine the geographical variations and patient-, provider-, and area-level factors that were associated with adjuvant hormonal therapy adherence and persistence. Of the 938 women in the cohort, 627 (66.8%) initiated adjuvant hormonal therapy. Most of the smaller HRRs have significantly higher or lower rates of treatment adherence and persistence rates relative to the median regions. The use of AHT varies substantially from one geographical area to another, especially for adherence, with an approximately two-fold difference between the lowest and highest areas, and area-level factors were found to be significantly associated with the compliance of AHT. There are geographical variations in AHT adherence and persistence in Texas. Patient-level and area-level factors have significant associations explaining these patterns.

Estimating a Model for Mental Healthcare Utilization Using Subjective Unmet Need and Psychological Distress Measures.

The objective of this study is to assess the predictive value of self-reported need and psychological distress in mental healthcare service use across racial and ethnic groups in California. Using 2014-2018 data for adults aged 18-64 in the California Health Interview Survey, both logistic and Poisson regression models are used to estimate mental healthcare utilization. Patient-reported outcome measures, such as psychological distress, are commonly used to evaluate healthcare utilization patterns. The Kessler-6 screener for psychological distress is frequently used as a tool for determining whether someone's level of distress necessitates evaluation by a mental healthcare professional. Serious psychological distress has been widely studied as a predictor of higher healthcare expenditures and use; however, moderate distress and self-reported need has been less examined in the literature. Seventy-two percent of individuals with moderate psychological distress felt like they needed to see a professional for their mental or emotional needs compared to 4% of individuals with serious psychological distress. Individuals with moderate psychological distress had 34% of all healthcare visits for mental or emotional needs during the study period, compared to 17% for those with serious psychological distress. Subjective unmet need for mental healthcare was reported by 77% of those who utilized mental healthcare during the study period. Studying subjective unmet need, in addition to moderate and serious distress, provides additional understanding of the need for mental healthcare and mental healthcare utilization.

Relationships between enabling services use and access to care among adults with cardiometabolic risk factors: findings from the 2014 National Health Center Patient Survey.

BACKGROUND: Community health centers (CHCs) provide comprehensive primary and preventive care to medically underserved, low-income, and racially/ethnically diverse populations. CHCs also offer enabling services, non-clinical assistance to reduce barriers to healthcare due to unmet social and material needs, to improve access to healthcare and reduce health disparities. For patients with modifiable cardiometabolic risk factors, including obesity, hypertension, and diabetes, enabling services may provide additional support to improve disease management. However, little is known about the relationship between enabling services and healthcare accessibility and utilization among patients with cardiometabolic risk factors. METHODS: This study uses data from the 2014 Health Center Patient Survey to examine the relationship between enabling services use and delayed/foregone care, routine check-ups, and emergency room visits, among adult community health center patients in the United States with cardiometabolic risk factors (N = 2358). Outcomes of enabling services users were compared to nonusers using doubly robust propensity score matching methods and generalized linear regression models. RESULTS: Overall, enabling service users were 15.4 percentage points less likely to report delayed/foregone care and 29.4 percentage points more likely to report routine check-ups than nonusers. Enabling service users who lived in urban areas, younger and middle-aged adults, and those with two cardiometabolic risk factors were also less likely to report delayed/foregone care and/or more likely to report routine check-ups in comparison with nonusers. However, among adults with three or more cardiometabolic risk factors, enabling services use was associated with a 41.3 percentage point increase in emergency room visits and a 7.6 percentage point decrease in routine check-ups. CONCLUSIONS: The findings highlight the value in utilizing enabling services to improve timeliness and receipt of care among CHC patients with heightened cardiometabolic risk. There is a need for targeting high-risk populations with additional enabling services to support management of multiple chronic conditions.

Disparities in Audio-only Telemedicine Use Among Medicare Beneficiaries During the Coronavirus Disease 2019 Pandemic.

