Mediators of Discrimination in Primary Care Appointment Access.

We examine how differences in questions asked and information provided by physicians' offices contribute to differences in new-patient appointment offers. Data is from a 2013-16 field experiment involving calls to a random sample of US primary care physicians on behalf of simulated new patients differentiated by race/ethnicity (Black, Hispanic, White), sex, and insurance. We find that the rates and stated reasons for denial of appointment offers differ substantially across patient groups.

Access to US primary care physicians for new patients concerned about smoking or weight.

Tobacco smoking and obesity are leading causes of preventable morbidity and mortality in the US, and primary care physicians are the main source of preventive care. However, it is not known whether access for new patients is affected by an expression of interest in preventive care. In a 2015 audit, we called US primary care physicians' offices to request appointment information regarding new patient physicals for simulated patients. Simulated patients were differentiated by smoking concerns (N = 907), weight concerns (N = 867), or no health concerns ("healthy" patients; N = 3561). Additionally, patient profiles varied by race/ethnicity, sex, and insurance type. We also examined whether access differed in states that expanded Medicaid under the Affordable Care Act. We found that physicians' offices were no more likely to offer appointments to patients with smoking concerns than to healthy patients (54% vs. 55%; p-value = 0.56), and patients with smoking concerns were offered fewer appointments than patients with weight concerns (54% vs. 62%, p-value < 0.01). In analyses adjusted for covariates, smoking concerns did not improve appointment offers for any patient group, and reduced Medicare patients' offers in Medicaid expansion states by 9 percentage points relative to healthy patients (95% CI: -16, -2). Health concerns did not statistically significantly affect waits-to-appointment. Our results suggest that patients with smoking concerns are no more likely to be offered new patient appointments than those with no health concerns. The greater likelihood of appointment offers for some patients with weight concerns is encouraging for obesity prevention and management.

State Medicaid fees and access to primary care physicians.

Medicaid and uninsured patients are disadvantaged in access to care and are disproportionately Black and Hispanic. Using a national audit of primary care physicians, we examine the relationship between state Medicaid fees for primary care services and access for Medicaid, Medicare, uninsured, and privately insured patients who differ by race/ethnicity and sex. We found that states with higher Medicaid fees had higher probabilities of appointment offers and shorter wait times for Medicaid patients, and lower probabilities of appointment offers and longer wait times for uninsured patients. Appointment offers and wait times for Medicare and privately insured patients were unaffected by Medicaid fees. At mean state Medicaid fees, our analysis predicts a 27-percentage-point disadvantage for Medicaid versus Medicare in appointment offers. This decreases to 6 percentage points when Medicaid and Medicare fees are equal, suggesting that permanent fee parity with Medicare could eliminate most of the disparity in appointment offers for Medicaid patients. The predicted decrease in the disparity is smaller for Black and Hispanic patients than for White patients. Our research highlights the importance of considering the effects of policy on nontarget patient groups, and the consequences of seemingly race-neutral policies on racial/ethnic and sex-based disparities.

Offers of appointments with nurse practitioners if a requested physician is unavailable.

BACKGROUND AND PURPOSE: Access to primary care remains a problem for a substantial portion of the U.S. population, and is predicted to worsen due to an aging population and the increasing burden of chronic diseases. Better integration of nurse practitioners (NPs) into the primary care workforce is a possible solution. We examine offers of appointments with NPs if a requested primary care physician is unavailable. METHODS: Data are from a 2013 audit (simulated patient) study requesting appointment information from a national random sample of primary care physicians. Outcome variables include appointment offers, wait-to-appointment times, and appointment offers with alternate providers, including NPs. CONCLUSIONS: Of 922 calls to primary care physicians serving the general adult population, 378 (41%) offered appointments with the requested physician. Alternate providers were offered by 63 (7%), including nine offers with NPs (<1%). Mean wait-to-appointment for NPs (3.6 days) was statistically significantly shorter (p-values < .01) than for requested physicians (22.5 days) or non-NP alternate providers (23.9 days). IMPLICATIONS FOR PRACTICE: NPs are an important part of the primary care workforce, and new patients seeking primary care physicians may substantially reduce their wait times if an NP is offered.

Aging baby boomers and the rising cost of chronic back pain: secular trend analysis of longitudinal Medical Expenditures Panel Survey data for years 2000 to 2007.

OBJECTIVES: The purposes of this study were to analyze data from the longitudinal Medical Expenditures Panel Survey (MEPS) to evaluate the impact of an aging population on secular trends in back pain and chronicity and to provide estimates of treatment costs for patients who used only ambulatory services. METHODS: Using the MEPS 2-year longitudinal data for years 2000 to 2007, we analyzed data from all adult respondents. Of the total number of MEPS respondent records analyzed (N = 71,838), we identified 12,104 respondents with back pain and further categorized 3842 as chronic cases and 8262 as nonchronic cases. RESULTS: Secular trends from the MEPS data indicate that the prevalence of back pain has increased by 29%, whereas chronic back pain increased by 64%. The average age among all adults with back pain increased from 45.9 to 48.2 years; the average age among adults with chronic back pain increased from 48.5 to 52.2 years. Inflation-adjusted (to 2010 dollars) biennial expenditures on ambulatory services for chronic back pain increased by 129% over the same period, from $15.6 billion in 2000 to 2001 to $35.7 billion in 2006 to 2007. CONCLUSION: The prevalence of back pain, especially chronic back pain, is increasing. To the extent that the growth in chronic back pain is caused, in part, by an aging population, the growth will likely continue or accelerate. With relatively high cost per adult with chronic back pain, total expenditures associated with back pain will correspondingly accelerate under existing treatment patterns. This carries implications for prioritizing health policy, clinical practice, and research efforts to improve care outcomes, costs, and cost-effectiveness and for health workforce planning.