BACKGROUND: Under emergency coronavirus disease 2019 pandemic regulations, Medicare granted temporary payment parity with in-person visits for audio-only (telephone) telemedicine visits. This policy was designed to expand telemedicine to patients without camera-equipped devices and broadband internet. However, audio-only telemedicine use has been substantial. OBJECTIVE: The aim of this study was to explore whether the rate of audio-only telemedicine during the pandemic is related to patient access to technology or provider behavior. DESIGN: Cross-sectional analysis of the Summer and Fall 2020 Medicare Current Beneficiary Survey coronavirus disease 2019 supplements, using multivariable logistic models and accounting for complex survey design. SUBJECTS: A total of 3375 participants in the summer survey and 2633 participants in the fall 2020 were offered a telemedicine visit to replace a scheduled in-person visit by their usual care provider. MEASURES: We compared beneficiaries who were exclusively offered audio-only telemedicine to beneficiaries who were offered video telemedicine or both audio and video. RESULTS: We found that among Medicare beneficiaries who were offered telemedicine to replace a scheduled in-person appointment, ~35% were exclusively offered audio-only. 65.8% of beneficiaries exclusively offered audio-only reported having a smartphone/tablet and home internet. After controlling for personal access to technology, Hispanic [adjusted odds ratio (AOR)=2.09, P<0.001], dually eligible (AOR=1.63, P=0.002), nonprimary English speaking (AOR=1.64, P<0.001), and nonmetro beneficiaries (AOR=1.71, P=0.003) were more likely to be offered audio-only during July-November 2020. CONCLUSIONS: These findings suggest audio-only telemedicine use during the pandemic is only partially related to patient access to technology. Policymakers must work to both expand programs that provide smartphones and broadband internet to disparity communities and telemedicine infrastructure to providers.

Maryland's Global Budget Revenue Program: Impact on Neonatal Intensive Care Unit Admissions and Infant Mortality.

BACKGROUND: In 2014, Maryland implemented the Global Budget Revenue (GBR) program to reduce unnecessary hospital utilization and contain spending. Little is known about its impact on pediatric health outcomes and high-cost services that are primarily financed by payers other than Medicare. OBJECTIVE: The aim was to examine the impact of the GBR program on neonatal intensive care unit (NICU) admission and infant mortality. RESEARCH DESIGN: We conducted a difference-in-differences analysis comparing changes of NICU admissions and infant mortality in Maryland with changes in 20 comparison states (including DC), before and after implementation of the GBR program. Effects were estimated for all infants and for risk groups defined by birthweight and gestation. SUBJECTS: A total of 11,965,997 newborns in Maryland and the comparison states was identified using US birth certificate data from 2011 to 2017. MEASURES: NICU admissions, the infant mortality rate, and the neonatal mortality rate. RESULTS: The GBR program was associated with a 1.26 percentage points (-16.8%, P=0.03) decline in NICU admissions over three full years of implementation. Reductions were driven by fewer admissions among moderately low to normal birthweight (1500-3999 g) and moderately preterm to term (32-41 wk) infants. The effects for very-low birthweight and very preterm infants were small and not statistically precise. There was no significant change in infant or neonatal mortality rates. CONCLUSIONS: Maryland's hospitals reacted to the GBR program by reducing NICU services for infants that did not have clear observed clinical need. Our results suggest that GBR constrained high-cost services, without adversely affecting infant mortality.

Disparities in Health Care Access and Utilization at the Intersections of Urbanicity and Sexual Identity in California.

Purpose: The aim was to examine differences in health care access at the intersections of urbanicity and sexual identity in California. Methods: We used the 2014-2017 Adult California Health Interview Survey paired with the sexual orientation special use research file to create dummy groups representing each dimension of urbanicity and sexual identity to compare access to health care outcomes. We calculated unadjusted proportions and estimated adjusted odds ratios of each dimension relative to urban heterosexual people using logistic regressions. Results: Relative to urban heterosexual people, urban gay/lesbian people had 1.651 odds of using the emergency room (ER). Urban bisexual people had 1.429 odds of being uninsured, 1.575 odds of delaying prescriptions, and 1.907 odds of using the ER. Rural bisexual people experienced similar access barriers having 1.904 odds of uninsurance and 2.571 odds of using the ER. Conclusions: Our study findings demonstrated disparate access to health care across sexual orientation and rurality. The findings are consistent with literature that suggests urban and rural sexual minority people experience health care differently and demonstrate that bisexual people experience health care differently than gay/lesbian people. These findings warrant further study to examine how social identities, such as race/ethnicity, interact with sexual orientation to determine health care access. Furthermore, these findings demonstrate the need to emphasize the health care access needs of sexual minority people in both rural and urban areas to eliminate health care access disparities.

Evidence of the Linkage Between Hospital-based Care Coordination Strategies and Hospital Overall (Star) Ratings.

BACKGROUND: In the new era of value-based payment models and pay for performance, hospitals are in search of the silver bullet strategy or bundle of strategies capable of improving their performance on quality measures. OBJECTIVES: To determine whether there is an association between adoption of hospital-based care coordination strategies and Centers for Medicare and Medicaid Services overall hospital quality (star) ratings and readmission rates. RESEARCH DESIGN: We used survey data from the American Hospital Association (AHA) and categorized respondents by the number of care coordination strategies that they reported having widely implemented. We used multiple logistic regression models to examine the association between the number of strategies and hospital overall rating performance and disease-specific 30-day excess readmission ratios, while controlling for hospital and county characteristics and state-fixed effects. SUBJECTS: A total of 710 general acute care noncritical access hospitals that received star ratings and responded to the 2015 AHA Care Systems and Payment Survey. MEASURES: Centers for Medicare and Medicaid Services overall hospital ratings, 30-day excess readmission ratios. RESULTS: As compared with hospitals with 0-2 strategies, hospitals with 3 to 4 strategies (P=0.007), 5-7 strategies (P=0.002), or 8-12 strategies (P=0.002) had approximately 2.5× the odds of receiving a top rating (4 or 5 stars). Care coordination strategies were positively associated with lower 30-day readmission ratios for patients with chronic medical conditions, but not for surgical patients. Medication reconciliation, visit summaries, outreach after discharge, discharge care plans, and disease management programs were each individually associated with top ratings. CONCLUSIONS: Care coordination strategies are associated with high overall hospital ratings.

Neonatal Intensive Care Variation in Medicaid-Insured Newborns: A Population-Based Study.

OBJECTIVE: To assess the contribution of maternal and newborn characteristics to variation in neonatal intensive care use across regions and hospitals. STUDY DESIGN: This was a retrospective population-based live birth cohort of newborn infants insured by Texas Medicaid in 2010-2014 with 2 subcohorts: very low birth weight (VLBW) singletons and late preterm singletons. Crude and risk-adjusted neonatal intensive care unit (NICU) admission rates, intensive and intermediate special care days, and imaging procedures were calculated across Neonatal Intensive Care Regions (n = 21) and hospitals (n = 100). Total Medicaid payments were calculated. RESULTS: Overall, 11.5% of live born, 91.7% of VLBW, and 37.6% of infants born late preterm were admitted to a NICU, receiving an average of 2 days, 58 days, and 5 days of special care with payments per newborn inpatient episode of $5231, $128 075, and $10 837, respectively. There was little variation across regions and hospitals in VLBW NICU admissions but marked variation for NICU admissions in late preterm newborn infants and for special care days and imaging rates in all cohorts. The variation decreased slightly after health risk adjustment. There was moderate substitution of intermediate for intensive care days across hospitals (Pearson r VLBW -0.63 P < .001; late preterm newborn -0.53 P < .001). CONCLUSIONS: Across all risk groups, the variation in NICU use was poorly explained by differences in newborn illness levels and is likely to indicate varying practice styles. Although the "right" rates are uncertain, it is unlikely that all of these use patterns represent effective and efficient care.

Role of Prices, Utilization, and Health in Explaining Texas Medicaid Newborn Care Spending Variation.

BACKGROUND: Newborn care is one of the most frequent types of hospitalization and Medicaid covers over 50% of all births nationwide. However, little is known about regional variation in Medicaid newborn care spending and its drivers. OBJECTIVES: To measure the contribution of market-level prices, utilization, and health risk on regional variation in spending among newborn Medicaid population in Texas. RESEARCH DESIGN AND METHODS: The study used 2014 Texas Medicaid newborn claims and encounters linked to birth and death certificate data. Newborn care spending was defined as Medicaid payments per newborn hospital stay, including hospital transfers, from birth through discharge home or death. Spending was further categorized into inpatient facility and related professional spending. Variation in spending across neonatal intensive care regions was decomposed into price and utilization, accounting for input price and health risk differences. RESULTS: Newborn care spending across Texas regions varied significantly (coefficient of variation, 0.31), with most of the variation attributed to spending on inpatient facility services (91%). Both price (41%) and utilization (27%) played a role in explaining this variation, after adjusting for health status (29%) and input price (4%). Though most regions with the highest spending indexes had high price and utilization indexes, some had high spending driven mostly by high prices and others by high utilization. CONCLUSIONS: Significant regional variations in price, utilization, and health status exist in Medicaid newborn care across Texas in 2014. Disentangling the effect of each driver is important to address spending variation and improve efficiency in newborn care.

Association between financial burden and adjuvant hormonal therapy adherence and persistent use for privately insured women aged 18-64 years in BCBS of Texas.