Implications of an economic model of health states worse than dead.

We introduce a formal definition of health equivalent to dead into a standard model to develop previously unrecognized insights. We find that the health state viewed as equivalent to dead will depend on an individual's health prognosis, probability of survival, and rate of time preference. Our work on maximum endurable time shows that using QALY scores based on long-run preferences to value health states that last for shorter periods can alter cardinal and ordinal valuations. Simulations show that errors of substantial magnitude in QALY scores can consequently result. We describe situations where biases are likely and identify possible corrections.

Determinants of costs and pain improvement for medical and chiropractic care of low back pain.

OBJECTIVE: The purpose of this study was to identify short-term and long-term determinants of costs and pain improvement for care of low back pain (LBP) provided by medical doctors (MDs) and chiropractors (DCs). METHODS: Determinants of office-based costs and pain improvement were modeled for 2872 patients with primary complaint of acute or chronic LBP of mechanical origin enrolled from practices of 111 MDs and 60 DCs using multiple regression analysis. The independent variables were baseline pain intensity (10 cm visual analog scale), chronicity (current episode > or <7 weeks), referred pain above/below the knee, history of LBP, physical health, depression screen, comorbidity, and stress index; age, sex, married, and smoker; pay variables including out-of-pocket, health insurance, auto insurance, Workers' Compensation, and Oregon Health Plan/Medicaid; and a choice of provider indicator based on relative confidence in DC and MD care. RESULTS: Determinants of increased office-based costs for MD care were Workers' Compensation, pain below the knee, and chronic LBP with comorbidity. Predictors of increased cost for DC care were Workers' Compensation, auto and health insurance, LBP chronicity, and baseline pain. Predictors of decreased DC cost were Medicaid and better physical health. Pain improvement was predicted consistently across groups by baseline pain, pain radiating below the knee, physical health, LBP chronicity, and chronicity by baseline pain interaction. There was also a large chronicity by comorbidity interaction at 12 months for both provider types. CONCLUSIONS: Cost predictors were driven by insurance type and pain improvement was driven by LBP complaint characteristics.

Short-term fluctuations in hospital demand: implications for admission, discharge, and discriminatory behavior.

We analyze admission and discharge decisions when hospitals become capacity constrained on high-demand days, and develop a test for discrimination that, under certain circumstances, does not require controls for differences across patient groups. On high-demand days, patients are discharged earlier than expected compared to those discharged on low-demand days. High demand creates no statistically significant differences in hospitals' admission behavior. Thus, hospitals appear to ration capacity by hastening discharges rather than by restricting admissions. We could not reject a null hypothesis of no discrimination against Medicaid patients in discharges

Cost-effectiveness of medical and chiropractic care for acute and chronic low back pain.

OBJECTIVES: To identify relative provider costs, clinical outcomes, and patient satisfaction for the treatment of low back pain (LBP). METHODS: This was a practice-based, nonrandomized, comparative study of patients self-referring to 60 doctors of chiropractic and 111 medical doctors in 51 chiropractic and 14 general practice community clinics over a 2-year period. Patients were included if they were at least 18 years old, ambulatory, and had low back pain of mechanical origin (n = 2780). Outcomes were (standardized) office costs, office costs plus referral costs for office-based care and advanced imaging, pain, functional disability, patient satisfaction, physical health, and mental health evaluated at 3 and 12 months after the start of care. Multiple regression analysis was used to correct for baseline differences between provider types. RESULTS: Chiropractic office costs were higher for both acute and chronic patients (P < .01). When referrals were included, there were no significant differences in either group between provider types (P > .20). Acute and chronic chiropractic patients experienced better outcomes in pain, functional disability, and patient satisfaction (P < .01); clinically important differences in pain and disability improvement were found for chronic patients only. CONCLUSIONS: Chiropractic care appeared relatively cost-effective for the treatment of chronic LBP. Chiropractic and medical care performed comparably for acute patients. Practice-based clinical outcomes were consistent with systematic reviews of spinal manipulation efficacy: manipulation-based therapy is at least as good as and, in some cases, better than other therapeusis. This evidence can guide physicians, payers, and policy makers in evaluating chiropractic as a treatment option for low back pain.

Adjusting to changes in health: implications for cost-effectiveness analysis.

This article introduces a model in which individuals incur adjustment costs associated with adaptations made following changes in their health. With adjustment costs, patients' preferences for health states depend on their initial health in such a way that improvements have lower values than corresponding deteriorations. Improvement and deterioration must therefore be treated asymmetrically in CEA. The inclusion of adjustment costs also has other consequences. It produces a more stringent CEA criterion, and may affect the relative rankings of interventions. In addition, when health is multi-dimensional, and adjustment costs are incorporated, we show that a consensus on even ordinal rankings of health states becomes impossible.

Patient attitudes, insurance, and other determinants of self-referral to medical and chiropractic physicians.

OBJECTIVES: This study identified predictors of patient choice of a primary care medical doctor or chiropractor for treatment of low back pain. METHODS: Data from initial visits were derived from a prospective, longitudinal, nonrandomized, practice-based observational study of patients who self-referred to medical and chiropractic physicians (n = 1414). RESULTS: Logistic regression showed differences between patients who sought care from medical doctors vs chiropractors in terms of patient health status, sociodemographic characteristics, insurance, and attitudes. Disability, insurance, and trust in provider types were particularly important predictors. CONCLUSIONS: The study highlights the importance of patient attitudes, health status, and insurance in self-referral decisions. The significance of patient attitudes suggests that education might be used to shape attitudes and encourage cost-effective care choices.

Economic evaluation of aromatase inhibitors for the treatment of breast cancer.

Breast cancer affects 1 million women a year. Hormonal therapy has been a mainstay of treatment for women with hormone-sensitive breast cancer. The newer class of aromatase inhibitors has challenged the use of the previous standard agent, tamoxifen, in the treatment and prevention of breast cancer. This article will provide a thorough review of the literature on the newer generation aromatase inhibitors and examine their role in metastatic, adjuvant, neoadjuvant and prevention settings. An in-depth review of the cost-efficiency analyses is also performed. Recent studies on the newer, third-generation aromatase inhibitors have challenged the previous gold standard (tamoxifen) in the prevention and management of hormone-sensitive breast cancer in postmenopausal women. These studies have supported the use of aromatase inhibitors as first-line therapy in both early (adjuvant) and advanced breast cancer management. Whether aromatase inhibitors should replace tamoxifen in these settings is still a matter of debate. Augmenting these studies and providing additional information to the debate are pharmacoeconomic appraisals, which help to place a societal value on newer therapies as compared with the previously established therapy. This review discusses the pharmacology and efficacy of the newer aromatase inhibitors as it applies to their role in the metastatic, adjuvant, neoadjuvant and prevention settings. The pharmacoeconomic studies performed on these agents are also discussed.

Chiropractic and medical care costs of low back care: results from a practice-based observational study.

OBJECTIVE: To compare the 1-year costs for patients treated for acute and chronic ambulatory low back pain by medical physicians and chiropractors. STUDY DESIGN: Prospective, practice-based observational study undertaken in 13 general medical practices and 51 chiropractic community-based clinics. PATIENTS AND METHODS: Of 2872 study patients, 2263 had complete 1-year records of services. Service data, collected from billing records, chart audits, and provider questionnaires, were assigned relative value units that were converted into 1995 dollar costs. Prescription drug costs for medical patients were included. Patient data on health status, pain and disability, and socioeconomic characteristics were obtained from self-administered questionnaires. RESULTS: The direct office costs of treating both chiropractic and medical patients over a 1-year period were relatively small. Forty-three percent of chiropractic patients and 57% of medical patients incurred costs of less than $100. However, the mean costs associated with chiropractic patients ($214) were significantly higher than those for medical patients ($123), especially when compared with medical patients who were not referred for further treatment or evaluation ($103). Chiropractic patients had somewhat lower baseline levels of pain and disability than nonreferred medical patients, but the 2 groups were relatively similar on most patient characteristics. There also were no statistically significant differences in the improvements in pain and disability between these 2 groups of patients. CONCLUSION: The results of this study indicate that patients treated in chiropractic clinics incur higher costs over a 1-year period, but have about the same degree of relief as nonreferred patients treated in medical clinics.

Efficacy and economics of hormonal therapies for advanced breast cancer.

Breast cancer is a leading cause of cancer-related mortality among postmenopausal women in the US, and the economic burden of breast cancer care comprises a large percentage of the healthcare budget. Hormonal therapies have a proven place in the management of advanced breast cancer. This type of therapy is more likely to be used in older, compared with younger, women, because tumours in older women are more likely to express estrogen and progesterone receptors. While it is difficult to measure the costs of cancer care because of variation in extent and duration of treatment, treatment-related costs including costs of hormonal agents used for advanced disease account for a relatively small component of the overall costs. Newer hormonal regimens such as the new third generation nonsteroidal (letrozole, anastrozole) and steroidal (exemestane) aromatase inhibitors have shown improved clinical efficacy compared with standard regimens such as megestrol and tamoxifen in the metastatic setting in terms of objective responses or time to tumour progression. In addition the newer agents have improved toxicity profiles. Cost analyses of the newer aromatase inhibitors (anastrozole and letrozole), compared with megestrol, show an optimistic outlook for these agents. Additional work needs to be done looking at a comparison of the efficacy and costs of the aromatase inhibitors relative to the currently recommended hormonal treatments used for women with metastatic breast cancer.