PURPOSE: The objective of this study is to understand an impact of financial burden on the adjuvant hormonal therapy (AHT) adherence and persistence for insured women aged 18-64 with early breast cancer in Texas. METHODS: We conducted a retrospective cohort study using claims data for population insured by Blue Cross Blue Shield of Texas from the year 2008 to 2013. Outcomes include adherence to adjuvant hormonal therapy, which was measured by medication possession ratio and persistence on AHT, which is the duration of time from initiation to discontinuation of therapy. Multivariate logistic regression models with repeated regional-level adjustments were used to explore the odds of AHT adherence. Cox proportional hazards model was conducted to assess time to the first 90+-day gap for persistence and a Kaplan-Meier curve were used to estimate probabilities to calculate the percentages of women who experienced 90+-day gaps in AHT. RESULTS: Of the 938 women in the cohort, 627 (66.8%) initiated the treatment. By year 1, 66.9% of women were adherent to the therapy, and by year 5, only 29% of those were adherent. The percentage of women with no gap in therapy greater than 90 days was 80.8%. Both higher out-of-pocket costs spent on all prescription drugs except AHT and AHT-specific out-of-pocket costs were negatively associated with adherence to AHT as well as continuing AHT as recommended. CONCLUSIONS: Financial burdens including both non-AHT medication and AHT-specific out-of-pocket costs were significantly associated with adherence and persistence to the therapy.

Total Lifetime and Cancer-related Costs for Elderly Patients Diagnosed With Anal Cancer in the United States.

OBJECTIVE: To determine the lifetime and phase-specific cost of anal cancer management and the economic burden of anal cancer care in elderly (66 y and older) patients in the United States. PATIENTS AND METHODS: For this study, we used Surveillance Epidemiology and End Results-Medicare linked database (1992 to 2009). We matched newly diagnosed anal cancer patients (by age and sex) to noncancer controls. We estimated survival time from the date of diagnosis until death. Lifetime and average annual cost by stage and age at diagnosis were estimated by combining survival data with Medicare claims. The average lifetime cost, proportion of patients who were elderly, and the number of incident cases were used to estimate the economic burden. RESULTS: The average lifetime cost for patients with anal cancer was US$50,150 (N=2227) (2014 US dollars). The average annual cost in men and women was US$8025 and US$5124, respectively. The overall survival after the diagnosis of cancer was 8.42 years. As the age and stage at diagnosis increased, so did the cost of cancer-related care. The anal cancer-related lifetime economic burden in Medicare patients in the United States was US$112 million. CONCLUSIONS: Although the prevalence of anal cancer among the elderly in the United States is small, its economic burden is considerable.

Clinical and Economic Evaluation of Treatment Strategies for T1N0 Anal Canal Cancer.

OBJECTIVE: A comparative assessment of treatment alternatives for T1N0 anal canal cancer has never been conducted. We compared the outcomes associated with the treatment alternatives-chemoradiotherapy (CRT), radiotherapy (RT), and surgery or ablation techniques (surgery/ablation)-for T1N0 anal canal cancer. MATERIALS AND METHODS: This retrospective cohort study was conducted using the Surveillance, Epidemiology and End Results (SEER) registries linked with Medicare longitudinal data (SEER-Medicare database). Analysis included 190 patients who were treated for T1N0 anal canal cancer using surgery/ablation (n=44), RT (n=50), or CRT (n=96). The outcomes were reported in terms of survival and hazards ratios using Kaplan-Meier and Cox proportional hazards modeling, respectively; lifetime costs; and cost-effectiveness measured in terms of incremental cost-effectiveness ratio, that is, the ratio of the difference in costs between the 2 alternatives to the difference in effectiveness between the same 2 alternatives. RESULTS: There was no significant difference in the survival duration between the treatment groups as predicted by the Kaplan-Meier curves. After adjusting for patient characteristics and propensity score, the hazard ratio of death for the patients who received CRT compared with surgery/ablation was 1.742 (95% confidence interval, 0.793-3.829) and RT was 2.170 (95% confidence interval, 0.923-5.101); however, the relationship did not reach statistical significance. Surgery/ablation resulted in lower lifetime cost than RT or CRT. The incremental cost-effectiveness ratio associated with CRT compared with surgery/ablation was $142,883 per life year gained. CONCLUSIONS: There was no statistically significant difference in survival among the treatment alternatives for T1N0 anal canal cancer. Given that surgery/ablation costs less than RT or CRT and might be cost-effective compared with RT and CRT, it is crucial to explore this finding further in this era of limited health care resources.

Examining Drivers of Health Care Spending: Evidence on Self-referral Among a Privately Insured Population.

BACKGROUND: Despite the enactment of laws to restrict the practice of self-referral, exceptions in these prohibitions have enabled these arrangements to persist and proliferate. Most research documenting the effects of self-referral arrangements analyzed claims records from Medicare beneficiaries. Empirical evidence documenting the effects of self-referral on use of services and spending incurred by persons with private insurance is sparse. OBJECTIVES: We analyzed health insurance claims records from a large private insurer in Texas to evaluate the effects of physician self-referral arrangements involving physical therapy on the treatment of patients with frozen shoulder syndrome, elbow tendinopathy or tendinitis, and patellofemoral pain syndrome. STUDY DESIGN: We used regression analysis to evaluate the effects of episode self-referral status on: (1) initiation of physical therapy; (2) physical therapy visits and services for those who had at least 1 visit; and (3) total condition-related insurer allowed amounts per episode. RESULTS: For all 3 conditions, we found that patients treated by physician owners were much more likely to be referred for a course of physical therapy when compared with patients seen by physician nonowners. A consistent pattern emerged among patients who had at least 1 physical therapy visit; non-self-referred episodes included more physical therapy visits, and more physical therapy services per episode in comparison with episodes classified as self-referral. Most self-referred episodes were short and the initial visit did not include an evaluation. CONCLUSION: Physician owners of physical therapy services refer significantly higher percentages of patients to physical therapy and many are equivocal cases.

Future expenditure risk of silent members: a statistical analysis.

BACKGROUND: Silent-members are members of a medical health plan who submit no claims for healthcare services in a benefit year despite 12 months of continuous-enrollment. This study was conducted to evaluate the future expenditure risk of commercial-insured members who avoid all medical care despite coverage. In order to determine if the silent-members were at greater risk, we compared them to members who received care in the anchor year (2009) but had low-expenditures. The low-expenditure members were assumed to represent persons without significant medical conditions and without care-avoidance behaviors. We examined the claims experience of a cohort of silent members in the 2 years after the silent year (2009) and compared it with the corresponding claims experience for a cohort of low-expenditure members from the same anchor year (2009). METHODS: Members of commercial health plans (BCBS of Texas) were selected based on continuous-enrollment in 2009. Two sub-groups were identified based on annual claims expenditure: Care avoiders were members with 12 months continuous-enrollment and no medical claims, and are thus referred to as "silent members" in the insurance industry. Low-Expenditure members were those with 12 months continuous-enrollment and total PMPY (per member per year) annual medical claims expenditure in the lowest 10th percentile of members with claims experience. "Low-expenditure" members served as a comparison group to the "silent members", under the assumption that such claimants were using benefits for minor healthcare issues as needed. Key variables were enrollment and expenditures. Enrollment data identified demographics and continuous-enrollment. Medical claims data were used to calculate utilization and expenditures. All claims data were de-identified and no consent was required, as approved by the Institutional Review Board. No research involved human subjects. Multivariate logistic regression models were applied. RESULTS: Silent members who seek care in subsequent years have a greater probability of becoming high-expenditure claimants than those with low-expenditure experience. CONCLUSIONS: For silent members who subsequently seek treatment, the probability of becoming high-expenditure is significantly greater than low-expenditure members from the anchor year. The implications of future high costs for silent members who become claimants may support the need for additional research to address the risks of care avoidance behaviors.

Migrant integration policies and health inequalities in Europe.

BACKGROUND: Research on socio-economic determinants of migrant health inequalities has produced a large body of evidence. There is lack of evidence on the influence of structural factors on lives of fragile groups, frequently exposed to health inequalities. The role of poor socio-economic status and country level structural factors, such as migrant integration policies, in explaining migrant health inequalities is unclear. The objective of this paper is to examine the role of migrant socio-economic status and the impact of migrant integration policies on health inequalities during the recent economic crisis in Europe. METHODS: Using the 2012 wave of Eurostat EU-SILC data for a set of 23 European countries, we estimate multilevel mixed-effects ordered logit models for self-assessed poor health (SAH) and self-reported limiting long-standing illnesses (LLS), and multilevel mixed-effects logit models for self-reported chronic illness (SC). We estimate two-level models with individuals nested within countries, allowing for both individual socio-economic determinants of health and country-level characteristics (healthy life years expectancy, proportion of health care expenditure over the GDP, and problems in migrant integration policies, derived from the Migrant Integration Policy Index (MIPEX). RESULTS: Being a non-European citizen or born outside Europe does not increase the odds of reporting poor health conditions, in accordance with the "healthy migrant effect". However, the country context in terms of problems in migrant integration policies influences negatively all of the three measures of health (self-reported health status, limiting long-standing illnesses, and self-reported chronic illness) in foreign people living in European countries, and partially offsets the "healthy migrant effect". CONCLUSIONS: Policies for migrant integration can reduce migrant health disparities.

Primary Care Availability, Safety Net Clinics, and Health Insurance Coverage: The Association of These Access Factors With Preventable Hospitalizations.

The objective of the study was to examine the relationship between physician/safety net availability and health insurance coverage and preventable hospitalizations (PHs) in nonelderly adults in an urban area. Preventable conditions (PHs) were identified for nonelderly adults in Harris County using the Texas Health Care Information Collection hospital database. Multivariable logistic regression models examined the association of health insurance and patient proximity to physicians and safety net clinics with the risk of a PH. Safety net availability reduced PH risk by 23% (P < .05) but only among the uninsured. Lack of health insurance increased PH risk by 30% (P < .05).

Fine particulate matter components and emergency department visits among a privately insured population in Greater Houston.

Although adverse health effects of PM2.5 (particulate matter with aerodynamic diameter less than 2.5µm) mass have been extensively studied, it remains unclear regarding which PM2.5 components are most harmful. No studies have reported the associations between PM2.5 components and adverse health effects among a privately insured population. In our study, we estimated the short-term associations between exposure to PM2.5 components and emergency department (ED) visits for all-cause and cause-specific diseases in Greater Houston, Texas, during 2008-2013 using ED visit data extracted from a private insurance company (Blue Cross Blue Shield Texas [BCBSTX]). A total of 526,453 ED visits were included in our assessment, with an average of 236 (±63) visits per day. We selected 20 PM2.5 components from the U.S. Environmental Protection Agency's Chemical Speciation Network site located in Houston, and then applied Poisson regression models to assess the previously mentioned associations. Interquartile range increases in bromine (0.003µg/m(3)), potassium (0.048µg/m(3)), sodium ion (0.306µg/m(3)), and sulfate (1.648µg/m(3)) were statistically significantly associated with the increased risks in total ED of 0.71% (95% confidence interval (CI): 0.06, 1.37%), 0.71% (95% CI: 0.21, 1.22%), 1.28% (95% CI: 0.34, 2.24%), and 1.22% (95% CI: 0.23, 2.23%), respectively. Seasonal analysis suggested strongest associations occurred during the warm season. Our findings suggest that a privately insured population, presumably healthier than the general population, may be still at risk of adverse health effects due to exposure to ambient PM2.5 components.

Novel Measure of Opioid Dose and Costs of Care for Diabetes Mellitus: Opioid Dose and Health Care Costs.

UNLABELLED: Diabetes mellitus (DM) has well known costly complications but we hypothesized that costs of care for chronic pain treated with opioid analgesic (OA) medications would also be substantial. In a statewide, privately insured cohort of 29,033 adults aged 18 to 64 years with DM and noncancer pain who filled OA prescription(s) from 2008 to 2012, our outcomes were costs for specific health care services and total costs per 6-month intervals after the first filled OA prescription. Average daily OA dose (4 categories) and total dose (quartiles) in morphine-equivalent milligrams were calculated per 6-month interval after the first OA prescription and combined into a novel OA dose measure. Associations of OA measures with costs of care (n = 126,854 6-month intervals) were examined using generalized estimating equations adjusted for clinical conditions, psychotherapeutic drugs, and DM treatment. Incremental costs for each type of health care service and total cost of care increased progressively with average daily and total OA dose versus no OAs. The combined OA measure identified the highest incremental total costs per 6-month interval that were increased by $8,389 for 50- to 99-mg average daily dose plus >900 mg total dose and, by $9,181 and $9,958 respectively, for ≥100 mg average daily dose plus 301- to 900-mg or >900 mg total dose. In this statewide DM cohort, total health care costs per 6-month interval increased progressively with higher average daily OA dose and with total OA dose but the greatest increases of >$8,000 were distinguished by combinations of higher average daily and total OA doses. PERSPECTIVE: The higher costs of care for opioid-treated patients appeared for all types of services and likely reflects multiple factors including morbidity from the underlying cause of pain, care and complications related to opioid use, and poorer control of diabetes as found in other studies.